Coping, More or Less
What is this people do in the face of serious illness?
Notes from a Family Meeting is a newsletter where I hope to join the curious conversations that hang about the intersections of health and the human condition. Poems and medical journals alike will join us in our explorations.
For those of you just joining, consider starting here to trace how I’ve been thinking about medicine and technology, a conversation I’ve been returning to time and again.
Sleep is sacred.
Before residency, I had never pulled an all-nighter, no matter how pressing my academic priorities. Once my residency schedule dictated that I would spend 28 hours in an ICU every third day, I no longer had a say in the matter. This was a problem I couldn’t really solve. So what was I to do? I had to cope with it.
We don’t cope with good things. No, it’s only the challenges, problems, afflictions, sufferings with which we must cope. And only those that are unsolvable or unfixable. My residency schedule wasn’t a problem I could solve. I had to endure the rigors of the ICU if I wanted to complete my training. So, I had to cope.
People cope in all sorts of ways. They might try to avoid the thing. If it’s not going away, though, they might find that the thing grows until it’s unavoidable. Maybe it’s also snuck around causing other problems. I’ve known patients who wanted to ignore their early stage cancer but then urgently returned months later with the pain of metastatic disease. Sometimes, though, we really do need to ignore a problem for a few moments to focus on a problem that’s more urgent or important. Sometimes we just need a reprieve. Vacation, for example, displaces us from everyday life so we can adopt a different, more simplified way of living. Substance use can be another way of coping through avoidance.
Other people cope through religious ritual, like prayer, or through conversation. They might cope through studying the problem. Even if no solution is forthcoming, there might be comfort in knowing more about the thing. Still other people cope through humor, exercise, or sublimating their concerns into still other activities. The list goes on.
What is it we’re trying to do with all this coping?
Reflecting on her experience caring for a man who uses dark humor to face his death, palliative care psychiatrist Dani Chammas writes:
“I have come to conceptualize every behavior I observe in patients, from the delightful to the infuriating, as an attempt at coping, at maintaining psychological integrity in the face of difficult situations. A patient’s way of coping is not “good” or “bad” — it’s simply the patient’s best in a particular moment with the internal and external resources at hand. Acceptance is not better than denial; humor is not better than anger; finding meaning is not better than renouncing all meaning. The questions are: Is it adaptive? Is it reducing stress and allowing patients to adjust to their new reality? How is it serving them and how is it hindering? How can I best aid their coping?”1
Coping, in Chammas’s view and I think shared by many, is someone’s attempt to hold their life together in the face of something threatening to tear it apart. That “something” might fit well with Eric Cassell’s “suffering,” which he described as a threat to the integrity of the person. Coping is whatever someone does to fend off that threat. It’s an attempt to preserve the status quo, whatever the status quo is.
Chammas frames it that way to claim that “a patient’s way of coping is not ‘good’ or ‘bad.” She instead substitutes another evaluation via a series of questions: “Is it adaptive? Is it reducing stress and allowing patients to adjust to their new reality? How is it serving them and how is it hindering? How can I best aid their coping?” I’m sympathetic to the word limits of such a short perspective piece in an academic journal, but hidden questions under these are left unasked: What is adaptivity? What does it mean to “adjust to a new reality?” What is service and what is hindrance? What is aid?
I think in trying to skip over moral evaluations, those who rely solely on adaptivity to frame coping overlook important resources that could help us better see and explore the landscape of the clinical encounter, and help us live better even in the face of suffering.
Knives and Pie
I wonder if one of the challenges of using moral language in pluralistic spaces is that concern that dynamics will rapidly devolve to condemnation and shame. Furthermore, the existence of pluralism challenges the possibility of objective moral truth. Mental health clinicians, in particular, feel they’re standing on firmer ground if they use words that carry the air of objectivity, like adaptivity. But ignoring morality doesn’t make it go away. It’s better to acknowledge it.
Consider a knife. A good knife does what it’s supposed to do, namely, cut well. A good cut is one that is easy, safe, and produces a good end product (e.g., not smashing a tomato, but slicing it). We wouldn’t evaluate a knife based on something it wasn’t meant to do, like starting a fire or curing pneumonia, although if I’m being ridiculous I might say, “A knife is bad for curing pneumonia.” A good pie also does what it’s supposed to do. The evaluation of a “good pie” is more nuanced but still possible based on taste, texture, originality, etc.
In both these examples, to call something “good” or “bad” is to imply you know something about its purpose. Knives and pies can only be evaluated based on what they’re supposed to do.
