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Self-esteem, social support, internalized homophobia and the coping strategies of HIV+ gay men Nicholson, William Dean 1989

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SELF-ESTEEM, SOCIAL SUPPORT, INTERNALIZED HOMOPHOBIA AND THE COPING STRATEGIES OF HIV+ GAY MEN By WILLIAM DEAN NICHOLSON B.Mus., The U n i v e r s i t y of B r i t i s h Columbia, 1985 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS i n THE FACULTY OF GRADUATE STUDIES (Department of C o u n s e l l i n g Psychology) We accept t h i s t h e s i s as conforming t o the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA J u l y 1989 © W i l l i a m Dean N i c h o l s o n , 1989 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of C o U M Sfc-LuMl ? C - U o L p t y ^ The Universjty of British Columbia Vancouver, Canada DE-6 (2/88) A b s t r a c t T h i s study had two aims: (a) t o examine the r e l a t i o n s h i p between s e l f - e s t e e m , s o c i a l support, i n t e r n a l i z e d homophobia and the coping s t r a t e g i e s used by HIV+ gay men; and (b) to examine the r e l a t i o n s h i p between the use of s p e c i f i c coping s t r a t e g i e s and mood s t a t e . E i g h t y - n i n e HIV+ gay men completed a q u e s t i o n n a i r e package c o n s i s t i n g of the Nungesser Homosexual A t t i t u d e s Inventory, the Rosenberg Self-Esteem S c a l e , the P r o f i l e of Mood St a t e s , the Revised Kaplan S c a l e , and the Ways of Coping S c a l e . H i e r a r c h i c a l stepwise r e g r e s s i o n s were conducted on the data with Avoidant (Escape-Avoidance and D i s t a n c i n g ) and P r o a c t i v e (Seeking S o c i a l Support and P o s i t i v e R e a p p r a i s a l ) coping s e r v i n g as c r i t e r i o n v a r i a b l e s and se l f - e s t e e m , s o c i a l support, homophobia, and the i n t e r a c t i o n terms of homophobia x s e l f - e s t e e m and homophobia x s o c i a l support s e r v i n g as p r e d i c t o r v a r i a b l e s . A f t e r removing the e f f e c t s of time s i n c e d i a g n o s i s and s t r e s s o r type, o n l y s m a l l amounts of the t o t a l v a r i a n c e f o r each coping s t r a t e g y c o u l d be e x p l a i n e d by the p r e d i c t o r v a r i a b l e s . C o r r e l a t i o n s between mood s t a t e and coping s t r a t e g i e s were a l s o low or n o n s i g n i f i c a n t . A r e c o n s i d e r a t i o n of the l i t e r a t u r e and an examination of the c o r r e l a t i o n s between coping s t r a t e g i e s suggested a d i f f e r e n t p a t t e r n of coping behaviours. The r e g r e s s i o n s were r e a n a l y s e d u s i n g Escape-Avoidance and Ac c e p t i n g R e s p o n s i b i l i t y (EAR coping) and Seeking S o c i a l Support and P l a n f u l Problem S o l v i n g (SPS c o p i n g ) . The equation p r e d i c t i n g EAR cop i n g reached s i g n i f i c a n c e (F(2,86)=20.2, 2<.01). Homophobia and s e l f - e s t e e m entered the equation and accounted f o r 30% of the e x p l a i n e d v a r i a n c e . The equation p r e d i c t i n g SPS coping a l s o achieved s i g n i f i c a n c e (F(3,85)=3.9, p.<.05) with s t r e s s o r type, homophobia and time s i n c e d i a g n o s i s e n t e r i n g and ac c o u n t i n g f o r 9% of the t o t a l v a r i a n c e . A t h i r d r e g r e s s i o n equation p r e d i c t i n g mood s t a t e a l s o achieved s i g n i f i c a n c e (F(4,84)=22.4, p_<.01). A f t e r removing the e f f e c t s of time s i n c e d i a g n o s i s , which accounted f o r 4% of the t o t a l v a r i a n c e , EAR coping entered and e x p l a i n e d 32% of the t o t a l v a r i a n c e . Homophobia and s e l f - e s t e e m entered a f t e r the coping v a r i a b l e , c o n t r i b u t i n g 3% and 10%, r e s p e c t i v e l y t o the t o t a l v a r i a n c e a f t e r the oth e r s i g n i f i c a n t v a r i a b l e s . The r e s u l t s help c l a r i f y the r e l a t i o n s h i p between p e r s o n a l , environmental and c o n t e x t u a l v a r i a b l e s and the g r e a t e r use of s p e c i f i c coping s t r a t e g i e s i n HIV+ gay men, as w e l l as the r e l a t i o n s h i p between cop i n g s t r a t e g i e s and mood s t a t e . i v Table of Contents Page A b s t r a c t i i Table of Contents i v L i s t of Tables v i Acknowledgement v i i D e d i c a t i o n v i i i I n t r o d u c t i o n 1 Review of L i t e r a t u r e 8 St r e s s and Coping 8 Functions of coping 10 The Ways of Coping Scale 11 Coping s t r a t e g i e s 12 M i t i g a t i n g F a c t o r s i n the Coping Process 15 Self-esteem and s o c i a l support 17 Coping s t r a t e g i e s as c r i t e r i o n v a r i a b l e s . . . . . 1 9 Adaptiveness of Coping S t r a t e g i e s 25 Coping s t a t e g i e s as p r e d i c t o r v a r i a b l e s 28 HIV i n f e c t i o n and i t s consequences 40 The HIV/AIDS continuum 40 P s y c h o l o g i c a l r e a c t i o n s t o i n f e c t i o n 41 AIDS, homosexuals and s o c i e t y 42 P s y c h o s o c i a l AIDS Research 45 AIDS and s o c i a l support 46 AIDS and i n t e r n a l i z e d homophobia 54 AIDS and s e l f - e s t e e m 56 AIDS and coping s t r a t e g i e s 57 AIDS and mood s t a t e s 62 Summary 62 Hypotheses 65 Method 67 Subjects 67 Procedure 68 Instruments 72 Demographic data 72 P r e d i c t o r v a r i a b l e s 74 C r i t e r i o n v a r i a b l e 78 Data A n a l y s i s 80 Re s u l t s 83 D e s c r i p t i v e S t a t i s t i c s 83 C o r r e l a t i o n s Between V a r i a b l e s 86 Hypotheses 88 Post-hoc Analyses 91 D i s c u s s i o n 98 References 118 Appendices 126 Appendix A. I n t r o d u c t o r y L e t t e r 12 6 Appendix B. Demographic Information 128 Appendix C. Rosenberg Self-Esteem Scale (RSES) . .. .131 Appendix D. Nungesser Homosexual A t t i t u d e s Inventory (NHAI) 132 Appendix E. Revised Ways of Coping Scale (WOCS). . .135 Appendix F. Revised Kaplan Scale (RKS) 139 v i L i s t of Tables Page Table 1. Demographic C h a r a c t e r i s t i c s of Sample. . . . 69 Table 2. Q u e s t i o n n a i r e D i s t r i b u t i o n and Return F i g u r e s 73 Table 3. Means, Standards D e v i a t i o n s , and I n t e r c o r r e l a t i o n s f o r P r e d i c t o r and C r i t e r i o n V a r i a b l e s 84 Table 4. A u x i l i a r y Demographic Information 85 Table 5. H i e r a r c h i c a l Stepwise Regression Equations f o r Avoidant and P r o a c t i v e Coping 90 Table 6. I n t e r c o r r e l a t i o n s f o r Coping S t r a t e g i e s . . . 92 Table 7. H i e r a r c h i c a l Stepwise Regression Equations f o r EAR and SPS Coping 95 Table 8. H i e r a r c h i c a l Stepwise Regression Equations f o r Mood State 97 Acknowledgement I thank Dr. Bonnie Long f o r the support, encouragement and a d v i c e she has f r e e l y g i v e n me throughout t h i s study. The o p p o r t u n i t y t o work under her t u t e l a g e has been a v a l u a b l e and e n r i c h i n g l e a r n i n g experience f o r me. I a l s o wish t o thank my other committee members, Dr. A n i t a DeLongis and Dr. J u d i t h Daniluk, f o r t h e i r a s s i s t a n c e through the course of t h i s study. I f u r t h e r thank the agencies and i n d i v i d u a l s who have helped d i s t r i b u t e q u e s t i o n n a i r e s and make t h i s r e s e a r c h v i a b l e . In p a r t i c u l a r I wish t o thank Ken Mann whose support and enthusiasm f o r the study were much a p p r e c i a t e d . F i n a l l y , I wish t o express my a p p r e c i a t i o n t o a l l those f r i e n d s and c o l l e a g u e s who pr o v i d e d encouragement, a d v i c e and p a t i e n c e through the ups and downs of t h i s p r o j e c t . My thanks t o a l l of you. v i i i D e d i c a t i o n I would l i k e t o d e d i c a t e t h i s t h e s i s t o a l l those people who are coping with HIV ( i n hopes t h a t a cure may-soon be found), and t o a l l those who s u f f e r u n j u s t l y from s t i g m a t i z a t i o n and s o c i a l b i a s . 1 I n t r o d u c t i o n Homosexual and b i s e x u a l men who t e s t p o s i t i v e f o r the Human Immunodeficiency V i r u s (HIV) face many of the same adjustment i s s u e s as other c h r o n i c a l l y or t e r m i n a l l y i l l p eople. There are a number of concerns unique t o both the d i s e a s e and the gay community, however, which can c r e a t e s p e c i f i c problems f o r gay men. In coping with i l l n e s s concerns, the use of d i f f e r e n t coping s t r a t e g i e s can have d i f f e r i n g e f f e c t s on adjustment. The purpose of t h i s study was to examine whether c e r t a i n p e r s o n a l , environmental and c o n t e x t u a l f a c t o r s r e l e v a n t t o HIV+ gay men, were a s s o c i a t e d with the coping s t r a t e g i e s they used i n d e a l i n g with i n f e c t i o n r e l a t e d s t r e s s . E a r l y coping r e s e a r c h suggested t h a t people coping w i t h i l l n e s s concerns were more l i k e l y t o use coping s t r a t e g i e s aimed at r e g u l a t i n g t h e i r emotional r e a c t i o n s to the i l l n e s s than s t r a t e g i e s aimed at changing or t a c k l i n g the problem, p a r t i c u l a r l y i f the s i t u a t i o n seemed out of t h e i r c o n t r o l (Folkman & Lazarus, 1980; P e a r l i n & Schooler, 1978). Subsequent r e s e a r c h , however, has i d e n t i f i e d a number of s p e c i f i c c l u s t e r s of behaviours and c o g n i t i o n s c o n s t i t u t i n g d i f f e r e n t s t r a t e g i e s f o r d e a l i n g with a s t r e s s o r (Folkman, Lazarus, Dunkel-Schetter, DeLongis, & Gruen, 1986), and people with c h r o n i c or t e r m i n a l i l l n e s s have been found t o use d i f f e r e n t s t r a t e g i e s t o v a r y i n g degrees ( F e i f e l , Strack, & Nagy, 1987; F e l t o n , Revenson, & H i n r i c h s e n , 1984; Namir, Wolcott, Fawzy, & Alumbaugh, 1987). 2 Coping has been c o n c e p t u a l i z e d as a process of c o n t i n u i n g a p p r a i s a l and r e a p p r a i s a l of the person/environment i n t e r a c t i o n (Lazarus & Folkman, 1984). Because the a p p r a i s a l s of a s t r e s s o r and c h o i c e of s t r a t e g i e s used i n response t o i t are a f f e c t e d by a wide range of f a c t o r s , r e s e a r c h examining coping processes must be b r o a d l y framed to i n c l u d e the p e r s o n a l , environmental and c o n t e x t u a l f a c t o r s r e l e v a n t t o the s t r e s s f u l encounter (Holahan & Moos, 1987; Lazarus & Folkman, 1984; Parkes, 1986). In r e s e a r c h with d i f f e r e n t p o p u l a t i o n s , s t u d i e s have shown t h a t v a r i o u s combinations of f a c t o r s p r e d i c t the use of d i f f e r e n t coping s t r a t e g i e s (Holahan & Moos, 1987; Long, 1989; Parkes, 1986). With r e s p e c t to i l l n e s s concerns, f o r example, F e i f e l et a l . (1987) found t h a t p e r s o n a l i t y v a r i a b l e s such as negative s e l f - p e r c e p t i o n and c o n t e x t u a l v a r i a b l e s such as l e n g t h of i l l n e s s were s i g n i f i c a n t l y a s s o c i a t e d with the g r e a t e r use of Avoidance or Acceptance-R e s i g n a t i o n coping as compared to C o n f r o n t a t i o n coping. In coping with i l l n e s s the use of d i f f e r e n t coping s t r a t e g i e s has been a s s o c i a t e d with d i f f e r i n g degrees of p s y c h o l o g i c a l adjustment. Coping s t r a t e g i e s aimed at m i n i m i z i n g or denying the t h r e a t , or i n v o l v i n g a r e t r e a t i n t o w i s h f u l f a n t a s i z i n g , have been shown to c o r r e l a t e p o s i t i v e l y with emotional d i s t r e s s and low s e l f - e s t e e m . Conversely, coping aimed at r e i n t e r p r e t i n g the i l l n e s s as a p o s i t i v e c h a l l e n g e f o r growth has been a s s o c i a t e d with higher l e v e l s of w e l l - b e i n g and s e l f - e s t e e m ( F e l t o n et a l . , 3 1984; Parker et a l . , 1988), w h i l e problem-focused coping has been shown to be n e g a t i v e l y a s s o c i a t e d with symptoms of p s y c h o l o g i c a l d i s t r e s s (Folkman, Lazarus, Gruen, & DeLongis, 1986) . E m p i r i c a l r e s e a r c h suggests t h a t an HIV i n f e c t i o n can be a d i f f i c u l t and s t r e s s f u l s i t u a t i o n f o r a gay man t o cope with (Donlou, Wolcott, G o t t l i e b , & Landsverk, 1985; Wolcott, Namir, Fawzy, G o t t l i e b , & Mitsuyasu, 1986). Given the negative impact s t r e s s can have on p s y c h o s o c i a l w e l l - b e i n g and because t h e r e i s s p e c u l a t i o n t h a t s t r e s s may a f f e c t the immune system and hence the p r o g r e s s i o n of the d i s e a s e (Coates, Temoshok, & Mandel, 1984; Solomon & Temoshok, 1987) , t h e r e i s a need t o understand the r e l a t i o n s h i p between i l l n e s s r e l a t e d s t r e s s o r s r e l e v a n t t o HIV+ gay men and the coping s t r a t e g i e s they use i n d e a l i n g with t h e i r i n f e c t i o n . The A c q u i r e d Immune D e f i c i e n c y Syndrome (AIDS) c r i s i s has been unique i n t h a t i t has impacted not o n l y on i n d i v i d u a l s , but on an e n t i r e s u b c u l t u r e . Because the m a j o r i t y of diagnosed cases of AIDS and HIV i n f e c t i o n i n North America have been i n homosexual or b i s e x u a l men ( G r e i g , 1987), AIDS has l a r g e l y been a s s o c i a t e d with the male homosexual community. As a r e s u l t , t h e r e has been a tendency to see AIDS as a homosexual problem, w i t h gay men b e i n g s t i g m a t i z e d , both because of t h e i r sexual o r i e n t a t i o n and because of t h e i r c o n n e c t i o n with the d i s e a s e (Dupras, Samson, Levy, & T e s s i e r , 1989; Herek & Glunt, 1988; N i c h o l s , 4 1984; V a l d i s e r r i , 1987). T h i s homophobic r e a c t i o n , however, has not been c o n f i n e d to the h e t e r o s e x u a l community. An i n c r e a s e i n i n t e r n a l i z e d homophobia has been p o i n t e d to as one of the c l e a r p s y c h o l o g i c a l r e a c t i o n s of gay men to the AIDS c r i s i s ( H i r s c h & Enlow, 1984) with gay men i n t e r n a l i z i n g s o c i e t y ' s homophobic p r e j u d i c e and a d o p t i n g a negative view of t h e i r o r i e n t a t i o n and l i f e s t y l e (Harowski, 1987; P r i c e , Omizo, & Hammett, 1986; Ross & Rosser, 1988). For some gay men the nature and t h r e a t of the d i s e a s e provokes the emergence of unresolved i s s u e s r e g a r d i n g t h e i r sexual o r i e n t a t i o n (Grant & Anns, 1988), which may cause some men to blame themselves f o r t h e i r i n f e c t i o n and see i t as punishment f o r t h e i r l i f e s t y l e ( D i l l e y , O c h i t i l l , P e r l , & V o l b e r d i n g , 1985; Furstenberg & Olson, 1984). While a p o s i t i v e a t t i t u d e towards homosexuality has been shown to c o r r e l a t e p o s i t i v e l y with lower emotional d i s t r e s s (Wolcott, Namir et a l . , 1986), self- b l a m e r e g a r d i n g i n f e c t i o n and h e a l t h improvement has been a s s o c i a t e d with emotional d i s t r e s s and h e a l t h r e l a t e d behaviours i n gay men with AIDS and ARC (Moulton, Sweet, Temoshok, & Mandel, 1987). HIV i n f e c t i o n poses a t h r e a t to the s e l f - e s t e e m of gay men. A lowering of s e l f - e s t e e m i s a common response to the stigma of b e i n g i l l ( F u r s t enberg & Olson, 1984) and p a t i e n t s with c h r o n i c p h y s i c a l i l l n e s s e s have been shown t o have impaired s e l f - e s t e e m (Simmons, K l e i n , & Simmons, 1977). Because HIV i s g e n e r a l l y a s e x u a l l y t r a n s m i t t e d d i s e a s e , the 5 t h r e a t of i n f e c t i o n through sexual a c t i v i t y can a l s o have a negative impact on the i d e n t i t y and s e l f - e s t e e m of gay men ( P r i c e et a l . , 1986), p a r t i c u l a r l y s i n c e the development of an ego-syntonic gay i d e n t i t y i n the gay community has t r a d i t i o n a l l y been r e i n f o r c e d through sexual a c t i v i t y ( F o r s t e i n , 1984; F u r s t e n b e r g & Olson, 1984; Harowski, 1987; Morin, C h a r l e s , & Malyon, 1984). Studies have found t h a t a c e r t a i n p r o p o r t i o n of i n f e c t e d gay men do manifest low l e v e l s of s e l f - e s t e e m a f t e r d i a g n o s i s , although t h e i r l e v e l s of s e l f - e s t e e m p r i o r t o i n f e c t i o n were not known (Donlou et a l . , 1985; Wolcott, Namir et a l . , 1986). As a r e s u l t of the stigma surrounding the d i s e a s e , an HIV i n f e c t e d person faces the p o s s i b i l i t y of r e a l and/or p e r c e i v e d s o c i a l i s o l a t i o n ( D i l l e y et a l . , 1985; Haney, 1988; Morin et a l . , 1984). I n d i v i d u a l s r i s k d i s c r i m i n a t i o n at work, as w e l l as d i s c r i m i n a t i o n by f r i e n d s and f a m i l y . This t h r e a t makes some men r e l u c t a n t t o d i s c u s s t h e i r i n f e c t i o n (Donlou et a l . , 1985), and they may i n t u r n d e l i b e r a t e l y withdraw from p o t e n t i a l s o c i a l support systems (Acevedo, 1986; H i r s c h & Enlow, 1984). For o t h e r s , f e a r s of being contaminated and i n f e c t i n g others may cause them t o a v o i d i n t i m a t e or p h y s i c a l c o n t a c t (Grimshaw, 1987). For gay men with AIDS and ARC (AIDS-Related Complex), s o c i a l support has been a s s o c i a t e d w i t h emotional d i s t r e s s (Wolcott, Namir et a l . , 1986; Z i c h & Temoshok, 1987) and with types of coping used (Namir et a l . , 1987). Research has shown t h a t coping s t r a t e g i e s used i n 6 response t o a h e a l t h s t r e s s o r change with time as circumstances change ( F e i f e l et a l . , 1987). Furthermore, Lipowski (1970) suggests t h a t the p a r t i c u l a r s and p e r c e p t i o n of an i l l n e s s can a f f e c t the coping response used. An HIV d i a g n o s i s can r e s u l t i n a number of d i v e r s e s t r e s s o r s which are l i k e l y t o change over time (Grant & Anns, 1988). The types of coping s t r a t e g i e s t h a t gay men use i n response t o these s t r e s s o r s , t h e r e f o r e , may be a f f e c t e d both by the nature of the p a r t i c u l a r s t r e s s o r and by the time s i n c e r e c e i v i n g an HIV+ d i a g n o s i s . A number of r e s e a r c h e r s suggest t h a t the i n t e r a c t i o n of v a r i o u s f a c t o r s may c o n t r i b u t e s i g n i f i c a n t l y t o the p r e d i c t i o n of coping s t r a t e g i e s (Long, 1989; Parkes, 1986). H i r s c h and Enlow (1984) have noted t h a t h e a l t h y gay men with high l e v e l s of i n t e r n a l i z e d homophobia tended t o manifest more g u i l t and d e p r e s s i o n and withdraw from s o c i a l support systems than gay men with low i n t e r n a l i z e d homophobia. S i m i l a r l y , a t t i t u d e towards homosexuality i n HIV+ gay men cou l d be expected t o i n t e r a c t with s e l f - e s t e e m and p e r c e p t i o n of s o c i a l support with a cumulative e f f e c t . There i s a l r e a d y some i n d i c a t i o n t h a t a v a r i e t y of coping s t r a t e g i e s are used by HIV+ gay men and t h a t use of these s t r a t e g i e s may be r e l a t e d t o v a r i o u s p s y c h o s o c i a l f a c t o r s ( H i r s c h & Enlow, 1984; Namir et a l . , 1987; Mandel, 1986). The purpose of t h i s study was t o examine the r e l a t i o n s h i p between i n t e r n a l i z e d homophobia, s e l f - e s t e e m , p e r c e i v e d s o c i a l support and the i n t e r a c t i v e e f f e c t s of 7 these v a r i a b l e s i n HIV+ gay men, with the use of d i f f e r e n t coping s t r a t e g i e s . In p a r t i c u l a r , i t was expected t h a t a f t e r a c c o u n t i n g f o r the e f f e c t s of time s i n c e d i a g n o s i s and s t r e s s o r type, low l e v e l s of s e l f - e s t e e m and s o c i a l support, and a negative a t t i t u d e towards homosexuality, and the i n t e r a c t i o n terms of homophobia times s e l f - e s t e e m and times s o c i a l support, would be a s s o c i a t e d with the g r e a t e r r e l a t i v e use of coping aimed at a v o i d i n g , denying or m i n i m i z i n g the emotional impact and s i g n i f i c a n c e of the d i a g n o s i s . A second e x p e c t a t i o n was t h a t , again a f t e r a c counting f o r the e f f e c t s of time s i n c e d i a g n o s i s and s t r e s s o r type, higher l e v e l s of s e l f - e s t e e m and s o c i a l support, i n c o n j u n c t i o n with a p o s i t i v e a t t i t u d e towards homosexuality, and the i n t e r a c t i o n terms of homophobia times s e l f - e s t e e m and times s o c i a l support, would be a s s o c i a t e d with the g r e a t e r r e l a t i v e use of coping aimed at engaging s o c i a l support and r e i n t e r p r e t i n g the i n f e c t i o n as an o p p o r t u n i t y f o r p e r s o n a l growth. F u r t h e r , i t was expected t h a t the s u b j e c t i v e experience of emotional w e l l - b e i n g i n i n f e c t e d gay men would be n e g a t i v e l y c o r r e l a t e d with the g r e a t e r use of an avoidant s t y l e of coping and p o s i t i v e l y c o r r e l a t e d with the g r e a t e r use of a support seeking and p o s i t i v e r e a p p r a i s i n g form of coping. Based on the findngs of other h e a l t h r e l a t e d s t u d i e s , however, the magnitude of these c o r r e l a t i o n s was expected to be moderate. 