Discussion

Journal of Cognitive Psychotherapy: An International Quarterly, Volume 9, Number 1,1995

Coping With Life-Threatening Illness: A Cognitive Therapy Perspective

Bruce S. Liese Mark W. Larson

University of Kansas Medical Center

For years, behavioral scientists have been examining the process of coping with life-threatening illnesses. In fact, much of the work in this area has been influenced by cognitive-behavioral theories (e.g., Lazarus & Folkman, 1984). The purpose of this article is to apply Beck's model of cognitive therapy to coping, to discuss specific cognitive processes related to life-threatening illnesses, and to suggest specific interventions appropriate for individuals diagnosed with life-threatening illnesses. AIDS, cancer, and myocardial infarction are discussed in terms of the emotional reactions they may produce (e.g., anxiety, depression, and anger). Cognitive processes related to these emotions are examined and cognitive therapy techniques are suggested for helping individuals with maladaptive emotional and behavioral coping re- sponses.

A life-threatening illness can be defined as any disease or physiologic process that endangers an individual's biological existence. Multiple factors determine the life-threatening potential of an illness, including the type and stage of disease, the availability of effective treatment, compliance with treatment, and the patient's general health. While some illnesses are almost invariably life- threatening (e.g., pancreatic cancer and AIDS), most serious illnesses vary greatly in their threat to life (e.g., myocardial infarction and prostate cancer).

In this article the cognitive processes involved in coping with life-threaten- ing illnesses are discussed. Cognitive therapy is offered as an approach to counseling persons with life-threatening illnesses. Three specific diseases are

© 1995 Springer Publishing Company 19

20 Liese and Larson

highlighted: acquired immune deficiency syndrome (AIDS), cancer, and myo- cardial infarction. Heart disease and cancer are the leading causes of death in the United States, while AIDS is perceived by many to be the most frightening and deadly disease.

REVIEW OF LITERATURE

There is substantial variability across individuals in how they cope with life- threatening illnesses. While some experience severe depression or anxiety in response to a life-threatening illness, most individuals ultimately adapt effec- tively. In fact, Stanton and Snider (1993) report that "the psychosocial func- tioning of cancer patients differs little from that of disease-free controls over the long run" (p. 16).

Lazarus and Folkman (1984) in their classic text explain that individuals' coping styles are determined by their cognitive appraisals. Negative appraisals might involve threat or loss, e.g., "I'm not ready to die." "My family will suffer without me." In contrast, positive appraisals might involve hope and determi- nation e.g., "My time has come." "I'm ready for whatever comes next." "I'll fight this illness as best I can." Individuals' cognitive appraisals are influenced by personal and situational variables, e.g., age and family structure. For example, younger cancer patients experience significantly more emotional distress than older patients (Stanton & Snider, 1993).

Acquired Immune Deficiency Syndrome (AIDS)

An individual diagnosed with AIDS may be at risk for psychological problems and crises, including depression, suicidal ideation or attempts, anxiety, and somatic complaints (Kelly & Murphy, 1992). Cote, Biggar, and Dannenberg (1992) found that persons with AIDS had suicide rates that were "7.4-fold higher than among demographically similar men in the general population" (p. 2066). Catania, Turner, Choi, and Coates (1992) used the term "death anxiety" to describe the emotional discomfort associated with thoughts of death or dying from AIDS. These authors, like others, report that emotional responses to AIDS are related to premorbid psychological functioning, as well as the course and severity of the disease.

In a recent article, Liese (1993) described the process of coping with AIDS from the perspective of cognitive therapy. He suggested that a diagnosis of AIDS serves as a "critical incident" which activates the patient's basic beliefs about himself, his personal world, and his future. He proposed cognitive therapy as a method for helping patients cope with the life-threatening nature of AIDS. In this report, Liese's (1993) work is extended to other life- threatening illnesses.

