The Medical Context of Parental Coping With Childhood Cancer 1

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American Journal of Community Psychology, VoL 14, No. 2, 1986

T h e M e d ic a l C o n t e x t o f P a r e n t a l C o p i n g W i th

C h i l d h o o d C a n c e r 1

O s c a r A . B a r b a ri n 2 a n d M a r k C h e s l e r

University of Michigan

This research as ses sed the ex ten t to w h ich con tex tua l fac to r s , e spec ia l ly theme d ica l con tex t , a re r e la ted to the use o f spec i f i c cop ing s t ra teg ies by 74p a r e n t s o f s u r v i v i n g c h i ld r e n w i t h ca nc er. P a r e n t s r e p o r t e d t h a t t h e y c o p e dreasonab ly w e l l by us ing in format ion - seek ing , p rob lem-so lv ing , he lp -seek ing ,main ta in ing emot iona l ba lance , r e ly ing on r e l ig ion , be ing op t im is t i c , deny-

ing , a nd accep ting . M or e h igh ly educa ted pare n t s t en ded to use pro b le m so lv -

ing, optimism , an d inform ation seeking s ignificantly m or e an d denial s ignificant-

ly less than less wel l -educated parents . H ow eve r , g ende r an d incom e w ereunre la ted to cop ing . The use o f spec i f i c cop ing s tra teg ies was no t r e la ted to

s e v e r it y o f t h e c h i l d 's m e d i c a l c o n d i t io n , s t re s s le v e l o r p a r e n t s " o w n e v a lu a -

t i o n s o f t h e i r c o p i n g e f fe c t iv e n e s s . H o w e v e r , t h e q u a l it y o f re l a ti o n s w i t ht h e m e d i c a l s t a f f w a s s t r o n g l y r e l a t e d t o c o p i n g s t ra t eg i es . U s e o f p a s s i v e

c o p i n g s t ra t e g ie s w a s p o s i t i v e l y r e l a te d t o g o o d r e l a ti o n s w i t h t h e m e d i c a l

s t a f f .

Most s tudies of s t ress fu l l i fe events indicate that i l lness or loss of a loved

o n e r e p re s e n ts a m a j o r s t r es s o r ( D o h r e n w e n d & D o h r e n w e n d , 1 97 4; D o h r e n -

w e n d , K r a s n o f f , A s k e n a s y , & D o h r e n w e n d , 1 9 78 ; H o l m e s & R a h e , 1 96 7).

A l t h o u g h d i a g n o s i s a n d t r e a t m e n t o f a c h i l d w i t h a s e r i o u s a n d c h r o n i c i l l -

ness se ldom app ears in such s tudies , i t a l so represents a s igni f ican t l i fe d i s rup-

t i o n w h i c h t h r e a t e n s p e r s o n a l e q u i l i b r i u m a n d f a m i l y w e l l- b e in g . T h e i n it ia l

i m p a c t o f t h e d i a g n o s i s is il l u s tr a t e d i n th e f o l l o w i n g re p o r t s f r o m p a r e n t s .

~ P r e p a r a ti o n o f t h i s p a p e r w a s g r e a t l y f a c il i ta t e d b y t h e a w a r d o f a p o s t d o c t o r a l f e l lo w s h i p

b y t h e P s y c h o l o g y D e p a r t m e n t a t S t a n f o r d U n i v e r s i ty a n d b y a g r a n t f r o m t h e U n i v e r si t y o f

M i c h i g a n ' s C o m m i t t e e o n t h e I n t e rn a t i o n a l Y e a r o f t h e C h i ld . T h a n k s a r e d u e t o P r o f e s s o r sP h i l i p Z i m b a r d o a n d E w a r t T h o m a s .

2 A ll c o r r e s p o n d e n c e s h o u l d b e a d d r e s s e d t o O s c a r A . B a r b a r i n , D e p a r t m e n t o f P s y c h o l o g y ,

U n i v e r s it y o f M i c h i g a n , A n n A r b o r , M i c h i g a n 4 81 0 9.

221

0091-0562/86/0400-0221505.00/0 © 1986 Plenum Pub lishingCorporation



222 Barbarin and Chesler

It tore me up. I didn't know from one minute to the next whether he was going tobe with us. You know I worried a lot. I felt bad. I was hurt. He is my only boy.I didn't know if I was there myself.I felt like my heart had been torn right out o f me. I was terribly despondent at first.I was bitter and asked myself why it had happened.

Al though med ica l p rogress has inc reased the l i ke l ihood tha t a ch i ld

diagnosed wi th cancer wi ll surv ive and resume a norm al l i fe (Am erican Canc er

Socie ty , (1982) , many chi ldren s t i l l d ie f rom the d isease . Painfu l medica l

t rea tm ents (perhaps surgery) and the i r s ide effec ts , repe ated hospi ta l iza t ions ,

and the un ce r t a in ty o f rec overy o r re l apse , o f l ife o r dea th seve rely t e st s

pa ren t s ' emot iona l s tab i li t y (Fu t t e rm an & Ho ffm an , 1973) . Mo reove r , man y

paren t s ' l ack o f fami l i a r i t y w i th the d i sease and i ts t rea tmen t , conce rn abo u t

insu rance coverage and f inances , and the un remi t t i ng dem ands o f ca ring fo r

a ser iously i l l ch i ld a l l c rea te s t ress (Desmond, 1980) . The effor t requi red

to deve lop and nu r tu re re l a t ionsh ips wi th fami ly , f r i ends , and med ica l p ro -

fess ionals ma y fur th er tax parents ' psychologica l reserves (Binger e t a l. , 1969;

Cass i le th & Ham i l ton 1979) . A l th oug h some o f t hese s tre sses m ay d imin i sh

over t ime , t hey se ldom van i sh en t i re ly .

