Chapter 1

Coping and Health

Susan Folkman
Department of Medicine and Center for AIDS Prevention Studies
University of California - San Francisco

It is practically impossible to avoid daily advice on how to cope with stress. This advice is proffered almost nonstop by talk show pundits, authoritative writers in magazines and newspapers, ads for over-the-counter stress antidotes, friends, and of course family members. This barrage of advice is based on widely held assumptions that (1) stress is omnipresent in our lives, (2) stress can be harmful to health, and (3) these harmful effects can be avoided or reduced if we cope well.

Few would quarrel with the notion that stress, no matter how it is defined, is omnipresent. It is commonly experienced by most people on most days. But the generalizability of the effects of stress on health is not as broad as the media would have us believe. A review of the literature by Adler and Matthews (1994)shows that while there is evidence that stress can increase vulnerability to certain health problems including respiratory infections, infectious disease, and pregnancy complications, evidence is lacking that it affects the etiology of other diseases including cancer and endocrine disease. But even if stress affects only a subset of all health problems, that it does so at all is important. Respiratory infections and infectious diseases, for instance, affect virtually all of us at one point or another, and they are responsible not only for discomfort and misery, but for missed days at work or school and increased medical costs.

Just as we believe that stress affects health, so too do we believe that the harmful effects of stress can be mitigated if somehow we learn how to cope with it. Presumably, those who cope well with stress will have fewer illnesses, fewer infections, and fewer days lost from work than those who do not cope well. This argument is logical, and it is appealing because it gives us hope that even if we cant escape stress, there are things we can do to keep it from harming us. The burgeoning scientific literature on coping and health confirms that psychologists and other behavioral scientists find this idea appealing, too.

Studies of the relationship between coping and health can be placed in two categories. In the first, coping is looked at in direct relationship to health. Here the researcher is concerned with how the way an individual copes with a stressful situation or condition has a direct impact on his or her health. In the second, coping is looked at in indirect relationship to health. Coping, for example, is examined in relation to health behaviors or mood, with the idea that behaviors or mood in turn affect health; but coping is not expected to affect health directly. Instead, coping affects health through its impact on the }mediating” variable such as health behavior or mood.

In the first part of this chapter, I review a few selected studies to illustrate each of these perspectives and summarize what they do and do not tell us about the relationship between coping and health. In the second part of the chapter, I offer some thoughts on where I believe the field of coping needs to go next in order to increase our understanding of the relationship between coping and health. Before the review begins, I outline a few important conceptual issues regarding coping to provide a foundation for the rest of the chapter.

The Literature on Coping and Health

Conceptual Issues

Over the last twenty years most studies on coping and health have come to conceptualize coping in surprisingly similar ways. The conceptualization is based on a definition of coping as the changing thoughts and behaviors that people use to manage distress (emotion-focused coping) and the problem underlying the distress (problem-focused coping) in the context of a specific stressful encounter or situation (e.g. Moos 1974; Pearlin & Schooler 1978; Folkman & Lazarus 1980; Lazarus & Folkman 1984; Folkman & Lazarus 1985; Moos & Schaefer 1993).

Since this definition of coping is widely used, it is helpful to understand some of its nuances because they can complicate the study of the relationship between coping and health. First, the definition implies that coping is a dynamic process that changes as a single stressful encounter unfolds and across diverse encounters, depending on changes in what the person is coping with. The changing and variable nature of coping poses challenges for the researcher. If coping were stable, it would be easier to use it to predict health outcomes because a single assessment would be highly reliable. But coping is not stable; it is changeable. Its changeable quality was demonstrated in a number of early studies that showed, for example, that coping changes depending on whether the event is a harm, loss, or threat (McCrae, 1984) , the social role that is involved (Menaghan, 1982) environmental and social factors (Parkes, 1986) , and what is at stake and what the options for coping are (Folkman & Lazarus, 1980; Folkman, et al. 1986) .

Even a seemingly simple stressful event, such as taking a final exam, has different phases, each posing different demands for coping. Lets say that the stakes are high: the course is an important prerequisite for graduate school, the exam is expected to be difficult, and the outcome is important because it determines the final grade. The encounter begins with a preparation phase, which requires organizing the environment so that it is possible to study, getting the right materials for study, and then actually studying. Then there is the exam itself, which requires managing anxiety so that it does not interfere with test taking, thinking clearly, and coming up with good answers. This is followed by a waiting period, while the exam is being graded. And then finally there is the outcome -- the grade itself. Each phase of the exam poses different coping demands, and as a consequence coping changes as the exam process moves from one phase to another (Folkman & Lazarus, 1985) .