Coping With Life-Threatening Illness 21

Cancer

To many people, "cancer" is synonymous with "death." However, different types of cancer have different courses, treatments, and outcomes. The potential for death from cancer varies from "low" (e.g., basal cell cancer, which is relatively "curable") to "high" (e.g., pancreatic cancer, which may cause death in several months). Similarly, Anderson (1992) ranks psychological and behavioral morbidity risk from "low" (when the patient's cancer is localized with favorable prognosis) to "high" (when the patient's cancer has metasta- sized to distant sites with dismal prognosis). She concludes, from her review of psychological interventions for cancer patients, that there is a significant correlation between severity of the disease/treatment and psychological ad- justment. In low-risk cancers, Anderson explains, "when localized disease is controlled and recovery proceeds unimpaired, the severe distress of diagnosis dissipates and emotions stabilize by 1 year post-treatment. In fact, the greatest improvement can be found as early as 3-4 months post-treatment" (p. 556). Anderson explains that psychological morbidity is much more variable in patients who are moderate-risk to high-risk. Patients with severe disease may experience extreme emotional distress in response to "increasing physical debilitation or difficult-to-manage symptoms, such as pain" (p. 560).

Dunkel-Schetter, Feinstein, Taylor, and Falke (1992) administered the Ways of Coping (WOC) inventory (Lazarus & Folkman, 1984) to study patients' patterns of coping with cancer. In their sample of 603 cancer patients, the emotional problems reported were fear or uncertainty about the future (41%), limitations in physical ability (24%), pain (12%), and problems in social relationships (3%). Some patients (9%) reported experiencing more than one of these problems, while others (6%) denied any stress from their cancer. In this study, investigators identified five patterns of coping with these problems: (a) seeking or using social support, (b) focusing on the positive, (c) distancing, (d) cognitive escape-avoidance and (e) behavioral escape-avoid- ance. Dunkel-Schetter and colleagues tested relationships between these pat- terns and sociodemographic characteristics, medical factors, stress appraisals, psychotherapy experience, and emotional distress. They found that cancer patients used multiple coping methods in a flexible fashion, depending on the nature of their particular problems and distress levels.

Stanton and Snider (1993) prospectively studied the course of coping in 117 women with newly diagnosed breast cancer. They found that patients diag- nosed with cancer (compared with those whose biopsies were negative) were more tense, depressed, angry, fatigued, and confused between the time of diagnosis and surgery. These problems, with the exception of fatigue, were found to return to levels equal to controls after surgery. The investigators reported that "Consistent with the model of Lazarus and Folkman (1984), personal attributes, cognitive appraisals, and coping processes all were asso- ciated with prebiopsy mood" (p. 21).

22 Liese and Larson

Myocardial Infarction

There have been numerous studies of the coping processes of individuals who experience acute myocardial infarctions (Mis). Faller (1990) focused on the immediate cognitive and emotional responses to an MI (i.e., denial and anxiety). He explained "anxiety can be understood as the turning of attention to features of threat, and denial as turning attention away from these features" (p. 9). In his study, 50 of 51 patients reported anxiety, while 45 admitted to denial of the event. He explained that most MI patients experiencing cardiac pain initially attribute their pain to some noncardiac cause. This psychological phenomenon (i.e., "denial") may account for numerous MI mortalities since most MI deaths occur shortly after the onset of symptoms. Faller interprets denial as the patient's attempt to cope by cognitively "undoing" the MI.

Scherck (1992) studied the cognitive and emotional processes occurring during the first 3 days after an MI. In a descriptive study of 30 acutely ill MI patients, she administered the WOC Inventory (Lazarus & Folkman, 1984) and the Jalowiec Coping Scale (Jalowiec, Murphy, & Powers, 1984). Scherck found that a wide variety of strategies were used by individuals to reduce, minimize, master, and tolerate the MI. In her sample, she found denial of an MI to be uncommon. The results of Scherck's study were limited by its small, nonrandom sample.

A number of studies have examined the incidence of major depression following an MI. In one study of 129 patients (Forrester, Lipsey, Teitelbaum, DePaulo, & Andrzejewski, 1992), 19% (N = 25) were found to have major depression. This diagnosis was found to correlate positively with severity of the MI, female sex, functional impairment, and prior history of a mood disorder.

