|Year : 2018 | Volume
| Issue : 1 | Page : 67-72
Proactive coping style and intentional self-harm: A cross-sectional study
D Bhattacharyya, M Namdeo, AK Dwivedi
Department of Psychiatry, Base Hospital Delhi Cantt, New Delhi, India
|Date of Web Publication||15-Oct-2018|
Dr. A K Dwivedi
Department of Psychiatry, Base Hospital Delhi Cantt, New Delhi - 110 010
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Coping style adopted by a person has been identified as an important factor in precipitating or preventing an intentional self-harm attempt. While the influence of reactive coping has received lot of research attention, effects of proactive coping on suicidal behavior has not been studied, even though it is known that proactive coping is associated with better mental health. The authors in the current study sought to investigate the relationship of proactive coping style with attempted deliberate self-harm. Materials and Methods: A total of 44 individuals who presented with intentional self-harm were compared with age, sex, marital status, and education-matched healthy controls. Pierce Suicide Intent Scale was used to ascertain suicidal intent, and Proactive Coping Inventory was used to assess proactive coping. Results: There were no significant differences between subjects and controls for proactive coping, preventive coping, emotional support seeking, avoidance coping, and instrumental support seeking. However, participants scored higher in strategic planning (P = 0.027). Conclusions: Proactive coping has no significant relationship with intentional self-harm; however, more studies with better designs are needed to comment conclusively.
Keywords: Intentional self harm, proactive coping style, suicide prevention
|How to cite this article:|
Bhattacharyya D, Namdeo M, Dwivedi A K. Proactive coping style and intentional self-harm: A cross-sectional study. Ind Psychiatry J 2018;27:67-72
Suicide is defined as an act deliberately initiated and performed by the person in the knowledge or expectation of its fatal outcome. Attempted suicide/deliberate self-harm (DSH)/intentional self-harm (International Classification of Diseases, Tenth Edition [ICD-10]: X60–X84) are terms used to describe intentional harm to self that may or may not have been motivated by desire to end life.
Numerous studies have been conducted in the past to explore possible etiological factors of suicide, and no single factor has yet been identified. The current knowledge points toward diverse and multiple etiological factors. Some of these factors are potentially modifiable and coping style is one of them.
Coping has broadly been defined as a conscious effort by an individual to solve personal and interpersonal problems, and seeking to master, minimize, or tolerate stress or conflict. Folkman and Lazarus defined it as “constantly changing cognitive and behavioral efforts to manage external or internal demands that are considered exceeding the psychological resources of the person.” Coping styles can be classified as problem focused and emotion focused. Whereas problem focused coping has been linked to better mental health, emotion-focused coping strategies have been shown to be linked to poorer mental health. Another method of classifying coping styles is adaptive and maladaptive coping which are respectively related to better and poorer mental health. Coping has also been classified as proactive and reactive. Most of the published literature on coping pertains to reactive coping. Proactive coping has received limited research attention in clinical fields though it has been studied in relation to occupational psychology. Proactive coping is a relatively new entrant in the psychological fields, and lot of research is ongoing to elicit its positive effects in various aspects of life.
It has been suggested that proactive coping requires proactive steps to identify potentially challenging future situations and develop resources and strategies to tackle them. Greenglass and Fiksenbaum showed that proactive coping was a partial mediator of social support on positive affect, which in turn, was associated with better psychological functioning. Greenglass and Burke report negative relationships in managers between job anxiety and problem-focused coping, and in particular, internal control, a coping strategy which depends on one's own efforts to change the situation. They also found significant negative correlation between job anxiety and preventive coping, i.e., higher use of preventive coping was associated with lower job anxiety.
According to Proactive Coping Theory (1999a), the proactive individual strives for improvement in his or her life and environment instead of mainly reacting to a past or anticipated adversity. According to Schwerzer, proactive coping is a process where an individual sets goals for himself, strives relentlessly to attain them and corrects himself in the process by bringing in personal improvement to attain the set goals (Schwarzer, 1999). As opposed to other coping forms, proactive coping incorporates and utilizes social and nonsocial resources, visualizes success, and uses positive emotional strategies. Proactive coping includes goal setting and persistent goal pursuit.
Coping is traditionally seen as occurring temporarily after a stressful event. The approach in proactive coping, however, is future oriented, in that the individual takes preparatory steps in dealing with anticipated stress. Whereas proactive coping comes into play before a demanding situation arises, in clinical settings, attention is sought by patients only after symptoms have been produced following failure of coping mechanisms in a psychologically demanding situation. The assessment and the clinical focus usually revolve around the reaction to the situation. Hence, application of proactive coping in clinical settings is limited and so has been the research.
