Hypothesis 4

The results partially supported the hypothesis with emotion-focused coping related to lower psychological and environmental QoL. In addition, accepting responsibility was negatively related to psychological QoL, whereas escape-avoidance was negatively related to all domains. As no comparative studies investigating coping in individual QoL domains in TBI caregivers were found, the findings from the present study are discussed using similar caregiver investigations. However, care must be taken when evaluating the findings in a different context, as TBI caregiving has quite specific aspects that affect this population. In addition, a wide range of measures were used to examine coping and QoL further limiting any conclusions drawn. The results will be discussed for each QoL domain.

9.4.4.1 Physical QoL

Physical QoL was not significantly related to emotion-focused coping overall, but weakly negatively related to escape-avoidance coping. This confirms the findings from previous research showing higher use of avoidance coping in caregivers to be related to lower scores on life satisfaction (Haley et al., 1996; Sun, Kosberg, Kaufman, & Leeper, 2010), whereas avoidant coping was unrelated to physical QoL in spouses of prostate or breast cancer patients (Kershaw et al., 2008; Kershaw, Northouse, Kritpracha, Schafenacker, & Mood, 2004).

It has been shown that stress related to caregiving can result in physical symptoms such as high blood pressure, tension headaches, neck pain, chronic back pain, chronic fatigue, sleep problem, and weight gain or loss (Goodhead & McDonald, 2007; Lee, 1999; Salter et al., 2010; Thomas, Hazif-Thomas, Pareault, Vieban, & Clement, 2010). Caregiving has been associated with poorer health compared to non-caregivers and it has been shown that it is at least partly influenced by coping strategies (Lim & Zebrack, 2004; Vitaliano et al., 2003). Several studies have found that the use of escape- avoidance strategies related to poorer physical health (Billings, Folkman, Acree, & Moskowitz, 2000; Neundorfer, 1991). Using escape-avoidance coping can potentially have negative effects on physical QoL by, for example, preventing the caregiver from engaging in dealing with their own health issues. Indeed, it has been found that

104 caregivers tend to neglect their own health in part by denying or minimising their own health requirements (Gallant & Connell, 1997; Goodhead & McDonald, 2007; Schulz et al., 1997). It is possible that a caregiver using escape-avoidance strategies successfully reduces emotional distress associated with a stressor at least for a short time, but also avoids addressing the problem through an active approach, which in the long run would be more effective (Lazarus & Folkman, 1984). Even though avoidance strategies can be adaptive in some situations such as dealing with acute stressors, in the long term it has been found to be related to reduced adherence to medical requirements, pain, distress, and less resistance to disease (Suls & Fletcher, 1985). Escape-avoidance coping in patients with chronic medical diseases has been found to lead to non-compliance with medical treatments (Sherbourne, Hays, Ordway, Dimatteo, & Kravitz, 1992).

Chronister and Chan (2006) found that avoidant coping was related to poorer QoL through experiencing lower levels of mastery, which is the sense of control caregivers feel they have over a caregiving situation. According to the theory appraising a situation as uncontrollable leads to the use of emotion focused coping (Lazarus & Folkman, 1984). This would suggest that in the current study caregivers felt that they had little or no sense of control leading to the use of escape-avoidance coping and resulting in lower physical QoL.

Dependence on medical substances is another component of physical QoL. As a large number of participants in this study have reported having either health problems or at least concerns about their health, or having symptoms of depression or anxiety, there is the possibility that they were using prescription drugs. However, this was not assessed and therefore no conclusions can be drawn. It has been found that caregivers are at risk of using alcohol, drugs, or medication in order to cope with stress related to caregiving (Gallant & Connell, 1997). Evidence is available that caregivers have an increase in their own medication as well as substance use (Hall et al., 1994; Kreutzer et al., 1992; Marsh et al., 1998a; Vitaliano et al., 2003). This can then have an impact on physical QoL. Avoidant coping has been linked to an increased use of alcohol and drugs (Wills & Hirky, 1996; Zeidner & Saklosfske, 1996). In assessing coping strategies, (Carver et al., 1989) found that denial, behavioural and mental disengagement, venting emotions, and alcohol use were moderately correlated. However, it has to be kept in mind that the correlation between escape-avoidance coping and physical QoL in the current research was only weak, suggesting that the clinical significance of using this coping strategy might not be very strong.

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9.4.4.2 Psychological QoL

Psychological QoL was negatively related to emotion-focused coping confirming the study’s hypothesis. That accepting responsibility and escape avoidance were also negatively related to this domain is particularly noteworthy as these were two of the least used coping strategies overall, suggesting that they were possibly less effective than other styles of coping in reducing emotional distress.

As discussed in hypothesis one, emotion-focused coping was related to higher levels of depression and anxiety. The significant relationships between emotional distress and the subscales accepting responsibility and escape-avoidance were also commented on. In hypothesis three, the finding that psychological QoL domain was related to depressive and anxiety symptoms was discussed. Therefore the finding that psychological QoL was related to emotion-focused coping, accepting responsibility, and escape-avoidance does not require any further examination.

9.4.4.3 Social QoL

Social QoL was not related to emotion-focused coping in general, but was significantly negatively related to escape-avoidance, therefore partially confirming the hypothesis. This is a novel finding and requires further investigation. There are however some possible explanations of how escape-avoidance coping and lower social QoL could be related. Previous research showed that caregivers are indeed reluctant to seek social support (Collins, King, Given, & Given, 1994). It is possible that the participants retreated from social support, as an avoidant way of coping for reasons such as not wanting to bother others with their problems, to avoid rejection, or being embarrassed because they are not coping. The majority of participants did not attend support groups and they might have lacked the opportunity to discuss issues related to their caregiving role with others in the same position. The caregiver might have felt selfish as in their view it is the TBI individual who needs help. They might have also been afraid of being judged as incompetent. It is also feasible that the caregivers were tired and exhausted and avoided social interaction, as it was perceived as being a further drain on their energy levels. Greater use of escape-avoidance coping has also been shown to be related to more conflict in personal relationships but this coping strategy can also be used to prevent an individual from feeling overwhelmed and therefore avoiding further stress (Olson et al., 1983; Stephens et al., 1988).

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9.4.4.4 Environmental QoL

Environmental QoL was negatively related to emotion-focused coping and escape- avoidance coping, supporting the hypothesis.

Environmental QoL contains a variety of aspects and how a caregiver copes can determine how areas contained in this domain are dealt with. Some of the aspects discussed in regards to escape-avoidance coping and social QoL also apply to environmental QoL, such as avoiding dealing with aspects related to this domain because the caregiver felt overwhelmed, was afraid of being judged, or was embarrassed. For example, a caregiver using escape-avoidance coping related to financial resources could prevent him or her considering alternative problem-focused coping strategies such as asking for financial assistance from social agencies.

Holahan and Moos (1987) suggested that people with more environmental resources rely more on approach coping and less on avoidance emotional coping. This could suggest that a lack of environmental resources, such as access to health and social care, financial resources, or opportunities for recreation or leisure activities might have been appraised as uncontrollable by the participants, which then led to the use of emotion- focused coping and escape-avoidance coping. As the current finding was a novel one, further investigation is required.

In summary, emotion-focused coping was negatively related to QoL in the psychological and environmental domains, therefore partially confirming the hypothesis. The negative relationship between accepting responsibility and psychological QoL was possibly due to this style of coping being related to anxiety. However, escape-avoidance coping was negatively related to QoL in all domains, suggesting that this style of coping can either have an impact on QoL or visa versa. This finding is interesting when considering that escape-avoidance was one of the least used copings strategies overall.