8 Review of L i t e r a t u r e Since i t was f i r s t diagnosed and recorded i n 1981, A c q u i r e d Immune D e f i c i e n c y Syndrome (AIDS) has been the focus of world wide a t t e n t i o n . The alarm surrounding the spread of t h i s f a t a l d i s e a s e has provoked a g r e a t d e a l of medical r e s e a r c h i n t o i t s e t i o l o g y and treatment. Research i n t o the p s y c h o l o g i c a l aspects of the d i s e a s e has not been as p r o l i f i c ( K i n n i e r , 1986). T h i s i s an u n f o r t u n a t e s i t u a t i o n given the degree of f e a r , s t r e s s and a n x i e t y the d i s e a s e i n s p i r e s , not o n l y i n people who are i n f e c t e d , but i n the p u b l i c a t l a r g e . In order f o r people to cope more e f f e c t i v e l y with AIDS i t i s important t o understand the r e l e v a n t i s s u e s and s t r e s s o r s a s s o c i a t e d with an HIV i n f e c t i o n . S t r e s s and Coping I n v e s t i g a t i n g how people cope with s t r e s s f u l events has been an important r e s e a r c h area of h e a l t h c o u n s e l l i n g . In the c o g n i t i v e - t r a n s a c t i o n a l model of s t r e s s and coping developed by Lazarus and Folkman (1984), s t r e s s i s viewed as "a r e l a t i o n s h i p between the person and the environment t h a t i s a p p r a i s e d by the person as r e l e v a n t to h i s or her w e l l -b e i n g and i n which the person's resources are taxed or exceeded" (Folkman & Lazarus, 1985, p. 152). Coping i s the method by which an i n d i v i d u a l d e a l s with a s t r e s s o r and i s c o n c e p t u a l i z e d as a dynamic and i n t e r a c t i o n a l process c o n s i s t i n g of an ongoing s e r i e s of " a p p r a i s a l s and r e a p p r a i s a l s of the s h i f t i n g person-environment 9 r e l a t i o n s h i p " (Lazarus & Folkman, 1984, p. 142). Lazarus and Folkman (1984) p o s i t two stages of a p p r a i s a l i n the coping p r o c e s s : primary and secondary. With the primary a p p r a i s a l the i n d i v i d u a l assesses the p e r s o n a l r e l e v a n c e of the encounter and determines whether i t i s i r r e l e v a n t , b e n i g n - p o s i t i v e or s t r e s s f u l . S t r e s s f u l encounters are a p p r a i s e d as t h r e a t , c h a l l e n g e or harm-loss. A t h r e a t a p p r a i s a l suggests the p o t e n t i a l f o r harm or l o s s , a c h a l l e n g e a p p r a i s a l holds the p o t e n t i a l f o r growth or g a i n , w h i l e a harm-loss a p p r a i s a l i n d i c a t e s i n j u r y a l r e a d y endured, be i t of a p h y s i c a l , m a t e r i a l or p s y c h o l o g i c a l nature. The secondary a p p r a i s a l i s c h a r a c t e r i z e d by the q u e s t i o n "What can I do?", and c o n s i s t s of the i n d i v i d u a l e v a l u a t i n g the coping r e s o u r c e s he or she has a v a i l a b l e to use i n response to the s t r e s s o r . The way t h a t an i n d i v i d u a l attempts t o cope with a s t r e s s f u l encounter i s t o a l a r g e degree a f f e c t e d by the a p p r a i s a l s t h a t are made of the encounter. Folkman and Lazarus (1985, 1988b) s p e c u l a t e t h a t the way an i n d i v i d u a l a p p r a i s e s a s t r e s s f u l s i t u a t i o n , whether i t demands a c t i o n or r e q u i r e s the person to take a 'wait and see' stance, and the t h r e a t i t poses to the person's p s y c h o l o g i c a l or p h y s i c a l h e a l t h c o u l d i n f l u e n c e the coping s t r a t e g i e s used. I f the primary a p p r a i s a l of a s i t u a t i o n i s t h a t i t i s i r r e l e v a n t , the i n d i v i d u a l would not be expected to adopt any d i f f e r e n t coping s t r a t e g y i n response. S i m i l a r l y , the i n d i v i d u a l would be expected t o mount a d i f f e r e n t response 10 to the s t r e s s o r i f the secondary a p p r a i s a l were one of c h a l l e n g e r a t h e r than one of t h r e a t . Functions of coping. Because d i f f e r e n t a p p r a i s a l s of a s t r e s s o r can y i e l d d i f f e r e n t c oping responses i t i s apparent t h a t coping can serve d i f f e r e n t f u n c t i o n s . Coping which i s aimed a t managing or a l t e r i n g the person-environment r e l a t i o n s h i p c a u s i n g the problem has been l a b e l e d i n s t r u m e n t a l or problem-focused coping, whereas coping which attempts t o r e g u l a t e the i n d i v i d u a l ' s emotional responses t o the s t r e s s f u l s i t u a t i o n has been c a l l e d p a l l i a t i v e or emotion-focused coping (Lazarus & Folkman, 1984). Although r e s e a r c h has shown t h a t people g e n e r a l l y use a combination of both forms of coping i n response t o a s t r e s s o r (Folkman & Lazarus, 1980, 1985), r e s e a r c h a l s o suggests t h a t c e r t a i n circumstances favour the predominance of one form of coping over the other. In the e a r l y stage of d e a l i n g with a s t r e s s o r , f o r example, problem-focused s t r a t e g i e s may be used t o a g r e a t e r degree w h i l e t h e r e appears to be p o s i t i v e steps t h a t can be taken i n response to the s t r e s s o r . Emotion-focused s t r a t e g i e s are more l i k e l y t o be used l a t e r i n the process i f the i n d i v i d u a l does not f e e l he or she can e x e r t an e f f e c t on the outcome (Folkman & Lazarus, 1985; Folkman, Lazarus, Dunkel-Schetter et a l . , 1986). G e n e r a l l y speaking, problem-focused coping s t r a t e g i e s are more l i k e l y t o be used i n s i t u a t i o n s i n which th e r e appears t o be the p o s s i b i l i t y f o r c o n s t r u c t i v e a c t i o n or i n which more i n f o r m a t i o n i s r e q u i r e d b e f o r e the i n d i v i d u a l can a c t (Folkman & Lazarus, 1980, 1985; Folkman, Lazarus, Dunkel-Schetter et a l . , 1986). Emotion-focused coping behaviours, on the other hand, tend t o take precedence when the i n d i v i d u a l f e e l s t h a t he or she has l i t t l e c o n t r o l over the s i t u a t i o n or t h a t problem-focused s t r a t e g i e s w i l l be i n e f f e c t i v e . T h i s i s p a r t i c u l a r l y t r u e i n coping with h e a l t h or i l l n e s s concerns ( F e l t o n & Revenson, 1984; Folkman _ Lazarus, 1980; P e a r l i n & Schooler 1978) . The Ways of Coping S c a l e . In order t o assess coping f u n c t i o n s Folkman and Lazarus (1980) developed a 68-item instrument which measured the use of a wide range of c o g n i t i v e and b e h a v i o u r a l c o p i n g responses. Respondents were asked t o i n d i c a t e 'yes' or 'no' whether they had used the response i n d e a l i n g with a s t r e s s o r . The items were seen as b e i n g e i t h e r problem-focused i n nature or emotion-focused. Examples of problem-focused responses i n c l u d e d "made a p l a n of a c t i o n and f o l l o w e d i t " , or "changed something so t h i n g s would t u r n out a l l r i g h t " , w h i l e emotion-focused responses i n c l u d e d such items as " t r i e d t o f o r g e t the whole t h i n g " and "accepted sympathy and understanding from someone". The Ways of Coping Scale (WOCS) was l a t e r r e v i s e d i n t o a 67-item instrument (Folkman & Lazarus, 1985). R e v i s i o n s i n c l u d e d the rewording or d e l e t i o n of c e r t a i n responses and the a d d i t i o n of new responses. Rather than a 'yes' or 'no' su b j e c t s were asked t o respond t o the items a l o n g a 4-point 12 L i k e r t - t y p e s c a l e i n d i c a t i n g frequency of use (e.g., 0 = not at a l l t o 4 = a grea t d e a l ) . Thus, the WOCS became a measure of coping response frequency. Coping s t r a t e g i e s . F u r t h e r r e s e a r c h with the 68-item and 67-item WOCS demonstrated t h a t w i t h i n the broader matrix of problem- and emotion-focused coping t h e r e are s p e c i f i c s u b s t r a t e g i e s which can be i s o l a t e d . These s t r a t e g i e s c o n s i s t of c l u s t e r s of b e h a v i o u r a l and c o g n i t i v e responses which r e p r e s e n t a more s p e c i f i c f u n c t i o n or approach t o coping. F a c t o r a n a l y s i s of WOCS scores have i s o l a t e d between f i v e and e i g h t separate coping subscales or f a c t o r s i n a wide range of s t u d i e s w i t h d i f f e r e n t p o p u l a t i o n s ( c f . Coyne, Aldwin, & Lazarus, 1981; Folkman & Lazarus, 1985; Folkman, Lazarus, Dunkel-Schetter et a l . , 1986; Revenson, 1981; Vingerhoets & F l o h r , 1984). Although t h e r e are some minor d i f f e r e n c e s i n the number of subscales and the items which comprise them, a l l the s t u d i e s have y i e l d e d a seeking s o c i a l support s c a l e , a p o s i t i v e r e a p p r a i s a l s c a l e , an a c c e p t i n g r e s p o n s i b i l i t y or sel f - b l a m e s c a l e , and a problem-s o l v i n g s c a l e . That these v a r i o u s s t u d i e s have produced s i m i l a r r e s u l t s across d i f f e r e n t p o p u l a t i o n s p r o v i d e s e m p i r i c a l support f o r the v a l i d i t y of the subscales and t h e i r use i n coping r e s e a r c h . The t h e o r e t i c a l framework of the pr e s e n t study i s based on the e i g h t subscales d e s c r i b e d by Folkman, Lazarus, Dunkel-Schetter et a l . (1986). They are: (a) C o n f r o n t i v e (CON) ("stood my ground and fought f o r what I wanted"); (b) 13 D i s t a n c i n g (D) ("went on as i f nothin g had happened", " t r i e d t o f o r g e t the whole t h i n g " ) ; (c) S e l f - C o n t r o l (SC) ( " t r i e d to keep my f e e l i n g s to m y s e l f " ) ; (d) Seeking S o c i a l Support (SSS) ("accepted sympathy and understanding from someone"); (e) A c c e p t i n g R e s p o n s i b i l t y (AR) ( " r e a l i z e d I brought the problem on m y s e l f " ) ; ( f ) Escape-Avoidance (EA) ("avoided being with people i n g e n e r a l " , " t r i e d t o make myself f e e l b e t t e r by d r i n k i n g or t a k i n g d r u g s " ) ; (g) P l a n f u l Problem S o l v i n g (PPS) ("made a p l a n of a c t i o n and f o l l o w e d i t " ) , (h) P o s i t i v e R e a p p r a i s a l (PR) ("came out of the experience b e t t e r than I went i n " ) . Although the use of separate coping subscales may be accessed by the WOCS, Folkman, Lazarus, Gruen, and DeLongis (1986) c a u t i o n t h a t t h e r e i s l i k e l y c o n s i d e r a b l e i n t e r c o r r e l a t i o n between the s t r a t e g i e s . T h i s has been demonstrated by s t u d i e s i n which the r e l a t i o n s h i p s between the e i g h t coping s t r a t e g i e s d i s c u s s e d above have been examined (Folkman, Lazarus, Dunkel-Schetter et a l . , 1986; Folkman, Lazarus, Gruen, & DeLongis, 1986; Folkman & Lazarus, 1988a). C o r r e l a t i o n matrixes between the e i g h t s t r a t e g i e s have y i e l d e d r ' s ra n g i n g from -0.16 to 0.55 f o r v a r i o u s s u b j e c t p o p u l a t i o n s , i n d i c a t i n g v a r y i n g degrees of c o l i n e a r i t y between the d i f f e r e n t s t r a t e g i e s . D i s t a n c i n g and Escape-Avoidance, f o r example, have had r ' s ra n g i n g from 0.12 to 0.36 with the m a j o r i t y b e i n g over 0.26. Higher i n t e r c o r r e l a t i o n s are c o n s i s t e n l y observed between S e l f -C o n t r o l l i n g , A c c e p t i n g R e s p o n s i b i l i t y and D i s t a n c i n g and 14 betweeen S e l f - C o n t r o l l i n g , A c c e p t i n g R e s p o n s i b i l i t y and Escape-Avoidance across a l l s t u d i e s . S i m i l a r l y , Seeking S o c i a l Support and P o s i t i v e R e a p p r a i s a l have y i e l d e d r ' s across the same s t u d i e s r a n g i n g from 0.2 7 t o 0.45, again suggesting a moderate degree of c o l i n e a r i t y . In c o n t r a s t D i s t a n c i n g had l i t t l e c o r r e l a t i o n with e i t h e r P o s i t i v e R e a p p r a i s a l or Seeking S o c i a l Support. C o r r e l a t i o n c o e f f i c i e n t s ranged from 0.06 t o 0.13 f o r D i s t a n c i n g and P o s i t i v e R e a p p r a i s a l and from -0.16 to 0.00, i n d i c a t i n g a s l i g h t negative r e l a t i o n s h i p between Seeking S o c i a l Support and D i s t a n c i n g , as might be i n t u i t i v e l y expected. S i m i l a r l y , low t o moderate i n t e r c o r r e l a t i o n s were a l s o observed between Escape-Avoidance and Seeking S o c i a l Support and P o s i t i v e R e a p p r a i s a l . C o r r e l a t i o n s ranged from 0.04 to 0.38 between Escape-Avoidance and Seeking S o c i a l Support and from 0.23 to 0.31 between Escape-Avoidance and P o s i t i v e R e a p p r a i s a l . These f i g u r e s suggest t h a t d i f f e r e n t combinations of s t r a t e g i e s are more l i k e l y t o be used t o g e t h e r than are other combinations. D i s t a n c i n g , f o r example, i s not l i k e l y t o be used i n combination w i t h P o s i t i v e R e a p p r a i s a l or Seeking S o c i a l Support. S i m i l a r l y , Escape-Avoidance seems t o be somewhat more s t r o n g l y a s s o c i a t e d with D i s t a n c i n g , than with P o s i t i v e R e a p p r a i s a l or Seeking S o c i a l Support. The s t r o n g e r p o s i t i v e c o r r e l a t i o n s between Seeking S o c i a l Support and P o s i t i v e R e a p p r a i s a l , however, suggest t h a t they are more l i k e l y t o be used c o n j o i n t l y . 15 Thus, although i n broad terms coping may serve a problem- and/or emotion-focused f u n c t i o n , i t i s not adequate to speak of these terms of as i f e i t h e r were a homogeneous group of behaviours and c o g n i t i o n s (Fleishman, 1984). D i s t a n c i n g and P o s i t i v e R e a p p r a i s a l , which are both forms of emotion-focused coping, f o r example, are q u i t e d i f f e r e n t i n the r e i n t e n t and would not be expected t o be used t o g e t h e r i n response t o a s t r e s s o r . At the same time, c e r t a i n s t r a t e g i e s are more l i k e l y t o be used i n c o n j u c t i o n with c e r t a i n other s t r a t e g i e s . The presence of d i f f e r e n t s t r a t e g i e s which, while s e r v i n g the same broad f u n c t i o n ( i . e . , emotion- or problem-focused), are u n l i k e l y t o be used simultaneously, suggests t h a t other f a c t o r s a c t i n g d u r i n g the secondary a p p r a i s a l process help determine the r e l a t i v e dominance of c e r t a i n coping s t r a t e g i e s over o t h e r s . These f i n d i n g s u n d e r l i e the importance of c o n s i d e r i n g coping s t r a t e g i e s s e p a r a t e l y or i n c o n j u n c t i o n with r e l a t e d s t r a t e g i e s when conducting r e s e a r c h i n t o coping p r o c e s s e s . M i t i g a t i n g F a c t o r s i n the Coping Process An i n d i v i d u a l ' s a p p r a i s a l s of a s t r e s s o r can be a f f e c t e d by a v a r i e t y of f a c t o r s . These f a c t o r s are t y p i c a l l y grouped i n t o t h r e e broad c a t e g o r i e s : (a) p e r s o n a l f a c t o r s which o r i g i n a t e w i t h i n the i n d i v i d u a l , such as optimism or self- e s t e e m , (b) environmental f a c t o r s which o r i g i n a t e o u t s i d e of the i n d i v i d u a l , such as monetary support or work demand, and (c) s i t u a t i o n a l or c o n t e x t u a l f a c t o r s which are r e l e v a n t t o the s t r e s s f u l episode, such as 16 type of s t r e s s o r or i t s p e r c e i v e d importance t o the i n d i v i d u a l (Holahan & Moos, 1987; Lazarus & Folkman, 1984; Parkes, 1986). In the case of h e a l t h concerns, the nature of the i l l n e s s i s a s i t u a t i o n a l f a c t o r which can a f f e c t the a p p r a i s a l s made by the i n d i v i d u a l (Lipowski, 1970). Although the way i n which p e r s o n a l , environmental and s i t u a t i o n a l f a c t o r s can a f f e c t an i n d i v i d u a l ' s a p p r a i s a l of a s t r e s s o r i s r e l a t i v e l y obvious, the r e l a t i o n s h i p between coping s t r a t e g i e s and these f a c t o r s i s c o n s i d e r a b l y more complex. Folkman and Lazarus (1988b) c o n s i d e r the r e l a t i o n s h i p between emotional s t a t e s and coping s t r a t e g i e s to be h i g h l y i n t e r a c t i o n a l , w i t h mood s t a t e a f f e c t i n g coping and coping subseguently a f f e c t i n g mood. The use of an avoidant s t r a t e g y , f o r example, may prove u s e f u l i n d e a l i n g with f e a r or a n x i e t y i n the e a r l y stage of a s t r e s s o r , and thus c o n t r i b u t e t o a more p o s i t i v e mood s t a t e . I f the continued use of avoidance r e s u l t s i n a p p r o p r i a t e a c t i o n not being taken and a worsening of the s i t u a t i o n , however, t h i s c o u l d r e s u l t i n a worsened mood s t a t e . The t r a n s a c t i o n a l complexity of the i n t e r a c t i o n s makes i t v e ry d i f f i c u l t t o a s s i g n r e l a t i v e importance or a c a u s a l o r d e r i n g t o the e f f e c t s of coping s t r a t e g i e s and the v a r i o u s f a c t o r s on the coping p r o c e s s . As a r e s u l t , r e s e a r c h has proceeded i n two ways: (a) u s i n g p e r s o n a l , environmental and co n t e x t u a l v a r i a b l e s t o p r e d i c t coping s t r a t e g i e s , and (b) us i n g coping s t r a t e g i e s ( o f t e n i n c o n j u c t i o n w i t h other v a r i a b l e s ) t o p r e d i c t some measure of adjustment. 17 Self-esteem and s o c i a l support. Two v a r i a b l e s which are b e l i e v e d t o have moderating e f f e c t s on the a p p r a i s a l and adjustment process are s e l f - e s t e e m and s o c i a l support. As a p e r s o n a l i t y v a r i a b l e , Lazarus and Folkman (1984) c o n s i d e r s e l f - e s t e e m t o be p a r t of a l a r g e r f a c t o r they c a l l p o s i t i v e b e l i e f . Higher l e v e l s of s e l f - e s t e e m have been shown t o p o s i t i v e l y c o r r e l a t e with r e d u c t i o n of s t r e s s or more s u c c e s s f u l coping i n s t u d i e s of h e a l t h y a d u l t s d e a l i n g with d a i l y s t r e s s o r s and people a d j u s t i n g t o s p i n a l c o r d i n j u r i e s (DeLongis, Folkman, & Lazarus, 1988; P e a r l i n _ Schooler, 1978; Van Den Bout, Van Son-Schoones, Schipper, & G r o f f e n , 1988). S o c i a l support has been shown to p l a y an important r o l e i n d e a l i n g with traumatic l i f e events such as major i l l n e s s or l o s s (see reviews by DiMatteo & Hays, 1981; S i l v e r & Wortman; 1980, Turner, 1983). Having reviewed the r e l e v a n t l i t e r a t u r e , Lazarus and Folkman (1984) suggest t h a t low l e v e l s of s o c i a l support are a s s o c i a t e d with n e g a t i v e h e a l t h outcomes. Recent coping r e s e a r c h has found s o c i a l support to be a s i g n f i c a n t environmental f a c t o r i n the adjustment t o d a i l y l i v i n g and w o r k - r e l a t e d s t r e s s (Holahan & Moos, 1987; Long, 1989; Parkes, 1986). In d i s c u s s i n g s o c i a l support r e s e a r c h , however, i t i s o f t e n d i f f i c u l t t o g e n e r a l i z e across s t u d i e s because s o c i a l support i s not a w e l l - d e f i n e d concept. Researchers o f t e n o p e r a t i o n a l i z e s o c i a l support i n d i f f e r e n t ways and use instruments which measure d i f f e r e n t concepts ( B a r r e r a , 1986; 18 Pearson, 1986; Turner, F r a n k e l , & L e v i n , 1983). S o c i a l support, f o r example, has been conceived of i n terms of enacted support, p e r c e i v e d support and s o c i a l embeddedness, and has been q u a n t i f i e d with instruments a s s e s s i n g numbers and types of others i n an i n d i v i d u a l ' s network, numbers and types of a c t u a l s o c i a l c o n t a c t s , and frequency of and s a t i s f a c t i o n with support r e c e i v e d . Cobb (1976) conceived of s o c i a l support as i n f o r m a t i o n b e l o n g i n g t o one or more of the f o l l o w i n g c l a s s e s : (a) i n f o r m a t i o n l e a d i n g the s u b j e c t t o b e l i e v e t h a t he or she i s cared f o r and loved; (b) i n f o r m a t i o n l e a d i n g the s u b j e c t t o b e l i e v e t h a t he or she i s esteemed and valued; and (c) i n f o r m a t i o n l e a d i n g the s u b j e c t t o b e l i e v e t h a t he or she belongs t o a network of communication and mutual o b l i g a t i o n . As such, Cobb's d e f i n i t i o n f a l l s i n t o the category of p e r c e i v e d s o c i a l support, as opposed t o enacted support or s o c i a l embeddedness ( B a r r e r a , 1986). An instrument designed by Kaplan (1977), based on Cobb's d e f i n i t i o n , attempts t o measure s o c i a l support a l o n g these t h r e e f a c t o r s . Subsequent work with the o r i g i n a l s c a l e and a r e v i s e d v e r s i o n by Turner et a l . (1983) found t h a t f a c t o r analyses y i e l d e d two p r i n c i p l e f a c t o r s : a l o v e -esteem f a c t o r and a network f a c t o r . U s i n g the r e v i s e d instrument Turner et a l . were able t o show s i g n i f i c a n t c o r r e l a t i o n s between s o c i a l support and p s y c h o l o g i c a l d i s t r e s s i n a group of 523 d i s c h a r g e d p s y c h i a t r i c p a t i e n t s , and between s o c i a l support and anger, a n x i e t y and d e p r e s s i o n 19 i n 989 p h y s i c a l l y d i s a b l e d a d u l t s ( a l l p_'s<.01). Coping s t r a t e g i e s as c r i t e r i o n v a r i a b l e s . Because of the wide number of f a c t o r s which can i n f l u e n c e the coping process, coping must be examined w i t h i n a b r o a d l y framed and i n t e g r a t i v e p e r s p e c t i v e i n which both the a d d i t i v e , as w e l l as the i n t e r a c t i v e e f f e c t s , of d i f f e r e n t v a r i a b l e s i s c o n s i d e r e d (Holahan & Moos, 1987; Lazarus & Folkman, 1984; Parkes, 1986). A number of r e c e n t s t u d i e s have used coping s t r a t e g i e s as c r i t e r i o n v a r i a b l e s i n m u l t i p l e r e g r e s s i o n models, i n t o which a v a r i e t y of p e r s o n a l , environmental and c o n t e x t u a l v a r i a b l e s have been entered as p r e d i c t o r v a r i a b l e s , t e s t i n g t h e i r s t r e n g t h of a s s o c i a t i o n with the coping s t r a t e g i e s . Holahan and Moos (1987) found t h a t a c o l l e c t i o n of sociodemographic v a r i a b l e s , i n c l u d i n g education and income, p e r s o n a l i t y d i s p o s i t i o n s of s e l f - c o n f i d e n c e and an easygoing manner, and c o n t e x t u a l f a c t o r s of f a m i l y support and n egative l i f e events, made s i g n i f i c a n t c o n t r i b u t i o n s to p r e d i c t i n g a c t i v e - b e h a v i o u r a l , a c t i v e c o g n i t i v e and avoidance coping i n samples of 424 community based i n d i v i d u a l s (194 men, 230 women, mean age = 39) and 424 persons e n t e r i n g p s y c h i a t r i c treatment f o r u n i p o l a r d e p r e s s i o n (189 men, 235 women, mean age = 41). Respondents were asked t o c o n s i d e r the most s t r e s s f u l episode they had experienced i n the past week. H i e r a r c h i c a l stepwise r e g r e s s i o n s u s i n g coping s t r a t e g i e s as c r i t e r i o n v a r i a b l e s were conducted f o r both 20 groups. Sociodemographic v a r i a b l e s were entered f i r s t , f o l l o w e d by p e r s o n a l i t y v a r i a b l e s and c o n t e x t u a l v a r i a b l e s . In both groups a l l t h r e e v a r i a b l e groups were s i g n i f i c a n t l y a s s o c i a t e d with the coping s t r a t e g i e s , with the e x c e p t i o n t h a t background v a r i a b l e s were not r e l a t e d t o a c t i v e -c o g n i t i v e coping i n e i t h e r group. Family support and s e l f -c onfidence were p o s i t i v e l y a s s o c i a t e d with both a c t i v e s t r a t e g i e s w h ile being n e g a t i v e l y a s s o c i a t e d w i t h avoidance. I n d i v i d u a l s who had more p e r s o n a l and environmental resources were more l i k e l y t o r e l y on a c t i v e coping and l e s s l i k e l y t o r e l y on avoidance coping. Avoidance coping tended to be more s t r o n g l y a s s o c i a t e d with negative events and was used i n response t o a t h r e a t e n i n g s i t u a t i o n when p e r s o n a l and c o n t e x t u a l resources were s c a r c e . Parkes (1986) examined the r e l a t i o n s h i p between i n d i v i d u a l d i f f e r e n c e s ( e x t r a v e r s i o n and n e u r o t i c i s m ) , environmental f a c t o r s ( s o c i a l support and work demand) and s i t u a t i o n a l c h a r a c t e r i s t i c s (type of s t r e s s f u l episode and i t s p e r c e i v e d importance) and the use of g e n e r a l , d i r e c t and suppression coping s t r a t e g i e s i n d e a l i n g with w o r k - r e l a t e d s t r e s s i n a group of 135 f i r s t - y e a r female n u r s i n g students. Coping s t r a t e g i e s were d e r i v e d from the WOCS. Separate h i e r a r c h i c a l stepwise r e g r e s s i o n analyses were conducted with a d d i t i v e and s p e c i f i c i n t e r a c t i v e e f f e c t s of the v a r i a b l e s p r e d i c t i n g the coping s t r a t e g i e s . The r e s u l t s i n d i c a t e d t h a t d i f f e r e n t combinations of the v a r i a b l e s were s i g n i f i c a n t p r e d i c t o r s of coping 21 s t r a t e g i e s , i n both the a d d i t i v e and i n t e r a c t i v e models. With d i r e c t coping, f o r example, the a d d i t i v e e f f e c t s of i n d i v i d u a l d i f f e r e n c e s and s i t u a t i o n a l f a c t o r s were both s i g n i f i c a n t and together accounted f o r 20% of the t o t a l v a r i a n c e , whereas with s u p p r e s s i o n coping the s i t u a t i o n a l f a c t o r s alone were s i g n f i c a n t and accounted f o r 11% of the t o t a l v a r i a n c e . With r e s p e c t t o ge n e r a l coping a l l f a c t o r s c o n t r i b u t e d s i g n i f i c a n t l y t o the equation and e x p l a i n e d 27% of the t o t a l v a r i a n c e . When the i n t e r a c t i v e e f f e c t s were i n c l u d e d i n the r e g r e s s i o n equations, e x t r a v e r s i o n , n e u r o