Sot. Sci. Med. Vol. 18. No. IO, pp. 889-898, 1984 0277-9536/84 S3.W + 0.

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Printed in Great Britain. All rights reserved CopyrIght Q 1984 Pergamon Press Ltd

STRESS AND COPING IN THE EXPLANATION OF

PSYCHOLOGICAL ADJUSTMENT AMONG
CHRONICALLY ILL ADULTS*

BARBARA J. FELTON’, TRACEY A. REVENS~N’ and GREGORY A. HINRICHSEN~

‘Department of Psychology, New York University, 6 Washington Place, New York, NY 10003,
2University of California-Irvine, Irvine, CA 92717 and ‘Long Island Jewish-Hillside Medical Center, NY,
U.S.A.

Abstract-This study evaluates the utility of a stress and coping paradigm for explaining individual
differences in psychological adjustment to chronic illness. Using data from the first wave of a longitudinal
study of 170 middle-aged and elderly adults faced with one of four chronic illnesses (hypertension, diabetes
mellitus, cancer and rheumatoid arthritis), this paper examines the relationship between the stresses of
chronic illness and coping, and the ability of coping to explain psychological adjustment. Results show
coping strategy use tends to be minimally explained by medical diagnosis. Cognitive strategies, including
information seeking, are related to positive affect while emotional strategies, particularly those involving
avoidance, blame and emotional ventilation, are related to negative affect, lowered self-esteem and poorer
adjustment to illness. While the findings suggest that a stress and coping model may be valuable in
understanding adjustment among the chronically ill, the general modesty of coping effects and the failure
of the stress buffering hypothesis to explain adjustment indicates a need for new research approaches and
some modification of current theories of coping.

Physical health is strongly linked to the emotional vestigating the coping responses made by a normative
well-being of older adults, as documented by numer- sample of adults faced with a variety of self-named
ous studies of mental health in late life [ 1,2]. Declines stressors including health problems, Folkman and
in health, frequently prompted by the onset and Lazarus [5] found the context of the stressful situ-
persistence of chronic illnesses, are a frequently ex- ation and the individual’s appraisal of its amenability
perienced form of stress in middle age and later to personal control to be important predictors of
adulthood, and the impact of such declines on psy- emotion-focused vs problem-focused modes of cop-
chological adjustment may be profound [3]. Individ- ing. Health-related stressors, particularly those ap-
ual differences in reaction exist, however, with some praised as requiring acceptance, were significantly
adults far more distressed by illness than others. The more likely to prompt emotion-focused coping, i.e.
study described here evaluates the utility of a ‘stress strategies directed at reducing the emotional distress
and coping paradigm’ [4] for explaining individual prompted by the problematic situation, rather than
variations in older adults’ psychosocial adjustment to those directed at altering the source of the stress itself.
illness. Similarly, Pearlin and Schooler [6] found situation
Current theories of stress and coping describe modification strategies, those most closely akin to
coping behavior as goal directed and responsive to problem-focused coping, to appear more frequently
stress; such cognitions and behaviors are seen as when the stresses (or, in their terminology, ‘enduring
critical in determining with what success people role strains’) occurred in the areas of marriage or
handle life stresses. Coping is presumably elicited parenting, both close interpersonal situations, than
when the individual cognitively appraises a situation when these strains lay in occupational or household
as posing threat, harm, loss or challenge; appropri- economic situations. More recently, McCrae [7], in
ately selected coping strategies buffer the individual two cross-sectional studies, found that differences in
under stress from emotional distress and mal- the types of stresses faced by adults were responsible
adjustment. for the apparent age differences which appeared in
Lazarus [4] proposes that the particular kinds of adults’ use of different coping strategies.
coping behaviors which people use are determined by A critical assumption of current conceptions of
both personal characteristics and those of their social coping is that coping strategies may have different
environment, and, most importantly, by the nature of consequences when used in response to different types
the stress with which they are contending. In- of stress. Thus, the effectiveness of any given strategy
depends upon its appropriateness for the particular
*This research was supported by the National Institute of stress faced. In Pearlin and Schooler’s study, coping
Mental Health Grant MH 29822. The authors gratefully strategies through which the individual remained
acknowledge the helpful comments made by Drs Stanley ‘committed to and engaged with the relevant others’
Lehmann and Marybeth Shinn on earlier drafts of this were not only more prevalent but were most success-
paper. ful in reducing emotional distress when prompted by