Legault, Joffe, and Armstrong (1992) studied the incidence of cognitive impairment, anxiety, and depression in 92 patients admitted to the cardiac care unit. In their sample, 52 patients were found to have Mis, 23 had unstable angina, and 17 were found to have noncardiac chest pain. The investigators compared psychological and cognitive functioning among these groups. They found a greater incidence of depression and cognitive impairment in the confirmed MI group. Depression was found to be correlated with increased morbidity and mortality on follow-up. Anxiety was found to be comparable between MI and non-Mi groups during hospitalization, and it was uncorrelated with posthospital cardiac and psychosocial morbidity.

In a study by Martin and Lee (1992), coping styles were found to be influenced by previous life events and by "insecurity" as a personality style. Patients with high levels of insecurity were found to see an MI as a threat rather than a challenge. In contrast, patients with positive life experiences were found to exhibit active coping styles in response to an acute MI.

In general, the process of coping with an MI is related to disease severity,

Coping With Life-Threatening Illness 23

beliefs about the MI, and patients' premorbid personalities. Thus, coping with an MI is analogous to coping with other life-threatening illnesses.

OVERVIEW OF COGNITIVE THERAPY

Background

Cognitive therapy has been developed over the past 30 years by Dr. Aaron T. Beck and his colleagues (Beck, 1991; Beck & Emery with Greenberg, 1985; Beck, Freeman, & Associates, 1990; Beck, Rush, Shaw, & Emery, 1979; Beck, Wright, Newman, & Liese, 1993). The basic model of cognitive therapy is presented in Figure 1. According to this model, individuals have early life, experiences which result in the development of schemas, basic beliefs, and conditional beliefs about themselves, their personal worlds, and their futures. These basic beliefs may lie "dormant" until they are activated by critical incidents. Upon activation, schemas and related beliefs manifest themselves as automatic thoughts which impact individuals' emotions, behaviors, and physi- ologic responses.

Early in life children experience minor illnesses such as colds, viruses, earaches, and so forth. Under normal circumstances these illnesses resolve themselves. As a result children develop the basic belief "Whenever I get sick I get better." As adults, individuals with minor illnesses typically believe "This is just an inconvenience" and "I'm never sick for very long; I'll recover soon." The automatic thoughts associated with these beliefs might be "No big deal!" or "Oh well!" Such thoughts facilitate relatively calm feelings, "normal" levels of physiologic arousal, and appropriate self-care behaviors (ranging from nose-blowing to bedrest).

In contrast to individuals with minor health problems, those diagnosed with life-threatening illnesses may undergo sudden changes in their thoughts about themselves, their personal worlds, and their futures. Life-threatening illnesses may therefore function as critical incidents which activate basic beliefs and automatic thoughts about death, dying, pain, and suffering. Such thoughts might trigger extreme negative emotions (e.g., anxiety, depression, and anger).

Maladaptive Thoughts and Life-Threatening Illnesses

Beck and colleagues (1979) explain that systematic errors in thinking (i.e., faulty information processing) account for a substantial degree of emotional distress. The following is a list of maladaptive thinking patterns (Beck et al., 1979; p. 14) with examples of thoughts potentially activated by life-threatening illnesses.

1. Arbitrary inference—drawing a specific conclusion in the absence of evidence (e.g., "My cancer is punishment for how I've lived.")

24 Liese and Larson

2. Selective abstraction—focusing on a detail taken out of context, ignoring more salient features of a situation (e.g., "Having a heart attack makes me an extremely weak person.")

3. Over generalization—drawing a general rule or conclusion, based on isolated incidents (e.g., "Everything has gone wrong with my life since my diagno- sis of HIV.")

4. Magnification and minimization—errors in evaluating the significance or magnitude of an event (e.g., 'There is nothing attractive about me since my mastectomy.")

FIGURE 1. The cognitive model.

Coping With Life-Threatening Illness 25

5. Personalization—relating external events to oneself without basis for doing so (e.g., "Ever since my diagnosis of AIDS I notice that everybody withdraws from me.")

6. Absolutistic, dichotomous thinking—placing events in one of two extreme, or opposite, categories (e.g., "If I can't live well I might as well die.")

