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From the School of Social Work, University of Haifa, Haifa, Israel.
Address reprint requests to: Dr. Hasida Ben-Zur, School of Social Work, University of Haifa, Haifa, Israel. Email: rpps302@ uvm.haifa.ac.il
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONLiterature Review: Coping and...Research Aims and HypothesesMETHODSRESULTSDISCUSSIONNOTESREFERENCES |
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METHODS: Seventy-three patients with breast cancer and their spouses completed questionnaires that measured distress (Brief Symptom Inventory), psychosocial adjustment, and coping strategies.
RESULTS: The patients’ distress was greater than their spouses’, but a similar level of psychosocial adjustment was reported. The patients used more strategies involving problem-focused coping than their spouses. The use of emotion-focused coping, which included ventilation and avoidance strategies, was highly related to distress and poor adjustment on the part of the patient. The spouses’ emotion-focused coping and distress were related to that of the patients. Dyad emotion-focused coping measures were highly associated with the patients’ distress and adjustment.
CONCLUSIONS: Spousal and dyad coping are important factors in a patient’s adjustment to breast cancer.
Key Words: adjustment • cancer • coping • dyad • spouse.
Abbreviations: BSI = Brief Symptom Inventory; GSI = Global Severity Index; EF = emotion-focused (coping); PF = problem-focused (coping); PSA = Psychological/Social Adjustment Scale.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONLiterature Review: Coping and...Research Aims and HypothesesMETHODSRESULTSDISCUSSIONNOTESREFERENCES |
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According to Mages and Mendelsohn (5), cancer engenders a state of prolonged stress resulting from the discovery of the disease, the process of diagnosis, surgical intervention, medical treatment, medical follow-up, and fear of recurrence. Additionally, women with breast cancer are under ongoing stress because breast surgery entails disfiguring mastectomy or lumpectomy. How cancer patients adjust to the alterations in their lives caused by these ongoing stressful experiences presumably depends on their coping strategies (6).
Coping strategies represent behavioral and cognitive efforts to deal with stressful encounters (eg, Refs. 7 and 8). Lazarus and Folkman (7) classified coping strategies as either problem-focused or emotion-focused, delineating the function of coping as dealing with the problem or with its emotional and physiological outcomes, respectively. In subsequent studies (9, 10), coping strategies were classified according to outcome in terms of their functional or adaptive value, and their effectiveness was assessed in terms of elimination of stressors and distress as well as preservation of social functioning and a sense of well-being (11). Other research has shown problem-focused coping to be more effective than emotion-focused coping in terms of neutralizing negative emotional reactions and improving performance levels (12–14).
During stressful encounters, people draw on a variety of resources to aid them in the coping and adjustment process, including finances, social support, education, intelligence, and personality disposition (7, 15). Although financial resources and skilled medical personnel are important in the medical context, special emphasis is placed on social and personal resources (6). Of these resources, the family is considered to be one of the most important resources for coping with stress (16), even though the threat to life caused by cancer also affects each family member as well (17, 18).
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Literature Review: Coping and Adjustment to Cancer |
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TOPABSTRACTINTRODUCTIONLiterature Review: Coping and...Research Aims and HypothesesMETHODSRESULTSDISCUSSIONNOTESREFERENCES |
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The studies that focus on both breast cancer patients and their spouses indicate divergent results when adjustment to the illness is assessed. Northouse and Swain’s studies (28, 29) showed no significant differences between patients and spouses in psychological distress (as assessed by the BSI). Hoskins’ (30) study, in contrast, indicated that breast cancer patients’ psychological distress and their well-being were higher than their spouses’. Baider and Kaplan De-Nour (1), however, found that spouses had more psychosocial problems than patients, and Gilbar et al. (31), who studied patients with gynecological cancer and their spouses, showed that the spouses’ psychological distress (as assessed by the BSI) was more severe than the patients’.
Significantly, appropriate adjustment to cancer depends on the totality of the cognitive, emotional, and behavioral responses to the diagnosis by the patients and their significant others. Past research has shown that emotional support by the family is related to a positive outlook on life among women with advanced breast cancer (32) and that a family environment characterized by more expressiveness and less conflict predicts better adjustment of cancer patients (33). Social constraints and unresponsiveness of spouses or other family members in talking about the illness have been related to poor mental health among prostate cancer patients (34). Manne (35) suggested that spouses are the primary source of support for married patients, with patients who perceive higher levels of critical or avoidant responses by spouses reporting greater psychological distress (36).