889
890 BARBARA J. FELTON er al.
the stresses of close interpersonal situations; coping
strategies which distanced the individual from the
problem, on the other hand, were most successful in
dealing with the stresses of more impersonal situ-
ations (p. 18). In addition to demonstrating that the
effectiveness of different coping strategies depends on
the nature of the stress faced, these results demon-
strate that strategies which involve avoidance, dis-
tance and cognitive distortions of the situation may,
under some circumstances, be adaptive. Thus these
results suggest that an accurate perception of reality
and direct confrontation with the stressor are not
always necessary for successful coping [4,8] and may,
in fact, be an adaptive approach to uncontrollable
stresses.
Studies of adults’ experiences with serious illnesses,
mostly anecdotal or case studies of specific illnesses,
have identified coping behaviors presumably re-
sponsive to the particular stresses of illness. De-
pending on the definition of coping used and on the
nature of the illness studied, these studies have found
typical coping strategies to include: denial, selective
ignoring, information seeking, taking refuge in activ-
ity, avoidance, reminiscence about former good
times, learning specific illness-related procedures,
blaming others and seeking comfort from others
[9-l 11.These studies have provided valuable descrip-
tions of the types of coping strategies provoked by
illness, and have pointedly raised the question of just
how effective individual coping efforts are at im-
proving emotional well-being and maintaining phys-
ical health. These studies, however, have most often
confounded measures of coping and adjustment, for
example, by defining groups of good vs poor capers
[12, 131; consequently, the question of the role of
coping in adjustment to illness has not yet been
directly addressed.
Research showing that emotion-focused or pal-
lative strategies are most effective in situations which
are not amenable to individual control [6] suggests
that the stresses of illness, at least those which are
unmanageable by individual or medical efforts, may
be most successfully dealt with through strategies
that focus on the emotional distress aroused by the
illness. Most studies of illness, however, have been
restricted to a single illness, a research strategy which
inevitably ignores variations in the controllability of
illnesses as well as other variations in other character-
istics of the multiple stresses or ‘adaptive tasks’ of
illness. Research on the role of health in psychosocial
adjustment in late life has relied for the most part on
a single continuum of self-rated health status as its
measure [l] and thus assumes a uniformity in the
nature of illness’ impact on adjustment which has not
been empirically demonstrated.
The study described here evaluates the utility of a
stress and coping paradigm for explaining psycho-
logical adjustment to chronic illness by comparing
adults with one of four different illnesses. Using
closed-ended self-report data about the problem- and
emotion-focused strategies used to cope with illness,
this study considers the characteristics of illness,
*Three cancer diagnoses were studied: chronic lymphocytic
leukemia, lymphoma and multiple myeloma. All three
were treated as a single group in data analyses.
particularly the illness’ amenability to medical and
personal control, which prompt the use of particular
coping strategies. It describes which coping strategies
are most effective in warding off the negative psycho-
logical consequences of illness.
This study’s examination of coping strategy
effectiveness includes an examination of the stress-
buffering hypothesis, or the idea that the relationship
between stress and psychological adjustment is non-
linear when coping responses are taken into account
[14]. In its most specific form, the stress-buffering
hypothesis maintains that particular levels of stress
must be experienced together with an absence of
coping in order for the negative effects of stress to
emerge [15] or, expressed differently, that coping will
be positively and most strongly related to adjustment
when stress is severe [16, 171. While empirical studies
have documented the presence of direct elects of
coping on adjustment, empirical evidence for a stress-
buffering conception of coping is minimal so far:
Pearlin and Schooler’s [18] efforts to locate statistical
‘stress-buffering’ interaction effects between stress
and coping behavior in relation to distress were
largely unsuccessful. Nonetheless, the theoretical
proposition deserves further testing, and is particu-
larly relevant in a study of illnesses which vary in the
amount and type of stress which they present.
METHOD
Sample
The study was designed to allow comparisons
among individuals faced with one of four chronic
illnesses: hypertension, diabetes mellitus, rheumatoid
arthritis and systemic blood cancers. In selecting the
illnesses, those which ran too rapid a course for study
or which were not moderately prevalent among
middle-aged and older Americans were excluded
from consideration; the illnesses chosen were fairly
equally ‘systemic’, i.e. none was primarily localized in
a specific body site. Most importantly, the four
illnesses were selected to represent a three-point
continuum of ‘controllability’ and, in the case of
‘least controllability, two qualitatively different types
of stress.
Hypertension is largely controllable by diet and/or
medication; both forms of treatment are self-
administered and adherence to prescribed treatment
is largely the responsibility of the patient [19]. Di-
abetes mellitus lies in the middle of the continuum:
though the symptoms of diabetes mellitus are usually
quite responsive to diet and/or medication, the long-
range effects of disease progression, particularly on
the circulatory and renal systems, are largely uncon-
trollable [20,21]. The diseases characterized as ‘least
controllable’- cancer and rheumatoid arthritis-are
both largely unpredictable in their progression and
variable in response, if not unresponsive, to treat-
ment. These illnesses, however, present very different
types of stress. The forms of cancer included in this
study* are often fatal and may run a course almost
completely beyond personal and medical control;
current cancer treatment necessitates a strong de-
pendency on physicians and often requires adjuvant
therapy, such as chemotherapy or radiation therapy
[22-251. Though it also has a fairly uncontrollable
 Coping and adjustment in chronically ill adults
course, rheumatoid arthritis, in contrast, is character-
ized by extreme pain and decreased joint mobility,
symptoms which are quite debilitating in their impact
on daily functioning [26] but which pose no immedi-
ate life threat. The differences between these two
illnesses allowed comparisons between the qualitative
impact of life threat and of non-life threatening
disability as aspects of chronic disease.
The sample was drawn from non-hospitalized
patients aged 40 and older who had a primary
diagnosis of one of these four illnesses. Referrals to
the research project were made by private physicians,
specialty clinics at metropolitan hospitals, and a
hypertensive screening agency. Respondents were
contacted initially through their physician and inter-
viewed by research staff with a structured protocol
including both open- and closed-ended questions on
illness characteristics, details of the treatment regi-
men, coping strategy use, social support, emotional
well-being, and demographic data. Of those adults
referred to the study who were deemed eligible for
participation by virtue of the above criteria, 170, or
68x, consented to participate in the study.
The illness groups were roughly comparable in size:
38 respondents had a primary diagnosis of hyper-
tension, 44 had diabetes, 45 had rheumatoid arthritis
and 42 had cancer. The average length of time over
which subjects had had their illnesses was 65 months
(SD = 91.2). Demographic differences among the ill-
ness groups were present in a few instances: the
rheumatoid arthritis and hypertensive groups con-
tained more women than the other two groups; social
class, measured according to Hollingshead and Red-
lich’s [27] education and occupation indices, was
lowest among rheumatoid arthritics, next lowest
among hypertensives and highest among respondents
with cancer or diabetes. No differences were found
among diagnoses for age or in the proportion of
respondents married or living alone. Overall, the
sample consisted of primarily white, married, middle-
to-upper middle class adults (67 men, 103 women),
aged 41-89, with a mean age of 61.
Measures
Medical diagnosis. The four illness groups, defined
by respondents’ primary medical diagnosis, were
assumed to represent a three-point continuum of
medical controllability and, in the case of cancer and
rheumatoid arthritis, a contrast between life threat
and ongoing disability as qualitative differences in
stress. Self-report data were used to verify that re-
spondents’ perceptions of their illnesses conformed to
these medically-derived characterizations of the ill-
nesses. F-tests of mean differences in these measures
used Duncan multiple range tests (P < 0.05) to eval-
uate specific disease-to-disease differences on these
variables.
Consistent with expectations, cancer patients per-
ceived the ‘seriousness of their illness’, a concept
closely akin to perceived life threat [28] and measured
here with a single question, significantly greater than
did other respondents (F = 7.56, P c 0.001). Patients
with rheumatoid arthritis, in response to a list of eight
activities of daily living derived from scales by Rosow
and Breslau [29] and by Caplan et al. [30], reported
more limitations in daily functioning than hyper-
891
tensives and diabetics; contrary to expectation, how-
ever, they did not report being more limited than
cancer patients (F = 16.93, P < 0.001). F-tests of
illness group scores on a ten-item version of the
Health Locus of Control Scale [31] revealed a three-
point continuum of controllability, with cancer and
rheumatoid arthritis patients perceiving themselves as
having comparably low levels of control over their
illnesses. Diabetics and hypertensives reported more
control than patients with cancer and rheumatoid
arthritis, as expected, although it was diabetics who
perceived themselves as having the greatest amount
of control, possibly because of the special meaning of
the term ‘control’ in diabetes treatment.
These data provide good support for the assump-
tions that these forms of cancer and rheumatoid
arthritis are equally uncontrollable but different from
each other in the degree to which they are perceived
as serious, or life threatening. Diabetics and hyper-
tensives did not order themselves on controllability in
relation to each other as medical data would have
predicted, but their responses confirm that they per-
ceive their illnesses as more controllable than cancer
and rheumatoid arthritis. While subjective reports of
health status are not necessarily more accurate than
‘objective’ reports [32], subjective data may reflect the
medical conditions of these particular respondents. In
this study, medical diagnosis was treated as a nominal
variable so that inferences about the effects of con-
trollability and of qualitative differences in stress
could be drawn on the basis of both objective and
subjective characterizations of the illnesses.
Coping. The coping measures consisted of six scales
describing qualitatively distinct coping strategies de-
rived through factor analysis of 55 self-report items.
Most of the items (45) were drawn from the ‘Ways of
Coping’ scale [5]; ten additional items were adapted
from the work of Pearlin and Schooler [6] or devel-
oped through pilot testing. Respondents were asked
to indicate on a five-point scale how often they used
each particular coping behavior, if ever, in response
to their illness; instructions read to respondents said,
“I’m going to read you a list of things that people do
in reaction to being ill. I would like you to tell me if
you have ever done any of these things in reaction to
your illness and if you have, do you do it seldom,
sometimes, often, or most of the time?’
The factor solution from which the six strategies
were derived, an orthogonal (varimax) rotation of a
six-factor principal axis solution, was that which
produced maximally independent factors with sets of
conceptually meaningful items of sufficient length
and internal consistency to permit their use as
scales[33]. Table 1 presents the individual items and
their factor loadings. Scales were computed for each
factor by unit weighting and summing items with
factor loadings greater than or equal to 0.30. While
the relatively small cases-to-variables ratio (about
3-to-l) poses the threat of unreliability, all of the
factors describe strategies similar or identical to
strategies described in research on other life stresses
[34,35].
Cognitive Restructuring (13 items, alpha = 0.80)
describes individual efforts at finding positive aspects
of the illness experience and at regarding the illness
as an opportunity for inner growth. Through com-
892 BARBARA J. FELTON et al.