S T R E SS A N D C O P I N G S T R A T E G I E S

Severa l scholars suggest tha t var ia t io ns in fam i l ies ' experie nce of s t ress

is re la ted to d i f feren ces in the i r use of copin g s t ra tegies (B arba r in , 1983;

Brehm, 1965; Kubler-Ross , 1978; Lazarus , 1966; Sel igman, 1975; Taylor ,

1983) . Ou r unde rs t and ing o f pa ren t s ' s t ra teg ies fo r cop ing w i th the s tre sses

o f ch i ldhood cance r has been advanced subs t an t i a l ly by seve ra l p ionee r ing

s tu d ie s . F o r i n s ta n c e , F r ie d ma n , C h o d o f f , M a s o n , a n d H a m b u r g (19 77 )

docu me n ted the use o f accep tance , re s igna t ion , re lig ious fa i th , ho pe and op -

t imism, denial , and ant icipatory grief by famil ies of chi ldren with cancer.

Spinet ta , Swa rner , and S hep0 sh (1981) obse rved severa l o th er Copings t ra t eg ies among such fami l i e s : a cons i s t en t ph i losophy / theo logy , suppor t

from a s igni f icant o ther , communicat ion wi th the chi ld , communicat ion wi th

s ib l ings, and ma in tenance o f no rm al fa mi ly func t ion ing . Ku ps t e t a l. (1982)

ca t egor i zed the cop ing s t ra teg ies t hey obse rved s om ewh a t d i f fe ren t ly : open

com mu nica t ion , l iv ing in the present , a ff i rm ing l i fe , t rea t ing the child as nor-

ma l , and deve lop ing a ph i losoph ica l ou t look on the d i sease .

Al tho ugh these descr ip t ive typologies advance ou r unde rs tanding of how

fami li e s ac tua l ly dea l w i th se r ious an d ch ron ic ch i ldh ood i ll ness, t hey do no t

t ake adv an tage o f recen t concep tua l i za t ions o f t he cop ing p rocess . La za rusand Laun ie r (1978) p ro pos ed a typ o log y o f cop ing s t ra teg ies based o n the

d i s t inc t ion be tween ac t ive o r p rob lem focused (e .g . , d i rec t ac t ion a imed a t

e l iminat ing or m i t iga ting ant ic ipa ted s tresses) and pass ive or em ot ion- focu sed



T h e C o n t e x t o f C o p i n g 223

(e.g., cognitive or emotional maneuvers aimed at moderat ing the impact of

stress by reinterpreting or avoiding it). Although Billings and Moos (1981)

made finer discriminations between the method (active/direct vs. passive/in-

direct) and the target (problem vs. emotions) their ways of classifying discrete

coping strategies are consistent. In these terms, both the list developed byFriedman et al. (1977) and Kupst et al. (1982) emphasized relatively passive

strategies. Spinetta et al. (1981) included some strategies that are more ac-

tive in nature: For example, support, communication, and maintenance of

family functioning. Unfor tunately, there are few data available from these

and other sources to assess the factors that may predispose parents to use

various active or passive strategies. Most importantly, few studies have ex-

amined the relationship between the medical factors and coping process.

The Medical Context of Parental Coping

Early analyses of the relationship between parental coping strategies

and the medical context relied primarily on observations of parents of dying

children and took the form of prescriptive reports. More recent studies that

have explored medical context effects typically have examined only the child's

medical condition (Spinetta et al., 1982). Attention to the child's medi-

cal condition is understandable. Indeed, parents' coping responses can

be expected to vary with the child's diagnosis and medical status because thelatter are associated with differential stress, prospects for survival, and in-

trusiveness of treatment (Chesler, Barbarin, Chesler, Hughes, & Lebo, 1981).

For example, children with Wilms tumors now have a 2-year survival rate

of over 85%0, whereas children with brain tumors have a 2-year survival rate

of under 50% (American Cancer Society, 1982). Varied treatment procedures

such as surgery, radiation, or chemotherapy create quite different concerns

and require somewhat different adaptations by parents and children. Similar-

ly, uncontrollable events such as relapse usually creates additional severe stress

and uncertainty. Learned helplessness theory (Seligman, 1975) predicts thatthe more severe and uncontrollable the stressor the more likely individuals

are to adopt passive and emotion-focused coping strategies such as accep-

tance, optimism, and religious beliefs. This prediction is consistent with the

emphasis on passive strategies observed by Friedman et al. (1977) and Kupst

et al. (1980).

However, the child's medical situation is only part of a more complex

medical context which includes evolving relations with a medical care

organization. Although the link between coping and transactions with im-

portant others has been noted elsewhere (Brickman et al., 1982; Coyne &Holroyd, in press; McCubbin & Patterson, 1982, 1983; Wortman & Dunkel-

Schetter, 1979), few studies have explicitly examined the interaction between

parents' ways of coping and their relationship with medical staff. Much of




the prior research has been conducted by staff responsible for the medical

or psychological care of children with cancer. As such, the staff's impact

on stress and coping has been taken as a given and not examined

systematically.

