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Adapting to Chronic Health Conditions and Disabilities (CCD)

by Erin Martz, Ph.D., Hanoch Livneh, Ph.D..

3 Credit Hours - $69
Last revised: 03/27/2018

Course content © Copyright 2018 - 2020 by Erin Martz, Ph.D., Hanoch Livneh, Ph.D.. All rights reserved.


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Course Outline


Introduction and course overview

Learning objectives

Definitions of chronic health conditions (i.e., chronic illness) and disabilities (CCD)

Definitions of stress, coping, and adaptation

Definitions of CCD-related Stress

Definitions of CCD-related Coping

Definitions of CCD-related Adaptation

Popular theoretical models of psychosocial adaptation to CCD

Unidimensional, linear models of adaptation

Pendular models of adaptation

Interactive models of adaptation  

Ecological models

Moos’ crisis and coping model.

Livneh and Antonak’s adaptation to CCD model.

Devins’ Illness Intrusiveness model.

Bishop’s Disability Centrality model.

Coping with CCD

Selected Empirical Findings of Coping with CCD

Engagement Coping Strategies

Disengagement Coping Strategies

Summary Points on Coping

Facilitating Coping with and Adapting to CCD

Promoting Generic Coping Skills for Common Life Stressors

Overview of Coping-based Interventions Specific to CCD

Psychotherapeutic-related interventions

Cognitive-behavior interventions

Coping Effectiveness Training Program

Goals of Coping Effectiveness Training Program

Coping Effectiveness Training Program steps

Emotion regulation strategy

Adaptive Coping (for changeable situations)

Signs of non-adaptive (or ineffective) coping strategies

Cognitive Coping Therapy (CCT)

Assimilation of Suffering

Energy Allocation

Frustration Management

Area Thinking

Identity coalescing

Anxiety-reduction training

Acceptance training




Introduction and Course Overview


“Life is sort of like a game of tennis—you have no choice of how the ball comes to you, but it is how you hit back that counts.” 

Margaret Moth (1951 – 2010) CNN photojournalist


Chronic health conditions (i.e., chronic illnesses) and disabilities are integral parts of life and their likelihood of occurrence increases with one’s age (see Figure 1). The onset/experience of chronic health conditions and disability (CCD) invariably requires personal adaptation to both the individual’s diminished abilities to function and the altered interactions with the physical and social environments. The exponential growth of research on psychosocial adaptation (PA) to CCD during the past 30 years has been evident in areas such as the development of clinically driven and empirically validated models of adaptation, and the investigation of numerous predictors, mediators and moderators of PA to CCD, which includes coping with CCD. This course will provide an overview of models of psychosocial adaptation, as well as provide definitions on coping with CCD, explore the association between coping and adaptation, and outline multiple types of interventions that can facilitate coping with CCD.


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Learning objectives


Define the concepts of chronic health conditions and disability (CCD).

Distinguish between the concepts of stress, coping, and adaptation.

Describe three of the major models on psychosocial adaptation to CCD.

List at least three coping-based therapeutic approaches that can help patients reduce their stress.


Definitions of Chronic health conditions and Disabilities (CCD)


There are a range of definitions of chronic health conditions (i.e., chronic illness). Burish and Bradley (1983) distinguished between acute, infectious diseases and “chronic illnesses” on four primary dimensions:


Cause, for which acute illnesses are a result of infectious agents, while chronic illnesses (i.e., chronic health conditions) often are a result of lifestyle choices;


Time-line, for which acute illnesses are brief and last a somewhat predictable period of time, while chronic illnesses “have a slow, insidious onset and endure over a long and indefinite period” (p. 4);


Identity, for which the individual has an idea of what is wrong and is able to readily identify the symptoms that are connected to specific causes, whereas chronic illnesses may not have a single, specific cause and may not manifest obvious symptoms until the illness is in an advanced stage (e.g., cancer or heart disease); and


Outcomes, for which acute illnesses will be cured over time with proper treatment, while chronic illnesses will continue to exist (despite treatment), for the remainder of a person’s life.


In contrast to chronic illness, hereafter called chronic health conditions, disability can be defined as the following: According to the International Classification of Functioning (ICF) system by the World Health Organization (WHO, 2001), disability is defined as a restriction or limitation of activity that results from an impairment (the latter is viewed as a loss, deficiency, abnormality, at an organ level or any of the body system). In their revision of their classification system (published in 2001), WHO focused more on the components of health, rather than the consequences of diseases. The WHO recognized that contextual factors, such as individual or environmental factors, also influence the impact of disability and functioning.


Definitions of Stress, Coping, and Adaptation


Definitions of CCD-related Stress


Because this course focuses on how people psychosocially manage the onset of chronic health conditions and disability (CCD), given that CCD is generally viewed as a challenging, difficult, and negative event, the concept of stress must first be discussed before examining psychosocial coping and adaptation. Stress has been viewed by Lazarus, Folkman, and their colleagues (Folkman & Moskowitz, 2004; Lazarus, 1966; Lazarus & Folkman, 1984; Lazarus & Launier, 1978) as a set of interacting personal and environmental characteristics and processes. Within this context, Lazarus and colleagues consider three broad frameworks for defining stress. These include:


Stimulus definitions. Stress is considered as acting on the organism from either internal (e.g., hunger, pain, sleep deprivation) or external (e.g., stimuli from the environment) sources. They can be further classified as to their durations and frequency as: (a) acute, time-limited (e.g., surgery, hospitalization); (b) chronic, intermittent (e.g., role strains, daily hassles); (c) chronic (existence of a CCD, or social isolation); and (d) sequential stressors (stresses resulting from job loss, bereavement, etc.) (Elliott & Eisdorfer, 1982).


Response definitions. This category regards stress as a response state or reaction of the individual (i.e., the subjective feeling of distress). The more common stressful reactions are indicated by bodily (i.e., physiological) reactions that can include increased heart rate, elevated blood pressure, increased perspiration, and heightened muscle tension. Hans Selye (1956), one of the founding fathers of stress research during the 1950’s and 1960’s, defined stress as “the non-specific (that is, common) result of any demand upon the body, be the effect mental or somatic” (Selye, 1982, p. 7). He proposed that stress ensues when existing coping modes and available external resources are inadequate in dissipating increased tension.


Relational definitions. These kinds of definitions offer the most comprehensive outlook and describe psychosocial stress as “a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being” (Lazarus & Folkman, 1984, p. 19). This relational definition has laid the groundwork for Lazarus’ highly influential paradigm that adds both cognitive appraisal and coping processes as influencing the relationship among the person, the environment (i.e., the person-environment fit), and the psychosocial outcome.


Aldwin (1994) provided another transactional view of stress, depicting stress as “that quality of experience, produced through a person-environmental transaction, that, through either over-arousal or under-arousal results in psychological or physiological distress” (p. 22). She further suggested that stress is composed of three components:


Strain, an internal stressful state, composed of both physiological (e.g., sympathetic activation, parasympathetic suppression) and emotional (i.e., negative affect) reactions;


Stressor, an external event that includes both the type of stress (e.g., traumatic event, negative life event) and a temporal dimension (e.g., duration); and


A transaction component that is made of cognitive appraisals (e.g., harm, threat) and intensity (weak, strong).


The latter component, reflecting Lazarus and his colleagues’ advancement in understanding by adding cognitive perspectives, provides an integrative framework to the study of stress, as it recognizes both the internal characteristics of the individual and the influence of the external environment.


The above views on the nature of stress acknowledge the person’s inherent ability to be aware of the experiences of stress; that is, an individual’s awareness of overtaxed internal (i.e., physiological, cognitive, affective, and motivational) processes, as well as the stifling (or, in contrast, accommodating) nature of the external environment. The experience of stress, therefore, can be described as a subjective dynamic, unfolding, only partially controllable, often unpredictable, and typically viewed as a negative experience that disrupts a person’s existing equilibrium. Stress can be triggered by an interaction of internal and external conditions, such that the psychosocial effects of the onset of CCD can be magnified by other stress-generating events that the individual has or is currently experiencing (see Table 1).