parisons with past stressful times and redefinition of
the illness, this strategy reflects a cognitive reap-
praisal for the illness which makes it appear less
threatening and distressing. Emotional Expression (8
items, alpha = 0.72) describes a coping response con-
sisting of expressions of emotional strain, such
as getting angry at other people or joking about
the illness. Wish -Fulfilling Fantasy (7 items,
alpha = 0.79) describes an indulgence in pining and
longing for the illness to go away or be over with.
This strategy presumably allows people to alleviate
the emotional distress of being ill by providing an
escape in fantasy. Self-Blame (7 items, alpha = 0.75)
is a strategy in which blaming oneself for the illness
coincides with other efforts to cloud the issue and
refocus attention in order to avoid accepting the
illness as a chronic problem (e.g. ‘Got mad at people
or things that caused the problem’). Information
Seeking (5 items, alpha = 0.67) describes the individ-
ual’s search for information and advice about the
illness and its treatment. More so than the other
factors, Information Seeking is characterized by an
active, instrumental orientation to illness. Threat
Minimzation (11 items, alpha = 0.65) invokes a re-
fusal to dwell on thoughts about the illness and a
conscious decision to put distressing thoughts aside.
The illness is implicitly acknowledged, but main-
tained at a comfortable psychological distance by a
refusal to discuss it with others. e.g. ‘Went on as if
nothing happened’, ‘Didn’t let it get to you’.
Comparison of mean levels of endorsement of each
coping strategy across the sample shows that Threat
Minimization was used most often and Self-Blame
most infrequently used (see Table 2). Informa-
tion Seeking, the one instrumental or problem-
focused strategy, was used with only moderate fre-
quency. Intercorrelations among coping scales were
modest, averaging 0.26.
Psychological adjustment. Four outcome measures
were used. Acceptance of Illness (8 items.
alpha = 0.83) assessed respondents’ success in feeling
acceptant of, and valuable despite, the disability,
dependency, and feelings of uselessness which illness
occasions. Items were drawn from Linkowski’s [36]
Sickness Impact scales and rated on a five-point
‘agree-disagree’ continuum. Exemplary items include

