Friday, February 25, 2005

Coping with illness

"Who are bad copers?" asks one of my most read (and most borrowed) handbooks. "(They) have more problems in coping with unusual, intense, and unexpected difficulties because of the following traits:

1. They tend to be excessive in self-expectation, rigid in outlook, inflexible in standards, and reluctant to compromise or to ask for help.

2. Their opinion of how should people should behave is narrow and absolute; they allow little room for tolerance.

3. Although prone to firm adherence to preconceptions, bad copers may show unexpected compliance or be suggestible on specious grounds, with little cause.

4. They are inclined to excessive denial and elaborate rationalization; in addition, they are unable to focus on salient problems.

5. Because they find it difficult to weigh feasible alternatives, bad copers tend to be more passive than usual and fail to initiate action on their own behalf.

6. Their rigidity occasionally lapses, and bad copers subject themselves to impulsive judgments or atypical behavior that fails to be effective."
So says Massachusetts General Hospital's "Handbook of General Hospital Psychiatry." I've run through this list so many times, with so many patients, that I can recite entire passages verbatim.

Every medical specialty refers patients to psychiatry. Often, the doc has worked mightily to help a patient cope with illness, and has reached an impasse. Psychiatrists become students of coping behavior. What's working, what isn't, and why?

Effective copers share some common traits. They aren't just people who have less to cope with (although sometimes I wonder about that):
1. They are optimistic about mastering problems and, despite setbacks, generally maintain a high level of morale.

2. They tend to be practical and emphasize immediate problems, issues, and obstacles that must be conquered before even visualizing a remote or ideal resolution.

3. They select from a wide range of potential strategies and tactics, and their policy is not to be at a loss for fallback methods. In this respect, they are resourceful.

4. They heed various possible outcomes and improve coping by being aware of consequences.

5. They are generally flexible and open to suggestions, but they do not give up the final say in decisions.

6. They are quite composed, although vigilant in avoiding emotional extremes that could impair judgment.
"These are collective tendencies; they seldom typify any specific individual except the heroic or the idealized. No one copes superlatively at all times, especially with problems that impose a risk and might well be overwhelming. Notably, however, effective copers seem able to choose the kind of situation in which they are most likely to prosper. In addition, effective copers often maintain enough confidence to feel resourceful enough to survive intact. Finally, it is our impression that those individuals who cope effectively do not pretend to have knowledge that they do not have; therefore they feel comfortable turning to experts they trust. The clinical relevance of these characterizations is the extent to which we can assess how patients cope by more accurately pinpointing which traits they seem to lack."

(pages 62-63, Massachusetts General Hospital Handbook of General Hospital Psychiatry by Theodore A. Stern, Gregory Fricchione, Ned H. Cassem (Editor), Michael S. Jellinek, Jerrold F. Rosenbaum. Chapter 7: Coping With Illness and Psychotherapy of the Medically Ill, by Steven C. Schlozman, MD, James E. Groves, MD, and Avery D. Weisman, MD.
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