There is scanty published research investigating the relationship of proactive coping with self-harm behavior. It has been shown in previous studies that better coping style leads to a better mental health and a better quality of life. A better mental health is known to be related to lesser depressive symptoms and with lesser attempts at self-harm. Hence, it was hypothesized by the authors that proactive coping may reduce suicidal ideations when an individual is faced with a challenging situation. The current study aimed to analyze the relationship of proactive coping with self-harm behavior using a cross-sectional study design.
| Materials and Methods|| |
This study was conducted in a psychiatry unit of a tertiary care hospital in New Delhi. The study population consisted of patients presenting to the hospital with recently attempted DSH for the first time. All patients 15 years or older with an ability to read Hindi/English or ability to understand spoken Hindi were included in the study. Patients with a past history of DSH, those reporting with comorbid chronic medical or neurological illnesses and those with preexisting mental and behavioral disorders were excluded from the study. The controls consisted of age, sex, marital status and education matched healthy individuals. Psychological morbidity when present was diagnosed as per ICD-10 Diagnostic Criteria for Research.
Patients either admitted in medical wards or presenting to the emergency/outpatient department with attempted self-harm were interviewed by Psychiatrist and were screened for inclusion in the study. Once included, demographic data was collected by a trained resident in psychiatry using a semi-structured proforma. Various scales were administered by one of the authors.
- A semi-structured proforma (clinical data sheet) was used for recording the sociodemographic profile along with evaluation of suicide attempt and exclusion of any psychopathology by history taking and examination. Different methods of suicide attempts were also identified and categorized on the basis of modes of suicide e.g. self poisoning, self-injury, and combination of self-poisoning and self-injury
- Pierce Suicidal Intent Scale  is a well-validated scale for the assessment of severity of intent of suicide. It consists of 12 items and severity of intent is divided as low (0–3), medium (4–10) and high (>10)
- The Proactive Coping Inventory (PCI): Participants were either given original English version by Greenglass or a validated Hindi adaptation made by Braj Bhushan and Ruchi Gautam from IIT Kanpur in collaboration with Greenglass et al. The current PCI consists of a total of 55 items in seven subscales - proactive coping, reflective coping, the reflective coping, strategic planning, preventive coping, instrumental support seeking, emotional support seeking, and avoidance coping.
The PCI can be administered either by an interviewer or self-administered in approximately 15–20 min. It has been used in a variety of sample of respondents. The PCI is in the public domain and the developers encourage its use by others. In scoring responses, 1 is assigned to “not at all true,” 2 to “barely true,” 3 to “somewhat true” and 4 to “completely true.” Three items of the proactive coping subscale are reverse scored.
The subscales of PCI have high internal consistency (Cronbach alphas reported from 0.71 to 0.85 for all seven scales) and good item total correlations. It has an acceptable skewness as an indicator of symmetry around the mean. A principal component analysis has confirmed its factorial validity and homogeneity. The PCI has good validity. The previous research has shown that scores on the proactive coping subscale are positively correlated with internal control and active coping, with self-efficacy, with life satisfaction, professional efficacy, and perceptions of fair treatment at work, and negatively correlated with self-blame, denial, job burnout, and with depression. Reflective coping correlated moderately highly with internal control and active coping. In addition, strategic planning and preventive coping were both highly correlated with internal control and moderately with active coping.
All the statistical analysis was performed using SPSS version 20 (IBM Corp., Armonk, New York, United States). The clinical profile of patients was analyzed using Chi-square test for qualitative variables. Student's t-test and one-way ANOVA were performed for comparison of quantitative variables. Binomial logistic regression was used to calculate odds ratios. Pearson's correlation coefficient was calculated to find out correlation between variables. 5% probability level was considered as statistically significant, i.e., P< 0.05.
| Results|| |
Out of total 86 patients who presented with attempted suicide, 34 did not meet the inclusion criteria, 5 did not consent, and 3 were lost to follow-up. A total of 44 patients completed the study. A similar number of age, sex, marital status, and academic qualification-matched controls were taken. Most of the patients were between 20 and 30 years of age accounting for 65.8% (n = 29) of suicide attempters. Males comprised 72.8% (n = 32) and females comprised only 27.2% (n = 12) of the total. About 50% individuals were single, and 50% were married. 27.2% were graduates and 4.6% were postgraduates while 13.6% had an education below matriculation.
