Irritable bowel syndrome (IBS) is a common, oftentimes disabling gastrointestinal
(GI) disorder affecting some 40 million individuals. For many people with IBS, pharmacological
and dietary options fall short of therapeutic objectives at least for the full range
of GI symptoms. When patients fail to respond, even the most technically skilled gastroenterologist
has little to offer but to encourage the patient with IBS to cope with it. While few
would argue with such advice, just what coping means is hard to define.
What Is Coping?
Coping refers to the specific thoughts and behaviors that people use to master, tolerate,
reduce, or minimize stressful events. One way that researchers categorize coping strategies
is in terms of their function.
1
Problem-focused strategies, such as taking direct action or confronting a problem
head on, are designed to resolve or fix a stressor. For example, a 57-year-old female
who suddenly experiences bouts of abdominal pain and finds blood in her stool relies
on problem-solving strategies when she calls to schedule an appointment with her gastroenterologist
and follow up colonoscopy. Emotion-focused strategies, on the other hand, are efforts
to manage the distress of stressful or potentially stressful events. Until she receives
the results of the colonoscopy, there is little the patient can do but to manage distress
caused by uncertainty by adopting emotion-focused strategies. Taking a walk, relaxing,
talking to friends, controlling “what if?” thoughts are examples of emotion-focused
strategies.
Research indicates that people use both types of strategies to deal with stressful
events
2
because both are useful in specific situations.
3
Problem-focused coping strategies work better for controllable problems such as work-related
problems and family-related problems, while emotion-focused coping works best in less
controllable situations, such as, certain kinds of physical health problems. This
means that that effective coping depends on matching ones control over life events
to the proper coping strategy. Calibrating coping strategies to control beliefs is
called “goodness of fit”
1
and its value has been supported in numerous studies with patients with different
medical problems including those undergoing hemodialysis,
4
women undergoing in vitro fertilization,
5
multiple sclerosis,
6
HIV,
7
and congestive heart failure.
8
These data indicate that effective coping requires a degree of mental flexibility
that allows one to toggle back and forth between emotion-focused and problem-focused
coping strategies depending on how changeable a problem is in a given situation.
A study published in a top tier behavioral science journal, Healthy Psychology, shows
that coping flexibility may be particularly important for patients with functional
gastrointestinal disorders.
9
The study9 was conducted by a research team led by Cecilia Cheng of Honk Kong University
of Science and Technology. They examined the typical coping strategies functional
GI disorder (FGID) patients relied on for managing different stressors that varied
in terms of controllability. The authors found that FGID patients have an inflexible
coping style that is geared toward fixing a problem regardless of its controllability.
For those medical professionals who struggle with managing complex IBS patients, the
study sheds light on the idiosyncratic way that FGID patients cope with stress and
offers clues to improving medical outcomes that depend on improving patients' coping
efforts.
Study Details
Participants included 120 adults (50% female) who formed three balanced groups. The
first group consisted of participants with IBS or functional dyspepsia. The second
group included arthritis patients, while the third group included healthy controls.
Individuals in all groups were matched on sociodemographic variables. Semi-structured
interviews were administered to examine type of coping responses (emotion-focused
vs problem focused) subjects used to deal with for uncontrollable and controllable
stressors.
Study Findings
The authors found that the healthy controls and arthritis patients had similar coping
styles for dealing with stress. They relied on a combination of emotion- and problem-focused
coping strategies and matched their use of coping strategy to the controllability
of the problem (Figure 1). As the figure below shows, when faced with controllable
problems, these individuals took direct action using problem-focused responses much
as the “goodness of fit” hypothesis predicts. With uncontrollable problems, they used
emotion-focused strategies, such as, acceptance, relaxation, or seeking support from
others. FGIDs patients, on the other hand, showed a more rigid coping style. Regardless
of whether the problem was uncontrollable or controllable they favored action-oriented
strategies, attempting to problem-solve or otherwise confront the problems head on
in an effort to solve them. The coping skills they used less frequently—emotion-focused
strategies—were associated with less severe physical symptoms.
At the time this study was published conventional wisdom held that effective coping
required patients to improve their ability to brainstorm solutions for problems.