In general, the role structure of bureaucratized medical care systemspress for compliant and relatively passive patient/parent roles (Antonovsky,

1980; DiMatteo, 1979; Friedson, 1970; Stone, 1979; Taylor, 1979). In this

context, passive strategies such as deference, optimism, and denial, and

reliance on religious faith may be regarded by the sta ff as most appropriate

or convenient behaviors for patients and their families. The use of active

coping strategies by patients and their guardians, such as information seek-

ing and participation in decision-making, may be construed as acting-out

responses or as intrusions on the medical staff's responsibilities. In addition,

medical staff may avoid constantly depressed or hopeless parents, just asthey appear to withdraw emotionally from their young patients and families

as death approaches (Binger et al., 1969; Vaux, 1977). Since the causal direc-

tion of the relation between parental coping and sta ff behaviors is unclear,

it is also possible that parents' coping choices may influence the ways in which

medical staff relate to parents.

An examination of the relations between parent-staf f transactions and

parents use of particular coping styles may offer valuable insights into why

parents respond they way they do in chronically stressful situations. In this

paper we examine how the various coping strategies covary with aspects ofthe medical context. The medical context is conceived in terms o f the child's

medical condition, parental stress from the illness, and the quality of parent's

relationships with the medical staff. Figure 1 presents the variables and the

relationships explored in this study.

This research is part of a larger study of stress and coping in families

of children with cancer. In the larger study, a total of 94 parents (55 families)

were sampled from a pool of 265 families of children with cancer treated

within the previous 5 years at a major university medical center. This sam-

ple population was selected randomly, after stratificat ion by the age and life

status of the child at the time of the study and by the type of cancer sus-

tained by the child. In all, 70 families were contacted and 15 declined to par-

ticipate.

Participants in this study include 74 parents from 45 families with

children living with cancer; 42 mothers and 32 fathers. With the exception

of one black family all participants were white. Twenty-three percent of the

parents o f children living with cancer reported an annual family income of

less than $15,000, 29°7o had an annual income between $15,000 and $25,000,

and 36O/o an annual income over $25,000; 11% of the informants did not

report their annual income. Ages of the wives ranged from 23 to 54 years



T h e C o n t e x t o f C o p i n g

Medical Context Coping

2 2 5

A. go

Child's Medical

Condition Stress

C.

Parent-

Staff

Relations

<.- ..~

A. Strategies

oactive

opassive

B . E f f e c t i v e n e s s

Social Status

Gender

Education

Income

Fig. 1. Rel~ionship between medicalcontext and parentalcoping.

with a median of 35; husbands' ages ranged from 28 to 57 with a median

of 38. The major forms of childhood cancer represented in this analysis in-

cluded leukemias (33%0), lymphomas (19%0), cancer o f the nervous system

(18%0), osteogenic sarcomas (12.5%0), Wilms' tumor (11%0), and miscellaneous

others (6.5%).

Measures

Extensive individual interviews using both open-ended and structured

formats, and lasting from 60 to 90 min, were conducted by trained graduate

and undergraduate psychology and sociology students. The interviews covered

parents' experience with and reactions to their child's illness: the history and

course of the illness, initial reactions, how individuals and the family coped

over time, the impact of the illness on the family, and the relationship be-

tween the family and the medical staff, extended family, friends, and school

personnel . Interviews were audiotaped, typed, and later coded by several in-

dependent raters. A structured questionnaire with 3- and 5-point Likert-typerating scales also was completed by the parents and mailed back several days

following the personal interview. Ninety percent of the parents who were




interviewed completed and returned the questionnaire. The high return rate

is due in part to the strong endorsement of the study by Share, a Candlelighter-

afffliated self-help group for families of children with cancer and by the parents'

view that information about their experiences might be helpful to newly

diagnosed families.Medical Context. The child's medical condition was assessed by parents'

interview reports of the number o f hospitalizations experienced after diagnosis

and initial treatment induction. Parents" medically related stress was assessed

by a composite index consisting of four items rated on a 3-point scale

indicating the degree of stress resulting from (a) the fact that my child has

cancer, (b) my child's reactions to drugs, (c) my fear of the child's death and,

(d) my fear of relapse. The correlations among these items range from .47

to .63. The estimate of internal consistency is high (Cronbach's alpha = .83).

Parents' assessment of the quality of relations with medical staff wasa composite measure developed by combining structured questionnaire ratings

of relationship qualities such as respect, tenseness, anger, liking, and sup-

port. This index includes (a) Respect for Medical Staff, a 5-point rating of

the effect of the illness on respect for medical staff (1 = much less, 5 =

much more); (b) Tension in Relations with Medical Staff, a 3-point rating

of stress resulting from tense relations with medical staff, (c) Support From

Medical Staf, a composite of two 5-point ratings indicating support received

from doctors and from nurses (Pearson r = .61, p < .001); (d) Anger Toward

the Medical System, a 5-point rating indicating the extent to which the ex-perience of childhood cancer resulted in more or less anger toward the medical

care systems; and (e) Liking the Medical Staff, a 5-point rating of change

in feelings about medical staff resulting from the illness experience. This in-

dex represents parents evaluation of the relationship quality along several

related but distinct lines. The combination of static ratings such as those of

tension and support with change measures of liking, anger, and respect is

justified by the strong correlations among these ratings (range -- - .35 to

+ .71). These correlations show that individuals who report increases in lik-

ing and respect and decreases in anger are also likely to make favorable static

ratings of support and tension. The static ratings and parents view of the

change resulting from the intensive interaction during the t reatment phase

provide slightly different slants on parents' evaluations of the relationship.

