Diabetes Spectrum
Volume 13 Number 3, 2000, Page 167
Lifestyle and Behavior

Coping and Diabetes


Margaret Grey, DrPH, FAAN, CDE


"I simply cannot cope with this!" How often have you uttered just these words when you felt completely overwhelmed by all that you had to accomplish at work or at home? How often have you heard one of your clients with diabetes say, "I cannot manage diabetes in addition to everything else I do! I simply cannot cope!" Have you ever wondered exactly what that patient meant and how you might help your clients cope?

There are many definitions of coping (almost as many as there are studies), but probably the most commonly used is that of Pearlin and Schooler,1 who define coping as behavior that protects people from being psychologically harmed by problematic social experiences. Coping serves a protective function that can be exercised in three ways: 1) by eliminating or modifying stressful conditions; 2) by perceptually controlling the meaning of the stressor; or 3) by keeping emotional consequences in bounds.

The other commonly used definition is that of Lazarus and Folkman,2 who define it as "constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person." In other words, coping allows people to use various skills to manage the difficulties they face in life. The Lazarus and Folkman framework is process-oriented, not trait-oriented, and emphasizes that the approaches people use to cope change with time, experience, and the nature of the stressor rather than people being "pre-programmed" to use the same coping behaviors regardless of the stressful experience. Further, this approach limits the problem of confounding coping with outcome and avoids equating coping with mastery. In other words, coping is the process that is used to help master a problem, but coping does not necessarily mean that one has mastered the problem.

Lazarus and Folkman2 believe that each individual represents a unique combination of individual and environmental factors and that stressors result from person-environment interactions, which cause the person to appraise the situation, appraise the coping resources that are available to him or her, and employ a repertoire of coping behaviors. Short-term effects of the response to the stressor include psychological and physiological changes. Long-term effects include psychosocial well-being, social functioning, and somatic health. The overall effectiveness of the stress-coping process places the individual in a position of being relatively resistant or vulnerable to further stress.

Coping With Diabetes
There are more than 200 articles in the literature on coping and diabetes. When the stressor is diabetes, people with diabetes are not able to eliminate the condition, so they need to find ways to make the condition manageable. Further, diabetes management is a full-time job; thus, coping with diabetes is also a full-time job.

Most researchers believe that coping is a complex process in which a stressor occurs with which the individual must "cope," and that coping leads to some outcome. In diabetes, the stressor is usually assumed to be the chronic demands of having diabetes with which one must cope, and that coping leads to certain metabolic and psychosocial outcomes. In a variety of studies, coping has been found to be associated with various metabolic or disease outcomes, as measured by glycosylated hemoglobin, functional status, symptom severity, body mass index, or body weight. Coping also may affect psychosocial outcomes, such as psychological adjustment, depression, and quality of life.

Lazarus and Folkman describe two major types of coping—problem-focused and emotion-focused. Problem-oriented coping is aimed at solving the problem that faces the person and is most likely to be used when the stressor is appraised by the individual as amenable to change. For a person with diabetes, problem-oriented coping strategies may be used in managing difficult eating situations. Emotion-focused coping is most useful when the individual appraises the experience as one for which nothing can be done to modify the event or stressor, or when the stressor is transitory and will resolve itself. There are many such coping strategies, most of which involve cognitive processes directed at lessening emotional distress. These strategies include avoidance, minimization, distancing, and finding positive value in negative events. For some patients with diabetes, adolescents in particular, avoidance of managing diabetes (not performing blood glucose testing or administering injections) provides a way of coping with the emotional distress of being different from one's peers. Obviously, not all of these approaches are positive coping strategies in terms of both psychological and medical outcomes.

In general, problem-focused coping strategies are associated with more successful medical outcomes than emotion-focused ones. Problem-oriented coping strategies have been associated with better self-care, metabolic control, and psychosocial well-being in both adults and children. On the other hand, several studies have demonstrated that in adults, palliative coping (the use of resignation or other more passive approaches to solving the situation) has a negative impact on diabetes-related outcomes, such as weight loss and metabolic control. Similarly, in children and adolescents, avoidance coping has also been associated with poorer metabolic control and psychological well-being. However, positive emotion-focused coping strategies, such as humor or "looking for the silver lining," can help relieve emotional distress without compromising medical outcomes. These strategies may also contribute to better medical outcomes by reducing the frustration and demoralization that can compromise self-care.

Assessing Coping Behaviors
There are several reliable and valid instruments that clinicians can use to assess coping among people with diabetes, such as the Ways of Coping Checklist2 or Patterson and McCubbin's Adolescent Coping Orientation for Problem Experiences Scale.3 In addition, there are instruments specific to measuring coping with diabetes, including Kovacs' Issues in Coping With Diabetes Scales for Children and Parents4 and the Problem Areas in Diabetes Scale5 for adults. In addition to these measures, many clinicians find it relatively easy to assess patients' coping behaviors by asking patients to describe how they usually respond to difficult situations and then asking how they deal with any problems they are having in managing their diabetes. In this way, patients who are coping in less constructive ways can be helped to develop more positive ways of coping.

Teaching Positive Coping Behaviors
Several studies have suggested that patients with diabetes, both adults and youths, can benefit significantly by learning coping strategies that they can apply to dealing with diabetes.6,7 This approach is often called "coping skills training" or "problem-solving skills training" Coping skills training builds on traditional diabetes education by providing tools that help clients apply what they have learned on a day-to-day basis. Generally, four coping skills are taught and reinforced; these skills include social problem-solving, communication skills training including assertiveness training, cognitive behavior modification, and conflict resolution.