It’s usually easier to know “bad” than “good.” Almost anyone can identify a bad knife, but some might mistake a good knife for bad if they lack the skill to use it well. It’s also easier to know a bad pie (e.g., burnt, too much salt, bland) than a good pie. Let’s be careful, though: are you claiming this is a bad pie, or simply a pie you don’t like? When considering pie, isn’t the point of a pie to satisfy my preference? If so, a pie may indeed be a bad pie if it doesn’t satisfy my particular preference. But it’s rare that any given pie would be made to please me, Josh Briscoe. It may have been baked to “taste good for the majority of people who typically enjoy eating blueberry pie with a butter crust.” If that’s the case, then I can’t claim, based on my tasting alone, that it’s a bad pie, because I’m not someone who typically enjoys eating blueberry pie.
Maybe it’s a problem of definition. Am I defining “pie” the same way you might? If I take a bite of shepherd’s pie and declare it a “bad pie,” since I was expecting something else, does that make it a bad pie? Or does that mean I’ve misunderstood what pie is?
It’s also possible that I might not like a good pie. That suggests my preferences can be out of alignment with the state of things, even for something like pie. My mere preference can’t settle whether something is bad or good, even when it comes to pie. It does depend on how we define a “good pie,” something about which I’m sure there’s controversy, but the quality of the pie doesn’t change with my preference for or against it unless the entire point of the pie was to satisfy my particular preference (e.g., if it were a birthday pie).
It’s often (usually?) the case that things exist for purposes other than satisfying our preferences. When considering something like pie, preference certainly matters, but it doesn’t encompass the entirety of what makes for a good pie. In considering knives again, perhaps I’ve declared a knife bad when really I just don’t know how to use it. Likewise, I might declare a pie bad when really I just don’t know how to taste it. It’s a bit silly when considering pie, but maybe I’d taste it “better” if I had the childhood associations with the flavors, the ambiance of eating it with good company, and satisfaction of having baked it myself. My preference would change, yes, but maybe I’d also bring my preferences more closely into alignment with what the pie was for. I can appreciate that this is, in fact, a good pie. Paul Hollywood and Prue Leith seem to do this on the Great British Baking Show when they say they don’t like a certain ingredient or pastry, but can appreciate how good it might be.
The opposite is possible too. I may have developed a preference for bad pie and not know any better. Reflecting on the disparity between what she and another guest thought of a particular pie at a party, Sarah Hinlicky Wilson writes:
“I think she’d just never had good pie, so there was no basis for comparison. As far as she knew, bad pie was just… pie.
All these years later, the symbolic force of that unnerves and troubles me more than anything else.
Because how many things do we now know only in their fake versions?”
She reflects on fake versions of human community, like a “rental person” in Tokyo who can simply be present with you and do nothing. These fake versions of things, like pie and friends, don’t ultimately satisfy. She concludes:
“It’s easy to be a snob about food. It’s easy to be moralistic about food. Both critiques of bad pie miss the point. Food is never just fuel but also a sign of larger truths. It’s worth examining our food—and so much more in our lives—to find out if we even know the difference between the real and the fake anymore.”
To see the difference between real and fake, you need to believe things have an essence that can’t be replicated. Not only that, but you need to believe such an essence is fit for a particular purpose. “Good pie” is good for eating, not for putting out a fire. A “good friend” means so much more than a “rental person.”
Moral evaluations carry this same suggestion of fittingness. If we try to get below the surface of things, this might be what makes some people uncomfortable about this part of the conversation: it brings us to big questions about the purpose of life and community. Their avoidance of moral language may also be how they cope with irreconcilable pluralism: how can we get along with one another when we believe such vastly different things about life, the universe, and everything? But ignoring that language only hides our beliefs about morality; it doesn’t dispense with them, and makes disagreement less helpful.
What does it really mean to evaluate something through a moral lens? If someone claims stealing is bad, that’s a moral evaluation. It means:
Stealing is bad for the thief: it does their character no good to become a person who steals.
Stealing is bad for the victim: it deprives them of resources, and disrespects them as a person with the agency to own property.
Stealing is bad for the community: it creates a culture in which people feel unsafe and become suspicious of their neighbors.
Some may believe stealing is bad because it violates a divine law, in which case it’s bad for one’s relationship with the divine (and probably also bad for oneself who will face divine retribution).2
Let’s turn these things upside down as a little thought experiment:
Stealing is good for the thief: it teaches them to be clever.
Stealing is good for the victim: it teaches them a lesson about how to guard their property.
Stealing is good for the community: it teaches vigilance, and ensures goods go to those who are most clever.