Table 1. Potential Stress-Generating Situations



Physical illness

Physical injury

Permanent illness/injury (i.e., CCD)


Aging (cognitive and physical)


Substance abuse/addiction


Death (loss, grief, and bereavement)

Burnout (work-related)

Academic/school failure

School/work/institutional violence/trauma

Financial/economic strain

Job loss/unemployment

Maturational crises (life stage-related)

Separation (child-parent)

Child abuse/neglect


Premature birth

Rape/sexual assault/incest

Battered wife/spouse/domestic violence


Hostage crisis



Natural disasters


Environmental conditions (pollution, crowding, noise)



Definitions of CCD-related Coping


Psychological research was dominated for decades by a focus on defense mechanisms, as defined and explained by Sigmund Freud and his daughter Anna. Yet, research on coping evolved out of interest in how individuals successfully with stress and life issues using conscious choices and particular strategies under individuals’ volitional control. Such a focus was in contrast to the Freudian depiction of drives being primarily unconscious and thus, out of direct control of the individual.


Regarding definitions of coping, Haan (1985), in her now classical treatise, argued for a tripartite model of coping, defense mechanisms, and fragmentation. Haan posited that coping, unlike the other two sets of processes, is distinguished by properties displayed in Table 2.  



Table 2. Coping Properties (Haan, 1985)



(a) Flexible and purposeful behaviors;

(b) Future-orientation, while recognizing the present;

(c) Reality orientation;

(d) Integration of both conscious and preconscious psychological elements;

(e) A titrated processing of distressing affect; and

(f) Affect release in a controlled fashion.



Haan further maintained that the following processes – objectivity, empathy, sublimation, concentration, and substitution --are the hallmarks of coping efforts. For an excellent and comprehensive review of the differences between defense mechanisms and coping strategies, the reader is referred to Radnitz and Tiersky (2007).


Probably the most influential and lasting definition of coping was provided by Richard Lazarus and his colleagues (Folkman & Moskowitz, 2004; Lazarus, 1966, 1993; Lazarus & Folkman; 1984, Lazarus & Launier, 1978). They defined coping as “constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person” (Lazarus & Folkman, 1984, p. 141). In defining coping in this way, Lazarus and Folkman argued that coping:


(a) Is process-oriented (rather than trait-based)


(b) Should not be confused with outcomes of these efforts to manage stress


(c) Should not be confused with the outcome of successful environmental mastery, because coping, as a process, focuses mostly on those attempts to master the environment.


Coping includes cognitive, affective, and behavioral attempts to master events that are overwhelming to an individual or that an individual has not experienced previously and thus does not have automatic responses (Inglehart, 1991; Lazarus & Folkman, 1984; Livneh, 2000).


Wright (1960, 1983) wrote extensively about coping in the context of CCD. She described a “coping versus succumbing” framework (see Table 3). The coping perspective emphasized the positive aspects, qualities, and abilities that are inherent in an individual, whereas the succumbing perspective focused on the impairment, pathology, or insufficiency in an individual’s mind or body (Wright, 1960, 1983).



Table 3. Coping versus Succumbing Framework     








The emphasis is on what the person can do.



The emphasis is on what a person cannot do.



Areas of life in which the person can participate are seen as worthwhile.



Little weight is given to the areas of life in which the person can participate.



The person is perceived as playing an active role in molding his or her life constructively.



The person is seen as passive, as a victim of misfortune.




The accomplishments of the person are appreciated in terms of their benefits to the person and others (asset evaluation), and not evaluated because they fall short of some irrelevant standard.



The person’s accomplishments are minimized by highlighting their shortcomings (comparative–status evaluation, usually measured in terms of “normal” standards).




The negative aspects of the person’s life, such as the pain that is suffered or difficulties that exist, are felt to be manageable. They are limited because satisfactory aspects of the person’s life are recognized.



The negative aspects of a person’s life, such as the pain that is suffered or difficulties that exist, are kept in the forefront of attention. They are emphasized and exaggerated and even seen to usurp all of life (spread).



Managing difficulties mean reducing limitations, dealing with changes in the social and physical environment, as well as in the person.  Examples are:


      eliminating barriers

      environmental accommodations

      medical procedures

      prostheses and other assistive devices

      learning new skills



Prevention and cure are the only valid solutions to the problem of disability.










Managing difficulties also means living on satisfactory terms with one’s limitations (although the disability may be regarded as a nuisance and sometimes a burden). This involves an important value changes.



The only way to live with the disability is to resign oneself or to act as if the disability does not exist.







The fact that individuals with disabilities can live meaningful lives is indicated by their participation in valued activities and by their sharing in the satisfactions living.



The person with a disability is pitied and his or her life essentially devaluated.





Quoted from p. 195 in Wright, B. A. (1983). Physical disability—a psychosocial approach (2nd ed.). New York: HarperCollins Publishers.



To summarize the definitions of coping, the following can be stated:


Coping is a broader construct than defense mechanisms. Defense mechanisms are inherently rigid, intra-psychic efforts that are, for the most part, automatically engaged, and that focus on thwarting anxiety and impending danger. In contrast, coping strategies are mostly flexible, integrated, and environmentally-attuned efforts that are concerned with both internal and external demands and available resources.   


Although coping is viewed by some as a global personality trait or disposition, it is not an inflexible, trans-situational psychological construct; coping efforts and behaviors are influenced by state or situational factors, such as the nature, severity, and duration of the encountered crisis, trauma, or loss.


Coping efforts encompass a wide range of cognitive, emotional, and behavioral strategies that are directed at both external or environmental stressors and internal demands and needs.


Coping efforts should not be confused with psychosocial outcomes, such as adaptation. Rather, coping efforts should be viewed as mediators between environmental or internal stressors (e.g., crises, losses, disabling conditions, negative cognitions) and the psychosocial end product they seek to influence (e.g., decrease in psychological distress, removal of noxious environmental conditions, increase of mastery, re-establishing a psychological homeostasis).


Definitions of Adaptation to CCD


The term adaptation is so broad that “it covers virtually the whole of psychology (if not biology)” (Costa, Somerfield, & McCrae, 1996, p. 45). Psychology is permeated with concepts on adaptation: Almost every type of psychotherapy is geared to helping individuals modify their adjustment patterns to facilitate long-term well-being (Summerfeldt & Endler, 1996). Given that there are innumerable ways of defining adaptation, this course will focus on the CCD-related definitions.


In order to comprehend some of the differences in the large bodies of scientific research on coping and adaptation, it is essential to make some distinctions between the two constructs. Psychosocial adaptation to CCD can be defined as containing psychological and social changes necessitated by disability that include three components: a) The ego-defensive, affective reactions following acute trauma (denial, anger, hostility, and depression); b) coping with the full psychological knowledge of the trauma; and c) long-term personality adjustments (Bracken & Bernstein, 1980). Hence, adaptation can be viewed as a master concept that includes coping (White, 1985).


One key distinction between coping and adaptation is the temporal element: Coping with disability can be described as the more immediate psychological defense reactions to disability (Bracken & Shepard, 1980). This is in contrast to adaptation, which can be depicted as the longer-term reactions to CCD-related events (Bracken & Shepard, 1980; Livneh, 2000). Snyder and Dinoff (1999) noted that the effectiveness of coping modes is linked to its ability to reduce psychosocial distress and, ultimately, to foster long-term psychological well-being. This reflects the perspective that coping influences the psychosocial outcome of adaptation to CCD.


Adaptation to disability should not be viewed solely as a theory focused solely upon the reactions of the mind, because many disabilities have a physical, anatomical, biological component to them. Hence, adaptation to disability should be viewed as not only as a person-environment interaction, but as a multidimensional process, including a holistic self-experience, cognitive, emotional, physical/biological, psychological, and social aspects of adaptation (Shontz, 1965). A multidimensional view on psychosocial adaptation to disability complements the multilevel paradigm of health conditions, impairment, disability, and handicap (World Health Organization, 2001). Other multidimensional models of psychosocial adaptation to CCD will be explored in the proceeding section.


Generally speaking, adaptation is a mastery construct that can include both psychological and physical mastery. Some research on adaptation makes a distinction between mastery of self and mastery of environment, while most CCD-related theories merge the two, combining physical and environmental factors with psychological factors—hence the term “psychosocial adaptation.” Consideration of multilevel factors is needed, in view of the process of adapting to a CCD often requires restoration or enhancement of remaining physical and psychological abilities and adjustment to attitudinal and physical barriers in the environment. Psychosocial adaptation is a dynamic, continuously evolving process that involves an integration of intrapersonal, interpersonal, and environmental elements.


