Promoting resilience, benefit finding , and post-traumatic growth help patients and families cope well with chronic illness. A resilient family has good problem-solving skills and communication, and a shared belief system ( Fam Process. 2003; 42:1-18 ). Benefit finding coexists with feelings of burden, grief, and loss, and post-traumatic growth can occur despite grief and loss. Convening family meetings, for example, is a way to provide a therapeutic space for families and an opportunity to reflect on ways that chronic illness has affected the family, both negatively and positively.
What is coping well?
Resilient families cope well by identifying and solving illness-related problems, communicating about symptoms, negotiating role changes, and developing new interests as a family and new ways of emotionally being together. In addition, resilient families are able to adapt or change their life goals or health behaviors, such as improving diet, increasing exercise, and stopping smoking. A family member may work fewer hours, for example, and older children may give up some childhood activities to take on caregiving responsibilities.
Families do not usually think about how they cope; they just get along the best they can. Families may not consider how each family member’s individual coping style meshes with the coping styles of other family members. Illness management often is punctuated by crises where change happens quickly, without the family having time to deliberate on what coping styles might work best. Family changes can become fixed, therefore, not by choice, but by happenstance.
The initial stage of coping is “assimilative.” This is when the impact of the illness is being understood and absorbed. Emotional coping occurs when distress is highest, for example, at the beginning of an illness – when uncertainty exists about the diagnosis. Another characteristic of emotional coping is that it is characterized by attempts to regulate negative emotions. For example, family members may blame themselves or others, engage in wishful thinking, or become avoidant.
At later stages of illness, coping becomes “accommodative” after attempts to change or cure the illness have been found to be ineffective. Emotional coping can then be replaced with a problem-based coping style, allowing a stressor to be discussed and a solution chosen from several alternatives. Reflective coping, a related concept, is the ability to generate and consider coping options, and to recognize the usefulness of a particular coping strategy in a particular situation.
Psychiatric imperatives
While providing psychotherapy with these couples, it is helpful to:
• Help families differentiate between emotional difficulties such as “I am the primary caregiver, and I feel overburdened,” and more general practical problems, such as “I am happy to be the primary caregiver, but I need some extra help.”
• Describe coping to the family. Coping is a dynamic process, and coping styles change over time. Each person copes in their own way, depending on their experiences of illness and expectations of living with illness. In a family, the experiences and behaviors of all the individuals influence the way the family unit functions as a whole.
• Promote a balance between acceptance and change.
• Encourage the family to talk about their experience with others who are experiencing the same stressors.
• Give the family a handout that outlines different coping styles to get the discussion started.
• Provide a therapeutic space for family members to think together about how they want to cope and what coping well means to their family.
Developing dyadic coping
When dyadic coping takes place, couples cope as a single entity. Dyadic coping research is relatively new; most studies have been conducted in the past 15 years. Couples who use positive dyadic coping employ joint problem solving, joint information seeking, sharing of feelings, mutual commitment, and relaxing together. Meanwhile, couples who use negative dyadic coping hide concerns from each other and avoid shared discussion. A systemic review of dyadic coping in couples with cancer found that couples using positive dyadic coping styles experienced higher relationship functioning ( Br J Health Psychol. 2015 Feb;20[1]:85-114 ).
Couples with good dyadic coping view the illness as “our problem.” This approach necessitates a shared understanding of the illness. The couple usually has prior experience working together as a team, for example, parenting and dividing roles within the house. They are able to relax together and provide emotional support, such as mutual calming and expressions of solidarity. Talking together about one’s worries and needs allows couples to share the experience more adequately. Dyadic coping is reflected in the amount of “we” talk.
The person in the family who copes “best” may provide the model for developing the family coping style. In a study of 66 couples faced with the stress of forced relocation, nearly all the couples adapted to the stress “as a couple,” rather than “as individuals” ( Fam Process. 1991 Sep;30[3]:347-61 ). At the 2-year follow-up, each husband and wife developed similar coping styles, with one individual’s coping ability driving the adjustment of his or her partner. The need to adjust together or to adapt as a couple lessened the stress of relocation. Adaptation occurred through the development of shared meaning of the relocation that emerged from conversation within the couples. In other words, the couple developed a shared worldview. The coping style of the person who coped best was the strongest predictor of adjustment for both members of the couple. For most couples, the style of the person who coped best dominated.
Questions to ask during therapy
While working with these couples, assess their motivation to develop dyadic coping, by asking:
• “Do either of you feel that the patient should do this alone?” If the answer is yes, it will be difficult, if not impossible, to move the couple to a dyadic coping style.
• “Do your efforts to work together result in greater conflict?”
• “How much do you want this to change?” This questions clarifies their motivation to work together.
• “When you think about problems related to your heart condition, to what extent do you view those as ‘our problem’ [shared by the patient and the spouse equally] or mainly as ‘your own problem?’ ”
• “When a problem related to your heart condition arises, to what extent do you and your partner work together to solve it?”
• “When you both talk about the illness, how much do you use ‘we-talk’?”
• “It is important that you both agree about what is causing the illness. Can I answer any questions that might help you reach this understanding?”
• “Are there times in the past where you have successfully solved difficult problems? How did you do that?”
• “How do you respond when your spouse becomes ill?”
• “What can your spouse do that will help you get better?”
• “Can you ask your spouse for help and support?”
• “Can you work on your spouse’s health problem together?”
