THE PSYCHOLOGICAL CHALLENGES FACING MELANOMA PATIENTS

There are better and worse ways of coping with a melanoma diagnosis or with any life-threatening illness—"better" or "worse" in the sense that some ways of coping have been found to promote the process of psychological adjustment and to foster emotional well-being over time, whereas other ways of coping are less successful along these lines. 13 The difference in outcome is one of degree: The better ways are not perfect, and worse ways are not totally useless. All ways of coping have an adaptive intent, for that is explicit in the concept of coping 16 ; but some ways lead to more adaptive outcomes. As a construct, "coping" includes emotions, attitudes, and behaviors. These are interrelated: How a person feels implies certain attitudes and beliefs, and these in turn result in certain behaviors. The better ways of coping with a serious illness, as several studies have shown, include certain key characteristics: •For the patient to face the reality of his or her illness and to seek to learn about the disease, the relevant treatment modalities or options, and factors relating to prognosis. 10,19 •For the patient to experience an emotional response that is proportional to this reality (I will return later to what this actually means) and to express these emotions. 21 •For the patient to adopt an active, participatory stance that involves the feeling of self-efficacy (that the person is an active agent who can influence psychosocial and/or medical outcomes) and behaviors that stem from this feeling. 5,20 •For the patient to have a perspective on illness as part of the human condition (as opposed to feeling singled out for adversity or deserving of it). 7 •For the patient to reach out for interpersonal support and help and to include loved ones in his or her illness experience (as opposed to stoically "going it alone" or protecting others from one's experience). 11,22 Many factors determine the degree to which a patient achieves these coping characteristics. One's personality, past coping style, and current psychosocial situation are all important. 12 Certain social expectations or norms about positive coping behavior also influence the person, often in nonconstructive ways. 17 Illness often takes on certain meanings in the context of one's personal life history (e.g., as a kind of "crowning blow" in light of other traumas in the person's life), and these also influence the patient's emotional and coping reactions. 7 The attitudes and expectations of the patient's physicians also affect how the person copes. If we had enough information about all these factors for any given patient, we would be able to predict a kind of coping profile that the patient is likely to display. This article focuses on the challenges and dilemmas facing melanoma patients with regard to their emotional reactions to their diagnosis and the prognosis associated with it. How patients feel, of course, is not the only aspect of their coping response. But it is a central component of their lived experience with the threat posed by the disease. Moreover, how patients feel usually implies a great deal about their psychological make-up and cognitive appraisals about their illness and also leads to certain behavioral coping responses. 16 As the following discussion shows, many conflicts and dilemmas complicate how patients feel and their striving to feel how they "should" (i.e., to adopt emotional responses that are optimally adaptive and right for them).