t i c i s m , and s o c i a l support x importance of episode, n e u r o t i c i s m x work demand and e x t r a v e r s i o n x importance of episode were a l l s i g n i f i c a n t . N e u r o t i c i s m and e x t r a v e r s i o n x importance of episode were n e g a t i v e l y a s s o c i a t e d with d i r e c t coping, whereas the remaining s i g n i f i c a n t f a c t o r s were p o s i t i v e l y a s s o c i a t e d . The i n t e r a c t i v e terms of e x t r a v e r s i o n x n e u r o t i c i s m and work demand x importance of episode were both s i g n i f i c a n t l y p o s i t i v e l y a s s o c i a t e d with suppression coping, while the terms of importance of episode x episode type, and n e u r o t i c i s m x work demand were n e g a t i v l e y a s s o c i a t e d . In a l l , the v a r i a b l e s accounted f o r 17% of the t o t a l v a r i a n c e . Long (1989) examined the a b i l i t y of the a d d i t i v e and i n t e r a c t i v e e f f e c t s of p e r s o n a l ( i n s t r u m e n t a l i t y and expressiveness) (Bern, 1981), environmental (work demands and i n t e r p e r s o n a l work resources) and s i t u a t i o n a l ( s t r e s s f u l episode importance) f a c t o r s t o p r e d i c t a c t i v e , problem 22 r e a p p r a i s a l or avoidance c o p i n g s t r a t e g i e s , as measured by a mo d i f i e d v e r s i o n of the WOCS, with r e s p e c t t o wo r k - r e l a t e d s t r e s s . Subjects were 132 managers (60 men, mean age = 42, 72 women, mean age = 3 9 ) . A s e r i e s of h i e r a r c h i c a l stepwise r e g r e s s i o n analyses were conducted i n which the a d d i t i v e e f f e c t s of the p e r s o n a l , environmental and c o n t e x t u a l v a r i a b l e s were entered with r e s p e c t t o a c t i v e , problem r e a p p r a i s a l , avoidance and t o t a l coping, f o l l o w e d by the hypothesized i n t e r a c t i v e e f f e c t s . The r e s u l t s suggested t h a t with r e s p e c t t o avoidance coping, sex and importance of episode had a s i g n i f i c a n t p o s i t i v e a s s o c i a t i o n w h ile the p e r s o n a l i t y v a r i a b l e and work resources were n e g a t i v e l y a s s o c i a t e d . In the case of r e a p p r a i s a l coping sex and the p e r s o n a l i t y v a r i a b l e were both s i g n i f i c a n t l y p o s i t i v e l y a s s o c i a t e d . The p e r s o n a l i t y v a r i a b l e , environmental v a r i a b l e , and the importance of the episode were a l l p o s i t i v e l y a s s o c i a t e d with a c t i v e coping. Sex, expressiveness and importance of episode were p o s i t i v e l y a s s o c i a t e d with t o t a l coping. The i n t e r a c t i v e terms were l a r g e l y n o n s i g n i f i c a n t i n ac c o u n t i n g f o r the ex p l a i n e d v a r i a n c e . These r e s u l t s suggest t h a t d i f f e r e n t types of v a r i a b l e s have g r e a t e r or l e s s e r importance i n p r e d i c t i n g the use of s p e c i f i c c oping s t r a t e g i e s . In the area of coping w i t h i l l n e s s concerns, F e i f e l et a l . (1987) examined the r e l a t i o n s h i p between demographic, i l l n e s s and p s y c h o l o g i c a l v a r i a b l e s and th r e e c o p i n g s t r a t e g i e s ( c o n f r o n t a t i o n , avoidance, acceptance-23 r e s i g n a t i o n ) used by m e d i c a l l y i l l p a t i e n t s t o d e a l with t h e i r i l l n e s s . The sample c o n s i s t e d of 223 male with d i f f e r e n t i l l n e s s e s (cancer, n=74; myocardial i n f a r c t i o n , n=77; c h r o n i c nonthreatening i l l n e s s , n=72) wit h a mean age of 54 y e a r s . Demographic v a r i a b l e s i n c l u d e d age, s o c i o -economic s t a t u s , v e r b a l IQ and l e n g t h of i l l n e s s . P s y c h o l o g i c a l v a r i a b l e s i n c l u d e d mood s t a t e , r e l i g i o s i t y , locus of c o n t r o l , s e l f concept, and p e r c e i v e d s o c i a l support. A combination of h i e r a r c h i c a l and stepwise analyses, with the coping s t r a t e g i e s as c r i t e r i o n v a r i a b l e s , were conducted i n which the demographic v a r i a b l e s were entered, f o l l o w e d by i l l n e s s c l a s s i f i c a t i o n s , the p s y c h o l o g i c a l v a r i a b l e s and the remaining v a r i a b l e s . The v a r i a b l e s were entered i n such an order as t o account f o r random v a r i a b l e s f i r s t , then f i x e d v a r i a b l e s , and f i n a l l y d i s p o s i t i o n a l v a r i a b l e s . Belonging t o a n o n - l i f e - t h r e a t e n i n g group was found t o be n e g a t i v e l y a s s o c i a t e d w i t h c o n f r o n t a t i o n coping w h i l e e x t r o v e r s i o n and the s e r i o u s n e s s of the i l l n e s s were p o s i t i v e l y a s s o c i a t e d . Socioeconomic s t a t u s and s e l f -d i r e c t i o n were n e g a t i v e l y a s s o c i a t e d with avoidance coping. A negative s e l f - p e r c e p t i o n was p o s i t i v e l y a s s o c i a t e d with avoidance coping. Length of i l l n e s s , n e g ative s e l f -p e r c e p t i o n , negative a f f e c t i v e e x p r e s s i o n and reduced a t t e n t i o n a l focus were p o s i t i v e l y a s s o c i a t e d with a c c e p t a n c e - r e s i g n a t i o n coping, w h i l e p o s i t i v e e x p e c t a t i o n s about recovery and about the f u t u r e were n e g a t i v e l y 24 a s s o c i a t e d . These r e s u l t s suggest t h a t a poor s e l f - c o n c e p t i s a s s o c i a t e d with g r e a t e r use of avoidance and acceptance-r e s i g n a t i o n coping s t r a t e g i e s . S i m i l a r l y , the longer one has had an i l l n e s s the more a c c e p t a n c e - r e s i g n a t i o n coping one i s l i k e l y t o use. I t i s a l s o important t o note t h a t a p e s s i m i s t i c outlook r e g a r d i n g the f u t u r e i s a s s o c i a t e d with g r e a t e r a c c e p t a n c e - r e s i g n a t i o n . The f a c t t h a t c o n f r o n t a t i o n was l e s s l i k e l y t o be used by those p a t i e n t s who d i d not have a l i f e - t h r e a t e n i n g i l l n e s s suggests t h a t the ser i o u s n e s s of the i l l n e s s a l s o has a b e a r i n g on the type of coping used. In g e n e r a l , then, r e s e a r c h suggests t h a t i t i s important t o c o n s i d e r a wide range of p e r s o n a l , environmental and c o n t e x t u a l v a r i a b l e s when examining the use of c e r t a i n coping s t r a t e g i e s . As of y e t i t i s not p o s s i b l e t o d i s t i n g u i s h c l e a r p a t t e r n s of v a r i a b l e s with coping s t r a t e g i e s . I t might be t e n t a t i v e l y s a i d t h a t a l a c k of p e r s o n a l resources (such as s e l f - e s t e e m or p o s i t i v e a f f e c t ) are a s s o c i a t e d with a g r e a t e r use of avoidant forms of coping. The r e s e a r c h a l s o suggests t h a t the nature of the s t r e s s o r a l s o has some b e a r i n g on the a s s o c i a t i o n between p r e d i c t o r v a r i a b l e s and coping s t r a t e g i e s . F u r t h e r r e s e a r c h needs t o take i n t o account, t h e r e f o r e , not o n l y the p a r t i c u l a r c o n t e x t u a l circumstances surrounding the s t r e s s f u l encounter, but a l s o the s p e c i f i c s t r e s s f u l encounter i t s e l f . I t may be t h a t r e s e a r c h i n which 25 p a r t i c i p a n t s are responding t o a ge n e r a l or l o o s e l y d e f i n e d s t r e s s o r misses d i f f e r e n c e s based on r e a c t i o n s t o d i f f e r e n t s t r e s s o r s . A f u r t h e r d i f f i c u l t y i n re v i e w i n g coping r e s e a r c h i s the l a c k of g e n e r a l i z a b i l i t y of the instruments used t o measure coping and coping s t r a t e g i e s . Although many of the st u d i e s c i t e d have used the WOCS or some m o d i f i e d v e r s i o n of i t , a number have used d i f f e r e n t instruments. Even those which have used the WOCS have o f t e n used d i f f e r e n t coping s t r a t e g i e s composed of d i f f e r e n t items. In some cases the choice of items and s t r a t e g i e s i s based on p r e v i o u s r e s e a r c h , i n other cases i t i s based on f a c t o r a n a l y s i s of the items or some t h e o r e t i c a l b a s i s f o r s e l e c t i o n . Whereas some r e s e a r c h e r s argue t h a t the de t e r m i n a t i o n of coping s t r a t e g i e s should be done a p r i o r i the a c t u a l data g a t h e r i n g and should be based on a t h e o r e t i c a l framework (Carver, S c h e i e r , & Weintraub, 1989), o t h e r r e s e a r c h e r have determined the s t r a t e g i e s based on a f a c t o r a n a l y s i s of the data ( c f . Folkman & Lazarus, 1985; Folkman, Lazarus, Dunkel-S c h e t t e r et a l . , 1986). Although the r e l a t i v e m e r i t s of these d i f f e r e n c e s i n approach have yet t o be f u l l y d i s c u s s e d , the f a c t t h a t d i f f e r e n t instruments and s t r a t e g i e s are used p r e s e n t s problems i n i n t e r p r e t i n g coping r e s e a r c h . Adaptiveness of Coping S t r a t e g i e s I t cannot g e n e r a l l y be s a i d t h a t any one s t r a t e g y of coping i s adaptive or maladaptive because an i n d i v i d u a l may 26 use d i f f e r e n t c o p i n g s t r a t e g i e s a t d i f f e r e n t t i m e s o r i n response t o d i f f e r e n t s t r e s s o r s . Both Folkman and L a z a r u s (1980) and P e a r l i n and S c h o o l e r (1978), i n s t u d i e s w i t h community based samples o f a d u l t s , found e v i d e n c e t o suggest t h a t d i f f e r e n t s t r a t e g i e s were more o r l e s s l i k e l y t o be used and were more o r l e s s e f f e c t i v e depending on t h e c o n t e x t and n a t u r e o f t h e s t r e s s f u l e n c o u n t e r . T y p i c a l l y t h e r e a r e t h r e e f u n c t i o n s w h i c h c o p i n g can s e r v e : (a) address o r change t h e s t r e s s i n d u c i n g problem so t h a t i t i s no l o n g e r s t r e s s f u l , (b) change t h e a p p r a i s a l o f t h e s i t u a t i o n o r m o d i f y t h e s u b j e c t i v e meaning o f t h e s i t u a t i o n , (c) manage t h e e m o t i o n a l r e s p o n s e t o t h e s i t u a t i o n ( L a z a r u s & Folkman, 1984). The a p p r o p r i a t e n e s s o f a c o p i n g s t r a t e g y , t h e r e f o r e , depends as much on t h e f u n c t i o n i t i s t r y i n g t o s e r v e , as on t h e b r o a d e r p a r t i c u l a r s o f t h e p e r s o n -environment r e l a t i o n s h i p i n whi c h t h e s t r e s s o r i s e x p e r i e n c e d . Because t h e person-environment r e l a t i o n s h i p i s c o n s t a n t l y s h i f t i n g , b o t h because of and i n s p i t e of t h e i n d i v i d u a l ' s c o p i n g r e s p o n s e s , a c o p i n g s t r a t e g y which i s e f f e c t i v e o r a p p r o p r i a t e a t one p o i n t i n t i m e may o r may not be e f f e c t i v e a t a l a t e r p o i n t i n t i m e . S i m i l a r l y , a c o p i n g s t r a t e g y used a t an i n a p p r o p r i a t e t i m e may have a n e g a t i v e e f f e c t on t h e o v e r a l l c o p i n g p r o c e s s . A l t h o u g h d i f f e r e n t s t r a t e g i e s may appear t o s e r v e t h e same f u n c t i o n ( i . e . , managing e m o t i o n a l r e s p o n s e s o r a l t e r i n g t h e s t r e s s f u l p r o b l e m ) , Folkman and L a z a r u s (1988b) suggest t h a t t h e r e l a t i o n s h i p s between s t r a t e g i e s and t h e i r 27 e f f e c t s are not always the same. D e n i a l , f o r example, i s an emotion-focused form of c o p i n g t h a t i s commonly used i n response to a l i f e - t h r e a t e n i n g i l l n e s s (Folkman & Lazarus, 1988b; H i r s c h & Enlow, 1984; Kubler-Ross, 1969; S t u l b e r g & Buckingham, 1988). In some cases d e n i a l i s a reasonable coping mechanism i n t h a t i t may a c t as a b u f f e r t o the hopelessness and powerlessness t h a t the i n d i v i d u a l experiences ( H i r s c h & Enlow, 1984; Moynihan, C h r i s t , & S i l v e r , 1988; P r i c e et a l . , 1986). D e n i a l becomes maladaptive, however, when i t i n t e r f e r e s with a person seeking medical help or r e s u l t s i n behaviours which c o u l d f u r t h e r aggrevate the course of the d i s e a s e . As another example, D i s t a n c i n g and P o s i t i v e R e a p p r a i s a l (Folkman, Lazarus, Dunkel-Schetter et a l . , 1986) are c o n s i d e r e d t o have s i m i l a r f u n c t i o n s i n t h a t they both are ways of changing the s u b j e c t i v e meaning of the person-environment s i t u a t i o n . Folkman and Lazarus (1988b) note, however, t h a t s e l e c t i v e a t t e n t i o n i s o f t e n e a s i e r t o maintain than i s d i s t o r t i o n of r e a l i t y . Thus, D i s t a n c i n g as a s t r a t e g y may not p r o v i d e continued r e l i e f from d i s t r e s s i n the face of c o n t r a d i c t o r y evidence from the environment, whereas P o s i t i v e R e a p p r a i s a l can p r o v i d e a boost t o s e l f -esteem and may be encouraged by o t h e r s . S i m i l a r l y , as an emotion-focused s t r a t e g y , the aim of Escape-Avoidance (Folkman, Lazarus, Dunkel-Schetter et a l . , 1986) i s t o help reduce the emotional d i s t r e s s of the i n d i v i d u a l . Folkman and Lazarus (1988b) c i t e a number of s t u d i e s , however, i n 28 which the use of Escape-Avoidance has been found t o be a s s o c i a t e d with g r e a t e r d e p r e s s i o n , a n x i e t y and psychosomatic symptoms. Although d e n i a l , D i s t a n c i n g , P o s i t i v e R e a p p r a i s a l and Escape-Avoidance are a l l s t r a t e g i e s which serve a s i m i l a r purpose i n r e d u c i n g the emotional d i s t r e s s of the i n d i v i d u a l , t h e r e i s some sugg e s t i o n t h a t whereas P o s i t i v e R e a p p r a i s a l may be a s s o c i a t e d w i t h more p o s i t i v e emotional s t a t e s , d e n i a l , D i s t a n c i n g and Escape-Avoidance may be a s s o c i a t e d with more negative s t a t e s . Thus, though emotion-focused coping s t r a t e g i e s are not maladaptive i n g e n e r a l terms, i f used i n a p p r o p r i a t e l y they can r e s u l t i n a worsened emotional s t a t e , and i n the case of coping with i l l n e s s , they can p o t e n t i a l l y i n c r e a s e the h e a l t h r i s k f o r the i n d i v i d u a l who uses them (Christman et a l . , 1988; F e l t o n & Revenson, 1984; F e l t o n et a l . , 1984; Lazarus & Folkman, 1984; Lipowski, 1970). Coping s t r a t e g i e s as p r e d i c t o r v a r i a b l e s . A number of s t u d i e s have examined the r e l a t i o n s h i p between coping s t r a t e g i e s , p e r s o n a l , environmental and c o n t e x t u a l v a r i a b l e s , and a v a r i e t y of measures of emotional adjustment. Coping s t r a t e g i e s and other v a r i a b l e s have been used t o p r e d i c t emotional s t a t e s (Folkman & Lazarus, 1988a), p s y c h o l o g i c a l symptoms (Folkman, Lazarus, Gruen, & DeLongis, 1986), d i s t r e s s and m a r i t a l adjustment (McLaughlin, Cormier, & Cormier, 1988), and p s y c h o l o g i c a l adjustment t o c h r o n i c i l l n e s s ( F e l t o n & Revenson, 1984; F e l t o n et a l . , 1984), 29 rheumatoid a r t h r i t i s (Parker et a l . , 1988) and myocardial i n f a r c t i o n (Christman et a l . , 1988). Studies have shown v a r i o u s coping s t r a t e g i e s t o be s i g n i f i c a n t l y a s s o c i a t e d with the outcome measures. Folkman and Lazarus (1988a) examined the r e l a t i o n s h i p between emotional s t a t e s throughout a s t r e s s f u l encounter, coping s t r a t e g i e s and fou r emotional outcomes ( w o r r i e d / f e a r f u l , disgusted/angry, c o n f i d e n t , pleased/happy) i n a community group of middle-aged i n d i v i d u a l s (N=85, mean age of women = 39.6, mean age of men = 41.4) and a second group of o l d e r i n d i v i d u a l s (N=161, mean age of women = 68.9, mean age of men = 68.3). The younger sample i n d i c a t e d t h e i r emotional r e a c t i o n s at the beginning, middle and end of the s t r e s s f u l encounter. The o l d e r sample i n d i c a t e d t h e i r emotional r e a c t i o n s at the most s t r e s s f u l p o i n t d u r i n g the encounter and at the end. Respondents were not asked t o respond t o a s p e c i f i c predetermined s t r e s s o r . The mean scores across time f o r each person were c a l c u l a t e d . Coping s t r a t e g i e s were assessed w i t h the WOCS. H i e r a r c h i c a l stepwise r e g r e s s i o n s were conducted i n which the mean emotional s c o r e s , emotions a t the beg i n n i n g of the encounter (younger group), emotions a t hei g h t of encounter ( o l d e r group) and coping s t r a t e g i e s were entered and compared with the f o u r emotional outcomes f o r each group. Coping s t r a t e g i e s c o n t r i b u t e d t o a s i g n i f i c a n t p r o p o r t i o n of the v a r i a n c e i n th r e e out of the f o u r r e g r e s s i o n s i n the younger group and i n a l l f o u r analyses i n 30 the o l d e r group. In a l l cases, however, the t o t a l v a r i a n c e accounted f o r by the coping s t r a t e g i e s was l e s s than nine percent. In the younger group D i s t a n c i n g and C o n f r o n t i v e coping were p o s i t i v e l y a s s o c i a t e d with disgusted/angry and n e g a t i v e l y a s s o c i a t e d with c o n f i d e n t and pleased/happy. Conversely, P o s i t i v e R e a p p r a i s a l and P l a n f u l Problem-Solving were n e g a t i v e l y a s s o c i a t e d w i t h the disgusted/angry outcome, and p o s i t i v e l y a s s o c i a t e d with c o n f i d e n t and pleased/happy. A c c e p t i n g R e s p o n s i b i l i t y was n e g a t i v e l y a s s o c i a t e d with the c o n f i d e n t outcome. In the o l d e r group A c c e p t i n g R e s p o n s i b i l i t y and P o s i t i v e R e a p p r a i s a l were p o s i t i v e l y a s s o c i a t e d with w o r r i e d / f e a r f u l , while P l a n f u l Problem S o l v i n g was n e g a t i v e l y a s s o c i a t e d with disgusted/angry. Seeking S o c i a l Support and P l a n f u l Problem S o l v i n g were p o s i t i v e l y a s s o c i a t e d with c o n f i d e n t and pleased/happy. Escape-Avoidance was a l s o p o s i t i v e l y a s s o c i a t e d with c o p n f i d e n t and D i s t a n c i n g was n e g a t i v e l y a s s o c i a t e d with pleased/happy. Although Folkman and Lazarus had expected t h a t P o s i t i v e R e a p p r a i s a l and D i s t a n c i n g would both h e l p reduce d i s t r e s s , the evidence suggested t h a t P o s i t i v e R e a p p r a i s a l was o n l y a s s o c i a t e d with an improved emotional s t a t e i n the younger group and t h a t i t was a s s o c i a t e d with an i n c r e a s e i n f e a r and worry i n the o l d e r group. S i m i l a r l y , i n the t h r e e analyses where D i s t a n c i n g was found to have an e f f e c t i t c o n t r i b u t e d to a worsened emotional s t a t e . Seeking S o c i a l Support, on the other hand, was r e l a t e d to a b e t t e r 31 emotional s t a t e i n the o l d e r group. This study p r o v i d e s evidence demonstrating t h a t the use of d i f f e r e n t coping s t r a t e g i e s i s a s s o c i a t e d w i t h d i f f e r e n t emotional outcomes. The f a c t t h a t d i f f e r e n c e s were found between the younger and o l d e r group suggest t h a t other p s y c h o s o c i a l or demographic v a r i a b l e s not assessed by the study may be a s s o c i a t e d with the c h o i c e of s t r a t e g i e s and t h e i r r e l a t i o n t o emotional s t a t e . Two problems with the study need t o be c o n s i d e r e d . F i r s t , the d i f f e r e n t data g a t h e r i n g format f o r the younger and o l d e r group may have c o n t r i b u t e d t o the d i f f e r e n t r e s u l t s . Second, becaue s u b j e c t s were allowed t o respond to any s t r e s s f u l s i t u a t i o n , any response d i f f e r e n c e s based on the nature of the s t r e s s o r i s l o s t . Given t h a t d i f f e r e n t s t r e s s o r s are l i k e l y t o invoke the use of d i f f e r e n t s t r a t e g i e s , i t i s a l s o l i k e l y t h a t t h i s w i l l have an impact on emotional outcomes. These two methodological weaknesses d e t r a c t from the r e l i a b i l i t y of the r e s u l t s . In an e a r l i e r study, Folkman, Lazarus, Gruen, and DeLongis (1986) examined the r e l a t i o n s h i p between p e r s o n a l i t y f a c t o r s , primary and secondary a p p r a i s a l s , coping s t r a t e g i e s and measure of p s y c h o l o g i c a l symptoms and somatic h e a l t h i n a community based sample of 150 a d u l t s . There were 75 men and 75 women i n the sample, w i t h mean ages of 41 and 40 years r e s p e c t i v e l y . Coping s t r a t e g i e s were assessed with the WOCS. A h i e r a r c h i c a l r e g r e s s i o n equation was conducted i n 32 which p e r s o n a l i t y c h a r a c t e r i s t i c s , a p p r a i s a l s and coping s t r a t e g i e s were used t o p r e d i c t p s y c h o l o g i c a l symptoms. C o n f r o n t i v e coping was p o s i t i v e l y a s s o c i a t e d w i t h the outcome v a r i a b l e s w hile P l a n f u l Problem S o l v i n g was n e g a t i v e l y c o r r e l a t e d . The authors noted the l a c k of s i g n i f i c a n t a s s o c i a t i o n s w i t h any of the emotion-focused s t r a t e g i e s , and suggest t h a t t h i s i s due to c o l i n e a r i t y amongst the s c a l e s . As wi t h the p r e v i o u s l y d e s c r i b e d study, the respondents were r e p l y i n g t o a n o n s p e c i f i c s t r e s s o r . I t i s u n l i k e l y t h a t t h i s p a t t e r n of response would be the same f o r s p e c i f i c a l l y i d e n t i f i e d types of s t r e s s o r s , and as such the r e s u l t s are not n e c e s s a r i l y g e n e r a l i z a b l e . McLaughlin et a l . (1988) found t h a t l e v e l s of s t r e s s , d i s t r e s s and m a r i t a l adjustment were a s s o c i a t e d with frequency and number of cop i n g s t r a t e g i e s used i n a group of 69 m u l t i p l e - r o l e women (mean age = 30). Two coping s t r a t e g i e s were examined, time-management and s e l f - c a r e . Coping was eva l u a t e d i n terms of type of s t r a t e g y i n gen e r a l , and number and frequency of s p e c i f i c s t r a t e g y items used. Pearson c o r r e l a t i o n s r e v e a l e d t h a t , i n g e n e r a l , higher l e v e l s of d i s t r e s s and poor m a r i t a l adjustment were a s s o c i a t e d with a l i m i t e d range of coping s t r a t e g i e s and i n f r e q u e n t use of s t r a t e g i e s . F u r t h e r a n a l y s i s c o n s i s t e d of noncumulative m u l t i p l e c o r r e l a t i o n s i n which cop i n g s t r a t e g i e s (time-management, s e l f - c a r e , t o t a l coping) were used t o p r e d i c t d i s t r e s s , s t r e s s and m a r i t a l adjustment. In 33 each case s i g n i f i c a n t c o r r e l a t i o n s were found ( a l l p_'s<.05) between coping s t r a t e g y and measure of adjustment. F e l t o n et a l . (1984) examined the r e l a t i o n s h i p between demographic f a c t o r s , d i a g n o s i s , and coping s t r a t e g i e s i n p r e d i c t i n g d i f f e r e n t measures of p s y c h o l o g i c a l adjustment i n a group of 170 c h r o n i c a l l y i l l p a t i e n t s ( h y p e r t e n s i o n , n=38; d i a b e t e s , n=44; rheumatoid a r t h r i t i s , n=45; cancer, n=42). The sample was p r i m a r i l y white, m i d d l e - c l a s s , c o n s i s t i n g of 67 men and 103 women, with a mean age of 61. They had had t h e i r i l l n e s s f o r 65 months on average. S i x coping s t r a t e g i e s were assessed u s i n g a m o d i