One multidimensional model of psychosocial adaptation to disability suggests that the process of adaptation includes eight particular reactions to the onset of CCD, namely, shock, anxiety, denial, depression, internalized anger, externalized anger, acknowledgment, and adjustment (Antonak & Livneh, 1991; Livneh, 2001; Livneh & Antonak, 1990, 1991, 1994, 1997). The shock reaction consists of an individual’s initial reactions to the onset of a CCD, which can include numbness, depersonalization, decreased speech and mobility, and cognitive disorganization (Livneh & Antonak, 1997). The anxiety reaction, in response to CCD, can be perceived as a reaction that may involve panic, confused thinking, cognitive flooding, a range of physiological responses, and purposeless over-activity (Livneh & Antonak, 1997). The denial reaction can be viewed as a defense mechanism that includes wishful thinking and an unrealistic expectation of recovery, with the utilization of selective attention (Livneh, 2009a, 2009b; Livneh & Antonak, 1997); Naugle (1988) depicted denial as "the tendency to negate or downplay the long-term consequences of an injury because of their psychological consequences" (p. 219). The depression reaction, which may represent a reaction of grieving for the lost body part or functioning, may include affective responses such as helplessness, hopelessness, despair, isolation, self-depreciation, and distress (Livneh & Antonak, 1997). Dunn (1975) included feelings of worthlessness, sadness, and loss of purpose. Livneh (1986) defined the internalized anger reaction as "a self-directed reaction associated with blaming self, and its ensuing guilt feelings regarding the onset of disability or the resulting loss" (p. 10). Resentment and bitterness turned inward toward oneself also surfaces as internalized anger (Livneh & Antonak, 1997). The externalized hostility reaction may include aggression, antagonism, criticisms, abusive accusations, and verbalizations against others, and passive-aggressive behavior that obstructs treatment (Livneh & Antonak, 1997). The acknowledgment reaction of CCD is defined as a cognitive acceptance of disability, whereas adjustment reaction is defined as an emotional and behavior acceptance and integration of CCD into one’s life (Livneh & Antonak, 1997).


Popular Theoretical Models of Psychosocial

Adaptation to CCD


A range of conceptual frameworks of adaptation to CCD exists that reflects a wide spectrum of views. Naturally, these models differ with regard to the essential components, processes, dynamics, and temporal relationships among the proposed ingredients of the model. Although virtually all share certain perspectives on the nature of human adaptation to adversity, they do differ in their philosophical-theoretical underpinnings and the complexities of the proposed systems. In this section, we offer a brief review of the models of PA that have sparked the most interest among researchers and clinicians.


Unidimensional, Linear Models of Adaptation


Earlier models of PA to CCD were noted mostly by their rather rigid adherence to the concept of linearity (Cohn, 1961; Dunn, 1975; Falek & Britton, 1974; Fink, 1967; Matson & Brooks, 1977; Shontz, 1965). Proponents of these models maintained that, following the onset of CCD, the human psyche typically followed a somewhat predictable, indeed almost universal, sequence of psychological experiences or reactions (also termed stages or phases). These experiences were viewed as largely internally-driven. Although certain structural discrepancies existed among these models regarding the purported nature, number, and sequencing of these psychic reactions, they nevertheless most often included such reactions as: shock, anxiety, denial, depression, anger, and some form of acceptance/reintegration (Livneh & Parker, 2005). A shared assumption by all these models was that reactions observed at a later time (more distal to CCD onset) can only be experienced after certain earlier reactions (more proximal to CCD onset) have been experienced and successfully resolved. These early models failed to consider the complexity of the human experience, that is, the continuously interactive power of external influences—both environmental and socio-cultural-- while lacking empirical support.


Pendular Models of Adaptation


Other models of psychosocial adaptation to CCD (Charmaz, 1983, 1993, 1995; Kendall & Buys, 1998; Stroebe & Schut, 1999; Yoshida, 1993) depicted the process of adaptation as an alternation (often referred to as “swings”) between pre-CCD and post-CCD identities. Put differently, the person with a sudden-onset CCD oscillates between perceptions of health or normalcy (past orientation) and realization of existing health condition or disability (present orientation). These alternating perceptions are portrayed as pendular motions or trajectories. The process of adaptation, accordingly, follows a gradual progression through which an altered identity (self with CCD) is reconstructed to include the physical losses and changes in functional abilities.


In such pendular models of psychosocial adaptation, adaptation is viewed as not following a linear trajectory but, instead, is composed of repeated experiences and efforts to accommodate and assimilate perceived losses and limitations. In a related vein, Paterson and her colleagues (Paterson, 2001; Thorne & Paterson, 1998), based on their meta-synthesis of qualitative research findings, arrived at a similar model that they calleda “shifting perspectives” model of CCD. They posit that following the onset of CCD, the individual lives in a dual world where both wellness and illness (chronic health conditions) exist. According to this model, individuals with CCD shift, after the CCD onset, from an adaptive (wellness in foreground) to non-adaptive (health condition in foreground), and may be influenced by both internal and external life events.


Interactive Models of Adaptation  


The roots of interactive models of PA to CCD could be traced to the seminal work of Kurt Lewin (Lewin, 1997; Lewin, Heider, & Heider, 1936) and his followers in the fields of social psychology and somatopsychology. These researchers (i.e., L. Meyerson, T. Dembo, R. Barker, G. Leviton, & B. Wright) viewed adaptation as a reciprocal, iterative process that emphasized that human behavior is best determined by two sets of interactive variables. The first set is comprised of intra-individual variables that include both physical determinants (e.g., nature and severity of the CCD) and psychological aspects (e.g., self-concept, belief system). The second set is made up of external variables that are part of the environment or life space in which the person operates, and refers to the physical, social, and vocational domains of one’s environment. The interaction between these two sets of variables, then, determines the person’s behavior, or more specifically, the level of PA to CCD (Livneh, 2001; Shontz, 1975; Smedema, Bakken-Gillen, & Dalton, 2009; Wright, 1983).


Ecological Models       


Ecological models of adaptation to CCD span a wide range of life conditions and, by necessity, vary along several dimensions, including their complexity, the nature and type of crisis (e.g., sudden onset vs. gradual, unexpected vs. expected), experienced symptoms, incurred functional limitations, duration of presenting problem(s), developmental stage, predictability and controllability of medical manifestations, and temporal unfolding of experienced reactions (for overview of several of these earlier ecological models, the reader is referred to Livneh & Antonak, 1997, chapter 23, and Smedema, et al., 2009). In this section, we focus on four of these models, namely: (1) Moos and colleagues’ Crisis and Coping model; (2) Livneh and Antonak’s Adaptation to CCD Model; (3) Devins’ Illness Intrusiveness Model; and (4) Bishop’s Disability Centrality Model.


Moos’ crisis and coping model. Moos and his colleagues’ model of coping with life crises and CCD has undergone several changes and refinements over the past 25 years. In reviewing this model we focus on its most recent version (Moos & Holahan, 2007). Broadly speaking, this biopsychosocial model consists of three sets of components. The first component addresses three interacting factors (panels):


a. Personal resources, including socio-demographic characteristics (age, gender, education) and personal (intellectual and affective) characteristics, such as cognitive ability, ego strength, belief system, self-concept, and perceived locus of control;


b. Health-related factors, including CCD-related characteristics that are inherent in the nature, severity, and duration of the condition (e.g., body part/function affected, progression of condition, stage and severity of CCD), as well as the nature of the health-care environment and availability of therapies; and


c. The person’s social-physical environment, including the person’s physical environment (e.g., accessibility of one’s community, home, and work settings) and social environments (e.g., individual’s social network).


The second component, which is influenced by the elements of the first component, is made up of three panels: cognitive appraisal, adaptive tasks, and coping skills. The cognitive appraisal panel refers to the perceived meaning that the person associates with the existence of CCD, and also includes perceptions regarding the condition’s controllability, predictability, and changeability. Adaptive tasks include a wide range of CCD-generated tasks, such as those that focus on managing symptoms of discomfort and pain; managing the hospital environment, treatment procedures, and relationships with health care providers; sustaining positive relationships with family members and social network; and managing and balancing one’s emotions. Coping skills are described by Moos and Holahan (2007) as consisting of eight categories of coping; examples of these coping modes include (a) Logical analysis (cognitive/approach); (b) seeking support (behavioral/approach), (c) avoidance-denial (cognitive/avoidance); and (d) emotional venting (behavioral/avoidance).


The third component of this model consists of a single panel of health-related outcomes. This panel addresses the end product of the interaction among and progression of the earlier six panels. Although health-related outcomes are viewed as the final component of the model, Moos and Holahan (2007, p. 109) maintain that “in a mutual feedback cycle, health-related outcomes may alter the preceding sets of factors and consequently change longer-term health outcomes.”


