STRESS AND COPING

Stress and coping with stress have been among the most popular research topics in the social and behavioral sciences over the past twenty years. Despite a long history and a substantial amount of literature on stress and coping, less attention has been paid to stress and coping processes among older adults than in younger persons. This is unfortunate because research on stress and coping in later life can not only improve our understanding of human development and adaptation, but also serve as a basis for interventions and social policies to enhance well-being in later life.

Research suggests that exposure to high levels of stress leads to increased vulnerability to physical and psychological problems in older adults. Highly stressed individuals are more likely to have various health problems, including diminished immune functioning, greater risk of infectious illness, psychological distress such as depressive symptoms, and even increased mortality. However, stress does not produce universally negative outcomes; because of individual differences in coping, some individuals report minimal ill effects from stress or even demonstrate personal benefits from stress. Thus, the study of stress requires attention not only to environmental stressors, but also to factors that may increase vulnerability or provide protection against the ill effects of stress.

There are various models of stress and coping, and different types of stressors and coping resources have been found to affect well-being in older adults. Common and important sources of stress in late life include health problems, family caregiving, and bereavement. There are, however, methodological and conceptual controversies that are particularly important in the field.

The stress process paradigm

A widely cited definition of the term stress describes it as a ‘‘particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering well-being’’ (Lazarus and Folkman, p. 19). Fundamental to this definition is the inclusion not only of stressors, or environmental demands, but also the individual’s appraisals and coping resources. Thus stress is much more than objective negative events that buffet an individual; a person’s reactions and subjective interpretations of potential stressors determine whether an environmental demand is even viewed as a stress, or leads to negative effects. Also of note in this definition is the idea that the stressfulness of a stimulus is related to levels of resources; individuals with strong coping skills, adaptive personality traits, strong social supports, and plentiful financial resources are likely to fare well when facing environmental demands. Although there are some variations in the specific content of stress process models, fundamental variables in the stress process can be generally summarized as stressors, appraisals, internal and external resources, coping responses, and the manifestations or outcomes of stress.

Types of stressors

Stressors refer to hardships, challenges, threats, and other circumstances that have the potential to adversely affect well-being. Stressors are broadly categorized into two types: life events and chronic strains. Life events are discrete stressors that have a relatively clear onset, an example being the death of a spouse. In contrast, chronic strains are continuing and enduring problems or threats, such as chronic disease and disability, or caregiving for a disabled family member. These two types of stressors are viewed by researchers as important risk factors that can threaten physical and psychological well-being. Some researchers have focused on the stressfulness of daily hassles—relatively minor daily events such as arguments or inconveniences. While life events, chronic strains, and daily hassles are conceptually distinct, in reality their effects may be difficult to disentangle. For example, the death of a spouse may follow years of caregiving strain; it may coexist with a chronic health problem; and it may lead to a variety of daily hassles, such as managing financial matters or the complexities of Medicare reimbursement.

Contrary to the widespread belief that old age is a highly stressful period of life, it has been found that older persons generally have a reduction in many kinds of stressful experiences, including family conflict and job stress. However, older adults are more likely to encounter some stressful situations, including health deterioration, reduced income, and the death of friends or a spouse. Some theorists believe that even though older adults experience fewer negative life events, once they occur, their adverse impacts are greater because aging may lead to declines in some coping resources. However, it is important not to assume that older persons are highly vulnerable. Many studies have found that common stressors in old age (such as health problems and the death of a spouse) may be stressful but are expected and normative experiences in late life, and that these events have less of an impact in older adults because older people are psychologically prepared to cope with them. Presumed stressors such as retirement are often found to have no ill effects among healthy persons retiring voluntarily.

Studies assessing exposure to stressful life events using checklists of life events have been utilized with older adults with mixed success. While greater numbers of negative life events have been found in a number of studies to predict depression in older adults, results have not been consistent and the magnitude of the life events–depression relationship is generally small. Because these instruments generally require individuals to report on events that have occurred in the past (such as the previous six months or year), retrospective reporting biases can occur. In addition, life events scales can confound stressors with outcomes. For example, life events such as family problems may be a result and not a cause of depression, and health problems may be included both as stressors and dependent variables. Special concerns have been raised about the use of life-events questionnaires in studies of older adults. Scales initially designed for younger adults include inappropriate items and exclude common events faced by older persons. The Louisville Older Persons Events Scale (LOPES) is an exception in that it was specifically designed for older adults on the basis of extensive pretesting with older populations.