In the case of breast cancer, the spouse’s vulnerability is heightened because he finds himself in a double, and conflictive, role: As the primary supporter, he must assume new roles in the household (37) and provide tangible as well as emotional support; at the same time he must cope with the distress emanating from the significance of his wife’s diagnosis in terms of her suffering and the threat to her life (6). Curiously, few studies have been devoted to the association between the coping strategies of both spouses and their adjustment to breast cancer, although spouse and dyad coping strategies have been recognized as mechanisms for the reduction of stress in the context of a wide range of diseases, including multiple sclerosis (38) and myocardial infarction (39, 40). Pakenham (38) suggests that the relationship between coping congruency of couples and adjustment may depend on the type of coping strategy used. A retrospective study (41) assessing 36 former breast cancer patients and their spouses showed that the spouses’ coping strategies were related to their own well-being and to marital satisfaction but that the state of the patients’ mental health was not correlated with their spouses’ coping. These results, though, are not compatible with those of other studies, which have showed that the partner is an important social resource for the adjustment of the patient (1, 6, 35, 42). If the spouse’s distress level is high and if he or she uses less efficient strategies, then he or she is likely to be less of a support for the ill partner.
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Research Aims and Hypotheses |
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TOPABSTRACTINTRODUCTIONLiterature Review: Coping and...Research Aims and HypothesesMETHODSRESULTSDISCUSSIONNOTESREFERENCES |
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Patient coping model.
The first hypothesis was based on prior research and on stress and coping theory (eg, Refs. 9, 12, and 25), namely, that problem-focused strategies used by breast cancer patients will be beneficial in adjustment to the illness, whereas emotion-focused strategies will be detrimental to adjustment. The model assumes that the patient’s demographic characteristics (eg, age, education, and work) contribute to her coping strategies, which in turn are related to her adjustment.
Spouse coping model.
The second hypothesis was based on studies of family and spousal support (32–37), namely, that the spouse’s high distress and low adjustment, as well as emotion-focused coping, will be related positively to the patient’s distress and poorer adjustment, whereas problem-focused coping will be related negatively to the patient’s distress and poorer adjustment. The model assumes that the spouse’s demographic characteristics contribute to his use of coping strategies, which in turn will be related to his distress and to the patient’s coping, distress, and adjustment.
Dyad coping model.
The third hypothesis, based on certain studies of dyad coping and illness (eg, Ref. 38), was that incongruity between the spouse’s emotion-focused coping strategies will be related to poorer patient adjustment and a high level of distress, whereas incongruity between the spouse’s problem-focused coping strategies will be related to better patient adjustment and a low level of distress.
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METHODS |
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TOPABSTRACTINTRODUCTIONLiterature Review: Coping and...Research Aims and HypothesesMETHODSRESULTSDISCUSSIONNOTESREFERENCES |
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The patients’ mean age was 52.24 years(SD = 8.28 years, range = 30–66 years), and the spouses’ mean age was 55.6 years (SD = 9.94 years, range = 33–86 years). Mean number of years of formal education was 12.15 (SD = 3.91, range = 0–21) for patients and 12.92 (SD = 3.82, range = 4–21) for spouses. Average number of children was 2.52 (1.11) for patients, with an average of 0.75 children under the age of 18. About half the patients (45.9%) were born in Israel, 35.1% in Europe or America, 13.5% in Asia or Africa, and 5.5% elsewhere. Comparable percentages for spouses were 48.6%, 24.3%, 21.6%, and 5.4%, respectively. Fifty-five percent of the patients and 74% of the spouses were employed during the interview period. The patients had undergone a lumpectomy (79.2%) or a mastectomy (20.8%). Most (95.8%) were currently receiving treatment, either chemotherapy (63.9%), radiation treatment (51.4%), or hormonal treatment (12.5%), with 26.4% receiving both chemotherapy and radiation and 5.6% receiving both radiation and hormonal treatment.