Livneh and Antonak’s adaptation to CCD model. Livneh and Antonak’s  model (Livneh, 2001; Livneh & Antonak, 1997) bears certain similarities to that of Moos and his colleagues and may even be considered an outgrowth of it. It consists of three main components, namely, antecedents, processes, and outcomes of adaptation. The first component (antecedents) includes two interacting sets of variables: CCD-triggering events (e.g., genetics, injury, chronic health conditions, and ageing processes) and contextual variables (existing biological, psychosocial, and environmental conditions). The latter are those mostly stable situational conditions that prevailed at the time of CCD onset and include: (a) a person’s health status, age, gender, and ethnicity (biological status); (b) cognitive and emotional developmental phase, personal and social identities (psychosocial status); and (c) physical, socioeconomic, and attitudinal contexts (environmental status) [see Figure 2].


These two sets of background variables (antecedents) exert considerable influence upon the second component (processes), consisting of two sets of interacting factors. These processes include: (a) unfolding psychosocial reactions to the onset of CCD and (b) contextual influences that exist during the time period following CCD onset. The first set of processes (i.e., psychosocial reactions) refers to reactions, such as anxiety, depression, anger, often reported by people following the onset of CCD. The latter set of processes (i.e., contextual influences) refers to those dynamic and interacting forces that, directly or indirectly, affect the nature and progression of the adaptation process. These continuously evolving external and internal forces commonly refer to the personal, interpersonal and environmental influences that undergo constant changes during the process of adaptation, which may include alterations in functional capacities, course of the CCD, the individual’s self-concept, perceived control, sense of coherence, coping modalities, architectural barriers, and available social support.     


The two interacting “process” sets (with the added influence of the previously described “antecedent” sets) determine to a large extent the third component in the model: the outcomes of the person’s psychosocial outcomes in the adaptation process. The outcome is viewed in terms of quality of life (QOL), which is depicted in this model as consisting of three broad domains. These are: (a) intra-personal functioning (subjective well-being, life satisfaction, perceived health), (b) interpersonal functioning (satisfaction with family life, peer relations, and social activities), and (c) extra-personal functioning (performance of work activities and/or recreational pursuits, living arrangements, financial status). The person’s adaptation to CCD is, accordingly, determined by his or her QOL across these life domains.


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Devins’ Illness Intrusiveness model. Devins’ model of illness intrusiveness is defined by the author as “illness-induced disruptions to valued activities and interests” (Devins & Binik, 1996, p. 642). As such, illness intrusiveness is regarded as a set of events that is experienced frequently by people with CCD. These CCD-triggered interruptions stem from both internally-induced characteristics (e.g., severity of symptoms, functional limitations, discomfort, pain, fatigue), as well as externally-derived influences. The latter are mostly associated with treatment-linked factors such as the nature of the available therapies, the time required for treatment, and the stress engendered by treatment. The model can be depicted as follows (Devins, et al., 1992; Devins, et al., 1993):


Burden of Illness → Functional Deficits → Physical Disability →


Illness Intrusiveness → Personal Control →


Psychosocial Well-Being


The first three components (burden of illness, functional deficits, physical disability) focus on: (a) CCD-triggered anatomical, physiological and biochemical changes in the person’s body (burden of illness); (b) the functional implications that follow these changes as expressed in diminished physical capacity (functional deficits), and (c) the progression of impairments discrete, organ-specific limitations to more complex, integrative body systems (physical disability). The next two components (illness intrusiveness and personal control) reflect the cumulative contributions of the first three components to more global lifestyle disruptions. These disruptions can be found in diminished participation in valued activities (illness intrusiveness), as well as in perceptions of decreased capacity to influence positive outcomes in one’s life (personal control). The final component of the model targets the impact of illness intrusiveness and diminished perceptions of personal control, indicated by measures of psychosocial well-being and its complementary concept of emotional distress.


In a later model, Devins and Shnek (2000) apparently realizing an earlier omission of the direct and moderating roles played by psychosocial factors in the model, offered a slightly expanded version that included these factors. These psychological (e.g., personality attributes) and social (e.g., stigma) factors are regarded in the revised model as forces that either directly or indirectly influence each of the model’s existing components including illness intrusiveness and the psychosocial well-being outcomes. Furthermore, psychosocial well-being and emotional distress were portrayed as two facets of a global outcome component of quality of life, according to Devins and Shnek (2000). The most current explanation of the model includes the following changes: (a) the first three components were categorized into two components called disease factors and treatment factors; (b) a cluster of variables called psychological, sociological, and contextual factors was added; and (c) the outcome variable of Psychosocial Well-Being was renamed as Subjective Well-Being (see Devins & Deckert, 2017 for a more detailed explanation of the new model).


Bishop’s Disability Centrality model. Bishop’s model (Bishop, 2005a, 2005b; Bishop, et al., 2009), has been described by its author as an extension of Devin’s Illness Intrusiveness Model. Bishop describes his model in terms of three broad underlying components. The first component focuses on the ultimate outcome of adaptation to CCD, namely, quality of life (QOL). He views QOL as a dynamic and balanced evaluation of well-being and life satisfaction in terms of the life domains invested with greater personal importance to the individual. Quality of life, therefore, is best understood by Bishop as a subjective overall perception of the person’s psychosocial adaptation to life, including life with CCD. The second component incorporates Devins’ Illness Intrusiveness Model. As such, the concept of illness intrusiveness is regarded as a main moderator of the impact of CCD-related factors on QOL. The third component consists of two additional psychosocial mechanisms that link the impact of CCD to QOL, namely domain satisfaction and domain control. Domain satisfaction is seen as “a dynamic process of maintaining satisfaction in central domains and reprioritizing domain centrality to close perceived gaps between the presently experienced QOL and the desired or expected level of QOL” (Bishop, et al., 2009, p. 537). Domain control refers to the perceived impact that CCD exerts on the individual’s ability to control changing life conditions (e.g., social, vocational, environmental) and pursued outcomes.


Bishop argues that after the onset of CCD, an individual will experience appreciable impact on his or her perceived QOL and may experience three possible outcomes. First, the person could deemphasize the importance of certain previously held beliefs as central life domains so that they now become marginalized to the overall QOL (importance change). Second, the person could seek to increase personal control over his or her life conditions (control change), such as by self-management, medical or psychosocial interventions, or environmental accommodations. Finally, the individual adopts neither of the two venues and the overall diminished QOL is not altered.


The four ecological models of adaptation to CCD reviewed in this section do not, by any means, offer a complete picture of all existing models. They do, however, offer a rather balanced view of those models encountered more frequently in both the historical and extant literatures on adaptation to CCD. The recent growth of ecological models of adaptation to CCD suggests that the new generation of research is being produced that expands our understanding of the adaptation process through the development of multidimensional, evidence-based models that more accurately portray the intricacy of human adaptation to the onset of CCD.           


In summary, the models of psychosocial adaptation to CCD present it as a multifaceted construct that spans a wide spectrum of components and domains (affective, cognitive, motivational, behavioral, physical, and spiritual). Earlier efforts to study CCD-related adaptation focused almost exclusively on negative indicators, while more recent models include positive indicators of adaptation. This inclusion of positive outcomes acknowledges that the human experience following the onset of CCD is not exclusively that of psychological distress or psychopathological processes; rather, adaptation to CCD can co-exist with the latter. Adaptation to CCD offers the potential for growth, benefit and meaning finding, the pursuit of lifestyles and behaviors conducive to better mental health, the improvement of interpersonal relations, and deepening the individual’s spiritual connectedness to the world around (see Livneh & Martz, 2012 for further details).   


Coping with CCD


In an earlier section of this document, various definitions of coping were examined. To reiterate, coping strategies can include cognitive, affective, and behavioral attempts to master events that are overwhelming to an individual or that an individual has not experienced previously and thus does not have automatic responses. Note that coping influences psychosocial adaptation to CCD. As Holahan, Moos and Schaefer (1996, p. 25) described, coping is “a stabilizing factor that can help individuals maintain psychosocial adaptation during stressful periods. It encompasses cognitive and behavioral efforts to reduce or eliminate stressful conditions and associated emotional distress.” Yet, in reality, the association between coping and adaptation is most likely reciprocal, because stress-induced coping influences psychological adaptation outcomes, while the latter may trigger the use of additional coping efforts to mitigate the impact of ongoing levels of distress, such as is often experiencing when having a chronic health conditions or disability.


