Australian Doctor 14th February 2025 | Page 22

14 FEBRUARY 2025 ausdoc . com . au their patients with coping skills . ‘ Coping ’ is not an inherent moral quality , but a series of learned behaviours and skills that are often taught and modelled in childhood . It is understandable that those who live with unstable or damaging family relationships may not have acquired these skills . It is equally understandable that some who have lived with considerable privilege have not had opportunities to practise and learn skills to cope with things beyond their control .

Coping theory suggests that there are four mechanisms that assist with coping ( see box 1 ). 1

Figure 3 illustrates the way people think threats behave , with a crisis event leading to an inevitable negative emotional outcome . In fact , coping modifies this outcome , reducing the impact of the threat and increasing a patient ’ s capacity to live with and manage it .

APPRAISAL

TO cope with a difficult situation , patients need to appraise the situation accurately , and appraise their own capacities appropriately . An honest appraisal of the threat can be difficult . Patients may hold incorrect assumptions that cause considerable stress . Examples include the idea that all cancers are fatal , or that childhood asthma is always life-threatening , or depression is untreatable . These assumptions can include beliefs about health and healthcare , which may be general ( such as , all doctors are under the control of Big Pharma ), or specific ( for example , that all antidepressants “ dope you out ” and are addictive ). Information is changing rapidly , and global communication has meant misinformation has flourished . Data are not information , and assuming that the presence of data in a brochure , on a website or through a website are ‘ available ’ does not mean the patient can access or understand it . It is important that information is presented in a way that patients can understand both the meaning and the specific , individual application of information .

It is important to recognise the limitations of literacy , health literacy and numeracy . People we consider highly literate may have no idea about healthcare and be completely confused about the language . 2 This is particularly the case for patients the author calls “ healthcare naive ”, the patients who have never been a patient , or if they have , their care has been managed by someone else , like a spouse or parent . These patients can feel ignorant and ashamed of their lack of knowledge . It is always worth asking if they are familiar with the health system before describing the treatment pathway .

Literacy in English in Australia is lower than many expect . The Australian Bureau of Statistics ’ adult literacy survey showed that fewer than 50 % of Australians who have not completed an advanced diploma or higher degree have ‘ adequate ’ literacy . 3 Only 25 % of adults who have completed no higher than grade nine high school education have ‘ adequate ’ literacy . 3 Most online health information is above the average level of Australian literacy meaning patients need help with its interpretation . 4 Handing them a URL and sending them home to interpret it is not patient education .

Figure 1 . Looking down over a cliff .

Coping

However , it is numeracy levels that are most surprising . 5 Health numeracy describes the skills needed to understand and use quantitative health information , including the ability to use information in documents and non-text formats such as graphs . 6 It is normal for health information to use figures or pictograms to represent survival rates or treatment impacts . However , around 50 % of year nine students cannot interpret the meaning of a graph , and apply that to their own context , and seem to plateau with that level of knowledge during their schooling . 8 As clinicians , we too often have gaps in our statistical understanding . 7

Patients cannot make good decisions , and cope well , if they do not

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understand the true nature of the threat . They also need to understand what tools they have to cope , which includes an appraisal of their own capacities . In crisis , people often lose their sense of agency . We need to bolster a sense of self-efficacy in our patients by reminding them of their strengths and the way they have coped in the past . We also

Box 1 . The four mechanisms that assist with coping

• Appraisal :

— This involves ensuring that the problem and its threats are understood and proportionate , and that the patient understands what support will be available to help them .

• Problem-focused coping : — Doctors will be familiar and comfortable with this . — Doctors help patients deal with the problems they face in practical ways , assisting them to access resources , reminding them of strategies to tackle their problems one step at a time and providing advice when their health is suffering .

• Emotion-focused coping :

— This includes listening , providing empathy and encouraging people to talk and to share the burden of suffering .

• Meaning-focused coping skills : — This is the most difficult strategy .

— When trauma is lifechanging and severe , and it cannot be ‘ fixed ’ with problem-solving or soothed with emotional support , we need to face the profoundly difficult existential questions .

• Why do bad things happen to good people ?

• Who am I in the wake of this trauma ?

• And of course , the most challenging one of all , where were the people and institutions I trusted when I needed them the most , and how is it that I was facing this trauma alone and unprotected ?

Source : Lazarus RS et al 1984 1

need to remind the patient that they are not coping alone , by helping them identify their social resources , and also reiterating our own availability and support .

The democratisation of online publishing means we all have access to lived experience narratives , in the form of blogs , discussions and multimedia presentations . Presenting information in a variety of media is often helpful , although it needs to be tailored to the literacy of the patient , and their stage of coping . Bombarding them with health information is rarely helpful , but introducing specific , reliable resources is very helpful .

The aim of appraisal is to ensure the patient has an accurate understanding of the nature of the threat , and the resources they have at their disposal to manage it . Further strategies for appraisal are shown in box 2 .

PROBLEM-FOCUSED COPING SKILLS

AS GPs , we are extremely capable problem solvers ( see figure 4 ). Most of our patients are also familiar with these strategies but may lose this capacity when they are