Poisoning or overdose of medicines was the most common mode of suicide, followed by multiple methods, hanging, and physical injury, in that order [Figure 1]. 50% participants scored high intent on Pierce Suicide Intent Scale (score >10) while 6.2% had low suicide intent (score <4) [Figure 2]. Elder patients (45–55 years age group) had higher intent of suicide compared to younger ones (P = 0.004) [Figure 3]. Postgraduates and those with an education below matriculation scored high on suicide intent compared to others (P< 0.001).
|Figure 3: Suicide intent in various age groups, subdivided as low, medium, and high suicide intent|
Click here to view
Participants scored lower on proactive coping, preventive coping, instrumental support seeking, and avoidance coping while they scored higher on reflective coping and strategic planning scales. Participants and controls had equal mean scores on emotional support seeking subscale. However, only statistically significant differences were observed for strategic planning subscale (P = 0.027) [Table 1]. Odds ratios for risk of suicide were calculated for various subscales and none of them were significant [Table 2]. Age wise, the only difference was observed in emotional support seeking, where patients in the age group of 25–35 years scored higher compared to older and younger ones (P = 0.002). There were no significant differences between participants and controls in other subscales. There were no statistically significant differences for proactive coping among male and female participants on any of the subscales. Only significant difference in educational status was a high score in avoidance coping in less educated individuals (≤ class 10th). Incidentally, these are the people who had lower suicide intent also. Correlation of PCI scores with suicide intent score was not significant.
|Table 1: Comparison between subjects and controls for subscales of proactive coping inventory|
Click here to view
|Table 2: Odds ratios calculated using binomial logistic regression for risk of suicides for various subscales|
Click here to view
| Discussion|| |
Proactive coping was not found to be significantly related to intentional self-harm in this study. However, interestingly, score of one subscale – strategic planning, was found to be higher in suicide attempters compared to controls.
The only similar study that the authors could find on Google Scholar (no study was found on MEDLINE search) was the one by Terraca Andriel Cato, published in 2012, done on college students to find an association between proactive coping, optimism, and suicide ideation. She found that a correlation between depression and proactive coping was significant (r = − 0.441, P = 0.009) and so was a correlation between optimism and proactive coping (r = 0.425, P = 0.010). The second test of the relationship between optimism and suicide ideation was also significant (r = − 0.441, P = 0.007). Thus, as proactive coping increased, so did optimism, which led to a decrease in suicide ideation. The drawback of the study was a small sample size.
Demographic data pertaining to suicides in the current study is in line with the existing research. Most of the suicide attempts in the current study were observed in subjects aged 20–30 years. Most of the suicide attempters were males.
Most of the published research on relationship of intentional self-harm with coping strategies has focused on reactive coping and has largely shown positive correlation of emotion orientated coping with suicidal behavior or negative correlation of problem-focused coping with suicidal behavior.
Konkan et al., compared 50 patients who had attempted suicide within the past 2 months and 52 healthy volunteers. They were evaluated with the Turkish version of COPE inventory. It was found that suicide attempters had lower scores on active coping, planning, positive reinterpretation, and growth than controls. On the other hand, total points in restraint coping, acceptance, 'focus on and venting of emotions', behavioral disengagement, substance use and nonfunctional coping were significantly higher in the suicide attempt group.
Similarly, Guerreiro et al., in their study found that emotion-focused coping style and in particular avoidant coping strategies have consistently been associated with DSH in adolescents. Problem-focused coping style seems to have a negative relation as per the study.
Asghari et al. in their study concluded that suicidal thoughts have a positive relationship with perceived stress, and stress management using active coping strategies, in particular, problem-focused coping strategies, was proposed to be associated with reduced suicidal ideation in college students. Active coping is defined as a behavioral response people engage in that uses one's own resources to minimize the physical, psychological, or social harm of a situation. It has been seen that developing social support and friendships as well as having secure relationships reduced suicidality in veterans of Operation Enduring Freedom and Operation Iraqi Freedom. Furthermore, active coping has been shown to reduce stress and symptoms of mental illness through creation of social and personal resources. Passive coping or reactive coping is characterized by feelings of helplessness, relying on others for stress resolution and is associated with vulnerability to psychopathology.,,
Proactive coping, on the other hand, is coping style in which a coping response aims to head off a future stressor or diminish stress response. The proactive individual accumulates resource, takes steps to prevent resource depletion, and is capable of mobilizing resources when needed. The skills associated with proactive behavior include planning, goal setting, organization, and mental stimulation. The resources are created and consolidated before a stressor is encountered or even anticipated, in contrast to reactive coping in which the coping mechanisms are activated once a stressor has been encountered or is anticipated. Whereas there is evidence that proactive coping helps in building resilience and well-being in an individual who is not under stress and prepares him to handle stress better, it is not known whether proactive coping is protective against suicides and attempts thereof. Some studies that have given the conceptualization of proactive coping state that it is better linked to well-being and positive emotions rather than dealing with negative emotions.