Questionnaires
Psychological distress.
Psychological distress was assessed by using the BSI (43), which is a shortened version of the revised Symptom Checklist-90 that correlates highly with it. The BSI contains 53 items, each describing a feeling or thought, and is scored on a five-point scale ranging from 0 (no such problem) to 4 (severe problems). The inventory is composed of 10 symptom dimensions: somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, psychoticism, and additional items. Internal consistency (Cronbach’s 
) for the 10 BSI dimensions ranges between 0.71 and 0.85. A GSI is obtained for each subject by averaging the 53 symptoms ratings. High scores are characteristic of subjects with greater psychological distress. The test-retest reliability of the GSI is 0.90. Several validation studies of the BSI have been conducted, establishing the construct validity of the instrument (43).
Because the correlations between the 10 BSI subscales were relatively high (range = 0.48–0.80), the GSI was used in this study ( = 0.97 and 0.96 for patients and spouses, respectively). However, the scale included a somatization subscale that might have substantially weighted the patients’ GSI because of the physical discomfort and pain resulting from surgery and treatment. Therefore, a partial GSI score was also created; this partial score included all but the somatization items. The correlation between the complete and partial GSIs was 0.99, and results were practically identical for the two scales. The complete GSI, therefore, was used in all analyses.
Psychosocial adjustment.
Psychosocial adjustment was assessed by using the PSA, a 15-item scale developed specifically for this research and used to assess cancer patients for the first time. It was constructed on the basis of a pretest of 56 items depicting functioning in five domains in everyday life: work, family, social relations, house care, and self-care. The items were phrased in both positive and negative directions (eg, "I do my work with enthusiasm" and "I postpone the house chores as much as possible"). The initial 56-item questionnaire was completed by 68 paid university students and 20 community resident volunteers, and after factor and correlation analyses, items were deleted, resulting in a 15-item scale ( = 0.80) with three items in each domain. No gender or age differences were observed. The correlation between the PSA score and depressive mood (44) was high (-0.57), and it remained high (-0.52) even after social desirability was partialed out.
The PSA items were rated on a five-point scale (1 = small extent, 5 = large extent), with satisfactory internal reliability ( = 0.78 and 0.74 for patients and spouses, respectively). A high mean score represents good adjustment and vice versa.
Pearson correlations between the two measures of adjustment to illness (PSA and GSI) for the patients and spouses were significant (r = -0.56 and -0.45, respectively; p < .0001). Psychological distress was thus negatively correlated with psychosocial adjustment for both patients and spouses.
Coping strategies.
Coping strategies were measured by using a 30-item short Hebrew version of the COPE Scale (9), used in previous research (45), with both patients and spouses instructed to assess the use of coping options in dealing with the patient’s illness. The items depict various coping options (eg, "I make a plan of action" and "I learn to live with it"). Respondents are asked to rate the extent to which each option is used on a four-point scale (0 = not at all, 3 = great extent; the scale was transformed so that the range was 1–4). The scale includes 15 strategies, each represented by a two-item subscale as translated from the original scale (range = 2–8). The strategies are active coping, planning, seeking instrumental social support, seeking emotional social support, suppression of competing activities, turning to religion, positive reinterpretation and growth, restraint coping, acceptance, focus on and ventilation of emotion, denial, mental disengagement, behavioral disengagement, disengagement through alcohol and drug use, and humor.
After conducting several factor analyses with Varimax rotation, two scales, which were similar to those used by one of the authors in earlier research (45), were created: 1) a problem-focused (PF) scale, composed of active coping, planning, suppression, instrumental support, emotional support, and positive reinterpretation (patients’ = 0.73, spouses’ = 0.82); and 2) an emotion-focused (EF) scale, composed of ventilation, denial, behavioral disengagement, religion, and restraint (patients’ = 0.79, spouses’ = 0.69). The correlations between the PF and EF coping scales were minimal for both patients and spouses ( = 0.00 and 0.28, respectively).
Demographic characteristics and medical history.
A demographic and medical questionnaire covered age, education, place of birth, number of children, employment, type of surgery, and type of treatment.
