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Healthy Coping Skills for Uncomfortable Emotions

Emotion-Focused and Problem-Focused Strategies

Amy Morin, LCSW, is a psychotherapist and international bestselling author. Her books, including "13 Things Mentally Strong People Don't Do," have been translated into more than 40 languages. Her TEDx talk,  "The Secret of Becoming Mentally Strong," is one of the most viewed talks of all time.

Rachel Goldman, PhD FTOS, is a licensed psychologist, clinical assistant professor, speaker, wellness expert specializing in eating behaviors, stress management, and health behavior change.

• Emotion-Focused Skills

Healthy Problem-Focused Coping Skills

• Unhealthy Coping Skills

Proactive Coping Skills

• Find What Works
• Next in Small Ways to Feel Better When You're Depressed Guide 10 Things to Do When You Feel Alone

Whether you’ve been dumped by your date or you’ve had a rough day at the office, having healthy coping skills can be key to getting through tough times. Coping skills help you tolerate, minimize, and deal with stressful situations in life.

Coping skills are the tactics that people use to deal with stressful situations. Managing your stress well can help you feel better physically and psychologically and impact your ability to perform your best.

But not all coping skills are created equal. Sometimes, it’s tempting to engage in strategies that will give quick relief but might create bigger problems for you down the road. It’s important to establish healthy coping skills that will help you reduce your emotional distress or rid yourself of the stressful situations you face. Examples of healthy coping skills include:

• Establishing and maintaining boundaries
• Practicing relaxation strategies such as deep breathing, meditation, and mindfulness
• Getting regular physical activity
• Making to-do lists and setting goals

This article explores coping skills that can help you manage stress and challenges. Learn more about how different strategies, including problem-focused and emotion-focused skills, can be most helpful.

Verywell / Emily Roberts 

Problem-Based vs. Emotion-Based

The five main types of coping skills are: problem-focused coping, emotion-focused coping, religious coping, meaning-making, and social support.

Two of the main types of coping skills are problem-based coping and emotion-based coping. Understanding how they differ can help you determine the best coping strategy for you.

• Problem-based coping is helpful when you need to change your situation, perhaps by removing a stressful thing from your life. For example, if you’re in an unhealthy relationship, your anxiety and sadness might be best resolved by ending the relationship (as opposed to soothing your emotions).
• Emotion-based coping is helpful when you need to take care of your feelings when you either don’t want to change your situation or when circumstances are out of your control. For example, if you are grieving the loss of a loved one, it’d be important to take care of your feelings in a healthy way (since you can’t change the circumstance).

There isn’t always one best way to proceed. Instead, it’s up to you to decide which type of coping skill is likely to work best for you in your particular circumstance. The following are examples of stressful situations and how each approach could be used.

Reading Your Performance Review

You open your email to find your annual performance review. The review states that you are below average in several areas and you’re surprised by this because you thought you were performing well. You feel anxious and frustrated.

• Problem-focused coping : You go to the boss and talk about what you can do to improve your performance. You develop a clear plan that will help you do better and you start to feel more confident about your ability to succeed.
• Emotion-focused coping : You spend your lunch break reading a book to distract yourself from catastrophic predictions that you’re going to be fired. After work, you exercise and clean the house as a way to help you feel better so you can think about the situation more clearly.

Getting a Teenager to Clean

You have told your teenager he needs to clean his bedroom. But it’s been a week and clothes and trash seem to be piling up. Before heading out the door in the morning, you told him he has to clean his room after school "or else." You arrive home from work to find him playing videos in his messy room.

• Problem-focused coping : You sit your teenager down and tell him that he’s going to be grounded until his room is clean. You take away his electronics and put him on restriction. In the meantime, you shut the door to his room so you don’t have to look at the mess.
• Emotion-focused coping : You decide to run some bathwater because a hot bath always helps you feel better. You know a bath will help you calm down so you don’t yell at him or overreact.

Giving a Presentation

You’ve been invited to give a presentation in front of a large group. You were so flattered and surprised by the invitation that you agreed to do it. But as the event approaches, your anxiety skyrockets because you hate public speaking .

• Problem-focused coping : You decide to hire a public speaking coach to help you learn how to write a good speech and how to deliver it confidently. You practice giving your speech in front of a few friends and family members so you will feel better prepared to step on stage.
• Emotion-focused coping : You tell yourself that you can do this. You practice relaxation exercises whenever you start to panic. And you remind yourself that even if you’re nervous, no one else is even likely to notice.

Problem-based coping skills focus on changing the situation, while emotional-based coping skills are centered on changing how you feel. Knowing which approach is right for a specific situation can help you deal with stress more effectively.

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Healthy Emotion-Focused Coping Skills

Whether you’re feeling lonely , nervous, sad, or angry , emotion-focused coping skills can help you deal with your feelings in a healthy way. Healthy coping strategies may soothe you, temporarily distract you, or help you tolerate your distress.

Sometimes it’s helpful to face your emotions head-on. For example, feeling sad after the death of a loved one can help you honor your loss.

So while it would be important to use coping skills to help relieve some of your distress, coping strategies shouldn’t be about constantly distracting you from reality.

Other times, coping skills may help you change your mood. If you’ve had a bad day at work, playing with your kids or watching a funny movie might cheer you up. Or, if you’re angry about something someone said, a healthy coping strategy might help you calm down before you say something you might regret.

Other examples of healthy ways to cope with emotions include:

• Care for yourself : Put on lotion that smells good, spend time in nature, take a bath, drink tea, or take care of your body in a way that makes you feel good such as painting your nails, doing your hair, putting on a face mask.
• Engage in a hobby : Do something you enjoy such as coloring, drawing, or listening to music .
• Exercise : Do yoga, go for a walk, take a hike, or engage in a recreational sport.
• Focus on a task : Clean the house (or a closet, drawer, or area), cook a meal, garden, or read a book.
• Practice mindfulness : List the things you feel grateful for, meditate , picture your "happy place," or look at pictures to remind you of the people, places, and things that bring joy.
• Use relaxation strategies : Play with a pet, practice breathing exercises, squeeze a stress ball, use a relaxation app, enjoy some aromatherapy, try progressive muscle relaxation , or write in a journal.

There are many ways you might decide to tackle a problem head-on and eliminate the source of your stress. In some cases, that may mean changing your behavior or creating a plan that helps you know what action you’re going to take.

In other situations, problem-focused coping may involve more drastic measures, like changing jobs or ending a relationship. Here are some examples of positive problem-focused coping skills:

• Ask for support from a friend or a professional.
• Create a to-do list.
• Engage in problem-solving.
• Establish healthy boundaries .
• Walk away and leave a situation that is causing you stress.
• Work on managing your time better.

Whether emotion-focused or problem-focused, healthy coping skills should help calm stress without avoiding the issue. The right coping skill often depends on the situation and your specific needs in the moment.

Unhealthy Coping Skills to Avoid

Just because a strategy helps you endure emotional pain, it doesn’t mean it’s healthy. Some coping skills could create bigger problems in your life. Here are some examples of unhealthy coping skills:

• Drinking alcohol or using drugs : Substances may temporarily numb your pain, but they won’t resolve your issues. Substances are likely to introduce new problems into your life. Alcohol, for example, is a depressant that can make you feel worse. Using substances to cope also puts you at risk for developing a substance use disorder and it may create health, legal, financial problems, and social problems.
• Overeating : Food is a common coping strategy. But, trying to "stuff your feelings" with food can lead to an unhealthy relationship with food and health issues. Sometimes people go to the other extreme and restrict their eating (because it makes them feel more in control) and clearly, that can be just as unhealthy.
• Sleeping too much : Whether you take a nap when you’re stressed out or you sleep late to avoid facing the day, sleeping offers a temporary escape from your problems. However, when you wake up, the problem will still be there.
• Venting to others : Talking about your problems so that you can gain support, develop a solution, or see a problem in a different way can be healthy. But studies show repeatedly venting to people about how bad your situation is or how terrible you feel is more likely to keep you stuck in a place of pain.
• Overspending : While many people say they enjoy retail therapy as a way to feel better, shopping can become unhealthy. Owning too many possessions can add stress to your life. Also, spending more than you can afford will only backfire in the end and cause more stress.
• Avoiding : Even “healthy” coping strategies can become unhealthy if you’re using them to avoid the problem. For example, if you are stressed about your financial situation, you might be tempted to spend time with friends or watch TV because that’s less anxiety-provoking than creating a budget. But if you never resolve your financial issues, your coping strategies are only masking the problem. 

Unhealthy coping techniques—such as drinking or avoiding the problem—may offer some temporary relief, but they tend to make things worse in the long run. These unhealthy tactics can also lead to other problems that create more stress and make coping more difficult.

Coping skills are usually discussed as a reactive strategy: When you feel bad, you do something to cope. But, research shows that proactive coping strategies can effectively manage the future obstacles you’re likely to face.

For example, if you have worked hard to lose weight, proactive coping strategies could help you maintain your weight after your weight loss program has ended. You might plan for circumstances that might derail you—like the holiday season or dinner invitations from friends—to help you cope. You also might plan for how you will cope with emotions that previously caused you to snack, like boredom or loneliness.

Proactive coping can also help people deal with unexpected life changes, such as a major change in health. A 2014 study found that people who engaged with proactive coping were better able to deal with the changes they encountered after having a stroke.

Another study found that people who engaged in proactive coping were better equipped to manage their type 2 diabetes. Participants who planned ahead and set realistic goals enjoyed better psychological well-being.

So, if you are facing a stressful life event or you’ve undergone a major change, try planning ahead. Consider the skills you can use to cope with the challenges you’re likely to face. When you have a toolbox ready to go, you’ll know what to do. And that could help you to feel better equipped to face the challenges ahead.

Proactive coping has been found to be an effective way to help people deal with both predictable changes like a decline in income during retirement, as well as unpredictable life changes such as the onset of a chronic health condition.

Find What Works for You

The coping strategies that work for someone else might not work for you. Going for a walk might help your partner calm down. But you might find going for a walk when you’re angry causes you to think more about why you’re mad—and it fuels your angry feelings. So you might decide watching a funny video for a few minutes helps you relax.

You might find that certain coping strategies work best for specific issues or emotions. For example, engaging in a hobby may be an effective way to unwind after a long day at work. But, going for a walk in nature might be the best approach when you’re feeling sad.

When it comes to coping skills, there’s always room for improvement. So, assess what other tools and resources you can use and consider how you might continue to sharpen your skills in the future.

It's important to develop your own toolkit of coping skills that you’ll find useful. You may need to experiment with a variety of coping strategies to help you discover which ones work best for you.

A Word From Verywell

Healthy coping skills can help protect you from distress and face problems before they become more serious. By understanding the two main types of coping skills, you can better select strategies that are suited to different types of stress.

If you are struggling to practice healthy coping skills or find yourself relying on unhealthy ones instead, talking to a mental health professional can be helpful. A therapist can work with you to develop new skills that will serve your mental well-being for years to come.

Get Help Now

We've tried, tested, and written unbiased reviews of the best online therapy programs including Talkspace, BetterHelp, and ReGain. Find out which option is the best for you.

Aldwin CM, Yancura LA. Coping . In: Encyclopedia of Applied Psychology . Elsevier; 2004:507-510. doi:10.1016/B0-12-657410-3/00126-4

Byrd-Craven J, Geary DC, Rose AJ, Ponzi D. Co-ruminating increases stress hormone levels in women . Horm Behav . 2008;53(3):489-92. doi:10.1016/j.yhbeh.2007.12.002

Drummond S, Brough P. Proactive coping and preventive coping: Evidence for two distinct constructs? . Personality and Individual Differences . 2016;92:123-127. doi:10.1016/j.paid.2015.12.029.

Tielemans NS, Visser-Meily JM, Schepers VP, Post MW, van Heugten CM. Proactive coping poststroke: Psychometric properties of the Utrecht Proactive Coping Competence Scale . Arch Phys Med Rehabil. 2014;95(4):670-5. doi:10.1016/j.apmr.2013.11.010

By Amy Morin, LCSW Amy Morin, LCSW, is a psychotherapist and international bestselling author. Her books, including "13 Things Mentally Strong People Don't Do," have been translated into more than 40 languages. Her TEDx talk,  "The Secret of Becoming Mentally Strong," is one of the most viewed talks of all time.

• Research Article
• Open access
• Published: 06 April 2021

Health anxiety, perceived stress, and coping styles in the shadow of the COVID-19

• Szabolcs Garbóczy 1 , 2 ,
• Anita Szemán-Nagy 3 ,
• Mohamed S. Ahmad 4 ,
• Szilvia Harsányi 1 ,
• Dorottya Ocsenás 5 , 6 ,
• Viktor Rekenyi 4 ,
• Ala’a B. Al-Tammemi 1 , 7 &
• László Róbert Kolozsvári   ORCID: orcid.org/0000-0001-9426-0898 1 , 7  

BMC Psychology volume  9 , Article number:  53 ( 2021 ) Cite this article

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Metrics details

In the case of people who carry an increased number of anxiety traits and maladaptive coping strategies, psychosocial stressors may further increase the level of perceived stress they experience. In our research study, we aimed to examine the levels of perceived stress and health anxiety as well as coping styles among university students amid the COVID-19 pandemic.

A cross-sectional study was conducted using an online-based survey at the University of Debrecen during the official lockdown in Hungary when dormitories were closed, and teaching was conducted remotely. Our questionnaire solicited data using three assessment tools, namely, the Perceived Stress Scale (PSS), the Ways of Coping Questionnaire (WCQ), and the Short Health Anxiety Inventory (SHAI).

A total of 1320 students have participated in our study and 31 non-eligible responses were excluded. Among the remaining 1289 participants, 948 (73.5%) and 341 (26.5%) were Hungarian and international students, respectively. Female students predominated the overall sample with 920 participants (71.4%). In general, there was a statistically significant positive relationship between perceived stress and health anxiety. Health anxiety and perceived stress levels were significantly higher among international students compared to domestic ones. Regarding coping, wishful thinking was associated with higher levels of stress and anxiety among international students, while being a goal-oriented person acted the opposite way. Among the domestic students, cognitive restructuring as a coping strategy was associated with lower levels of stress and anxiety. Concerning health anxiety, female students (domestic and international) had significantly higher levels of health anxiety compared to males. Moreover, female students had significantly higher levels of perceived stress compared to males in the international group, however, there was no significant difference in perceived stress between males and females in the domestic group.

The elevated perceived stress levels during major life events can be further deepened by disengagement from home (being away/abroad from country or family) and by using inadequate coping strategies. By following and adhering to the international recommendations, adopting proper coping methods, and equipping oneself with the required coping and stress management skills, the associated high levels of perceived stress and anxiety could be mitigated.

Peer Review reports

Introduction

On March 4, 2020, the first cases of coronavirus disease were declared in Hungary. One week later, the World Health Organization (WHO) declared COVID-19 as a global pandemic [ 1 ]. The Hungarian government ordered a ban on outdoor public events with more than 500 people and indoor events with more than 100 participants to reduce contact between people [ 2 ]. On March 27, the government imposed a nationwide lockdown for two weeks effective from March 28, to mitigate the spread of the pandemic. Except for food stores, drug stores, pharmacies, and petrol stations, all other shops and educational institutions remained closed. On April 16, a week-long extension was further announced [ 3 ].

The COVID-19 pandemic with its high morbidity and mortality has already afflicted the psychological and physical wellbeing of humans worldwide [ 4 , 5 , 6 , 7 , 8 , 9 ]. During major life events, people may have to deal with more stress. Stress can negatively affect the population’s well-being or function when they construe the situation as stressful and they cannot handle the environmental stimuli [ 10 ]. Various inter-related and inter-linked concepts are present in such situations including stress, anxiety, and coping. According to the literature, perceived stress can lead to higher levels of anxiety and lower levels of health-related quality of life [ 11 ]. Another study found significant and consistent associations between coping strategies and the dimensions of health anxiety [ 12 ].

Health anxiety is one of the most common types of anxiety and it describes how people think and behave toward their health and how they perceive any health-related concerns or threats. Health anxiety is increasingly conceptualized as existing on a spectrum [ 13 , 14 ], and as an adaptive signal that helps to develop survival-oriented behaviors. It also occurs in almost everyone’s life to a certain degree and can be rather deleterious when it is excessive [ 13 , 14 ]. Illness anxiety or hypochondriasis is on the high end of the spectrum and it affects someone’s life when it interferes with daily life by making people misinterpret the somatic sensations, leading them to think that they have an underlying condition [ 14 ].

According to the American Psychiatric Association—Diagnostic and Statistical Manual of Mental Disorders (fifth edition), Illness anxiety disorder is described as a preoccupation with acquiring or having a serious illness, and it reflects the high spectrum of health anxiety [ 15 ]. Somatic symptoms are not present or if they are, then only mild in intensity. The preoccupation is disproportionate or excessive if there is a high risk of developing a medical condition (e.g., family history) or the patient has another medical condition. Excessive health-related behaviors can be observed (e.g., checking body for signs of illness) and individuals can show maladaptive avoidance as well by avoiding hospitals and doctor appointments [ 15 ].

Health anxiety is indeed an important topic as both its increase and decrease can progress to problems [ 14 ]. Looking at health anxiety as a wide spectrum, it can be high or low [ 16 ]. While people with a higher degree of worry and checking behaviors may cause some burden on healthcare facilities by visiting them too many times (e.g., frequent unnecessary visits), other individuals may not seek medical help at healthcare units to avoid catching up infections for instance. A lower degree of health anxiety can lead to low compliance with imposed regulations made to control a pandemic [ 17 ].

The COVID-19 pandemic as a major event in almost everyone’s life has posed a great impact on the population’s perceived stress level. Several studies about the relation between coping and response to epidemics in recent and previous outbreaks found higher perceived stress levels among people [ 18 , 19 , 20 , 21 ]. Being a woman, low income, and living with other people all were associated with higher stress levels [ 18 ]. Protective factors like being emotionally more stable, having self-control, adaptive coping strategies, and internal locus of control were also addressed [ 19 , 20 ]. The findings indicated that the COVID-19 crisis is perceived as a stressful event. The perceived stress was higher amongst people than it was in situations with no emergency. Nervousness, stress, and loss of control of one’s life are the factors that are most connected to perceived stress levels which leads to the suggestion that unpredictability and uncontrollability take an important part in perceived stress during a crisis [ 19 , 20 ].

Moreover, certain coping styles (e.g., having a positive attitude) were associated with less psychological distress experiences but avoidance strategies were more likely to cause higher levels of stress [ 21 ]. According to Lazarus (1999), individuals differ in their perception of stress if the stress response is viewed as the interaction between the environment and humans [ 22 ]. An Individual can experience two kinds of evaluation processes, one to appraise the external stressors and personal stake, and the other one to appraise personal resources that can be used to cope with stressors [ 22 , 23 ]. If there is an imbalance between these two evaluation processes, then stress occurs, because the personal resources are not enough to cope with the stressor’s demands [ 23 ].

During stressful life events, it is important to pay attention to the increasing levels of health anxiety and to the kind of coping mechanisms that are potential factors to mitigate the effects of high anxiety. The transactional model of stress by Lazarus and Folkman (1987) provides an insight into these kinds of factors [ 24 ]. Lazarus and Folkman theorized two types of coping responses: emotion-focused coping, and problem-focused coping. Emotion-focused coping strategies (e.g., distancing, acceptance of responsibility, positive reappraisal) might be used when the source of stress is not embedded in the person’s control and these strategies aim to manage the individual’s emotional response to a threat. Also, emotion-focused coping strategies are directed at managing emotional distress [ 24 ]. On the other hand, problem-focused coping strategies (e.g., confrontive coping, seeking social support, planful problem-solving) help an individual to be able to endure and/or minimize the threat, targeting the causes of stress in practical ways [ 24 ]. It was also addressed that emotion-focused coping mechanisms were used more in situations appraised as requiring acceptance, whereas problem-focused forms of coping were used more in encounters assessed as changeable [ 24 ].

A recent study in Hunan province in China found that the most effective factor in coping with stress among medical staff was the knowledge of their family’s well-being [ 25 ]. Although there have been several studies about the mental health of hospital workers during the COVID-19 pandemic or other epidemics (e.g., SARS, MERS) [ 26 , 27 , 28 , 29 ], only a few studies from recent literature assessed the general population’s coping strategies. According to Gerhold (2020) [ 30 ], older people perceived a lower risk of COVID-19 than younger people. Also, women have expressed more worries about the disease than men did. Coping strategies were highly problem-focused and most of the participants reported that they listen to professionals’ advice and tried to remain calm [ 30 ]. In the same study, most responders perceived the COVID-19 pandemic as a global catastrophe that will severely affect a lot of people. On the other hand, they perceived the pandemic as a controllable risk that can be reduced. Dealing with macrosocial stressors takes faith in politics and in those people, who work with COVID-19 on the frontline.

Mental disorders are found prevalent among college students and their onset occurs mostly before entry to college [ 31 ]. The diagnosis and timely interventions at an early stage of illness are essential to improve psychosocial functioning and treatment outcomes [ 31 ]. According to research that was conducted at the University of Debrecen in Hungary a few years ago, the students were found to have high levels of stress and the rate of the participants with impacted mental health was alarming [ 32 ]. With an unprecedented stressful event like the COVID-19 crisis, changes to the mental health status of people, including students, are expected.