In view that a broad range of coping strategies exist, spanning cognitive, affective, and behavioral areas, the research on coping has produced a variety of analyses and models on the structural composition of coping. One model proposes a hierarchy for understanding coping (see Table 4): Krohne’s (1996) framework involves a hierarchy of 3 levels of coping that clusters specific microanalytic coping efforts into broad macroanalytic coping: (a) Coping dimensions/constructs/dispositions depicting a higher level of abstraction (e.g., engagement versus disengagement coping); (b) coping strategies/modalities/ways that reflect a middle level of abstraction and focus on conceptually-coherent groups of coping reactions (e.g., denial, confrontation, distancing, seeking social support); and (c) coping behaviors/acts/ reactions that operate at a lower level of abstraction and focus on situationally-influenced specific coping behaviors (e.g., specific items on coping measures). Most of the empirical research on coping with CCD could be categorized as microanalytic in nature by the study of how various cognitive and behavioral coping strategies influence psychosocial adjustment to CCD.



Table 4. Hierarchical View of Coping Strategies



Level I: Coping Dimensions/Constructs/Tendencies


These operate at a higher level of abstraction, aggregation, and stability of construct. Coping is viewed as a personality trait or disposition. This is viewed as representing the macroanalytic level of coping strategies.







Vigilance--- Avoidance




Level II: Coping Strategies/Modalities/Ways


These operate at a middle level of abstraction and focus on conceptually coherent groups of coping reactions, strategies, or acts, which include varying behaviors.


Examples:  There are up to 30 coping strategies listed in the coping literature (i.e., a coping strategy, such as distancing, can be exhibited by various behaviors, e.g., drinking, listening to music, reframing problem).



Level III: Coping Behaviors/Acts/Reactions


These operate at a lower level of abstraction and focus on situationally-influenced, specific coping behaviors. This is viewed as representing the microanalytic level of coping strategies. These coping behaviors, acts, or reactions lack a theoretical basis in which to understand usage of these coping devices; a theoretical framework is provided on the macroanalytic level.


Examples: There are hundreds of examples of coping reactions, many of which are grouped as emotion-focused and problem-focused coping strategies. Mostly, they are found as specific items on coping measures. There are approximately 20 well-known, psychometrically-sound measures of coping.



Adapted from Krohne (1996)



In contrast to Krohne’s hierarchical model of coping, some researchers argue that coping strategies can be grouped into two overarching functional categories, such as Lazarus and Folkman’s (1984) categories of problem-focused and emotion-focused coping, while other researchers added a third category of avoidance coping (e.g., Billings & Moos, 1981). Still other researchers have proposed additional categories that are focused on social support or coping appraisals, or offer different ways of categorizing coping strategies. This course will be limited to a focus on basic categories and models of coping as an introduction to the research. Readers can to refer to Chronister and Chan (2007) and Livneh and Martz (2007) for further details and analysis of coping with CCD research.


Generally accepted definitions of broad categories of coping are the following. Problem-focused coping reflects coping strategies that are directed at modifying the problem that lies at the root of the distress. Emotion-focused coping focuses on regulating or altering one’s emotions. Avoidance coping seeks to ignore or downplay the stressor. Note that usage of emotion-focused or avoidance coping is not necessarily ‘negative’ or ‘pathological’ because in some circumstance, when individuals are unable to change or eliminate the problem, emotion-focused or avoidance coping could be beneficial by helping to maintain emotional balance or regulation (Aldwin, 1994; Mattlin, Wethington & Kessler, 1990; Suls & Fletcher, 1985; Taylor, 1999; Zeidner & Saklofske, 1996).


Livneh and Martz (2007, p. 13) summarized various researchers’ views on the functions (or goals) of coping as including:


Securing accurate information about the demands imposed by the external (i.e., social and physical) environment.

Maintaining adequate internal mechanisms to process incoming information and initiating action.

Creating stable psychological (emotional) equilibrium that successfully directs energy and skilled behaviors to meet external demands.

Making decisions following a search and evaluation of the obtained information.

Reducing, and if possible eliminating, harmful environmental conditions.

Maintaining a positive self-image and psychological well-being.

Increasing tolerance of negative events and situations or changing those situations that trigger stressful experiences.

Controlling the meaning of the stressful experiences, so as to thwart their deleterious nature.

Reducing existing psychological stress, or conflict, while it is being experienced.

Maximizing the probability of returning to pre-stress activities.


Finally, Livneh and Martz (2007, pp. 17-18) suggested another area that should be considered when viewing coping strategies, that is, the temporal context of coping:


Preventive or proactive coping that occurs long before stress (a) is experienced or (b) might even occur; this is referred to as distal anticipatory coping. Examples include planned retirement and age-related health condition.


Anticipatory coping that occurs when stress is being anticipated to occur in the immediate future (pending threat); this is referred to as proximal anticipatory coping. Examples include waiting for a doctor appointment and preparing for an important exam. 


Dynamic (or present) coping that is being employed while stress is ongoing (i.e., while stress is being experienced). Examples include experiencing a severe marital discord and dealing with acute pain.


Reactive coping that occurs after stress has been experienced, typically in the immediate past. Examples include recent loss of a job and dealing with the aftermath of an automobile accident.


Residual coping that occurs long after stress has been experienced and when the person deals with the long-term effects of the stress. Examples include living with an early life onset disabling condition and mourning the loss of a parent.


Livneh and Martz (2012) summarized literature indicating that coping efforts are differentially applied, depending upon how stress is temporally perceived. For example, preparatory or anticipatory coping occurs when stress is anticipated in the near future (e.g., prior to surgery, intense medical regimen). On the other, dynamic or crisis-related coping is employed during ongoing acute, stressful encounters (e.g., when injury occurs, when experiencing acute pain). Finally, reactive and residual coping are typically applied following the experienced stressful episode or the recovery period (e.g., dealing with the aftermath of an accident, living with the long lasting implications of disability).


In summary, there are a wealth of coping definitions and ways of categorizing coping strategies. Krohne’s (1996) hierarchy of coping strategies was used as a model for understanding the broad range of coping strategies. Table 5 provides a summary of numerous issues that influence the definitions of coping.



Table 5. Issues Related to Definitions of and Processes of Coping



The Following Issues Produce a Range of Definitions of Coping:


State (situation-specific) vs. Trait (durable dispositions)


Global (coping as a macro-analytic concept; high level of abstraction or aggregation) vs. Specific (coping as a micro-analytic concept; low level of abstraction such as a distinct behavior)    


Problem-focused (eliminating or reducing stressful events; externally-oriented efforts) vs. Emotion-(or perception) focused (regulating or managing distressing emotions; internally-oriented efforts)


Conscious vs. unconscious processes


Adaptive vs. Non-adaptive (degree of coping successfulness; adaptive nature is judged in relation to the nature, duration, controllability, and changeability of the stressful event)


Temporality (preventive/proactive vs. present/ongoing vs. reactive/residual coping efforts)



Selected Empirical Findings of Coping with CCD


Empirical research on coping with CCD has been rapidly expanding over the past several decades (see Martz & Livneh’s 2007 book for in-depth chapters on specific CCD-related research). The following are summaries (Livneh, unpublished manuscript) of numerous empirical articles on coping with CCD, which will provide the reader with a flavor of the research findings on CCD (note: citations are not provided here, because the purpose is to provide an overview of trends in research). The summaries are grouped into engagement coping and disengagement coping strategies, which can be viewed as a macroanalytic category of coping.



Table 6. Engagement and Disengagement Coping Strategies



Engagement Coping Strategies



Approach coping was related to fewer psychological symptoms (problem-solving and information-seeking moderate the adverse influence of negative life events and role stressors on psychological functioning)


Greater use of problem-solving was related to less depression and fewer physical symptoms following treatment


Active coping was associated with success in self-management drinking problem


Cognitive approach was associated with better treatment outcome for alcohol abuse


Cognitive (cognitive restructuring) and behavioral (problem solving) coping approaches were linked to maintenance of smoking cessation


Problem/active-focused coping is predictive of positive adaptation


Optimism is linked to more active, problem-oriented coping in medical patients


Internal locus of control is linked to both active problem and emotion-focused coping


Active, problem-focused coping is related to better adjustment to chronic health condition


Active, problem-focused  coping was associated with higher self-esteem and life satisfaction


Active, problem-focused coping is associated with successful psychological and physical adjustment among patients


Active coping (problem-solving, information seeking) was associated with decreased depression and physical limitations (in pain patients)


Cognitive and behavioral coping methods that divert attention from pain to other activities/events, and use relaxation and transformational imagery, were found to be effective in coping with chronic pain


Behavioral coping (information seeking, decision making, direct action) was found to be a protective factor in lowering levels of tobacco and alcohol use

Problem-focused coping is more adaptive when a stressor is (seen as) controllable


Problem-focused coping was negatively associated with the severity of PTSD.