These six categories are not mutually exclusive. In fact, there is substantial overlap between these categories. For example, the thought "If I can't live well I might as well die" reflects dichotomous thinking, overgeneralizing, magni- fication, and minimization. This classification system provides an objective method for identifying and labeling distortions that might result in maladaptive feelings and behaviors. A major goal of cognitive therapy for patients with life- threatening illnesses is to help them think about their illnesses in objective, adaptive ways.

Emotional Responses to Life-Threatening Illnesses

When life-threatening illnesses activate strong negative beliefs, resulting emotions can include anxiety, depression, and anger. Individuals with life- threatening illnesses face particularly uncertain futures. For example, those who have colon cancer with distant metastases (e.g., to the liver) have 5-year survival rates of less than 10% (Boring, Squires, & Tong, 1991). As a result of profound uncertainty about the future, such individuals might experience acute anxiety, panic or terror. In their study, Dunkel-Schetter and colleagues (1992) found that fear (i.e., uncertainty about the future) was the most frequently reported problem in patients facing cancer. Stanton and Snider (1993) found that peak levels of anxiety occurred between the time the cancer was diagnosed and surgical intervention.

Individuals with life-threatening illnesses might be vulnerable to depres- sion as a result of negative beliefs activated by their illnesses. In fact, some diseases create more vulnerability to depression than others, especially if individuals blame themselves for developing the disease. A cigarette smoker, for example, might experience feelings of guilt related to such beliefs as "I deserve cancer since I brought it upon myself." An individual diagnosed with AIDS might believe "Only worthless, terrible people get this disease." In fact the moral stigma associated with AIDS adds to a person's risk of becoming depressed.

Quite often medical decisions are made for individuals with life-threatening illnesses, including decisions about medical tests, examinations, diet, sleep, and so forth. When faced with these experiences, some individuals might perceive themselves as losing independence, autonomy, privacy, and even dignity. In response some individuals might think, "I don't have to take this! I'll show them!" which results in hostile behaviors and ultimately exacerbates

26 Liese and Larson

their problems. In these cases cognitive therapy might be used to teach individuals moreadaptive ways of viewing such situations. Behaviorally they might be taught alternative methods for seeking validation (e.g., assertiveness training).

Eventually, individuals with life-threatening illnesses experience relief from emotional distress. Such relief might result from perceived improve- ments in their health. Since anxiety is related to uncertainty, relief might also occur when individuals receive objective information about their illnesses. Stanton and Snider (1993) found that patients experience relief after cancer surgery, when they are more optimistic about their health. Individuals also experience relief when they accept their medical prognoses or learn to distract themselves from their medical problems. Another goal of cognitive therapy, then, is to help individuals with life-threatening illnesses accept their condi- tions and to focus on comforting aspects of living and dying.

The crisis of a life-threatening illness provides an opportunity for personal growth. In cognitive terms, personal growth involves the development of more objective, adaptive, "healthy" thoughts, resulting in more adaptive feelings and behaviors. Anderson (1992) explains that the psychological gains which occur during the diagnostic, treatment, or early recovery periods often con- tinue or increase during the first posttreatment year. She describes this process as "the continuation of active behavioral coping, positive cognitions, and so forth" (p. 562).

For many individuals the diagnosis of a life-threatening illness activates "spiritual" or "existential" questions, for example: "Why me?" "Why now?" "What have I done with my life?" "What happens when I die?" "Is there an afterlife?" and so forth. In response to these questions, individuals may reflec on previously held beliefs or they may seek new answers to these questions. When these questions are satisfactorily answered, personal growth can occur. Thus, another goal of cognitive therapy is to facilitate exploration of these issues when they are raised by patients.

THE APPLICATION OF COGNITIVE THERAPY Cognitive therapy consists of five main components: (a) therapist-patient collaboration, (b) case conceptualization, (c) therapeutic structure, (d) patient education, and (e) cognitive-behavioral techniques. Each of these components of cognitive therapy is important for helping patients with life-threatening illnesses.

Therapist-Patient Collaboration

Anderson (1992) explains that interventions for patients with severe life- threatening illnesses can be "demanding." The therapist must be "comfortable with difficult topics and circumstances" (p. 563). Difficult topics might include pain, death, suffering, God, religion, spirituality, afterlife, and so forth.

