For a person with diabetes, problem-oriented coping strategies may be used in For patients with diabetes, teaching problem-solving techniques can be helpful …
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
ones 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 McCubbins Adolescent Coping Orientation for
Problem Experiences Scale3 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 diabetes6,7 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 ones 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 individuals 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: Childrens 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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Copyright 2000 American Diabetes Association
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