‘Benefit finding’ and PTG
Benefit finding emerges later in the adjustment to chronic illness. For example, caregivers may develop a greater appreciation of their own health and ability to enjoy their own pursuits. Family connectedness is a frequent source of meaning, and a critical aspect of well-being and benefit finding. Seven factors make up benefit finding: compassion/empathy, spiritual growth, mindfulness, family relations growth, lifestyle gains, personal growth, and new opportunities ( Psychol Health. 2009 Apr;24[4]:373-93 ). Benefit finding is associated with higher marital adjustment, improved life satisfaction, and a more positive affect, especially at high levels of stress.
Post-traumatic growth, or PTG, refers to positive changes that occur after traumatic life events. People who experience PTG are transformed by their struggles with adversity. It is the struggle after the trauma, not the trauma itself, that produces PTG. In contrast to resilience, PTG refers to changes that go beyond pretrauma levels of adaptation and beyond benefit finding. Relational benefits in the aftermath of a cancer diagnosis are well recognized. An instrument used to assess these outcomes is called the Post-traumatic Growth Inventory, or PTGI ( J Trauma Stress. 1996 Jul;9:455-71 ).
Interventions for couples coping with cancer resulted in improvements in communication, dyadic coping, quality of life, psychosocial distress, sexual functioning, and marital satisfaction ( Psychooncology. 2014 Apr;23[7]:731-9 ). PTG may, however, be more apparent in patients than spouses.
Potential interventions
Promoting dyadic coping is effective if the couple wants to engage in intervention. According to one study, a partner-assisted emotional disclosure improved relationship functioning and intimacy ( J Marital Fam Ther. 2012 Jun;38 Suppl 1:284-95 ). Couples therapy improves relational functioning in couples coping with cancer, at 1-year follow-up ( Psychooncology. 2009 Mar;18[3]:276-83 ). Most important, as a first step, the couple must agree that they want to develop dyadic coping. The concept of individual versus dyadic coping may be novel for couples, and it is worth spending time on this review before offering couples intervention.
A psychoeducational program also can teach dyadic coping. The Resilient Partners discussion group developed in collaboration with the Multiple Sclerosis Society focused on developing couples’ strengths in coping with multiple sclerosis (Rolland, J., McPheters, J., and Carbonell, E., 2008). This multifamily group program is based on the Family Systems Illness Model, which integrates the demands of multiple sclerosis over time within a family developmental framework. In a comparison of a couple skills intervention with a psychoeducation program, women in the couple skills intervention benefited more in terms of their relationship functioning ( Ann Behav Med. 2012 Apr;43[2]:239-52 ).
Dr. John S. Rolland’s Family Systems Illness ( FSI ) model provides a framework for the psychoeducation, assessment, and intervention with families dealing with chronic illness. This model, developed in clinical experience with more than 1,000 families, views families as valued partners and resources, and emphasizes resilience and growth. The FSI model takes into account the interaction of an illness with the individual’s development and the family’s development, the multigenerational ways of coping with illness, the family’s health/illness belief system, available resources, and relationships between health care providers.
The PTGI includes five domains: improved relationships, new possibilities for one’s life, a greater appreciation for life, a greater sense of personal strength, and spiritual development. Several family oriented themes within the PTGI can be used by the psychiatrist to inquire about positive change. These themes are:
• Knowing that I can count on people in times of trouble.
• A sense of closeness with others.
• Having compassion for others.
• Putting effort into my relationships.
• I learned a great deal about how wonderful people are.
• I accept needing others.
To promote PTG, the psychiatrists can listen for accounts of the experience of growth, label the experience, decide when the patient is ready for more focused questioning, and recognize that a life narrative including the aftermath of a trauma has value. In order to get the patient to recognize PTG, the psychiatrist can state and ask: “You may have heard people say that they have found some benefit in their struggle with trauma. Given what has happened to you, do you think that is possible?” Another exchange might flow like this: “You mentioned last time that you noticed that you and your wife have grown closer since this happened. Can you tell me more about this closeness. What is it about this struggle that has produced this closeness?”
Conclusion
Strengths, resilience, and post-traumatic growth are distinct constructs that share conceptual overlap. Using these constructs, the psychiatrist can help the patients and their families move forward. At the time of diagnosis/trauma/bereavement, family and couple interventions provide support, education, and symptom management. Specific psychoeducational interventions or family therapy can be used if needed. As the illness progresses and the family moves from an assimilative stance to an accommodative stance, and as problem-solving moves from emotional problem solving to reflective problem solving, the possibility of benefit finding and PTG emerge. Most importantly, the psychiatrist can provide the family with a therapeutic space to consider their coping styles, and offer the family a path forward through discussion of dyadic coping and family growth.
Further reading
1. Tedeschi and Kilmer, “Assessing Strengths, Resilience, and Growth to Guide Clinical Interventions,” Professional Psychology: Research and Practice. 2005;36(3), p. 230-7.
2. Heru A.M., “ Working With Families in Medical Settings ,” (New York: Routledge), 2013.
3. Rolland J.S. “ Families, Illness, & Disability: An Integrative Treatment Model, ” (New York: Basic Books), 1994. New edition in press.
Thank you to Dr. Jennifer Caspari for assisting with resources for this article.
Dr. Heru is with the department of psychiatry at the University of Denver, Aurora. She has no conflicts of interest to disclose.