Coping With Life-Threatening Illness 27

Difficult circumstances might include bedside counseling of barely clothed patients who are connected to pumps and monitors with tubes and wires.

Since individuals with life-threatening illnesses are particularly vulnerable it is assumed that they will appreciate therapeutic relationships which are collabo- rative in nature. Collaboration involves the sharing of responsibility for therapeutic process and outcome. When the therapist and patient are collaborative they function as a team where each views the other as essential to the therapeutic process. Unfortunately, medical settings are not generally conducive to such collaboration. In fact, the medical model traditionally assigns "expert" status to medical personnel and "passive-dependent" status to patients.

Case Conceptualization

The case conceptualization is defined as the comprehensive formulation of the patient's psychological and behavioral problems. This formulation provides the therapist with an understanding of the "whole patient." The case conceptualization is the compilation and synthesis of the patient's identifying information, presenting problem, current functioning, psychiatric diagnoses, developmental profile, and cognitive profile (Beck.Wright, Newman, & Liese, 1993).

The case conceptualization is extremely important in helping patients with life-threatening illnesses because it enables the clinician to assess past and present cognitive, behavioral, and affective coping processes. In particular, it enables the cognitive therapist to understand how the patient's present coping processes relate to past coping patterns and life experiences.

The following case example is provided to illustrate the cognitive case conceptualization.

Identifying Information. "Paul," a 38-year-old attorney, was diagnosed with AIDS approximately three months ago. At the time of his diagnosis he had been in a 2-year monogamous homosexual relationship with his lover, "Curt."

Presenting Problem and Current Functioning. Paul was referred by his family physician for problems with depression. His symptoms included sad- ness, crying spells, sleep difficulties, poor concentration, irritability, and extreme anxiety. He denied suicidal ideation or intent. He reported distractibil- ity at work, as well as increased tension and "bickering" with Curt.

Psychiatric Diagnoses.

Axis I: Major depressive episode, moderate severity Axis II: Avoidant and dependent features (insufficient for diagnosis of

personality disorder) Axis III: AIDS (pneumocystis, frequent night sweats) Axis IV: Extreme stress (severe illness; score = 5) Axis V: Global Assessment of Functioning = 60 (moderate impairment)

28 Liese and Larson

Developmental Profile. Paul was raised in an upper-middle-class family where academic and career success were extremely important. He completed his law degree with honors and became a partner after 5 years at his law firm.

Paul was an "only child" whose parents expected him to perform well in all facets of his life. He learned early that their attention and affection were contingent upon his doing well in school and in sports. Though actually a shy person, Paul compensated for his shyness by entertaining others with his wit and humor. As a result he became very popular (i.e., a "people pleaser").

Cognitive Profile. As a result of his early life experiences, Paul developed the following two basic beliefs about himself in relation to others: "I am lovable only when I please others" and "I am adequate only when others love me." As his main compensatory strategy, Paul engaged in numerous approval seeking behaviors. For example, he acquired AIDS prior to his relationship with Curt by engaging in promiscuous sexual behaviors. He described his sexual promiscuity as an attempt to "avoid feeling desperately lonely."

Upon entering therapy Paul had the following basic beliefs and automatic thoughts:

"Now I'm really unlovable and defective." "I have disappointed everyone who matters to me." "I deserve AIDS because of my behavior." "I am likely to die soon so I might as well give up."

At the time he entered therapy Paul felt sad, lonely, and guilty. He had also begun to isolate himself from others, which exacerbated these feelings.

Summary and Integration. From childhood, Paul's self-esteem was contin- gent upon others' opinions of him. As a result he was particularly vulnerable to depression and self-defeating behaviors. Paul's diagnosis of AIDS served as a critical incident which activated his negative schemas, beliefs, and automatic thoughts.

Therapeutic Structure

Each cognitive therapy session is structured as follows: (a) Agenda items are generated by the patient, (b) the therapist checks the patient's mood, (c) the therapist "bridges" from the last visit, (d) agenda items are prioritized and discussed, (e) capsule summaries are provided throughout and at the end of the session by the therapist, (f) previous homework is reviewed and new home- work is initiated, and (g) feedback is elicited from the patient.