Aims of the study

In our present study, we aimed at assessing the levels of health anxiety, perceived stress, and coping styles among university students amidst the COVID-19 lockdown in Hungary, using three validated assessment tools for each domain.

Methods and materials

Study design and setting.

This study utilized a cross-sectional design, using online self-administered questionnaires that were created and designed in Google Forms® (A web-based survey tool). Data collection was carried out in the period April 30, 2020, and May 15, 2020, which represents one of the most stressful periods during the early stage of the COVID-19 pandemic in Hungary when the official curfew/lockdown was declared along with the closure of dormitories and shifting to online remote teaching. The first cases of COVID-19 were declared in Hungary on March 4, 2020. On April 30, 2020, there were 2775 confirmed cases, 312 deaths, and 581 recoveries. As of May 15, 2020, the number of confirmed cases, deaths, and recovered persons was 3417, 442, and 1287, respectively.

Our study was conducted at the University of Debrecen, which is one of the largest higher education institutions in Hungary. The University is located in the city of Debrecen, the second-largest city in Hungary. Debrecen city is considered the educational and cultural hub of Eastern Hungary. As of October 2019, around 28,593 students were enrolled in various study programs at the University of Debrecen, of whom, 6,297 were international students [ 33 ]. The university offers various degree courses in Hungarian and English languages.

Study participants and sampling

The target population of our study was students at the University of Debrecen. Students were approached through social media platforms (e.g., Facebook®) and the official student administration system at the University of Debrecen (Neptun). The invitation link to our survey was sent to students on the web-based platforms described earlier. By using the Neptun system, we theoretically assumed that our survey questionnaire has reached all students at the University. The students who were interested and willing to participate in the study could fill out our questionnaire anonymously during the determined study period; thus, employing a convenience sampling approach. All students at the University of Debrecen whose age was 18 years or older and who were in Hungary during the outbreak had the eligibility to participate in our study whether undergraduates or postgraduates.

Study instruments

In our present study, the survey has solicited information about the sociodemographic profile of participants including age (in years), gender (female vs male), study program (health-related vs non-health related), and whether the student stayed in Hungary or traveled abroad during the period of conducting our survey in the outbreak. Our survey has also adopted three international scales to collect data about health anxiety, coping styles, and perceived stress during the pandemic crisis. As the language of instruction for international students at the University of Debrecen is English, and English fluency is one of the criteria for international students’ admission at the University of Debrecen, the international students were asked to fill out the English version of the survey and the scales. On the other hand, the Hungarian students were asked to fill out the Hungarian version of the survey and the validated Hungarian scales. Also, we provided contact information for psychological support when needed. Students who felt that they needed some help and psychological counseling could use the contact information of our peer supporters. Four International students have used this opportunity and were referred to a higher level of care. The original scales and their validated Hungarian versions are described in the following sections.

Perceived Stress Scale (PSS)

The Perceived Stress Scale (PSS) measures the level of stress in the general population who have at least completed a junior high school [ 34 ]. In the PSS, the respondents had to report how often certain things occurred like nervousness; loss of control; feeling of upset; piling up difficulties that cannot be handled; or on the contrary how often the students felt they were able to handle situations; and were on top of things. For the International students, we used the 10-item PSS (English version). The statements’ responses were scored on a 5-point Likert scale (from 0 = never to 4 = very often) as per the scale’s guide. Also, in the 10-item PSS, four positive items were reversely scored (e.g. felt confident about someone’s ability to handle personal problems) [ 34 ]. The PSS has satisfactory psychometric properties with a Cronbach’s alpha of 0.78, and this English version was used for international students in our study.

For the Hungarian students, we used the Hungarian version of the PSS, which has 14 statements that cover the same aspects of stress described earlier. In this version of the PSS, the responses were evaluated on a 5-point Likert scale (0–4) to mark how typical a particular behavior was for a respondent in the last month [ 35 ]. The Hungarian version of the PSS was psychometrically validated in 2006. In the validation study, the Hungarian 14-item PSS has shown satisfactory internal consistency with a Cronbach’s alpha of 0.88 [ 35 ].

Ways of Coping Questionnaire (WCQ)

The second scale we used was the 26-Item Ways of Coping Questionnaire (WCQ) which was developed by Sørlie and Sexton [ 36 ]. For the international students, we used the validated English version of the 26-Item WCQ that distinguished five different factors, including Wishful thinking (hoped for a miracle, day-dreamed for a better time), Goal-oriented (tried to analyze the problem, concentrated on what to do), Seeking support (talked to someone, got professional help), Thinking it over (drew on past experiences, realized other solutions), and Avoidance (refused to think about it, minimized seriousness of it). The WCQ examined how often the respondents used certain coping mechanisms, eg: hoped for a miracle, fantasized, prepared for the worst, analyzed the problem, talked to someone, or on the opposite did not talk to anyone, drew conclusions from past things, came up with several solutions for a problem or contained their feelings. As per the 26-item WCQ, responses were scored on a 4-point Likert scale (from 0 = “does not apply and/or not used” to 3 = “used a great deal”). This scale has satisfactory psychometric properties with Cronbach's alpha for the factors ranged from 0.74 to 0.81[ 36 ].

For the Hungarian students, we used the Hungarian 16-Item WCQ, which was validated in 2008 [ 37 ]. In the Hungarian WCQ, four dimensions were identified, which were cognitive restructuring/adaptation (every cloud has a silver lining), Stress reduction (by eating; drinking; smoking), Problem analysis (I tried to analyze the problem), and Helplessness/Passive coping (I prayed; used drugs) [ 37 ]. The Cronbach’s alpha values for the Hungarian WCQ’s dimensions were in the range of 0.30–0.74 [ 37 ].

Short Health Anxiety Inventory (SHAI)

The third scale adopted was the 18-Items Short Health Anxiety Inventory (SHAI). Overall, the SHAI has two subscales. The first subscale comprised of 14 items that examined to what degree the respondents were worried about their health in the past six months; how often they noticed physical pain/ache or sensations; how worried they were about a serious illness; how much they felt at risk for a serious illness; how much attention was drawn to bodily sensations; what their environment said, how much they deal with their health. The second subscale of SHAI comprised of 4 items (negative consequences if the illness occurs) that enquired how the respondents would feel if they were diagnosed with a serious illness, whether they would be able to enjoy things; would they trust modern medicine to heal them; how many aspects of their life it would affect; how much they could preserve their dignity despite the illness [ 38 ]. One of four possible statements (scored from 0 to 3) must be chosen. Alberts et al. (2013) [ 39 ] found the mean SHAI value to be 12.41 (± 6.81) in a non-clinical sample. The original 18-item SHAI has Cronbach’s alpha values in the range of 0.74–0.96 [ 39 ]. For the Hungarian students, the Hungarian version of the SHAI was used. The Hungarian version of SHAI was validated in 2011 [ 40 ]. The scoring differs from the English version in that the four statements were scored from 1 to 4, but the statements themselves were the same. In the Hungarian validation study, it was found that the SHAI mean score in a non-clinical sample (university students) was 33.02 points (± 6.28) and the Cronbach's alpha of the test was 0.83 [ 40 ].

Data analyses

Data were extracted from Google Forms® as an Excel sheet for quality check and coding then we used SPSS® (v.25) and RStudio statistical software packages to analyze the data. Descriptive and summary statistics were presented as appropriate. To assess the difference between groups/categories of anxiety, stress, and coping styles, we used the non-parametric Kruskal–Wallis test, since the variables did not have a normal distribution and for post hoc tests, we used the Mann–Whitney test. Also, we used Spearman’s rank correlation to assess the relationship between health anxiety and perceived stress within the international group and the Hungarian group. Comparison between international and domestic groups and different genders in terms of health anxiety and perceived stress levels were also conducted using the Mann–Whitney test. Binary logistic regression analysis was also employed to examine the associations between different coping styles/ strategies (treated as independent variables) and both, health anxiety level and perceived stress level (treated as outcome variables) using median splits. A p-value less than 5% was implemented for statistical significance.

Ethical considerations

Ethical permission was obtained from the Hungarian Ethical Review Committee for Research in Psychology (Reference number: 2020-45). All methods were carried out following the institutional guidelines and conforming to the ethical standards of the declaration of Helsinki. All participants were informed about the study and written informed consent was obtained before completing the survey. There were no rewards/incentives for completing the survey.

Sociodemographic characteristics of respondents

A total of 1320 students have responded to our survey. Six responses were eliminated due to incompleteness and an additional 25 responses were also excluded as the students filled out the survey from abroad (International students who were outside Hungary during the period of conducting our study). After exclusion of the described non-eligible responses (a total of 31 responses), the remaining 1289 valid responses were included in our analysis. Out of 1289 participants (100%), 73.5% were Hungarian students and around 26.5% were international students. Overall, female students have predominated the sample (n = 920, 71.4%). The median age (Interquartile range) among Hungarian students was 22 years (5) and for the international students was 22 years (4). Out of the total sample, most of the Hungarian students were enrolled in non-health-related programs (n = 690, 53.5%), while most of the international students were enrolled in health-related programs (n = 213, 16.5%). Table 1 demonstrates the sociodemographic profile of participants (Hungarian vs International).

Perceived stress, anxiety, and coping styles

For greater clarity of statistical analysis and interpretation, we created preferences regarding coping mechanisms. That is, we made the categories based on which coping factor (in the international sample) or dimension (in the Hungarian sample) the given person reached the highest scores, so it can be said that it is the person's preferred coping strategy. The four coping strategies among international students were goal-oriented, thinking it over, wishful thinking, and avoidance, while among the Hungarian students were cognitive restructuring, problem analysis, stress reduction, and passive coping.

The 26-item WCQ [ 31 ] contains a seeking support subscale which is missing from the Hungarian 16-item WCQ [ 32 ]; therefore, the seeking support subscale was excluded from our analysis. Moreover, because the PSS contained a different number of items in English and Hungarian versions (10 items vs 14 items), we looked at the average score of the answers so that we could compare international and domestic students.

In the evaluation of SHAI, the scoring of the two questionnaires are different. For the sake of comparability between the two samples, the international points were corrected to the Hungarian, adding plus one to the value of each answer. This may be the reason why we obtained higher results compared to international standards.

Among the international students, the mean score (± standard deviation) of perceived stress among male students was 2.11(± 0.86) compared to female students 2.51 (± 0.78), while the mean score (± standard deviation) of health anxiety was 34.12 (± 7.88) and 36.31 (± 7.75) among males and females, respectively. Table 2 shows more details regarding the perceived stress scores and health anxiety scores stratified by coping strategies among international students.

In the Hungarian sample, the mean score (± standard deviation) of perceived stress among male students was 2.06 (± 0.84) compared to female students 2.18 (± 0.83), while the mean score (± standard deviation) of health anxiety was 33.40 (± 7.63) and 35.05 (± 7.39) among males and females, respectively. Table 3 shows more details regarding the perceived stress scores and health anxiety scores stratified by coping strategies among Hungarian students.

Concerning coping styles among international students, the statements with the highest-ranked responses were “wished the situation would go away or somehow be finished” and “Had fantasies or wishes about how things might turn out” and both fall into the wishful thinking coping. Among the Hungarian students, the statements with the highest-ranked responses were “I tried to analyze the problem to understand better” (falls into problem analysis coping) and “I thought every cloud has a silver lining, I tried to perceive things cheerfully” (falls into cognitive restructuring coping).

On the other hand, the statements with the least-ranked responses among the international students belonged to the Avoidance coping. Among the Hungarians, it was Passive coping “I tried to take sedatives or medications” and Stress reduction “I staked everything upon a single cast, I started to do something risky” to have the lowest-ranked responses. Table 4 shows a comparison of different coping strategies among international and Hungarian students.

To test the difference between coping strategies, we used the non-parametric Kruskal–Wallis test, since the variables did not have a normal distribution. For post hoc tests, we used Mann–Whitney tests with lowered significance levels ( p  = 0.0083). Among Hungarian students, there were significant differences between the groups in stress ( χ 2 (3) = 212.01; p < 0.001) and health anxiety ( χ 2 (3) = 80.32; p  < 0.001). In the post hoc tests, there were significant differences everywhere ( p  < 0.001) except between stress reduction and passive coping ( p  = 0.089) and between problem analysis and passive coping ( p  = 0.034). Considering the health anxiety, the results were very similar. There were significant differences between all groups ( p  < 0.001), except between stress reduction and passive coping ( p  = 0.347) and between problem analysis and passive coping ( p  = 0.205). See Figs.  1 and 2 for the Hungarian students.

Perceived stress differences between coping strategies among the Hungarian students

Health anxiety differences between coping strategies among the Hungarian students

Among the international students, the results were similar. According to the Kruskal–Wallis test, there were significant differences in stress ( χ 2 (3) = 73.26; p  < 0.001) and health anxiety ( χ 2 (3) = 42.60; p  < 0.001) between various coping strategies. The post hoc tests showed that there were differences between the perceived stress level and coping strategies everywhere ( p  < 0.005) except and between avoidance and thinking it over ( p  = 0.640). Concerning health anxiety, there were significant differences between wishful thinking and goal-oriented ( p  < 0.001), between wishful thinking and avoidance ( p  = 0.001), and between goal-oriented and avoidance ( p  = 0.285). There were no significant differences between wishful thinking and thinking it over ( p  = 0.069), between goal-oriented and thinking it over ( p  = 0.069), and between avoidance and thinking it over ( p  = 0.131). See Figs.  3 and 4 .

Perceived stress differences between coping strategies among the international students

Health anxiety differences between coping strategies among the international students

The relationship between coping strategies with health anxiety and perceived stress levels among the international students

We applied logistic regression analyses for the variables to see which of the coping strategies has a significant effect on SHAI and PSS results. In the first model (model a), with the health anxiety as an outcome dummy variable (with median split; median: 35), only two coping strategies had a statistically significant relationship with health anxiety level, including wishful thinking (as a risk factor) and goal-oriented (as a protective factor).

In the second model (model b), with the perceived stress as an outcome dummy variable (with median split; median: 2.40), three coping strategies were found to have a statistically significant association with the level of perceived stress, including wishful thinking (as a risk factor), while goal-oriented and thinking it over as protective factors. See Table 5 .

The relationship between coping strategies with health anxiety and perceived stress levels among domestic students

By employing logistic regression analysis, with the health anxiety as an outcome dummy variable (with median split; median: 33.5) (model a), three coping strategies had a statistically significant relationship with health anxiety level among domestic students, including stress reduction and problem analysis (as risk factors), while cognitive restructuring (as a protective factor).

Similarly, with the perceived stress as an outcome dummy variable (with median split; median: 2.1429) (model b), three coping strategies had a statistically significant relationship with perceived stress level, including stress reduction and problem analysis (as risk factors), while cognitive restructuring (as a protective factor). See Table 6 .

Comparisons between domestic and international students

We compared health anxiety and perceived stress levels of the Hungarian and international students’ groups using the Mann–Whitney test. In the case of health anxiety, the results showed that there were significant differences between the two groups ( W  = 149,431; p  = 0.038) and international students’ levels were higher. Also, there was a significant difference in the perceived stress level between the two groups ( W  = 141,024; p  < 0.001), and the international students have increased stress levels compared to the Hungarian ones.

Comparisons between genders within students’ groups (International vs Hungarian)

Firstly, we compared the international men’s and women’s health anxiety and stress levels using the Mann–Whitney test. The results showed that the international women’s health anxiety ( W  = 11,810; p  = 0.012) and perceived stress ( W  = 10,371; p  < 0.001) levels were both significantly higher than international men’s values. However, in the Hungarian sample, women’s health anxiety was significantly higher than men’s ( W  = 69,643; p  < 0.001), but there was no significant difference in perceived stress levels among between Hungarian women and men ( W  = 75,644.5; p  = 0.064).

Relationship between health anxiety and perceived stress

We correlated the general health anxiety and perceived stress using Spearman’s rank correlation. There was a significant moderate positive relationship between the two variables ( p  < 0.001; ρ  = 0.446). Within the Hungarian students, there was a significant correlation between health anxiety and perceived stress ( p  < 0.001; ρ  = 0.433), similarly among international students as well ( p  < 0.001; ρ  = 0.465).

In our study, we found that individuals who were characterized by a preference for certain coping strategies reported significantly higher perceived stress and/or health anxiety than those who used other coping methods. These correlations can be found in both the Hungarian and international students. In the light of our results, we can say that 48.4% of the international students used wishful thinking as their preferred coping method while around 43% of the Hungarian students used primarily cognitive restructuring to overcome their problems.

Regulation of emotion refers to “the processes whereby individuals monitor, evaluate, and modify their emotions in an effort to control which emotions they have, when they have them, and how they experience and express those emotions” [ 41 ]. There is an overlap between emotion-focused coping and emotion regulation strategies, but there are also differences. The overlap between the two concepts can be noticed in the fact that emotion-focused coping strategies have an emotional regulatory role, and emotion regulation strategies may “tax the individual’s resources” as the emotion-focused coping strategies do [ 23 , 42 ]. However, in emotion-focused coping strategies, non-emotional tools can also be used to achieve non-emotional goals, while emotion regulation strategies may be used for maintaining or reinforcing positive emotions [ 42 ].

Based on the cognitive-behavioral model of health anxiety, emotion-regulating strategies can regulate the physiological, cognitive, and behavioral consequences of a fear response to some degree, even when the person encounters the conditioned stimulus again [ 12 , 43 ]. In the long run, regular use of these dysfunctional emotion control strategies may manifest as functional impairment, which may be associated with anxiety disorders. A detailed study that examined health anxiety in the view of the cognitive-behavioral model found that, regardless of the effect of depression, there are significant and consistent correlations between certain dimensions of health anxiety and dysfunctional coping and emotional regulation strategies [ 12 ].

Similar to our current study, other studies have found that health anxiety was positively correlated with maladaptive emotion regulation and negatively with adaptive emotion regulation [ 44 ], and in the case of state anxiety that emotion-focused coping strategies proved to be less effective in reducing stress, while active coping leads to a sense of subjective well-being [ 17 , 27 , 45 , 46 , 47 ]

SHAI values were found to be high in other studies during the pandemic, and the SHAI results of the international students in our study were found to be even slightly higher compared to those studies [ 44 , 48 ]. Besides, anxiety values for women were found to be higher than for men in several studies [ 44 , 48 , 49 , 50 ]. This was similar to what we found among the international students but not among the Hungarian ones. We can speculate that the ability to contact someone, the closeness of family and beloved ones, familiarity with the living environment, and maybe less online search about the coronavirus news could be factors counting towards that finding among Hungarian students. Also, most international students were enrolled in health-related study programs and his might have affected how they perceived stress/anxiety and their preferred coping strategies as well. Literature found that students of medical disciplines could have obstacles in achieving a healthy coping strategy to deal with stress and anxiety despite their profound medical knowledge compared to non-health-related students [ 51 , 52 ]. Literature also stressed the immense need for training programs to help students of medical disciplines in adopting coping skills and stress-reducing strategies [ 51 ].

The findings of our study may be a starting point for the exploration of the linkage between perceived stress, health anxiety, and coping strategies when people are not in their domestic context. People who are away from their home and friends in a relatively alien environment may tend to use coping mechanisms other than the adequate ones, which in turn can lead to increased levels of perceived stress.

Furthermore, our results seem to support the knowledge that deep-rooted health anxiety is difficult to change because it is closely related to certain coping mechanisms. It was also addressed in the literature that personality traits may have a significant influence on the coping strategy used by a person [ 53 ], revealing sophisticated and challenging links to be considered especially during training programs on effective coping and management skills. On the other hand, perceived stress which has risen significantly above the average level in the current pandemic, can be most effectively targeted by the well-formulated recommendations and advice of major international health organizations if people successfully adhere to them (e.g. physical activity; proper and adequate sleep; healthy eating; avoiding alcohol; meditation; caring for others; relationships maintenance, and using credible information resources about the pandemic, etc.) [ 1 , 54 ]. Furthermore, there may be additional positive effects of these recommendations when published in different languages or languages that are spoken by a wide range of nationalities. Besides, cognitive behavioral therapy techniques, some of which are available online during the current pandemic crisis, can further reduce anxiety. Also, if someone does not feel safe or fear prevails, there are helplines to get in touch with professionals, and this applies to the University of Debrecen in Hungary, and to a certain extent internationally.

Naturally, our study had certain limitations that should be acknowledged and considered. The temporality of events could not be assessed as we employed a cross-sectional study design, that is, we did not have information on the previous conditions of the participants which means that it is possible that some of these conditions existed in the past, while others de facto occurred with COVID-19 crisis. The survey questionnaires were completed by those who felt interested and involved, i.e., a convenience sampling technique was used, this impairs the representativeness of the sample (in terms of sociodemographic variables) and the generalizability of our results. Also, the type of recruitment (including social media) as well as the online nature of the study, probably appealed more to people with an affinity with this kind of instrument. Besides, each questionnaire represented self-reported states; thus, over-reporting or under-reporting could be present. It is also important to note that international students were answering the survey questionnaire in a language that might not have been their mother language. Nevertheless, English fluency is a prerequisite to enroll in a study program at the University of Debrecen for international students. As the options for gender were only male/female in our survey questionnaire, we might have missed the views of students who do not identify themselves according to these gender categories. Also, no data on medical history/current medical status were collected. Lastly, we had to make minor changes to the used scales in the different languages for comparability.