Table I. Factor analysis of coping items

Factor
I II III IV V VI

I. Cognitive Resrructuring (Cronbach’s alpha = 0.80)

Concentrated on something good that could come out
of the whole thing 0.78 -0.02 0.09 0.09 0.01 0.06
Rediscovered what is important in life 0.59 0.15 0.10 0.03 0.10 0.05
Felt like you changed or grew as a person in a good
way 0.58 0.35 0.01 0.17 0.02 -0.01
Found new faith or some truth about life 0.53 0.3 I 0.11 0.10 0.09 0.03
Remembered times when your life was more difficult 0.42 -0.02 0.05 0.06 0.02 0.01
Turned to work or other things to take your mind off
the problem 0.39 0.06 0.18 0.05 0.24 0.10
Religion became more important 0.36 0.38 0.08 0.12 0.06 -0.00
Thought about people who were worse off than you 0.35 0.17 0.19 -0.06 0.16 0.16
Reminded yourself that things could be worse 0.34 0.15 0.26 -0.15 0.18 -0.16
Looked for the silver lining, so to speak; tried to
look on the bright side of things 0.34 -0.06 - 0.17 -0.21 0.01 0.1 I
Did something totally new that you never would have
done if this hadn’t happened 0.32 0.17 0.07 0.00 021 0.05
Changed the way you did things so that the illness
was less of a problem 0.3 I 0.00 0.19 0.23 0.10 -0.10
Got away from it for a while; tried to rest or take
a vacation 0.30 0.12 0.14 -0.07 0.23 0.18

II. Emotional Expression (Cronbach’s alpha = 0.72)

Took it out on other people 0.12 0.62 0.01 0.23 0.06 0.01
Got help with day-to-day chores or travel 0.14 0.48 0.13 -0.08 0.09 -0.05
Joked about it 0.21 0.44 0.03 0.05 0.15 0.02
Let your feelitigs out somehow 0.13 0.40 0.15 0.23 0.28 -0.21
Avoided being with people in general 0.10 0.40 0.07 0.08 0.06 0.14
Recalled past successes 0.17 0.38 0.3 I 0.13 0.09 0.09
Daydreamed or imaged a better time or place than
the one you were in 0.08 0.37 0.24 0.29 0.12 0.07
Slept more than usual 0.06 0.34 0.14 0.03 0.1 I -0.05

III. Wish-Furfihg Fantasy (Cronbach’s alpha = 0.79)

Wished that you could change what had happened 0.07 -0.01 0.67 0.13 0.05 0.02
Wished that you could change the way you felt 0.08 0.25 0.67 0.03 -0.02 -0.05
Felt bad that you couldn’t avold the problem 0.11 0.17 0.61 0.14 -0.09 -0.01
Wished that the situation would go away or somehow
be over with 0.25 0.02 0.58 -0.06 0.21 -0.00
Hoped a miracle would happen 0.12 0.14 0.49 0.07 0.14 -0.20
Wished you were a stronger person 0.16 0.3 I 0.40 0.08 -0.14 -0.01
Had fantasies or wishes about how things might turn
O”t 0.06 0.33 0.35 0.29 0.21 -0.02

IV. Self-f?/ome (Cronbach’s alpha = 0.75)

Blamed yourself 0.20 0.15 0.17 0.56 0.07 0.07
 Coping and adjustment in chronically ill adults 893