f i e d v e r s i o n of the WOCS. A h i e r a r c h i c a l a n a l y s i s of c o v a r i a n c e i n d i c a t e d t h a t w i s h - f u l f i l l i n g f a n t a s y was the o n l y s t r a t e g y t o be s i g n i f i c a n t l y c o r r e l a t e d t o d i a g n o s i s (rheumatoid a r t h r i t i s ) . Length of i l l n e s s was not r e l a t e d t o coping s t r a t e g i e s . A s e r i e s of h i e r a r c h i c a l m u l t i p l e r e g r e s s i o n s equations were conducted i n which demographics, d i a g n o s i s , i n d i v i d u a l coping s t r a t e g i e s and the i n t e r a c t i o n terms of coping with d i a g n o s i s were used t o p r e d i c t adjustment, measured i n terms of p o s i t i v e a f f e c t , n e g ative a f f e c t , s e l f -esteem and i l l n e s s acceptance. C o g n i t i v e r e s t r u c t u r i n g and i n f o r m a t i o n seeking were p o s i t i v e l y a s s o c i a t e d with p o s i t i v e a f f e c t , w h i l e emotional e x p r e s s i o n , w i s h - f u l f i l l i n g f a n t a s y , and s e l f - b l a m e were n e g a t i v e l y a s s o c i a t e d with n e g a t i v e a f f e c t . While c o g n i t i v e r e s t r u c t u r i n g was p o s i t i v e l y a s s o c i a t e d with s e l f - e s t e e m , emotional e x p r e s s i o n , wish-34 f u l f i l l i n g f a n t a s y and sel f - b l a m e were n e g a t i v e l y a s s o c i a t e d . S i m i l a r l y , t h r e a t m i n i m i z a t i o n was p o s i t i v e l y a s s o c i a t e d with acceptance of i l l n e s s w h i l e emotional ex p r e s s i o n , w i s h - f u l f i l l i n g f a n t a s y and sel f - b l a m e were n e g a t i v e l y a s s o c i a t e d . I n d i v i d u a l s t r a t e g i e s accounted f o r between 3% and 11% of the e x p l a i n e d v a r i a n c e . These r e s u l t s suggest t h a t i n d e a l i n g with i l l n e s s r e l a t e d s t r e s s , emotion-focused s t r a t e g i e s such as emotional ex p r e s s i o n , w i s h - f u l f i l l i n g f a n t a s y and s e l f - b l a m e , are g e n e r a l l y a s s o c i a t e d with poorer p s y c h o l o g i c a l adjustment. C o g n i t i v e r e s t r u c t u r i n g , however, may be a s s o c i a t e d with more p o s i t i v e a f f e c t and hi g h e r s e l f - e s t e e m . The authors note t h a t by having p a r t i c i p a n t s respond t o i l l n e s s r e l a t e d s t r e s s i n g e n e r a l , r a t h e r than t o s p e c i f i c s t r e s s o r s , between d i s e a s e d i f f e r e n c e s may have been obscured. F u r t h e r , t h i s approach a l s o f a i l s t o d i s t i n g u i s h between d i f f e r e n t s t r e s s o r s experienced w i t h i n a p a r t i c u l a r d i s e a s e group, the nature of which may a l s o be r e l a t e d t o coping s t r a t e g i e s and adjustment. F e l t o n and Revenson (1984) examined the r e l a t i o n s h i p of two coping s t r a t e g i e s , one p a l l i a t i v e and one i n s t r u m e n t a l , with acceptance of i l l n e s s and emotional a f f e c t . The su b j e c t s came from the same study as F e l t o n et a l . (1984) and c o n s i s t e d of 151 p a t i e n t s ( h y p e r t e n s i v e , n=33; d i a b e t i c , n=41; a r t h r i t i c , n=45; cancer, n=32) who agreed t o both the i n i t i a l i n t e r v i e w and a 7-month follow-up. W i s h - f u l f i l l i n g f a n t a s y was chosen as an emotion-focused s t r a t e g y and 35 i n f o r m a t i o n seeking was chosen as a problem-focused s t r a t e g y because of t h e i r t h e o r e t i c a l and e m p i r i c a l importance i n coping with h e a l t h concerns. The coping s t r a t e g i e s were d e r i v e d from the WOCS, and c o n s i s t e d of 5 items f o r the i n f o r m a t i o n seeking subscale and 8 items f o r the wish-f u l f i l l i n g f a n t a s y . A s e r i e s of m u l t i p l e r e g r e s s i o n analyses were conducted to determine the e f f e c t s of i l l n e s s c o n t r o l l a b i l i t y , coping s t r a t e g i e s and the i n t e r a c t i v e e f f e c t s of the two, on adjustment measured i n terms of p o s i t i v e a f f e c t , n e g ative a f f e c t and i l l n e s s acceptance at each i n t e r v i e w . Somewhat s u r p r i s i n g l y , a f t e r a c c o u n t i n g f o r i l l n e s s c o n t r o l l a b i l i t y , i n f o r m a t i o n seeking was s i g n i f i c a n t l y p o s i t i v e l y a s s o c i a t e d with both p o s i t i v e and negative a f f e c t , a c c o u n t i n g f o r 13% and 4% of the v a r i a n c e r e s p e c t i v e l y a t Time 1. The authors note, however, t h a t the e n t i r e equation p r e d i c t i n g negative a f f e c t d i d not reach s i g n i f i c a n c e , and t h e r e f o r e b r i n g s i n t o q u e s t i o n the s i g n f i c a n c e of i n f o r m a t i o n s e e k i n g with negative a f f e c t . Information seeking was not s i g n i f i c a n t l y r e l a t e d t o any of the outcome v a r i a b l e s a t Time 2. Wish-f u l f i l l i n g f a n t a s y had a s i g n i f i c a n t p o s i t i v e r e l a t i o n with negative a f f e c t and a ne g a t i v e r e l a t i o n s h i p w i t h acceptance of i l l n e s s at both Time 1 (a c c o u n t i n g f o r 11% and 15% of v a r i a n c e r e s p e c t i v e l y ) , and a t Time 2 (accounting f o r 8% and 15% of v a r i a n c e r e s p e c t i v e l y ) . In both cases the i n t e r a c t i v e e f f e c t s were n o n s i g n i f i c a n t . Another r e g r e s s i o n equation was conducted i n which 36 adjustment a t Time 1, i l l n e s s c o n t r o l l a b i l i t y , coping and the i n t e r a c t i o n s of c o n t r o l l a b i l i t y and coping were used t o p r e d i c t adjustment a t Time 2. In t h i s case i n f o r m a t i o n seeking was n e g a t i v e l y a s s o c i a t e d with negative a f f e c t , and accounted f o r 2% of the e x p l a i n e d v a r i a n c e , w h i l e wish-f u l l f i l l i n g f a n t a s y was n e g a t i v e l y a s s o c i a t e d w i t h acceptance of i l l n e s s and e x p l a i n e d 3% of the v a r i a n c e . These r e s u l t s suggest t h a t d i f f e r e n t s t r a t e g i e s have d i f f e r e n t a s s o c i a t i o n s with measures of emotional adjustment, and may be r e l a t e d t o time. In p a r t i c u l a r , w i s h - f u l f i l l i n g f a n t a s y seems t o be a s s o c i a t e d w i t h poorer a f f e c t i v e s t a t e and l e s s acceptance of i l l n e s s c o n s i s t e n t l y over time, whereas i n f o r m a t i o n seeking i s a s s o c i a t e d with a b e t t e r a f f e c t i v e s t a t e i n the e a r l y stages of coping. Parker et a l . (1988) examined the r e l a t i o n s h i p between coping s t r a t e g i e s and a number of i n d i c a t o r s of p s y c h o l o g i c a l adjustment i n a group of 84 p a t i e n t s with rheumatoid a r t h r i t i s . The group c o n s i s t e d of 81 men and 3 women, whose mean age was 61. Coping s t r a t e g i e s were assessed w i t h a m o d i f i e d v e r s i o n of the WOCS. Ca n o n i c a l c o r r e l a t i o n s and m u l t i p l e r e g r e s s i o n s were used t o examine the r e l a t i o n s h i p between cop i n g s t r a t e g i e s and adjustment. The s u b j e c t s were grouped a c c o r d i n g t o d i s e a s e d u r a t i o n (0-5 years, 6-10 years, 11-20 ye a r s , 20+ y e a r s ) . A one-way MANOVA r e v e a l e d no s i g n i f i c a n t group d i f f e r e n c e s on coping s t r a t e g i e s used. The c a n o n i c a l c o r r e l a t i o n r e v e a l e d a s i g n f i c a n t r e l a t i o n s h i p between coping s t r a t e g i e s and the 37 adjustment measures . M u l t i p l e r e g r e s s i o n s showed t h a t c o g n i t i v e r e s t r u c t u r i n g was n e g a t i v e l y a s s o c i a t e d w i t h d e p r e s s i o n , w h i l e w i s h - f u l f i l l i n g f a n t a s y and s e l f - b l a m e were p o s i t i v e l y a s s o c i a t e d w i t h d e p r e s s i o n . S i m i l a r l y , w i s h - f u l f i l l i n g f a n t a s y and s e l f - b l a m e were p o s i t i v e l y a s s o c i a t e d w i t h d a i l y h a s s l e s . W i s h - f u l f i l l i n g f a n t a s y , s e l f - b l a m e and t h r e a t m i n i m i z a t i o n were p o s i t i v e l y a s s o c i a t e d w i t h p s y c h o l o g i c a l d i s t r e s s , w h i l e c o g n i t i v e r e s t r u c t u r i n g was n e g a t i v e l y a s s o c i a t e d . S u b j e c t s were then grouped i n t o h i g h c o g n i t i v e r e s t r u c t u r i n g / l o w w i s h -f u l f i l l i n g f a n t a s y (HC/LW), and low c o g n i t i v e r e s t r u c t u r i n g / h i g h w i s h - f u l f i l l i n g f a n t a s y (LC/HW) and compared on the h a s s l e s and d e p r e s s i o n measures . S i g n i f i c a n t d i f f e r e n c e s were found between the groups on both measures . Once a g a i n these r e s u l t s i n d i c a t e t h a t w i s h - f u l f i l l i n g f a n t a s y , s e l f - b l a m e and t h r e a t m i n i m i z a t i o n are p o s i t i v e l y a s s o c i a t e d w i t h g r e a t e r e m o t i o n a l d i s t r e s s , w h i l e c o g n i t i v e r e s t r u c t u r i n g i s a s s o c i a t e d w i t h l e s s d i s t r e s s . The g r o u p i n g of s u b j e c t s based on the r e l a t i v e use o f the two s t r a t e g i e s p r o v i d e s a u s e f u l example o f a means o f examining the e f f e c t o f p a t t e r n s of c o p i n g r e s p o n s e s . The f a c t t h a t no o t h e r r e l e v a n t p s y c h o s o c i a l v a r i a b l e s were i n c l u d e d i n the c o r r e l a t i o n or r e g r e s s i o n e q u a t i o n s weakens the s t u d y , however, as o t h e r r e s e a r c h suggests t h a t o t h e r v a r i a b l e s are s i g n i f i c a n t i n p r e d i c t i n g adjustment and may have a g r e a t e r impact than c o p i n g s t r a t e g i e s a l o n e . Chr i s tman et a l . (1988) examined the r e l a t i o n s h i p 38 between v a r i o u s demographic v a r i a b l e s , i l l n e s s s e v e r i t y and i l l n e s s u n c e r t a i n t y , coping s t r a t e g i e s ( p a l l i a t i v e , emotive, c o n f r o n t i v e ) with emotional d i s t r e s s i n a group of 16 female and 54 male myocardial i n f a r c t i o n p a t i e n t s (mean age = 58). Emotional d i s t r e s s was measured with the P r o f i l e of Mood States (POMS; McNair, L o r r , & Droppelman, 1971). Measurements were taken p r i o r t o d i s c h a r g e and a t one and four week i n t e r v a l s a f t e r d i s c h a r g e . H i e r a r c h i c a l m u l t i p l e r e g r e s s i o n s were conducted f o r each measurement examining the r e l a t i o n s h i p between demographics, u n c e r t a i n t y , and coping i n e x p l a i n i n g emotional d i s t r e s s . U n c e r t a i n t y was s i g n i f i c a n t l y p o s i t i v e l y r e l a t e d t o emotional d i s t r e s s a t a l l t h r e e measurements, acc o u n t i n g f o r between 16% and 26% of the ex p l a i n e d v a r i a n c e . At the one week p o i n t coping s t r a t e g i e s accounted f o r 27% of the v a r i a n c e e x p l a i n i n g emotional d i s t r e s s . Of t h i s , 23% was e x p l a i n e d by emotive coping, which had a p o s i t i v e c o r r e l a t i o n with emotional d i s t r e s s . Coping s t r a t e g i e s d i d not c o n t r i b u t e s i g n i f i c a n t l y t o the v a r i a n c e at the other two measurements. U n c e r t a i n t y was n e g a t i v e l y c o r r e l a t e d with c o n f r o n t i v e coping, which i n t u r n was n e g a t i v e l y a s s o c i a t e d with emotional d i s t r e s s . These r e s u l t s suggest t h a t u n c e r t a i n t y i s a s i g n i f i c a n t p r e d i c t o r of emotional d i s t r e s s i n t h i s p o p u l a t i o n , and t h a t s h o r t l y a f t e r d i s c h a r g e emotive coping i s a l s o a s s o c i a t e d with g r e a t e r emotional d i s t r e s s . I t i s s u r p r i s i n g t h a t emotive coping was not more s t r o n g l y a s s o c i a t e d w i t h 39 u n c e r t a i n t y as would be expected based on pr e v i o u s r e s e a r c h . T h i s r e l a t i o n s h i p may have become more evi d e n t as time s i n c e d i s c h a r g e i n c r e a s e d , a p o s s i b i l i t y which i s suggested by the i n c r e a s i n g c o r r e l a t i o n between the v a r i a b l e s a c r o s s the three measurements. Taken together these s t u d i e s p r o v i d e s t r o n g evidence demonstrating t h a t , i n c o n j u n c t i o n with other v a r i a b l e s , coping s t r a t e g i e s are a s s o c i a t e d with d i f f e r e n t degrees and types of adjustment. With r e s p e c t t o coping w i t h i l l n e s s concerns the evidence suggests emotion-focused s t r a t e g i e s such as w i s h - f u l f i l l i n g f a n t a s y or self- b l a m e are a s s o c i a t e d with g r e a t e r emotional d i s t r e s s , whereas c o g n i t i v e r e s t r u c t u r i n g i s a s s o c i a t e d w i t h an improved emotional s t a t e . As with the r e s e a r c h on coping s t r a t e g i e s as c r i t e r i o n v a r i a b l e s , a d i s c u s s i o n of the above s t u d i e s as a whole i s hampered by the f a c t t h a t d i f f e r e n t instruments and coping s t r a t e g i e s are used. Another weakness of the s t u d i e s i s t h a t types of s t r e s s o r s have not been c l e a r l y d e f i n e d , p o s s i b l y r e s u l t i n g i n an i n a b i l i t y t o d i s t i n g u i s h d i f f e r e n t response p a t t e r n s f o r d i f f e r e n t s t r e s s o r s . The moderating e f f e c t of other v a r i a b l e s on the ch o i c e of s t r a t e g i e s used i s a l s o not w e l l d e f i n e d . Folkman, Lazarus, Gruen, and DeLongis (1986) suggest t h a t problem-focused s t r a t e g i e s ( P l a n f u l Problem S o l v i n g , C o n f r o n t i v e , Seeking S o c i a l Support) may be more s t r o n g l y a f f e c t e d by s i t u a t i o n a l v a r i a b l e s , whereas P o s i t i v e R e a p p r a i s a l may be more s t r o n g l y a f f e c t e d by p e r s o n a l i t y f a c t o r s . In order t o have a c l e a r e r 40 understanding of the r e l a t i o n s h i p of coping s t r a t e g i e s t o adjustment, both with regards t o h e a l t h concerns and with r e s p e c t t o s t r e s s i n g e n e r a l , i t i s important t h a t analyses be made which take i n t o account the impact of d i f f e r e n t types of s t r e s s o r s , and t h a t the p e r s o n a l , environmental and c o n t e x t u a l v a r i a b l e s which h e l p determine the use of c e r t a i n coping s t r a t e g i e s be b e t t e r understood. HIV I n f e c t i o n and I t s Consequences The HIV/AIDS continuum. AIDS i s the end stage of an i l l n e s s p r o g r e s s i o n which begins with exposure t o the Human Immunodeficiency V i r u s (HIV). When an i n d i v i d u a l r e c e i v e s an HIV+ d i a g n o s i s i t i n d i c a t e s t h a t he or she has been exposed t o and i s a c a r r i e r of the v i r u s . Once exposed, however, t h e r e i s not a c o n s i s t e n t course of development from HIV s e r o p o s i t i v i t y t o f u l l - b l o w n AIDS. HIV+ i n d i v i d u a l s may manifest no h e a l t h problems f o r many yea r s , or they may develop symptoms such as n i g h t sweats, e x c e s s i v e d i a h r e a , l o s s of weight, swollen glands, and p e r s i s t e n t coughs. These v a r i o u s symptoms have a t times been c a l l e d AIDS-Related Complex (ARC). The s t a t u s of f u l l - b l o w n AIDS i s t y p i c a l l y r e s e r v e d f o r evidence of s p e c i f i c symptoms and o p p o r t u n i s t i c i n f e c t i o n s i n c l u d i n g Kaposi's sarcoma, Pneumocystis c a r i n i i pneumonia, wasting and dementia. A rec e n t study found t h a t a f t e r t h r e e years, 22% of an HIV+ p o p u l a t i o n had developed AIDS wit h an a d d i t i o n a l 19% having developed AIDS r e l a t e d c o n d i t i o n s . The study p r o j e c t e d t h a t by s i x years over h a l f of the p o p u l a t i o n would develop AIDS 41 and 75% would have AIDS or AIDS r e l a t e d c o n d i t i o n s (Moss et a l . , 1988). Although e a r l i e r a r t i c l e s o f t e n r e f e r r e d t o ARC as a s p e c i f i c c o n d i t i o n i t has proven d i f f i c u l t t o c l e a r l y d e f i n e as a d i a g n o s t i c e n t i t y . The c u r r e n t t r e n d i s t o no longer use ARC as a d e s c r i p t i v e term, the d i s t i n c t i o n b e i n g made between HIV p o s i t i v e s t a t u s and f u l l blown AIDS. In t h i s study, unless otherwise s t a t e d , HIV+ w i l l r e f e r t o both nonsymptomatic HIV p o s i t i v e s t a t u s as w e l l as ARC. As a r e s u l t of the i n c r e a s e d h e a l t h r i s k and the nature and s e v e r i t y of the a s s o c i a t e d i l l n e s s e s , an AIDS d i a g n o s i s i s u s u a l l y seen as d i s t i n c t i v e from an HIV+ or ARC d i a g n o s i s . In terms of p s y c h o l o g i c a l r e a c t i o n s and coping i s s u e s , as w e l l , d i s t i n c t i o n s have been made between people with AIDS and people with HIV or ARC ( M i l l e r & Green, 1985; Morin et a l . , 1984; Moynihan et a l . , 1988; Ross & Rosser, 1988). Given t h a t q u a l i t a t i v e d i f f e r e n c e s may e x i s t between people who are HIV+ and people who have AIDS, i t i s important t h a t r e s e a r c h i n t o the p s y c h o s o c i a l aspects of HIV i n f e c t i o n d i s t i n g u i s h between the two groups. P s y c h o l o g i c a l r e a c t i o n s t o i n f e c t i o n . An HIV+ d i a g n o s i s has the p o t e n t i a l t o impact on a l l aspects of a person's l i f e . S i m i l a r t o ot h e r s who have c h r o n i c or t e r m i n a l i l l n e s s (Kubler-Ross, 1969), the r e a c t i o n s of people wi t h HIV or AIDS can i n c l u d e f e e l i n g s of g u i l t , shame, self-blame, anger, d e p r e s s i o n and d e n i a l (Furstenberg & Olson, 1984; H i r s c h & Enlow, 1984; Morin et a l . , 1984; 42 Ross & Rosser, 1988; S t u l b e r g & Buckingham, 1988; Wolcott, Namir et a l . , 1986). In some cases, the t h r e a t a s s o c i a t e d with i n f e c t i o n can c o n t r i b u t e t o meaningful changes i n the i n d i v i d u a l ' s l i f e (Grimshaw, 1987). Predominantly, though, w r i t e r s t a l k of the negative r e a c t i o n s t o i n f e c t i o n . Because HIV can remain dormant or o n l y r e s u l t i n low grade i n f e c t i o n s f o r a number of y e a r s , HIV+ i n d i v i d u a l s have no c l e a r sense of t h e i r p r e s e n t or f u t u r e h e a l t h s t a t u s and must l i v e with a high degree of u n c e r t a i n t y and ambiquity. As a r e s u l t of t h i s u n c e r t a i n t y HIV+ i n i d i v i d u a l s have been d e s c r i b e d as b e i n g i n the "grey zone" (Morin et a l . , 1984), p l a y i n g a " w a i t i n g game" ( M i l l e r & Green, 1985) i n which they must be c o n s t a n t l y v i g i l a n t f o r the t e l l - t a l e s igns of ARC or AIDS. T h i s u n c e r t a i n t y can cause an enoromous amount of s t r e s s and a n x i e t y , as w e l l as f e e l i n g s of l o s s of c o n t r o l and a sense of powerlessness, i n the l i v e s of i n f e c t e d i n d i v i d u a l s ( Furstenberg & Olson, 1984; Haney, 1988; K i n n i e r , 1986; M i l l e r & Green, 1985). The f e e l i n g s of hopelessness and a n x i e t y may be worse f o r people with HIV than f o r people with AIDS (Moynihan et a l . , 1988). AIDS, homosexuals and s o c i e t y . Before the d i s e a s e was b e t t e r understood and b e f o r e i t was o f f i c i a l l y r e c o g n i z e d , AIDS was known as Gay-Related Immuno-Deficiency (GRID) or simply as the "gay plague" (Macks _ Turner, 1986). T h i s has i n l a r g e p a r t been due to the f a c t t h a t t o date i n North America the m a j o r i t y of diagnosed cases of AIDS and HIV 43 i n f e c t i o n have been i n homosexual or b i s e x u a l men. As of A p r i l , 1987, 66% of the diagnosed cases of AIDS i n the U.S. were i n gay men (Gr e i g , 1987). Of the 2046 diagnosed cases of AIDS i n Canada as of December, 1988, 1765 or 86.3% of those were i n homosexual or b i s e x u a l men ( F e d e r a l Centre f o r AIDS) and 1985 of the 2430 people who t e s t e d p o s i t i v e f o r HIV i n B.C. between October, 1985 and J u l y , 1988, 1917 were homosexual or b i s e x u a l men (AIDS Information L i n e ) . T h i s preponderance of cases i n the gay community has served t o exaggerate the p r e v a i l i n g homophobic sentiments of s o c i e t y to the p o i n t t h a t the " t r a d i t i o n a l dread of homosexuality has become p a r t of the i r r a t i o n a l r e a c t i o n t o AIDS" ( N i c h o l s , 1984, p. 86), which i n t u r n has c r e a t e d a negative metaphor with r e s p e c t t o the d i s e a s e (Herek & Glunt, 1988; V a l d i s e r r i , 1987) encompassing both AIDS and the gay community. AIDS r e p r e s e n t s a t h r e a t t o the l i f e s t y l e and i d e n t i t y of the gay male and the gay community ( P r i c e et a l . , 1986). The apparent connection between homosexuality and AIDS i s a l s o f e l t w i t h i n the gay community, and may be heightened or exagerated as a r e s u l t of the homophobic c l i m a t e surrounding the community. One conseguence of t h i s t h r e a t i s t h a t some gay men develop an i n t e r n a l i z e d homophobic r e a c t i o n i n which they experience t h e i r own s e x u a l i t y and l i f e s t y l e i n a negative way (Grant & Anns, 1988; Harowski, 1987; H i r s c h & Enlow, 1984; Ross & Rosser, 1988). H i r s c h and Enlow (1984) s t a t e t h a t : 44 An i n c r e a s e i n i n t e r n a l i z e d homophobia i s one of the c l e a r p r e s e n t i n g p s y c h o l o g i c a l r e a c t i o n s t o the t h r e a t of AIDS f o r the gay man...Within the gay community, the homophobic response to AIDS i s a m p l i f i e d , i n c o r p o r a t e d i n t o the p e r c e p t i o n of the s e l f , and i n t e r n a l i z e d i n t o the i n d i v i d u a l ' s n e g a t i v e s e l f - i m a g e (pp. 275-276). There i s o f t e n a tendency f o r people t o a s s i g n g u i l t and r e s p o n s i b i l i t y t o the i l l f o r t h e i r i l l n e s s (Namir, 1986; V a l d i s e r r i , 1987), and the i l l themselves o f t e n "assume a burden of g u i l t i n a c c e p t i n g the n o t i o n t h a t t h e i r l i f e s t y l e or p e r s o n a l inadequacies have c a u s e d . . . t h e i r i l l n e s s " ( C a s s i l e t h , Lusk, M i l l e r , Brown, & M i l l e r , 1985, p. 1555). Some have openly t o u t e d AIDS as evidence of the immorality of homosexual p r a c t i c e s and l i f e s t y l e ( F l e t c h e r , 1984) and many w r i t e r s have noted with dismay the presence of a 'blame the v i c t i m ' m e n t a l i t y i n both the s t r a i g h t and gay communities ( B a t c h e l o r , 1984; F u r s t e n b e r g & Olson, 1984; Grimshaw, 1987; Haney, 1988; Harowski, 1987; Herek & Glunt, 1988; Kopelman, 1988; Quadland & S h a t t l s , 1987; Ross, 1988). As a r e s u l t , some gay men blame themselves f o r t h e i r i n f e c t i o n and see t h e i r d i a g n o s i s as punishement f o r t h e i r o r i e n t a t i o n and l i f e s t y l e ( D i l l e y et a l . , 1985; F u r s t e n b e r g & Olson, 1984 ) . The p a r t i c u l a r s of an HIV+ d i a g n o s i s p r e s e n t a p o t e n t i a l l y l a r g e number of c o m p l i c a t i n g f a c t o r s which c o u l d impinge on or a f f e c t the coping of gay men. Gay men must face not one t h r e a t but a host of p o t e n t i a l s t r e s s o r s . 