Second, coping is multidimensional. Most coping measures include multiple kinds of problem- and emotion-focused coping, usually between 6 and 8, although sometimes more than 20 (McCrae, 1984). The multidimensional quality of coping poses challenges for analysis. Although the various types of coping are conceptually distinct, they tend to be related empirically. For example, in a study of men who had undergone coronary artery by-pass surgery, Scheier and his colleagues (1989) found that efforts to regulate distress, an emotion focused form of coping, interfered with making plans and setting goals for the future, a problem focused form of coping. As another example, the use of cognitive reframing or positive reappraisal is typically associated with planful problem-focused coping (e.g. Folkman, et al. 1986; Carver, et al. 1989) . This lack of independence makes it more difficult (although not impossible) for any one type of coping to stand out as a single, strong predictor.

Third, most coping scales are inherently less internally consistent than are measures of other constructs, such as attitudes. The internal consistency of a measure refers to the extent to which the items on a scale are measuring the same thing. The greater the internal consistency of a measure, the more reliable it is as a research tool. A person who responds to a questionnaire with good internal consistency about his or her attitude toward environmental preservation, for example, is likely to endorse all items that are consistent with that attitude. Unfortunately, it is difficult to achieve high levels of internal consistency with coping scales because of the nature of coping. If a specific coping strategy, e.g., turning to another task to get ones mind off the problem, is successful the person does not have to turn to other strategies within that category. The one strategy worked, and therefore there is no need to do more. This quality lowers the likelihood that an individual will check multiple strategies within a given category, thereby lowering the internal consistency of the measure of that category. This can be a problem because the coefficient that describes internal consistency puts a ceiling on the strength of the correlation that measure can attain with any other variable.

These quirky characteristics of coping create methodological obstacles in the study of the relationship between coping and health. Therefore, if a relationship is observed between coping, which is inherently variable and multidimensional, and a health outcome, such as recurrence of an illness, days in hospital, or recovery, that relationship should be taken seriously. It is there despite great odds.

The study of the relationship between coping and health also depends on characteristics of the dependent variable. The dependent variable must have the potential for change over the time of the study. General health status variables, for example, tend to be quite stable in the general population and the probability that such variables might change during a study period that is arbitrarily chosen is not great (Folkman, 1992) . On the other hand, health variables that are more changeable, such as upper respiratory infections, muscular and skeletal problems, and gastrointestinal infections are more likely to change over the course of several months and are more appropriate for the study of coping and health.

Fortunately, these conceptual and methodological issues have not brought research on coping and health to a halt. But it is helpful to understand these issues when reviewing the literature because they can help explain inconsistencies in findings across studies.

Questions about coping and health are generally asked in one of three ways: 1) Do the ways people cope with stress in their daily lives affect their health? 2) Do the ways people cope with a health problem affect outcomes related to the health problem such as illness progression or mortality? 3) Do the ways people cope with a health problem affect their mental health or adjustment to the health problem?

Coping with daily stress and health

Has research shown that the ways we cope with the stresses of our daily lives make a difference in our physical health? It would be nice if we could say }Yes, and heres how you should cope.” Unfortunately, studies have not revealed any consistent insights about the direct effects of general coping with daily stress on general health in the general population. But coping with daily stress has been linked to health in the more specific cases of coping strategies that take the forms of injurious behaviors.

More than 40 years ago Conger (1956) formally proposed that people drink in response to stress as a method of reducing tension. Viewed from this perspective, drinking is a method of coping with stress. Drinking is normatively considered a maladaptive response because it neither helps resolve the underlying problems nor does it effectively regulate distress. In fact, alcohol use generally increases distress, and alcohol abuse has a deleterious effect on health.

That such behaviors are in fact often a response to stress was demonstrated in a study of abstinent male drinkers (Brown, et al. 1995) . Those abstinent drinkers who experienced high levels of stress were more likely to lapse than abstaining individuals not experiencing such stress. But whether or not drinking is the coping strategy of choice depends in part on the extent to which the individual generally relies on avoidant forms of coping, the availability of alternative ways of coping, social skills, and expectancies regarding the effects of alcohol (Cooper, et al. 1992) . A number of community studies have shown that avoidant coping in particular is strongly associated with alcohol use (Cronkite & Moos, 1984; Timmer, et al. 1985; Cooper, et al. 1988; Moos, et al. 1990) . For a review of research on coping and substance use, see Wills and Hirky (1996). Maladaptive health behaviors such as smoking and high risk sexual behavior (McKusick, et al. 1985; Chesney, 1988) and decreases in exercise (Ogden & Mitandabari, 1997) have also been interpreted as coping responses to stress. Alcohol, high-risk sexual behavior, and recreational drug use in particular are considered behavioral forms of escape-avoidant coping (Lazarus & Folkman, 1984) that can be directly injurious to health.

Coping with health problems and health outcome

The most fruitful explorations of the relationship between coping and health have taken place within the context of health problems. The literature is dominated by studies that explore the relationship from the two perspectives mentioned earlier: the effects of coping with a health problem on health outcomes related to that problem, and the effects of coping with a health problem on mental health.