Moreover, the estimate of internal consistency supports the reduction of these

ratings into a single index (Cronbach's alpha = .76).

Coping. Guided by earlier work on stress and coping, a typology of

coping strategies was developed inductively from parents' actual feelings and

behaviors reported in the interviews. Specific measures of coping techniques

were generated from parents' responses to interview questions about how

they coped with the diagnosis, treatment, treatment side effects, and the en-

tire illness situation. A score for each of eight coping strategies was obtained



The Context of Coping 227

by tabulating each instance in which a parent indicated use of a particular

strategy. The range of scores on each strategy is 0-4 except for religious faith

(range = 0-10), which has several additiona l items specifically addressing

the role of religion in coping. The interr ater agre ement for the coding of

the strategies incl uded in the ty polo gy is .83. The eight copi ng strategies a ndtwo coping styles are as follows:

1. In fo rm at io n seeking involves parents seeking and using inf orm a-

tion to help them understand the meaning of the diagnosis, to place their

emot ional reactions to the illness in perspective, or to reduce uncert ainty and

fear regarding their child 's survival.

I tried to find out everything I could about it. I read everything I could about it.The things I read about medical technology and its advances have helped me throughthe hard times. I keep some of these articles close at hand whenever I feel down.

2. Prob lem solving refers to the use of behaviorall y oriented solutions

for specific problems, such as increased work hour s to raise mon ey to meet

medical expenses, re arra nging schedules to be with the child in the hospital,

or pl an ni ng with teachers for the child's retur n to school.

Its like solving a problem. I am going to solve that problem, and I will not allowcertain things to happen. I don't know how to describe the strength within a humanindividual except that I said I was stronger than whatever that problem is and I willprevail.

She was in great pain, and I didn't think they cared very much. I got their attentionand they finally did something for the pain.

3. Inf orm al help seeking refers to the self-initiated use of inf orm al

helping networks of family members and friends for inst rumenta l aid or emo-

t ional support .

Friends and family are very important. I don't know if we could have handled it aswell without the support of our friends and family. Other people are not quite asinvolved, and sometimes you need to talk with them. It was too much of a burdenfor me so I turned to my family, I turned to my friends, I turned to my co-workers.

4. Main tai nanc e of emot ional balance refers to active efforts de-

signed to moderate emotional reactions and to avoid extreme mood swings,

especially thr ough cognitive self-control and related be haviors. In some sense

it means trying to retain or recapture some degree of previous normality in

one's personal style and social relations.

I try to see that the hustle and bustle of life is not important. I'm trying to take eachday as it comes and to experience each day more. I've often practiced hypnotherapyand relaxation techniques, and I also use a little rationalization.

5. Reliance on religious beli efs/ fait h refers to the use of prayer and

religious interpretations for emotional comfort or to evolve an acceptable

explanation for the illness.



2 2 8 B a r b a r in a n d C h e s l e r

I th ink pray ing had done m ore than anything else. I practice m y belief mo re. I feelthat was the on ly place I co uld turn to get help when I really needed i t . M y religiousbeliefs have helped me.

6 . O p t i m i s m i n v o l v es t h e u se o f i d e a t i o n s o r s e l f - s ta t e m e n t s t h a t t h in g s

w i l l t u r n o u t w e l l a n d r e p r e s e n t s a n e f f o r t t o f o c u s o n p o s i t i v e r a t h e r t h a nn e g a t i v e p o s s i b i l i t i e s .

After the init ial shock and everything we looked to the brighter side. Now we arenot the scared of i t .

I th ink positively . I th ink in terms of her growing up and going to school and gett ingbet ter and do ing the th ings tha t a norma l ch i ld would do . W e' re p repar ing her fo rthe future.

7 . D e n i a l r e f e rs t o d i s b e l i e f o f t h e d i a g n o s i s o r i ts n e g a t i v e i m p l i c a -

t i o n s , r e f u s a l t o f o c u s o n i l ln e s s - r e l a t e d i s s ue s a n d w i t h d r a w a l f r o m s i t u a -t i o n s r e m i n i s c e n t o f t h e i l ln e s s . I n t h e a b s t r a c t i t m a y b e d i f f i c u l t t o d r a w

t h e l i n e b e t w e e n o p t i m i s m a n d d e n i a l b u t m o s t r e p o r t s d o p e r m i t s u ch

d i s t i n c t i o n s .

M y husband doe sn ' t wan t to know abou t our son hav ing to go to the hosp i ta l p r io rto when he has to go. I t was 2 weeks befo re he could pronounc e the word leukemia.

I try to keep my m ind off i t . I d on ' t watch TV shows or anything pertaining to i t .I shut it off. I don 't want to hear ab out it. W hy hurt yourself by watching that garbage?

8 . A c c e p t a n c e r e f e r s t o a r e s p o n s e c h a r a c t e r i z e d b y a s o m e w h a tf a t a l i s t ic p e r c e p t i o n o f a s i t u a t i o n a s i n e v i ta b l e a n d u n c o n t r o l l a b l e . I t

r e p r e s e n t s c o m i n g t o t e r m s w i t h a p r o b l e m w i t h o u t a c t i n g d i r e c t ly o n i t .