The COVID-19 pandemic crisis has imposed a significant burden on the physical and psychological wellbeing of humans. Crises like the current pandemic can trigger unprecedented emotional and behavioral responses among individuals to adapt or cope with the situation. The elevated perceived stress levels during major life events can be further deepened by disengagement from home and by using inadequate coping strategies. By following and adhering to the international recommendations, adopting proper coping strategies, and equipping oneself with the required coping and stress management skills, the associated high levels of perceived stress and anxiety might be mitigated.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available due to compliance with institutional guidelines but they are available from the corresponding author (LRK) on a reasonable request.

Abbreviations

Centers for Disease Control and Prevention

Coronavirus Disease 2019

Perceived Stress Scale

Short Health Anxiety Inventory

Middle East Respiratory Syndrome

Severe Acute Respiratory Syndrome

Ways of Coping Questionnaire

World Health Organization

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Acknowledgments

We would like to provide our extreme thanks and appreciation to all students who participated in our study. ABA is currently supported by the Tempus Public Foundation’s scholarship at the University of Debrecen.

This research project did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Szabolcs Garbóczy, Szilvia Harsányi, Ala’a B. Al-Tammemi & László Róbert Kolozsvári

Department of Psychiatry, Faculty of Medicine, University of Debrecen, Debrecen, Hungary

Szabolcs Garbóczy

Department of Personality and Clinical Psychology, Institute of Psychology, University of Debrecen, Debrecen, Hungary

Anita Szemán-Nagy

Faculty of Medicine, University of Debrecen, Debrecen, Hungary

Mohamed S. Ahmad & Viktor Rekenyi

Department of Social and Work Psychology, Institute of Psychology, University of Debrecen, Debrecen, Hungary

Dorottya Ocsenás

Doctoral School of Human Sciences, University of Debrecen, Debrecen, Hungary

Department of Family and Occupational Medicine, Faculty of Medicine, University of Debrecen, Móricz Zs. krt. 22, Debrecen, 4032, Hungary

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Contributions

All authors SG, ASN, MSA, SH, DO, VR, ABA, and LRK have worked on the study design, text writing, revising, and editing of the manuscript. DO, SG, and VR have done data management and extraction, data analysis. Drafting and interpretation of the manuscript were made in close collaboration by all authors SG, ASN, MSA, SH, DO, VR, ABA, and LRK. All authors read and approved the final manuscript.

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Correspondence to László Róbert Kolozsvári .

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Ethical permission was obtained from the Hungarian Ethical Review Committee for Research in Psychology (Reference number: 2020-45). All methods were carried out following the institutional guidelines and conforming to the ethical standards of the declaration of Helsinki. All participants were informed about the study and written informed consent was obtained before completing the survey.

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Garbóczy, S., Szemán-Nagy, A., Ahmad, M.S. et al. Health anxiety, perceived stress, and coping styles in the shadow of the COVID-19. BMC Psychol 9 , 53 (2021). https://doi.org/10.1186/s40359-021-00560-3

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Examining Coping Skills, Anxiety, and Depression Dynamics Amidst the COVID-19 Pandemic

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This cross-sectional study, conducted amid the COVID-19 pandemic, delves into the intricate connections between coping strategies and levels of anxiety and depression, presenting vital implications for medical, clinical, and broader societal contexts. As crises like the pandemic highlight the importance of adaptive coping, this investigation underscores the imperative to comprehend and address maladaptive coping strategies. The study utilized a diverse sample of 386 participants during the pandemic's peak, employing online platforms for recruitment and ensuring broad demographic representation. Data were collected through self-report measures, including the Patient Health Questionnaire-4 (PHQ-4) for depression and anxiety symptoms and the Brief Coping Orientation to Problems Experienced (COPE) inventory to assess coping skills across various domains. The coping skills assessment measured strategies such as Self-Distraction, Active Coping, Denial, Substance Use, Emotional and Instrumental Support, Behavioral Disengagement, Venting, Positive Reframing, Planning, Humor, Acceptance, Religion, and Self-Blame. The Colorado Multiple Institutional Review Board prioritized and approved ethical considerations, and participants provided informed consent. Data analysis involved rigorous cleaning, recoding, and quantitative analysis using SPSS. Descriptive statistics, regression analyses, and correlation analyses were employed to uncover nuanced relationships between coping strategies and mental health outcomes, contributing to understanding the phenomena under investigation within the context of the pandemic. The findings highlight the pivotal role of individualized approaches and the potential of humor as an essential coping mechanism, emphasizing the need for tailored interventions during crises.

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A Systematic Review of Coping Skill Interventions to Reduce Anxiety and Depressive Symptoms among Adults with Hematologic Malignancies

Lucy andersen.

1 University of Pennsylvania, School of Nursing, Philadelphia, PA

2 The NewCourtland Center for Transitions and Health, Philadelphia PA

Molly McHugh

Connie m. ulrich, salimah h. meghani, associated data, background:.

Patients with hematologic malignancies experience anxiety and depressive symptoms from diagnosis through survivorship. The aim of this systematic review is to determine if coping skill interventions can reduce anxiety and depressive symptoms for persons with hematologic cancer.

Databases including PubMed, Embase, CINAHL, APA PyschInfo, Scopus, and Cochrane were searched in June of 2021 for coping skill interventional studies with adult patients with hematologic cancer and outcomes of anxiety and depressive symptoms. Search terms, definitions, and inclusion/exclusion criteria were guided by the Transactional Model of Stress and Coping, and quality appraisal utilized the Johns Hopkins Evidence Based Practice Appraisal tool. The study was registered in PROSPERO under “CRD42021262967.”

Eleven studies met inclusion criteria with ten studies evaluating anxiety symptoms (n = 449) and nine studies evaluating depressive symptoms (n = 429). Of ten studies evaluating anxiety, five studies showed significant reduction (p< 0.05), three found small to moderate effect size reductions not reaching statistical significance (p>0.05), and only two showed no reduction in anxiety symptoms. Of nine studies evaluating depressive symptoms, three had significant reductions (p <0.05), three reported small to moderate effect size reductions not reaching statistical significance (p >0.05), and three found no effect on depressive symptoms. Coping interventions that were problem-focused as opposed to emotion-focused were most effective for both anxiety and depressive symptoms.

Conclusion:

This systematic review finds evidence that problem-focused coping interventions reduce anxiety symptoms among patients with hematologic malignancies, with mixed evidence for reduction of depressive symptoms. Nurses and other clinicians caring for patients with hematologic cancers may employ coping skill interventions as a potential way to mitigate anxiety and depressive symptoms.

PROSPERO registration ID:

CRD42021262967

1. Introduction

Over 18.1 million people worldwide received a new diagnosis of cancer in 2020 ( Sung et al., 2021 ). This diagnosis can be disruptive and emotionally challenging as individuals come to terms with all the decisions that need to be made related to their cancer diagnosis. In fact, persons with hematologic malignancies often have complicated treatment courses with prognostic uncertainty ( Gray et al., 2021 ). The hematologic malignancy population broadly includes persons with diagnoses of leukemia, lymphoma, and multiple myeloma, though there are many cancer diagnoses under these main disease groups. Individuals may receive therapies resulting in significant side effects such as high dose intensive chemotherapy or hematopoietic stem cell transplants (HSCT). This patient population can experience anxiety and depressive symptoms during chemotherapy treatment ( Hochman et al., 2018 , Senf et al., 2020 ), before stem cell transplantation ( Posluszny et al., 2019 ), and at the end of life ( Ramsenthaler et al., 2019 ).

Between 15 – 47% of patients with hematologic malignancies report depressive symptoms while 22 – 47% of patients report anxiety symptoms throughout diagnosis, treatment, and recovery ( Abuelgasim et al., 2016 , Bergerot et al., 2015 , Clinton-McHarg et al., 2014 , Shreders et al., 2018 ). Anxiety symptoms often range from restlessness, inability to control worrying, sleep problems, muscle tension, and loss of appetite, among others ( Bates et al., 2017 ), while depressive symptoms may include irritability, loss of interest in previously enjoyed activities, and thoughts of death, or suicide ( Smith, 2015 ). Anxiety and depressive symptoms may persist, leading to formal diagnoses. A recent study reported almost 5% of patients receive a new diagnosis of anxiety or depression after being diagnosed with a hematologic malignancy ( Kuczmarski et al., 2022 ) Anxiety and/or depressive symptoms negatively impact one’s quality of life, and alarmingly, depression is tied to higher mortality rates for persons with cancer ( Pinquart and Duberstein, 2010 ). There is a critical need to better address anxiety and depressive symptoms in persons with cancer to improve quality of life ( Niedzwiedz et al., 2019 ).

2. Background

Persons with hematologic malignancies experience high levels of symptom burden, often comparable to those with advanced solid tumor cancer ( Manitta et al., 2011 ). Unfortunately, the presence of anxiety and depressive symptoms, are associated with poorer quality of life ( El-Jawahri et al., 2015 , Papathanasiou et al., 2020 ). Baseline anxiety symptoms are associated with fatigue and shortness of breath during stem cell transplantation ( Seo et al., 2019 ). Pre-cancer treatment depression is correlated with lower overall survival and higher instance of graft vs. host disease among allogeneic stem cell transplant recipients ( El-Jawahri et al., 2017 ). Anxiety and depressive symptoms interfere with other parts of an individual’s life and are correlated with a lower likelihood of returning to work during and after treatment ( Horsboel et al., 2015 ).

Psychosocial interventions such as cognitive behavioral therapy (CBT), offer the potential to mitigate and address anxiety and depressive symptoms in cancer patients. Advantages of psychosocial interventions include minimal risk of harm to patients, accessibility, and improvement of other patient outcomes, such as quality of life and improving coping skills ( Forsman et al., 2011 , Guo et al., 2013 , van Luenen et al., 2018 ). Coping skill interventions have generally been categorized as problem-focused or emotion-focused per the Transactional Model of Stress and Coping (TMSC) by Lazarus and Folkman (1984) . The goal of problem-focused coping is to actively manage or reduce the stressor. CBT is an example of problem-focused coping ( Lazarus and Folkman, 1984 ). Emotion-focused coping centers around managing emotions elicited by the stressor and is used in situations where the stressor is perceived as uncontrollable ( Lazarus and Folkman, 1984 ). Meditation or mindfulness exercises are examples of emotion-focused coping that may benefit persons with cancer.

Adaptive coping, or using positive methods to deal with a stressor, reduces anxiety and depression among persons living with cancer ( Niedzwiedz et al., 2019 ). Maladaptive coping, on the other hand, predicts anxiety and depression in among persons living after cancer ( Cheng et al., 2019 ). Emotion and problem-focused coping interventions, including CBT ( Jassim et al., 2015 ) and mindfulness interventions ( Carlson et al., 2016 , Reich et al., 2017 ), are shown to reduce anxiety and depressive symptoms among breast cancer survivors. It is unclear whether coping interventions also reduce anxiety and depressive symptoms among persons with hematologic malignancies ( Yi and Syrjala, 2017 ). While there are differences among various hematologic malignancies and their subtypes, there are similarities across treatments, symptoms, and side effects experienced by this population ( Manitta et al., 2011 , Society, 2021 ). Understanding the effectiveness of coping skills interventions in this population is essential to better assist patients to manage anxiety and depressive symptoms, thus improving quality of life.

To our knowledge, no systematic reviews have evaluated the effect of coping interventions on anxiety and depressive symptoms among persons with hematologic malignancies. The aims of this systematic review are to investigate the effects of coping interventions on anxiety and depressive symptoms and to identify whether problem- or emotion-focused coping interventions are effective in adults with hematologic malignancies.

3.1. Design

The reporting of this systematic review is according to the updated PRISMA 2020 guidelines ( Page et al., 2021 ) and was registered with the International Prospective Register of Systematic Reviews (PROSPERO). Due to the heterogeneity of study designs and diverse methodologies of included studies, we have employed narrative synthesis for this review ( Siddaway et al., 2019 ). Narrative synthesis involves finding similarities, differences, relationships between and amongst studies, as well as assessing the quality of studies, to answer a specific question to inform practice ( Lisy and Porritt, 2016 ).

3.2. Definitions and Conceptual Framework

Lazarus and Folkman’s Transactional Model of Stress and Coping (TMSC)(1984) , often used in cancer coping literature ( Bigatti et al., 2012 , Paek et al., 2016 , Sumpio et al., 2017 ), directed the study definitions and search terms. The coping definition included “adaptation” and “resilience” ( Audulv et al., 2016 , Association, 2021 ), and excluded the terms “self-care” and “self-management” as these activities refer to disease-controlling or health management strategies. Audulv et al., note that self-care can occur during healthy or a relaxed state of being (2016) , while coping occurs in reaction to a specific stressor ( Lazarus and Folkman, 1984 ).

3.3. Inclusion Criteria

The inclusion criteria included for this review were the following: use of a coping skill intervention, evaluation of anxiety or depressive symptoms before and after the intervention, adult participants with a primary diagnosis of a hematological malignancy, and studies published in English between 2001 and 2021. This time frame was selected to reflect changes in standard of care treatment for hematologic malignancies ( Pulte et al., 2020 ) and technological advances for delivering supportive care interventions, such as telehealth. Studies with a variety of cancer diagnoses were included if over half of participants had a primary hematologic malignancy diagnosis.

3.4. Exclusion Criteria

Studies that were observational, qualitative, or published study protocols were excluded from the review. Studies with pediatric participants, participants without a hematologic malignancy, and articles not published in the past twenty years were also excluded.

3.5. Search Strategy

Two librarians experienced in health science literature searches assisted with developing, revising, and finalizing a search strategy. Database searches in PubMed, Cumulated Index to Nursing and Allied Health Literature (CINAHL), Embase, APA Psych INFO, and Scopus databases using Boolean phrases and MeSH terms occurred in June of 2021 ( Table 1 ). The database search yielded 1,992 articles. In addition, searches of the Cochrane Clinical Trials database, ProQuest dissertation database, the American Society of Clinical Oncology abstracts, and American Society of Hematology abstracts found an additional 246 articles.

Search Strategy:

ASH = American Society of Hematology

ASCO = American Society of Clinical Oncology

3.6. Screening Process and Data Extraction

The EndNote reference manager was used to organize all citations and remove duplicate articles (n=628 )( EndnoteTeam, 2013 ). Rayyan was utilized for title and abstract screening ( Ouzzani et al., 2016 ). Using the inclusion and exclusion criteria, all titles and abstracts were independently screened by L.A. A total of 91 articles remained after the initial title / abstract screening. A full text screening was done on 87 articles, as four articles could not be found with EndNote and manual searches. Of the 87 full text articles, 11 met criteria and were included in the final review, with 8 articles from the formal literature search and 3 studies identified via other methods. Studies were excluded if: no coping intervention was found, non-hematologic cancer, qualitative or observational study, pediatric participants, no depression or anxiety symptom evaluation of participants with cancer, or a study protocol ( Figure 1 PRISMA Flow Diagram).

*Consider, if feasible to do so, reporting the number of records identified from each database or register searched (rather than the total number across all databases/registers).

**If automation tools were used, indicate how many records were excluded by a human and how many were excluded by automation tools.

From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71 . For more information, visit: http://www.prisma-statement.org/

The following information was extracted to create a Table of Evidence: Citation, Sample, Methods, Design, Intervention, Depressive / Anxiety symptom outcomes, Limitations, and Findings ( Table 1 ). An asterisk notes the primary outcome measure of each study ( Table 2 ). We organized studies by the type of intervention ( Table 3 ). Articles were independently assessed by L.A. and M.M. for quality using the Johns Hopkins Nursing Evidence Based Practice (JHNEBP) appraisal tool. The JHNEBP tool consists of a two-part grading system to evaluate the study’s evidence and quality ( Dang and Dearholt, 2018 ). The study gives a numeric level (I, II, or II) based on the overall type of study; for example, a randomized controlled trial (RCT) or systematic review of RCTs receives level I, quasi-experimental studies or systematic review of RCT and quasi-experimental studies receive a level II, and observational studies or qualitative studies receive a level III ( Dang and Dearholt, 2018 ). The second part of the appraisal involves assessing the quality of the evidence with “A” denoting a high quality study with generalizable results, acceptable control, consistent recommendations, and adequate sample size ( Dang and Dearholt, 2018 ). A “B” denotes a good quality study with adequate control, fairly consistent results, and reasonably decisive conclusions while a “C” study denotes a low quality study, including with inconsistencies, limited sample size, or inconclusive findings ( Dang and Dearholt, 2018 ). Any discrepancies in evaluation were discussed between L.A. and M.M. until an agreement was reached ( Table 4 ).

Table of Evidence

Abbreviations in order of use:

JHNEBP (Johns Hopkins Nursing Evidence Based Practice); CBT (Cognitive Behavioral Therapy); HSCT (Hematopoietic Stem Cell Transplant); HADS (Hospital Anxiety and Depression Scale); STATE (Spielberger State Anxiety Inventory); CES-D (Centers of Epidemiologic Studies – Depression); BSI-D (Brief Symptom Inventory – Depression); BAI (Beck Anxiety Inventory); PROMIS (Patient Reported Outcomes Measurement Information System); MPN (Myeloproliferative Neoplasms); DASS (Depression Anxiety Stress Scale); GAD-7 (General Anxiety Disorder)

Table of Study Interventions

Quality of Evidence Table

In total, 11 studies met the eligibility criteria for this systematic review. Seven of the studies were conducted in the United States and four studies were international: two from Iran ( Faryabi et al., 2021 , Moeini et al., 2014 ), one from Germany ( Balck et al., 2019 ), and one from Spain ( de Linares-Fernández et al., 2017 ). Ten studies evaluated anxiety symptoms, nine studies evaluated depressive symptoms, and eight studies evaluated both anxiety and depressive symptoms. Studies evaluating anxiety symptoms had a total of 449 participants (sample size ranged from n = 25 ( Amonoo et al., 2021 ) to n= 95 ( Balck et al., 2019 )) with an average age of 52.3 years. Studies evaluating depressive symptoms had a total of 429 participants (sample size range from n=25 ( Amonoo et al., 2021 ) to n=95 ( Balck et al., 2019 )) with an average age of 53.1 years. Study interventions included positive psychology interventions ( Amonoo et al., 2020 , Amonoo et al., 2021 ), problem-solving training ( Balck et al., 2019 ), Tibetan yoga and meditation ( Cohen et al., 2004 ), CBT ( de Linares-Fernández et al., 2017 , DuHamel et al., 2010 , Faryabi et al., 2021 ) acceptance and commitment therapy ( Faryabi et al., 2021 ), yoga / mindfulness ( Huberty et al., 2019 , Huberty et al., 2016 ), a spiritual care program with active listening ( Moeini et al., 2014 ), and the Stress Management and Resilience Training- Relaxation, Response, Resilience Program (SMART-3RP Lymphoma) ( Perez et al., 2020 ). Study attrition ranged from 0% ( Moeini et al., 2014 ) to 52% ( Amonoo et al., 2020 ) with common reasons for attrition including high symptom burden ( Amonoo et al., 2020 ), worsening health status, death ( Balck et al., 2019 ), or lack of time ( Perez et al., 2020 ).

Studies used a variety of validated measures to evaluate anxiety and/or depressive symptoms. The most commonly used was the Hospital Anxiety and Depression Scale (HADS). Four studies used the HADS scale ( Amonoo et al., 2020 , Amonoo et al., 2021 , Balck et al., 2019 , de Linares-Fernández et al., 2017 ), two used the Patient Reported Outcomes Measurement Information System (PROMIS) for anxiety and depressive symptoms ( Huberty et al., 2016 , Huberty et al., 2019 ), and two used the Center of Epidemiologic Studies – Depression (CES-D) scale ( Perez et al., 2020 , Cohen et al., 2004 ). Other studies used the Spielberger State Anxiety Inventory ( Cohen et al., 2004 ), the Brief Symptom Inventory – Depression scale (BSI-D) ( DuHamel et al., 2010 ), the Beck Anxiety Inventory (BAI) ( Faryabi et al., 2021 ), the Depression, Anxiety, and Stress Scale (DASS −42) ( Moeini et al., 2014 ), and the General Anxiety Disorder scale (GAD – 7) ( Perez et al., 2020 ). These scales are typically screening tools for anxiety and depressive symptoms and are not often used for diagnostic purposes.

4.1. Quality Appraisal

Of the eleven studies included in this review, one was IA quality, indicating a randomized controlled trial of high quality ( DuHamel et al., 2010 ), and three met level IB quality, indicating a randomized controlled trial with “good” quality ( Balck et al., 2019 , Huberty et al., 2019 , Moeini et al., 2014 ). Three studies were of IIB quality, indicating a quasi-experimental study with “good” quality ( Cohen et al., 2004 , de Linares-Fernández et al., 2017 , Faryabi et al., 2021 ). The remaining four studies were of IIC quality, indicating a quasi-experimental study with of lower quality, commonly due to no control group, small sample size, and/or unknown treatment fidelity ( Amonoo et al., 2020 , Amonoo et al., 2021 , Huberty et al., 2016 , Perez et al., 2020 ). Overall, study quality was moderate, with four excellent or good quality RCTs and seven good or lower quality quasi-experimental studies.