Physical health outcomes. A number of studies have examined the relationship between coping with a disease such as cancer, myocardial infarction, rheumatoid arthritis, asthma, or HIV/AIDS, and a disease-related outcome such as recurrence, recovery, disease progression, or mortality. Rather than review all the studies in this area, I begin this section by describing a series of studies on coping with cancer that summarizes quite nicely what is known about coping and cancer and illustrates the complicated issues involved in investigating this question. Then I review a few selected studies from other diseases that illustrate other issues that are related to the question of coping and health in the context of specific disease.

A study by Epping-Jordan, et al. (1994) of the relationship between coping and disease progression demonstrates how the relationship between coping and health is ultimately quite complicated. They studied coping and health in a sample of 66 cancer patients diagnosed with a variety of different types of cancer including breast cancer, gynecologic cancers, hematological malignancies, brain tumors, and malignant melanoma. They focused on avoidance, which refers to efforts to suppress dysphoric feelings, because several studies had shown a relationship between avoidance and poor physical outcomes (Suls & Fletcher, 1985; Holahan & Moos, 1986) . Instead of relying on the self-report that has been used in earlier studies, Epping-Jordan and her colleagues measured disease variables by reviewing medical charts and patients reports of the prognosis they received from their oncologist. They measured disease status one year post diagnosis as a dichotomous variable: (a) no disease or (b) disease, including presence of original cancer, recurrence, of cancer, or death. Avoidance thoughts were measured with the Impact of Event Scale (IES) (Horowitz, et al. 1979) . They also assessed psychological symptoms. Participants answered the question on the IES with respect to their cancer.

One-year post-diagnosis, 48 patients (73%) were disease free, and 19 patients (27%) had their original cancers, had experienced a recurrence, or had died. After controlling for initial prognosis, avoidance predicted disease status one year later, but psychological symptoms did not. The authors commented that previous studies (e.g., Cassileth, et al. 1985; Jamison, et al. 1987) may have failed to find relationships between psychological symptoms and cancer progression because psychological symptoms did not clearly reflect the cognitive and emotional processes that are most closely related to subsequent disease progression in cancer patients. Presumably, avoidance -- the suppression of feelings -- is more closely related to subsequent disease progression than psychological symptoms.

The reasons avoidance might directly affect disease progression are not immediately clear. Epping-Jordan et al. (1994) offer two hypotheses: avoidance might affect immune functioning in cancer patients by contributing to continued high distress and emotional arousal; or avoidance might result in decreased compliance with cancer treatments, which in turn could lead to worsened disease status. We will return later to these hypotheses, because they are at the very core of the explanation about how coping might be related to health.

Other studies of coping and disease outcome in early breast cancer provide mixed support for the role of coping. A series of studies by Greer and his colleagues (Greer, et al. 1985; Greer, et al. 1990) and Dean and Suertees (1989, described by Buddeberg, et al., 1996) categorized patients as using one of four styles of coping assessed with structured interviews: denial (described as positive avoidance), fighting spirit, stoic acceptance, and helplessness/hopelessness. The earlier studies by Greer, et al. (1985) included longitudinal assessments of 62 women with nonmetastatic breast cancer. Fifteen years later, women who had used fighting spirit or denial were significantly more likely to be alive and free of recurrence than those with fatalistic or helpless responses. But as Buddeberg and his colleagues point out, the sample was small, and the histological node status, which is the best predictor of disease-free survival, was not documented.

Dean and Surtees (1989) replicated the study by Greer with a larger sample of 121 women. The women were interviewed twice, before and 3 months after mastectomy, and these data were related to disease outcome 6 to 8 years after the primary surgical treatment. Coping was assessed using the same method as Greer had used, only Dean and Surtees assessed coping twice. Dean and Surtees found a relationship between coping and disease outcome, but the relationship depended on when it was measured. The patients coping responses were not consistent over time, and no clear relationship could be determined.

Buddeberg et al. (1996) continued this line of research, focusing on the relationship between coping and survival in 107 breast cancer patients at a 5- to 6-year follow up. This study was strengthened by the inclusion of detailed medical data for each patient. Coping was assessed annually for the first three years. At the conclusion of the follow-up period, 25 patients had died, and 81 survived. (One patient was eliminated because she died of cardiac arrest.) Clinical variables, including tumor size and histological node status were related to survival. Coping was not.

These studies of coping and cancer illustrate the challenges in determining the role of coping in health outcomes. The changeable nature of coping makes it difficult to use it as a predictor of health outcomes. More important, the final study (Buddeberg, et al. 1996) shows that when dealing with a disease, biological variables rather than psychological ones are likely to have more influence on survival.