45 These can range from concerns about the f u t u r e , d i f f i c u l t i e s i n t e l l i n g others of one's d i a g n o s i s , changes i n l i f e s t y l e , or f e e l i n g s of g u i l t and blame over b e i n g i n f e c t e d , t o name a few. Given the stigma surrounding AIDS and the homophobic sentiment pres e n t i n much of today's s o c i e t y i t i s p o s s i b l e t h a t , with r e s p e c t to Cobb's (1976) d e f i n i t i o n of s o c i a l support, HIV+ gay men would not l i k e l y f e e l loved, valued, r e s p e c t e d and p a r t of a network of mutual o b l i g a t i o n with r e s p e c t to s o c i e t y a t l a r g e . As w e l l , gay men run the r i s k of i n t e r n a l i z i n g t h i s n e g ative a t t i t u d e , f u r t h e r damaging a s e l f - e s t e e m a l r e a d y shaken as a r e s u l t of i n f e c t i o n with a p o t e n t i a l l y l e t h a l s e x u a l l y t r a n s m i t t e d d i s e a s e . Taken together these v a r i o u s f a c t o r s c o u l d be expected t o a f f e c t the coping s t r a t e g i e s used by HIV+ gay men i n response t o the s t r e s s e s a s s o c i a t e d with t h e i r i n f e c t i o n . P s y c h o s o c i a l AIDS Research Although t h e r e has been c o n s i d e r a b l e r e s e a r c h i n t o the medical aspects of AIDS, t h e r e has been c o n s i d e r a b l y l e s s r e s e a r c h i n t o the p s y c h o s o c i a l aspects of the i l l n e s s . The d i s p a r i t y i s even g r e a t e r when the d i s t i n c t i o n i s made between people who are HIV+ and people with f u l l blown AIDS. Many w r i t e r s have r e p o r t e d a n e c d o t a l i n f o r m a t i o n on the p s y c h o s o c i a l consequences of AIDS and/or HIV i n f e c t i o n f o r gay men, but t h e r e have been t o date o n l y a handful of s t u d i e s which have i n v e s t i g a t e d the problem e m p i r i c a l l y . A number of the s t u d i e s t h a t have been undertaken examined the r e l a t i o n s h i p s between f a c t o r s such as s o c i a l support, 46 i n t e r n a l i z e d homophobia, s e l f - e s t e e m , coping s t r a t e g i e s and self-blame, and mood s t a t e s or emotional d i s t r e s s . The analyses used i n these s t u d i e s t y p i c a l l y c o n s i s t e d of determining the Pearson product-moment c o r r e l a t i o n s amongst the v a r i a b l e s . More s o p h i s t i c a t e d a n a l y s e s , such as m u l t i p l e r e g r e s s i o n s , were l e s s commonly used. AIDS and s o c i a l support. S o c i a l support i s a f a c t o r which has been examined by many of the s t u d i e s . S o c i a l support was c o n c e p t u a l i z e d i n d i f f e r e n t ways by d i f f e r e n t r e s e a r c h e r s but t y p i c a l l y was e v a l u a t e d i n terms of some combination of numbers of peoples i n the respondent's support network, a v a i l a b i l i t y of support, type of support d e s i r e d and s a t i s f a c t i o n w i t h support r e c e i v e d . Donlou et a l . (1985) conducted a study which examined the r e l a t i o n s h i p between s o c i a l support, s e l f - e s t e e m and mood s t a t e . Four gay men w i t h ARC and 17 with AIDS p a r t i c i p a t e d , a l l of who were o u t p a t i e n t s a t UCLA Med i c a l Center. S o c i a l support was assessed by the Resources and S o c i a l Supports Q u e s t i o n n a i r e (Meyers, 1982), a newly d e v i s e d instrument, f o r which r e l i a b i l i t y and v a l i d i t y s t u d i e s were underway. The instrument conceived of s o c i a l support i n terms of numbers and types of i n d i v i d u a l s i n the respondent's network ( i . e . , f a m i l y , f r i e n d s , l o v e r s , h e a l t h care p r o f e s s i o n a l s ) , the p r o b a b i l i t y t h a t the respondent would ask f o r help from t h i s person and the l i k e l i h o o d help would be u s e f u l i f r e c e i v e d . The instrument d i d not d i s t i n g u i s h between a v a i l a b l e and u t i l i z e d support. S e l f -47 esteem was measured by the 9-item Simmons s c a l e (Simmons et a l . , 1977), and mood s t a t e was ev a l u a t e d u s i n g the POMS. Pearson c o r r e l a t i o n s were c a l c u l a t e d f o r the 21 respondents between the POMS subscales and t o t a l mood di s t u r b a n c e , the s e l f - e s t e e m s c a l e , and the s o c i a l support s c a l e s . The study found no s i g n i f i c a n t d i f f e r e n c e s between AIDS and ARC s u b j e c t s on any of the v a r i a b l e s . Self-esteem was not s i g n i f i c a n t l y c o r r e l a t e d with the t o t a l s o c i a l support score but was n e g a t i v e l y c o r r e l a t e d with the p r o f e s s i o n a l component of the s o c i a l support s c a l e (r=-.59, p_<.01), and c o r r e l a t e d p o s i t i v e l y with the p a r t n e r / l o v e r component (r=.58, p_<.01). T h i s i s somewhat s u r p r i s i n g given t h a t p r o f e s s i o n a l s were ranked much higher than l o v e r s on the l i k e l i h o o d t h a t they would be asked f o r help and t h a t t h e i r support would be h e l p f u l . T h i s perhaps suggests t h a t respondents with low s e l f - e s t e e m f e l t they had no other o p t i o n but t o seek help from p r o f e s s i o n a l s , whereas men with higher s e l f - e s t e e m were more l i k e l y t o have or be abl e t o approach a p a r t n e r / l o v e r f o r support. The t o t a l mood di s t u r b a n c e score on the POMS (POMS-TMD) d i d not c o r r e l a t e s i g n i f i c a n t l y with any of the s o c i a l support s c o r e s . As p a r t of a l a r g e r study Wolcott, Namir et a l . (1986) assessed s o c i a l support i n a group of 50 gay men who were AIDS o u t p a t i e n t s w i t h i n t h r e e months of d i a g n o s i s . S o c i a l support was assessed with the same instrument used by Donlou et a l . (1985). U n l i k e Donlou et a l . , Wolcott, Namir et a l . made a d i s t i n c t i o n between s o c i a l support s a t i s f a c t i o n and 48 numbers of people t h a t the i n d i v i d u a l r e c e i v e d help from, thus the r e s u l t s are somewhat d i f f e r e n t . S o c i a l support s a t i s f a c t i o n was found t o c o r r e l a t e p o s i t i v e l y with s e l f -esteem, as measured by the Simmons s c a l e (r=.51, p_<.01), and n e g a t i v e l y with mood d i s t u r b a n c e as measured by the POMS (r=-.54, p_<.001). The number of people h e l p i n g d i d not c o r r e l a t e s i g n i f i c a n t l y w i t h s e l f - e s t e e m but d i d c o r r e l a t e with mood d i s t u r b a n c e (r=-.34, p_<.05). N e i t h e r aspect of s o c i a l support c o r r e l a t e d s i g n i f i c a n t l y with homophobia as measured by the Nungesser Homosexual A t t i t u d e s Inventory (NHAI; Nungesser, 1979). C o n t r a r y t o the authors' e x p e c t a t i o n s , gay men with AIDS were not found t o have small d y s f u n c t i o n a l s o c i a l support networks. The two s t u d i e s p r o v i d e c o n f l i c t i n g i n f o r m a t i o n on numbers i n support networks and types of s o c i a l support deemed d e s i r a b l e as compared t o types used. In terms of numbers, Donlou et a l . (1985) found respondents had a mean of 39.0 (SD=11.3) i n t h e i r s o c i a l network, e x c l u d i n g p r o f e s s i o n a l s , t h a t they f e l t they c o u l d t u r n t o f o r support. Of these, 81% f e l t they were l i k e l y t o ask a c l o s e f r i e n d f o r help, f o l l o w e d by 47% f o r a d o c t o r and 42% f o r a p r o f e s s i o n a l c o u n s e l l o r . Family members and l o v e r s ranked below 40%. Wolcott, Namir et a l . (1986), however, r e p o r t e d a mean of 9.3 (SD =8.4) f o r number i n s o c i a l network. S i m i l a r l y , Donlou et a l . found t h a t s u b j e c t s had a mean of 17.8 f a m i l y members i n t h e i r s o c i a l network, w h i l e Wolcott, Namir et a l . found a mean of 2.3. Wolcott, Namir et a l . 49 took t h i s t o i n d i c a t e a p o s s i b l e estrangement between gay-men and t h e i r f a m i l i e s , y e t t h i s c o n t e n t i o n would not seem to be supported by Donlou et a l . ' s f i n d i n g s . At the same time, however, Donlou et a l . a l s o found t h a t respondents d i d not p e r c e i v e f a m i l y members t o be a h e l p f u l r e s o u r c e and were more l i k e l y t o t u r n to f r i e n d s or p r o f e s s i o n a l s f o r help. Wolcott, Fawzy, Landsverk, and McCombs (1986) examined the p s y c h o s o c i a l s e r v i c e needs of AIDS p a t i e n t s and t h e i r f a m i l i e s . Subjects were i n d i v i d u a l s who were r e c e i v i n g help from the AIDS P r o j e c t / L o s Angeles (AP/LA) and the Gay and L e s b i a n Community S e r v i c e s Centre (GLCSC). Seventy-one men with AIDS and 7 f a m i l y members of AIDS p a t i e n t s were surveyed. U n f o r t u n a t e l y , not o n l y d i d the authors n e g l e c t e d to d e s c r i b e the instruments used i n t h e i r survey, but a f t e r s u r v e y i n g 30 s u b j e c t s they shortened t h e i r r e s e a r c h form. Because of these p r o c e d u r a l weaknesses the r e l i a b i l i t y of the data must be c o n s i d e r e d . With r e s p e c t t o s o c i a l support, 90% of the respondents s a i d they turned to f r i e n d s f o r support, 82% t o p h y s i c i a n s , 73% to f a m i l y members, with o n l y 44% t u r n i n g t o l o v e r s or spouses. These f i g u r e s are somewhat d i f f e r e n t from those found by Donlou et a l . (1985) where, although f r i e n d s a l s o ranked high and l o v e r s low, p h y s i c i a n s and f a m i l y members were a l s o found to rank lower. With r e s p e c t t o the degree of h e l p f u l n e s s , 90% of s u b j e c t s r a t e d l o v e r s as extremely or very h e l p f u l , f o l l o w e d by 87% f o r f a m i l y , with 52% r a t i n g 50 p h y s i c i a n s as extremely or v e r y h e l p f u l . T h i s again d i f f e r s from Donlou et a l . ' s f i n d i n g s i n which l o v e r s , f a m i l y and doctors were ranked by l e s s than 43% of the s u b j e c t s as very h e l p f u l . In the case of Donlou et a l . , however, the s u b j e c t s were responding to how h e l p f u l support would l i k e l y be, whereas with Wolcott, Fawzy et a l . s u b j e c t s were responding to a c t u a l h elp r e c e i v e d . AIDS s u b j e c t s r a t e d a g r e a t e r i n t e r e s t i n medical i n f o r m a t i o n than emotional support, which i n t u r n was r a t e d higher than p r a c t i c a l a s s i s t a n c e . However, i n a l l cases those who s t a t e d i n t e r e s t i n a s e r v i c e outnumberd those who a c t u a l l y u t i l i z e d a s e r v i c e . For example, 93% expressed an i n t e r e s t i n c u r r e n t treatment i n f o r m a t i o n while o n l y 43% u t i l i z e d such i n f o r m a t i o n . S i m i l a r l y , w h ile 81% of respondents i n d i c a t e d an i n t e r e s t i n i n d i v i d u a l therapy and 73% i n group therapy, o n l y 28% had a c t u a l l y engaged i n i n d i v i d u a l therapy and o n l y 36% i n group therapy. S i m i l a r l y , Wolcott, Namir et a l . (1986) found t h a t 31% of respondents were c u r r e n t l y i n i n d i v i d u a l therapy and 18% were i n group therapy. In c o n t r a s t , Donlou et a l . (1985) found t h a t 43% of the respondents f e l t t h a t they would be l i k e l y t o ask a p r o f e s s i o n a l c o u n s e l l o r f o r h e l p . These f i g u r e s i n d i c a t e t h a t although expressed i n t e r e s t i n s o c i a l support may be high, fewer gay men a c t u a l l y seek out support, p a r t i c u l a r l y of a p r o f e s s i o n a l nature. In another study Z i c h and Temoshok (1987) expected t o f i n d t h a t s o c i a l support would c o r r e l a t e n e g a t i v e l y with 51 i n d i c e s of d i s t r e s s , which were i n p a r t assessed by the subscales of the POMS. F i f t y - t h r e e gay men with ARC and 50 with AIDS made up the sample. The s o c i a l support instrument was newly c r e a t e d by the f i r s t author, and examined the p e r c e p t i o n of s o c i a l support a l o n g f o u r parameters: how d e s i r a b l e i t was, how a v a i l a b l e , how o f t e n used, and how u s e f u l . The instrument c o n s i s t e d of e i g h t q u e s t i o n s which the s u b j e c t answered along a 5-point s c a l e w i t h r e s p e c t t o each of the above f o u r parameters. The qu e s t i o n s were a l s o broken down i n t o two subscales of t h r e e q u e s t i o n s each which addressed e m o t i o n a l l y - s u s t a i n i n g support ("someone t o t a l k t o " , "someone who understands your problems or f e e l i n g s " ) and p r o b l e m - s o l v i n g support ("someone who gi v e s you suggestion or advice about how t o s o l v e a problem", "someone to whom you can t u r n when you need t o borrow something"). The instrument d i d not assess numbers or types of support. R e l i a b i l i t y c o e f f i c i e n t s f o r the t o t a l e i g h t q u e s t i o n s f o r each parameter ranged from .84 t o .89, while f o r the e m o t i o n a l l y - s u s t a i n i n g q u e s t i o n s they ranged from .74 to .88 and from .64 to .73 f o r the pr o b l e m - s o l v i n g . The authors p r o v i d e no v a l i d i t y data f o r the instrument. Being newly devi s e d , the v a l i d i t y and r e l i a b i l i t y of the instrument must be questioned. With r e s p e c t t o persons with ARC, n e i t h e r the d e s i r a b i l i t y nor the u s e f u l n e s s of the s o c i a l support c o r r e l a t e d s i g n i f i c a n t l y with the d i s t r e s s i n d i c e s . The p e r c e i v e d a v a i l a b i l i t y of support, however, c o r r e l a t e d 52 n e g a t i v e l y with the d e p r e s s i o n - d e j e c t i o n s u b s c a l e on the POMS (r=-.43, p_<.01), the t e n s i o n - a n x i e t y s u b s c a l e (r=-.32, p_<.05), and the a n g e r - h o s t i l i t y s ubscale (r=-.44, p_<.005). S i m i l a r l y , how o f t e n a support was used c o r r e l a t e d n e g a t i v e l y with d e p r e s s i o n - d e j e c t i o n (r=-.40, p_<.05) and a n g e r - h o s t i l i t y (r=-.31, p_<.05). These r e s u l t s tend t o suggest t h a t i t i s the p e r c e i v e d a v a i l a b i l i t y and the enacted use of s o c i a l support t h a t i s more important i n determining d i s t r e s s f o r gay men with ARC than the d e s i r a b i l i t y or u s e f u l n e s s of support. Because Z i c h and Temoshok do not show the c o r r e l a t i o n of the s o c i a l support measures with the t o t a l POMS score i t i s d i f f i c u l t t o compare the r e s u l t s with those of Wolcott, Namir et a l . (1986) or Donlou et a l . (1985). Although Wolcott, Namir et a l . d i d f i n d a s i g n i f i c a n t c o r r e l a t i o n between s a t i s f a c t i o n w ith s o c i a l support and the POMS-TMD, i t i s not c l e a r how s a t i s f a c t i o n r e l a t e s t o the f o u r parameters used by Z i c h and Temoshok. The authors s t a t e t h a t no s i g n i f i c a n t d i f f e r e n c e s were found between ARC and AIDS s u b j e c t s i n terms of emotional-and p r o b l e m - s o l v i n g support, and t h a t the scores of the two groups were t h e r e f o r e combined f o r f u r t h e r a n a l y s i s . E m o t i o n a l l y - s u s t a i n i n g support was found t o r a t e h i g h e r across a l l f o u r parameters than p r o b l e m - s o l v i n g support. T h i s i s c o n s i s t e n t with Folkman and Lazarus' (1980) f i n d i n g t h a t emotion-focused coping was used more than problem-focused when d e a l i n g with i l l n e s s concerns and wit h Wolcott, 53 Namir et a l . (1986) who found t h a t emotional support and i l l n e s s - r e l a t e d emotional support were r a t e d as very important by 68% and 58% of the respondents r e s p e c t i v e l y . I t i s a l s o somewhat suggested by Namir et a l . (1987) who found an a c t i v e - e x p r e s s i v e coping s t r a t e g y to c o r r e l a t e higher with t h e i r s o c i a l support v a r i a b l e s than d i d an a c t i v e - r e l i a n c e s t r a t e g y . Although these s t u d i e s p r o v i d e much i n f o r m a t i o n on s o c i a l support needs and p e r c e p t i o n s of gay men w i t h AIDS and ARC t h e r e are a number of concerns which must be c o n s i d e r e d . F i r s t , as has been p o i n t e d out, the instruments used to assess s o c i a l support are o f t e n examining q u a n t i t a t i v e l y and q u a l i t a t i v e l y d i f f e r e n t concepts. T h i s makes comparisons across s t u d i e s d i f f i c u l t and may e x p l a i n some of the i n c o n s i s t e n t r e s u l t s o btained. Second, the d i f f e r i n g r e s u l t s with r e s p e c t t o d e s i r a b i l i t y and u s e f u l n e s s of d i f f e r e n t types of support do not p r o v i d e a c l e a r p i c t u r e of t h i s i s s u e and suggest t h a t f u r t h e r study i s r e q u i r e d . T h i r d , o n l y one study ( Z i c h & Temoshok, 1987) i s a ble to d i s t i n g u i s h between persons with AIDS and persons with ARC. The study by Donlou et a l . (1985) s u f f e r s from a low number of s u b j e c t s to begin with and has o n l y 4 s u b j e c t s with ARC, making i t d i f f i c u l t t o draw f i r m c o n c l u s i o n s about t h i s group from the r e s u l t s . As such, the i n f o r m a t i o n obtained by these s t u d i e s may or may not be r e l e v a n t t o HIV+ gay men. Although Z i c h and Temoshok d i d f i n d some d i f f e r e n c e s between men with AIDS and men with ARC, 54 sugges t i n g t h a t t h e r e may be d i f f e r e n c e s between men with AIDS and men with HIV g e n e r a l l y , t h i s p o s i t i o n cannot be s t a t e d with c o n f i d e n c e . Furthermore, these f i n d i n g s do not suggest t h a t gay men with AIDS as a group have s m a l l e r or l e s s adequate s o c i a l support than other gay men. What the s t u d i e s do suggest, however, i s t h a t i n gay men wi t h AIDS s o c i a l support i s a s s o c i a t e d both with mood s t a t e and with sel f - e s t e e m , and i s t h e r e f o r e an important p s y c h o s o c i a l v a r i a b l e t o c o n s i d e r . AIDS and i n t e r n a l i z e d homophobia. Although much of the l i t e r a t u r e suggests t h a t i n t e r n a l i z e d homophobia i s a f a c t o r t h a t many gay men have t o come to terms with, both as a r e s u l t of having an HIV i n f e c t i o n , and as a r e s u l t of the AIDS c r i s i s i n g e n e r a l , t h e r e has been l i t t l e s y stematic r e s e a r c h t o examine the e f f e c t s of homophobia on the l i v e s of HIV+ gay men. Wolcott, Namir et a l . (1986) examined the r e l a t i o n s h i p between i n t e r n a l i z e d homophobia, s o c i a l support, s e l f - e s t e e m and i l l n e s s concerns i n 50 gay men w i t h i n t h r e e months of an AIDS d i a g n o s i s . I n t e r n a l i z e d homophobia was assessed u s i n g the NHAI, an instrument d e v i s e d f o r use with gay men i n which a higher score i n d i c a t e s a g r e a t e r acceptance of homosexuality. Wolcott, Namir et a l . (1986) found t h a t on the whole gay men with AIDS had a more negative a t t i t u d e towards homosexuality than a group of h e a l t h y gay men (M=111.7, SD=13.5; M=131.0, SD=19.3 r e s p e c t i v e l y ) , but they suggest t h a t these d i f f e r e n c e s are not s i g n i f i c a n t . T h i s c o n c l u s i o n 55 must be co n s i d e r e d with c a u t i o n , however, as the f i g u r e s f o r hea l t h y gay men were o b t a i n e d from an e a r l i e r u n r e l a t e d study (McDonald, 1984) and may not be a p p r o p r i a t e f o r comparison. Wolcott, Namir et a l . suggest t h a t , as a group, an i n c r e a s e i n i n t e r n a l i z e d homophobia i s not e v i d e n t i n newly diagnosed gay men with AIDS, although i t may be an i s s u e f o r c e r t a i n i n d i v i d u a l s . Although the authors do not suggest the p o i n t , t h e i r f i n d i n g s are c o n s i s t e n t with the i d e a t h a t a homophobic r e a c t i o n i s more l i k e l y f o r some men than o t h e r s , and t h a t i t may be a s s o c i a t e d w i t h other v a r i a b l e s , such as degree of having 'come out' or involvement i n the gay community. The authors found t h a t a p o s i t i v e a t t i t u d e towards homosexuality was not s i g n i f i c a n t l y c o r r e l a t e d with s o c i a l support s a t i s f a c t i o n or with s e l f - e s t e e m . I t i s somewhat s u r p r i s i n g t h a t a p o s i t i v e a t t i t u d e towards one's s e x u a l i t y would not be more s t r o n g l y c o r r e l a t e d with s e l f - e s t e e m i n g e n e r a l . As was mentioned e a r l i e r , s o c i a l support and s e l f -esteem d i d show a s i g n i f i c a n t p o s i t i v e c o r r e l a t i o n (r=.51, p_<.01). I n t e r n a l i z e d homophobia d i d c o r r e l a t e s i g n i f i c a n t l y w ith emotional d i s t r e s s (r=-.40, p_<.05) as measured by the POMS-TMD score, and with h i g h e r l e v e l s of t o t a l i l l n e s s concerns (r=-.50, p_<.01). Although t h i s study suggests t h a t i n t e r n a l i z e d homophobia may be a s s o c i a t e d w i t h the w e l l - b e i n g of gay men with AIDS, i t does not n e c e s s a r i l y suggest the same would be t r u e f o r HIV+ gay men. A second area of concern i s t h a t the 56 study was conducted a t a time when AIDS was s t i l l a r e l a t i v e l y new phenomenon, and i t s connection w i t h the gay community was not as w e l l understood. In subseguent years s c i e n t i f i c understanding and p u b l i c education have i n c r e a s e d . Because of t h i s i t i s not unreasonable t o expect t h a t t h e r e may be d i f f e r e n c e s i n the NHAI and POMS-TMD scores of gay men of today as opposed t o gay men of 1984-85. The c o n s t a n t l y changing context of the AIDS c r i s i s demands t h a t a l l e a r l y s t u d i e s be viewed from a somewhat h i s t o r i c a l p e r s p e c t i v e , r e c o g n i z i n g t h a t changing circumstances may be r e f l e c t e d i n changing scores on i n d i c e s of s e l f - e s t e e m , homophobia and mood. AIDS and s e l f - e s t e e m . A number of s t u d i e s have examined s e l f - e s t e e m i n connec t i o n with other v a r i a b l e s . Donlou et a l . (1985) assessed s e l f - e s t e e m u s i n g the 9-item Simmons s c a l e . As a group (N=21) the respondents r e p o r t e d i n t a c t s e l f - e s t e e m , although 7 of the 21 manifested low s e l f - e s t e e m by s c o r i n g 3 or l e s s on the Simmons s c a l e . Wolcott, Namir et a l . (1986) a l s o used the Simmons s c a l e and found t h a t as a group (N=50) s u b j e c t s had i n t a c t s e l f - e s t e e m (M=4.0, SD=2.9), although, s i m i l a r t o the f i n d i n g s of Donlou, 37% of the respondents had a s e l f - e s t e e m score of 3 or l e s s , i n d i c a t i n g low s e l f - e s t e e m . As was mentioned e a r l i e r , s e l f - e s t e e m was found t o be s i g n f i c a n t l y a s s o c i a t e d with h e a l t h concerns (Wolcott, Namir et a l . , 1986) and with aspects of s o c i a l support (Donlou et a l . , 1985; Wolcott, Namir et a l . , 1986). Donlou et a l . found s e l f - e s t e e m showed 57 a s i g n i f i c a n t negative c o r r e l a t i o n with the POMS-TMD (r=-.44, p_<.01). U n f o r t u n a t e l y , Wolcott, Namir et a l . do not pro v i d e i n f o r m a t i o n as to the c o r r e l a t i o n between s e l f -esteem scores and mood d i s t u r b a n c e (POMS) s c o r e s . S i m i l a r l y , Namir et a l . (1987), r e p o r t i n g on d i f f e r e n t aspects of the same study r e p o r t e d on by Wolcott, Namir e t a l . , a l s o f a i l t o p r o v i d e c o r r e l a t i o n s between s e l f - e s t e e m and mood s t a t e . In s h o r t , the p r e v i o u s s t u d i e s suggest t h a t , as a group, gay men with AIDS do not s u f f e r a l o s s of s e l f - e s t e e m a f t e r d i a g n o s i s , although a c e r t a i n p r o p o r t i o n of the p o p u l a t i o n does