4.2. Synthesis

Study-reported p values determined a significant effect (p <0.05), a small to moderate ES reduction in anxiety or depressive symptoms that did not reach statistical significance (p > 0.05), or no effect on anxiety or depressive symptoms (no reduction in symptoms and p > 0.05). Of the ten studies that evaluated the effects of coping skill interventions on anxiety, five reported a significant reduction in anxiety, p <0.05 with study quality of IB, ( Balck et al., 2019 , Moeini et al., 2014 ), IIB ( de Linares-Fernández et al., 2017 , Faryabi et al., 2021 ) and IIC ( Huberty et al., 2016 ). Three studies reported small to moderate ES reductions that did not reach statistical significance (ES, d =0.027 to 0.037) with study quality IB ( Huberty et al., 2019 ), d=0.18 to 0.41 with study quality IIC, ( Perez et al., 2020 ) and d = 0.31 with study quality IIC ( Amonoo et al., 2021 ). Two studies reported no reduction in anxiety, with study quality IIB ( Cohen et al., 2004 ) and study quality IIC ( Amonoo et al., 2020 ). Interventions that reduced anxiety included problem-solving ( Balck et al., 2019 ), CBT ( de Linares-Fernández et al., 2017 , Faryabi et al., 2021 ),, acceptance and commitment therapy ( Faryabi et al., 2021 ), yoga / mindfulness ( Huberty et al., 2016 ), and a spirituality program ( Moeini et al., 2014 ). Interventions showing small to moderate ES anxiety reduction but did not reach statistical significance included the SMART-3RP Lymphoma program ( Perez et al., 2020 ) yoga / mindfulness ( Huberty et al., 2019 ) and positive psychology ( Amonoo et al., 2021 ). The interventions that did not reduce anxiety were positive psychology ( Amonoo et al., 2020 ) and Tibetan yoga and meditation ( Cohen et al., 2004 ). Overall, five studies showed significant reductions, three showed small to moderate ES reductions that did not reach statistical significance, and two showed no reduction in anxiety symptoms.

Of the nine studies that evaluated coping skill intervention effectiveness on depressive symptoms, three resulted in a significant reduction in depressive symptoms and were of IA ( DuHamel et al., 2010 ), IIB ( de Linares-Fernández et al., 2017 ), and IIC quality ( Huberty et al., 2016 ). The interventions that significantly reduced depressive symptoms included CBT ( de Linares-Fernández et al., 2017 , DuHamel et al., 2010 ) and a yoga / mindfulness intervention ( Huberty et al., 2016 ). Three studies found small to moderate ES reductions that did not reach statistical significance (p>0.05) in depressive symptoms with the SMART-3RP program with d = 0.23 to 0.29 of IIC quality ( Perez et al., 2020 ), a yoga / mindfulness intervention with d = −0.53 to −0.78 of IB quality ( Huberty et al., 2019 ), and a positive psychology intervention with d = −0.29 of IIC quality ( Amonoo et al., 2021 ). The remaining three interventions did not reduce depressive symptoms: A problem-solving training of IB quality ( Balck et al., 2019 ), Tibetan yoga and meditation of IIB quality ( Cohen et al., 2004 ), and a positive psychology intervention of IIC quality ( Amonoo et al., 2020 ). Of nine studies, three found significant reductions, three studies reported small to moderate ES reductions not reaching statistical significance, and three found no reduction in depressive symptoms.

4.3. Synthesis by Intervention Type

To further understand coping intervention effectiveness, we categorized interventions according to Lazarus and Folkman’s definition of problem-focused and emotion-focused coping ( Lazarus and Folkman, 1984 ). Of interventions evaluating anxiety, six were emotion-focused, four were problem-focused and two were combined problem and emotion-focused, as Faryabi et al. compared CBT and acceptance and commitment therapy (2021) . Emotion-focused interventions included yoga ( Cohen et al., 2004 , Huberty et al., 2016 , Huberty et al., 2019 ) to positive psychology interventions ( Amonoo et al., 2020 ). Of the emotion-focused interventions, only two showed significant reduction in anxiety; the spirituality program ( Moeini et al., 2014 ) and yoga/mindfulness ( Huberty et al., 2016 ). Another yoga ( Huberty et al., 2019 ) and positive psychology intervention had small to medium effect sizes ( Amonoo et al., 2021 ). However, a similar positive psychology intervention ( Amonoo et al., 2020 ) and a Tibetan yoga intervention had no effect on anxiety ( Cohen et al., 2004 ). Of the interventions that evaluated depressive symptoms, five were emotion-focused, four were problem-focused and one was combined problem and emotion-focused. Five emotion-focused coping interventions evaluated depressive symptoms, with a positive psychology intervention ( Amonoo et al., 2020 ) and Tibetan yoga ( Cohen et al., 2004 ) also not reducing depressive symptoms. A positive psychology intervention resulted in a small effect size (d=−0.29) ( Amonoo et al., 2021 ) and a yoga / mindfulness intervention resulted in a medium effect in reducing depressive symptoms (d=−0.53 – 0.78) ( Huberty et al., 2019 ). However, a similar yoga/mindfulness intervention found a significant reduction in depressive symptoms ( Huberty et al., 2016 ). The emotion-focused coping interventions had varied results on anxiety and depressive symptoms, with most having a small to moderate ES reductions that did not reach statistical significance effect. The type of intervention did not align with patient outcomes, as the yoga/mindfulness and positive psychology interventions had mixed results across the four studies.

The problem-focused coping interventions consisted of CBT or problem solving training. All three interventions significantly decreased anxiety ( Faryabi et al., 2021 , de Linares-Fernández et al., 2017 , Balck et al., 2019 ). Of the three problem-focused interventions measuring their effects on depressive symptoms, two CBT interventions significantly decreased depressive symptoms ( de Linares-Fernández et al., 2017 ) ( DuHamel et al., 2010 ) while the problem solving intervention did not. Problem-focused coping interventions were all effective in significantly reducing anxiety, though only the CBT interventions significantly reduced depressive symptoms.

Two interventions involved components of both problem and emotion-focused coping. One was the SMART-3RP program, involving CBT, mindfulness, and positive psychology, which resulted in small ES in reducing anxiety and depressive symptoms ( Perez et al., 2020 ). The other was acceptance and commitment therapy, which significantly reduced anxiety but did not measure its impact on depressive symptoms ( Faryabi et al., 2021 ). Over half of the interventions in this systematic review utilized emotion-focused coping and had mixed results in reducing anxiety. However, problem-focused interventions, such as CBT, were more effective, and all resulted in significant reductions in anxiety. A similar trend was found for depressive symptoms, with emotion-focused interventions less effective, and problem-focused interventions more effective at reducing depressive symptoms.

4.4. Synthesis by Intervention Delivery

Three interventions were delivered to groups of participants and five were delivered to individuals. Two of the group interventions found no significant improvement in depressive or anxiety symptoms ( Amonoo et al., 2020 , Cohen et al., 2004 ), and one had a small ES in reducing depressive and anxiety symptoms ( Perez et al., 2020 ). Of the individual interventions that evaluated anxiety, three of the four had significant reductions in anxiety symptoms ( Balck et al., 2019 , de Linares-Fernández et al., 2017 , Moeini et al., 2014 ), while another had a small ES, d=−0.31 ( Amonoo et al., 2021 ). Of the individual interventions that evaluated depressive symptoms, two of the four found significant reduction in depressive symptoms, ( de Linares-Fernández et al., 2017 , DuHamel et al., 2010 ), one found a small ES, d=−0.29 ( Amonoo et al., 2021 ), and one had no reduction in depressive symptoms ( Balck et al., 2019 ).

Of the 11 total studies, four interventions were in person: three resulted in significant reductions in anxiety ( Balck et al., 2019 , de Linares-Fernández et al., 2017 , Moeini et al., 2014 ), though one in person intervention did not reduce anxiety nor depressive symptoms ( Cohen et al., 2004 ). Four utilized phones ( Amonoo et al., 2020 , Amonoo et al., 2021 , DuHamel et al., 2010 ),, or video apps ( Perez et al., 2020 ). One of the three phone delivered interventions had a significant reduction in depressive symptoms ( DuHamel et al., 2010 ), one resulted in small ES reductions in depressive and anxiety symptoms ( Amonoo et al., 2021 ), and one had no reduction in depressive nor anxiety symptoms ( Amonoo et al., 2020 ). The SMART-3RP program used a video app and found small-medium ES reductions in anxiety and depressive symptoms ( Perez et al., 2020 ). Two online asynchronous yoga/mindfulness interventions resulted in significant ( Huberty et al., 2016 ) or small-medium ES reductions in anxiety and depressive symptoms ( Huberty et al., 2019 ). One study did not report whether it was in-person or remote ( Faryabi et al., 2021 ). Though interventions varied, in person and individual sessions seemed more effective in reducing anxiety, with less evidence available to evaluate the effect on depressive symptoms.

4.5. Synthesis by Intervention Duration

We also evaluated the duration of interventions, with one study not disclosing the length of the intervention period ( Faryabi et al., 2021 ). One intervention was delivered over three days, with a significant reduction in anxiety ( Moeini et al., 2014 ). Two interventions, both problem-focused, were delivered over 1 to 2 weeks, both with significant reductions in anxiety, but only one intervention found a significant reduction in depressive symptoms ( de Linares-Fernández et al., 2017 ), while the other did not ( Balck et al., 2019 ). Four interventions were between 7 to 8 weeks in length, with two resulting in small-medium ES in symptom reduction ( Amonoo et al., 2021 , Perez et al., 2020 ) and two with no improvement in depressive or anxiety symptoms ( Amonoo et al., 2020 , Cohen et al., 2004 ). Three interventions continued for over 10 weeks, with two showing significant reduction in anxiety and/or depressive symptoms ( DuHamel et al., 2010 , Huberty et al., 2016 ) and one with small to medium ES in reducing anxiety and depressive symptoms ( Huberty et al., 2019 ). Assessing outcomes based on intervention duration is difficult due to heterogeneity in intervention type and participants, as well as the intervention “dose” (e.g. multiple sessions per week vs. once per week). However, it appears that interventions occurring more than once per week and over a longer period of time showed some effectiveness.

4.6. Synthesis by Type of Cancer / Treatment

The studies recruited a heterogenous mix of participants by type of cancer. Two studies enrolled patients with lymphomas: one study had no reduction in anxiety or depressive symptoms ( Cohen et al., 2004 ) and the other had small ES reductions in anxiety and depressive symptoms ( Perez et al., 2020 ). Two studies enrolled patients with leukemia ( Faryabi et al., 2021 , Moeini et al., 2014 ), with both interventions reducing anxiety and not measuring depressive symptoms. Finally, two yoga / mindfulness studies enrolled patients with myeloproliferative disorders ( Huberty et al., 2016 , Huberty et al., 2019 ). One study found significant reductions and the other found small-medium ES reductions in anxiety and depressive symptoms. One study enrolled only allogeneic stem cell transplants and found small ES reductions in anxiety and depressive symptoms ( Amonoo et al., 2021 ). Four studies enrolled allogeneic and autologous HSCT recipients. One found significant reduction in both anxiety and depressive symptoms ( de Linares-Fernández et al., 2017 ), one found significant reduction in anxiety but not depressive symptoms ( Balck et al., 2019 ), one found in significant reductions in depressive symptoms only ( DuHamel et al., 2010 ), and one study had no symptom reductions ( Amonoo et al., 2020 ). Time since transplant varied, with one study starting before day 0 ( de Linares-Fernández et al., 2017 ) and another including participants who were 39 years post-transplant ( Amonoo et al., 2020 ). We did not identify any commonalities in coping skill intervention effectiveness by cancer type or treatment due to the heterogeneity of the participant’s illnesses and treatments.

5. Discussion

To our knowledge, this is the first systematic review to evaluate whether and which types of coping skill interventions reduces anxiety and depressive symptoms in adults with hematologic cancers. Included studies ranged from quasi-experimental studies with limited study quality to high quality RCTs. This review found coping skill interventions can be effective in reducing anxiety symptoms but are less effective in reducing depressive symptoms in the hematologic malignancy population. Interventions that were most effective at reducing anxiety included problem-focused coping interventions such as CBT and problem-solving training. We found that problem-focused interventions, such as CBT, were more effective in reducing anxiety and depressive symptoms for persons with hematologic malignancies, though some emotion-focused interventions were somewhat effective in reducing anxiety. Reported effect sizes ranged from small to medium for both anxiety and depressive symptoms. Underlying mechanisms behind these differences are unclear, however a recent longitudinal study among healthy adolescents exposed to stressful life events found those who used problem-focused coping were less likely to experience depressive symptoms compared to those using emotion-focused coping ( Pelekanakis et al., 2022 ). While coping skill interventions may not reduce anxiety or depressive symptoms in all persons with hematologic cancer, they may be effective for some. Our findings were less clear for intervention duration and delivery, though interventions lasting more than 8 weeks appeared to be more effective. In addition, differences among disease subtypes or treatment stage were not apparent, in part due to the heterogeneity of participants in our included studies. This review did find that problem-focused interventions, such as CBT, were more effective at anxiety and depressive symptom reduction than emotion-focused interventions alone.

A recent systematic review with meta-analysis found patients with early-stage breast cancer benefit from CBT in reducing anxiety symptoms, but the effectiveness of CBT on depressive symptoms was unclear ( Sun et al., 2019 ). In a systematic review with meta-analysis of coping skills training among mostly patients with solid tumor cancers, coping interventions were found to significantly reduce both anxiety and depressive symptoms, though effects were small ( Buffart et al., 2020 ). The Buffart et al. review of coping skills training aligns with our results indicating some significant reduction or small to medium effects among anxiety and depressive symptoms among persons with hematologic malignancies (2020) . We found in-person sessions to be more effective for anxiety symptoms, with less clarity around depressive symptoms, however, the Buffart et al. review found that in-person sessions were effective in reducing both anxiety and depressive symptoms in the solid tumor cancer population (2020) . The in person- experience may be more personalized and / or therapeutic to patients than remote interventions, however, further research is needed to determine optimal settings for coping skill interventions.

It is critical to address anxiety and depressive symptoms in persons with hematologic malignancies throughout and after treatment: survivors of hematologic malignancies remain at an elevated risk for experiencing depressive symptoms even twenty years after diagnosis ( Kuba et al., 2019 ). A benefit of coping skill interventions is that they can be delivered in tandem with medications to reduce anxiety or depression. Notably, some anti-depressants can interact with chemotherapy and may not be an option for certain patients due to drug interactions ( Smith, 2015 ). Of note, the Oncology Nursing Society recommends CBT, mindfulness stress reduction, music therapy, psychoeducation, and yoga to reduce anxiety, and antidepressants, CBT, behavioral health care, mindfulness, and psychoeducation to reduce depressive symptoms in their general guidelines for oncology patients (2019a , 2019b ). Novel interventions are needed given the small to medium effect sizes of current coping and other interventions that are recommended to reduce depressive and anxiety symptoms among persons with cancer.

5.1. Limitations

This review has the following notable limitations. We were unable to distinguish between depressive and anxiety symptoms and a clinical diagnosis of depression or anxiety, which may have influenced the overall effect of the coping skill interventions. Furthermore, the heterogeneity of the types of coping interventions, method of delivery, and type of evaluation created a challenge for synthesizing the study results. Also, some of the included studies did not include theoretical frameworks and were of lower quality evidence: no control group or randomization as well as other risks of bias. Participants tended to be white and college educated for studies that reported patient characteristics, similar to our other systematic review in this population ( Andersen et al., 2022 ). Moreover, our findings may not be generalizable to non-white persons and those with lower educational attainment due to underrepresentation of these groups in the final sample of the studies. Unfortunately, disparities in treatment for hematologic cancers exist among non-white, lower socioeconomic status, and Medicare beneficiaries who are less likely to receive HSCT ( Vardell et al., 2019 ) and may be diagnosed at later stages ( Becnel et al., 2017 ). Despite limitations, this systematic review presents critical findings to inform targeted future research and current psychosocial interventions for persons with hematologic malignancies.

Coping skills should be evaluated throughout the illness trajectory, both before and after the intervention to determine whether the outcomes stem from the improvement of coping skills or therapeutic aspects of the intervention. Future interventions evaluating the effects of coping skill and pharmaceutical interventions on anxiety and depressive symptom outcomes are needed in this population. In addition, the timing of the intervention can be investigated to determine the optimal time to introduce coping skills to the patient. Attrition of these studies indicates that these interventions may be burdensome and that patients experience high symptom burden leading to attrition. Further research is needed to find effective and feasible interventions to reduce anxiety and depressive symptoms among persons with hematologic cancer and to identify from patients what they find to be most burdensome about the different types of coping skill interventions. Future research should emphasize inclusion of diverse participants by age, sex, and social determinants of health such as race, ethnicity, gender, socioeconomic status, and educational attainment. These factors may modify the relationship between coping intervention and patient outcomes ( Brouwer and Menard, 2020 ). Persons with hematologic malignancies experiencing anxiety and depressive symptoms may require novel interventions in order to cope with and manage their symptoms.

5.2. Practice Implications

Unfortunately, patients with hematologic malignancies often have inaccurate perceptions of their prognosis, with El-Jawhari et al. finding 71.7% of participants had an inaccurate perception of their prognosis compared to their oncologist (2014) . Patients that did have a more accurate understanding of their prognosis reported worsening depressive symptoms, higher rates of depression, and poorer quality of life ( El-Jawahri et al., 2014 ). Cancer supportive care programs should consider including problem-focused coping interventions to support patients and their caregivers as they navigate the uncertainty of a hematologic malignancy and discuss goals of care. Clinicians must be aware of the potential for heightened anxiety or depressive symptoms, and initiate screening. If a patient is flagged as having symptoms, clinicians should discuss appropriate interventions with patients and their families and ascertain their preferences and goals for their care trajectory.

6. Conclusion

Our systematic review found that coping skill interventions can reduce anxiety among persons with hematologic malignancies, although effect sizes were small to medium. Persons with depressive symptoms were found to benefit from problem-focused coping skill interventions, however, this review found general coping skill interventions did not reduce depressive symptoms. Notably, problem-focused interventions were more effective in reducing anxiety and depressive symptoms than interventions that were emotion-focused only. Persons with hematologic cancers can suffer from heightened levels of anxiety and depression that affect their overall well-being and quality of life. Future research should focus on the most effective types of coping skill interventions to best meet the needs of this cancer population; and, to provide them with the most timely and useful resources to support their emotional health.

Supplementary Material

Acknowledgements:.

The authors acknowledge Penn librarians, Richard James and Maylene Qiu for their guidance in formulating a search strategy and process for the review.

Molly McHugh is supported by a T32 grant. Research reported in this publication was supported by the National Institute of Nursing Research of the National Institutes of Health under Award Number T32NR009356. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

CRediT Author Statement:

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Research Article

A count of coping strategies: A longitudinal study investigating an alternative method to understanding coping and adjustment

Roles Conceptualization, Formal analysis, Methodology, Project administration, Software, Validation, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Department of Psychology, Brock University, St. Catharines, Ontario, Canada

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

• Taylor Heffer, 
• Teena Willoughby

• Published: October 5, 2017
• https://doi.org/10.1371/journal.pone.0186057
• Reader Comments

Researchers recently have suggested that coping flexibility (i.e., an individual’s ability to modify and change coping strategies depending on the context) may be an important way to investigate coping. The availability of numerous coping strategies may be an important precursor to coping flexibility, given that flexibility can only be obtained if an individual is able to access and use different coping strategies. Typically, studies examining the use of coping strategies compute means-based analyses, which assess not only what strategies are used but also how much they are used. Thus, there is limited ability to differentiate between individuals who use a lot of strategies infrequently, and individuals who use only one or two strategies a lot. One way to address this confound is to count the number of strategies that an individual uses without attention to how frequently they use them (i.e., a count-based approach). The present longitudinal study compares a count-based model and a means-based model of coping and adjustment among undergraduates ( N = 1132). An autoregressive cross-lagged path analysis revealed that for the count-based approach, using a greater number of positive coping strategies led to more positive adjustment and less suicide ideation over time than using a smaller number of positive coping strategies. Further, engagement in a greater number of negative coping strategies predicted more depressive symptoms and poorer emotion regulation over time. In comparison, the means-based model revealed identical results for negative coping strategies; however, engagement in more frequent positive coping strategies did not predict better positive adjustment over time. Thus, a count-based approach offers a novel way to examine how the number of coping strategies that individuals use can help promote adjustment among university students.

Citation: Heffer T, Willoughby T (2017) A count of coping strategies: A longitudinal study investigating an alternative method to understanding coping and adjustment. PLoS ONE 12(10): e0186057. https://doi.org/10.1371/journal.pone.0186057

Editor: Scott McDonald, Hunter Holmes McGuire VA Medical Center, UNITED STATES

Received: August 17, 2016; Accepted: September 25, 2017; Published: October 5, 2017

Copyright: © 2017 Heffer, Willoughby. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are available at: http://hdl.handle.net/10464/11163 .

Funding: This work was supported by Social Sciences and Humanities Research Council, Grant Number: 435-2014-1929 (TW). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

For many students, attending university can be stressful and challenging [ 1 , 2 ]. Students often are faced with many demands (e.g., moving away from home, struggling with financial constraints, etc.) often without the close social support of family and friends that they experienced when living at home [ 3 , 4 ]. Importantly, accumulation of these daily stressors can impact students’ adjustment [ 2 , 5 , 6 ]. Indeed, the rates of suicide ideation and depressive symptoms among university students are alarming. In a study of 16,760 American undergraduates, 36.1% reported feeling so depressed in the past year that it was difficult to function and 10.3% seriously considered suicide—yet many students may not seek out or be aware of appropriate resources that are available to them [ 7 , 8 ]. Thus, managing these challenges places a reliance on students’ own ability to cope. The current study seeks to investigate how the number of coping strategies that individuals use may be associated with adjustment over time.