I would like to comment on a study by Reed, Kemeny, Taylor, Wang, and Visscher (1994) in which the focus is not cancer, but AIDS, because it reports some intriguing findings on coping and survival. From the early 1980s, when AIDS first appeared on the national public health agenda, until the mid 1990s when protease inhibitors and new antiretroviral treatments became available, the disease was largely untreatable. Most people who were diagnosed with AIDS died within a few years of that diagnosis. Although treatments became available to treat specific opportunistic infections, little could be done to significantly extend survival time.

During that period, Reed and his colleagues studied psychosocial factors that might affect survival time in a cohort of 74 gay men with AIDS. At the conclusion of their study in 1991, 61 had died of complications related to AIDS. The researchers found a relationship between realistic acceptance, a passive coping strategy, and decreased survival time in their prospective analysis. This study included a number of biological and medical measures (e.g., data from medical charts, measures of the immune system) and behavioral measures (e.g., smoking, alcohol use, and recreational drug use) in addition to psychosocial measures (e.g., optimism, distress, and coping). Six kinds of coping were assessed: community involvement and spiritual growth, active cognitive coping, avoidance and self-blame, seeking social support, realistic acceptance, and seeking information. Realistic acceptance (}Try to accept what might happen,” }Prepare myself for the worst,” }Go over in my mind what I would say or do about this problem”) was associated with decreased survival time, even when the effects of other variables known to be important contributors to survival time were accounted for in the statistical models. These authors used only one assessment of coping in their predictions, so in this regard their study design was not as strong as others. On the other hand, they included a wide range of medical, biological, and behavioral variables in their analyses, and the coping variable still remained the most important predictor of survival time.

Reed et al. (1994) offer a number of possible explanations for the relationship between coping (realistic acceptance) and mortality, many of which will by now have a familiar ring. They suggest that men who report more accepting responses may engage in different behaviors relevant to health outcomes than their less accepting counterparts. Also though the study controlled for a number of such behaviors, other health-related behaviors, such as monitoring of relevant symptoms, seeking medical advice, and compliance with medical treatment may have been adversely affected by realistic acceptance. It is also possible that realistic acceptance was sensitive to unfavorable changes in health status that were too subtle to be captured by their measures. This would account both for realistic acceptance and increased mortality. Finally, they suggest that realistic acceptance may have an impact on immune or viral processes affecting health status in individuals diagnosed with AIDS. In short, Reed et al point out that realistic acceptance, rather than directly affecting health, probably operates through other mechanisms that affect health.

Occasionally we come across studies that illustrate how certain coping strategies may be maladaptive with respect to health in the contexts of certain diseases, but not in others. Studies of coping with coronary heart disease, for example, suggest that denial-like coping, which is traditionally considered maladaptive, can be health-protective at certain stages of disease. Meta-analyses by Suls and Fletcher (1985) were consistent with clinical observation that denial can be adaptive immediately following an acute myocardial infarction, but less adaptive in later stages. In their review of coping with chronic diseases, Maes, Leventhal and de Ridder (1996) summarize a number of studies that are consistent with this pattern. They cite studies, for example, reporting that strong deniers spend fewer days in the coronary care unit and have fewer signs of cardiac dysfunction during their hospitalization compared with weak deniers, but in the year following discharge they are less compliant with medical recommendations and are rehospitalized more often (Levine, et al. 1987) .

Studies of coping with chronic pain show that cognitive or behavior strategies that divert the patients attention from the pain to some other activity help reduce the patients awareness of pain (for review see Katz, et al. 1996) . Such strategies differ from denial in that diversion does not imply denial of what is happening. But diversion strategies are similar to denial in that they are a way of avoiding or reducing awareness of an aversive condition. Diversion types of coping, however, can be maladaptive if there are treatments or procedures that require the patients attention and effort. HIV+ individuals who are on complicated treatment regimens that require a great deal of vigilance, for example, would have adverse health outcomes if they engaged in diversion and denial (Ickovics & Chesney, 1997) . The same is true of diabetic patients whose disease requires close control.

As another example, information seeking is generally considered an adaptive form of coping. But information seeking is associated with adverse outcomes under certain conditions. For example, education and information were associated with increased reports of pain and disability in rheumatoid arthritis patients (Park, 1994) . Maes et al. (1996) explain this counterintuitive result by suggesting that the increase in education and information, which was provided through an intervention, increased the patients sense of vulnerability and diminished the adequacy of patients disability. A similar finding was reported by Chesney and her colleagues (1996) in a study of a coping intervention for HIV+ gay men. This study included a coping skills group, an HIV/AIDS education and information group, and a no-treatment control. The anxiety level of the HIV/ADS education and information group increased, suggesting that the additional knowledge, while possibly helpful with respect to strategies of the management of their illness, was also anxiety provoking, especially in the absence of training in skills for coping with the anxiety.