manifest low s e l f - e s t e e m . Because these s t u d i e s a l l take p l a c e a f t e r the respondents have been diagnosed, however, i t i s not p o s s i b l e t o determine what the s e l f - e s t e e m l e v e l of respondents was be f o r e d i a g n o s i s . As a r e s u l t , i t i s u n c l e a r what impact an AIDS d i a g n o s i s has on the s e l f - e s t e e m of gay men. Self-esteem does seem t o be r e l a t e d to other p s y c h o s o c i a l v a r i a b l e s ( s o c i a l support, h e a l t h concerns), however, and, as might be expected, has been shown by one study t o have a negative a s s o c i a t i o n with poor mood s t a t e . AIDS and coping s t r a t e g i e s . There have been few s t u d i e s which have attempted t o examine the s p e c i f i c coping s t r a t e g i e s used by HIV+ or AIDS diagnosed gay men. Namir, Wolcott, Fawzy, and Alurabaugh (1987) examined the r e l a t i o n s h i p between coping s t y l e s and s e l f - e s t e e m , h e a l t h and mood s t a t e s . Because the r e s u l t s are based on the same 58 sample as was r e p o r t e d on by Wolcott, Namir et a l . (1986), the c r i t i c i s m s which can be made of the Wolcott's r e s u l t s can a l s o be made of Namir's r e s u l t s . In order t o assess c o p i n g s t y l e s and coping s t r a t e g i e s the authors used the D e a l i n g With I l l n e s s Inventory, which was developed by the authors f o r the study, and was based on the WOCS and i n c l u d e d many of the same or s i m i l a r items. Subjects responded t o statements along a 5-point L i k e r t s c a l e r a n g i n g from 'never' t o 'always'. U n l i k e the WOCS, though, i n which c l i e n t s are asked t o respond t o a s t r e s s o r they have experienced i n the past week, the D e a l i n g With I l l n e s s Inventory had no time frame (other than the t h r e e months s i n c e the s u b j e c t ' s d i a g n o s i s ) . T h i s i n t r o d u c e s the r i s k of t i m e - l a g b i a s and reviewers of the WOCS (Tennen & Herzberger, 1985) have s t r o n g l y recommended t h a t s u b j e c t s be focused t o a d e f i n e d time frame. Subjects were a l s o not asked t o i d e n t i f y a s p e c i f i c s t r e s s o r but responded t o coping with t h e i r i l l n e s s i n g e n e r a l . Once again, i t has been suggested t h a t i n conducting s t r e s s r e s e a r c h i t i s more e f f e c t i v e t o have the s u b j e c t i d e n t i f y a s p e c i f i c s t r e s s o r (Folkman, 1982), as d i f f e r e n t s t r e s s o r s may be a p p r a i s e d d i f f e r e n t l y and e l i c i t d i f f e r e n t coping s t r a t e g i e s . I t i s apparent from the p r e c e d i n g d i s c u s s i o n t h a t an HIV d i a g n o s i s can impact i n a number of ways on an i n d i v i d u a l ' s l i f e . Subjects may experience these d i f f e r e n t s t r e s s o r s i n d i f f e r e n t ways and may invoke the use of d i f f e r e n t coping s t r a t e g i e s t o d e a l with them. By having respondents o n l y 59 address coping with t h e i r i l l n e s s i n a g e n e r a l way, Namir et a l . ' s r e s u l t s do not c l e a r l y d e l i n e a t e between d i f f e r e n t s t r e s s o r s and p o t e n t i a l l y d i f f e r e n t approaches t o coping. Namir et a l . (1987) i d e n t i f i e d e i g h t coping s t r a t e g i e s ( p o s i t i v e involvement, e x p r e s s / i n f o r m a t i o n seeking, r e l i a n c e on o t h e r s , p o s i t i v e u n d e r s t a n d i n g / c r e a t e meaning, p a s s i v e / r u m i n a t i v e , d i s t r a c t i o n , p a s s i v e r e s i g n a t i o n and s o l i t a r y / p a s s i v e ) which were grouped i n t o t h r e e broad coping methods ( a c t i v e - b e h a v i o r a l , a c t i v e - c o g n i t i v e , and avoidance). Cronbach alphas f o r the e i g h t s t r a t e g i e s ranged from .63 t o .90. A c t i v e - c o g n i t i v e was the most used coping method (M=3.40, SD=1.08), f o l l o w e d by a c t i v e - b e h a v i o u r a l (M=2.97, SD=1.01), and avoidance (M=2.48, SD=1.09). Of the coping s t r a t e g i e s , c o g n i t i v e - p o s i t i v e / c r e a t e meaning, which i s s i m i l a r t o the P o s i t i v e R e a p p r a i s a l s t r a t e g y of Lazarus, Folkman, Dunkel-Schetter et a l . (1986), was used most f r e q u e n t l y (M=3.97, SD-.99). The next s i x s t r a t e g i e s had means ran g i n g from 3.07 t o 3.53. Avoidance as a coping s t r a t e g y was used the l e a s t (M=1.86, SD=1.57). Namir et a l . (1987) found t h a t the use of avoidance as a means of coping showed a s i g n i f i c a n t p o s i t i v e c o r r e l a t i o n with d e p r e s s i o n (r=.43, p_<.01) a n c * a n x i e t y (r=.31, p_<.05) as measured by the POMS, and a s i g n i f i c a n t n e g ative c o r r e l a t i o n with s e l f - e s t e e m (r=-.47, p_<.01) and the numbers of people i n one's s o c i a l support network (r=-.32 t o -.33, p_<.05). Although c o g n i t i v e - b e h a v i o u r a l was the most used method, an a c t i v e - b e h a v i o u r a l method of coping was a s s o c i a t e d with a 60 more p o s i t i v e a f f e c t i v e s t a t e and higher s e l f - e s t e e m . A c t i v e - b e h a v i o u r a l was n e g a t i v e l y c o r r e l a t e d w i t h t o t a l mood di s t u r b a n c e (r=-.45, p_<.01), and was p o s i t i v e l y c o r r e l a t e d with s e l f - e s t e e m (r=.36, p_<.05) and with the s o c i a l support v a r i a b l e s (r=.35 t o .51, p<.05). An a c t i v e - c o g n i t i v e approach, showed a s i m i l a r d i r e c t i o n t o the a c t i v e -b e h a v i o u r a l approach, but not reach s t a t i s t i c a l s i g n i f i c a n c e with any of the v a r i a b l e s . When s a t i s f a c t i o n with support, i n s t r u m e n t a l support, and coping methods were entered i n t o a stepwise r e g r e s s i o n p r e d i c t i n g the POMS-TMD score, avoidance (F=6.69, p_<.01) and a c t i v e - b e h a v i o u r a l (F=4.08. p.<.05) entered s i g n i f i c a n t l y and accounted f o r 7% and 8% of the va r i a n c e r e s p e c t i v e l y . Avoidance had a p o s i t i v e r e l a t i o n s h i p with poor mood s t a t e (B=.50), w h i l e a c t i v e -b e h a v i o u r a l had a negative r e l a t i o n s h i p (B=-.45). In terms of s p e c i f i c c o p i n g s t r a t e g i e s , a c t i v e - p o s i t i v e and d i s t r a c t i o n both showed s i g n i f i c a n t n e g a t i v e c o r r e l a t i o n s with the POMS-TMD (r=-.58, p_<.001; r=-.38, p_<.05, r e s p e c t i v e l y ) , w h i l e avoidance and c o g n i t i v e -p a s s i v e / r u m i n a t i v e showed s i g n i f i c a n t p o s i t i v e c o r r e l a t i o n s (r=.42, p_<.01; r=.40, p_<.01, r e s p e c t i v e l y ) . A c t i v e - p o s i t i v e and c o g n i t i v e - p o s i t i v e had s i g n i f i c a n t p o s i t i v e c o r r e l a t i o n s with s e l f - e s t e e m (r=.58, p_<.0001; r=.34, p_<.05, r e s p e c t i v e l y ) , w h i l e avoidance and c o g n i t i v e -p a s s i v e / r u m i n a t i v e showed s i g n i f i c a n t n e gative c o r r e l a t i o n s (r=-.40, p_<.01; r=-.39, p_<.01, r e s p e c t i v e l y ) . S i m i l a r l y a c t i v e - p o s i t i v e and d i s t r a c t i o n c o r r e l a t e d n e g a t i v e l y with 61 the POMS-TMD scores (r=-.58, p_<.001; £=--38, p_<.05, r e s p e c t i v e l y ) , w h ile c o g n i t i v e - p a s s i v e / r u m i n a t i v e and avoidance c o r r e l a t e d p o s i t i v e l y (r=.40, p_<.01; r=.42, p_<.01, r e s p e c t i v e l y ) . These r e s u l t s i n d i c a t e t h a t the use of the s t r a t e g i e s , avoidance and c o g n i t i v e - p a s s i v e / r u m i n a t i o n , i s a s s o c i a t e d with emotional d i s t r e s s and lower s e l f - e s t e e m , w h i l e the use of a c t i v e - p o s i t i v e and d i s t a n c i n g s t r a t e g i e s i s a s s o c i a t e d with b e t t e r mood s t a t e and s e l f - e s t e e m . These r e s u l t s imply t h a t the use of a more a c t i v e - b e h a v i o u r a l coping approach by people with AIDS or ARC i s more l i k e l y t o be a s s o c i a t e d with b e t t e r emotional adjustment, whereas the use of avoidance or rumination i s l i k e l y t o be a s s o c i a t e d with poorer emotional adjustment. The way i n which Namir e t a l . (1987) have grouped the e i g h t coping s t r a t e g i e s i n t o t h r e e c o p i n g methods causes some d i f f i c u l t i e s i n t r y i n g t o i n t e r p r e t the r e s u l t s . Avoidance as a coping method c o n s i s t s of the items from the d i s t r a c t i o n and avoidance c o p i n g s t r a t e g i e s . Yet avoidance as a coping s t r a t e g y was a s s o c i a t e d with lower s e l f - e s t e e m w h i l e d i s t r a c t i o n was not. In terms of i n t e r p r e t a t i o n i t would make more sense t o c o n s i d e r the f i n d i n g s i n terms of coping s t r a t e g i e s as opposed t o the broader c o p i n g methods, as t h i s g i v e s a c l e a r e r p i c t u r e of s p e c i f i c groupings of r e l a t e d thoughts and behaviours. A second a l t e r n a t i v e i s to reexamine the s t r a t e g i e s which have been grouped together to form the coping methods. An examination of the Pearson 62 c o r r e l a t i o n s between the s t r a t e g i e s would i n d i c a t e which s t r a t e g i e s were more s t r o n g l y a s s o c i a t e d , and hence more l i k e l y t o be o c c u r i n g t o g e t h e r , and would t h e r e f o r e suggest more a p p r o p r i a t e groupings of s t r a t e g i e s from which t o form coping methods. AIDS and mood s t a t e s . Donlou et a l . (1985) compared POMS scores of AIDS p a t i e n t s w i t h other c h r o n i c and/or s e r i o u s l y i l l p a t i e n t s . Subjects with AIDS or ARC (n=21) had higher group means on f o u r of f i v e s u b s c a l e s and the TMD (M=89.4, SD=36.2) f o r the POMS when compared with s i m i l a r groups of men w a i t i n g f o r bone marrow t r a n s p l a n t s (n=5) and those with c h r o n i c r e n a l f a i l u r e (n=22). These r e s u l t s suggest t h a t a d i s t u r b a n c e of mood may be a s s o c i a t e d with a d i a g n o s i s of AIDS or ARC, and t h a t , on average, i t w i l l be of g r e a t e r degree than t h a t experienced by other groups of c h r o n i c a l l y i l l people. These f i g u r e s must be c o n t r a s t e d with those of Wolcott, Namir et a l . (1986) who r e p o r t e d a somewhat lower POMS-TMD (M=79.5, SD=38.6). Summary The evidence accumulated t o date suggests t h a t s e l f -esteem, s o c i a l support, homophobia and coping s t r a t e g i e s are a s s o c i a t e d with mood s t a t e s i n AIDS diagnosed gay men. Fur t h e r , gay men with an AIDS or ARC d i a g n o s i s are l i k e l y t o experience g r e a t e r mood d i s t u r b a n c e than h e a l t h y i n d i v i d u a l s and other groups of c h r o n i c a l l y i l l people. These s t u d i e s have weaknesses, however, which l i m i t the u s e f u l n e s s or r e l i a b i l i t y of t h e i r f i n d i n g s when c o n s i d e r i n g the s i t u a t i o n 63 of HIV+ gay men. One drawback i s t h a t the m a j o r i t y of the s t u d i e s have focused on men with f u l l - b l o w n AIDS, and thus the r e s u l t s may or may not be a p p l i c a b l e to men who are HIV+. As w e l l , the analyses used i n the m a j o r i t y of s t u d i e s have c o n s i s t e d of simple c o r r e l a t i o n s , which o n l y i n d i c a t e s i g n i f i c a n t r e l a t i o n s h i p s between any two v a r i a b l e s independently, r a t h e r than t a k i n g i n t o account the i n t e r a c t i v e e f f e c t s of the other v a r i a b l e s i n the study. To date no study has been conducted to determine whether these v a r i o u s f a c t o r s have any a s s o c i a t i o n with s p e c i f i c c oping s t r a t e g i e s used by HIV+ gay men i n d e a l i n g with t h e i r i n f e c t i o n . Although the work of Namir et a l . (1987) suggests t h a t d i f f e r e n t coping s t r a t e g i e s are a s s o c i a t e d with d i f f e r i n g l e v e l s of s e l f - e s t e e m , s o c i a l support, and emotional w e l l - b e i n g i n i n f e c t e d gay men, the study does not g i v e any i n d i c a t i o n of which f a c t o r s might p r e d i c t the use of d i f f e r e n t coping s t r a t e g i e s . Given t h a t v a r i o u s combinations of p e r s o n a l , environmental and c o n t e x t u a l v a r i a b l e s have been found t o be a s s o c i a t e d with the use of d i f f e r e n t coping s t r a t e g i e s i n p o p u l a t i o n s with h e a l t h or i l l n e s s concerns, the p r e s e n t study i s designed to i n v e s t i g a t e the a s s o c i a t i o n of a number of f a c t o r s r e l e v a n t to HIV+ gay men with t h e i r use of c e r t a i n coping s t r a t e g i e s i n d e a l i n g with i n f e c t i o n r e l a t e d s t r e s s . Furthermore, given t h a t the use of d i f f e r e n t coping s t r a t e g i e s has been a s s o c i a t e d with v a r y i n g degrees of emotional w e l l - b e i n g and adjustment i n other h e a l t h r e l a t e d 64 a r e a s , i n c l u d i n g A I D S , t h i s s t u d y w i l l a l s o e x a m i n e t h e r e l a t i o n s h i p b e t w e e n t h e g r e a t e r r e l a t i v e u s e o f one s t r a t e g y o v e r a n o t h e r a n d t h e e m o t i o n a l w e l l - b e i n g o f HIV+ ga y men. B a s e d on p r e v i o u s r e s e a r c h f i n d i n g s i t i s e x p e c t e d t h a t d i f f e r e n t c o m b i n a t i o n s o f f a c t o r s w o u l d be a s s o c i a t e d w i t h t h e g r e a t e r r e l a t i v e u s e o f d i f f e r e n t c o p i n g s t r a t e g i e s , a n d t h a t t h e g r e a t e r r e l a t i v e u s e o f d i f f e r e n t s t r a t e g i e s w o u l d i n t u r n be a s s o c i a t e d w i t h d i f f e r i n g l e v e l s o f e m o t i o n a l w e l l - b e i n g . 65 Hypotheses Hypothesis 1. S i n g l y or i n combination t h e r e i s a s i g n i f i c a n t l i n e a r r e l a t i o n s h i p between time s i n c e d i a g n o s i s , s t r e s s o r type, i n t e r n a l i z e d homophobia, s e l f -esteem, s o c i a l support, the i n t e r a c t i v e e f f e c t s of i n t e r n a l i z e d homophobia wi t h s e l f - e s t e e m and with s o c i a l support, and the r e l a t i v e use of Avoidant coping. Avoidant coping c o n s i s t s of the items comprising the D i s t a n c i n g and Escape-Avoidance subscales from the WOCS (Folkman, Lazarus, Dunkel-Schetter et a l . , 1986). Hypothesis 2. S i n g l y or i n combination t h e r e i s a s i g n i f i c a n t l i n e a r r e l a t i o n s h i p between time s i n c e d i a g n o s i s , s t r e s s o r type, i n t e r n a l i z e d homophobia, s e l f -esteem, s o c i a l support, the i n t e r a c t i v e e f f e c t s of i n t e r n a l i z e d homophobia with s e l f - e s t e e m and with s o c i a l support, and the r e l a t i v e use of P r o a c t i v e coping. P r o a c t i v e coping c o n s i s t s of the items comprising the P o s i t i v e R e a p p r a i s a l and Seeking S o c i a l Support subscales from the WOCS (Folkman, Lazarus, Dunkel-Schetter et a l . , 1986). Hypothesis 3. There i s a s i g n i f i c a n t r e l a t i o n s h i p between the r e l a t i v e use of Avoidant coping and mood d i s t u r b a n c e or emotional d i s t r e s s . The r e l a t i o n s h i p w i l l be of moderate s t r e n g t h (r<.40). Hypothesis 4. There i s a s i g n i f i c a n t r e l a t i o n s h i p between the r e l a t i v e use of P r o a c t i v e coping and mood di s t u r b a n c e or emotional d i s t r e s s . The r e l a t i o n s h i p w i l l be m o d e r a t e s t r e n g t h ( r < . 67 Method Subjects E l i g i b l e s u b j e c t s (N=89) f o r the study c o n s i s t e d of gay men who had t e s t e d p o s i t i v e f o r HIV and who i d e n t i f i e d homosexual c o n t a c t as the cause of t h e i r i n f e c t i o n . Only i n d i v i d u a l s whose present d i a g n o s t i c s t a t u s was HIV+ or ARC were u t i l i z e d . Although ARC has proven d i f f i c u l t t o d e f i n e as a d i a g n o s t i c e n t i t y and the t r e n d i s t o no longer use i t as a d e s c r i p t i v e term, i t was f e l t t h a t some s u b j e c t s might use the term t o c h a r a c t e r i z e t h e i r s t a t u s , g i v e n t h a t i t has been i n common usage. In t h i s study, however, HIV+ r e f e r s to both asymptomatic HIV p o s i t i v e s t a t u s as w e l l as to ARC, unless otherwise s t a t e d . Respondents were p r i m a r i l y Caucasian, middle-aged (M=35.7) and w e l l educated. The m a j o r i t y were working f u l l -time, with over h a l f b e i n g i n p r o f e s s i o n a l or managerial p o s i t i o n s , e a r n i n g over 10 thousand d o l l a r s Canadian per annum. Most men i d e n t i f i e d themselves as homosexual (89%) as opposed to b i s e x u a l (11%), but i n e i t h e r case had c o n s i d e r e d themselves so f o r an average of n e a r l y 20 y e a r s . Roughly h a l f were s i n g l e w h i l e one t h i r d were l i v i n g with a l o v e r . A t h i r d of the respondents s t a t e d no r e l i g i o u s a f f i l i a t i o n w h i l e h a l f were e i t h e r C a t h o l i c or P r o t e s t a n t . N e a r l y t h r e e q u a r t e r s of the respondents were HIV+, w h i l e the remaining were diagnosed w i t h ARC. S i m i l a r t o the f i n d i n g s of Donlou et a l . (1985) and Wolcott, Namir et a l . (1986), respondents i n d i c a t e d t h a t they had approached more 68 f r i e n d s and f a m i l y members f o r help than d o c t o r s or other p r o f e s s i o n a l s . O v e r a l l , the demographic makeup of the respondents (see Table 1) i s c o n s i s t e n t with the samples of other A I D S - r e l a t e d s t u d i e s i n v o l v i n g gay men (Joseph, Montgomery et a l . , 1987; Moulton et a l . , 1987; S t u l b e r g & Smith, 1988; Wolcott, Namir e t a l . , 1986). Procedure An anonymous s e l f - r e p o r t q u e s t i o n n a i r e package was d i s t r i b u t e d with the a s s i s t a n c e of agencies and i n d i v i d u a l s i n Vancouver, Winnipeg and Toronto working with HIV+ persons. In Vancouver these i n c l u d e d AIDS Vancouver, the Persons With AIDS C o a l i t i o n (PWA), and the I n f e c t i o u s Diseases C l i n i c at St. Paul's H o s p i t a l . In Toronto d i s t r i b u t i o n took p l a c e through the AIDS Committee of Toronto and the Hassle Free C l i n i c , w h i l e the V i l l a g e C l i n i c helped d i s t r i b u t e i n Winnipeg. V a r i o u s d o c t o r s and h e a l t h p r o f e s s i o n a l s working p r i v a t e l y with HIV+ i n d i v i d u a l s i n each c i t y a l s o helped d i s t r i b u t e q u e s t i o n n a i r e s . The study was f u r t h e r p u b l i c i z e d and v o l u n t e e r s r e c r u i t e d i n Vancouver through l o c a l newspapers and r a d i o s t a t i o n s . P a r t i c i p a t i o n i n the study was on a s t r i c t l y v o l u n t a r y b a s i s and was not con t i n g e n t on r e c e i v i n g h elp from any of the agencies or i n d i v i d u a l s . Subjects who agreed t o p a r t i c i p a t e f i l l e d out a q u e s t i o n n a i r e package c o n s i s t i n g of i n v e n t o r i e s a s s e s s i n g t h e i r p e r c e i v e d s o c i a l support, t h e i r a t t i t u d e s towards homosexuality, t h e i r s e l f - e s t e e m , t h e i r p resent mood s t a t e , and the cop i n g s t r a t e g i e s they used i n 69 Table 1 Demographic C h a r a c t e r i s t i c s of Sample (N=89) C h a r a c t e r i s t i c % M SD Range Age (n=87) 35.7 7.3 23-62 Numbers and type of s o c i a l support u t i l i z e d F r i e n d s or f a m i l y (n=73) 7.5 8.3 0-50 P r o f e s s i o n a l support (n=81) 4.3 3.4 1-15 O r i e n t a t i o n Homosexual 88.8 B i s e x u a l 11.2 D i a g n o s t i c s t a t u s HIV+ 71.9 ARC 28.1 Education (n=88) Less than Grade 12 14.8 High sc h o o l graduate 19.3 Some u n i v e r s i t y 33.0 Bachelors degree 22.7 Masters degree 4.5 D o c t o r a l degree 5.7 Employment F u l l - t i m e 73.0 Part-time 4.5 Unem p l o y e d / D i s a b i l i t y 21.3 70 Occupation (n-88) P r o f e s s i o n a l 30.7 Managerial 21.6 C l e r i c a l 6.8 T e c h n i c a l 12.5 Sales 4.5 S e r v i c e 11.4 Manual 5.7 Other 6.8 Income Under $10,000 7.9 $10,000 t o $19,999 24.7 $20,000 t o $29,999 22.5 $30,000 to $49,999 32.6 $50,000 to $100,000 11.2 Over $100,000 1.1 E t h n i c background Black 1.1 Caucasian 97.8 Na t i v e Indian 1.1 R e l i g i o n C a t h o l i c 22.5 Jewish 1.1 P r o t e s t a n t 36.0 None 31.5 Other 9.0 71 R e l a t i o n s h i p s t a t u s S i n g l e 44.9 In committed r e l a t i o n s h i p , but not l i v i n g with l o v e r 7.9 L i v i n g with l o v e r 36.0 Separated/divorced/widowed 10.1 M a r r i e d 1.1 Note. D i f f e r e n t n's are the r e s u l t of m i s s i n g data. 72 response t o s t r e s s o r s a s s o c i a t e d w i t h having an HIV+ i n f e c t i o n . Subjects were p r o v i d e d with a stamped, s e l f -addressed envelope with which t o r e t u r n the package. C o n f i d e n t i a l i t y was a p r i o r i t y of the study. To ensure t h i s , the o n l y i d e n t i f i c a t i o n appearing on the package was a q u e s t i o n n a i r e i d e n t i f i c a t i o n number. Subjects were e x p r e s s l y c a u t i o n e d not t o put t h e i r name on the package. (See Appendix A) D i s t r i b u t i o n and c o l l e c t i o n of g u e s t i o n n a i r e s took p l a c e between December 15, 1988 and A p r i l 30, 1989. A t o t a l of 369 q u e s t i o n n a i r e s were g i v e n t o the v a r i o u s agencies and i n d i v i d u a l s f o r d i s t r i b u t i o n . Of t h i s number 104 (28.2%) were completed and r e t u r n e d . Of the 104 which were r e t u r n e d 15 (14.4%) were i n e l i g i b l e f o r use. Three of these were i n c o r r e c t l y or i n c o m p l e t e l y f i l l e d out. Three of the su b j e c t s were u n c e r t a i n how they had been i n f e c t e d w h ile , another t h r e e i d e n t i f i e d s h a r i n g of IV drug needles. Three of the respondents had AIDS w h i l e the f i n a l t h r e e were unable t o i d e n t i f y an HIV r e l a t e d s t r e s s o r . The remaining t o t a l of 89 q u e s t i o n n a i r e s were a c c e p t a b l e and were used i n the a n a l y s e s . See Table 2 f o r a complete breakdown of numbers and l o c a t i o n s of q u e s t i o n n a i r e s d i s t r i b u t e d , r e t u r n r a t e s and i n e l i g i b l e q u e s t i o n n a i r e s . Instruments Demographic i n f o r m a t i o n . A wide range of demographic i n f o r m a t i o n was gathered i n c l u d i n g age, occu p a t i o n , education, r e l i g i o u s p r e f e r e n c e , the number of years the 73 Table 2 Q u e s t i o n n a i r e D i s t r i b u t i o n and Return F i g u r e s N n % Released f o r d i s t r i b u t i o n Returned C l i n i c s and agencies Vancouver 150 51 33.3 Winnipeg 25 3 12.0 Toronto 75 14 18.7 Doctors and i n d i v i d u a l s Vancouver 119 36 30.3 T o t a l 369 104 28.2 74 s u b j e c t had i d e n t i f i e d h i m s e l f as homosexual or b i s e x u a l , degree of involvement i n the gay community, number of p r o f e s s i o n a l and n o n - p r o f e s s i o n a l people t o l d about the d i a g n o s i s , and the respondent's e x p e c t a t i o n of d e v e l o p i n g AIDS. (see Appendix B) P r e d i c t o r V a r i a b l e s . Respondents were asked t o i n d i c a t e how long i t had been i n years and/or months s i n c e they r e c e i v e d t h e i r HIV+ d i a g n o s i s . T h i s f i g u r e was converted i n t o months f o r use i n a n a l y s i s . Respondents were asked t o p i c k from a l i s t of f i v e s t r e s s o r s i d e n t i f i e d i n the l i t e r a t u r e as b e i n g common i s s u