**12. Emotional coping strategies in COPD**

COPD is an imposing illness in its effects on normal body functioning, daily management of the body and the home environment and on the lives of family members who give support. People find strategies around 'conscious management of self' to counter the impact of the unpredictability of the disease. Many of these strategies can be found across the literature of other chronic illnesses. These strategies include conscious control of emotions, comparing

Psychosocial Dimensions of COPD for the Patient and Family 167

months (Salman et al., 2003). The physical effectiveness gains also appear to be tied to the

Having a specific COPD class means participants are empathetic towards others with symptoms of breathlessness and sputum production, and so are less self-conscious about their bodies' unpredictable behaviours (Gullick, 2008, Arnold et al., 2006). Under supervision, people become more comfortable exerting their body and are less likely to become panicked by exertional dyspnoea (Williams et al., 2010). Chris learned to manage his panic through the classes: *"The most helpful was avoiding panic attacks… It changed my outlook… I probably looked at it from the aspect 'Well, Bugger it! I can do these things' and I'd have a go at whatever it might be."* The increased sense of disease control due to greater confidence with managing medications and breathing techniques leads to a reduced likelihood of

Perceived physical gains include improved muscle strength, balance and mobility, reduced breathlessness and fatigue, and an improvement in joint mobility and pain management for those with musculoskeletal comorbidities. The result is that daily tasks are more achievable and require less pacing to complete (O'Shea et al., 2007, Gullick, 2008). Pulmonary rehabilitation has led to improvements in health related quality of life even where no significant improvement in lung function is demonstrated (Haave et al., 2007, Camp et al., 2000). This is in part, due to the reduction in social isolation and improved opportunities for expression of 'self' (Gullick, 2008, Toms & Harrison, 2002); patients describe feelings of enhanced well-being and hope (Milne et al., 2009, O'Shea et al., 2007), have higher self-esteem and mood (Arnold et al., 2006) and, following rehabilitation, are more likely to talk about their abilities rather than their limitations (Williams et al., 2010). Pulmonary rehabilitation can lead to a change in physical appearance and in turn, body image, and creates a sense of pride, satisfaction and

The intrinsic motivation of the person with COPD is important in determining the most successful approach to exercise training. Home-based programs may not be so successful for people who live alone or who do not have high internal levels of motivation. The notion of locus of control (Rotter, 1966) is a useful construct to predict those who may be most successful. People with a higher internal locus of control are more likely to seek information about their circumstances. They perceive a greater power to influence events through their own activities and behaviours and are more likely to believe that their labours will be successful. Those with a lower internal locus of control tend to see events as influenced by their environment, powerful others or fate. People with COPD who describe a higher intrinsic drive demonstrate more active engagement with rehabilitation and seem more successful with continuing on a home-based maintenance routine. Petra had severe COPD, but was carrying on a home-based exercise program more than a year after her initial rehabilitation: *"I have a walker… I only have to look at that and I'm at it. Never, ever will I fail! But I have two days off … Wednesdays comes my cleaning lady… Sunday… I entertain… So all the other days, that's exercise. That's like going to a job"* (Gullick, 2008). Those whose motivation is linked to exercising with others are less likely to benefit from a home-based rehabilitation (Milne et al., 2009). Jim (60 yrs) found maintaining a homebased program challenging: *"It's pretty right what they say – 'In a group you'll do it', whereas* 

frequency of sessions per week (Gullick, 2008).

presentation to hospital (Camp et al., 2000).

achievement (O'Shea et al., 2007).

*a lot of times you'll put it off at home."*

oneself to others worse off and learning to 'go with the flow' and make the best of unpredictable symptoms (Gullick & Stainton, 2008, Seamark et al., 2004, Cicutto et al., 2004). For some people, religious faith and spirituality provide an important emotional support that can reduce feelings of powerlessness (Leidy & Haase, 1999, Bergs, 2002, Milne et al., 2009, Seamark et al., 2004, Boyle, 2009b). Coming to a point of acceptance of the disease is named by many, but elegantly articulated by Lindqvist & Hallberg (2010) who describe the process of embodying and making a relationship with the disease. This requires a conscious replacement of the previously known life structure with a new, adapted one. This allows a determination of a reframed identity and normality that includes COPD. Patricia explains *"I've just got to learn to live with it. I call it 'me and my friend'*." Part of this acceptance lies in finding different foundations upon which to build hope; from cure to coping; from old dreams to new, realistic goals; and by discovering hope in the 'rewards of the moment' (Milne et al., 2009). People find simple and meaningful pleasure in realising skills, in having a good day, in being able to achieve a walk in the park or a shopping trip or in remembering past experiences with affection (Milne et al., 2009, Ek & Ternestet, 2008, Seamark et al., 2004).

Perhaps the most significant recognition for both the carers and people with COPD is of their family as 'the best thing in life' (Gullick & Stainton, 2008). Family is not only a practical support structure, but a reason for surviving and enduring, and through children and grandchildren, embodies an important source of meaningful connectivity and joy (Leidy & Haase, 1999, Cicutto et al., 2004, Bergs, 2002, Barnett, 2004).