Another tactic in studying the impact of life events is to identify individuals who have faced a particular type of life event, such as retirement, natural disasters, or the death of a spouse, and then to assess the impact of this particular event on well-being. Cross-sectional studies may compare individuals who have experienced a life event (such as the death of a spouse), with controls who have not experienced the event. Prospective longitudinal projects have assessed large populations at an initial point in time (perhaps with a life-events checklist), and then identified individuals who subsequently experience onset of a major life event, allowing for a prospective study of the consequences of a stressor. This strategy avoids the problems faced when assessing life events via checklists, but requires large samples and longitudinal research projects. Research utilizing prospective methods has demonstrated that stressors, including the trauma of a major flood, and spousal bereavement, increase the risk of depression in older adults.

Compared to the voluminous literature on life events, chronic strains have been understudied. Chronic strains are the enduring problems, conflicts, and threats that people face in their daily lives. The extended duration of chronic strains may deplete an individual’s resources and eventually have adverse physical and psychological effects. A number of different chronic strains have been identified that are both common in older adults and are risk factors for declining mental and/or physical health. These include chronic health problems, physical disability, and family caregiving for relatives with dementia. Chronic strains have been consistently shown to be risk factors for depression in older adults.

There has been considerable debate on whether life events or chronic strains are greater risks to well-being. However, studies have consistently shown that chronic strains have a greater negative impact than life events. Chronic strains are continuing and unresolved demands, and they therefore have more power to undermine equilibrium.

Regarding the interaction of life events and chronic strains, some researchers have suggested that chronic strains have the power to amplify the impact of life events. For example, individuals with chronic illness may be more susceptible to the effects of other stressful events. A combination of chronic strains and life events may therefore cause more adverse outcomes. In contrast, other researchers suggest that experience with chronic strains might actually mute the impact of minor stressful events, because those minor stressful events pale in comparison to the more chronic stressors. In sum, chronic strains and discrete life events may shade into one another and interact in a variety of ways, and both should be taken into consideration in models of the stress and coping process.

Individual differences in coping with stress

Both clinical experience and the results of research demonstrate that older adults vary considerably in the impact that stress has upon well-being. Stress-process models have identified a number of factors that may decrease the negative impacts of stressors, including appraisals, internal and external resources, and coping responses. These may be thought of as factors that can protect a person from the negative consequences of stress. From the perspective of a stress-process model, the experience of stress may be seen as a ‘‘balancing act’’ between stressors and resources. High levels of stressors, with few resources, will place individuals at high risk, while individuals with substantial psychological or social resources may be less vulnerable.

Depending on the mechanism through which variables affect the relationship between stressors and well-being, these responses and resources may have direct effects, or they may serve as either mediators or moderators of the relationship between stressors and well-being. In a direct effect, people with a high level of a resource (such as income) may be found to have higher well-being regardless of whether highly stressful circumstances occur. A moderator variable, on the other hand, may confer either risk or protection only on individuals facing a high level of stress. For example, research on the stress-buffering hypothesis suggests that under circumstances of high stress, individuals with strong social support may be at lower risk for depression than individuals with weaker social support, but that social support may matter little under conditions of low stress. In other words, the moderator model tests the significance of interactions among independent variables in predicting outcome. A mediator functions as an intermediate factor between stress and well-being; for example, research may find that a life event only affects depression if is subsequently appraised as a threat to well-being. Identification of these mechanisms of vulnerability and resistance to stress may be very useful in targeting interventions that may be helpful when a life event occurs.

Early writers who addressed coping in older persons tended to view older adults as unable to cope with stress, and they suggested that coping in late life was characterized by rigidity in coping mechanisms, and even regression. Contrary to these early speculations, older adults are often found to cope with stress as well as, if not more successfully than, younger individuals, due in part to the benefits of life experience. Older persons often face stressors that are expected, and they have either coped successfully with such stresses themselves or seen their peers cope with common late-life stressors.