The transactional theory of coping posits that coping is an evolving process that changes in response to context, in an effort to manage different internal and external demands [ 9 ]. Accordingly, the transactional theory of coping presumes that successful coping involves an ability to adjust and change coping strategies in a way that facilitates positive outcomes.

With this in mind, current models of coping have focused on the idea of coping flexibility- a way of studying coping that identifies an individual’s ability to modify their coping behavior according to the nature of each stressful situation (see [ 10 ]).

The availability of numerous coping strategies when stressed may be an important precursor to coping flexibility—in order to demonstrate flexibility among a variety of coping strategies, individuals must first possess a diverse range of coping strategies that they are able to use when stressed [ 11 ]. Studies investigating the use of coping strategies typically compute means-based analyses whereby they not only investigate what strategies are used, but also how much (i.e., a little, a medium amount, a lot) each is used—a composite score then is computed based on the average frequency of use across all the strategies [ 12 – 15 ]. As a result, this approach is unable to differentiate between individuals who use a lot of strategies infrequently and individuals who use only one or two strategies a lot. For example, an individual who uses three coping strategies “a little” (scored as a 2 on the Likert scale) would have an identical mean to someone who indicates using two strategies “not at all” (scored as a 1) and a third strategy “a lot” (scored as a 4); both means would be 2. In other words, when using a means-based analysis, distinct coping patterns can present with identical means, limiting the conclusions that can be made regarding the relationship between the number of coping strategies used and adjustment. One way to address this confound is to count the number of strategies that an individual uses when stressed without attention to how frequently they use them (i.e., a count-based approach).

Regardless of approach (count or mean), it also is important to note that some strategies may not be advantageous, regardless of how well an individual is able to use that specific strategy [ 16 ]. For instance, consider a person who copes with different situations by blaming themselves, self-medicating through alcohol use, and seeking support; this person would not be expected to have a more favourable outcome compared to if they had just used only one strategy such as seeking support, given that self-blame and alcohol use are unlikely to help. Thus, adaptive coping may require an ability to use coping strategies that are at least relatively positive in nature. The current study examines this hypothesis by separating coping strategies based on positive and negative coping. In doing so, differential associations between adjustment and the count of positive strategies versus the count of negative coping strategies used can be assessed. Of note, however, there may be some instances where certain coping strategies may not be considered to be truly negative or positive (e.g., distraction coping may not help an individual succeed on an exam). Thus, we acknowledge that these terms may be oversimplified.

Coping and negative adjustment

Despite the potential benefits of using multiple strategies to cope with stress, doing this may be difficult for individuals experiencing poor adjustment. Two indicators of poor adjustment that are examined in the current study are depressive symptoms and suicide ideation. Importantly, individuals with high levels of depressive symptoms demonstrate a more negative attribution style (i.e., a stable and internalized attitude that unpleasant circumstances will persist) compared to their non-depressed peers ([ 17 , 18 ]; see [ 19 ] for a review). Thus, believing that nothing can be done to alter an aversive situation may discourage an individual from seeking out new positive ways to cope with problems.

In line with this idea, concurrent studies using a means-based approach have found that using more frequent negative coping strategies (e.g., self-blame) are associated with higher depressive symptoms [ 20 ]. Further, in a longitudinal investigation, Lee and colleagues [ 21 ] found that more frequent engagement in avoidant coping was associated with more depressive symptoms over time, although they only tested one direction—from coping to depressive symptoms over time (see also [ 22 ]). Thus, interpretation of these findings generally is that negative coping leads to more depressive symptoms over time. However, a longitudinal study testing bidirectionality is necessary before conclusions about the direction of effects can be ascertained.

Suicide ideation also is associated with how well individuals are able to cope with stress [ 23 – 26 ]. For example, findings from concurrent studies indicate that individuals with higher levels of suicide ideation engage in more frequent (calculated by a means-based approach) maladaptive coping strategies [ 23 , 25 ] and tend to have more trouble problem solving in the face of stress [ 27 ], compared to individuals with lower levels of suicide ideation. Thus, individuals who engage in more suicide ideation may have more difficulty accessing multiple productive coping strategies when faced with stress. But it also may be that individuals who use more negative coping strategies in the face of stress have higher suicide ideation over time- a longitudinal study testing both directions of the effects is required in order to address these hypotheses.

Overall, while there is evidence of a means-based association between coping and negative adjustment, less is known about whether these results are transferable when looking solely at the number of strategies individuals have available to them. Interestingly, researchers often suggest that one way to help decrease negative adjustment (e.g., depressive symptoms and suicide ideation) may be to reduce the number of negative coping strategies that individuals use. Yet, a direct test of this hypothesis has not been conducted. Research examining a count-based approach is necessary before concluding that the number of strategies that individuals use is associated with adjustment. In addition, the current study will investigate the direction of effects of these relations over time. For example, it may be that individuals who engage in a greater number of negative coping strategies when stressed report more depressive symptoms and suicide ideation over time than their peers. On the other hand, individuals who report depressive symptoms and suicide ideation at Time 1 may engage in a greater number of negative coping strategies over time. In fact, both possibilities may be true—the effect may be bidirectional. Thus, an important goal of the present study is to investigate the direction of effects of these relations for both positive and negative coping.

Coping and positive adjustment

A second objective of the current study is to investigate the relationship between coping and positive adjustment. Coping often is investigated in terms of its ability to decrease negative outcomes. The current study, however, seeks to investigate whether coping can also play an important role in increasing positive outcomes. Indeed, having a higher number of positive coping strategies available in the face of stress may provide the individual with more resources to deal with stress. This may allow an individual to manage stress more effectively and be more confident in their ability to deal with problems. There is less research directly investigating coping and positive adjustment than coping and negative adjustment, and the research that has been done generally is concurrent rather than longitudinal.

As adjustment can be examined in a variety of ways, in the present study we will focus on three indicators: emotion regulation, self-esteem and academic achievement. All three are associated with coping [ 28 – 30 ] and represent particularly important indicators of adjustment among students. One indicator of positive adjustment that is associated with coping is emotion regulation. Individuals who are better able to regulate their emotions and engage in more positive affect may be more likely to seek out and use a number of positive coping strategies. According to the broaden-and-build theory, the experience of positive emotions (e.g., joy) broadens attention and thinking (i.e., heightens openness to new possibilities, big picture focus, etc.), in comparison to negative emotions, which tend to result in a narrowing of focus (i.e., fight or flight, etc., [ 31 ]). This broadening of attention is hypothesized to build personal resources, such as adaptive coping strategies [ 32 ]. In light of this, individuals who are better able to regulate emotions in a more positive manner may have a heightened ability to think more broadly, allowing for engagement in a variety of positive coping strategies, compared to those who have more narrow thinking. Alternatively, it may be that individuals who engage in a greater number of positive coping strategies may have a greater sense of control, and demonstrate a greater ability to adjust their coping responses and adapt to stress. As a result, these individuals may become more proficient in their ability to regulate their emotions. Fredrickson [ 33 ] posits that both interpretations warrant investigation (i.e., bidirectionality) by emphasizing that experience of positive emotion should help facilitate a broader source of coping, which could help improve later experiences of positive emotions.

Another way that coping has been implicated in promotion of positive adjustment is in its association to self–esteem [ 21 ]. For instance, individuals with high self-esteem are thought to have more effective and appropriate coping resources available to deal with stress (e.g., planning and problem solving [ 34 ]. With regards to the count of coping strategies used, it could be that individuals with high self-esteem may be more confident in their ability to cope with different stressors (and thus be more likely to engage in a variety of positive coping strategies). It also may be, however, that individuals who are able to use a greater number of positive coping strategies may develop a sense of control and feelings of confidence in their ability to handle different situations appropriately, thus leading to increased self-esteem.

In addition, academic achievement may be another important factor associated with coping. Academic achievement typically requires an ability to work well under pressure (e.g., writing exams, oral presentations) as well as an ability to collaborate on group projects. The ability to cope efficiently and employ more frequent positive orientated strategies when under stress/pressure has been found to be associated with better academic achievement, compared to those who rely on less effective coping strategies [ 35 , 36 ]. Further, Zeidner [ 37 ] emphasizes that success on exams is associated with a combined use of multiple strategies (i.e., increase study time, seek support from friends. While associations have been found between academic achievement and use of effective coping strategies, less is known about the longitudinal association between academic achievement and a count of the number of coping strategies used.

The current study seeks to investigate relationships between positive adjustment and a count of the number of strategies individuals use. A count-based analysis will help to clarify if having a number of positive coping strategies available when stressed will be associated with positive adjustment over time. It also is necessary to use a longitudinal design in order to assess bidirectionality. As an example, interpretations of concurrent studies surrounding academic achievement imply that having better coping strategies leads to better academic achievement; it also could be, however, that the ability to succeed in an academic setting may help build confidence and lead to a broadening of focus which could help increase the use of a variety of coping strategies. The same issues with interpretations can be applied to emotion regulation and self-esteem, thus further longitudinal examination is required.

Stress as a moderator

While a key goal of the present study is to investigate bidirectionality, it is quite possible that the associations among these variables may differ depending on the individuals’ level of stress. For instance, coping is generally considered in the context of stress; thus if an individual is not experiencing stress, we might not expect them to apply and use a number of coping strategies compared to individuals who are experiencing stress [ 38 , 39 ]. Indeed, it may be that individuals who have a lot of different stressors in their life may benefit more from using a variety of strategies, compared to individuals who have few stressors.

The current study

There are three main research questions associated with this longitudinal study. First, how is a count-based approach associated with adjustment over time, and are these effects bidirectional? Although research using a means-based approach has provided evidence for associations between coping and adjustment, little work has used a count-based approach or used this approach with a longitudinal design. We predict that using a greater number of positive coping strategies when stressed might be associated with better adjustment (i.e., less depressive symptoms, less suicide ideation, more self-esteem, better emotion regulation and higher academic achievement) over time than using a smaller number of positive coping strategies. We also expect that using a higher number of negative strategies will be associated with poorer adjustment (e.g., greater depressive symptoms, and higher suicide ideation) than using a smaller number of negative coping strategies. Given the lack of research, it is not clear whether using a greater number of negative coping strategies will be associated with poorer self esteem, emotion regulation and academic achievement over time. Further, the analyses examining bidirectionality in these associations over time are exploratory.

Second, the current study offers a comparison of a count-based approach and a means-based approach to studying coping and adjustment. Given that a counts-based model does not take into consideration how much individuals use each strategy and only examines the number of coping strategies individuals use, it also would be beneficial to compare this model to a means-based model that takes both of these factors into consideration. In doing so, differential associations between the two models can be compared in order to address the ways in which a count-based approach may be an alternative method to studying coping.

A third purpose of this study is to investigate whether stress is an important moderator of the association between coping (for both the count-based and the means-based methods) and adjustment. Additionally, all analyses controlled for sex and parental education given research suggesting that these variables are associated with coping and adjustment [ 40 – 42 ].

Participants

The current sample of 1,132 (70.5% female) first-year undergraduate students ( M age = 19.06, SD = .92) from a mid-sized Canadian university was drawn from a larger longitudinal study examining adjustment in university. In total, 87.5% of the participants were born in Canada. Consistent with the broader demographics for the region; the most common ethnic backgrounds endorsed other than Canadian were British (19%), Italian (16.8%), French (9.5%) and German (9%; [ 43 ]). Data on socioeconomic status indicated mean levels of parental education falling between “some college, university or apprenticeship program” and “completed a college/ apprenticeship/ technical diploma.”

Missing data occurred within each assessment time point because some students did not finish the entire questionnaire (average missing data = 1.8%) and because some students did not complete both waves of the data. Out of the original sample that completed the survey at Time 1, 73.1% completed Time 2 of the survey. The overall multivariate test for missingness was significant, Λ = .941, F (9, 1010) = 7.017, p < .001, η 2 = .059. Participants who were missing at the second time point were not significantly different from participants who were there at both time points, with two exceptions. Specifically, those who completed both waves of the study were more likely to be females and to have higher grades compared to those who only completed one wave of the study ( p s < .001). Missing values were imputed using the expectation–maximization algorithm (EM; iterations = 200) with all study measures included in the analysis, thus avoiding the biased parameter estimates that can occur with pairwise deletion, list-wise deletion or means substitution [ 44 ].

First-year university students were invited to participate in the survey examining factors related to stress and adjustment. The study was advertised by way of posters, emails, classroom announcements, website posting, and residence visits. Students could participate regardless of academic major, and were given monetary compensation or course credit for their participation. Only students who completed the first wave were invited (by email and/or phone) to participate again in the second wave. The Social Science Research Ethics Board approved the study (Ethics Approval Number: 09–118) and all participants provided informed written consent. Trained research assistants administered the survey. To ensure the safety of our participants a full debriefing was provided at the end of the survey and a list was given of both available mental health resources and researcher contact information. Participants also were given the opportunity during the survey to provide their contact information so that they could be contacted by a mental health professional if they were experiencing any distress.

Demographics.

Sex and parental education (one item per parent, scale ranged from 1 ( did not finish high school ) to 6 ( professional degree ), averaged for participants reporting on both parents; r = .40) were assessed at Time 1.

Coping was assessed using a shortened version of the Brief COPE (15 items) at Time 1 and then again one year later at Time 2 [ 45 ]. The Brief COPE includes positive and negative coping strategies. In order to differentiate between these positive and negative coping strategies, a principal components factor analysis with direct oblimin rotation was conducted using the data from Time 1. Four components emerged with eigenvalues > 1. Factor 2 was comprised of four negative coping items that hung together (i.e., self-blame, self-criticism, alcohol use, and giving up; eigenvalues = 2.73) with factor loadings ranging from 0.63 to 0.77. These items thus were included in the count of negative coping strategies. The three remaining factors reflected different subtypes of positive coping strategies such as religion (e.g., I pray or meditate), seeking support (e.g., I get emotional support from others), and reframing/humor (e.g., I look for something good in what is happening). Indeed, previous research has found that positive adjustment is associated with positive reframing and humor [ 46 ], seeking support [ 47 ] as well as religious coping strategies (see [ 48 ]). As the focus of this study was to investigate how many strategies individuals have access to using (regardless of the subtype of positive strategies), the items from the three remaining factors were grouped together in order to create the count of positive coping strategies (see S1 Table for more information on the factors).

When filling out the coping measure, participants were asked to indicate what they do when under a lot of stress on a scale ranging from 1 ( I usually don’t do this at all ) to 4 ( I usually do this a lot ). In order to create a count of how many strategies individuals use when stressed, the items were recoded such that that 0 represented not using the strategy (i.e., I usually don’t do this at all ), while 1 represented using the strategy to any degree (i.e., I usually do this a little bit , I usually do this a medium amount , I usually do this a lot ).

The count of negative coping strategies was created by counting the number of negative strategies individuals use when stressed (e.g., “I blame myself”, “I use alcohol and other drugs to make myself feel better,” etc.). An average of these strategies (based on the original items with the four-point scale) was also created and used in the means-based approach. Cronbach’s alpha was .68 at Time 1 and .72 at Time 2. The count of positive coping strategies was assessed by counting the number of positive strategies individuals use when stressed (e.g., “I get comfort and understanding from someone,” “I look for something good in what is happening” etc.). An average of these strategies (based on the original items with the four-point scale) was also created and used in the means-based approach. Cronbach’s alpha was .76 at Time 1 and .74 at Time 2. The Brief COPE has been shown to have good internal consistency and validity in previous research [ 45 ].

Depressive symptoms.

Participants completed The Center for Epidemiological Studies Depression Scale at Time 1 and Time 2 in order to assess their level of depressive symptoms (CES-D Scale; [ 49 ]; e.g., “I felt lonely” and “My sleep was restless”). Individuals indicated on a scale of 1 ( none of the time ) to 5 ( most of the time ) how often they experienced 20 symptoms associated with depression. Cronbach’s alpha in the present study was .91 at Time 1 and .92 at Time 2.

Suicide ideation.

Suicide ideation in the past year was assessed at Time 1 and Time 2 using a question from the Suicide Behaviors Questionnaire-Revised (SBQR; [ 50 ]; “How often have you thought about killing yourself in the past year?”). This item was rated using a 5-point scale that ranged from 1 ( never ) to 5 ( very often ). The SBQR has been shown to have good internal consistency and validity in previous research [ 50 ].

Self esteem.

Self-esteem was measured at Time 1 and Time 2 using the Rosenberg Self-Esteem Scale [ 51 ]. The measure included 10 items (e.g., “I take a positive attitude toward myself”) that were rated on a scale from 1 ( strongly disagree ) to 5 ( strongly agree ). Cronbach’s alpha was .904 at Time 1 and .916 at Time 2.

Academic achievement.

Academic achievement was measured at both Time 1 and Time 2 using students’ academic average for the corresponding year, recorded in percentages (e.g., 70%). Information was obtained from the University Registrar with the participants’ permission.

Emotion regulation.

Emotion regulation was assessed at both Time 1 and Time 2 using 6 items from the Difficulties in Emotion Regulation (DERS; [ 52 ]); e.g., ‘‘When I’m upset or stressed, I have difficulty concentrating”). The responses were based on a five-point Likert scale ranging from 1 ( almost never ) to 5 ( almost always ). The scale was recoded so that higher scores indicated better emotion regulation. Cronbach’s alphas at Time 1 and Time 2 were .73 and .74, respectively.

Stress was measured using The Daily Hassles Scale. Participants indicated how bothered they felt by 25 daily hassles. Hassles related to daily life stressors such as peer conflict, family, school and money (e.g., “Being lonely” and “Not having enough time”). Responses were rated on a scale from 1 ( almost never bothers me ) to 3 ( often bothers me ). Cronbach’s alpha for these 25 items was .84.

Preliminary analyses

The means and standard deviations of all study variables are outlined in Table 1 . All variables demonstrated acceptable levels of skewness and kurtosis with the exception of suicide ideation, which was transformed using the log-likelihood method to correct for non-normality. There was a significant main effect of sex on the number of positive coping strategies used, with females reporting using a greater number of positive coping strategies than males at both Time 1 and Time 2, p s < .004. Females also reported having more depressive symptoms than males at Time 1, p < .001, and higher academic achievement at Time 2, p = .006, than males. In contrast, males were significantly more likely to have better emotion regulation than females at both Time 1 and Time 2, ps < .001. At Time 2, males were more likely to engage in a greater number of negative coping strategies, p = .027, and also reported higher suicide ideation, p = .014, than females. There were no significant differences on parental education, p > .05.

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https://doi.org/10.1371/journal.pone.0186057.t001

Primary analyses

The primary statistical analyses were carried out using an auto-regressive cross-lagged path analysis in MPlus 7. Two models were run, a count-based model and a means-based model. The models were comprised of seven variables measured over 2 years: positive coping strategies, negative coping strategies, depressive symptoms, suicide ideation, academic achievement, emotion regulation, and self-esteem (see Figs 1 and 2 ). Across the two time periods, we included cross-lag paths among all seven key study variables, autoregressive paths (i.e., within each variable), and concurrent associations among all variables within each wave. Sex and parental education also were included as covariates, such that correlations were specified between each of the covariates and each variable at Time 1 and paths were estimated between the covariates and each variable at Time 2. Any significant path, therefore, accounted for covariates, previous scores on the outcome variables, correlations among variables within a wave, as well as any other predictors in the model (i.e., estimating the unique relation between study variables). Significant paths among the seven key study variables for both models (count-based and means-based) are depicted in Figs 1 and 2 (see S2 and S3 Tables for full results among key variables). Model fit was not relevant given that the models were saturated.

Numbers 1 and 2 indicate Time 1 and Time 2, respectively. Values indicate standardized beta weights (standard errors are in parenthesis). Pos = Positive, Neg = Negative.

https://doi.org/10.1371/journal.pone.0186057.g001

https://doi.org/10.1371/journal.pone.0186057.g002

The following results for the paths related to coping were consistent across both the count-based model and the means-based model (See Figs 1 and 2 as well as S2 and S3 Tables for specific path results as well as all results among adjustment indicators). There was a bidirectional association between the use of negative coping strategies and depressive symptoms, such that using more (as measured by a count and a mean) negative coping strategies at Time 1 was associated with higher depressive symptoms at Time 2, and depressive symptoms at Time 1 were positively associated with more engagement in negative coping strategies at Time 2. There also was a unidirectional association found between the use of negative coping and emotion regulation; specifically, using less negative coping strategies (as measured by a count and a mean) at Time 1 was associated with better emotion regulation at Time 2.

Critically, some results were not consistent among the two models. For the count-based model, using a greater number of positive coping strategies at Time 1 was associated with less suicide ideation, engagement in fewer negative coping strategies, higher self-esteem, as well as higher academic achievement one year later. There was also a bidirectional association between the number of positive coping strategies used and emotion regulation. Using a greater number of positive coping strategies at Time 1 was associated with better emotion regulation at Time 2, and better emotion regulation at Time 1 was associated with use of a greater number of positive coping strategies at Time 2.

