Person-Centered Interviews: Coping Strategies
Person-Centered Interviews: Coping Strategies
Eight categories of coping strategies were identified: avoidance behavior, utilizing supportive others, taking medications, enacting cognitive strategies, controlling the environment, engaging spirituality, focusing on well-being, and being employed or continuing their education. The 16 individuals who identified strategies typically identified multiple strategies. Use of strategies varied, with some used consistently and others used only when the person was faced with a particular symptom. Illustrative quotes are provided below. [Additional quotes are available in an online supplement.]
Avoidance behavior.
Participants discussed avoiding specific behaviors or situations to maintain stability. Individuals discussed avoidance of alcohol and illegal drugs to circumvent symptom exacerbation. Participants also mentioned avoiding situations that could be personally stressful or interpreted as chaotic. If such situations arose without their effects being anticipated, the situation was abandoned. For example, one individual said, “If I’m seeing something that is frightening . . . I can’t watch the sci-fi channels ‘cause if it’s gory and bloody I know it’ll start my symptoms, so I get away from that.” Avoidance of specific behaviors or situations most often was the result of a trial-and-error process over the individual’s lifetime rather than a result of education or instruction that these should be avoided. Typically, the individual experienced the situation multiple times, always or often followed by an exacerbation of symptoms, and then decided that it was best avoided. Person-Centered Interviews: Coping Strategies
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Utilizing supportive others.
Most participants described connecting with family, friends, or professional supports as an important strategy to provide objective insights into symptom exacerbation (for example, psychotic thoughts and odd behavior) and nonjudgmental support during those times. One participant said, “I think, ‘Who can I talk this [symptom] out with?’ and generally it’s [a friend]. It is not to fix what’s going on [symptoms] but to restore me to where I am comfortable.” Several discussed participating in therapeutic groups (for example, NAMI) that provided considerable peer support. Some participants highly valued working or being involved in a recovery-oriented group or organization, where they were with like-minded individuals and felt implicitly understood.
Taking medications.
Most participants discussed medications as a key part of their regimen to maintain or regain stability. For some there was a distinct point (for example, a specific hospitalization or achieving a desired life goal) at which they recognized the necessity of medication, and for others it was knowledge gained after many medication trials. One individual stated, “I realized that I felt better on the medication. . . . A light bulb went off on my head. And then after that I pretty much understood the importance of taking the medication, which became more fully engrained into me.” Individuals discussed the challenge and frustration of finding the medication that best addressed symptom reduction and dealing with troublesome side effects (for example, lethargy and weight gain). Participants explained that medication adherence did not mean disappearance of symptoms, but rather enhanced stability. Medication adherence was varied, with a few participants saying they had always been adherent, whereas others said they had been nonadherent intentionally at times during their lives. Person-Centered Interviews: Coping Strategies
Enacting cognitive strategies.
Participants discussed specific cognitive strategies that they used in the face of symptoms—some self-taught and others learned from a professional. These strategies involved ways to systemically reason through their problematic thinking, its basis in reality, and possible alternative interpretations. For example, one person said about hearing derogatory comments from voices when driving alone down the road, “I think to myself is this—is this logical. I mean, we both have our windows closed, we’re on opposite sides of the freeway . . . that couldn’t be possible.” The cognitive strategies mentioned are similar to those taught and practiced as part of evidence-based cognitive-behavioral therapy (CBT) for psychosis (26), and although individuals did not specifically speak of engagement in CBT, they discussed how professionals had taught them cognitive techniques.
Controlling the environment.
Participants described adjusting their surroundings to help prevent, minimize, or address symptom exacerbation. One participant said, “I have to kinda prep my environment around me to be able to be the way I am because I don’t like to be alone in my bedroom when I’m symptomatic. It just freaks me out, ya’ know.” Some participants preferred quiet, calming environments that are clear of clutter or distraction, and others liked to drown out the thoughts and voices with environments filled with sounds and activity.
Engaging spirituality.
A few participants described ways in which they found support through religion and spirituality, including one who said, “I [use] my Buddhist meditations.” Use of spirituality was for some a form of social support and for others a place to avoid stress and find solitude.
Focus on well-being.
A few participants talked about the importance of exercise, diet, or wellness as a component of staying psychiatrically stable or combatting symptoms. One participant said, “I started working out like five days a week and that helped immensely . . . with symptoms, and like everything . . . like my head is so clear.” Person-Centered Interviews: Coping Strategies
Being employed or continuing their education.