Appraisals of stress. Appraisal is a subjective judgment about the nature of a stressor. It reflects individual variations in how people perceive and interpret their events or circumstances. One widely studied type of appraisal is primary appraisal, which is the perception of the degree of threat, harm, or challenge represented by potentially stressful life events. Research on family caregivers of patients with Alzheimer’s disease has shown that, even after controlling for the objective stressors of caregiving, subjective primary appraisals are important factors predicting care-giver depression.

In addition to primary appraisals, appraisals of self-efficacy, or one’s ability manage a stressor, can be important factors in successful coping. Other appraisals that have been studied include perceptions of the predictability or controllability of a stressor. A relatively recent innovation in stress-process research is the study of positive appraisals. Contrary to earlier research that focused only on the negative impacts of stress, it has been increasingly found that individuals undergoing stress may report benefits and positive experiences. For example, people may find meaning in adversity, or stress may provide a way to strengthen relationships or develop spiritual growth. The ability to appraise stress as being a challenge or growth experience, and to identify positive aspects of stress, may be a major asset in coping.

The consideration of appraisal as a variable has led researchers to go beyond the assumption that stressors can be quantified regarding their relative stressfulness, and to study individual differences in appraisal of stress. For example, the death of a spouse after a long and painful illness may be experienced quite differently than a sudden, unexpected death. A financial stress may be appraised as less threatening by an individual with substantial financial resources. Thus, assessment of the occurrence of life events may be less informative than the personal appraisal of such events in evaluating the potential impact on depression or life satisfaction. Despite important theoretical distinctions between occurrence and appraisals of life events, subjective appraisals of the impact of life events in older adults have received much less attention than studies viewing stressors as objective experiences.

In terms of age differences in the appraisal process, older adults are more likely to perceive their situations as unchangeable, but they are also more likely to face situations that are objectively difficult to change. As discussed below, an appraisal of the changeability of a stressor is an important predictor of the type of coping response utilized.

Internal resources. Individuals’ psychological resources constitute an important domain of individual differences in the stress process. Psychological resources include the personality characteristics that people draw upon to respond to stress. Research has demonstrated that psychological resources have great effects on how individuals perceive stressors and how stressors manifest themselves. Some positive personality traits such as optimism, self-esteem, internal locus of control, and mastery—and more negative traits such as neuroticism—have been shown to affect appraisal and choice of coping responses. For example, neurotic individuals are likely to focus on negative aspects of stressors, while optimists are more likely to view stress as a challenge and to cope positively.

As of 2002, there has been increasing interest in the role of spiritual beliefs and religious participation as factors promoting successful coping, although few studies of this topic have been completed. Results suggest that religious or spiritual beliefs and religious participation may improve coping with a variety of stressors. Possible mechanisms for such effects include aiding people in finding meaning in the face of adversity, and allowing access to a social support network including clergy and others in the faith.

External resources. Besides internal sources of coping, such external factors as economic resources or social resources may be valuable aids in dealing with stress. Higher socioeconomic status and income are often found to be protective factors in studies of stress, because financial resources can be used to provide concrete assistance such as transportation, medical care, and optimal housing arrangements. Other important external resources include social networks and social supports. Social networks are comprised of individuals with whom an older person can interact, and they represent potential sources of assistance. Social support refers to the actual receipt of some emotional, tangible, or informational help from others, and the subjective perceptions of support. Numerous studies have confirmed that social resources play important roles in improving life satisfaction and well-being Studies indicate that individuals with strong social networks and social support are often in better physical and mental health.

Coping responses

Older adults vary in the extent of their coping resources, and thus in the types of coping that they bring to bear when under stress. Coping responses are behavioral responses, which refer to what people do in confronting stress. In one widely used definition, coping is defined as ‘‘constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person’’ (Lazarus and Folkman, p. 141). Coping involves those things individuals do to prevent, avoid, or control emotional stress in order to maintain psycho-social adaptation during stressful situations and conditions; it encompasses direct actions to resolve the problems as well as cognitive responses to control emotional distress.