Table I (conhued)
Factor
I II III IV V VI
__.__
Thought about fantastic or unreal things that made
you feel better 0.20 0.25 0.2 I 0.47 0.22 0.15
Saw the doctor and did what he recommended 0.06 0.16 0.00 -0.47 0.09 0.05
Got mad at the people or things that caused the
problem 0.02 0.32 0.03 0.44 0.10 0.09
Criticized OT took it out on yourself 0.19 0.40 0.22 0.42 -0.01 0.01
Realized you brought the problem on yourself 0.30 0.10 -0.01 0.40 0.12 -0.06
Refused to b&eve it had happened 0.14 0.25 0.20 0.39 -0.02 0.21
V. h~formarion-seeking (Cronbach’s alpha = 0.67)
Looked up medical information 0.08 0.11 0.09 0.05 0.80 -0.04
Read books or magazine articles (or watched TV)
about (your illness) 0.1 I 0.24 0.21 0.10 0.61 0.04
Came up with a couple of different solutions to the
problem 0.24 0.29 -0.05 0.13 0.42 0.10
Asked someone other than a doctor you respected
for advice and followed it 0.26 0.20 -0.01 0.14 0.38 -0.23
Made a plan of action and followed it 0.33 -0.05 -0.25 0.07 0.32 0.03
VI. Threar Minimizarion (Cronbach’s alpha = 0.65)
Kept your feelings to yourself 0.06 -0.04 0.21 -0.00 -0.10 0.58
Went on as if nothing had happened -0.06 -0.04 -0.20 0.08 -0.00 0.50
Talked to someone about how you were feeling 0.27 0.39 0.04 0.00 0.06 -0.46
Didn’t let it get to you: refused to think too
much about it 0.06 0.10 -0.09 -0.07 0.17 0.44
Kept others from knowing how bad things were 0.24 0.04 0.18 0.04 -0.08 0.37
Tried to forget the whole thing 0.19 0.01 -0.02 0.07 0.01 0.36
Talked to someone other than a doctor who could do
something about the problem for you 0.23 0.28 -0.04 0.23 0.25 -0.32
Tried to work it out by yourself 0.12 -0.06 -0.16 0.03 0.02 0.31
Accepted sympathy and understanding from someone 0.13 0.39 0.14 -0.05 -0.14 -0.31
Made light of the situation; refused to get too
serious about it 0.15 0.23 -0.10 0.12 0.02 0.31
Went along with fate; sometimes you just have bad
luck -0.18 0.25 0.15 -0.03 -0.03 0.30
items Loading Eeh 0.30, Nor Included in Scales
Concentrated on following the doctor’s orders 0.10 -0.20 0.10 -0.27 -0.07 0.08
Tried to make yourself feel better by eatmg.
drinking. smokmg, etc 0.19 0.25 0.04 0.18 0.09 0.03
Faced the situation head on 0.01 -0.05 -0.11 -0.25 -0.03 -0.02
Accepted it, since nothing could be done -0.08 0.05 0.05 -0.07 -O.lY 0.21
These factor analysis results were computed with the FACTOR program from the Statistical Package for the Social Sciences (SPSS: Nie,
Hull, Jenkins, Steinbrenner and Bent, 1975) using orthogonal (varimax) rotation. Two items were dropped prior to factor analysis
because of low vanance. and the remaining 55 items were submitted to factor analysis.
Coping scales were computed by summing the respondent’s scores on all of the items listed under each factor name. Scores on items with
negative loadings were reversed before scale construction.

Table 2. Mean levels of coping strategy use for diagnostic groups

Total
sample Hypertension Diahetes Cancer arthritis
(N = 170) fN = 39) (N =44) (N = 42) (N = 45)

Cognitive Mean 2.85 2.78 2.84 2.66 3.13

Restructuring SD 0.73 0.64 0.83 0.69 0.68
F(3, 166) = 3.30, P < 0.05

Emotional Mean 2.17 2.03 1.97 2.20 2.47

Expression SD 0.71 0.74 0.74 0.74 0.53
F(3, 166) = 4.79, P < 0.01

Wish-Fulfilling Mean 2.87 2.49 2.65 2.81 3.48

Fantasy SD 0.99 0.99 0.94 0.80 0.93
F(3, 166) = 9.92, P < 0.001

Self-Blame Mean I.61 I .66 1.58 1.54 1.67

SD 0.66 0.77 0.57 0.71 0.61
(F(3, 166) c 1.00
Infonnatmn Mean 2.52 2.53 2.63 2.25 2.67
Seeking SD 0.91 0.74 1.03 0.86 0.93
F‘(3, 166) = 1.88, NS
Threat Mean 3.38 3.56 3.32 3.38 3.30
Minimization SD 0.66 0.58 0.77 0.64 0.63
P(3, 166) = 1.33, NS
Summated scores were dwided by the number of items in each scale in order to permit comparisons across scales;
thus coping scale scores presented above range from I (low use) to 5 (high use).
 894 BARBARA J. FELTON et al.