e s f o r HIV+ gay men. These i n c l u d e d : (a) f e e l i n g b adly about b e i n g i n f e c t e d ; (b) worrying about one's h e a l t h or the f u t u r e ; (c) t a l k i n g with or t e l l i n g others about one's d i a g n o s i s ; (d) d e a l i n g with changes i n l i f e s y l e ; (e) a s t r e s s o r not l i s t e d . I f respondents i d e n t i f i e d more than one category as s t r e s s f u l t h i s was coded as ( f ) m u l t i p l e s t r e s s o r s f o r purpose of a n a l y s i s . With regards t o s t r e s s o r s , 49% of the respondents s a i d t h a t worrying about t h e i r h e a l t h or the f u t u r e was s t r e s s f u l , changes i n l i f e s t y l e was i d e n t i f i e d by 15% of the p a r t i c i p a n t s , t e l l i n g others about t h e i r d i a g n o s i s was a s t r e s s o r f o r 11%, and 11% i d e n t i f i e d m u l t i p l e s t r e s s o r s . These r e s u l t s were converted i n t o a dichotomous v a r i a b l e , w i t h worry about h e a l t h or f u t u r e forming one group s e t equal to 1, and the other s t r e s s o r s c o l l a p s e d i n t o a second category s e t equal t o 0. The Nungesser Homosexual A t t i t u d e s Inventory (NHAI; 75 Nungesser, 1979) i s a 34-item instrument which p r o v i d e s a gene r a l measure of homophobic p r e j u d i c e i n homosexual men. I t was developed f o r use wit h and t e s t e d with homosexual men. Subjects respond t o gu e s t i o n s on a 5-point L i k e r t s c a l e r a n g i n g from 1 ( s t r o n g l y d i s a g r e e ) t o 5 ( s t r o n g l y a g r e e ) . The questions are roughly e q u a l l y d i v i d e d between those i n which a response i n d i c a t i n g agreement wi t h the statement i n d i c a t e s a p o s i t i v e a t t i t u d e and those i n which i t i n d i c a t e s a negative a t t i t u d e . The instrument i s comprised of t h r e e subscales which r e s p e c t i v e l y assess a t t i t u d e s towards one's own homosexuality, towards homosexuality i n g e n e r a l , and towards s e l f - d i s c l o s u r e of one's homosexuality. The t o t a l NHAI score i s summed from the t h r e e subscale scores w i t h a higher score i n d i c a t i n g a more p o s i t i v e a t t i t u d e t o homosexuality. In t h i s study the t o t a l NHAI score was used. R e l i a b i l i t y of the subscales has been p r e v i o u s l y assessed (Nungesser, 1979) with the f o l l o w i n g Cronbach's alphas o b t a i n e d : s u b s c a l e A ( s e l f ) ; .88, subscale B ( o t h e r s ) ; .67, subscale C ( d i s c l o s u r e ) ; .93; f u l l s c a l e ; .95. In t h i s study the s t a n d a r d i z e d item alpha of the e n t i r e instrument was c a l c u l a t e d a t r=.94. The instrument has been used i n p r e v i o u s AIDS r e s e a r c h (Wolcott, Namir et a l . , 1986), i n r e s e a r c h on s e l f - e s t e e m and de p r e s s i o n i n gay men (Alexander, 1987) and i n i d e n t i t y congruence i n gay men (McDonald, 1984). (see Appendix D) The Rosenberg Self-Esteem Scale (RSES; Rosenberg, 1965) i s a 10-item instrument which i s used t o measure s e l f -76 esteem. Subjects respond t o q u e s t i o n s on a 4-point L i k e r t s c a l e r a n g i n g from 1 ( s t r o n g l y agree) t o 4 ( s t r o n g l y d i s a g r e e ) . The v a l i d i t y of the instrument was e v a l u a t e d and found to be a c c e p t a b l e i n the o r i g i n a l study i n v o l v i n g a d o lescent boys (Rosenberg, 1965) by comparing scores generated w i t h a number of o b s e r v a t i o n a l and b e h a v i o u r a l v a r i a b l e s t y p i c a l l y a s s o c i a t e d with s e l f - e s t e e m . The i n t e r n a l r e l i a b i l i t y of the instrument i n a r e c e n t study (DeLongis et a l . , 1988) was .78, which i s c o n s i s t e n t with previous r e s e a r c h . In t h i s study the s t a n d a r d i z e d alpha c o e f f i c i e n t of the instrument was c a l c u l a t e d a t r=.90. The instrument has been used i n a v a r i e t y of s t r e s s r e s e a r c h (DeLongis et a l . , 1988; F e l t o n et a l . , 1984; Fleishman, 1984; Folkman, Lazarus, Gruen, & DeLongis, 1986; P e a r l i n & Schooler, 1978). (see Appendix C) The Revised Kaplan S c a l e (RKS; Turner et a l . , 1983) i s a m o d i f i e d v e r s i o n of an o r i g i n a l s c a l e developed by Kaplan (1977). The s c a l e i s a 9-item instrument which assesses l o v e , esteem, and s o c i a l network support as d e f i n e d by Cobb (1976). Subjects read t h r e e v i g n e t t e s i n which a p a r t i c u l a r person i s d e s c r i b e d and then r a t e who they are most s i m i l a r with along a 5-point L i k e r t - l i k e s c a l e r a n g i n g from 'I'm l i k e person A ' ( l ) to 'I'm l i k e person C'(5). F a c t o r a n a l y s i s of the s c a l e by Turner et a l . (1983) found t h a t the l o v e and esteem s c a l e s were h i g h l y c o r r e l a t e d s u g g e s t i n g they r e p r e s e n t a s i n g l e dimension. The RKS i s thus a two dimensional i n v e n t o r y . Summing the items scores y i e l d s the 77 t o t a l p e r c e i v e d s o c i a l support s c o r e . Turner et a l . assessed the r e l i a b i l i t y of the instrument a c r o s s two s t u d i e s and found Cronbach's alphas of .83 and .81 f o r the e n t i r e s c a l e and alphas f o r the subscales of .79 and .87 f o r the love-esteem dimension, and .73 and .78 f o r the network support dimension. In a l o n g i t u d i n a l study with p h y s i c a l l y d i s a b l e d men and women i n t e r n a l r e l i a b i l i t y was found t o be .83 and .82 a t two separate t e s t i n g s (Turner & Noh, 1988), while the c o e f f i c i e n t of t e s t - r e t e s t s t a b i l i t y was found t o be 0.6 a f t e r c o n t r o l l i n g f o r other v a r i a b l e s (Turner, p e r s o n a l communication). In t h i s study the s t a n d a r d i z e d item alpha of the e n t i r e instrument was c a l c u l a t e d a t r=.89. The instrument, and a s l i g h t l y s h o r t e r v e r s i o n (Turner, 1981), have been used t o assess s o c i a l support w i t h the p h y s i c a l l y d i s a b l e d , the m e n t a l l y i l l , mothers wi t h newborns, and a d u l t s with a c q u i r e d h e a r i n g l o s s . (see Appendix F) The P r o f i l e of Mood St a t e s (POMS; McNair e t a l . , 1971) i s a 65-item a d j e c t i v e c h e c k l i s t i n which moods experienced i n the past week are scored on a 5-point L i k e r t s c a l e ranging from 0 (not at a l l ) t o 4 (extremely). The instrument i s composed of 6 f a c t o r - a n a l y t i c a l l y d e r i v e d subscales ( a n g e r - h o s t i l i t y , c o n f u s i o n , d e p r e s s i o n - d e j e c t i o n , f a t i g u e - i n e r t i a , t e n s i o n - a n x i e t y , v i g o r - a c t i v i t y ) . A t o t a l mood d i s t u r b a n c e score (TMD) i s obtained by summing the f i r s t 5 subscale scores and s u b t r a c t i n g the v i g o r - a c t i v i t y s c o r e . The TMD score was used f o r the presen t study. The 78 instrument, o r i g i n a l l y normed wi t h c o l l e g e students and p s y c h i a t r i c o u t p a t i e n t s , has s i n c e seen wide use. Besides having high face v a l i d i t y , the p r e d i c t i v e and c o n s t r u c t v a l i d i t y has been demonstrated i n a number of d i f f e r e n t r e s e a r c h s t u d i e s (Weckowicz, 1978). S i m i l a r l y , two s t u d i e s which sought t o eval u a t e the i n t e r n a l r e l i a b i l i t y o b t a i n e d alphas r a n g i n g from .84 t o .95 (Eichman, 1978). The instrument has been used i n p r e v i o u s r e s e a r c h w i t h AIDS and HIV+ s u b j e c t s (Donlou et a l . , 1985; Moulton et a l . , 1987; Wolcott, Namir et a l . , 1986). C r i t e r i o n V a r i a b l e s . The Ways of Coping S c a l e (WOCS) used i n t h i s study i s a m o d i f i c a t i o n of the Ways of Coping Scale (Lazarus & Folkman, 1984), based on the subsequent work of Folkman, Lazarus, Dunkel-Schetter et a l . (1986). T h i s 52-item v e r s i o n of the s c a l e omits 15 items from the o r i g i n a l WOCS which d i d not l o a d s i g n i f i c a n t l y through f a c t o r a n a l y s i s onto the e i g h t s u b s c a l e s . The presen t v e r s i o n has a l s o broken the statement r e l a t i n g t o use of food, d r i n k i n g or drugs i n t o t h r e e q u e s t i o n s ; one d e a l i n g with food, one with smoking, d r i n k i n g and drugs, and one with sex ( i . e . , 'I t r i e d t o make myself f e e l b e t t e r by smoking, d r i n k i n g or t a k i n g drugs', ' T r i e d t o make myself f e e l b e t t e r by e a t i n g ' , ' T r i e d t o make myself f e e l b e t t e r by having s e x ' ) . When completing the WOCS s u b j e c t s are asked t o c o n s i d e r a s t r e s s o r they have experienced i n a given time p e r i o d , t y p i c a l l y the past week. With t h i s s t r e s s o r as t h e i r frame 79 of r e f e r e n c e they then answer ques t i o n s c o n c e r n i n g t h e i r coping behaviours on a 4-point L i k e r t s c a l e r a n g i n g from 0 (not used at a l l ) t o 3 (used a gre a t d e a l ) . In t h i s study s u b j e c t s were asked t o choose one s t r e s s o r from the l i s t of f i v e s t r e s s o r s d i s c u s s e d above and c o n s i d e r t h e i r response to t h i s s t r e s s o r over the p a s t month. (see Appendix E) Tennen and Herzeberger (1985) d i s c u s s an ex t e n s i v e l i s t of s t u d i e s u s i n g the WOCS which demonstrate the c o n s t r u c t and concurrent v a l i d i t y of the instrument. The instrument has been used i n a l a r g e number of s t u d i e s a s s e s s i n g coping, i n c l u d i n g r e s e a r c h i n t o coping with i l l n e s s . T e s t - r e t e s t a n a l y s i s of the WOCS t y p i c a l l y show low c o r r e l a t i o n s . T h i s i s t o be expected, however, as coping i s c o n s i d e r e d an i n t e r a c t i o n a l process which changes a c c o r d i n g t o the changing person-environment s i t u a t i o n . A review of the l i t e r a t u r e on the p s y c h o s o c i a l r e a c t i o n s of gay men to an HIV+ d i a g n o s i s suggested two d i f f e r e n t coping s t r a t e g i e s which might be used. One of these s t r a t e g i e s would i n v o l v e an attempt t o deny, minimize or a v o i d the i m p l i c a t i o n s of the HIV+ d i a g n o s i s and the a s s o c i a t e d s t r e s s e s . T h i s s t r a t e g y was c a l l e d Avoidant coping and was conceived of i n terms of the items comprising the Escape-Avoidance and D i s t a n c i n g subscales of the WOCS. The second s t r a t e g y would i n v o l v e the i n f e c t e d i n d i v i d u a l r e a p p r a i s i n g the s i t u a t i o n as a ch a l l e n g e or s e e i n g p o s i t i v e aspects t o i n f e c t i o n , as w e l l as engaging i n the a c t i v e seeking of s o c i a l support. T h i s s t r a t e g y was termed 80 P r o a c t i v e coping and was conceived of i n terms of the P o s i t i v e R e a p p r a i s a l and Seeking S o c i a l Support subscales of the WOCS. Sc o r i n g of the WOCS f o l l o w e d t h a t proposed by V i t a l i a n o , Maiuro, Russo, and Becker (1987) i n which r e l a t i v e scores were analysed r a t h e r than raw s c o r e s . In t h i s approach the raw mean score f o r a given s u b s c a l e i s d i v i d e d by the sum of the raw mean scores f o r a l l e i g h t s u b s c a l e s . T h i s method p u r p o r t e d l y p r o v i d e s a c l e a r e r p i c t u r e of the r e l a t i v e s t r e n g t h of a p a r t i c u l a r s t r a t e g y as p a r t of the e n t i r e coping s t r a t e g y used by an i n d i v i d u a l and has been recommended as a means of d e l i n e a t i n g r e l a t i o n s h i p s between ways of coping and h e a l t h - r e l a t e d behaviour ( V i t a l i a n o et a l . , 1987). For t h i s study the raw means of the Escape-Avoidance and D i s t a n c i n g subscales were summed t o y i e l d an Avoidant Coping s c o r e , which was then d i v i d e d by the t o t a l summed raw means of the e i g h t s u b - s c a l e s . S i m i l a r l y , the raw means of the P o s i t i v e R e a p p r a i s a l and Seeking S o c i a l Support s u b s c a l e s were summed t o y i e l d the P r o a c t i v e Coping score which was then d i v i d e d by the t o t a l summed raw means. These f i g u r e s were then used i n the anal y s e s . Data A n a l y s i s In order t o t e s t the f i r s t two hypothesis two m u l t i p l e r e g r e s s i o n analyses were conducted t o examine the nature and s t r e n g t h of the l i n e a r r e l a t i o n s h i p between the p r e d i c t o r v a r i a b l e s (time s i n c e d i a g n o s i s , s t r e s s o r type, 81 se l f - e s t e e m , s o c i a l support, homophobia, and the i n t e r a c t i v e e f f e c t s of homophobia with s e l f - e s t e e m , and homophobia with s o c i a l s u p p o r t ) , and the c r i t e r i o n v a r i a b l e s (Avoidant coping and P r o a c t i v e coping) (see Table 3). A h i e r a r c h i c a l model of r e g r e s s i o n a n a l y s i s was used (Cohen & Cohen, 1983) i n which p r e d i c t o r v a r i a b l e s were entered i n t o a stepwise a n a l y s i s i n the f o l l o w i n g o r d e r : (a) l e n g t h of time s i n c e d i a g n o s i s , (b) type of s t r e s s o r , (c) homophobia, (d) s e l f -esteem and s o c i a l support, and (e) i n t e r a c t i v e e f f e c t s , the products of homophobia x s e l f - e s t e e m , and homophobia x s o c i a l support. The advantage of the h i e r a r c h i c a l r e g r e s s i o n i s t h a t i t allowed f o r the e f f e c t s of the main v a r i a b l e s (homophobia, s e l f - e s t e e m , s o c i a l support) to be examined a f t e r c o n t r o l l i n g f o r the e f f e c t s of the other v a r i a b l e s (time s i n c e d i a g n o s i s , s t r e s s o r t y p e ) , as w e l l as f o r the i n t e r a c t i v e e f f e c t s of v a r i a b l e s i n combination to be examined. Separate analyses were conducted u s i n g Avoidant coping and P r o a c t i v e coping as the c r i t e r i o n v a r i a b l e . In d e t e r m i n i n g the order i n which v a r i a b l e s were entered a number of f a c t o r s were c o n s i d e r e d . I t has been suggested t h a t problems experienced and coping s t r a t e g i e s used by HIV+ gay men i n i t i a l l y a f t e r d i a g n o s i s may be d i f f e r e n t than those used l a t e r i n the adjustment process (Grant & Anns, 1988). S i m i l a r l y , Cohen and Lazarus (1979) suggest t h a t d i f f e r e n t coping s t r a t e g i e s w i l l be used at d i f f e r e n t p o i n t s i n time i n d e a l i n g with i l l n e s s r e l a t e d 82 s t r e s s . Folkman and Lazarus (1985) have a l s o found t h a t d i f f e r e n t coping s t r a t e g i e s are used a t d i f f e r e n t p o i n t s i n time i n response t o a n o n - i l l n e s s r e l a t e d s t r e s s o r . Length of time s i n c e d i a g n o s i s was, t h e r e f o r e , entered f i r s t i n t o the equation because of i t s p o s s i b l e e f f e c t s on the types of coping s t r a t e g i e s used. S i m i l a r l y , because the type of s t r e s s o r was expected t o be a s s o c i a t e d w i t h the coping response i t was entered i n t o the r e g r e s s i o n on the second l e v e l . F o l l o w i n g the suggested procedure f o r t e s t i n g the s i g n i f i c a n c e of i n t e r a c t i o n e f f e c t s (Cohen & Cohen, 1983), the product terms were entered l a s t i n t o the equation, a f t e r the main e f f e c t s had been entered. Based on the r e s u l t s of other s t u d i e s , emotional w e l l -b e i n g was expected t o show a s t r o n g a s s o c i a t i o n with other v a r i a b l e s i n t h i s study. A Pearson product-moment c o r r e l a t i o n matrix was computed i n order t o examine the s t r e n g t h of r e l a t i o n s h i p between emotional w e l l - b e i n g and the other p r e d i c t o r v a r i a b l e s . I t was a l s o hypothesized t h a t w e l l - b e i n g would show a p o s i t i v e r e l a t i o n s h i p with P r o a c t i v e coping and a ne g a t i v e r e l a t i o n s h i p with Avoidant coping. Based on the r e s u l t s of other studes the magnitudes of the c o r r e l a t i o n s between cop i n g s t r a t e g i e s and mood s t a t e were expected t o be moderate (r<.40). 83 R e s u l t s D e s c r i p t i v e S t a t i s t i c s T a b l e 3 shows t h e means, s t a n d a r d d e v i a t i o n s and i n t e r c o r r e l a t i o n s f o r t h e p r e d i c t o r and c r i t e r i o n v a r i a b l e s (N=89). The mean ti m e s i n c e d i a g n o s i s (TSD) o f 23 months i s c o n s i d e r a b l y l o n g e r t h a n t h e t i m e r e p o r t e d i n o t h e r s t u d i e s (TSD<2 months, M o u l t o n e t a l . , 1987; TSD<3 months, Namir e t a l . , 1987; TSD<3 months, W o l c o t t , Namir e t a l . , 1986; TSD<8 months, Z i c h & Temoshok, 1987), and may be i n d i c a t i v e o f t h e f a c t t h a t t h e v i r u s has now been i n t h e community f o r a g r e a t e r l e n g t h o f t i m e , and/or t h a t gay men a r e b e i n g t e s t e d f o r HIV e a r l i e r , p r i o r t o t h e development o f h e a l t h problems. The responses on t h e homophobia measure (NHAI) (M=131.9, SD=21.5) a r e h i g h e r t h a n t h o s e o b t a i n e d by W o l c o t t , Namir e t a l . (1986) w i t h a group o f gay AIDS p a t i e n t s (M=111.7, SD=13.5), b u t a r e comparable t o t h o s e o b t a i n e d by McDonald (1984) w i t h a group o f h e a l t h y gay men (M=131.0, SD=19.3). W o l c o t t e t a l . s u g g e s t e d t h a t t h e f i g u r e s o b t a i n e d i n t h e i r s t u d y i n d i c a t e d t h a t p a r t i c i p a n t s i n g e n e r a l h e l d a p o s i t i v e a t t i t u d e towards h o m o s e x u a l i t y . The v a l i d i t y o f t h i s c o n j e c t u r e i s f u r t h e r s u p p o r t e d by t h e moderate c o r r e l a t i o n s between t h e NHAI s c o r e and o t h e r i n f o r m a l measures of a t t i t u d e towards h o m o s e x u a l i t y . These i n c l u d e d t h e respo n d e n t s c o m f o r t w i t h t h e i r s e x u a l o r i e n t a t i o n p r i o r t o d i a g n o s i s (r=.64), and t h e i r a c t i v i t y i n t h e gay community (r=.44) (see T a b l e 4 ) . The s e l f - e s t e e m s c o r e s (RSES) (M=32.2, SD=5.9), as might be e x p e c t e d , a r e Table 3 Means, Standard Deviations, and I n t e r c o r r e l a t i o n s f or  Predictor and C r i t e r i o n Variables fN=89) Measure V a r i a b l e M SD 1 2 3 4 5 6 7 8 9 10 11 1. Time since diagnosis (months) 23.1 15.5 -2. S t r e s s o r 3 .5 .5 .08 -3. Homophobia 131.9 21.5 .26 .19 -4. Self-esteem 32.2 5.9 .12 .04 .52 -5. S o c i a l support 34.1 6.1 .20 .04 .45 .56 -6. Homophobia x self-esteem 4311.5 1208.0 .20 .12 .82 .90 .57 -7 . Homophobia x s o c i a l support 4554.1 1215.3 .28 .15 .83 .64 .85 .82 -8. Mood state 72.3 44.0 -.23 • -.07 --.44 --.64 -.45 -.62 -.53 9 . Avoidant coping .15 .08 .11 .00 --.17 --.15 -.20 -.19 -.23 .08 -10. Proactive coping .23 .07 -.04 .18 .26 .10 .20 .20 .26 -.22 • -.50 -11. EAR coping .13 .07 -.12 -.15 --.42 • -.54 -.35 -.57 -.45 .60 .48 • -.44 -12. SPS coping .23 .11 -.10 .21 .24 .08 .13 .17 .22 -.04 • -.58 .68 --.22 Note. EAR coping i s Escape-Avoidance and Accepting R e s p o n s i b i l i t y , SPS coping i s Seeking S o c i a l Support and P l a n f u l Problem Solving a S t r e s s o r s were coded 0 and 1. r.05,80 = .22 r.01,80 = .28 r.001,80 = .36 Table 4 A u x i l i a r y Demographic Information (N=89j C h a r a c t e r i s t i c % M SD Years c o n s i d e r e d homosexual/bisexual (n= =82) 19. 3 8.9 Comfort w i t h o r i e n t a t i o n 3 4. 2 1.1 A c t i v e i n gay community 8 . 2. 8 1.1 Expected l i k e l i h o o d of d e v e l o p i n g AIDS a 3. 3 1.3 Aware of support s e r v i c e s Yes 98. 0 No 2. 0 Used support s e r v i c e s (n=88) Yes 58. 0 No 42. 0 Note. D i f f e r e n t n's are the r e s u l t of m i s s i n g data. a Range from 1 (Not a t a l l ) t o 5 (Ver y ) . 86 s l i g h t l y lower than those o b t a i n e d by Delongis et a l . (1988) i n a study with h e a l t h y couples (M=35.2, SD =4.3). The r e s u l t s on the p e r c e i v e d s o c i a l support s c a l e (RKS) (M=34.1, SD=6.1) are s l i g h t l y higher than those r e p o r t e d by Turner and Noh (1988) i n a group of p h y s i c a l l y d i s a b l e d men (M=32.9). The mood s t a t e scores (POMS-TMD) (M=72.3, SD=44.0) are s l i g h t l y lower than those found by Donlou et a l . (1985) and Wolcott, Namir et a l . (1986) (M=89.4, SD=36.2; M=79.5. SD=38.6, r e s p e c t i v e l y ) . Both of these s t u d i e s , however, were wi t h gay men wit h AIDS, perhaps suggesting t h a t HIV+ gay men as a group are e x p e r i e n c i n g somewhat l e s s emotional d i s t r e s s . A s i g n i f i c a n t c o r r e l a t i o n was found between the POMS-TMD and how l i k e l y i t was the respondents f e l t they would develop AIDS (r=.39). With r e s p e c t t o the r e l a t i v e use of Avoidant and P r o a c t i v e coping as compared t o the gen e r a l use of a l l s t r a t e g i e s , P r o a c t i v e coping accounted f o r 23% of the coping used w h i l e Avoidant coping accounted f o r 15%. The g r e a t e r use of an a c t i v e -c o g n i t i v e / b e h a v i o u r a l coping s t r a t e g y as compared t o an avoidant s t r a t e g y i s c o n s i s t e n t with the f i n d i n g s of Namir et a l . (1987) . C o r r e l a t i o n s Between V a r i a b l e s C o r r e l a t i o n s between the p r e d i c t o r v a r i a b l e s were g e n e r a l l y i n the expected d i r e c t i o n s . Moderate p o s i t i v e c o r r e l a t i o n s were found between s e l f - e s t e e m and p e r c e i v e d s o c i a l support (r=.56), and s e l f - e s t e e m and a p o s i t i v e a t t i t u d e towards homosexuality (r=.52). P e r c e i v e d s o c i a l 87 support showed a moderate p o s i t i v e c o r r e l a t i o n w i t h a p o s i t i v e a t t i t u d e towards homosexuality (r=.45). A poor mood s t a t e was moderately n e g a t i v e l y c o r r e l a t e d with s e l f -esteem (r=-.64), p e r c e i v e d s o c i a l support (r=-.45), and a p o s i t i v e a t t i t u d e towards homosexuality (r=-.44). Time s i n c e d i a g n o s i s was n e g a t i v e l y r e l a t e d t o a poor mood s t a t e (r=-.23) and p o s i t i v e l y r e l a t e d t o a p o s i t i v e a t t i t u d e towards homosexuality (r=.26). In g e n e r a l , the c r i t e r i o n v a r i a b l e s d i d not show s i g n i f i c a n t c o r r e l a t i o n s with the p r e d i c t o r v a r i a b l e s . P r o a c t i v e coping had a p o s i t i v e c o r r e l a t i o n with a p o s i t i v e a t t i t u d e towards homosexuality (r=.26). As expected, P r o a c t i v e and Avoidant coping had a negative r e l a t i o n s h i p with each other (r=-.50). Three one-way m u l t i v a r i a t e a n a l y s i s of v a r i a n c e (MANOVAs) were conducted t o examine s p e c i f i c d i f f e r e n c e s between those respondents who were s i n g l e versus l i v i n g with a l o v e r , those with HIV versus ARC, and those who c a l l e d themselves homosexual versus b i s e x u a l , i n r e l a t i o n t o the p r e d i c t o r and c r i t e r i o n v a r i a b l e s . Because of the unequal numbers of respondents i n each group, c e l l s i z e s were weighted f o r a l l t h r e e MANOVAs. There was no s i g n i f i c a n t m u l t i v a r i a t e or u n i v a r i a t e group e f f e c t f o r any of the v a r i a b l e s f o r gay men who were s i n g l e (n=40) and gay men who were l i v i n g with a l o v e r (n=32). Although the m u l t i v a r i a t e group e f f e c t between respondents with ARC (n=25) and those who were HIV+ (n=64) was n o n - s i g n i f i c a n t , t h e r e was a 88 s i g n i f i c a n t d i f f e r e n c e i n terms of mood s t a t e ( F ( 1 , 8 7 ) = 7 . 