For the means-based analysis, in addition to the overlapping findings among both models, there also was a unidirectional association found between positive coping and emotion regulation, such that better emotion regulation at Time 1 was associated with more positive coping (means-based) at Time 2. Further, there was a unidirectional association between academic achievement and negative coping. Specifically, higher academic achievement at Time 1 was associated with less negative coping (means-based) at Time 2.

We assessed whether stress was a significant moderator of the pattern of results in both the count-based and means-based models. Stress was categorized into two equal percentiles (50% each) encompassing higher versus lower daily stress. The Chi-Square Difference Test of Relative Fit was not significant for either the count model, χ 2 diff (42) = 45.516, p = .292, or the means-based model χ 2 diff (42) = 42.727, p = .439, indicating that the pattern of associations for both models was not different between people with lower stress compared to people with higher stress. We also assessed whether stress might be a significant moderator if we only included individuals who scored at the more extreme ends of stress (bottom 33% vs top 33%). Consistent with the previous result, the Chi-Square Difference Test of Relative Fit was not significant for either the count-based model, χ 2 diff (42) = 25.439, p = .980 or for the means-based model χ 2 diff (42) = 27.275, p = .961. Overall, these results reveal that stress does not appear to be a moderator of the pattern of results between coping and adjustment.

A large volume of research has been conducted on coping, stress, and adjustment [ 53 ]. In line with the transactional theory of coping, coping flexibility is an important way of studying coping that accounts for an individual’s ability to adjust and change coping styles in response to different internal and external demands [ 9 ]. Importantly, the availability of numerous coping strategies may be an important precursor to coping flexibility, given that flexibility may only be obtained if an individual is able to access and use different coping strategies [ 11 ]. Studies that have investigated the use of coping strategies, however, typically compute a means-based analysis—an approach that does not allow for differentiation between individuals who use a lot of strategies infrequently and individuals who use only one or two strategies a lot. In order to address this limitation, the current study created a count-based measure of coping, whereby the number of strategies that an individual uses was counted without attention to how frequently they use them.

The focus of the present study was to investigate the relationship between a count-based approach to coping and adjustment. Critically, using a greater number of positive coping strategies was associated with better adjustment (e.g., less suicide ideation, using a fewer number of negative coping strategies, higher self-esteem and better academic achievement) over time. Of note, this finding was not true for the means-based analysis. This is an important finding as it suggests that encouraging students to use a greater number of positive coping strategies can not only help to decrease negative adjustment, but also aid in promoting positive adjustment.

In terms of bidirectionality, there was a bidirectional relationship between using a greater number of negative coping strategies and more depressive symptoms. This finding is in line with the research suggesting that individuals with depression may have a more negative attribution style and thus may be more likely to use strategies such as giving up. Additionally, using these types of negative coping strategies predicted more depressive symptoms over time. In line with the broaden-and-build theory, a bidirectional association also was found between emotion regulation and the number of positive coping strategies used when stressed. Our results suggest that emotion regulation may be a distinct way to help broaden an individual’s positive coping resources when stressed, and in turn, individuals who use a greater amount of positive coping strategies when stressed may be better able to regulate their emotions in a more positive manner.

Another goal of the current study was to compare a means-based approach to a counts-based approach. Overall, it appears that the count-based approach offers similar findings to the means-based approach in terms of negative coping. The count-based approach, however, provided additional findings that suggest that using a greater number of positive coping strategies may be distinctly important for promoting positive adjustment as well as decreasing negative adjustment. Further research is needed to investigate why using a greater number of positive coping strategies may be adaptive. For instance, it could be that having more resources available or alternative ways to deal with stress allows individuals to deal with problems more effectively. It also is important for future research to identify the factors that lead some individuals to use more coping strategies than their peers (e.g., access to role models, higher executive functioning and planning skills, openness to experience, etc.). In addition, future research would benefit from identifying if there are differences between the number of strategies individuals think they might use in a situation (e.g., using hypothetical scenarios) compared to the number of strategies that they actually use when faced with stress. This would help identify whether individuals have certain strategies available but do not use them. Studies addressing these issues could help inform interventions aimed at teaching individuals how to use a variety of positive coping strategies as a way to promote adjustment.

The current study also found that stress was not a significant moderator of the relation between coping strategies and adjustment. This finding suggests that the using a greater number of positive coping strategies as well as using less negative coping strategies (lower average and a fewer number of negative strategies) may be beneficial for people with either high or low stress. Thus, even if an individual does not have a lot of stress in their life, it is still beneficial to have a greater number of positive coping strategies available to deal with problems effectively.

This study has important strengths, including a large sample, multiple indicators of adjustment, as well as being the first longitudinal study to offer a comparison between a means-based approach and a count-based approach to coping and adjustment. At the same time, the study has several limitations. First, generalizability is limited due to a predominantly Caucasian sample of university students. Second, the measure of stress comes from a self-report questionnaire of daily hassles. Thus, this measure is targeting more minor daily stressors, compared to major or severe stressors. It is worth noting, however, research findings emphasize the importance of cumulative daily stress/hassles in the role of negative adjustment [ 54 , 55 ]. Nonetheless, future research may benefit from investigating if the relationship between the number of coping strategies used and adjustment is more prominent among individuals facing major stressors. Another limitation is that coping was assessed via retrospective reports. It would be valuable for future research to assess these constructs in real time through techniques such as ecological moment sampling (e.g., daily diaries). Of note, the current study was unable to assess how coping may change depending on the situational context. Admittedly, it would be extremely difficult to evaluate and account for varying subjective stressors, as well as dispositional and environmental factors, in order to identify an objective measure of how coping may be adaptive in response to specific contexts [ 56 ]. Future research is needed to help disentangle how context may play a role in the relationship between a count of coping strategies used and adjustment.

In conclusion, the present study helps to elucidate the associations between adjustment and two methods of investigating coping over time. Understanding coping behaviours over time can help researchers and practitioners implement programs to improve coping efficiency and adjustment. Studies that investigate only a means-based approach are unable to differentiate between individuals who use one or two strategies a lot as opposed to those who use multiple strategies infrequently. Thus, a count-based method offers an innovative and practical way to implement interventions that could focus on teaching individuals to use a larger variety of coping strategies. Indeed, using a greater number of positive coping strategies is associated with less use of negative coping strategies, less suicide ideation, as well as higher self-esteem, emotion regulation, and academic achievement over time. Further, decreasing the ways in which individuals use negative coping strategies (average and count), can help to decrease depressive symptoms as well as increase emotion regulation over time. Given that university students report alarming rates of depressive symptoms and suicide ideation [ 8 ], there is a strong need for research investigating ways to decrease mental health problems as well as promote more positive adjustment.

Supporting information

S1 table. exploratory factor analysis..

https://doi.org/10.1371/journal.pone.0186057.s001

S2 Table. Autoregressive cross-lagged results for the count-based model.

https://doi.org/10.1371/journal.pone.0186057.s002

S3 Table. Autoregressive cross-lagged results for the means-based model.

https://doi.org/10.1371/journal.pone.0186057.s003

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Nurturing My Mental & Emotional Health

Mental and emotional wellbeing is critical to overall health. By supporting teens in developing healthy coping skills, you can set them up for success in dealing with stress and challenging circumstances in the future. This activity helps promote mindfulness and teaches teens how to practice health-enhancing behaviors, which can support better management of stress and reduce the chances of exploring substance use as an alternative.

Lesson Plan Highlights:

This lesson includes:.

• Questions for students
• Student activity sheets
• Teacher's prompts

Grade Level(s):

Student skills:.

• English language arts
• Health and life skills

Time / Duration:

• Computer and internet access

Academic Standards:

Healthy behavior outcomes.

• MEH-2. Engage in activities that are mentally and emotionally healthy
• MEH-4. Prevent and manage emotional stress and anxiety in healthy ways
• MEH-5. Use self-control and impulse-control strategies to promote health

National Health Education Standards

• 7. Students will demonstrate the ability to practice health-enhancing behaviors and avoid or reduce health risks

Introduction

Stress has been linked to substance use. 1 If someone has a hard time coping with stress, it may play a role in their use of drugs or alcohol. 1 Teens can learn to use healthy coping strategies to help build resilience in response to challenging circumstances and events. For example, mindfulness –slowing down to pay attention to what’s going on around you at the moment–can help teens create mental “breathing space” for dealing with distressing emotions. 2 That breathing space can look like teens’ increased awareness of their thoughts, feelings, and senses, as well as the ability to distance themselves from those thoughts and feelings. Mindfulness-based activities can also enhance teens’ emotional wellbeing and decrease how overwhelmed they feel from stress. 3 Activities that help teens build resilience can benefit all teens who participate in them. 4

This activity is designed to be delivered in virtual classroom settings. It can also be adapted as an assignment for students to complete at home.

Student Objectives

Students will be able to...

• Practice health-enhancing activities that promote and nurture their mental and emotional health.

Teacher prompts are in italics .

Your mind and emotions affect your overall health. Unmanaged stress can increase the risk that a person may attempt to deal with stressors—including mental health issues and trauma—by using drugs and other substances. Today, we’re going to do an activity that can help you nurture your own mental health. Since every person is unique, the activities that help you relax or feel better may be different than the ones that may help your friends or family members.

[For virtual and in-person instruction]   Ask students: With a show of fingers, how stressed are you now? One finger (not the middle, please) indicates barely any stress, 10 fingers means super stressed.

[For at home assignment] On a scale of 1 to 10, how stressed are you now? With 1 indicating barely any stress and 10 indicating super stressed. Circle your response on the scale below.

The 4-7-8 breath.  This breathing exercise involves breathing in for a count of 4, holding the breath for a count of 7, and exhaling for a count of 8. You can adjust the speed of each breath based on how fast you count. When a person does this for the first time, they should do it seated or lying down and only for a few breaths, as it can make some people feel a bit giddy or light-headed.

Source: U.S. Department of Veterans Affairs .

Say: It's OK to feel “not OK.” It can be hard to handle difficult circumstances. That’s why it’s really important to take care of your emotional and mental health, and to practice healthy ways to cope. Hopefully by the end of this activity, when I ask about your stress level, it might go down at least one number.

Select an activity from the list below, and practice doing it for the next 10 minutes. You may even want to try something you haven’t tried before to see if it’s relaxing and something you might enjoy. Ideas for activities may include…

• Draw a picture of a favorite place or memory.
• Close your eyes and focus on your breathing. You can use a free app, like this one, Breathe2Relax .
• Read or listen to a mindfulness passage ( example ).
• Write about what’s on your mind.
• Write down 10 things you feel grateful for.
• Practice guided imagery .
• Exercise (either aerobic, like dancing along with music videos, or stretching, like yoga).
• Listen to music that helps you relax.

Give students about 10 minutes to select something and practice. Consider using chimes or a bell to bring them back.

[For virtual and in person instruction] Say: Write in the chat or in your notebook how you felt before the activity and how you feel now. For example (place in chat) , tight in my chest/open and easier to breathe .

[For at home assignment]  Write down how you felt before the activity and how you feel now. For example, tight in my chest/open and easier to breathe.

Ask: Did anyone feel more stress, or a feeling that wasn’t positive, related to the activity you chose?  Provide time to listen and discuss.

It’s important to find activities that support your mental health. If what you tried today didn’t help you feel less stressed, consider trying another option from the list. It may take a few tries to find what works best for you . W hat works for your family members or friends might not work for you.

Did you notice that the options listed included different kinds of things: physical activity and movement, reading, drawing, writing? That’s because it’s important to know that taking care of your mental and emotional health might mean taking a nap, or running a mile. It might include writing down your feelings, or listening to music. Knowing what you can do to support and manage your mental and emotional health is half the work! Plus, bringing yourself back to a state of calm may help you in other areas of health and life.

[For virtual and in person instruction] Ask: With a show of fingers, how stressed are you now? One finger (not the middle, please) indicates barely any stress, 10 fingers means super stressed.

Did you learn something about what could help you feel less stressed—or what doesn’t help?

To supplement this lesson, play this  new kahoot   to help youth understand how acute stress affects their bodies, how it differs from the more dangerous constant (or chronic) stress, and learn strategies to support their mental and emotional health.

For more information on healthy ways to cope with stress, check out these interactive videos from the National Academies of Sciences, Engineering, and Medicine, developed with support from the Centers for Disease Control and Prevention (CDC). 

• Deep Breathing    
• Increasing Favorite Activities  
• Calming Your Mind  
• [1] Sinha R. How does stress increase risk of drug abuse and relapse? Psychopharmacology . 2001;158(4):343. doi:10.1007/s002130100917
• [2] Sapthiang S, Van Gordon W, Shonin E. Mindfulness in Schools: a Health Promotion Approach to Improving Adolescent Mental Health. International Journal of Mental Health & Addiction . 2019;17(1):112-119. doi:10.1007/s11469-018-0001-y
• [3] Galla BM. Within-person changes in mindfulness and self-compassion predict enhanced emotional well-being in healthy, but stressed adolescents. Journal of Adolescence . 2016;49:204-217. doi:10.1016/j.adolescence.2016.03.016
• [4] Dray J, Bowman J, Campbell E, et al. Systematic Review of Universal Resilience-Focused Interventions Targeting Child and Adolescent Mental Health in the School Setting. Journal of the American Academy of Child & Adolescent Psychiatry . 2017;56(10):813-824. doi:10.1016/j.jaac.2017.07.780

Student Worksheet

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Stress? It matters what you think.

By Michael R. Malone [email protected] 04-25-2024

You’re striding to the podium, heart pounding, hyper-aware, about to give that commencement address in front of a packed room. Are you “energized” and “excited,” ready to meet the challenge? Or are you “nervous” and “anxious,” wilting under the pressure?

Stress is the body and brain’s response to change, challenge, or demand. It’s inevitable, and everyone experiences it. Though not in the same way. 

“Stress can be regarded as a matter-of-fact statement of a pressure or tension being exerted on an object. In this respect, the term is descriptive and neither positive nor negative,” explained Scott Rogers , a University of Miami School of Law professor and longtime advocate for mindfulness practice. Tea, coffee, cortisol, the psychic pressure of a looming deadline, and trying to find where a puzzle piece belongs, can all be viewed as stressors, he added.

Given this neutrality, psychologists use the Yerkes-Dodson Law to plot the relationship between stress and performance, Rogers noted. The plot depicts an inverted U such that with little stress, performance is low while as stress grows, performance improves to a point where it is optimal. But too much stress becomes detrimental to performance.

“The optimal state emerges when we have the capacity to meet the stressor. Stress that is useful is known as ‘eustress,’ whereas the stress that pushes the envelope is known as distress,” Rogers said. “Finding the sweet spot at the top of the inverted U can be very satisfying, and mindfulness practice—and becoming more mindfully aware—can help us course correct throughout the day as we begin to slip down either side. This is due to our becoming adept at noticing the tell-tale signs of overwhelm as it begins to kick in.”

Since 1992, April has been recognized as Stress Awareness Month, an intent to bring attention to the causes and cures for our modern-day stress epidemic.

Cognitive Behavioral Therapy (CBT) and Coping Skills Training can be counted among the cures that strengthen resiliency and increase our efficiency in managing stress, according to Michael Antoni , professor and director of the Health Psychology Division in the Department of Psychology .

“One of the most widely accepted and empirically supported methods for changing the ways people interpret challenges is through CBT and specifically, techniques referred to as ‘cognitive restructuring’ where we teach people to entertain alternative interpretations of stressors/challenges to be less threatening, less uncertain, etc. by addressing the extremeness and rigidity of some of their stress appraisals,” Antoni explained.

CBT, conducted in combination with Coping Skills Training, involves having them call upon their arsenal of coping strategies that can be applied to the challenge, but with an eye toward efficient use of energies. Facilitators help differentiate elements of stress that are, and may remain, less controllable versus those that are actually more controllable, Antoni explained. 

People learn to “match” more action-oriented coping responses (e.g., making plans, seeking information) to the controllable elements, and use more emotion-focused coping responses (e.g., relaxation, pleasurable activities, seeking social support) to deal with the uncontrollable elements. Together these cognitive-behavioral techniques may greatly increase the efficiency with which one manages stressors; helps to avoid burnout, hopelessness, and frustration; and can provide greater opportunities for self-mastery and gaining helpful social support.  

Mindfulness training can help us cultivate greater present moment awareness so that we might perceive things more clearly, suggested Rogers, founder and director of the Mindfulness in Law Program , UMindfulness, the University’s Mindfulness Research and Practice Initiative , and author of several books on the topic. 

“There are stressors in life that bring about responses, mentally and physically, that can be helpful to meeting the challenge,” he said. “So too, we are all susceptible to over-reacting to a challenge when we misperceive what is at stake. The more clearly we see what is actually taking place (e.g., that thoughts forecasting gloom and doom over a change in job or a relationship are just thoughts—not facts—and worth further investigation; that a person yelling is, in fact, sad or scared), the better we size things up and our expectations and assessments are better balanced and more in alignment with reality.” 

Most mindfulness training programs teach meditative practice that direct attention in ways that improve our ability to notice the emerging, changing, and dissipating of thoughts and feelings arising in the mind, and of physical sensations arising in the body.

“As these capacities develop with practice (and experience) we relate to our thoughts, feelings, and sensations differently,” Rogers pointed out. “We notice them arising sooner and are less likely to resist. We can become more resilient because we see things more clearly and are less likely to get swept away by assumptions, preconceptions, and biases (largely mental activity) and by moments of physiological distress and agitation. Hence, we become steadier and less reactive.”  

If stress—our response to change, challenge, and demand—is relatively neutral, what are some of the factors that determine our varied responses? 

When we sense a stimulus (through our eyes, ears, nose and other sensory organs) our cerebral cortex interprets the meaning of these through a perceptual process—whether they indicate pleasure, pain, danger, etc.—and signals other brain regions to organize a response, which can range from approach to avoidance to mounting some sort of defensive maneuver, according to Antoni. 

When we interpret that a stimulus or challenge outweighs our means for easily responding then these cortical regions may signal subcortical “stress response centers” involving the hypothalamus and other parts of our “limbic” system and the brainstem, he explained. These cortical “decisions” may depend on the degree of certainty that we have about the nature and impact of the stimuli and our cognitive, behavioral, and social “resources” for responding. 

These brain changes can signal neuroendocrine stress hormones in ways that affect peripheral physiology through interactions with cells and tissues that contribute to physical health and disease. This area of study, called psychoneuroimmunology, characterizes much of the work done in the past 37 years in the Health Psychology Division in the Department of Psychology in collaboration with colleagues at the Miller School of Medicine, noted Antoni, also a Sylvester Comprehensive Cancer Center professor of psychology, psychiatry, and behavioral sciences.

“One could argue that a lifetime of learning, a set of rich and memorable experiences, and the development of wisdom all comes from a series of encounters with challenges that we handle and grow from. These may involve acute stress episodes,” said Antoni, in noting some of the more severe consequences associated with acute and chronic stress.

“Short-term stress—and our successful resolution of it—may also bring about positive psychological states such as positive mood, and a sense of self-efficacy or mastery,” Antoni pointed out.  

Students: Learn how to prioritize well-being during final exams

For anyone seeking emotional support, the Faculty and Staff Assistance Program (FSAP) team is available to assist during work hours at 305-284-6604 or visit fsap.miami.edu . ​

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10+ Coping Skills Worksheets for Adults and Youth (+ PDFs)

Coping is something we all do, whether we do it consciously or without thinking.

That might mean watching a funny movie when you’re sad, calling a friend to help you get through a breakup, or going out for a drink after a challenging workday.

Some of the ways we cope are healthy and build resilience, while others are ways to avoid dealing with a problem or are destructive.

In this piece, we’ll provide more than 60 healthy coping strategies, explain why they’re different from negative coping methods, and provide worksheets that teach you how to cope in a more positive way.

Before you read on, we thought you might like to download our three Resilience Exercises for free . These engaging, science-based exercises will help you to effectively deal with difficult circumstances and give you the tools to improve the resilience of your clients, students or employees.

This Article Contains:

60+ essential positive coping skills, 6 coping skills worksheets for adults, printable coping skills worksheets for youth, coping skills worksheets for mental illness.

• Substance Abuse, Recovery & Relapse Prevention Worksheets

A Take-Home Message

There are nearly infinite ways to cope, and we all use the methods that suit our unique personalities and needs. An activity that causes stress in one individual might help another person cope.

It doesn’t matter whether you cope like everyone else. The important thing is that you find effective coping methods that will help you to thrive and build resilience.

Below, you’ll find Blake Flannery’s master list of coping methods and skills organized into categories (2016). No matter what you need in a given moment, there is probably at least one activity listed below that will help.

• Write, draw, paint, photography;
• Play an instrument, sing, dance, act;
• Take a shower or a bath;
• Take a walk, or go for a drive;
• Watch television or a movie;
• Watch cute kitten videos on YouTube;
• Play a game;
• Go shopping;
• Clean or organize your environment;
• Take a break or vacation.

Social/Interpersonal Coping

• Talk to someone you trust;
• Set boundaries and say “no”;
• Write a note to someone you care about;
• Be assertive;
• Spend time with friends and/or family;
• Serve someone in need;
• Care for or play with a pet;
• Role-play challenging situations with others;
• Encourage others.