Table 3. The relationship between diagnosis and strategy use [9] analyses (whose results are not
coping controlling for the effects of demographic shown) indicated that this variable was unrelated to
factors
coping in this sample.
Diagnosis F* P
Cognitive Restructuring 0.50 NS The relationship between coping and ps~&ologicui
Emotional Expression 1.85 NS adjustment
Wish-Fulfilling Fantasy 4.90 <O.Ol
Self-Blame 0.47 NS Multiple regression analysis was used to provide
Information Seeking 0.29 NS information on the direction and strength of re-
Threat Minimization 0.76 NS lationships between coping and adjustment with the
effects of demographic factors and diagnosis re-
The set of demographic covariates includes sex, age, moved. In order to test the unique contribution of
socioeconomic status, marital status and em-
ployment status. The proportions of variance in
each type of coping strategy, a set of six separate
coping strategies explained by the set of de- hierarchical regression equations was computed for
mographic variables ranged from 3 to 9’?/,. each of the coping strategies with each of the adjust-
*F-ratios were computed using a hierarchical analy- ment measures. The hierarchical entry of the vari-
sis of covariance with the set of demographic
ables in each equation reflected the most likely causal
variables entered on the first step.
ordering among the sets of predictors: the set of
demographic factors was controlled for first, followed
by a set of three dummy variables representing the
‘I have a hard time adjusting to the limitations of my four diagnostic groups in the sample; then the partic-
illness’, and ‘Because of my health, I miss the things ular coping strategy under consideration was entered
I like to do most’. to assess main effects, and finally, the term carrying
Rosenberg’s [37] ten-item Self-Esteem scale was the statistical interaction between diagnosis and the
used to evaluate the individual’s overall sense of particular coping strategy. The interaction term in
being capable, worthwhile and competent. Items were each case consisted of the arithmetic product of the
answered using a five-point agree-disagree format. effects-coded dummy variable and a coping scale. The
This scale, used extensively and found to have high significance of this term demonstrates ‘non-linearity‘
construct validity across diverse samples [38], pro- in the relationship between stress and adjustment
duced a coefficient alpha of 0.81 in this sample. when coping is taken into account [14].
Both positive and negative affective components of Results of these analyses are presented in Table 4.
well-being were measured, since the factors which Overall, the full regression equations explained small
contribute to positive affect have been shown to be to moderate proportions of the variance in adjust-
different from those which create feelings of dissatis- ment: 9-21% in positive affect, 11-219, in negative
faction [39]. The five-item Positive and Negative affect, 17-25% in self-esteem and 26-347; in accept-
Affect subscales of the Bradburn Affect Balance scale ance of illness. Information about the power of
[40] were used to assess positive and negative mood coping to explain individual differences in adjustment
states over the past few months; the scales obtained is contained in column 3, which shows the increase in
alpha coefficients of 0.72 and 0.64 respectively. the proportion of variance in adjustment due to
Demographic data. Variables considered particu- coping after the effects of demographic factors and
larly important in this study and thus measured diagnosis have been removed.
through self-reports and used in analyses, were those Each of the adjustment measures was significantly
previously shown to be related to stress, coping explained by two or three coping strategies which,
and/or psycho-social well-being: sex, current marital depending on the particular equation under consid-
status, age, current employment status (employed vs eration, uniquely accounted for up to 11”; of the
non-employed), and social class [27,41,6]. variance in adjustment. Positive affect, unrelated
to medical diagnosis, was significantly related to
RESULTS two coping strategies: cognitive restructuring
(AR2 = 0.11, P < 0.01) and information seeking
Illness-to -illness dtferences in coping (AR2 = 0.10, P < 0.01). These two coping strategies
One-way analyses of variance assessing the effect of were, with only one exception, unrelated to the other
diagnosis on the frequency with which each coping outcome variables.
strategy was used were performed to determine Negative affect, related to demographic factors but
whether illness controllability or other characteristics independent of diagnosis, was significantly related to
of illness were related to coping strategy use. Results the use of three coping strategies: emotional expres-
(Table 2) show the strategies of cognitive restruc- sion (AR2 = 0.88, P < O.Ol), wish-fulfilling fantasy
turing, emotional expression and wish-fulfilling fan- (AR2 = 0.11, P < 0.01) and, to a somewhat lesser
tasy to be more frequently used by rheumatoid extent, self blame (AR’ = 0.03, P < 0.05). The direc-
arthritis patients than other patients (Duncan range tion of this relationship shows greater use of these
tests, P < 0.05). Two of these effects, however, disap- strategies linked to reports of greater negative affect.
peared when statistical controls for demographic Results using self-esteem as the dependent variable
factors were introduced into the analyses. After de- were quite similar: even with the significant effects
mographic differences between the illness groups of diagnosis removed, emotional expression
were partialled (Table 3), wish-fulfilling fantasy alone (AR2 = 0.07, P < 0.01), wish-fulfilling fantasy
persisted as a significant correlate of diagnosis. (AR2 = 0.03, P < 0.05), and self-blame (AR2 = 0.06,
Though the length of the respondents’ illness has P < 0.01) were significantly linked to lowered self-
been proposed by some to be a determinant of coping esteem. In addition, cognitive restructuring explained
 Table 4. Hierarchical multiple regression of demographic factors, diagnosis, coping and diagnosis-by-coping interactions 011 psychological adjustment