Stealing is ultimately good: it’s divinely approved and scores you points with the gods.
Do you feel these latter evaluations are bizzaro when you compare them with the former? If so, I wonder if it’s because we have a vague intuition that we aren’t made to be merely clever and vigilant. There’s some intuition about what kind of character and community our actions are meant to build, which theft tears down. There really may be some objective state of flourishing toward which human activity is generally oriented.
When we displace moral language by relying on therapeutic language (like adaptiveness), we miss what Aristotle was trying to teach: “Every art and every inquiry, and similarly every action and pursuit, is thought to aim at some good; and for this reason the good has rightly been declared to be that which all things aim.” We’re always doing this, but if we skip over it or assume others know what we’re talking about, we miss important opportunities for clarity and may stumble into intractable, unproductive disagreement.
The Moral Life
I might have the immediate desire of fulfilling the good of my having a pie by stealing yours. Theft would satisfy that immediate good. But in a broader, more abstract sense, my life of thievery is meant to satisfy deep longings for wholeness that we all have: stability, satisfaction, comfort. Virtue and vice intend the same thing, ultimately, but only virtue has any hope of achieving it. Both virtue and vice are attempts to pursue what is ultimately good (sometimes referred to as flourishing or eudaimonia). Virtue does this well and vice poorly. This is why Bruce Marshall wrote, “…the young man who rings the bell at the brothel is unconsciously looking for God.” The immediate good the young man seeks is pleasure, but there is a deeper, broader sense in which he seeks the same thing we’re all seeking in our own peculiar ways.
That doesn’t mean eudaimonia is whatever we want it to be. Sometimes we want things that are contrary to our good. Paul Wadell put it this way:
“When [Aristotle] speaks of eudaimonia as ‘that which taken by itself makes life something desirable and deficient in nothing,' he does not mean that what counts as eudaimonia is whatever any person finds desirable. Indeed, one of the most pressing signs of moral weakness for Aristotle is never learning to desire the right things, never learning to take pleasure in what is good. Aristotle knows there is much disagreement over what eudaimonia is, but he traces that confusion not to the complexity of eudaimonia, but to a general lack of virtue. For him, eudaimonia has a definite, normative meaning. It represents not just a way of life which is lacking in nothing because it satisfies one's desires, for indeed they may be improper desires, but, more exactly, a life that can satisfy the desires of the good person precisely because it is capable of making her good. Eudaimonia is not an empty, formless concept each person is free to identify through whatever desires he or she wants fulfilled. On the contrary, eudaimonia is the most desirable of lives because it satisfies the person who desires nothing more than to become good.”
“Desiring the right things” is highly contextual. In one situation, what you desire might be brave; in another, foolhardy. You need wisdom, another virtue, to discern at any given moment what is good. The good person desires eudaimonia but the good person only comes to desire eudaimonia through the cultivation of virtue, which is itself a movement toward eudaimonia. If this feels a bit cyclical, I feel that way too. I think that’s part of moral development: you dive in somewhere, and that development becomes iterative.
Obviously there can only be pockets of agreement on what this is. Perhaps for Aristotle, eudaimonia, in concrete terms, was the fulfillment one could achieve by contemplating philosophy as a citizen of Athens. For a barbarian warlord, eudaimonia (if it could ever translate into that culture) might have been a life of valor, strength, and tribalism. For the mid-20th century white American, it may have been the white picket fence and the 2.5 children.
My point isn’t that our understanding of flourishing is culturally conditioned. Of course it will be. Even if eudaimonia is objective, human experience is not homogeneous, so its interpretation and experience will vary from culture to culture, even moment to moment. It’s not just that the warlord believes that the good life is possible through valor, strength, and tribalism (or whatever else). That really is the good life as the warlord sees it, and all else falls short or works contrary to it. So, too, for the male citizen of Athens or the white American with their own grasping after flourishing.
So, too, for adaptivity. Chammas ponders what she may have done had her patient’s humor not be so adaptive:
“But even if I’d gotten the sense that the humor was keeping my patient from processing and integrating his illness, it would not have become the enemy. As a palliative care clinician, I am rarely, if ever, in the business of using a sledgehammer to break down the defenses that are holding my patients together. Those defenses are there for a reason, nearly always deserving of honor and respect. Rather, a different read on the room would have affected how I related to his humor. It would have helped me titrate how much I engaged with it while seeking moments when he could tolerate me leaning away from it in an attempt to help him. (Of course, any choice to lean away from a patient’s defenses should include offering an alternative for the patient to hold onto, be it the connection to us or other sources of grounding.) The calculus of this balance is not only unique to each patient, it also varies over time or context for any given patient.”