Disengagement Coping Strategies



Avoidance coping was related to psychological distress (denial, withdrawal were associated with more depression)


Increased reliance on emotional discharge was related to greater depression and more physical symptoms after treatment


Denial can be beneficial in the initial stages after health crisis/medical injury but is generally detrimental in the longer term


Wishful thinking, self-criticism, and social withdrawal were associated with failure to quit smoking


Expressing emotions was associated with increased reporting of pain


Emotion/passive-focused coping is associated with negative adaptation


Pessimism is linked to more passive, avoidance-oriented coping


External locus of control is linked to passive-avoidant coping


Avoidant, emotion-focused coping is related to more difficulty in adjusting to chronic health conditions


Avoidant, emotion-focused coping is associated with lower quality of life


Avoidant, emotion-focused coping is associated with poor psychological adjustment and adherence to medical advice among patients


Passive, emotion-focused coping (e.g., escape-avoidance, wishful thinking) and active, emotional-focused coping (e.g., positive reappraisal, self-control) can reduce anxiety among cancer patients


Denial can be adaptive during the first few days following myocardial infarction (e.g., decreased anxiety) but is usually less adaptive later on (e.g., less compliance with medical advice and less attention to physiological distress signs)


Passive coping (praying, hoping, wishful thinking) was associated with increased pain, depression, and poor psychological adjustment (in pain patients)


Avoidance coping (selective ignoring, withdrawal, emotional discharge) was linked to substance abuse


Self-blaming and self-attribution of victimization were linked to depression and hopelessness among victims of crimes


Emotion-focused coping is more adaptive when the stressor is (seen as) uncontrollable and when the source of stress is unclear


Emotion-focused and avoidance coping are more frequently employed by individuals with depression


Emotion-focused coping was associated with severity of PTSD and levels of anxiety.



When examining the two summaries above, several trends are evident. In general, problem-focused coping leads to better psychosocial adaptation and psychological outcomes (e.g., quality of life). Emotion-focused coping is often related with poorer psychosocial adaptation and psychological outcomes; however, emotion-focused coping can be useful in contexts that cannot be altered.


Note that investigations into the associations between coping and psychosocial adaptation are complicated, due to a variety of reasons (see Livneh & Martz, 2012 for more details). One example, which may explain some contradictions found in the research on the coping/adaptation association, is that respondents in research studies are not assessed as to which reaction(s) of adaptation to CCD that they operated in when completing the coping measure. Hence, their coping answers may look differently if they were further along in the process of adapting to their CCD. As was pointed out earlier, research has demonstrated that the relationships between some predictors and outcomes of adaptation to CCD may not be a linear association, but may, in fact, demonstrate a curvilinear or non-linear trend. Most researchers to date, who have studied the associations between demographic and disability-related variables, coping, and adaptation to CCD, have used linear predictive models. Yet, the real-life complexity of exploring coping and adaptation to CCD may require more sophisticated analysis of non-linear trends (for a discussion, see Livneh & Parker, 2005), especially in view that models of psychosocial adaptation describe it as an on-going, dynamic process—which further complicates the efforts to measure the associations between coping and adaptation constructs.


Summary Points on Coping


A few tentative summary points can be made about coping (Livneh & Martz, 2007, p. 20):


Coping strategies vary both within (they change over time) and between (they are person-specific) individuals. When they change over time, they are typically used to manage the effects of both short-term and long-term stressful situations.


Specific coping strategies are differentially effective (or adaptive), depending on the type of stressor (e.g., entrance vs. exit events), severity, duration (acute vs. chronic), and context of the experienced stress.


Coping effectiveness demands a good balance (or fit) between the person-environment transaction and the coping strategies adopted to manage the stressful situation.


Adaptive, or successful, coping requires a flexible and versatile repertoire of coping strategies, and the combined use of both problem-focused and emotion-focused efforts. That is, problem-focused coping may be more adaptive under changeable and controllable conditions, while emotion-focused coping may be more adaptive under unchangeable and uncontrollable situations.


Regardless of their level of effectiveness, coping strategies may be viewed as a mediating factor between stressful encounters and the ultimate psychosocial outcomes.


Note also (as previously mentioned) that demographic, medical, personal, and interpersonal variables may influence coping strategies, and consequently, adaptation to CCD (e.g., see Table 7 and the previously discussed Figure 2).



Table 7. Variables that Influence the Coping Processes



Chronological age

Age of CCD onset

Duration of CCD

Functional limitations

Level of pain or discomfort

Nature of stressful event/situation (e.g., controllability, changeability, course, familiarity)



Facilitating Coping with and Adapting to CCD


Health professionals may experience pressure to categorize psychological states of individuals with CCD, such as using diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013) or ICD (WHO, 2001); yet, such a reliance on medical frameworks for understanding psychological reactions to CCD serves to dilute the complexity of the adaptation process. As mentioned above, a range of reactions of both positive and negative affectivity may occur after the onset of CCD, and thus, multidimensional models of psychosocial adaptation to CCD are needed. This also reflects the need to use assessment instruments that evaluate the multidimensional psychosocial nature inherent in such a process of adaptation. Table 8 provides examples of items from a multidimensional adaptation scale (Reactions to Impairment and Disability Inventory; RIDI) used to measure adaptation to CCD.



Table 8. Sample Questions from the RIDI    



  1. Since I acquired my disability, I am less interested in other people.
  2. If I become a better person, my problems will be cured.
  3. Since I acquired my disability, I cry more often than I used to.
  4. When I look back on what has happen to me, I feel bitter.
  5. God will cure me, if I improve my behavior and follow His ways.
  6. I am a failure as a person.
  7. I am satisfied with my present abilities despite my disability.
  8. Since I acquired my disability, I have attacks of panic.



More details about the RIDI are available from: Livneh and Antonak’s (2008) ”Reactions to Impairment and Disability Inventory Users Manual” and from Livneh and Antonak (1990, 1997).



The following sections will cover ways of promoting coping with CCD, beginning first with an overview of general coping skills for life stressors. Table 9 provides samples of items from a questionnaire used to assess the coping strategies used by individuals. Each item on the scale is score from “I haven’t been doing this at all (1) to “I’ve been doing this a lot” (4).



Table 9.  Sample Questions from Brief COPE scale



  1. I've been turning to work or other activities to take my mind off things.
  2. I've been concentrating my efforts on doing something about the situation I'm in.
  3. I've been saying to myself "this isn't real."
  4. I've been using alcohol or other drugs to make myself feel better.
  5. I've been getting emotional support from others.
  6. I've been giving up trying to deal with it.
  7. I've been taking action to try to make the situation better.
  8. I've been refusing to believe that it has happened.



More details about the Brief COPE scale are available from Carver (1997) or on-line here. It is available for free.  



 Promoting Generic Coping Skills for Common Life Stressors


The following coping principals, as generic coping skills, are based on Kleinke (1991):



Table 10.  Coping Principals



  1. Use social-support systems:
    1. for emotional support
    2. for tangible support
    3. for informational support
  2. Implement problem-solving:
    1. Identify/define the problem
    2. Assess the consequences of the problem
    3. Generate a list of possible solutions
    4. Make a decision/choose the most appropriate solution
    5. Evaluate your success
  3. Promote self-relaxation
  4. Maintain internal control and self-efficacy
  5. Confronting the situation:
    1. preparing for the challenge
    2. confronting the challenge
    3. reflecting on the experience (what was learned)
  6. Use sense of humor:
    1. helps to avoid reaching negative conclusions
    2. increases feelings of self-efficacy
  7. Exercising:
    1. enhances physical fitness
    2. improves self-concept and mood
    3. enhances sense of internal control and self-efficacy




Overview of Coping-based Interventions Specific to CCD


The following overview of coping-based interventions for individuals with CCD is based on Carver et al. (1993), Lazarus and Folkman (1984), Pearlin and Schooler (1978), and Zeidner and Saklofske (1996).