Demographic Diagnosis x Coping Total Percent of
factors Diagnosis Coping Interactions Variance Explained
Adjustment
Measure AR’ Ft AR2 Ff AR= 4 Beta B AR= _!I1 ~~~ AR’ Fl
Positive affect Cognitive Restructuring 0.05 I .92 0.03 2.20 0.1 I 21.85” 0.34 0.14 0.01 0.20 3.17”
Emotional Expression I .76 2.01 0.00 0.06 0.05 0.04 2.44 0.13 I.81
Wish-Fulfilling Fantasy I .68 1.92 0.00 -0.07 -0.02 0.00 0.09 1.20
Self-Blame 1.70 I .93 0.00 0.04 0.03 0.01 0.09 1.30 0
Information Seeking 1.95 2.23 0.10 20.33” 0.33 0.1 I 0.04 2.7l’tt 0.21 3.89” +.
Threat Minimization I .70 1.94 0.00 -0.04 -0.01 0.01 0. IO 1.34
tz
Negative alTect Cognitive Restructuring 0.09 3.24’* 0.01 0.00 0.00 0.01 0.11 1.9lf :
Emotional Expression 3.43” 0.08 15.79” 0.31
-0.00 0.12 0.01 0.19 3.75” n
Wish-Fulfilling Fantasy 3.64.’ 0.11 22.31** 0.37 0.11 0.00 0.21 3.34’. h
_.
Self-Blame 3.43” 0.03 5.72* 0.17 0.06 0.03 I.91 0.16 2.40**
2.20 E
Information Seeking 3.371. 0.02 3.76 0.16 0.06 0.03 I .88 0.15
Threat Minimization 3.28” 0.02 3.66 -0.14 -0.07 0.01 0.13 I .79 $
SelCesteem Cognitive Restructuring 0.12 4.83” 0.04 2.45 0.02 3.96* 0.13 0.08 0.02 1.32 0.19 2.97
Emotional Expression 5.18’ 2.83’ 0.07 14.85” -0.29 -0.23 0.01 - 0.25 4.08,. 5’
Wish-Fulfilling Fantasy 4.91 l * 2.88* 0.03 6.03’ -0.18 -0.08 0.02 1.34 0.20 3.21” B
Self-Blame 5.03” 2.95’ 0.06 12.35” -0.24 -0.18 0.01 0.23 3.71**
3.17” 2
I.
Information Seeking 4.89’. 2.87. 0.00 - -0.04 -0.05 0.04 8.02tt 0.20
Threat Minimization 4.69’. 2.75’ 0.00 0.03 0.01 0.01 I .92 0.17 2.51** P
=
v:
Acceptance of Cognitive Restructuring 0.12 6.16** 0.1 I 7.96’. 0.00 0.06 0.03 0.03 2.17 0.26 4.44**
5.55” 6
illness Emotional Expression 5.52** 8.49** 0.07 16.21” -0.29 -0.29 0.01 0.3 I
0
Wish-Fulfilling Fantasy 5.77” 8.87” 0.1 I 26.62” -0.36 -0.27 0.00 0.34 6.37..
4.83** 2
Self-Blame 4.77” 8.12” 0.05 10.35” -0.22 -0.22 0.00 0.28
E
Information Seeking 5.20” 7.99” 0.00 -0.07 -0.09 0.03 2.18 0.27 4.50**
Threat Minimization 5.19’1 1.99” 0.03 6.53’ 0.17 0.16 0.01 0.27 4.87**
lf cnns. **P <nOI df.=t5. 16n: t1. 160: 61.l60: 113.160:712.160.
tjThbiit;re of this interaction-.&/ i~&h;hat’if x 2 inform&n Seeking, the prediction of Positive alText(Y) is as follows: Y = 0.20X + 0.98 for respondents with rheumatoid arthritis: Y = O.Ol.\’ + I .47
for those with cancer: Y =0.10X + I.31 for those with diabetes; and Y = 0.1 IX + 1.37 for those with hypertension.
$$The nature of this interaction eflect is such that if X = Information Seekmg, the prediction of Self-Esteem is as follows: Y =0.01X + 3.15 for respondents with rheumatoid arthritis: Y = -0.14X + 3.70
for those with ‘cancer; Y = 0.1 IX + 3.09 for those with diabetes; and Y = -0.20X + 3.94 for those with hypertension.
896 BARBARA J. FELTON er al.
a small but significant proportion of unique variance
in self-esteem (AR* = 0.02, P < 0.05), with this form
of coping related to greater self-esteem. With accept-
ance of illness as the dependent variable, emotional
expression, wish-fulfilling fantasy and self-blame
again proved significantly related to poorer adjust-
ment (AR* = 0.07, 0.11 and 0.05, respectively;
P < O.Ol), with the effects of demographic factors
and diagnosis removed. The coping strategy of threat
minimization also explained a unique significant pro-
portion of the variance in acceptance of illness
(AR* = 0.03, P < 0.05), with coping being related to
better adjustment. Examination of the dummy vari-
able sets show that relationships between diagnosis
and the dependent variables of illness acceptance and
self-esteem were due to the higher levels of adjust-
ment among hypertensives and diabetics as compared
to cancer patients and rheumatoid arthritics (Duncan
range, P < 0.05).
Evidence that the relationship between coping and
adjustment conforms to that predicted by a stress-
buffering perspective was minimal. As shown in
column 4 of Table 4, in only two of the 24 analyses
(8%) did the diagnosis x coping interaction term
attain a 0.05 level of statistical significance. Although
both cases showed information seeking to be posi-
tively related to adjustment for diabetics, the overall
paucity and inconsistency of interaction effects leaves
the stress-buffering hypothesis largely unsupported.
DISCUSSION
The issue of central importance in this study was
that of the utility of a stress and coping paradigm [4]
for explaining individual differences in psychological
adjustment to chronic illness. Our results suggest that
a modest part of the variation in adjustment can be
explained by considering the nature of individual
coping responses. All of the qualitatively different
coping strategies examined in this study made a
significant contribution to the explanation of vari-
ance in at least one of the adjustment measures even
after the effects of demographic factors and type of
illness had been removed. While the proportions of
the variance in adjustment explained by coping are
not always large, the results suggest that further
efforts to clarify the role of coping in the explanation
of psychological adjustment is warranted.
Despite wide variation in medical treatment de-
mands, levels of disability and immediacy of life
threat posed by the illnesses in this study, the types
of coping strategies used by respondents with
different illnesses were largely the same. Differences
among illnesses may have been partially obscured in
this study by the use of a coping measure which asked
about reactions to the illness in general rather than
to specific kinds of stress. Nonetheless, in contrast
with some psychosomatic research which, in studies
of single illnesses, has identified ‘syndromes’ of be-
havior or personality traits characteristic of specific
types of illness [43], the findings of this study suggest
that particular diseases are not exclusively linked with
particular styles of coping.
The illnesses studied here did vary in their impact
on two aspects of psychological adjustment. The
distinction between having cancer and rheumatoid
arthritis, on the one hand. and diabetes melhtus and
hypertension, on the other, made the difference be-
tween being low in self-esteem and nonacceptant of
illness rather than high in self-esteem and acceptant
of the illness. Thus, illness controlability. as rated by
subjects or by medical opinion. did not completely
explain coping or adjustment; level of disability mat