I 've a lways sa id that ' I f i t 's gonna happen , i t ' s gonna happe n . '

W hy shou ld I cry? I jus t hand led i t and accep ted i t and that was that .

9 . A c t i v e c o p i n g st y le s r e p r e s e n t a c o m p o s i t e in d e x f o r m e d b y s u m -

m i n g t h e s c o r e s o f c o p i n g s t r a t e g ie s j u d g e d t o b e a c t i v e i n o r i e n t a t i o n ( n o s .

1 - 4 a b o v e ) ,

1 0. P a s s i v e c o p i n g s t y le s r e p r e s e n t a c o m p o s i t e i n d e x f o r m e d b y s u m -

m i n g t h e s c o r e s o f c o p i n g s t r a t e g ie s j u d g e d t o b e p a s s i v e in o r i e n t a t i o n ( n o s .

5 - 8 a b o v e ) .

C o p i n g e f f e c t i v e n e s s w a s b a s e d o n a 4 - p o i n t r a t in g m a d e b y i n f o r m a n t s

o f h o w w e l l t h e y f e l t t h e y h a n d l e d t h e i r c h i l d 's i l ln e s s (1 = p o o r l y , 4 - - v e r y

w e l l ) .

Social Status. T h e s o c i a l d e m o g r a p h i c v a r i a b l e s u s e d in t h is s t u d y i n -

c l u d e g e n d e r , y e a r s o f f o r m a l e d u c a t i o n , a n d a n n u a l f a m i l y i n c o m e . F o r c h i -

s q u a r e a n a l y s e s p a r e n t s a r e d i v i d e d i n to t h r e e i n c o m e g r o u p s b a s e d o n t h e i r

r e p o r t e d t o t a l f a m i l y i n c o m e ( < $ 1 0 , 0 0 0 , n = 1 3; $ 1 0 - $ 2 5, 0 0 0 , n = 2 6; a n d

> $ 25 , 00 0 , n = 2 3) a n d i n t o t h r e e g r o u p s b a s e d o n y e a r s o f f o r m a l e d u c a -



T h e C o n t e x t o f C o p i n g 2 2 9

tion (high schoo l educ atio n or less, n = 24; some college, n = 20; and col-

lege graduate or more, n = 23).

RESULTS

Most parents felt that they coped reasonably well. Of the 74 parents

in the sample only one gave herself a poo r rating, 13 (17.6%) gave themselves

fair ratings, 42 (56.8%) gave themselves good ratings, and 18 (24.3%) gave

themselves excellent ratings. Table I presents correlations among the coping

strategies. This table clearly shows tha t the specific coping strategies are not

highly correlated with one another. These correlations are low to moderate,

with a range of -.36 to +. 19. The highest correlation occurs between Ac-

ceptance and Pr oble m solving and suggests, reasonably enough, that engage-

ment in active efforts to solve instrumental problems of the illness is

inconsistent with passive acceptance of the situation. Table II presents the

correlations among the four measures of medical context. None of the cor-

relations is significant.

Demographics, Coping Strategies, and Medical Context

In order to assess the effects of potentially mediating variables, cor-relations or chi-square were computed between demographic variables and

measures of medical context. Demographic and situational variables tested

include the amou nt of medical stress, time spent by parents in the hospital,

numbe r of child hospitalizations, diagnostic of ca tegory of the child, gender,

education, and income. A significant correlation was found between educa-

tion and the quality of relations with medical staf f (r = - . 4 3 , p = .0002).

More highly educated parents reported poo rer relations with the medical staff

Table I. Pearson Product-Moment Correlation Matrix for Parental Coping Strategies

Coping strategy 1 2 3 4 5 6 7

1. Informationseeking2. Problem solving -.023. Optimism - .02 .074. Informal

help-seeking .00 .00 .135. Acceptance -.18 -.36 .05 .106. Denial .06 .05 -.09 -.177. Maintenance of

emotional balance .06 .14 .03 - . 118. Relianceonreligious beliefs .19 -.06 .09 -.14

- .06

.04 - .01

.13 .09 .03



2 3 0 B a r b a r i n a n d C h e s l e r

T a b l e I I . C o r r e l a t i o n M a t r i x f o r M e a s u r e s o f M e d i c a l

C o n t e x t

V a r i a b l e 1 2 3 4

1 . R e l a t i o n s w i t h t h e

m e d i c a l s t a f f2 . N o . o f h o s p i t a l i-

z a t i o n s - . 11

3 . M e d i c a l s t r e s s . 0 9

4 . C o p i n g e f f e c t iv e n e s s

( se l f - r a t e d ) - . 08

- .0 6

.0 8 .0 3

t h a n p a r e n t s w i t h le ss e d u c a ti o n . M A N O V A w e r e u s e d t o a se ss s ex , in c o m e ,

a n d e d u c a t i o n d i f f e r e n c e s i n t h e u s e o f c o p i n g s t r a te g i es . N o s i g n i f ic a n t d i f-

f e r e n c e s a r e f o u n d w i t h r e s p e c t t o g e n d e r ( m u l t i v a r i a t e F ( 8 , 5 9 ) = 1 .3 2 , p- - n s ) , i n c o m e ( m u l t i v a r i a t e F ( 1 6 , 9 4 ) = 0 . 5 5 5 , p = n s ) . H o w e v e r ,

m u l t i v a r i a t e a n a l y s i s s u g g e s t s t h a t e d u c a t i o n a p p r o a c h e s s i g n i f i c a n c e

( m u l t i v a r i a t e F ( 1 6 , 1 1 4) = 1 .6 4 , p = . 0 7) . T a b l e I II r e p r e s e n t s t h e m e a n s

f o r e a c h o f th e e d u c a t i o n g r o u p s o n t h e c o p i n g s t r a te g i e s a ss e ss e d in t h e

M A N O V A a n a l y s e s .