A few participants discussed the benefits of education or employment, especially because of its absorbing and distracting nature but also for providing a sense of belonging. One participant said, “I work on the weekends too because it’s just distraction, it’s good, it’s what I call the distraction factor.”
Discussion
During the course of in-depth interviews, 16 participants with a diagnosis of schizophrenia identified coping strategies that helped them with their symptoms. Most participants described knowledge and use of multiple strategies—a menu of coping strategies. Typically, strategies were discussed in relation to positive symptoms of the disorder (for example, hallucinations) rather than negative symptoms (for example, avolition). Four participants did not identify any specific strategies, perhaps because they were not aware that they were using strategies.
Participants articulated active strategies to combat symptom exacerbation; they did not describe passive acceptance of symptoms, as found in the Cohen and Berk (12) study. Furthermore, many strategies were preventive to keep symptoms from occurring. As in the sample in the Corin (13) study, participants described the value of routine, the role of spirituality, and the importance of recovery-oriented language. We surmise that the use of strategies in a preventive fashion, the effectiveness of the identified strategies, and the fact that individuals were comfortable with several different strategies supported these individuals in achieving their occupational goals.
It is important to note that although participants identified strategies for coping with symptoms, they experienced life challenges that related, at least in part, to their illness. Half the sample did not feel close to another person in the past week. Many reported difficulty managing day-to-day life and experienced recent hallucinations or delusions or both. These findings highlight the fact that having ongoing symptoms and struggles does not mean that individuals cannot pursue occupational and educational goals that are important to them. If fact, the results indicate that at least some participants felt that being employed or continuing their education was an important coping strategy, contributing to quality of life (27).Person-Centered Interviews: Coping Strategies
The study had some limitations. Data were collected in only one city, and recovery was defined solely through occupational functioning. Despite these limitations, the study revealed unique perspectives on how individuals cope with symptoms of schizophrenia while maintaining occupations that require a high degree of responsibility, productivity, and accountability. The legitimacy of the findings is strengthened by the gold-standard diagnostic approach, the careful and systematic operationalization of functioning, and the phenomenological method used to elicit participants’ experiences.
Although there are a considerable number of evidence-based practices for treating people with schizophrenia, these practices are limited in terms of long-term symptom reduction, psychosocial rehabilitation, and overall recovery. Most patients continue to face symptoms throughout their lifetime and, in order to achieve their goals, will need a menu of coping strategies to draw upon. Some of the coping strategies identified in this sample align with the skills taught in evidence-based practices, but some are unique. This is the benefit of gathering information directly from recovered individuals. We propose that the next wave of revisions to evidence-based practices would benefit from the incorporation of consumer input, particularly from consumers who have developed successful strategies to manage symptoms and lessen their impact on functional roles.
Conclusions
The shift of mental health services to a recovery orientation has been slow, and the social stigma associated with psychiatric illnesses, such as schizophrenia, continues, perpetuated by popular culture and media. This research demonstrates that individuals with serious mental illness can articulate numerous ways in which they manage their symptoms while also achieving their goals. Service providers, consumers, caregivers, and researchers can reflect and expand on the strategies shared by our participants in order to reconceptualize and advance what is possible in mental health recovery, especially when consumer voices and lived experiences are prioritized.
Dr. Cohen and Dr. Marder are with the Desert Pacific Mental Illness Research, Education and Clinical Center, Dr. Hamilton and Ms. Glover are with the Center for the Study of Healthcare Innovation, Implementation, and Policy, and Dr. Glynn is with the Research Service, all at the Greater Los Angeles Department of Veterans Affairs Healthcare System, Los Angeles (e-mail: ancohen@ucla.edu). Dr. Cohen, Dr. Hamilton, Dr. Glynn, and Dr. Marder are also with the Department of Psychiatry and Biobehavioral Sciences, The David Geffen School of Medicine, University of California, Los Angeles. Ms. Glover is also with the California School of Professional Psychology, Alliant International University, Alhambra, California. Dr. Saks is with the Gould School of Law and Dr. Brekke is with the School of Social Work, University of Southern California, Los Angeles.
Dr. Cohen reports receipt of research support from Ameritox. Dr. Saks reports serving as a consultant to Alkermes. Dr. Marder reports serving on advisory boards of or as a consultant to Allergan, Forum, Lundbeck, Otsuka, Takeda, and Teva and receipt of research support from Forum, Neurocrine, and Synchroneuron. The other authors report no financial relationships with commercial interests.
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