10
The thinking was that FGID patients had problem solving deficits that made it difficult
for them to generate solutions to problems. But the Cheng et al. data suggest that
the problem for FGID patients was not an inability to solve problems. After all, problems
that got under their skin were uncontrollable and therefore largely insolvable. Teaching
patients to brainstorm for solutions to insolvable problems ran the risk of reinforcing
an overreliance of problem focused strategies which in turn can magnify stress, disrupt
brain-gut interactions, and aggravate GI symptoms. To us, this was a prescription
for stress not its relief. More important than knowing how to solve a problem was
the ability to accurately gauge just how much control they had over a problem and
respond accordingly. This meant teaching patients to expand their coping skills by
learning emotion-focused coping strategies.
To this end, FGID patients needed to learn how to appraise accurately the controllability
of a stressor and then deploying the best coping strategy (Figure 2). What type of
coping strategy patients picked should flow from how much control the patient realistically
has over the event not their personal preference for fixing a problem. We call this
flexible problem solving and it is a core component of the behavioral treatment program
we have developed at the University at Buffalo and featured in 3 NIH grants over the
past 15 years.
11, 12
Our approach teaches flexible coping skills for tackling both controllable and uncontrollable
problems. Through didactic instruction and structured exercises, patients learn to
break down a problem, assess its controllability, and adopt the best coping strategy
across different situations. For uncontrollable problems, patients learn concrete
strategies geared toward managing the emotional unpleasantness of the situation (e.g.,
cultivating acceptance, “letting go”, worry control, muscle relaxation, emotional
disclosure, and enlisting social support). For controllable stressors, patients are
encouraged to do what comes easy to them: employ strategies for solving or “fixing”
the situation itself. This approach is captured in the above figure.
Practical Implications for The Clinical Gastroenterologist
The “goodness of fit” principle can serve as a useful decision making model for GEs
managing complex IBS patients. From this perspective, many behaviors that frustrate
GEs (e.g., requests for further diagnostic testing, reassurance seeking, “doctor shopping”,
complaining, and so on) can be understood as a product of a rigid coping response
geared toward fixing a problem. Well-intentioned physicians who often feel a need
to “do something” risk reinforcing action-oriented coping efforts. The use of a problem-focused
coping response for a problem that is either uncontrollable or less controllable than
desired is a prescription for patient dissatisfaction, distress, worry, and health
care inefficiency. A more useful strategy is to recognize the largely uncontrollable
nature of residual symptoms and strengthen patients' use of emotion-focused coping
strategies. This can be facilitated through the use of improved communication skills.
13
A coping skills approach that highlights the importance of matching control beliefs
to coping efforts is what we call a “top down” approach. It has inherent advantages
over a “bottom up” approach that is driven by patient or physician preferences for
fixing a problem. Because a bottom up approach circumvents the critical question of
whether a situation is changeable it is inherently problematic when the patient confronts
stressors for which there is no satisfactory solution. (Anecdotally, of the different
self-management skills we teach patients, flexible problem solving is a strategy patients
theyenrolled in our clinical trials find particularly useful.)
The Cheng study, like others in the stress literature, emphasizes that coping is a
dynamic process not defined by the situation per se but the relationship between the
person and the situation. This means there is no such thing as a patient who is a
good or bad coper. Stressful situations are not static events, nor do individuals
respond uniformly to all stressful events. The effectiveness of coping effort depends
on the how a person appraises aspects of a stressful event such as its controllability.
For patients to cope effectively with the daily burden of IBS, they need to adopt
the best strategy among a menu of options tailored to the demands of the situation.
Problem focused strategies work best for changeable stressors; emotion focused strategy
work best for unchangeable ones. While emotion-focused strategies do not fix a problem,
they are most effective in containing the “emotional fallout” of a stressor which
may explain why they are associated with less severe physical symptoms in FGID patients.
9, 14
By linking coping strategies to their control over stressful events, patients are
relieved of the burden of trying to solve insolvable problems and free to tackle problems
that are truly under their control. In short, they learn the paradoxical lesson that
the way to gain control over a problem is to accept its uncontrollability and deploy
the best available coping strategy. This is a lesson that can not only benefit patients
but gastroenterologists who recognize that the best solution for intractable GI symptoms
does not always come in a bottle but by supporting patients efforts to learn to manage
unresolved symptoms on their own.
9