Social problem-solving. This skill is designed to help clients when faced with peer pressure or any decision involving a dilemma. Social problem-solving is a process by which an individual learns to think through the process of having a problem and reaching a decision. The process helps individuals to look at all possible outcomes of situations and the possible consequences of their decisions. Forman8 identifies six major problem-solving steps: 1) identify the problem, 2) determine goals, 3) generate alternative solutions, 4) examine consequences, 5) choose the solution, and 6) evaluate the outcome.

For patients with diabetes, teaching problem-solving techniques can be helpful in managing complex situations such as pressure to overeat. Such techniques can be used to identify what situations create difficulty for those struggling to control their weight and to generate approaches to solve the problem in a way that is helpful to that person.

Communication skills training. Social problem-solving is closely connected to communication skills training. Communication skills training aims to help clients express themselves in ways that are clear, appropriate, and constructive. Two main skills are identified under communication skills training: social skills training and assertiveness training.

Social skills training models strive to teach clients how to work with others in a way that will result in positive outcomes for all. The following steps are followed to teach social skills: 1) provide concrete instructions on how to handle a social situation, 2) allow participants to witness a role-play of an appropriate model, 3) practice their own role-play, 4) provide feedback on the role-play, 5) real-life practice, and 6) group follow-up. For example, if a patient is having difficulty figuring out how to do blood glucose testing in front of colleagues at work or school, social skills training can help the individual decide how much and what they need to explain to others about testing. Often, patients believe that they need to develop long-winded explanations about testing, when often, a simple, "I have diabetes and this tests my blood sugar level" will suffice.

Assertiveness training enables one to communicate in ways that are direct, honest, and appropriate. Working in a group setting allows members to observe the behavior of others as well as practice and obtain feedback on how effectively they communicate with the other members of the group. These models can also be used to help clients with eating situations, such as ordering food prepared in a healthy manner in a restaurant and assuring that one's needs are met.

Cognitive behavior modification. Cognitive behavior modification is composed of three steps. These steps are: 1) recognition of thoughts and feelings, 2) problem-solving, and 3) guided self-dialogue. The first step is working with the person to reflect on how he or she thinks and then responds to situations. The individual's thoughts are examined to consider if the thoughts are based on fact or assumption. Once the thoughts are examined, the next step is to problem-solve. The third step is teaching the person to use thoughts to help follow through on the decision made in the previous step.

The use of pen and paper is appropriate when teaching this skill. Group members can list their negative thoughts and then the member and the group can formulate alternate positive thoughts to counter the negative thoughts. An example of how this skill can be used is provided by our work with teenagers. Many teens are quite frightened by the possibility of severe hypoglycemia, but sometimes, this fear is out of proportion to the likelihood of its occurrence. When teens exaggerate in this way, they can be taught to change their thinking about the likelihood of a severe hypoglycemic event, thereby eliminating this barrier to striving for better metabolic control.

Conflict resolution. The basis of conflict resolution is the acquisition of skills necessary to resolve conflict in a positive manner that results in positive outcomes for all parties involved in the conflict. The first step in this training is development of the understanding that in any conflict, both parties can win and that each and every conflict should be approached in this manner. The client is helped to focus on clear communication and problem-solving skills. Once the conflict is identified, all possible outcomes and the consequences to these outcomes are explored. A role-play can then be set up to "try out" the communication of the decision. For example, spouses who are having difficulty negotiating various aspects of diabetes management can be taught to resolve these conflicts in this manner.

In summary, diabetes is a long-term stressor that has the potential for patients to have difficulty in coping with the day-to-day management of diabetes. Clinicians can evaluate their clients' coping abilities in both formal and informal ways, and this information can be used to assist the patients in developing better coping skills. Such improved coping skills may assist clients in achieving better metabolic control and quality of life.


References
1Pearlin LI, Schooler C: The structure of coping. J Health Soc Behav 19:2-21, 1978.

2Lazarus RS, Folkman S: Coping and adaptation. In The Handbook of Behavioral Medicine. Gentry WD, Ed. New York, Guilford, 1984, p. 282-325.

3Patterson JM, McCubbin HI: A-COPE Adolescent Coping Orientation for Problem Experiences. In Family Assessment Resiliency, Coping, and Adaptation. McCubbin HI, Thompson AI, McCubbin MA, Eds. Madison, Wisc., University of Wisconsin, 1995, p. 537-83.

4Kovacs M, Brent D, Feinberg TF, Paulauskas S, Reid J: Children's self-reports of psychologic adjustment and coping strategies during the first year of insulin-dependent diabetes mellitus. Diabetes Care 9:472-79, 1986.

5Welch GW, Jacobson AM, Polonsky WH: The Problem Areas in Diabetes Scale. Diabetes Care 20:760-66, 1997.

6Grey M, Boland EA, Davidson M, Tamborlane WV: Coping skills training as adjunct for youth on intensive therapy. Appl Nurs Res 12:3-12, 1999.

7Rubin RR, Peyrot M, Saudek CD: The effect of a comprehensive diabetes education program incorporating coping skills training on emotional well-being and diabetes self-efficacy. Diabetes Educ 19:210-14, 1993.

8Forman SG: Coping Skills Interventions for Children and Adolescents. San Francisco, Jossey-Bass, 1993.


Acknowledgment
This work was supported in part by grant 1 RO1 NR04009 from the National Institute of Nursing Research.


Margaret Grey, DrPH, FAAN, CDE, is the Independence Foundation Professor of Nursing and Associate Dean for Research Affairs at Yale University School of Nursing in New Haven, Conn.


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