Finally, there is also a growing literature on the adverse health consequences of suppression of emotion, an emotion-focused coping strategy, such as that described by Epping-Jordan and her colleagues (1994) in the study of cancer that I mentioned earlier. Since 1983, James Pennebaker has conducted a number of studies based on a general theory of inhibition and confrontation. This theory assumes that inhibiting or holding back ones thoughts, feelings, or behaviors requires work. Over time, the work of inhibition can be viewed as a long-term form of low level stress that can create or exacerbate illness and health problems (Pennebaker, 1992) . In a number of studies, Pennebaker and his colleagues have found that individuals who suffered major trauma in childhood are far more likely to become ill if they never talked about the trauma (Pennebaker & Susman, 1988; Pennebaker, 1989) . Others have found that inhibiting forms of emotion-focused coping are also associated with poorer recovery from surgery. In their study of patients undergoing coronary artery bypass surgery, for example, Scheier and his colleagues (Scheier, et al. 1989) found that patients who tried to suppress emotion just before surgery had poorer recovery patterns six months later. This provocative line of research is still in its early and exploratory stages, but it has generated interest among health psychologists.

Mental health outcomes. Both acute and chronic illnesses and conditions create psychological stress for the individual. The most severe psychological challenges are posed by those illnesses or conditions that are painful, interfere with the individuals daily role functioning, disrupt personal relationships, cause disfigurement, and result in both temporary and permanent loss. Uncertainty, whether about test results, efficacy of treatment, recurrence of symptoms or the disease, effects of the disease, time until recovery, degree of recovery, and so on, is pervasive, and this is the source of a great deal of stress in any acute or chronic illness. To maintain well-being in the face of these kinds of stressors requires coping. The psychological stress caused by health problems is thus fertile territory in which to examine how coping with psychological health-related stress affects outcomes related to adjustment and mood. And, in fact, a great deal of research has been done to determine what kinds of coping seem to promote good adjustment outcomes to health-related problems and what kinds of coping seem to make things worse.

Mental health outcomes of coping with health-related stressors are important not only because they have inherent value with respect to patients well-being and quality of life, but also because they may be important mediators of the relationship between coping and physical health. For example, our study of the effects of the chronic stress of caregiving in the context of AIDS on the physical health of the primary informal caregiver showed that coping was not directly related to health symptoms, but it was related indirectly through its relationship to negative mood (Folkman, August, 1997) .

The findings regarding relationships among health problems, coping, and distress are quite consistent across diseases including cancer (e.g., Dunkel-Schetter, et al. 1992; Stanton & Snider, 1993; Chen, et al. 1996) , rheumatoid arthritis (e.g., Felton & Revenson, 1984; Zautra & Manne, 1992) , systemic lupus erythematosus (e.g., McCracken, et al. 1995) , myocardial infarction (e.g., Estreve, et al. 1992) , heart transplantation (e.g., Dew, et al. 1994) , and HIV/AIDS (e.g., Friedland, et al. 1996) . Avoidant forms of coping are generally associated with greater distress, and problem-focused coping and positive reappraisal are generally associated with less distress. The pattern is observed in both cross-sectional and longitudinal studies. This consistency of this pattern suggests that regardless of the disease, disease severity, or the specific kinds of adaptive tasks that confront the individual, taking an active stance and trying to look at the situation as positively as possible is beneficial in terms of mood, whereas engaging in cognitive and behavioral forms of escape and avoidance is detrimental.

The danger of making a sweeping generalization of this sort is that inevitably there are exceptions. In this case, the exceptions are found when characteristics of the person and the situation are taken into account. Both exceptions have to do with the fit between the personal or situational characteristic and the type of coping. With respect to person characteristics, for example, Suzanne Miller (e.g., Miller, 1987) has examined dispositional coping styles related to information-processing behavior. Monitors are disposed to seek information about threat, and blunters are disposed to avoid threat-relevant information. Miller and her colleagues have examined the relationship between preferences for monitoring and blunting, information, and health behaviors and distress and found that high monitors and low blunters fare better with more information and more attention and reassurance and low monitors and high blunters fare better without information, attention, and reassurance (for review, see Miller, et al. 1988) .

With respect to situational characteristics, the extent to which the situation is one that can be changed or that has to be accepted affects the relationship between coping and mood and behavioral outcomes, too. Theoretically, people fare better psychologically when there is a fit between options for coping and actual coping processes. Problem focused coping is more appropriate in situations where something can be done, less so in situations that have to be accepted; and emotion focused coping is more appropriate in situations that have to be accepted, and less so in situations where something can be done. This hypothesis, which has been called the }goodness of fit” hypothesis (Folkman, et al. 1979; Folkman, 1984) , has been examined in a variety of settings including natural disaster (Baum, et al. 1983) and stressful life events (Forsythe & Compas, 1987; Mattlin, et al. 1990; Vitaliano, et al. 1990; Conway & Terry, 1992) . With respect to health, Christensen, Benotsch, Lawton and Wiebe (1995) found that it helped explain adherence to fluid intake in hemodialysis patients. For controllable stressors related to hemodialysis, problem focused coping was associated with more favorable adherence, and for less controllable stressors, emotion focused coping was associated with more favorable adherence.