Paul (from the example above) was surprised to discover the high degree of structure in cognitive therapy. During his second session Paul commented that the structure made therapy seem "kind of impersonal." With a great deal of encouragement from the therapist, Paul was able to admit (to the therapist):

Coping With Life-Threatening Illness 29

"You seem more concerned about problem-solving than you are about me as a person." They discussed this belief and Paul learned from his therapist that such beliefs reflect "mind-reading." Paul eventually realized from his therapist's spontaneous warmth and empathy that his therapist genuinely cared about him. He further learned that therapeutic structure would contribute substantially to defining problems and resolving them.

Patient Education

Patient education is an important component of cognitive therapy. Through patient education, cognitive therapists present important information to pa- tients in order to modify their existing maladaptive thoughts and beliefs. Cognitive therapists can provide education about numerous issues, including their patients' psychiatric diagnoses, cognitive distortions, the cognitive model as it applies to patients' problems, and so forth.

In order to be effective, patient education must be well-timed and appropri- ately presented. To the patient with a life-threatening illness, for example, direct disputation of distorted beliefs in an untimely fashion (i.e., prematurely) might be counterproductive to the therapeutic process. For example Paul admits to the belief "I am likely to die soon so I might as well give up." If his therapist responds with the statement "That's all-or-none thinking!" Paul is likely to perceive the therapist as minimizing his problem or being naive about AIDS. Alternatively the therapist is encouraged to use probing questions and empathetic reflective responses in order to guide Paul to his own conclusions about this thought. (This technique, known as the Socratic method, will be discussed more fully in the next section.)

Cognitive and Behavioral Techniques

Cognitive and behavioral techniques are strategies used to modify patients' maladaptive thoughts, feelings, and behaviors. There are hundreds of such techniques associated with cognitive therapy. Several of these are summarized in this section: the Socratic method, the three-question technique, the Daily Thought Record , and the weekly activity schedule.

The Socratic method, also known as "guided discovery," is an approach to interviewing which facilitates patients' insight and understanding (i.e., dis- covery) of their psychological and behavioral coping processes (Overholzer, 1987,1993a, 1993b). This is a method of interviewing whereby therapists ask open-ended, probing questions of patients, and they reflect (i.e., paraphrase) patients' verbal and nonverbal responses. These two techniques (open-ended questions and reflection) allow patients to gain more objective, adaptive perspectives on their problems.

The following dialogue between Paul and his therapist illustrates the

30 Liese and Larson

Socratic method. (The techniques of open-ended questioning and reflection are noted in parentheses.)

Therapist

Paul: Pretty depressed.

You seem depressed, (reflection) What have you been think- ing about? (open question) My life seems wasted at this point.

Therapist: What do you mean by "wasted"? (open question) Paul: It seems like nothing matters anymore. Therapist: "Nothing." (reflection)... [long pause] Can you think of

anything that does matter? (open question)

Paul: [long pause] Curt is important, I guess.

Therapist: You only "guess?" (reflection/question)

Paul: Okay, Curt really is important.

Therapist:

Paul: I guess my friends are still important to me.

Therapist:

Paul: They really seem to care about me.

Therapist: what thoughts do you have? (open question)

Paul: Well, I guess my life isn't completely wasted.

Therapist: (open question)

Paul: Somewhat less upset...

In this dialogue, the therapist has begun to help Paul feel emotional relief simply by guiding him to think about his important relationships with Curt and his friends. The Socratic method facilitates Paul's ability to discover his own positive thoughts, resources, and strengths, rather than having the therapist advise or dispute maladaptive thoughts.

The three-question technique is a specific form of the Socratic method. In the three-question technique, therapists ask a series of three open-ended questions in order to help patients review and revise their negative thoughts. It may be tempting for therapists to reassure and advise patients of ways to feel better. However, advice and reassurance are often ineffective under such conditions. The three questions help patients discover, for themselves, reasons for feeling better. After a negative, distorted belief has been identified, the therapist asks: (1) What evidence do you have for that belief? (2) How else can you look at the situation? (3) If the belief is true, what are the implications? To illustrate the three-question technique, consider the following continuation of

Therapist:

Paul:

are you feeling today? (open question)

What makes your friends important to you? (open question)What mak

What else is important to you? (open question)

es your friends important to you? (open question)

When you consider your importance to Curt and your friends,

And how do you feel when you think your life is not wasted?