Sohl SJ et al. in their study in 2009 demonstrated that conceptualizing proactive coping as a positively-focused striving for goals was predictive of well-being, whereas conceptualizing proactive coping as focused on preventing a negative future was not particularly predictive of well-being. The lack of significant differences in proactive coping between participants and controls in the current study may be because of this very reason. It has been suggested that proactive coping should not be studied in a cross section but rather should be a longitudinal study because proactive coping is a dynamic process. Hence, the design of the current study might be a hindrance in true assessment of proactive coping and the effects thereof on the suicide attempts.
Mirkovic et al. in their study demonstrated that while controlling for age, sex, and depression, there was a significant positive association between the coping strategy to focusing on solving the problem and suicidal ideation. They concluded that problem-solving strategies in the immediate aftermath of a suicide attempt may prevent adolescents with borderline personality disorder from overcoming a crisis and may increase suicidal ideation. The high scores of participants on “strategic planning” subscale in the current study are in line with this hypothesis. Unmet expectations could be another explanation of this result and need further research into the causes and correlates of such a finding.
There are certain drawbacks in the study. The patients and controls belonged to a particular working environment that may have produced a bias in the selection of cases and the results may not be generalizable to the entire population. Design of the study is another possible drawback as mentioned earlier. The strength of the study is that it is the only study as per authors' knowledge which has assessed effects of proactive coping on DSH. Matching of controls provided strength to the study.
| Conclusions|| |
It was found that Proactive Coping was not associated significantly with Deliberate Self Harm. However, before such a statement can be made with confidence, more inquiry into this question is needed with better prospective study designs and larger sample size.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gelder M, Gath D, Mayou R. Oxford Textbook of Psychiatry. Oxford, UK: Oxford University Press; 1989.
Greenglass E, Schwarzer R, Jakubiec D, Fiksenbaum L, Taubert S, editors. The proactive coping inventory (PCI): A multidimensional research instrument. 20th
International Conference of the Stress and Anxiety Research Society (STAR). Cracow, Poland; 1999.
Folkman S, Lazarus RS. An analysis of coping in a middle-aged community sample. J Health Soc Behav 1980;21:219-39.
Williams F, Hasking P. Emotion regulation, coping and alcohol use as moderators in the relationship between non-suicidal self-injury and psychological distress. Prev Sci 2010;11:33-41.
Greenglass ER, Fiksenbaum L. Proactive coping, positive affect, and well-being: Testing for mediation using path analysis. Eur Psychol 2009;14:29-39.
Greenglass ER, Burke RJ. Work and family precursors of burnout in teachers: Sex differences. Sex Roles 1988;18:215-29.
Schwarzer R, editor. Proactive coping theory. 20th
International Conference of the Stress and Anxiety Research Society (STAR). Cracow, Poland; 1999.
Singh G, Kaur D, Kaur H. Presumptive stressful life events scale (psles) – A new stressful life events scale for use in India. Indian J Psychiatry 1984;26:107-14.
] [Full text]
Cato TA. The relationship among suicide ideation, depression, and optimism. Xavier Univ La Undergrad Res J 2012;10:21-6.
Konkan R, Erkuş GH, Güçlü O, Şenormanci Ö, Aydin E, Ülgen MC, et al.
Coping strategies in patients who had suicide attempts. Noro Psikiyatr Ars 2014;51:46-51.
Guerreiro DF, Cruz D, Frasquilho D, Santos JC, Figueira ML, Sampaio D, et al.
Association between deliberate self-harm and coping in adolescents: A critical review of the last 10 years' literature. Arch Suicide Res 2013;17:91-105.
Asghari F, Sadeghi A, Aslani K, Saadat S, Khodayari H. The survey of relationship between perceived stress, coping strategies and suicide ideation among students at University of Guilan, Iran. Int J Educ Res 2013;1:111-8.
Youssef NA, Green KT, Beckham JC, Elbogen EB. A 3-year longitudinal study examining the effect of resilience on suicidality in veterans. Ann Clin Psychiatry 2013;25:59-66.
Zeidner M, Endler NS. Handbook of Coping: Theory, Research, Applications. Hoboken, New Jersey, United States: John Wiley and Sons; 1996.
Billings AG, Moos RH. Coping, stress, and social resources among adults with unipolar depression. J Pers Soc Psychol 1984;46:877-91.
Aspinwall LG, Taylor SE. A stitch in time: Self-regulation and proactive coping. Psychol Bull 1997;121:417-36.
Sohl SJ, Moyer A. Refining the conceptualization of an important future-oriented self-regulatory behavior: Proactive coping. Pers Individ Dif 2009;47:139-44.
Mirkovic B, Labelle R, Guilé JM, Belloncle V, Bodeau N, Knafo A, et al.
Coping skills among adolescent suicide attempters: Results of a multisite study. Can J Psychiatry 2015;60:S37-45.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]