Procedures
The interviews were conducted at the participants’ homes after they provided written, informed consent to be interviewed. The interviews were conducted separately for each patient and spouse. The interviews took place in the evening because most of the couples worked during the day. Each interview lasted 30 to 45 minutes. Data were collected from August 1998 through May 1999. The research protocol was approved by a Helsinki committee.
Data Analyses
A two-part analytical procedure was used. The first part tested the similarities and differences between patients and spouses in coping and adjustment, using t tests for within-couple analyses (ie, analyzing difference scores) and Pearson correlational analyses. Pearson correlations were also used to assess the simple associations between the patients’ and spouses’ coping and adjustment scores. The second part tested the three hypotheses using path analytical models based on multiple regressions. The outcome measures of distress and psychosocial adjustment in each of the models were regressed on the compatible demographic and coping variables. Additionally, Pearson correlational analyses were used to assess the specific strategies that were most helpful or detrimental to adjustment. In light of the multiple tests involved, a conservative level of significance (p 
.01) was used.
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RESULTS |
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TOPABSTRACTINTRODUCTIONLiterature Review: Coping and...Research Aims and HypothesesMETHODSRESULTSDISCUSSIONNOTESREFERENCES |
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The similar demographic characteristics of the patients and spouses may account for the similarity of psychological distress levels and coping patterns. A Pearson correlation analysis revealed a high level of similarity (all correlations >0.55) between patients and spouses in age, number of years of education, and place of birth. Some of these variables were correlated with psychological distress, psychosocial adjustment, and coping. Therefore, partial correlations controlling for all demographic variables were computed. As Table 1 shows, the partial correlations remained positive and significant.
Pearson correlations between patients’ and spouses’ coping subscales and adjustment measures (psychological and psychosocial) showed that both patients’ and spouses’ EF coping scores were significantly related to patients’ psychological distress (r = 0.67, p < .0001 and r = 0.35, p < .01, respectively) and psychosocial adjustment (r = -0.51, p < .0001 and r = -0.30, p < .01, respectively). PF coping was not related to adjustment measures.
Testing the Hypotheses
Patient coping model.
This model was designed to assess the associations between patients’ distress and adjustment, coping strategies, and personal demographic characteristics. Two path analyses were conducted separately using the GSI or PSA score as outcomes, whereas PF and EF coping scores were the mediators between outcomes and patient’s age, education, and work.1 Figure 1R2pR2pR2p
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Spouse coping model.
This model was designed to assess the patient’s psychosocial and psychological adjustment associations with the spouse’s personal demographic characteristics, distress, and coping strategies. At the same time it assessed the patient’s coping strategies and work status (patients’ education and age were not included because of high correlations with the spouses’). Again, two path analyses were conducted with the GSI or PSA score used as the outcome and patient’s PF and EF coping scores used as mediators between her outcomes and her spouse’s GSI or PSA score. These, in turn, were used as mediators between patient’s and spouse’s coping strategies. The spouse’s coping strategies were seen as a mediator of spouse’s age, education, and work as well as the patient’s work. The results of the analyses are depicted in Figure 2.
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Dyad coping model.
This model tested mean EF and PF coping by patients and spouses as well as the absolute differences between their EF and PF coping. The mean coping scores assess dyad coping, with very high or very low scores representing high or low coping levels on the part of both spouses, respectively. High absolute-difference scores point to an incongruity between patient and spouse coping, whereas very low scores represent coping compatibility. Table 2 presents the results of the multiple regressions, with patients’ GSI and PSA score regressed on mean and absolute-difference scores and on demographic variables. Simple correlations are shown in parentheses. As can be seen, both mean EF scores and absolute-difference scores for EF are predictive of a high level of psychological distress and poor psychosocial adjustment. Thus, when both spouses cope by means of EF strategies, psychological distress is greater and functioning is poor. The analysis reveals that even when only one spouse uses a high level of EF coping, adjustment is impaired as well.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONLiterature Review: Coping and...Research Aims and HypothesesMETHODSRESULTSDISCUSSIONNOTESREFERENCES |
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The first hypothesis of the study was partially confirmed, with the results showing that the patient’s emotion-focused coping was associated with high psychological distress and low psychosocial adjustment, a pattern revealed in other studies of cancer patients (25, 26). An examination of the patients’ specific coping strategies showed ventilation, restraint, denial, religion, and behavioral disengagement to be positively related to distress. Thus, the results suggest that avoidance (eg, denial), vigilance (eg, ventilating) and more passive strategies (eg, restraint) are related to low adjustment in the initial stage of cancer.