B e c a u s e t h e m u l t i v a r i a t e F f a i l e d t o r e a c h a n a c c e p t a b l e l e v e l o f

s i g n if ic a n c e n o f o l l o w - u p o f a n a l y s es w e r e c o m p u t e d t o d e t e r m i n e t h e s p e ci fi c

c o p i n g s t ra t eg i e s a l o n g w h i c h t h e e d u c a t i o n g r o u p s d i f f e r e d . H o w e v e r , p a r e n t s

l ev e l o f e d u c a t i o n w a s p o s i t iv e l y c o r r e l a t e d w i t h t h e u s e o f p r o b l e m s o l v in g

( r = . 3 0 , p < . 0 2 ), i n f o r m a t i o n se e k i n g ( r = . 2 9 , p < . 0 2) a n d o p t i m i s m

( r = . 2 6 , p < . 0 3 ) a n d i s n e g a t i v e l y c o r r e l a t e d w i t h th e u s e o f d e n i a l ( r =

- . 26 , p < . 03 ). M o r e o v e r , p a r e n t s l e v el o f e d u c a t i o n i s s t r o n g l y p o s i t i v e l y

c o r r e l a t e d w i t h th e c o m p o s i t e d i n d e x o f a c ti v e c o p i n g s t y le s ( r = . 49 , p <

.001) .

T a b l e I V p r e s e n t s th e r e g r e s s i o n c o e f f ic i e n t s a n d t h e z e r o - o r d e r c o r -

r e l a t io n s b e t w e e n th e c o p i n g s t r a te g i e s a n d f o u r m e a s u r e s o f m e d i c a l c o n -

T a b l e I II . R e s u l ts o f M A N O V A A n a l y s e s C o m p a r i n g C o p i n g S t r at e g ie s b y

E d u c a t i o n a l G r o u p s

H i g h s c h o o l S o m e c o l le g e C o l l e g e g r a d u a t e

C o p i n g s t r a t e g i e s ( n = 2 4 ) ( n = 2 0 ) ( n = 2 3 )

I n f o r m a t i o n s e e k i n g 1 .2 1 1 .3 5 1 .5 2

P r o b l e m s o l v i n g 1 .3 8 1 .6 0 1 .8 3

H e l p S e e k i ng 1 .13 1 .10 1 .26

Em ot i on a l ba l a nc e 1 .58 1 .85 1 .43

R e l i g i o u s b e l i e f s 4 . 7 9 9 . 0 5 6 . 0 0O pt i m i sm 1 .42 1 .55 1 .78

De nia l 1 .67 1 .50 1 .30

A c c e p t a n c e 1 . 7 9 1 .7 0 1 .5 7



T h e C o n t e x t o f C o p i n g

T a ble I V . R e g r e s s i o n C o e ff i c ie n t s a n d Z e r o - O r d e r C o r r e l a t i o n s B e t w e e n C o p i n g

S t r a t e g y , E d u c a t i o n , a n d M e a s u r e s o f M e d i c a l C o n t e x t

2 3 1

C r i t e r i o n m e a s u r e s

P a r e n t - C o p i n g

H o s p i t a l i - M e d i c a l s t a f f e f f e c t i v e-V a r i a b l e z a t i o n s t re s s r e l a t i o n s n e s s

C o p i n g s t r a te g y

I n f o r m a t i o n s e e k i n g . 05 . 01 - . 1 3 . 0 0

P r o b l e m s o l v in g - . 0 1 . 08 - . 2 4 a - . 0 5

H e l p s e e k i n g - . 1 8 . 0 4 - . 0 4 . 08

E m o t i o n a l b a l a n c e . 0 9 - . 0 6 - . 1 3 - . 05

R e l i g i o u s b e l i e f s - . 0 7 . 1 5 . 1 8 - . 1 7

O p t i m i s m - . 0 4 - . 0 6 - . 0 6 . 0 9

D e n i a l . 0 2 - . 0 8 . 0 3 .2 6 ~

A c c e p t a n c e - . 2 4 a . 0 6 . 4 8 b . 1 4

E d u c a t i o n - . 1 8 - . 1 7 - . 4 3 c . 0 8

M u l t i p l e r . 3 2 . 2 1 . 6 5 . 3 8

F v a l u e . 9 0 . 3 8 4 . 7 6 1 . 3 6

~ p _< .05 .

b p < . 0 1 .

~ p _ . 0 0 1 .

t e x t u s e d a s c r i t e r ia i n t h e m u l t i p l e r e g r e s s i o n a n a l y s e s . T h e c o p i n g s t r a t e g i e s

a s a g r o u p d o n o t s i g n i f ic a n t l y r e l a te to h o s p i t a l i z a t io n , F ( 8 , 6 5 ) = 0 . 9 0 ,

p = ns , pa ren ta l med ica l s t re ss , F (8 , 65) - - 0 .38 , p = ns) , o r se l f - ra ted co p-

i n g e f f e c t i v e n e s s , F ( 8 , 6 5 ) -- 1 . 36 . H o w e v e r , c o p i n g s t r a t e g i es a r e s t r o n g l y

r e l a t e d t o t h e q u a l i t y o f r e l a ti o n s w i t h m e d i c a l s t a f f , F ( 9 , 5 7 ) = 4 . 7 6 , p =

.0001 .