Table 11.  Overview of Coping-based Interventions



Psychotherapeutic-related interventions typically emphasize the following components: 

  1. Interpersonal support
  2. Validation of feelings
  3. Exploration of issues
  4. Interpretive feedback
  5. Encouragement to maintain hope


Cognitive-behavior interventions typically emphasize the following skills: 

  1. Stress-management skills, such as:
    1. Relaxation
    2. Meditation
    3. Breathing exercises
  2. Cognitive restructuring skills, such as:
    1. Challenging irrational beliefs/thoughts
    2. Cognitive reframing
  3. Problem-solving skills (see previous description of the problem-solving process)




Case Study



Case Study #1



Alice experienced 3rd degree burns when she was 24 years old when her family home caught on fire, due to a cigarette (three family members died in the fire). Now Alice is 30 years old and has high school and college diplomas but has been repeatedly unemployed after she graduated. She does like to babysit kids in her home. She is not especially interested in working in the workplace, but she is not happy “just” babysitting. She does not like to look in mirrors, because of her burns. Alice is unable to go grocery shopping but gets friends and neighbors to pick up items for her. She broke up with her long-time boyfriend after the accident and at that time, and then started to drink alcohol (i.e., three glasses of wine at night). She recently broke up with her boyfriend of 6 months and went to the emergency ward because she had swallowed about 20 sleeping pills.



When approaching this case study, there are several psychological issues that could be addressed. First is the experience of 3rd degree burns, which in and of itself may trigger a range of psychological reactions. Second is the experience of losing three family members in the fire, which may be a source of unresolved grief. Third is a more recent occurrence of a break-up of a relationship and her suicidal behavior after the break-up. Other issues include her possible alcoholism and her lack of satisfying and satisfying gainful employment.


While multiple techniques could be utilized with Alice in counseling sessions (see Sharoff, 2004), health professionals in general can identify the following in this case study:


  • Alice’s alcoholism is one way she is attempting to cope with her problems.


  • Alice appears not to have fully adapted to her disability, as reflected by an inability to look at herself in the mirror, in addition to not being able to tolerate public interactions, as found in the workplace and grocery shopping.


  • She also has terminated two intimate relationships—and it can be explored to see if those actions reflected anger toward herself or others due to the disability (burns).


Two Coping Interventions


Coping Effectiveness Training Program


The Coping Effectiveness Training (CET) program was created by Chesney, who was a colleague of Folkman (Chesney & Folkman, 1994). Three primary types of coping are taught in CET: problem-focused strategies for changeable situations, emotion-focused for unchangeable situations, and social support strategies for seeking appropriate types of support from others. The emotion-focused coping strategies were renamed as “stress management strategies” in a recent research study (Martz et al., in press). CET teaches stress management strategies for aspects of life that are unchangeable or uncontrollable and problem-solving strategies for stressors that are changeable.


Numerous studies have indicated that CET is effective in increasing coping strategies among individuals with a range of impairments or disabilities (Chesney, Chambers, Taylor, Johnson, & Folkman, 2003; Chesney, Folkman, & Chambers, 1996; Kennedy, Duff, Evans, & Beedie, 2003; King & Kennedy, 1999; Martz et al., in press; Nahlén Bose et al., 2016). In the CET model, adaptive (or effective) coping is a result of a realistic appraisal of the stressful situation and an appropriate choice or ‘fit’ of coping strategies to tackle it, which should result in  a decrease of stress.


Goals of CET: 

  1. To clarify and modify the nature of stress and coping with stress
  2. To develop and improve stress assessment (e.g., specific vs. global stress, changeable vs. unchangeable stress factors)
  3. To teach a range of stress-reducing coping skills:
    1. Problem-solving skills
    2. Activity-planning skills
    3. Social/assertiveness skills
    4. Relaxation (management) skills
    5. Time-management skills
    6. General stress-management skills
  4. To reduce engagement in non-adaptive coping strategies
  5. To improve the ability to obtain and maintain social-support networks


The CET program includes the following strategies: 

  1. Developing appraisal skills:
    1. Identifying cause(s) of stress (i.e., stress-triggering situations)
    2. Becoming aware of signs/indicators of stress (i.e., emotional, cognitive, physiological and behavioral reactions)
  2. Breaking down complex/global stressors into specific stressors:
    1. Who is involved?
    2. What type of situation/context elicits stress?
    3. Where are these situations likely to occur?
    4. When did they last occur?
  3. Coping realistically by examining if the stressful situation represents:
    1. Loss or harm (incident already occurred)
    2. Possible threat (potential stress)
    3. Challenge (opportunity for growth or gain)
  4. Deciding what can and cannot be changed:
    1. Can it be changed?  Then, usually adopt a problem-focused approach (doing something to alter situation)
    2. Can it not be changed?  Then, usually adopt an emotion-focused approach      (regulating emotions or thoughts about the situation)
  5. Using emotion-regulation strategies (for an “unchangeable” situation):
    1. Participate in pleasant social activities
    2. Find competency (goal-achievement) activities
    3. Do activities incompatible with emotional distress
    4. Relaxation
    5. Acceptance (of the event/reality)
    6. Reframing/challenging negative thinking
    7. Using religious practices (when appropriate)
    8. Humor
    9. Seeking social support (for venting of emotions/concerns)
  6. Using adaptive coping (for changeable situations):
    1. Problem solving
    2. Active/direct coping
    3. Planning
    4. Obtaining information
    5. Confronting the stressor (when appropriate)
    6. Seeking social support (for instrumental purposes)


The following are signs of non-adaptive (or ineffective) coping strategies, which may be a result of a mismatch between the type of stressor and the choice of coping strategies:


  1. Behavioral disengagement (i.e., avoids “doing” things and getting involved in activities)
  2. Mental disengagement (i.e., avoids “thinking” about things and considering plans to diffuse problem)
  3. Denial (when used as a long-term strategy)
  4. Expressing negative emotions (with no efforts to channel emotions or to follow-up with plans to diffuse problem)
  5. Thinking about using drugs/alcohol
  6. Wishful thinking (i.e., fantasizing about future/world without the stressful situation)



Cognitive Coping Therapy (CCT)


Cognitive coping therapy (CCT) by Sharoff (2004) is based on cognitive-behavioral therapy (CBT), which is therapeutic perspective that asks individuals not to take their thoughts as facts, but rather, view thoughts as hypotheses that need to be tested for validity. Sharoff’s CCT is based on a holistic model that utilizes cognitive, emotional, perceptual, physical, and behavioral abilities. Sharoff proposed that there is no such thing as a bad coping skill, because a skill is only part of a particular strategy: What matters most is how, when, and where it is used. Sharoff asserted that even non-adaptive strategies and psychological symptoms contain invaluable, viable skills that can aid adaptation; this requires a focus on finding the positive within the negative.


Sharoff (2004) proposed numerous techniques for bolstering coping. A brief overview of the numerous techniques that he proposed is listed below; these are examples of the extensive skills that he described in his book, which focused on facilitating coping among individuals with chronic and terminal health conditions.