One of the unanswered questions is whether coping affects mood, or mood affects coping. Although longitudinal designs in which coping is used to explain changes in mood over time indicate that coping is associated with changes in mood (e.g., Felton & Revenson, 1984; Stanton & Snider, 1993; McCracken, et al. 1995; Folkman, et al. 1996) , this does not rule out the possibility that mood also influences coping. The relationship between escape-avoidant forms of coping and depressed mood, for example, suggests a bi-directional process in which depressed mood leads to escape-avoidant (passive) forms of coping, which in turn increases depressed mood (possibly because the underlying problem remains or even gets worse in the absence of more active coping). The vicious cycle between avoidant coping and negative mood was proposed by Felton and Revenson as a way of understanding deterioration in adjustment indices of patients with chronic illness.

To the extent that the relationship between depressed mood and escape-avoidant coping is indeed reciprocal, the causal relationships can be established in both directions. Why, then, do most researchers focus on the coping ----> mood direction rather than the mood ----> coping direction? One compelling reason is that coping is potentially amenable to change. Cognitive-behavior interventions, for example, that try to alleviate depressed mood involve the teaching of coping skills. The assumption is that the vicious cycle between escape-avoidant coping and depressed mood can be interrupted by reducing reliance on maladaptive escape-avoidant coping and increasing the use of adaptive problem-focused coping and strategies for reframing or reappraising a situation.

Conclusions

The vast literature on coping and health is evidence of the widespread belief that the ways people cope is somehow linked to their health. Direct effects of coping on health are probably relatively infrequent, and are most likely limited to behavioral forms of coping that can be injurious to health, such as substance use and high risk sexual behavior. Indirect effects of coping on health, on the other hand are probably relatively frequent. One likely causal pathway suggested by research is the pathway through mood. Coping is strongly associated with mood, which in turn can affect health behavior and ultimately health. Another pathway that merits consideration is when active and avoidant forms of coping directly influence health behaviors, such as entry into the medical system, adherence to a treatment program, or ordinary behaviors of eating and exercising. There are also hypotheses, largely untested, that coping can affect immune function, possibly through mood, and immune function can in turn affect resistance to infectious diseases.

Research on Coping and Health: Where to Go from Here?

The overarching conclusion that emerges from research on coping and health is that to the extent that such a relationship does exist, it is most likely mediated through behavioral, affective, or immunological pathways, or some combination of all three. I am not expert enough to comment on possible immunological pathways. For those interested in the specific relationship between immune function and coping I recommend the work of Margaret Kemeny, Janice Kiecolt-Glaser, and Arthur Stone.

One of the most obvious directions for research on coping and health has to do with the subject of adherence. Advances in treatment have transformed some diseases that were previously fatal, such as HIV/AIDS, into chronic diseases that require adherence to treatment regimens over many years, and they have increased the complexity of other treatment regimens, such as Type I diabetes. As more and more previously terminal illnesses are transformed into chronic diseases that require long-term management, adherence becomes an increasingly important mediator of the coping-health relationship. We need more research on factors that interfere with adherence and factors that promote adherence. Coping is implicated in this research to the extent that stress affects individuals motivation and capacity to adhere.

It is clear that research about the relationship between coping and health will be helped along by improved measures of coping and coping outcomes. With respect to coping, paper-and-pencil measures can always be improved, but I would like to suggest that we turn to more qualitative techniques. It is time to supplement what we can learn with paper-and-pencil measures of coping with the analysis of narrative data. Peoples stories can provide us with different ways of thinking about coping and how it might be related to health. Our study of caregivers of partners with AIDS contained narratives that gave us exciting insights into meaning-based coping. In fact, the narratives that the men provided at the time of their partners deaths were so rich that I believed no one set of analyses would do them justice. So I invited four sets of investigators, each with experience in narrative analysis in the areas of bereavement, or emotion, to analyze the same set of narratives from 30 men. This study resulted in four articles on the same data, each using a different theoretical framework and a different method of qualitative analysis, and each producing different insights into responses to bereavement (see Folkman, 1997; Pennebaker, et al. 1997; Stein, 1997; Weiss & Richards, 1997; Nolen-Hoeksma, et al 1997) .

The measurement of coping outcomes also needs improvement. Thought needs to be given to the domains of outcomes that coping can reasonably be expected to affect. Currently, little thought seems to be given to this question. Measures of distress or psychological symptoms seem to be included in most coping studies almost automatically, without a clear rationale. Likewise, measures of physical health are included without a clear rationale as to why or how coping might be related to them. One entire domain of coping outcome that is rarely assessed has to do with the individuals ability to sustain his or her social roles in the face of stress and distress. People who are in the midst of severe stress may have high levels of distress no matter how well they cope, but they may still need to be able to function in their roles at work, with their family, or in the community. A good measure of coping outcomes should therefore also include an assessment of role functioning (Folkman & Moskowitz, 1998) .