I agree with her sentiment. I’m also mindful of the boundaries of my patients’ defenses and consider what function they might be serving in any given moment. What piques my interest is what she leaves unwritten. What would “an attempt to help him” look like if she felt his humor wasn’t adaptive? She admits this will vary over time for any given patient, and among patients as well. In allowing herself this latitude, she doesn’t help us better understand what she’s going to help her patients adapt to or for. This leaves ethical and metaphysical assumptions hidden and allows her perspective to appear amoral when it really isn’t.
This reminds me of one of my favorite papers on supportive psychotherapy by Donald Misch. Dynamic supportive therapy is often what eclectic therapists do in general terms and what psychiatrists do in lieu of overt psychotherapy (like cognitive-behavioral therapy or acceptance and commitment therapy). Its principles are also worthwhile for any clinician to learn - e.g., making a hypothesis about the patient’s behavior and inner life, fostering the therapeutic alliance, managing transference/countertransference, etc.
What Chammas and Misch both skip over, though, is the good at which they’re aiming. They take it for granted. Misch uses the same language of adaptive and maladaptive defense mechanisms. He discusses (mental) “health” as if the reader shares his understanding. Elsewhere, when recommending that a therapist can lend their patient psychological strength, Misch writes, “Often of key importance is reality testing, since it is difficult to negotiate one’s environment successfully if one cannot distinguish between reality and fantasy.” He leaves “success” undefined.
You need only scratch at these reflections to reveal deep ethical commitments underneath. Despite a clinical vocabulary that strains to avoid it, we find ourselves facing it again and again: what does it mean to live a good life? Embedded within assumptions about adaptivity is a belief that people can want things that don’t serve them well (that is, they behave maladaptively). Our desires are often conflicted. We sometimes do the things we don’t want to do, or don’t do the things we want to do. This presupposes a target at which we’re aiming, though. It wouldn’t make sense to suggest that target is our mere preference, because our preferences are the very source of our angst. The challenge isn’t satisfying my desire, but figuring out what I should desire in the first place.
Scratch that again and you’ll find commitments about the nature of reality and humanity under those ethical commitments. For example, to neglect moral reflection entirely in a discussion about coping might be to suggest humans have no need to struggle with good and evil in their own lives, that what we think is evil is actually pathology, and that only the knowledge afforded us by empiricism is valid within the clinical encounter, and not philosophy or theology. Indeed, perhaps science will allow us to dispense with philosophical and theological reflection altogether as we follow it into a more empirical future.
Abram Brummett, reflecting on whether Jehovah’s Witnesses should be permitted to refuse life-saving blood transfusions for their children, observes that mere concerns about harm are insufficient to justify overriding a parental objection in those cases. Most clinicians and ethicists take it for granted that a hospital can override a parental refusal to save a child’s life in this case. However, what Brummett observes is that such a judgment is bound up in a metaphysical commitment: the hospital denies the belief of the Jehovah’s Witness that spiritual harm will befall their child if they receive a blood transfusion. The hospital’s view of reality wins out but without justification. It really comes down to the fact that the law empowers the institution to force the intervention.
Brummett wishes for institutions, clinicians, ethicists - all of us - to be more open not only about our ethical commitments, but also our metaphysical commitments, and how they justify our judgments: “Naturalism [what the hospital presupposes in forcing a life-saving blood transfusion over the objection of a Jehovah’s Witness parent] is not somehow free of its own metaphysical claims; its claims about the ultimate nature of reality need to be argued for and defended like those of any other religion. Therefore, the denial of a positive metaphysical, religious, theological claim (e.g., there is no God, there is no soul, there is no sin) is no less a metaphysical, religious, theological claim.” In the case of hospitals facing a Jehovah’s Witness refusing a life-saving blood transfusion for their child, Brummett would prefer the hospital to put its nickel down explicitly: spiritual harm will not befall this child in such a case.3
By making the implicit explicit, we might better learn from one another and see the challenges in our own perspectives. The staunch moralist, who may be at risk of forcing round people through the square hole of their dogma, might come to learn from Chammas and Misch their compassionate stance toward someone’s best attempts to hold a life together that is falling apart in the face of cancer. Likewise, I wonder if we better appreciate the moral valence of coping, we can see how it’s not only an attempt to hold life together, but to move life toward some ideal. Moral language is what we use to describe that journey, with all its hopes and pitfalls. Even if we disagree about it, we can learn to have conversations that sharpen our own commitments and challenge us where we might be mistaken.