T h e s e d a t a p r o v i d e m o d e s t e v i d e n c e o f s o m e r e l a t i o n s h i p s b e t w e e n

m e a s u r e s o f t h e m e d i ca l c o n t e x t o f c o p i n g a n d p a r e n t s ' u s e o f s p e c if ic co p -

i n g s t r a t e g i e s . A l t h o u g h p a r e n t s ' r e p o r t s o f d i s e a s e - r e l a t e d s t r e s s d o e s n o t

d e m o n s t r a t e a s i g n i f ic a n t r e la t i o n s h i p w i t h a n y o f th e c o p i n g s t r at e g ie s , i t

a p p e a r s t h a t a s t h e n u m b e r o f h o s p i t a li z a t io n s i n c r e a s es , p a r e n t s a r e le ss li k e ly

t o e m p l o y a c c e p t a n c e a s a c o p i n g s t r a te g y . P a r e n t s r e p o r t s o f q u a l i ty o f r e la -

t i o n s w i t h m e d i c a l s t a f f is p o s i ti v e l y c o r r e l a t e d w i t h a c c e p t a n c e a n d n e g a t i v e l y

c o r r e l a t e d w i t h p r o b l e m - s o l v i n g .

T h e r e a l s o i s a s i g n i f ic a n t p o s i t iv e c o r r e l a t i o n b e t w e e n d e n i a l a n d s e lf -

e v a l u a t e d c o p i n g e f f e c t iv e n e s s . P e r h a p s p a r e n t s f e el t h e y a r e c o p i n g b e t t e r

-to t h e e x t e n t t h e y c a n d e n y t h e s e r i o u s n e s s o f t h e i r c h i l d 's i l ln e s s a n d i ts i m -

p l i c a t i o n s , b u f f e r i n g t h e m s e l v e s f r o m p a i n f u l r e a l i t i e s .

The r e su l t s o f t he mu l t ip l e r e g r e s s ion o f c op ing s t r a t e g ie s on r e l a t ions

w i t h m e d i c a l s t a f f a r e p r e s e n t e d i n T a b l e V . I n o r d e r t o c o n t r o l f o r t h e

m e d i a t i n g r o l e e d u c a t i o n m a y h a v e i n t h e r e l a ti o n s h i p b e t w e e n c o p i n g s ty le s

a n d r e l a ti o n s w i t h t h e m e d i c a l s ta f f , e d u c a t i o n w a s i n c l u d e d a m o n g t h e p r e d i c -




Table V. Multiple Regressions using Quality of Relations with

Medical Staff as the Criterion and Coping Strategies and Educa-

tion as the Predictors

Partial Beta

Variable correl ation coefficients t value

Coping strategy

Info rmat ion seeking .10 0.90 0.73

Pro ble m solving .09 0.78 0.50

Help seeking -. 10 - 1.26 -0 .7 4

Em ot io na l bal anc e - .28 - 1.82 - 2.16 ~

Religi ous beliefs .10 0.25 0.79

Opti mism .09 0.60 0.65

Den ia l - . 06 -0 .46 -0 .46

Acce pta nce .45 3.99 3.83 b

Ed uc at io n - .44 - 2.11 - 3.68 b

ap ___ .05.

bp _< .01.

t o r v a r ia b le s . T o g e t h e r e d u c a t i o n a n d c o p i n g s tr a te g ie s a c c o u n t f o r 4 3 % o f

the variance in relat ions with the medical staff. The coping strategies which

con t r ib u te m os t s t rong ly to the p red ic t ion o f re l a t ionsh ip wi th the med ica l

s t a f f a re accep tance (pa r t ia l r = .45 ) and em ot iona l ba l ance (pa rt i a l r =

- .27). No te tha t once edu cat i on (part ial r = - .44) is entere d into the regres-

s ion problem-solv ing i s no longer s igni f icant .

D I S C U S S I O N

These da t a pa r t i a l ly suppor t t he a rgumen t t ha t t he med ica l con tex t i s

re la ted to indiv idual coping s t ra tegies . Coping s t ra tegies are not s t rongly

re l a t ed to the ch i ld ' s med ica l s i t ua t ion no r t o the deg ree to wh ich pa ren t s

exper i ence i l lness - re l a ted s t ress . T hus , con t ra r y to p red ic t ions o f l ea rned

helplessness, high degrees of medical st ress are not related to the adoption

of a pass ive cop ing s ty l e. I f any th ing , t he mo re the ch i ld was hosp i t a l i zed ,

the less l ikely pare nts were to ac cept the si tuat io n passively. Cop ing strategies

a re no t re l a t ed s t rong ly to how pa ren t s eva lua t e the i r cop ing e f fec t iveness

but are re la ted s t rongly to the qual i ty of the i r re la tions wi th the medica l s ta ff .

Parents who adopted passive coping strategies tended to be less well educated

and to have be t t e r re l a t ions wi th med ica l s t a f f t han pa ren t s w ho d id no t .