In this section, however, I want to discuss coping and positive affect in the context of stress, a topic that has intrigued me for years. Although positive affect is sometimes included in studies of coping and mental health, little thought seems to have been given to its significance in the coping process. The domain of positive affect holds the potential for an exciting expansion of our understanding of how coping affects health. Let me make my case.

Coping and positive affect: Future directions

My interest in positive affect was reinforced by findings from our study of caregiving partners of me with AIDS that we conducted from 1990 until 1997. The 253 participants were for the most part in their late 30s and early 40s when the study began. This is a time of life when most people devote themselves to establishing long-lasting relationships, not bringing such relationships to a close. The participants were their partners primary caregivers, and as such they were confronted with challenges that were extraordinary in their complexity, intensity, duration, and requirements for expertise. These caregivers needed empathy, clinical knowledge, technical expertise, advocacy skills in the formal health care system, and what seemed to be unlimited emotional, mental, and physical stamina (Wrubel & Folkman, 1997) . As if this were not enough, about one-third of the participants were themselves HIV+. We assumed that this group would be doubly stressed because of the double-whammy of the caregiving and their own vulnerability to AIDS. Participants were interviewed every two months for the first two years and then every six months for three follow-up years. In addition to caregivers, the study also included a comparison group of 61 HIV+ men who were in relationships with healthy partners. The inclusion of this group allowed us to specify effects in the HIV+ caregiver group that were attributable to their HIV serostatus vs. their caregiver status.

We used multiple measures of both positive and negative psychological states. We expected and found high levels of negative psychological states. Throughout caregiving, participants levels of depressive symptomatology were typically more than one standard deviation above the norm in the general community, rising to two standard deviations above the norm at the time of the ill partners death (Folkman, et al. 1996) . Among the 156 caregivers whose partners died, levels of depressive symptoms reported during their first seven months of bereavement were comparable to those of bereaved spouses, and at seven months following the partners death, mean scores for depressive symptoms were still one standard deviation above the general community norm (Folkman, et al. 1996) . We were not surprised by these findings, given the extensive literature on the profound and enduring effects caregiving and bereavement have on depressed mood.

What we did not expect was that participants also reported high levels of positive psychological states during the course of caregiving and bereavement (Folkman, 1997) . Caregivers whose partners did not die during the course of the study reported positive states of mind at a level that was comparable to a community sample of urban university students not experiencing unusual stress (Horowitz, et al. 1988) . Throughout this same two year period, caregivers whose partners did not die experienced positive affect with at least as much frequency as they experienced negative affect (Folkman, 1997 ). Among caregivers whose partners died during the two-year period, the death of the partner was associated with modestly lowered scores on measures of positive psychological states during the month leading up to the partners death and for the five after the partners death. But after five months, scores on measures of positive states returned to their pre-bereavement levels.

A number people suggested that our finding might be limited to the community of gay men living in San Francisco, possibly because of the social support network that evolved in this community during the 1980s and 1990s, and possibly because of the upbeat influence of }New Age” beliefs. We were offered the opportunity to include the measures of depressive mood (CES-D, Radloff, 1977) and positive and negative affect (modified Bradburn, 1969) that we had used in our study of AIDS caregivers in Dr. Miriam Stewart's study of mothers of chronically ill children (diabetes, spina bifida, or cystic fibrosis) at Dalhousie University, Halifax, Nova Scotia. Dr. Stewarts sample differed from the San Francisco sample of AIDS caregivers not only in that it was all female, but unlike the San Francisco sample, the Nova Scotia sample was not advantaged educationally or financially, and they lived about as far from San Francisco as is possible within the North American continent. Despite these demographic differences, we found the same patterns in the mothers of chronically ill children as we had in the sample of gay men in San Francisco: depressive mood was elevated, but at the same time the frequency of positive affect was not only comparable to the frequency of negative affect, it was even significantly greater .

Zautra and his colleagues (Zautra, et al. 1990) examined positive and negative events in a longitudinal study of mental health in disabled and bereaved older adults. Both kinds of events were reported, again indicating the co-occurrence of positive and negative events. Zautra and his colleagues also made the interesting observation that the value of daily positive events vis a vis mental health was variable across groups. Bereaved individuals showed no positive effects of these events on their mental health, whereas disabled individuals showed sizable impacts. These researchers suggest that the major loss suffered by the bereaved group may overshadow all other experiences, changing the way in which positive events are interpreted. In contrast, for those who are disabled, daily positive events can represent significant achievements that can boost morale.