Cognitive Coping

• Make a gratitude list ;
• Brainstorm solutions;
• Lower your expectations of the situation;
• Keep an inspirational quote with you;
• Be flexible;
• Write a list of goals;
• Take a class;
• Act opposite of negative feelings;
• Write a list of pros and cons for decisions;
• Reward or pamper yourself when successful;
• Write a list of strengths;
• Accept a challenge with a positive attitude.

Tension Releasers

• Exercise or play sports;
• Engage in catharsis (yelling in the bathroom, punching a punching bag);
• Get enough sleep;
• Eat healthy foods;
• Get into a good routine;
• Eat a little chocolate;
• Limit caffeine;
• Practice deep/slow breathing.
• Pray or meditate;
• Enjoy nature;
• Get involved in a worthy cause.

Limit-Setting

• Drop some involvement;
• Prioritize important tasks;
• Use assertive communication;
• Schedule time for yourself.

Suggestions from Mental Health Wellness Week

Good Coping Skills

• Practicing  meditation and relaxation techniques ;
• Having time to yourself;
• Engaging in physical activity or exercise;
• Spending time with friends;
• Finding humor;
• Spending time on your hobbies;
• Engaging in spirituality ;
• Spending quality time with your pets;
• Getting a good night’s sleep;
• Eating healthy.

Negative Coping Skills

• Using drugs;
• Drinking alcohol excessively;
• Engaging in self-mutilation;
• Ignoring or bottling up feelings;
• Taking sedatives;
• Taking stimulants;
• Working too much;
• Avoiding your problems;
• Being in denial.

10 Ways to Build Resilience

Aside from using the positive coping methods, the Mental Health Wellness Week website also suggests ten tips you can put to use to strengthen your mental state and build resilience to life’s stressors:

• Build up your confidence ;
• Accept compliments when they are given to you;
• Make time for your loved ones;
• Give support to others when needed and accept support from others when needed;
• Create and stick to a realistic budget;
• Volunteer in your community;
• Find ways to manage your stress on a regular basis;
• Share your burdens with others, especially those who have been through the same things;
• Identify and address your shifting moods;
• Learn how to be at peace with yourself.

It takes some work to follow these tips, but they are sure to provide you with the strength and resilience you need to navigate difficult times in your life (Mental Health Wellness Week).

If you’re still looking for more coping methods, see these suggestions  for positive coping methods from mental health organization Reach Out Australia.

To make it easier for you, we’ve selected some of our favorites and included them below.

Growing Stronger From Trauma

Bright and colorful, this Growing Stronger From Trauma worksheet is perfect for adolescents, teens, and adults who have undergone trauma in their past. It helps the user cope with traumatic experiences by focusing on the person’s strengths.

The worksheet starts by asking the person to list five strengths he or she had before the traumatic incident. Then, the person is instructed to name strengths that helped him or her deal with the traumatic experience.

The worksheet also has the person list strengths he or she gained because of the traumatic experience, and also write about how he or she feels about those new strengths.

This worksheet can help people see the silver lining of a traumatic experience, and help them recognize the strengths that allowed them to cope with that trauma.

Emotion Masks

This worksheet encourages you to think about the ways in which you manage your feelings in front of other people. It explains that we all “wear masks” at times in order to hide our true feelings from others.

It presents some examples of imaginary masks, like acting fine when you don’t feel fine or acting angry when you really feel hurt.

Now, the creative part: At the end of the worksheet, there is space to draw the mask or masks you frequently use to hide your feelings.

This worksheet can be helpful for older kids and for adults since we all wear masks sometimes. Put your creativity and imagination to use, and think of all the times you put on a “mask” to hide how you feel.

Download the Emotion Masks worksheet and give it a try.

Coping Skills Inventory

This colorful worksheet helps you to categorize the different coping mechanisms you find most helpful. The categories include:

• Distraction;
• Emotional Release;
• Thought Challenge;
• Access to Your Higher Self.

In the Challenging Thoughts section, you can list the ways that you can effectively challenge the negative and unhelpful thoughts that arise. Replacing these with positive and realistic thoughts can be a great coping tool.

The Releasing Emotions category includes actions that help you vent, express your feelings, and move on, like screaming into a pillow or punching a punching bag.

The Practicing Self-Love section is where you can write down how you practice self-compassion and show yourself appreciation, like treating yourself to a massage or writing down good things about yourself.

In the Distracting section, you can write down the skills and techniques that are most helpful for distracting you from negative and/or irrational thoughts.

The section on Tapping Into Your Best Self is for listing the things you do that help you access your ‘higher self’. For example, this may be volunteering for others or extending compassion to everyone around you.

In the grounding section, you will list the ways that you can ground yourself in the present and keep your mind focused on what is happening around you. Mindfulness techniques are perfect grounding exercises.

If you aren’t great at the skills in any of these categories, that’s okay! Just write down why you struggle with it and what you plan to do to improve your skills.

Click to see the Coping Skills Inventory worksheet.

Coping with Stress Worksheets

You’ll find two handy activities in this Coping With Stress exercise.

Part 1 instructs you to list the physiological signs and symptoms of stress, brainstorm some common responses to stress, and rate your levels of stress with each event or situation that can act as a trigger. This worksheet is a great way to begin dealing with your stress.

Part 2 will help you to brainstorm new and healthier ways to cope with your stress. It first instructs you to identify the ways in which you can and cannot control the situations that trigger you. Then, you brainstorm ways to cope with a triggering situation in the moment. Finally, you brainstorm ways to cope with the situation that reduce or eliminate your stress.

These worksheets will help you come up with a solid and thought-out plan for dealing with stress and overcoming urges to cope in unhealthy ways.

Decatastrophizing

This is a great worksheet for anyone suffering from panic or anxiety . The worksheet instructs you to imagine the worst possible outcomes, and how you’d cope if those outcomes came true.

The worksheet first instructs you to list the catastrophe you are afraid of and rate how bad you think it will be on a scale from 0 to 100. You’ll then consider the actual likelihood of that event, how awful it would be if it happened, and how you’d cope.

In the last section, you have space to list the positive and reassuring things you want to say to yourself about the catastrophe. Finally, you once again rate how bad you think the catastrophe would be.

Simply thinking through the likelihood and possible outcomes of a catastrophe you are fixated on can help you to decrease your anxiety about the potential situation.

Click here if you’d like to give this worksheet a try.

If you’re still hungry for more coping worksheets, check out our Cognitive Distortions article, which is packed with tons of resources to help you cope with any problem you may be experiencing.

Children may not have the same stressors as adults, but their problems are just as difficult to face as the problems of their elders.

This website is an excellent resource for learning about kids and coping. It emphasizes that good coping skills must be learned because no one is born with all the coping skills they need.

Coping skills can be learned through three main avenues:

• By observing others, including parents and other family members, friends and classmates, teachers and other adults in the learning environment, and from entertainment;
• Through trial and error—we all need to learn what methods work best for us, and that can only be accomplished by testing different methods and reflecting on the results;
• Through education programs, especially those geared toward teens and preteens; starting early can have a huge impact on coping skills later in life.

We can’t use the first two learning methods in this article, but we can make suggestions for educational worksheets and tools. Some of the best coping worksheets for kids are listed below. All of these worksheets can be found at this website .

Coping Worksheets for Young Children (Under 10)

To help children identify and work through difficult feelings, it can help to engage them in a fun activity, like the ones described in these worksheets.

My Feelings, My Body

This worksheet is simple—it’s just an outline of a body, along with instructions for putting it to use.

There are many ways to use this worksheet, such as having your child:

• Draw what different emotions look like
• Draw a diary of their school day, or
• Splitting the outline in half with a vertical line to compare the good and bad things they have heard, seen, or done recently.

There are also suggestions for what to focus on in each part of the body outline.

For example, children can write worries, hopes, ideas, and fears in the head; instincts and urges in the stomach; and spoken words from the past, present, and future in the mouth.

My Feelings, My Body  presents the opportunity to talk through whatever your child draws.

Even if it doesn’t make sense to you, let your child draw or write whatever comes to him or her and encourage a discussion about it afterward.

Deep Breathing For Kids

Breathing exercises are a great way to feel less stressed, anxious, and overwhelmed. The potential benefits are not exclusive to adults—kids can also get in on this practice.

This guided script includes basic steps to deep breathing that you can read aloud to your child very easily.

Those include:

• Sharing with your child how deep breathing can help when you’re angry or nervous
• Doing five deep breaths together, and
• Encouraging him or her to practice deep breathing regularly.

Deep Breathing For Kids is an easy, simple, and free coping method–a win for both parent and child.

Noodle Caboodle

Another exercise borrowed from mindfulness training ,  Noodle Caboodle is simply a child’s version of progressive muscle relaxation.

Like the deep breathing exercise, this worksheet has you to read the instructions aloud with your child, with both of you following along.

The worksheet has you explain that our bodies can get tight when we’re stressed and anxious, and has you compare a relaxed body to wet noodles. You’ll then walk your child through the process of scrunching and tightening parts of the body before relaxing into their noodle state.

The worksheet encourages you to tell your child that this exercise can help him or her relax and to encourage him or her to practice it regularly

Noodle Caboodle  is a great exercise to join in on with your child. If they’re having trouble understanding the steps, you can help model how to do them.

In a Nutshell

In a Nutshell  involves body relaxation as well as self-compassion by teaching children to do the “nutshell” a body position that promotes feelings of calm and safety.

To do the nutshell,

• Start out by standing with your feet slightly apart and your shoulders tall.
• Then, crouch down so that your bottom is down to your heels, and wrap your arms around your legs.
• Next, put your nose or chin on your knees, if it’s comfortable.
• Finally, give yourself a big, warm hug, and sustain that for however long it takes to feel safe and happy.

Parents or guardians can encourage their children to practice this exercise frequently in order to feel better.

Coping Worksheets for Older Children and Teens (10 and up)

With that in mind, you can try one of these worksheets that are geared toward more mature youth.

Bubbling Over

Bubbling Over uses the metaphor of a pot boiling over to explain feeling overly stressed, angry, or anxious.

There are three columns with illustrations of pots: one at a simmer, one at a rolling boil, and one bubbling over.

The worksheet lists goals that correspond to each boiling stage, and they correspond to the responsibilities of both the child and the adult when stress, anxiety, or anger take over.

The child is responsible for bringing their bubbling “pot” back to a simmer, and the adult’s responsibility is to aid them in their goal.

• The goal for the simmering pot is simply to keep it simmering.
• The goal for the pot at a rolling boil is to return it to a simmer.
• The goal for the bubbling over pot is also to return it to a simmer, but it may require some more drastic action to get there.

Children can use this worksheet by writing down some coping skills for each situation.

• For the simmering pot, children can write down coping methods that help them maintain their happy thoughts and good mood.
• Under the second pot, they should write down ways to cope when they’re feeling a little off or out of sorts.
• For the third pot, they must identify some of the most powerful coping skills at their disposal, especially ones that work fast, like deep breathing and sharing their feelings with an adult.

They also have an opportunity to tell the adults in their lives how to help when the pot is starting to boil.

For each situation, they can write down things that an adult can do to help maintain their happy mood, calm them down, or help them address some really bad moods.

This worksheet is a great way for kids to think about and plan ahead for stressful and difficult situations that will arise. It’s also a great way for them to let adults in on how they’re feeling and what they need when the going gets tough.

Complete this exercise with your children, and you will learn about how to help them when they need you most.

Visualization For Kids

This is another technique that is frequently used by adults to address stress, anxiety, or anger.

Employing imagery when you are feeling overwhelmed can be a great way to take you back to feeling calm and collected. With their vivid imaginations, kids are especially adept at using imagery.

This worksheet identifies two keys to effective imagery. The first is to utilize all five of your senses—the more sensory-rich the imagery is, the more effective it will be. The second is to breathe deeply and calmly throughout.

It also provides some ideas for how to use imagery.

One example is to imagine your favorite place and to focus all of your senses on that place in order to go there in your mind.

Another is to imagine your favorite person—someone that makes you feel safe, fictional characters you like, or a higher power (if you believe in one)—and to focus on what they look like, what they say, and what it feels like to be with them.

Imagery can be a powerful tool, especially in a particularly difficult moment. Encourage your child to put his or her imagination to good use.

Ups and Downs

Children that love making lists, thinking about pros and cons, or coming at problems with a well-thought-out plan will love this worksheet.

The Ups and Downs worksheet helps kids to think through a difficult decision by listing the ups and downs, or pros and cons, of each choice.

For each choice, the worksheet provides a space to write down the ups and downs of choosing each option and the ups and downs of not choosing each option.

It’s a simple worksheet, but it can be useful for guiding a child through a difficult decision.

Help your child complete this worksheet, making suggestions if needed, and you can be involved in practicing good decision-making.

Progressive Relaxation: Easy Basics

This is a slightly more mature version of the Noodle Caboodle exercise described above.

The worksheet teaches a technique called Progressive Muscle Relaxation, and it can be done anywhere and anytime your child feels overwhelmed with emotion.

The full steps can be seen here , but this is the outline:

• Sit or stand tall but comfortably, and close your eyes;
• Take three deep breaths through your nose;
• Start from your feet and work your way up to your head, totally relaxing all the muscles in each area;
• If you want to, you can take another relaxing sweep from your head back down to your feet.

The worksheet encourages the child to practice this regularly in times of stress, sadness, or anxiety.

Other Coping Skills

These are just a few of the coping skills kids can use to deal with stress, anxiety, anger, and other difficult emotions. For more ideas, see the following articles:

• 6 Scales to Measure Coping + The Brief Cope Inventory
• The Connor Davidson + Brief Resilience Scales (Incl. PDF)
• What is Coping Theory?

Given this reality, it is essential to learn the skills and tools we can use to combat the negative effects of mental illness.

There are several effective ways to cope with depression, many of them borrowed from cognitive behavioral therapy .

The three worksheets below should help you deal with the difficult feelings that come with depression.

Simple Thought Record

Sometimes, all we need to face our negative thoughts and feelings is to identify and confront them.

This worksheet is a good way to do that.

The worksheet consists of six columns:

• Date and time
• Situation (who, what, when, where);
• Automatic Thoughts (what was going through your mind, thoughts or images).
• Emotions (what you felt, how strongly you felt it);
• Alternative Thoughts (evidence that challenges or refutes Automatic Thoughts), and
• Outcome (the results of challenging the Automatic Thought)

In the first column, write down the date and time that an automatic negative thought came into your head.

In the Situation column, describe what happened to trigger a negative reaction.

Outline what Automatic Thoughts and images came to mind as you dealt with this negative reaction in the next column along. What popped up that was unwelcome or seemingly came out of nowhere?

In the fourth column, note the Emotions you were feeling and rate their intensity from 0 to 100.

In the next, Alternative Thoughts , try to come up with facts that challenge the credibility of that negative thought. What else might be true, instead?

Use the last column to re-assess the credibility of your Automatic Negative Thought once more. Have your feelings changed? Have some new possibilities emerged?

Simply identifying what is happening to us when we are stressed and upset is the first step toward successfully addressing the problem.

Challenging Negative Thoughts

Just in case you skipped ahead, the Getting Rid of ANTs, Identifying ANTs, and Positive Thought Replacement worksheets above offer different ways to deal with those pesky negative and irrational thoughts that can plague all of us.

When we are feeling depressed, it’s much more difficult to not buy into those thoughts.

In general, challenging Automatic Negative Thoughts – or ANTS – frequently involves answering some questions that can help you address them directly, including:

• Is there substantial evidence for my thought?
• Is there evidence contrary to my thought?
• Am I attempting to interpret this situation without all the evidence?
• What would a friend think about this situation?
• If I look at the situation positively, how is it different?
• Will this matter a year from now? How about five years from now?

Asking yourself these simple but profound questions can help you move from fretting to feeling better.

Gratitude Journal

Keeping a gratitude journal is more of a long-term maintenance method than a way to feel better immediately, but it’s a powerful tool nonetheless.

The exercise is simple: You just write down what you are grateful for.

Simply noticing the good things in your life is a great way to protect yourself against the negative. Acknowledging the positive can construct a buffer of “good” around you that makes it harder for the “bad” to get in.

This worksheet provides space to write a list about ten things one can be grateful for. We recommend filling out this worksheet twice a day and spending about 5 minutes on it each time.

Give this exercise a try, and encourage the flow of gratitude !

10 Coping skills when you’re feeling down – Kati Morton

Many people experience anxiety as a normal part of life and are able to combat it, but when it gets to be too much to deal with, there are many coping methods at our disposal.

Interoceptive Exposure

This Interoceptive Exposure worksheet provides several methods of Interoceptive Exposure . By exposing yourself to the bodily sensations that you experience when you’re anxious, you’ll become more comfortable with them and less likely to panic when they arise.

To simulate breathlessness, you can breathe through a straw for several minutes, or hold your breath for about 30 seconds.

To experience a racing heartbeat, you can run in place or run up and down steps.

To practice feeling lightheaded or dizzy, you can twirl around in a desk chair, twirl around while standing, or shake your head from side to side before looking straight ahead with open eyes. You can also put your head between your thighs and then sit up quickly, or lie down and relax for at least one minute before standing up quickly.

And to simulate feelings of unreality, you can stare at yourself in a mirror without blinking for two minutes, stare at a dot on a blank wall, or stare at a 60-Watt light for one minute before trying to read small print in a newspaper.

Once you try some of these exposures, record how you felt and what you were thinking during the activity. Next, rate your anxiety after completing the activity on a scale from 0 to 100.

The What If? Bias

With this worksheet, you will think of positive and negative outcomes that can result from different situations.

We often get bogged down with worrying about all the bad things that can happen, but this exercise can help balance out those negative thoughts. Think of it as coming up with a “glass half full” way to think about things as well as a “glass half empty” one.

The worksheet is simple, with only two columns:

• “What if” it’s Negative?
• “What if?” it’s Positive?

On each side, write down the possible outcomes of the same situation. For example, if you are nervous about giving a presentation, you might write “What if I freeze and can’t speak?” on the negative side, and “What if I do well?” or “What if I stumble, but laugh about it?” on the positive side.

This exercise can help you balance out the good and bad potential outcomes, and take on a more realistic outlook. Click here to give The What If Bias a try.

Bipolar Disorder

Bipolar disorder causes periods of depression as well as sudden, intense mood and energy swings. Many of the worksheets for coping with depression can help, but here are some that are especially helpful for those struggling with bipolar disorder.

Fighting Irrational Thoughts With Logic

This worksheet is another simple one, with only three columns:

• Irrational Thought
• Logical Response
• Fresh Thought

The goal of this technique is to challenge your negative and/or irrational thoughts and replace them with fresh, more positive, logical, and realistic thoughts.

First, you write down the irrational thought that is nagging at you, like “ Everyone hates me. ” Then, you write down a more reasoned response, perhaps something like “ There are billions of people in the world, and there’s no way they all hate me. ” Finally, you write down a fresh  thought to replace the negative one, such as “ Some people may not like me, but that’s okay because I like me. ”

To learn more about this technique and see an example worksheet, click here: Fighting Irrational Thoughts With Logic .

Coping: Stressors and Resources

Coping – Stressors and Resources  helps you to identify the sources of your stress and sadness. It also instructs you to list resources you can use to help you cope, some of the obstacles that hinder coping, and the strategies you can use to overcome the obstacles.

You can use this worksheet to create a master plan for combating stress that’s caused by any mental health issues, including depression, anger, anxiety, or irrational thinking.

The worksheet has four columns to work through.

The first column is split into three parts:

• Present sources of stress;
• Past sources; and
• Expected future problems and stressors.

Write down at least one problem or source of stress in each category.

The second column is where you can identify the resources that help you cope. These can be coping skills, exercises, and techniques that you have found to be helpful.

The third column is your space for thinking of the things that can get in the way of your coping, like strict deadlines at work, tensions in your personal relationships, etc.

The final column provides a space to write down how you can address these obstacles to effective coping, like planning ahead to increase the chances of meeting those deadlines or attending couples counseling to address the problems in your relationship.

Substance Abuse Recovery and Relapse Prevention Worksheets

Even though we all know that these negative effects are potential outcomes of substance abuse, addiction can make it extremely difficult to pull away.

These worksheets are intended to help you face this challenge head-on, although they aren’t a replacement for interacting with a qualified professional. Hopefully, they can be a useful complement to professional treatment.

Modes Influencing Recovery

This worksheet is a great way to start your journey toward wellness . It can be employed for just about any behavioral or mental health problem, including substance abuse and addiction. Of course, it should complement treatment from a qualified professional rather than standing on its own.

It lists the seven different modes or factors that influence recovery, provides space to write down the problems you have in these areas, and prompts you to decide what you need to quit doing, or reduce, and what you need to start doing or increase, to facilitate recovery.

The seven modes are:

• Feelings/affect (what you feel and what makes you feel this way);
• Behavior (actions, coping strategies, what you do or avoid doing);
• Cognition (thoughts, attitudes, beliefs, values, opinions, and thought patterns);
• Sensations (what you see, hear, taste, smell, touch, what makes you feel pain or tension, your sexuality);
• Physical Health (physical exercise, diet, sexual health, substance use).
• Social (communication with others, relationships); and
• Mental Imagery (the pictures in your mind, your self-image, fantasies);

Beside each mode, identify the problems you encounter. For example, if you are struggling with substance abuse, you might write “putting myself in dangerous situations” for the behavior modality, or “wanting to use when I get depressed” in the affect/emotions category.

For each modality, think of the problems you face and make a plan to stop or reduce the actions that do not facilitate your recovery and start or increase the actions that facilitate your recovery.