  1. Assimilation of suffering (i.e., how to manage suffering related to CCD) includes:
    1. Self-instruction training. set up self dialogue to help when situations trigger suffering or hatred of one’s health condition.
    2. Predetermined imagery or symbolic gesturing can be used when suffering is triggered, in order to facilitate coping.
    3. Enacting a role model: a person is asked to notice someone who handles their medical problems well, to analyze what they are doing, and then use them as role model for a period of time.
    4. Anchoring: a person is asked to think about a time when they were able to deal with their suffering and then to imagine that time very clearly and to touch a certain part of his or her body, which is part of the anchoring process. The anchor is then used when the individual has difficulty, and needs to trigger positive coping strategies.
  2. Energy allocation. Having a CCD often requires more time and energy to fulfill daily activities. Because a major source of discomfort among individuals with CCD can arise from over-commitment and overexertion, then managing one’s energy is important, in order to plan out tasks that will require a specific resource of energy (e.g., a person with diabetes will need to plan the time and extent of exercise, in order to avoid hypoglycemia). This coping strategy includes the following skills:
    1. Self-awareness and self-monitoring
    2. Prioritizing to help decrease impulsive actions
    3. Value clarification to help reorder actions based on their “old self” and which values must be put aside (i.e., letting go of activities that one used to do)
    4. Objectivity to help the person problem-solve and make decisions related to energy allocation
    5. Acceptance training: recognizing that certain actions can no longer be done and that more reasonable actions (that fit within one’s CCD-related limitations) should be undertaken.
    6. Limit-setting: communication training on assertiveness and conflict resolution. Because the individual with a CCD has a “gatekeeper” function, they will have to be assertive about not doing actions, when those actions may be harmful, given the CCD-related limitations.
  3. Frustration management. Individuals with CCD may feel frustrated, discouraged, and defeated by the continuous existence of CCD-related symptoms or limitations; as a result, they physically may feel tense and aroused with increased energy and ‘no place to go.’ Frustration can add to the psychological stress and strain that an individual with CCD may be experiencing. The following are examples of coping skills that address frustration.
    1. Frustration tolerance: Multiple therapeutic techniques can help build this skill for handling frustration, including cognitive restructuring (i.e., confronting irrational beliefs), cognitive rehearsal (i.e., practicing self-statements to prepare a plan of action without stress present), self-monitoring, relaxation training, symbolic gesturing, and imagery usage.
    2. Frustration accommodation: developing flexibility, given that the existence of a CCD may require more time and energy to fulfill activities of daily living. The CCD-related limitations may also create frustration in other people (e.g., having to walk more slowly to accommodate the individual with a CCD). Frustration accommodation targets the commonly experienced frustrations related to CCD, and encourages acceptance that some level of frustration is inevitable for individuals with CCD. Self-instruction training, or creating positive self-talk, in preparation for the times of frustration that will be experienced, is one means of encouraging frustration accommodation, according to Sharoff.
  4. Area thinking. Frustration triggered by CCD may arise, due to that fact that their CCD is ever-present, and that many CCD-related effects and limitations cannot be altered, as much as the person would like to change specific aspects related to their CCD (e.g., a person with diabetes would like to stop having to test blood sugar levels). The fact that certain aspects of their CCD cannot be changed can create frustration, a sense of helplessness, and even anger that areas of a person’s life is out of one’s control. An example is that a person may seek a cure to a CCD, which in fact, cannot be cured due to the current state of  medical and scientific knowledge, and the specific type of health-related issues; such a goal may create frustration and anger. Area thinking encourages an individual with a CCD to select goals that are within the area of the individual’s control and that are realistic about what an individual can and cannot alter in one’s life. Skills include the following:
    1. Surrendering versus non-surrendering strategy: this involves knowing “when to surrender, when not to surrender, or when surrender is inevitable” (Sharoff, 2004, p. 73).
    2. Prioritizing: understanding which goal is the most important at that moment.
    3. Acceptance if what cannot be changed related to one’s CCD.
    4. Identity coalescing.  Because chronic health conditions or disability affects one’s identity, identity coalescing involves designing a new identity. Skills that are needed include:
    5. Blending one’s old and new identities, which involves “weighting”—balancing the power of the new images with old ones, so that one does not focus only on negative images
    6. Continual effort needed by a person with CCD to blend old and new identitie
    7. Avoid value judgments by changing to descriptive judgments, which records actions and experiences but does not condemn or criticize
    8. Acting without comparing to norms/standards: Try to suspend standards and instead, set goals
    9. Self-booster training: Overemphasize one’s abilities and underemphasize the negative aspects/shortcomings of one’s life (e.g., “I like how I….”) The emphasis in this technique is not realistic thinking, but stresses the positive, in order to counteract the common effect of the CCD triggering negative thinking.
  5. Anxiety-reduction training.
    1. Self-monitor autonomic arousal, which is a strategy to help an individual understand what is triggering the reactions and how to distinguish the types of anxiety reactions. Monitoring can be done on an hourly schedule with a rating of its intensity.
    2. Relaxation exercises, such as deep breathing, muscle relaxation, or imagery. Stress is reduced, but not eliminated by decreasing anxiety reactions.
    3. Self-instruction training, which is preparing for how one will react during anxiety-producing moments and then using cognitive rehearsal.
    4. Systematic desensitization: an individual categorizes anxiety-producing stimuli. Then, each stimulus is imagined while relaxation is paired with the resulting anxiety.
    5. Worry management training: individual is told to worry only at a specific time (e.g., for 6 p.m. to 8 p.m.), which helps the person learn control over the worrying. Thought-stopping (e.g., commanding oneself to stop thinking a thought) can also be used.
    6. Time projection: the individual with CCD thinks 6 months to 1 year ahead to imagine when they are more used to the CCD and have better coping/problem-solving skills.
  6. Acceptance training.
    1. Emotional recognition of reality: If people are intellectually but not emotionally recognizing the facts related to health condition, then confrontation can be used, followed by processing comments. Note: this technique should be used only if denial is creating a life-threatening or dangerous situation. Habituation and time projection will help people recognize some CCD-related facts.
    2. Incorporation of the reality into one’s life: because acceptance does not mean surrendering, people are encouraged to try to make behavioral changes or disapprove of the reality. They may emotionally react to this incorporation, so affective counseling can be used at this point.
    3. Coexisting with reality: Rejection tolerance is cultivated by examining what life will be life after rejection. The person is encouraged to think that rejection will not be awful, just unpleasant. Imagery can be used here. One technique is to restrict irrational, unrealistic thinking to odd days of the week and self-dialogue on even days; have the person document differences in thoughts experienced on those days.
    4. Accepting unwanted consequences: typically psychological pain is one of the major consequences of rejection. Help an individual with CCD frame the choice: either fight with the pain triggered by rejection of one’s CCD, or learn how to cope with the pain. This choice demonstrates that the person has some responsibility for negative emotions related to CCD. Imagery and symbolic gesturing can be also used to facilitate acceptance.


Case Study



Case Study #2



Phil is a 51-year old, self-employed farmer with an 8th grade education, who while mowing on a slope, his tractor hit a hole, throwing him from the tractor and subsequently running over his right leg. The leg subsequently had to be amputated, due to the severity of the injury. Phil does not believe in following directions (i.e., “rules are made to be broken”), so that he did not take basic safety precautions when he was mowing. He received prosthesis for his leg, but experienced considerable depression after his injury; he was unmotivated to learn to walk with the artificial limb and refused the help that was offered to make accommodations in his house or farm equipment. Phil also has high blood pressure for which he takes no medication. He participated in Vietnam War and still experiences nights of sleeplessness, due to intrusive images related to his war experiences. His wife divorced him ten years prior to the accident, claiming that he was too irritable and angry to live with anymore. He claims to not drink too much alcohol (i.e., four beers at night), but his wife accused him of being addicted when she divorced him.



When approaching this case study, there are several psychological issues that could be addressed. First is the experience of an amputation, which may trigger a range of psychological reactions. Second is the experience of going through a divorce, which may be a source of unresolved grief. Third is Phil’s experience in the Vietnam War, which continues to impact him as evident by his experience of intrusive imagery and sleeplessness (thus, posttraumatic stress disorder may be an issue). Other issues include lack of motivation to walk again, his current unemployment, possible alcoholism, and lack of taking care of his high blood pressure.


While multiple techniques could be utilized with Phil in counseling sessions (see Sharoff, 2004), health professionals in general can identify the following in this case study: 1) Phil’s personality (i.e., does not like to follow rules) and his possible posttraumatic stress disorder (i.e., intrusions, sleeplessness, irritability and anger possibly related to war-time experiences) will interact with his psychological reactions to his amputation, hence making the psychological picture more complicated; 2) Phil is experiencing depression, which appears to be related to his amputation, although other factors may be influencing depression levels (e.g., unemployment, divorce); 3) Phil may also be experiencing denial, in view of his refusal to allow accommodations in his house or farm equipment, as well as his refusal to take medication for his blood pressure; and 4) Phil should be assessed for alcoholism, which can be one way that he is attempting to cope with his problems.




The preceding sections cover a range of coping-related interventions. Many of these skills can help limit the “spread” of disability, which Wright (1983) depicted as a process in which the negative aspects of a person’s life dominates the attention, and even becomes the identity, of a person with CCD. Hence, building up the coping skills of individuals with CCD can not only help them better function in life and manage their CCD-related symptoms and limitations, but coping skills can help to reduce the negative emotions and cognitions that may spontaneously arise (and at times, linger) when dealing with the continuous presence of a CCD.


Because coping is assumed theoretically to influence psychosocial adaptation to CCD, and because coping and adaptation have been found to be empirically associated, a focus was placed in this course on examining the difference between the two concepts. Further, because coping is viewed as the shorter range strategies used to manage the CCD, emphasis was placed in this course on summarizing interventions used to alter coping strategies; it is expected that as individuals’ coping skills improve, so will their adaptation to CCD, as well as self-management of the CCD (Martz, 2017). Other resources, which are not focused just on coping, but rather on a broader range of psychological theories and interventions for individuals with CCD, include the following books: Chan, Berven, and Thomas (2004), Martz (2017), Radnitz (2000), Sperry (2006), and Taylor (2006).




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