Coping With Life-Threatening Illness 31

the above dialogue.

Therapist: (reflection) What is your evidence for this belief? (question #1)

Paul: I don't have any evidence. I just feel that way. Therapist: You "just feel that way." (reflection) How else could you look

at the situation? (question #2)

Paul: I guess my life isn't wasted if I'm still important to Curt.

Therapist: If, in fact, you weren't important to Curt, what would the implications be? (question #3)

Paul: I guess it might be tolerable if my friends didn't abandon me.

In this very brief interaction, Paul's therapist helps him to become more objective about his own worth. In fact, when Paul realizes that his life has some meaning, he begins to experience emotional relief.

Another important cognitive therapy technique is the Daily Thought Record (DTK). Following the structure of the DTR, patients are asked to monitor their emotions and the automatic thoughts, situations, and rational responses which correspond to these emotions. As a result of completing DTRs, patients become more attentive to their maladaptive thought processes. If the DTR is done correctly, patients will experience relatively rapid relief from emotional distress.

Paul's therapist had him complete at least two DTRs daily when Paul first began therapy. At that time Paul had reported feeling extremely depressed. Hence, "entering counseling" was written in the situation column and "depres- sion" was written in the emotions column. Paul revealed that his automatic thoughts about counseling were: "It's hopeless. I won't benefit from this." These were written in the automatic thoughts column. The therapist helped Paul, using the Socratic method, to identify rational responses to his belief "It's hopeless." With prompting, Paul proposed the alternative, more adaptive thoughts: "In fact, I can't say for sure that there is no hope." "Maybe there is some hope for me."

The weekly activity schedule can be a useful cognitive-behavioral technique for helping patients to cope with the disorganization and loss of structure which often accompany a life-threatening illness. Using a blank calendar, therapists have patients keep hour-by-hour records of activities for a specified period of time (e.g., 1 week). At the end of that time, they review patients' activities, with attention paid to those which improve or exacerbate the patient's emotional distress. Again, consider a dialogue which takes place between Paul and his therapist.

Therapist: How did you do on your homework? (open question)

Paul: Fine. Here is my calendar for the week. [They both look at the

(reflection) What is your evidence for this belief?asted.,

32 Liese and Larson

completed weekly activity schedule.]

Therapist: What did you learn from this schedule? (open question)

Paul: I learned that I've really isolated myself since my diagnosis.

Therapist: You've "isolated" yourself, (reflection) What do you mean by that? (open question)

Paul: I just don't do any of the important things I used to do.

Therapist:

Paul: Like spending quality time with Curt.

Therapist: What's keeping you from doing those things now? (open question)

Paul: Only myself, I guess.

Therapist: What do you mean by "only myself? (open question)

Paul: I guess I could still do all of that stuff.

Therapist: And if you did, how would you feel? (open question)

Paul: Better, I'm sure.

Therapist: So how can you begin to stop isolating yourself? (open question)

Paul: By making some plans.

Therapist: Okay, let's try that. Let's start with a new weekly activity schedule. [The therapist provides a blank calendar.]

Upon gaining a better understanding of his current activities, Paul and his therapist collaboratively planned a more self-enhancing schedule. As home- work, Paul continues to monitor his activities and they review the weekly activity schedule in follow-up visits.

These cognitive-behavioral techniques are most effective when they are used in conjunction with each other. In fact, the Socratic method of interview- ing is vital to the success of almost all cognitive strategies. Unfortunately, space limitations prohibit extensive review of these techniques. (For a more detailed presentation of these, see Beck et al., 1979,1985,1990,1993.)

Life-threatening illnesses such as AIDS, cancer, and heart disease are critical incidents which may trigger emotional crises (i.e., anxiety, depression, anger, and other distressing emotions). The process of coping with these illnesses is related to the course and severity of the illness, personal variables, situational variables, and cognitive appraisal processes. Cognitive therapy is a time-limited, structured psychotherapy, well suited to individuals with life- threatening illnesses.