Coping behaviors are used to help alleviate a difficult situation, to reduce perceived threats, and to manage the symptoms of stress. One basic classification of coping strategies recognizes two types of coping: problem-focused coping and emotion-focused coping. Presented by Folkman and Lazarus (1980), this classification has been used as a guideline in coping research. Problem-focused coping includes active strategies to change stressful situations, whereas emotion-focused strategies are efforts to control one’s emotional responses to modify the meaning of the stress. Coping is most effective when the strategy employed matches the characteristics of the individual, the individual’s needs, and the nature of the stressors involved.

Some studies have shown that older individuals use fewer active problem-focused strategies and employ more emotion-focused strategies. However, such age differences between young and old may be due to functions of different types of stressors. Older persons facing relatively uncontrollable stressors (such as a chronic disease) may cope effectively via acceptance and other emotion-focused coping strategies. In fact, empirical studies have shown that after controlling for types of stressors, few age differences exist in either the number of coping strategies or in their effectiveness. Therefore, it is important to consider the types of stressors and their natures when trying to identify true age differences in coping. Also, older adults have gone through a variety of stressful experiences through life course transition. They may come to know what strategies are effective in particular situations, and to develop their own ways to cope from their experiences. Therefore, older adults may use fewer but more effective coping strategies.

Nolen-Hoeksema and Davis (1999) published a paper on bereavement illustrating the way that stressors, personality, coping, and social support interact. Individuals who suffered the loss of a loved one and who scored high in a personality dimension indicating a tendency to ruminate as a coping style were increasingly likely to seek out social support from others after bereavement. These high ruminators also tended to appraise themselves as having received low levels of social support, but showed increased benefit from social support, when compared with low ruminators. Thus the personality trait not only affected the use of social support as a coping technique, but also the subjective perception and effectiveness of support.

Outcomes of stress

Studies focusing on stress and coping in older adults find considerable evidence that stress places older adults at risk for problems in both mental and physical health. Reviews of literature on stressors such as chronic health problems, bereavement, and family caregiving conclude that these stressors are significantly associated with greater risk of negative outcomes such as mortality, lower psychological well-being, and higher incidence of mental disorders such as depressive symptoms. One study of caregiving stress deserves special attention. Schulz and Beach (1999) found evidence that caregivers who feel highly stressed in their roles showed a 63 percent increase in mortality over a four-year period compared with noncaregivers. This increase in risk of mortality was found only among caregivers who reported being highly stressed; caregivers who did not report the subjective experience of being stressed showed no elevation in mortality. Other studies of caregivers and health functioning have provided convincing evidence that caregivers can experience elevated blood pressure, altered lipid profiles, impaired immune functioning, and greater vulnerability to infectious illness due to caregiving stress. These projects find that negative effects of stress are not uniform and vary according to the types of coping strategies and psychological and social resources used to cope.

Future directions

Research on stress and coping has successfully identified a variety of stressful life events and chronic strains that are risk factors for depression and declining health in older adults. In addition, research has identified promising mediating and moderating factors that can be useful both for research and clinical purposes aimed at enhancing coping with stress. Intervention research has generally been promising, in that older adults can successfully be taught new coping skills that improve coping with such stressors as family caregiving, health problems, and bereavement.

However, several major concerns are apparent. Research on stress and coping in old age usually examines age differences using cross-sectional study designs. Few attempts have been made to explore developmental changes in stress and coping processes with advancing age. An important issue to explore is how stress appraisals and coping strategies change over time in the context of development.

Another concern is that the widespread use of checklists to assess stressful life events and coping strategies may have serious limitations in advancing our knowledge about stress. New research methods using self-monitoring have been developed to look at the coping of individuals with daily stressors across daily episodes of coping. Some of these studies have focused specifically on problems relevant to aging (such as coping with pain and alcohol use as a coping strategy) and may provide researchers with new methodologies to improve our understanding of this vital area of research.

Finally, a relatively unexplored area has been the study of racial and ethnic diversity as factors affecting stress and coping in late life. A small but compelling body of literature suggests that such stressors as caregiving may be coped with quite differently by subgroups such as African Americans and Mexican Americans. For example, African Americans have been found to perceive caregiving in late life as a relatively benign and expected responsibility, and to evidence lower levels of depression than white caregivers in several studies. As the older population in the United States is becoming increasingly diverse, studies of how cultural diversity affects stress and coping will be extremely important.

William Haley Yuri Jang

See also Life Events; Stress.

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