Severa l cavea t s mus t be obse rve d in in t e rp re t ing these da t a . F i r s t, t he

da ta a re gene ra t ed by in t erv i ews w i th pa ren t s whose ch i ld ren a l l were t rea t ed

at a s ingle la rge teaching fac i l i ty wi th few ps ycho logica l sup po rt serv ices (a t

the t ime o f s tudy) . The re su l t s migh t be d i f fe ren t i n a sma l l e r communi tyhosp i t a l o r i n a se t t i ng tha t rou t ine ly p rov ides ex tens ive psychosoc ia l se t -



The Contex t o f Coping 233

vices. Thus as the medical context itself varies, parents' reactions to the con-

text may vary as well.

Second, the coping indices are derived inductively from clusters of

parents's responses to open-ended questions rather than from explicitly struc-

tured ratings of coping. The approach adopted has the advantage ofphenomenological validity, insofar as parents described what they did.

However it imposes a degree of structure that parents did not bring to their

self-descriptions. It also relies upon retrospective reports o f how parents felt

and what they did. These reports may well involve selective memory and

distortion.

In spite of these cautions, it is important to explain why relatively passive

or acquiescent coping strategies may be associated with favorable relation-

ships with the medical care staff. Perhaps parents with good medical rela-

tionships have less need or desire to exert active control over the medicalsituation and thus view acceptance of what cannot be changed as an effec-

tive coping strategy. For their part, doctors and other medical staff may find

it easier to be supportive of parents who are passive rather than active (Taylor,

1979) and may subtly reinforce passive styles through contingent approval

and attention. It is especially interesting that parents with higher levels of

education report poorer relations with the medical staff than parents with

lesser levels of education. To be sure, these same parents reported greater

use of precisely those coping strategies that broke from passive patient norms

(more information seeking, more problem solving, and less denial). Perhaps

parents with higher status and more active coping strategies are more threaten-

ing to medical staffs, harder to deal with, harder to control, harder to relate

with harmoniously. Because parents with higher levels of education are closer

to the professional status of the medical staff they may be less willing to be

compliant and to "sit still" in the face of questionable staff behaviors

and attitudes. Perhaps too they are more likely to see clearly and discuss

openly the uncertain grounds on which all treatment for cancer rests.

These findings on coping effectiveness indicate that parents' evalua-

tions of their own coping are most highly associated with the use of denial

as a strategy. In highly stressful situations parents may feel satisfied if they

are simply able to keep on going and to ward off excessive pessimism by

moderate amounts of denial. Interpreted in this light, moderate amounts of

denial can be a healthy and functional response. Lazarus (1981) noted that

denial can be detrimental when it reduces vigilance to imminent threats and

delays adaptive responding but it may also preserve morale and hope through

selective avoidance of pessimistic information. The ability to put things out

of their mind may permit parents to return to apparent normality and to

triumph over continual worry and despair. Moreover, Featherstone (1980)

and Wortman and Dunkel-Schetter (1979) observed that medical staf f



234 Barbarin and Ches ler

m e m b e r s a n d c lo s e f r i e n d s o f t e n p r e f e r p e o p l e w i t h c a n c e r t o b e u p b e a t a n d

t o h a n d l e t h e c ri s i s w i t h e q u a n i m i t y . P a r e n t s w h o a r e p r e o c c u p i e d m a y d i s a p -

p o i n t t h e ir f r ie n d s a n d e x p e r ie n c e d i s a p p r o v a l a n d w i t h d r a w a l f r o m t h e m .

T h e m e d i c a l s t a f f 's p r e f e r e n c e f o r p a s s iv e p a r e n t / p a t i e n t c o p i n g s ty le s

m a y n o t b e c o n d u c i v e t o e f f e c t i v e l o n g - t e r m a d j u s t m e n t f o r s o m e p a t i e n t sa n d t h e i r f a m i l i e s . B r i c k m a n e t a l . ( 19 8 2) a n d o t h e r s c r i t ic i z e d t h e t r a d i t i o n a l

m e d i c a l m o d e l b e c a u s e o f t h e a s y m m e t r i c a l s t a f f - p a t i e n t r e l a t i o n s h i p s i n

w h i c h t h e s t a f f u n i l a t e r a l l y e s t a b l is h t h e r u l es g o v e r n i n g b e h a v i o r i n t h a t s e t -

t i n g a n d p a t i e n t s a r e e x p e c t e d t o a d o p t p a s s i v e ro l e s ( A n t o n o v s k y , 1 98 0) .

E m e r g i n g t r e n d s i n th e t r e a t m e n t o f c h i l d h o o d c a n c e r , s u c h a s t h e

s k y r o c k e t i n g f i n a n c ia l b u r d e n o n p a r e n t s , i n c r e a s e d li f e e x p e c t a n c y , a n d

r e l i a n c e o n o u t p a t i e n t t r e a t m e n t , a r e l ik e l y t o i n c r e a s e t h e n e e d f o r p a r e n t s

t o m o n i t o r m e d i c a l a n d p s y c h o s o c i a l se r v i c e s a n d t o p r o v i d e a d d i t i o n a l c a r e

o v e r a n e x t e n d e d t i m e p e r io d . N e w p a r t n e r s h i p s a m o n g p a r e n t s a n d m e d i c a lp r o f e s s i o n a l s r e q u i r e b o t h t o e x p e r i m e n t w i t h c o m p a t i b l e f o r m s o f s u p p o r t

a n d e d u c a t i o n f o r a c t i v e p a r e n t r o l e s i n t h e m e d i c a l c a r e o f i ll c h i l d r e n .

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