Affleck and Tennen (1996) focus on the related question of discovery of benefits from living with adversity. This phenomenon has been documented in the context of numerous medical problems. Affleck and Tennen distinguish between benefit-finding, which refers to beliefs about benefits from adversity, and benefit-reminding, which is the use of such knowledge as a deliberate strategy of coping with the problem. Thus, a person with a new medical condition that limits her mobility might come to believe that this is an opportunity for her to develop new strengths (benefit-finding), and she might draw on this belief (benefit-reminding) in situations where the limits to her mobility are particularly stressful.

I go even further in considering co-occurrence of positive and negative events or moods in terms of coping. My colleagues and I have suggested that positive psychological states -- whether in the form of positive events or positive affect -- serve three important coping functions under conditions of chronic and severe stress (Lazarus, et al. 1980; Folkman, 1997; Folkman, et al. 1997) . Positive emotions, such as eagerness and excitement, help motivate people to initiate coping under adverse conditions. These emotions -- challenge emotions -- go hand in hand with threat emotions such as anxiety, fear, and worry. Positive emotions, such as pleasure in what one has accomplished, or love for the one is caring for, help sustain people when the going gets tough. Positive emotions such as happiness at seeing a beautiful sunset or the enjoyment of a humorous comment, provide relief from distress. Events that give rise to these emotions might ordinarily be considered unremarkable or unnoteworthy. The need for relief -- for a psychological time-out -- from distress is what motivates these emotion responses. All three functions could help explain the finding by Zautra, Reich et al. (1990) that positive events had a salubrious effect on the mental health of disabled individuals.

Further, I don't think people are passive with respect to generating these emotions. I think people generate these emotions through a deliberate and effortful coping process. A number of very fine scientists, including Shelly Taylor and her colleagues (e.g., Taylor & Brown, 1988; Taylor & Brown, 1994 ), Ronnie Janoff-Bulman (1989) , Roxane Silver and Camille Wortman (Silver & Wortman, 1980; Silver, et al. 1983; Wortman, et al. 1993) , and Glenn Affleck and Howard Tennen (Affleck & Tennen, 1996) have written about psychological and social processes that people use to generate positive states when bad things happen. In our own research, we identified four meaning-based coping mechanisms that help account for positive affect: positive reappraisal, which is cognitive reframing of what has happened or that which might happen; goal-directed problem-focused coping, which includes knowing when to abandon goals that are no longer tenable and substituting new goals that are both tenable and meaningful; using spiritual or religious beliefs to seek comfort; and the infusion of meaning into the ordinary events of daily life in order to gain a psychological time-out from distress (Folkman, 1997; Folkman, et al. 1997; Stein, et al. 1997) .

Because most coping research has focused on negative affective outcomes and states of mental health, we know only part of the story. We need to address this imbalance in coping research by researching questions related to positive outcomes, including the coping processes that sustain them, underlying characteristics of the person and the social environment that promote these coping processes, and the functions of positive affective outcomes in the overall process of coping with health-related stress. The methodological issues that both characterize and impede research on coping and health, including the variability of coping processes, the problems inherent in trying to measure appropriate health outcomes, and the measurement of coping itself, apply to the study of coping and positive affect every bit as much as they do to the study of coping and other health-related outcomes. There are some excellent discussions of these methodological issues (for reviews see Aldwin, 1994; Zeidner & Endler, 1996) . Taking these methodological problems into account, and with the belief that future researchers in this area will be creative and thoughtful enough to solve them, I strongly encourage researchers on coping and health to look more carefully at positive as well as negative affective outcomes, to understand the relationship of these outcomes to health related behaviors, and to identify the cognitive and behavioral coping processes that uniquely support positive outcomes.

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Susan Folkman, Ph.D., is the Director of the University of California-San Francisco Osher Center for Integrative Medicine and the Bernard Osher Foundation Distinguished Professor of Integrative Medicine. She was appointed to these positions in 2001. She has been Professor of Medicine at UCSF since 1990, and from 1994 until 2001 she was Co-Director of the UCSF Center for AIDS Prevention Studies (CAPS). Dr. Folkman received her Ph.D. from the University of California at Berkeley in 1979, where she remained as a research psychologist until coming to UCSF and CAPS in 1988. She is internationally recognized for her theoretical and empirical contributions to the field of psychological stress and coping, with several of her publications among the most widely cited in psychology. Her work over the past 12 years has focused on stress and coping in the context of HIV disease and other chronic illness, especially on issues having to do with caregiving and bereavement. Her research is supported by grants from the National Institute of Mental Health and the National Institute of Nursing Research.. She currently serves on the NIH/NIMH National Advisory Mental Health Council and the NIH/Office of AIDS Research Advisory Council. She has chaired or been a member of various NIH study sections, served on Institute of Medicine and NIH workgroups, and was co-chair of the American Psychological Association task force on ethics in research with human participants. In 1997, she was awarded an honorary doctorate from the University of Utrecht, The Netherlands, for her contributions to coping theory and research.

The author may be reached at folkman@ocim.ucsf.edu

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