Download 3 Free Resilience Exercises (PDF)

These detailed, science-based exercises will equip you or your clients to recover from personal challenges and turn setbacks into opportunities for growth.

Download 3 Free Resilience Tools Pack (PDF)

By filling out your name and email address below.

Managing Cravings

This worksheet can be an extremely useful resource for identifying when and why your strongest cravings arise, which is the first step to learning how to effectively combat them.

In the first column, identify the situation in which a craving arose, including what happened, where you were when it occurred, and who you were with.

The second column is where you write down the mental processes that went through your mind when the craving hit, like “I’m weak and I’m useless, I might as well give in.”

The third column is for sensations, where you identify the emotions and physical sensations you felt when the craving hit. You might write something like “knot in my stomach, hopeless.”

The fourth column provides space to rate the intensity of your craving from 0 to 100.

The final column is the most important one. This is where you brainstorm an alternative, more balanced thought, and coping response. For example, you might write something like, “I overreacted to the situation. It was only a small issue. Next time I can practice deep breathing to work through it.”

Managing Cravings can help you realize when you tend to be most vulnerable to cravings and gives you a chance to put together a plan of action for when the next craving hits.

Preventing Relapse

This worksheet can be an excellent resource for outlining a plan for remaining sober.

The first part provides space for you to list coping strategies that can help you resist the temptation to use again. The second instructs you to list three people that can provide you with the social support you need when you are most vulnerable.

The third section encourages you to think about the consequences of your actions. On one side, you write down the potential outcomes of relapsing. On the other, you list the potential outcomes of staying sober. This is a simple but powerful way to compare your two possible futures and to help you see which one is more appealing.

The final section contains tips to help you avoid relapse, like distracting yourself from cravings and avoiding situations that will put you at risk of relapsing.

Click to download this Preventing Relapse worksheet.

For more information on coping with substance abuse and addiction, check out these articles, websites, and worksheets:

• Substance Abuse Client Workbook
• Oxford Clinical Psychology

17 Tools To Build Resilience and Coping Skills

Empower others with the skills to manage and learn from inevitable life challenges using these 17 Resilience & Coping Exercises [PDF] , so you can increase their ability to thrive.

Created by Experts. 100% Science-based.

We hope you walk away from this article knowing that there are hundreds of positive ways to cope when facing challenging or demotivating situations. Reading this article may have taught you a few new ways to cope, or you may have realized that some of the ways you cope are not healthy or constructive. If so, don’t be too hard on yourself—we all have a few unhealthy coping mechanisms.

No matter what you’re going through, there’s no shortage of ways to cope. Try some of these methods and add the ones you like to your proverbial toolbox—that way, you can use them when you need them most.

What are your favorite coping strategies? How do you make sure those coping skills are healthy? Let us know your thoughts in the comments below.

We hope you enjoyed reading this article. Don’t forget to download our three Resilience Exercises for free .

• Coping Skills for Kids: Brain Works Project (n.d.). Retrieved from www.copingskills4kids.net
• Flannery, B. (2016, December 18). A list of coping skills for anger, anxiety, and depression. Retrieved from https://healdove.com/mental-health/Coping-Strategies-Skills-List-Positive-Negative-Anger-Anxiety-Depression-Copers
• Getselfhelp.co.uk (n.d.). Retrieved from https://www.get.gg/
• Mental Health Wellness Week (n.d.) Retrieved October 2017 from www.mhww.org
• Plum Tree: Child & Adolescent Psychology (n.d.). Retrieved from https://theplumtree.net/
• Psychology Tools (n.d.) Retrieved from https://www.psychologytools.com/
• ReachOut.com (n.d.). Retrieved from https://au.reachout.com/
• Schuder, K. (n.d.). Coping skills worksheets for adults. Retrieved from http://stress.lovetoknow.com/stress-management-techniques/coping-skills-worksheets-adults
• Therapist Aid (n.d.). Retrieved from https://www.therapistaid.com/
• Unstress Yourself (n.d.). Retrieved from www.unstressyourself.com/

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Article feedback

What our readers think.

It is very useful, thank you.. Can you explain with examples, how coping mechanisms are used by humans in the real world.. Thank you

So glad you found this useful. One example of using coping skills in the real world might be an employee who is growing anxious about a challenging task but then takes ten minutes to go for a walk to help calm their negative emotions and allow their mind to detach from the problem for a little while.

Another example would be if a person was experiencing intense distress over the loss of someone they loved, and took some time off to lean on the support of family.

These forms of ‘taking care of oneself’ and using the resources available to you during difficult circumstances are both examples of positive coping.

Let me know if this helps 🙂

– Nicole | Community Manager

This is some really good info. I am the recovery counselor at 2 facilities, one male and one female. I would love to be able to download a couple of the worksheets you mention. I do not see any links for the worksheets?

Thank you for caring,

You’re very welcome — we’re so glad you’re finding these resources useful. If you look at the subsection with the worksheet you are interested in, you’ll find that some of the body text (usually the name of the worksheet) is hyperlinked and in bold. If you click this, it will take you to the worksheet.

However, if you find that a particular link isn’t working, please let us know so we can correct it.

Hope this helps!

Courtney, I am looking for a blank copy of the “My personal coping skills list” activity. Thank you

Thanks so much,it’s really benefit for me, i can avoid negative thougths!.

Thank you so much this is a great resource and some fantasic hints, tips and brilliant exercises.

Enjoyed examining this, very good stuff, regards.

Thanks a lot madam your given a wonderful worksheet and that it is gives a lot of benefit to me. A.Yashoda (Research scholar)

Hi, Just curious to know as to what theory or evidence based practice that is behind the ‘Boiling Pans’ worksheet. I really enjoyed that worksheet activity but was curious as to how I can explain it. Thank you

Dear Courtney Very helpful suggestions and doable too !! But again I feel we need to connect through a chat room or else a live discussion forum I am based out of India and I find a great paucity of online forums on this subject in my country Could you guide me to an interactive forum which is truly helpful and the country of residence is not an issue ? Would be truly grateful

These are great ideas and wonderful resources. Unfortunately when I printed this webpage with Google Chrome, some of the information was cut off at the top by the “sharing is caring” tweet frame on every single page. I know this is not your problem, but it’s really annoying. Perhaps there is some way to offer a tweet without it disrupting the actual content.

Let us know your thoughts Cancel reply

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Promoting Resilience Interventions for Mental Well-being in Youth

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What to Talk About in Therapy? 22 Topics to Consider

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Mental health is an important aspect of everyday life. Back in the day, it was not promoted as something important.

Many people overlook their mental health and emotional well-being as a result, including those with mental disorders who need treatment.

The unwillingness came from the social stigma associated with mental illness . You risk getting criticized or called insane if you dare mention seeing a therapist or mental health counselor.

Fortunately, things have changed tremendously . More people are open to psychotherapy and appreciate the value of talking with a therapist.

Once you’ve decided to explore psychotherapy, the next thing is to identify what to talk about in therapy. Getting a clear idea of your mental health needs is a good starting point. This can serve as a guide to deciding what to discuss with a licensed therapist.

Before scheduling an appointment, take a few minutes to learn what is therapy, the types of therapists to choose from, and the benefits of therapy. Next, we’ll run through a list of therapy topics to consider and  matters to address during your therapy sessions.

Table of Contents

What Is Therapy?

Psychotherapy, also called therapy, talk therapy, or counseling, is a type of mental health treatment. It primarily involves discussing and addressing mental and emotional health concerns with a licensed therapist.

The therapist is trained to set up a treatment plan to help meet the patient’s individual needs. The overall goal of therapy is to provide patients with coping skills to make behavioral changes.

The changes can help them to overcome certain mental health challenges.

As a patient, you can meet for one-on-one or  group sessions  with your therapist. Although therapy is an alternative to medication, some doctors may recommend it alongside medical treatments.

What are the Benefits of Therapy?

Therapists are required to follow evidence-based therapies and guidelines to match the needs of patients. Each patient’s experience and result are unique. Regardless of your specific diagnosis,  therapy can help in the following ways:

• Help you discover unhealthy behavior patterns
• Give you an opportunity to talk about your thoughts, feelings, and experiences in a non-judgmental setting
• Provide tools for shifting to a positive or  growth mindset
• Learn healthy communication skills for resolving conflict
• Improve family and romantic relationships
• Develop skills to cope with everyday challenges and mental health conditions
• Cope with and heal from emotional and childhood trauma
• Assist you in overcoming fear, shame, or guilt linked to various negative life events
• Live  healthier, happier,  and more motivated
• Improve physical health

Types of Therapists and Techniques

Psychiatrists, psychologists, psychotherapists, and mental health counselors play fundamental roles in the area of mental health. They are trained and certified to evaluate clients and provide the  appropriate treatment or therap y.

Some mental health professionals are authorized to prescribe medication alongside  evidence-based therapies .

The appropriate mental health professional and treatment techniques will depend on your needs.  Below are the top in-demand therapists who can provide coping strategies:

• Marriage and Family Therapists
• Behavioral Therapists
• Trauma Therapist
• Grief and Loss Therapist
• Motivational therapist
• Sex Therapist
• Attachment Therapist

Common Psychotherapy Techniques

A  variety of treatment techniques  are available to assist patients in overcoming their difficulties. Depending on your needs, your therapist may recommend the following techniques after diagnosing your symptoms:

• Family therapy  for improving communication and resolving conflicts
• Cognitive Behavioral Therapy (CBT)  for changing core beliefs that create personal challenges
• Motivational Enhancement Therapy (MET)  for increasing the patient’s willingness to change their behavior
• Breathing and relaxation techniques  for anxiety and phobias
• Mindfulness techniques  to combat stress, worry, anxiety, and negative thoughts
• Exposure Therapy  for confronting fear and other symptoms related to phobias
• Eye Movement Desensitization And Reprocessing Therapy (EMDR) : Used mainly for treating PTSD symptoms
• Psychodynamic Psychotherapy  for coping mainly with social anxiety and depression
• Grief and Loss Therapy  for assisting individuals in overcoming death or loss of a loved one or pet

Common Reasons for Seeing a Therapist

A general physician usually recommends seeing a therapist after evaluating your symptoms at your checkup. Referrals are typically provided for the following  common complaints, symptoms, and disorders :

• Severe or chronic stress
• Self-defeating thoughts
• Substance abuse
• Eating disorders
• Traumatic events, e.g., the death of a loved one and childhood abuse
• Insomniaor trouble sleeping for a prolonged period
• Anxiety disorder symptoms, e.g., strong feelings of fear, dread, or panic
• Depressionsymptoms, e.g., loss of interest in everyday activities
• Behavioral disorders, e.g., attention-deficit hyperactivity disorder (ADHD), bipolar disorder, and borderline personality disorder (BPD)
• Suicidal thoughtsor ideations

22 Ideas on What to Talk About in Therapy

The main goal of therapy is to teach you skills to cope with common life problems. These include behavior issues, traumatic events, sexuality, and mental health disorders. Your therapist will engage you based on your diagnosed mental health needs.

Even though you’re seeking treatment for one aspect of your mental health, you may have unrelated concerns.

They won’t know what you’re going through unless you provide information and ask questions for clarity. Some therapists give prompts, while others may wait for you to broach a subject matter or ask questions.

Therapy is done in a non-judgmental setting, so there’s no “wrong” or “stupid” question. Your therapist is here to  listen and help you make sense of your experiences, thoughts feelings, and behavio r.

They also provide guidance and strategies on how to cope and help you accomplish the overall treatment goals.

Below is a list of things you can bring up before you start therapy or before your next session. You can zoom in on the ones that apply to your circumstances.

Childhood Trauma

Unresolved childhood trauma happens when the brain suppresses overwhelming or traumatic events as a child. The brain does this to protect you from emotional pain you’re too young to handle.

The trauma may lead to emotional detachment and trouble regulating emotions. A trauma therapist can provide an environment for you to discuss the following traumatic childhood events.

1. Parental neglect or abandonment

Neglect or partial abandonment by a parent occurs when a child does not get their physical and emotional needs met. In some cases, the parent leaves the home leading to total child abandonment.

Not only is this devastating for you as a child, you’re only able to make sense of it as an adult.

Try opening up to your therapist about strong trust or  abandonment issues , social avoidance, anxiety, and low self-esteem. These symptoms are related to neglect and abandonment.

2. Childhood abuse

Abuse in childhood can happen by witnessing violence in the home. Being subject to physical or sexual assault is also abuse in childhood. Victims do not easily open up about their experiences out of  fear, shame, and guilt .

The therapy environment is a safe haven for you to freely discuss these traumatic childhood experiences.

3.   Parental death

The death of a parent in your childhood is similar to parental abandonment. The devastation of the loss leads to severe emotional trauma that goes on into adulthood.

The trauma often leads to mental health disorders, e.g., anxiety, mood disorders, substance abuse, or low-life success. Your therapist can help determine if your symptoms have to do with the trauma of parental loss.

Relationships and Family

A licensed Marriage & Family Therapist, LMFT, works with  couples and families  to help them work through relationships, marriage, or family challenges. Therapy is geared toward helping clients build happy healthy relationships.

4.   Blended family

Two families coming together to live under the same roof is considered a major life event. Usually, this happens after marriage. Parents and children can find it stressful and difficult to deal with the changes.

Different  parenting styles  are a common source of conflict in blended families. Discussing the life transition openly and expressing your feelings is a healthy way to cope.

5. Generational patterns

Mental health conditions and behavioral patterns can pass from one generation to the next through genetics. Consider informing your therapist about patterns such as addiction, domestic violence, depression, or suicide.

Together, you can discuss the signs you may be at risk and ways to break the pattern.

6. Attachment styles

Some therapists specialize in attachment styles therapy. They can help if you express your struggles in building healthy relationships. Attachment therapy helps you trace back to childhood experiences that caused you to develop  insecure attachment styles .

During your sessions, you can explore ways to create healthy and a secure attachment style. A secure attachment style is  essential for building meaningful relationships.

7. Boundaries

Establishing healthy boundaries is an area many of us struggle with. However, setting up  healthy boundaries protects you  from behavior by others that can impact your mental health. Let your therapist know about your difficulties in this area.

They’ll help you understand how personality traits, such as being empathic or a people-pleaser, can cause others to use you. They can also provide the right tools and approach for building healthy boundaries.

8. Emotional abuse

You may have to deal with a  narcissistic  or other type of controlling individual who treats you in an emotionally abusive way. This can be at home, work, or in a romantic relationship. Explain what is happening to your therapist.

They can assess your symptoms to determine if  emotional abuse  is taking a toll on your emotional health.

Everyday Issues

These are things a cognitive, behavioral, or motivational therapist can help with. Motivational therapists help patients  find motivation from within themselves  to make positive behavior changes.

Consider whether you’re  “what to talk about in therapy”  list should include any of the following concerns.

9. Anger problems

Do you have  uncontrollable anger  that gets in the way of job and relationship success? Your therapist may not know this simply by looking at you.

Inform them of your anger tendency and struggles to manage it. Some behavioral therapists are trained to provide anger management skills to their clients.

10. Problems at work

The way your  narcissistic boss  or co-workers behave towards you can turn your workplace into a hostile environment. You may experience anxiety or depression or think of quitting.

Discuss your workplace dynamics to see if your therapist can assist you in navigating those challenges.

11. Emotional triggers

Have you noticed your reactions in certain settings often go overboard but can’t explain why? For example, triggers like noise, certain smells, or even a baby crying can cause you to feel overwhelmed, angry, sad, or anxious.

Your therapist can help you explore what triggers reactions that are  not proportionate to the situation . Additionally, they can provide tools to help you manage those triggers.

12. Low self-esteem

Low self-esteem can arise in adults who did not receive the essential love and care needed in childhood. Explore feelings of unworthiness,  negative self-image , poor boundaries, or sensitivity to criticism with your therapist.

They may ask you about other symptoms, such as difficulty asking for help and people-pleasing. Based on your responses, they can tell if you may benefit from therapy for  low self-esteem .

13. Frequent drinking or drug use

Therapy can be helpful before problems get out of control or become a disorder. Raising the issue in therapy can save you from substance abuse, dependency, or addiction. A therapist can stage what’s called a  “brief intervention.”  

Intervention can involve helping you to  understand the consequences of substance use . Other strategies include encouraging you to try nonuse to quit on your own or attending a  twelve-step program .

14. Negative thought patterns

Changing thinking patterns can help relieve issues such as  rumination  and catastrophizing. These unhelpful thinking patterns may be an underlying reason for anxiety and depression.

A cognitive behavioral therapist can use the  cognitive restructuring technique  designed to help patients replace negative thoughts with positive ones.

15. Sexual orientation

Too many people continue to struggle with their sexual orientation despite widespread societal acceptance of LBGTQA++. If you struggle with shame or low self-esteem, you can discuss your feelings with your therapist.

You may have difficulty informing loved ones about your sexual orientation due to strong fears of rejection or condemnation. Ask your therapist if they can provide tools to  build confidence and cope with potential negative feedback.

Mental Health Disorders or Conditions

19.86% of adults were living with a mental illness  in 2022, according to research data provided by  Mental Health America .

Anxiety disorders are the most prevalent followed by major depressive disorder, PTSD, bipolar disorder, and borderline personality disorder, in that order.

Untreated mental illness is problematic because it is often the cause of missed work or school, substance abuse, and relationship conflicts.

In short, the symptoms can affect your overall quality of life on a long-term basis if you fail to receive the treatment needed.

16. Anxiety symptoms

People develop chronic anxiety due to long-term fears about various things. Common sources of anxiety are socializing, memories of traumatic events, sickness, death, and uncertainties about the future.

Discussing what triggers fear, worry, or nervousness brings it to your awareness. From there, your therapist can decide what  anxiety disorder treatment  may work for you.

17. Depression symptoms

Ongoing depressive symptoms or major depressive disorder (MDD) often interfere with daily functioning. Work and academic performance may decline. Relationships in the home or with your partner can be affected. 

Don’t be afraid to let your therapist know what’s happening in your inner world.  They are there to assist you in managing the symptoms or refer you to a professional who specializes in depression psychotherapy.

18. Borderline personality disorder (BPD)

An individual may suspect they suffer from BPD based on their dysfunctional behavior. However, they are afraid to tell anyone out of fear of being called ‘crazy’.

This is something you can share with your therapist without fear of judgment.

They are trained to evaluate the symptoms of mental health disorders and provide behavioral therapy.  Dialectical behavioral therapy (DBT)  is a specialized treatment for BPD.

19. PTSD symptoms

Those who experienced or witnessed a traumatic event such as an accident, death of a loved one, or war, may develop PTSD: Posttraumatic stress disorder (PTSD) is a psychiatric disorder.

Ask your doctor why you have intense and disturbing thoughts, flashbacks, or nightmares about the past  emotional trauma  months or years later. These are all common symptoms of PTSD.

Grief and Loss

Grief counseling is a type of therapy designed to help patients cope with negative emotions in various stages of recovering from a loss. This type of therapy can work for grief related to death and divorce.

20. Stages of grief

Grief is a set of complex emotions and feelings experienced after the death or loss of a loved human or pet.

These emotions, such as intense anger, guilt, sadness, numbness, and denial, are considered natural responses. You may wish to learn more about the stages a bereaved person goes through.

Perhaps, you’re confused as to why you swing back and forth to the  different stages . Your therapist can explain why and provide reassurance that grief normally comes to an end.

21. Long-term grief

The  average timeline  for acute grief to resolve is  six months to one year . You may wish to find out why you still feel devastated after more than a year. Getting stuck in the stages of grief for longer than 12 months is considered complicated grief.

Your therapist can shed light on how  accepting the loss  is a powerful method to alleviate persistent grief symptoms.

22. Divorce loss and grief

Relationship breakups and divorce cause grief symptoms similar to when a loved one passes away. The grief stages are also similar. While grief is a natural reaction, taking longer than normal to recover can interfere with everyday life.

A therapist can provide the tools to cope with the symptoms of grief as well as setbacks related to the divorce process. The ultimate treatment goal is to help you come to terms with the loss and see that there’s a bright and  happy future  after divorce.

Final Thoughts on What to Talk About in Therapy

The idea of going to therapy can be scary, especially if it’s your first time, and you don’t know what to expect.

Don’t worry, you’ll be meeting with professionals trained to engage you with compassion and empathy. They are  equipped with the knowledge and tools to help you cope  with and manage your challenges.

All there is to do now is to work up the courage to ask questions, raise topics, and express yourself. The  success of therapy depends mostly on your mindset .

Being open to doing the work to facilitate the behavioral changes and life transitions you seek can lead to a successful outcome

If you’re in search of a therapist, look online for the type of therapist near you using your zip code.

Here’s a link to resources to  locate a therapist  in your area. With Telehealth making virtual therapy sessions possible, you may not need to physically go to your therapist’s office.

Many patients find it easier to decide what to talk about in therapy because they feel more comfortable doing virtual sessions. Before you go, be sure to learn the difference between  Psychologist VS Psychiatrist: How to Choose between Each Option .

And if you want more articles about mental health, be sure to read the following articles:

• 9 Common Signs Someone Has a Porn Addiction
• 11 Signs of Bad Parenting That Negatively Impact Your Kids
• 9 Tips to Avoid the News to Reduce Your Life Stress

Finally, if you want to identify YOUR personality type, then take one of these 11 personality tests to better understand what makes you tick .