also be important in explaining these aspects ot
adjustment. Cancer and rheumatoid arthritis patients
reported larger numbers of daily tasks which they
could not perform better than the other patients.
Further, in response to an open-ended question
about the stresses of illness, patients with the cancer
and rheumatoid arthritis named more illness-related
problems overall, the vast majority of which were
descriptions of disabilities, as compared to re-
spondents with hypertension and diabetes. These
findings and those showing disability to be a central
element in people’s perceptions of their overall health
[32] help clarify the persistent relationship between
physical health and emotional well-being in middle
age and late life [44].
Neither level of disability nor any other distinction
among illnesses, however, played a role in deter-
mining which coping strategies were effective in pro-
moting adjustment and alleviating distress, as the
small number of interaction effects which proved
significant could well have occurred by chance. The
consequences of coping seem to be relatively consis-
tent for the different types of illness examined, not
varied as they would be if the ‘stress-buffering hy-
pothesis’ described the primary modus operandi for
the health-protective effects of coping. The failure of
interaction terms to explain psychological adjustment
may mean that theories of adaptation have to modify
their conception of the way in which coping buffers
adults from the harmful effects of stress.
The nature of the significant relationships found
between outcome measures of adjustment and the
coping strategies of wish-fulfilling fantasy, emotional
expression and self-blame suggests that the con-
sequences of individual coping effects are not alto-
gether positive. Using such strategies did not prevent
loss of self-esteem, promote acceptance of illness, nor
protect the individual from feeling sad or depressed;
on the contrary, emotion-based coping was related to
poorer adjustment. The cross-sectional nature of
these data makes it unclear whether use of these
strategies prompted negative feeling states or whether
these strategies were in fact behavioral reactions to
stress. Despite the fact that causal direction cannot.be
clearly established, however, the findings are note-
worthy in that they are clearly discrepant with a
major current conception of coping: that strategies
involving avoidance and perceptual distortions of
reality may well be adaptive, particularly when the
stressful situation is an unalterable one [4. 6,451.
The emergence of two distinct patterns of re-
lationships between coping behavior and adjustment
shows that their interrelationship is not a constant
one. The patterns showed that greater positive
affective states, while unrelated to stress, were associ-
ated with primarily cognitive strategies, i.e. incorpo-
rating relevant information or changing the nature of
one’s cognitions in order to construe the illness as an
occasion for personal growth. A pattern of height-
 Coping and adjustment in chronically ill adults
ened negative affect coupled with lowered self-esteem
and poorer adjustment, on the other hand, was also
linked to stress and, independently, to the use of
emotionally expressive, avoidant and blaming coping
strategies. That there is divergence between the types
of psychological adjustment states coinciding with
particular coping strategies is consistent with other
research demonstrating that positive and negative
affect are linked to different personality styles [39].
The specialized consequences of different coping stra-
tegies may provide an alternative basis for
classifications of coping: in addition to distinguishing
between coping strategies according to the locus of
their efforts (e.g. problem-focused vs emotion-
focused), it may be useful in future investigations to
distinguish among coping strategies according to the
locus of their effects.
It is important to note the possibility that a stress
and coping paradigm is a more viable conception of
coping than suggested by these data: evidence of its
operation might appear only when variations in stress
are more extreme than those studied here. The nature
of chronic illness, and the kind of underlying uncon-
trollability characteristic of a health condition which,
by definition, will not go away, may be sufficiently
great to overwhelm differences in coping effectiveness
across the range of stresses represented by the illness
studied. Future tests of the stress-buffering theory of
coping ought to consider differences in the effects of
coping across diverse arrays of health conditions and
treatments, as the nature and critical range of stress
in illness conditions may not yet have been fully
explored.
Taking the current findings at face value, however,
prompts the conclusion that the effects of individual
coping efforts on emotional distress are rather
modest. This conclusion is consistent with research
showing that the emotional consequences of uncon-
trollable stresses other than illness are largely
unaffected by individual coping efforts [6]. The con-
sistency of the relationship between physical and
emotional well-being [ 1,2] reinforces the view that
individuals, acting with their own solitary capacities,
can do relatively little to alter the emotional distress
which illness so often occasions.
As evidence accumulates to demonstrate that long
term physical health can be a consequence of emo-
tional state [46,47], the ineffectiveness of individual
coping efforts becomes even more significant: further
deterioration of physical health may be the outcome
of a vicious cycle of illness-based stress, ineffective
coping, and poor emotional adjustment [48]. While
we lack definitive information about the value of
alternative coping agents, research and theory on
social supports [16,49] points to relationships with
significant others-including the physician [30l_as
important areas of influence. Subsequent research
should examine the variations in illness stresses and
social supports and their interaction with individual
coping efforts to determine how we can best prevent
physical illness from inevitably compromising mental
health.
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