Like what? (open question)

Coping With Life-Threatening Illness 33

REFERENCES Anderson, B.L. (1992). Psychological interventions for cancer patients to enhance the

quality of life. Journal of Consulting and Clinical Psychology, 60(4), 552-568. Beck, A.T., Wright, F.D., Newman, C.F., & Liese, B.S. (1993). Cognitive therapy of

substance abuse. New York: Guilford. Beck, A.T. (1991). Cognitive therapy: A 30-year retrospective. American Psycholo-

gist, 46(4), 368-375. Beck, A.T., Freeman, A., & Associates (1990). Cognitive therapy of personality

disorders. New York: Guilford. Beck, A.T., & Emery, G., withGreenberg, R.L. (1985). Anxiety disorder sand phobias:

A cognitive perspective. New York: Basic Books.. Beck, A.T., Rush, A.J., Shaw, B., & Emery, G. (1979). Cognitive therapy of depres-

sion. New York: Guilford. Boring, C. C., Squires, T.S., & Tong, T. (1991). Cancer statistics, 1991. CA - A Cancer

Journal for Clinicians, 41(1), 19-36. Catania, J.A., Turner, H.A., Choi, K., & Coates, TJ. (1992). Coping with death

anxiety: Help-seeking and social support among gay men with various HIV diagnoses. AIDS, 6, 999-1005.

Cote, T.R., Biggar, R.J., & Dannenberg, A.L. (1992). Risk of suicide among persons with AIDS: A national assessment. Journal of the American Medical Associa- tion, 268(15), 2066-2068.

Dunkel-Schetter, C., Feinstein, L.G., Taylor, S.E., & Falke, R.L. (1992). Patterns of coping with cancer. Health Psychology, 11(2), 79-87.

Faller, H. (1990). Coping with myocardial infarction: A cognitive emotional perspec- tive. Psychotherapy and Psychosomatics, 54, 8-17.

Forrester, A.W., Lipsey, J.R., Teitelbaum, M.L., DePaulo, J.R., Andrzejewski, P.L., & Robinson, R.G. (1992). Depression following myocardial infarction. Interna- tional Journal of Psychiatry in Medicine, 22, 33-46.

Jalowiec, A., Murphy, S.P., & Powers, M.J. (1984). Psychometric assessment of the Jalowiec Coping Scale. Nursing Research, 33, 157-161.

Kelly, J.A., & Murphy, D.A. (1992). Psychological interventions with AIDS and HIV: Prevention and treatment. Journal of Consulting and Clinical Psychology, 60(4), 576-585.

Lazarus, R.S. & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer Publishing Company.

Legault, S.E., Joffe, R.T. & Armstrong, P.W. (1992). Psychiatric morbidity during the early phase of coronary care for myocardial infarction: Association with cardiac diagnosis. Canadian Journal of Psychiatry, 37, 316-325.

Liese, B.S. (1993). Coping with AIDS: A cognitive therapy perspective. Kansas Medicine, 94(3), 80-84.

Martin, P., & Lee, H. (1992). Indicators of active and passive coping in myocardial infarction victims. Journal of Gerontology :Psycholog ical Sciences, 47(4), 238- 241.

Overholzer, J.C. (1987). Facilitating autonomy in passive-dependent persons: An integrative model. Journal of Contemporary Psychotherapy, 17(4), 250-269.

Overholzer, J.C. (1993a). Elements of the Socratic method: I. Systematic questioning. Psychotherapy, 30(1), 67-74.

Overholzer, J.C. (1993b). Elements of the Socratic method: II. Inductive reasoning. Psychotherapy, 30(1), 75-84...

Scherck, K.A. (1992). Coping with acute myocardial infarction. Heart & Lung, 21, 327-334.

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Stanton, A.L., & Snider, P.R. (1993). Coping with a breast cancer diagnosis: A prospective study. Health Psychology, 12(1), 16-23.

Offprints. Requests for offprints should be directed to Bruce S. Liese, PhD, UKMC-Family Practice, 3901 Rainbow Blvd., Kansas City, KS 66160-7370.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.