In contrast to other research findings (eg, Refs. 20, 25, and 26), however, the present study suggests that problem-focused coping is not related to adjustment. What factors, then, constitute a positive contribution to the adjustment of breast cancer patients? The findings indicate that a high level of education among patients contributed to low emotion-focused coping, which suggests that patients with a low educational level may be particularly vulnerable to distress. A high level of education is considered a resource (7, 15) that may enhance coping through the ability to understand the situation and use information more efficiently. In addition, an examination of specific coping strategies shows that positive reinterpretation, humor, and planning on the part of the patient seem to be particularly related to good adjustment. These strategies have to do with appraisal-focused coping, which is termed cognitive-approach coping in Moos and Schaefer’s coping model (15). Thus, specific cognitive strategies that are not active or behavioral but that may attenuate the threat by shifting perspective might be the best coping options available in this situation.
Over and above the patient’s characteristics and behaviors that contribute to distress, an important support may lie in the spouse’s reactions to cancer (34–36) as well as in the coping of the dyad. Regarding the spousal model, the second hypothesis of this study, as the first, was confirmed for emotion-focused coping but not for problem-focused coping. Both the spouse’s emotion-focused coping and his distress relate to the breast cancer patient’s emotion-focused coping and distress. Because high levels of distress and emotion-focused coping are connected with highly threatening and uncontrolled situations (7), such spousal reactions may be perceived by the wife as indicating helplessness and therefore lack of support during a particularly difficult situation. That an extant study (41) did not reveal similar data may have been due to the small range of coping strategies tested as well as to the retrospective nature of the study.
The dyad model, aimed at testing the spouses’ collective coping strategies, showed results that were compatible with the first two models but also added a new perspective on the pattern of relationships between distress and coping. In testing the dyad’s emotion- and problem-focused coping, not only was total spousal emotion-focused coping related to a high level of psychological distress and poor psychosocial adjustment, but a high level of disparity between the spouses’ emotion-focused coping was also associated with greater distress. The patient’s distress is greater when one spouse tries to deny the situation while the other does not or when one tries to vent emotions related to the situation and the other does not. Thus, the third hypothesis, relating to emotion-focused coping disparity, was confirmed, but the problem-focused coping disparity was not found to be significant in the anticipated negative association with distress.
In summary, this study showed emotion-focused coping by either or both spouses to be related negatively to the patient’s adjustment. The advantages of the study are that it was conducted both with breast cancer patients and their spouses during the course of the illness; it used a relatively large sample in which there were few refusals to participate; and each spouse was interviewed individually. Nevertheless, the fact that the research was conducted at a single point in time limited the conclusions that could be made, because changes in distress and coping processes over time could not be assessed. The cause-and-effect relationship suggested by the path analyses, therefore, is only one of several possibilities. Notably, the data were treated according to the cognitive paradigm, which views distress and emotion as outcomes of the coping process (7). Conceivably, however, the reverse process may occur: A high level of distress will lead to the use of emotion-focused coping and prevent efficient use of problem-focused coping by both spouses. Similarly, patient distress may be seen as dependent on spousal distress and coping, as highlighted in the present analysis, but by the same token, spousal distress may be seen as dependent on the patient’s distress and coping. Lastly, it should be noted that the study used a newly constructed psychosocial adjustment scale that was applied to cancer patients for the first time. The results obtained with this scale, therefore, are preliminary. The similarity of patterns of psychosocial adjustment between patients and spouses obtained in this research should be tested for replication in future studies.
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NOTES |
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TOPABSTRACTINTRODUCTIONLiterature Review: Coping and...Research Aims and HypothesesMETHODSRESULTSDISCUSSIONNOTESREFERENCES |
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Received for publication October 28, 1999.
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TOPABSTRACTINTRODUCTIONLiterature Review: Coping and...Research Aims and HypothesesMETHODSRESULTSDISCUSSIONNOTESREFERENCES |
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