Coping, Good and Bad
I appreciate the desire to de-moralize coping. People do all kinds of weird, tragic things when they hurt. Compassion should have us cut them a bit of slack. Condemnation and shame, perhaps the most disparaged of morality’s tools, carry the odor of a bygone era that pre-dates science and modern medicine.
But in going the route that Chammas, Misch, and others do, we don’t erase morality from the clinic. We hide it. We bury ethical judgments and metaphysical commitments under layers of therapeutic language. That makes it harder to reach negotiate disagreements and discern what we ourselves actually believe.
I think we’d better of if we re-moralized this conversation about coping. There’s more to be said about what this means for condemnation and shame, but suffice it to say for now, in a pluralistic society, these need not be instruments clinicians rely on to support their patients. Clinicians could bring psychological sensitivity to someone’s use of a defense mechanism while at the same time acknowledging that they’re doing themselves a disservice by behaving that way. They’re doing themselves a disservice not only because they’re acting “maladaptively” and failing to “navigate their environment successfully,” but also because they’re being taken further from a good life. We have traditions to offer a rich language describing what this can look like. We could engage what Warren Kinghorn and colleagues call “open pluralism: a commitment to explore, understand, and hear the voices of the particular moral communities that constitute our culture.” They go on to write, “Open pluralism would reject the still-common assumption that scientific empiricism is the only epistemological ground of medical practice and would acknowledge that all parties involved inthe conversation find themselves living within one or more particular moral traditions that inform professional judgment.” Like Brummett, my appeal is that we should be open and honest about what those traditions are and bring them into conversation with each other.
In such an openly pluralistic environment, a re-moralized conversation about health and human flourishing, we could discuss the good life and the role of health care in pursuing it. We could help each other see all the many facets of coping.
However, you must still ask, why was a divine law given? At least in the Judeo-Christian tradition, stealing is bad not only because God commands that we should not steal, but that stealing detracts from the possibility of drawing near to God and near to others in the way that God intends we should. Stealing detracts from our telos as humans.
What qualifies the hospital to make such a claim? That takes us far afield of our present exploration, but Brummett does unearth the challenge facing clinicians and hospitals in such instances. Either they make their metaphysical commitment explicit, and reckon with what they must do to justify it, or else they risk unjustified coercion that further erodes the trust people place in them.
I listened to the Geripal episode with Dani Chammas a few days ago and was inspired by her inclusive understanding of coping mechanisms. I was also slightly baffled at the peculiarity of what could be considered adaptive and maladaptive. In her article, “Should I Laugh at That? Coping in the Setting of Serious Illness” (which you quoted), Dani Chammas writes:
“Acceptance is not better than denial; humor is not better than anger; finding meaning is not better than renouncing all meaning.”
As stages of anticipatory grief that arise and pass, then this makes sense. But is a primary coping strategy of denial or anger truly “not better” than a primary coping strategy of genuine acceptance? Adaptive coping that reduces stress and aligns with one’s existential reality is important. Still, chronic denial or anger (or even relentless humor) could create a challenging environment for those caring for the individual, personally and professionally, and limit the individual's potential for well-being and spiritual growth.
As a Buddhist, I’m familiar with the traditional language of “skillful/unskillful” or “wholesome/unwholesome,” which translates the Pali word “kusala.” In Buddhism, there is an explicit goal to investigate and then move away from the sources of unnecessary suffering rooted in unskillful/unwholesome behavior and thinking. This is realized through the development of the Eightfold Path, which can be divided into three categories: wisdom, virtue, and meditation. Parallels have been drawn between the goals of early Buddhism (as a movement away from harm and unnecessary suffering toward peace, joy, and harmony) and the concept of eudaimonia, notably by Stephen Batchelor.
From this perspective, I find it hard to see the absolute equality of all coping mechanisms that may support a patient. Some seem less harmful — and create less additional suffering — for the sick person and to those who care for them. As a chaplain, I find myself walking the line between accepting and acknowledging a patient's coping mechanisms and gently challenging them when it seems they might be adding extra layers of suffering on top of their already heavy load.
Thank you so much for your clear elucidation of this issue.
I loved reading this and agree that there are often ethical and metaphysical assumptions underlying appeals to harm or whether a behavior is adaptive. But isn't there also some value in using language/concepts that will find wide agreement among those with different moral and metaphysical commitments? E.g. diverse perspectives can agree that reducing stress is a good metric by which to assess a patient's coping mechanisms?