3 , p_<.01), w i t h gay men w i t h ARC r e p o r t i n g h i g h e r l e v e l s o f mood d i s t u r b a n c e (ARC: M=91.8, SD=46.8; HIV+: M=64.7, S D - 4 0 . 8i. A l t h o u g h no s i g n i f i c a n t m u l t i v a r i a t e group e f f e c t was observed between men who c o n s i d e r e d themselves homosexual (n=79) and men who c o n s i d e r e d themselves b i s e x u a l (n=10), the d i f f e r e n c e s between means of the p r e d i c t o r and c r i t e r i o n v a r i a b l e s suggest t h a t t h i s i s a d i s t i n c t i o n which bears f u r t h e r i n v e s t i g a t i o n . B i s e x u a l men r e p o r t e d lower s e l f - e s t e e m (M=28.1, SD=6 .2) , a more n e g a t i v e a t t i t u d e towards homosexua l i ty (M=112.5, SD=2 6 . 4 ) , l e s s p e r c e i v e d support (M=29.7, SD=2.6) , and a worsened mood s t a t e (M=103.8, SD=49.8) than homosexual men ( s e l f - e s t e e m : M=32.7, SD=5.7; homophobia: M=134.4, SD=19.7; s o c i a l s u p p o r t : M=34.6, SD=5.6; mood s t a t e : M=68.4, SD=41.9). A C h i - s q u a r e a n a l y s i s was conducted between the d i c h o t o m i z e d s t r e s s o r types and the t h r e e group ings d i s c u s s e d above, w i t h the d i f f e r e n c e t h a t the r e l a t i o n s h i p group had t h r e e c a t e g o r i e s : s i n g l e , l i v i n g w i t h l o v e r , o r o t h e r ( i . e . , m a r r i e d , i n committed r e l a t i o n s h i p but not l i v i n g w i t h l o v e r ) . No s i g n i f i c a n t d i f f e r e n c e s were found f o r any o f the g r o u p i n g s , ( r e l a t i o n s h i p , ( X 2 ( 2 , N=89)=8.40,ns); H I V / A R C , ( X 2 ( l , N=89)=12.36/ns); h o m o s e x u a l / b i s e x u a l , ( X 2 ( l , N=89)=4.94 ,ns) . Hypotheses In o r d e r t o t e s t hypotheses 1 and 2, two h i e r a r c h i c a l s tepwise r e g r e s s i o n s were conducted i n which t ime s i n c e d i a g n o s i s , s t r e s s o r t y p e , homophobia, s e l f - e s t e e m , s o c i a l 89 support, and the i n t e r a c t i v e e f f e c t s of s e l f - e s t e e m and s o c i a l support w i t h homophobia were used as p r e d i c t o r v a r i a b l e s and P r o a c t i v e and Avoidant coping were used as c r i t e r i o n v a r i a b l e s . The equations c o n s i s t e d of f i v e l e v e l s i n which time s i n c e d i a g n o s i s was allowed t o step i n f i r s t , f o l l o w e d by s t r e s s o r type, l e v e l of homophobia, s e l f - e s t e e m and s o c i a l support, and l a s t l y the i n t e r a c t i o n terms. An F-l e v e l of 3.0 was r e g u i r e d f o r i n c l u s i o n i n the equation. Table 5 shows the r e s u l t s of the r e g r e s s i o n s . Although the t o t a l equation p r e d i c t i n g Avoidant coping d i d not reach s i g n i f i c a n c e (F( 1, 87 ) =3 . 6, p_<.10), s o c i a l support d i d enter the equation (F=3.6) and accounted f o r 3% of the t o t a l v a r i a n c e . None of the other v a r i a b l e s reached s i g n i f i c a n c e . With r e s p e c t to P r o a c t i v e coping, s t r e s s o r type entered (F=3.07) and accounted f o r 2% of the t o t a l v a r i a n c e . L e v e l of homophobia then entered (F=4.8), a c c o u n t i n g f o r an a d d i t i o n a l 4% of the v a r i a n c e . Together the r e g r e s s i o n equation accounted f o r 6% of the t o t a l v a r i a n c e (F(2,86)=4.0, p_<.05). The s t a n d a r d i z e d r e g r e s s i o n c o e f f i c i e n t s i n d i c a t e d t h a t worrying about one's h e a l t h and a p o s i t i v e a t t i t u d e towards homosexuality were a s s o c i a t e d with the g r e a t e r use of P r o a c t i v e coping. An examination of the zero-order c o r r e l a t i o n s was made i n order t o t e s t hypotheses 3 and 4. Avoidant c o p i n g was not s i g n f i c a n t l y c o r r e l a t e d with mood s t a t e w h i l e P r o a c t i v e coping had a low negative c o r r e l a t i o n (r=-.22). Thus, t h e r e was weak support f o r hypothesis 4 while hypothesis 3 was not 90 Table 5 H i e r a r c h i c a l Stepwise Regression Equations  f o r Avoidant and P r o a c t i v e Coping (N=89) V a r i a b l e R 2 R 2 R 2 F to B a a d j u s t e d i n c r e a s e enter Avoidant coping S o c i a l support .04 .03 .03 3.61 -.20 F( l , 8 7 ) = 3.61, p_<.10 P r o a c t i v e coping S t r e s s o r .03 .02 .02 3.07 .14 Homophobia .09 .06 .04 4.83* .23 F(2,86) = 4.02, p_< -05 a B = s t a n d a r d i z e d r e g r e s s i o n c o e f f i c i e n t *p_< . 05. 91 supported. Post-hoc Analyses P r i o r t o a n a l y s i s two g e n e r a l e x p e c t a t i o n s were made of the r e s u l t s . F i r s t , t h a t combinations of the s e l e c t e d p e r s o n a l , environmental and c o n t e x t u a l v a r i a b l e s would account f o r s i g n i f i c a n t p r o p o r t i o n s of the e x p l a i n e d v a r i a n c e i n p r e d i c t i n g the use of both coping s t r a t e g i e s ; and second, t h a t coping s t r a t e g i e s would show moderate and o p p o s i t e a s s o c i a t i o n s w i t h mood s t a t e . Although the r e s u l t s p r o v i d e weak support f o r two of the f o u r hypotheses, the r e s u l t s are of a l e s s e r magnitude than was expected based on the r e s u l t s from e a r l i e r r e s e a r c h ( c f . F e i f e l e t a l . , 1987; Long, 1989; Namir et a l . , 1987; Parker et a l . , 1988). One e x p l a n a t i o n f o r these r e s u l t s was t h a t the s e l e c t e d coping s t r a t e g i e s d i d not f u n c t i o n t o g e t h e r as o r i g i n a l l y hypothesized. T h i s was f u r t h e r suggested by an examination of the c o r r e l a t i o n s between the r e l a t i v e scores of the o r i g i n a l e i g h t coping s t r a t e g i e s (see Table 6). Escape-Avoidance and D i s t a n c i n g showed p r a c t i c a l l y no a s s o c i a t i o n (r=.08) wi t h each other and Seeking S o c i a l Support was s i g n i f i c a n t l y n e g a t i v e l y a s s o c i a t e d with P o s i t i v e R e a p p r a i s a l (r=-.28). A r e c o n s i d e r a t i o n of the l i t e r a t u r e suggested the l i k e l i h o o d of a d i f f e r e n t p a t t e r n of coping. F i r s t , higher l e v e l s of i n t e r n a l i z e d homophobia and poor s e l f - e s t e e m would more l i k e l y be a s s o c i a t e d w i t h g u i l t and s e l f - b l a m e r e g a r d i n g i n f e c t i o n or s t r e s s e s r e l e v a n t t o i n f e c t i o n , than T a b l e 6 I n t e r c o r r e l a t i o n s f o r Coping S t r a t e g i e s (N=89) Strategy- 1 2 3 4 5 6 7 1. D i s t a n c i n g -2. Escape-avoidance .08 -3. Seeking s o c i a l support -.57 -.19 -4. P o s i t i v e r e a p p r a i s a l -.12 -.37 -.28 -5. C o n f r o n t i v e -.33 -.12 .03 .13 -6. S e l f - c o n t r o l l i n g .50 -.09 -.51 -.10 -.33 -7. A c c e p t i n g r e s p o n s i b i l i t y -.13 .32 -.20 -.30 -.20 .09 -8 . P l a n f u l problem s o l v i n g -.51 -.42 .27 .19 .17 -.43 -.35 r.05,80 = .22 r.01,80 = .28 r.001,80 = .36 93 would lower l e v e l s of homophobia and high s e l f - e s t e e m be a s s o c i a t e d with a p o s i t i v e r e a p p r a i s a l of the s i t u a t i o n . As such g r e a t e r homophobia and lower s e l f - e s t e e m c o u l d be expected t o be more s t r o n g l y a s s o c i a t e d with the A c c e p t i n g R e s p o n s i b i l i t y s t r a t e g y , which c o n s i s t s of a c t i v e r e c o g n i t i o n of r e s p o n s i b i l i t y w i t h r e s p e c t t o a s t r e s s o r , r a t h e r than D i s t a n c i n g , which c o n s i s t s of a m i n i m i z i n g of the impact of the s t r e s s o r . Second, Namir et a l . (1987) d i s t i n g u i s h e d between a c o g n i t i v e and a b e h a v i o u r a l coping s t y l e , and found t h a t an A c t i v e - B e h a v i o u r a l coping approach, composed i n p a r t of items from the P l a n f u l Problem S o l v i n g s t r a t e g y of the WOCS, was s i g n i f i c a n t l y a s s o c i a t e d with s e l f - e s t e e m and p o s i t i v e mood s t a t e . These c o n s i d e r a t i o n s suggested t h a t Escape-Avoidance and A c c e p t i n g R e s p o n s i b i l i t y (EAR), and Seeking S o c i a l Support and P l a n f u l Problem S o l v i n g (SPS) might be groupings of coping s t r a t e g i e s more l i k e l y t o occur t o g e t h e r . The c o r r e l a t i o n s i n Table 6 were a l s o s u g g e s t i v e of t h i s . Of a l l p a i r - w i s e c o r r e l a t i o n s o n l y t h r e e showed a s i g n i f i c a n t p o s i t i v e a s s o c i a t i o n . These were D i s t a n c i n g and S e l f -C o n t r o l l i n g (r=.50), Escape-Avoidance and A c c e p t i n g R e s p o n s i b i l i t y (r=.32), and Seeking S o c i a l Support and P l a n f u l Problem S o l v i n g (r=.27). On average EAR coping accounted f o r 13% of coping i n general while SPS accounted f o r 23%. C o n s i s t e n t with e x p e c t a t i o n s , the two s t r a t e g i e s had a negative c o r r e l a t i o n with each other (r=-.22) (see Table 3). 94 Using the same format as was used with Avoidant and P r o a c t i v e coping, two separate h i e r a r c h i c a l stepwise r e g r e s s i o n s were conducted w i t h EAR and SPS coping used as c r i t e r i o n v a r i a b l e s . The r e s u l t s are shown i n Table 7. With r e s p e c t to EAR coping, n e i t h e r time s i n c e d i a g n o s i s nor s t r e s s o r type were s i g n i f i c a n t . Homophobia entered (F=18.3) f o l l o w e d by s e l f - e s t e e m (F=18.5). Together they accounted f o r 30% of the e x p l a i n e d v a r i a n c e (F(2,86)=20.2, p_<.01) wit h homophobia c o n t r i b u t i n g 16% and s e l f - e s t e e m 14% towards the t o t a l v a r i a n c e . The s t a n d a r d i z e d r e g r e s s i o n c o e f f i c i e n t s suggest t h a t g r e a t e r i n t e r n a l i z e d homophobia and poorer s e l f - e s t e e m are a s s o c i a t e d with the r e l a t i v e l y g r e a t e r use of EAR coping. With r e s p e c t t o SPS coping, s t r e s s o r type entered (F=4.0) f o l l o w e d by homophobia (F=4.0). Time s i n c e d i a g n o s i s , which had not been s i g n i f i c a n t i n i t i a l l y , then entered (F=3.0). Combined, the t h r e e v a r i a b l e s accounted f o r 9% of the t o t a l v a r i a n c e (F( 3, 85 ) =3 . 8, p_<.05) with each v a r i a b l e c o n t r i b u t i n g 3%. The s t a n d a r d i z e d r e g r e s s i o n c o e f f i c i e n t s suggest t h a t g r e a t e r time s i n c e d i a g n o s i s i s a s s o c i a t e d with l e s s SPS coping, w h i l e worry about one's h e a l t h and a p o s i t i v e a t t i t u d e towards homosexuality are a s s o c i a t e d with g r e a t e r SPS coping. F i n a l l y , the r e l a t i o n s h i p between mood s t a t e and EAR and SPS coping was examined. Table 3 shows the zero-order c o r r e l a t i o n s between mood s t a t e and coping s t r a t e g i e s . EAR coping has a moderate p o s i t i v e r e l a t i o n s h i p with a poor mood 95 Table 7 H i e r a r c h i c a l Stepwise Regression Equations  f o r EAR and SPS Coping (N=89) V a r i a b l e R 2 R 2 R 2 F to B a a d j u s t e d i n c r e a s e enter EAR coping Homophobia .17 .16 .16 18.25** -.18 Self-esteem .32 .30 .14 14.36** -.45 F(2,86) = 20.21, p.< .01 SPS coping S t r e s s o r .04 .03 .03 Homophobia .09 .06 .03 Time s i n c e d i a g n o s i s .12 .09 .03 F(3,85) = 3.78, p.<.05 Note. EAR coping i s Escape-Avoidance and A c c e p t i n g R e s p o n s i b i l i t y s u b s c a l e s , SPS coping i s Seeking S o c i a l Support and P l a n f u l Problem S o l v i n g subscales a B = s t a n d a r d i z e d r e g r e s s i o n c o e f f i c i e n t *p_<.05. **p_<.01. 3.96* .18 4.01* .26 3.03* -.18 96 s t a t e (r=.60), while SPS copi n g has no r e l a t i o n s h i p (r=-.04). To f u r t h e r examine what v a r i a b l e s were s i g n i f i c a n t l y a s s o c i a t e d with mood s t a t e , a h i e r a r c h i c a l stepwise r e g r e s s i o n a n a l y s i s was conducted i n which time s i n c e d i a g n o s i s entered, f o l l o w e d by s t r e s s o r type, coping s t r a t e g i e s , homophobia, s e l f - e s t e e m , s o c i a l support and the i n t e r a c t i o n terms of homophobia times s e l f - e s t e e m and s o c a l support. Coping s t r a t e g i e s were expected t o account f o r a s i g n i f i c a n t amount of the t o t a l v a r i a n c e and hence were entered b e f o r e the homophobia and the other v a r i a b l e s . The r e s u l t s are shown i n Table 8. Time s i n c e d i a g n o s i s entered (F=5.0), f o l l o w e d by EAR copi n g (F=45.7), homophobia (F=4.7) and s e l f - e s t e e m (F=17.7). Together they e x p l a i n e d 50% of the t o t a l v a r i a n c e (F( 4, 84 )=22 .4, p_<.01), with EAR coping and s e l f - e s t e e m a c c o u n t i n g f o r 33% and 10%, r e s p e c t i v e l y , a f t e r the ammount accounted f o r by time s i n c e d i a g n o s i s (4%) and homophobia ( 3 % ) . The s t a n d a r d i z e d r e g r e s s i o n c o e f f i c i e n t s i n d i c a t e t h a t g r e a t e r time s i n c e d i a g n o s i s , higher s e l f - e s t e e m and a p o s i t i v e a t t i t u d e towards homosexuality are a l l n e g a t i v e l y a s s o c i a t e d with poor mood s t a t e , w hile the use of EAR coping i s p o s i t i v e l y a s s o c i a t e d with a poor mood s t a t e . 97 Table 8 H i e r a r c h i c a l Stepwise Regression Equation  f o r Mood State (N=89) V a r i a b l e R 2 E 2 R 2 F t o a d j u s t e d i n c r e a s e enter Time s i n c e d i a g n o s i s .05 .04 .04 4.97* -.13 EAR coping .38 .37 .33 45.67** .33 Homophobia .41 .40 .03 4.69* -.05 Self-esteem .52 .50 . 10 17 . 68** -.41 F(4,84) = 22.41, p_<.01 Note* EAR coping i s Escape--Avoidance and A c c e p t i n g R e s p o n s i b i l i t y s u b s cales a B = s t a n d a r d i z e d r e g r e s s i o n c o e f f i c i e n t *p_<.05. **p.<.01. 98 D i s c u s s i o n T h i s study examined the r e l a t i o n s h i p between a number of i n d i v i d u a l , environmental and c o n t e x t u a l v a r i a b l e s and the use of s p e c i f i c c oping s t r a t e g i e s i n HIV+ gay men. In d e v e l o p i n g the study i t was hypothesized t h a t d i f f e r e n t v a r i a b l e s would have d i f f e r e n t l e v e l s of importance i n p r e d i c t i n g the r e l a t i v e use of two e s s e n t i a l l y d i f f e r e n t approaches t o coping. In p a r t i c u l a r , a f t e r a c c o u n t i n g f o r the e f f e c t s of c o n t e x t u a l v a r i a b l e s (time s i n c e d i a g n o s i s and s t r e s s o r t y p e ) , i n t e r n a l i z e d homophobia was expected t o be the most important i n d i v i d u a l v a r i a b l e , f o l l o w e d by s e l f -esteem ( i n d i v i d u a l ) and s o c i a l support (environmental). I t was expected t h a t HIV+ gay men who r e p o r t e d low l e v e l s on these measures would tend t o engage i n r e l a t i v e l y more coping aimed at a v o i d i n g or m i n i m i z i n g the impact of i l l n e s s r e l a t e d s t r e s s o r s (Avoidant c o p i n g ) . Conversely, gay men who scored higher on these measures were expected t o use r e l a t i v e l y more coping i n v o l v i n g seeking out support and r e e v a l u a t i n g the s t r e s s f u l s i t u a t i o n i n a p o s i t i v e l i g h t ( P r o a c t i v e c o p i n g ) . These c o p i n g s t r a t e g i e s were conceived of i n terms of subscales comprising the Ways of Coping S c a l e . S p e c i f i c a l l y , Avoidant coping was expected t o c o n s i s t of the items of the Escape-Avoidance and D i s t a n c i n g s u b s c a l e s , whereas P r o a c t i v e coping would i n v o l v e the Seeking S o c i a l Support and P o s i t i v e R e a p p r a i s a l s u b s c a l e s . The i n i t i a l r e s u l t s of the study, however, suggested t h a t the p a i r s of coping subscales were not b e i n g used 99 c o n j o i n t l y as a n t i c i p a t e d . T h i s l a c k of a s s o c i a t i o n was suggested by the r e s u l t s of the h i e r a r c h i c a l stepwise r e g r e s s i o n equations p r e d i c t i n g the two s t r a t e g i e s , which, although o b t a i n i n g s i g n i f i c a n c e , were of a much lower magnitude than was a n t i c i p a t e d . The c o r r e l a t i o n matrix f o r the i n d i v i d u a l coping s t r a t e g i e s r e v e a l e d a ne g a t i v e c o r r e l a t i o n between Seeking S o c i a l Support and P o s i t i v e R e a p p r a i s a l (r=-.28), and a n o n s i g n i f i c a n t c o r r e l a t i o n between Escape-Avoidance and s D i s t a n c i n g (r=.08). The c o r r e l a t i o n matrix was i n t e r e s t i n g i n t h a t o n l y t h r e e p a i r s of subscales showed a s i g n i f i c a n t p o s i t i v e r e l a t i o n s h i p , w h i l e 11 p a i r s of subscales showed a s i g n i f i c a n t n e g ative a s s o c i a t i o n . These f i g u r e s suggest t h a t the use of coping s t r a t e g i e s tended t o be q u i t e s p e c i f i c and t h a t , whereas on l y a few types of subscales were l i k e l y t o be used together, t h e r e are very c l e a r p a t t e r n s of subscales t h a t were not be i n g used simult a n e o u s l y . The l a c k of c o r r e l a t i o n between Escape-Avoidance and D i s t a n c i n g suggests t h a t the context i n which HIV+ gay men use D i s t a n c i n g i s d i f f e r e n t from t h a t of Escape-Avoidance. T h i s i s f u r t h e r suggested by the p o s i t i v e c o r r e l a t i o n between D i s t a n c i n g and S e l f - C o n t r o l l i n g (r=.50). Although a number of s t u d i e s have found a p o s i t i v e c o r r e l a t i o n between D i s t a n c i n g and S e l f - C o n t r o l l i n g ( c f . Folkman & Lazarus, 1988a; Folkman, Lazarus, Dunkel-Schetter et a l . , 1986; Folkman, Lazarus, Gruen, & DeLongis, 1986), they have a l s o 100 found p o s i t i v e c o r r e l a t i o n s between these s t r a t e g i e s and others (e.g., Escape-Avoidance and C o n f r o n t i v e ) . In t h i s sample of HIV+ gay men, though, D i s t a n c i n g was a s s o c i a t e d with an i n t e r n a l i z e d attempt, both c o g n i t i v e l y and b e h a v i o u r a l l y , t o continue on i n the f a c e of i n f e c t i o n -r e l a t e d s t r e s s o r s . T h i s suggests t h a t an HIV+ gay man who d e a l s with a s t r e s s o r through a m i n i m i z a t i o n of i t s impact and a r e p r e s s i o n of f e e l i n g s , was u n l i k e l y t o a l s o cope by attempting t o a v o i d the s t r e s s o r through w i s h f u l t h i n k i n g . The g r e a t e r use of Escape-Avoidance, however, showed a p o s i t i v e c o r r e l a t i o n with A c c e p t i n g R e s p o n s i b i l i t y (r=.32). Although a p o s i t i v e c o r r e l a t i o n between these two subscales has been p r e v i o u s l y observed ( c f . Folkman & Lazarus, 1988a; Folkman, Lazarus, Dunkel-Schetter et a l . , 1986; Folkman, Lazarus, Gruen, & DeLongis, 1986), other s t u d i e s have not noted the s i n g u l a r and e x c l u s i v e r e l a t i o n s h i p so c l e a r l y demonstrated i n t h i s study. T h i s connection suggests t h a t gay men who blame themselves f o r t h e i r i l l n e s s - r e l a t e d s t r e s s are a l s o more l i k e l y t o cope by u s i n g avoidant behaviour and w i s h f u l t h i n k i n g . U n l i k e other s u b s c a l e s , the use of Escape-Avoidance and A c c e p t i n g R e s p o n s i b i l i t y are s i g n i f i c a n t l y n e g a t i v e l y a s s o c i a t e d with h i g h e r s e l f - e s t e e m (r=-.50, r=-.34, r e s p e c t i v e l y ) , a p o s i t i v e a t t i t u d e towards homosexuality (r=-.34, r=-.40, r e s p e c t i v e l y ) , and g r e a t e r s o c i a l support (r=-.34, r=-.21, r e s p e c t i v e l y ) . Taken together these f i g u r e s suggest t h a t A c c e p t i n g R e s p o n s i b i l i t y and Escape-Avoidance coping r e p r e s e n t a d i s t i n c t c l u s t e r of 101 coping s t r a t e g i e s used by HIV+ gay men, and t h a t they i n t u r n are d i s t i n c t l y a s s o c i a t e d with other p s y c h o s o c i a l v a r i a b l e s . Self-blame and acceptance of r e s p o n s i b i l i t y have been a s s o c i a t e d with the g r e a t e r use of problem-focused forms of coping (Bulman & Wortman, 1977; Folkman, Lazarus, Dunkel-S c h e t t e r et a l . , 1986). Moulton et a l . (1987) found t h a t a t t r i b u t i o n of r e s p o n s i b i l i t y t o o n e s e l f f o r improvement of one's h e a l t h was p o s i t i v e l y a s s o c i a t e d with h e a l t h behaviour change i n a group of AIDS p a t i e n t s (although t h e r e was no a s s o c i a t i o n i n a group of respondents with ARC). The f i n d i n g s of t h i s study, however, suggest t h a t the g r e a t e r use of A c c e p t i n g R e s p o n s i b i l i t y i s a s s o c i a t e d w i t h a g r e a t e r use of emotion-focused coping aimed a t a v o i d i n g d e a l i n g with the s t r e s s o r . The negative c o r r e l a t i o n between P o s i t i v e R e a p p r a i s a l and Seeking S o c i a l Support may i n d i c a t e t h a t seeking s o c i a l support i s a s s o c i a t e d w i t h a r e c o g n i t i o n of d i f f i c u l t y on the p a r t of the i n f e c t e d gay man. I t c o u l d be s p e c u l a t e d t h a t an i n d i v i d u a l u s i n g P o s i t i v e R e a p p r a i s a l would see the s t r e s s o r as a c h a l l e n g e with an a t t e n d i n g p o t e n t i a l boost t o t h e i r s e l f - e s t e e m . Someone u s i n g Seeking S o c i a l Support, on the other hand, may be e x p e r i e n c i n g the s t r e s s o r i n a more negative l i g h t , and t h e i r need t o seek help may undermine t h e i r s e l f - e s t e e m . Donlou e t a l . (1985) found t h a t seeking p r o f e s s i o n a l support was n e g a t i v e l y a s s o c i a t e d w i t h s e l f -esteem i n gay men with AIDS. T h i s i s somewhat suggested by 102 the c o r r e l a t i o n s of the two s t r a t e g i e s with s e l f - e s t e e m i n which P o s i t i v e R e a p p r a i s a l shows a low p o s i t i v e c o r r e l a t i o n (r=.16) w h i l e Seeking S o c i a l Support shows no c o r r e l a t i o n (r=-.02). As an a c t i v e - b e h a v i o u r a l coping approach Seeking S o c i a l Support i s a problem-focused form of coping s i m i l a r t o C o n f r o n t i v e and P l a n f u l Problem S o l v i n g . In t h i s sample Seeking S o c i a l Support and P l a n f u l Problem S o l v i n g were s i g n i f i c a n t l y p o s i t i v e l y a s s o c i a t e d (r=.27), with each b e i n g l e s s s t r o n g l y a s s o c i a t e d w i t h C o n f r o n t i v e coping. T h i s i n d i c a t e s t h a t HIV+ gay men who are u s i n g problem-focused forms of coping are more l i k e l y t o do so i n a d i r e c t , n o n c o n f r o n t i v e way than i n a c o n f r o n t i v e way. Because the r e s u l t s suggested d i f f e r e n t a s s o c i a t i o n s between subscales than was o r i g i n a l l y hypothesized, and because these a s s o c i a t i o n s suggested d i s t i n c t and e x c l u s i v e p a t t e r n s of coping, i t was c o n s i d e r e d a p p r o p r i a t e t o r e a n a l y s e the r e g r e s s i o n eguations u s i n g Escape-Avoidance and A c c e p t i n g - R e s p o n s i b i l i t y (EAR coping) and Seeking S o c i a l Support and P l a n f u l Problem S o l v i n g (SPS coping) as c r i t e r i o n v a r i a b l e s . A f t e r time s i n c e d i a g n o s i s and s t r e s s o r type were allowed t o enter the equation, both of which were n o n s i g n i f i c a n t , homophobia entered, f o l l o w e d by s e l f - e s t e e m . A f t e r homophobia accounted f o r 16% of the t o t a l v a r i a n c e , s e l f - e s t e e m accounted f o r an a d d i t i o n a l 14% i n e x p l a i n i n g EAR coping. The negative d i r e c t i o n of the a s s o c i a t i o n s i n d i c a t e s t h a t higher l e v e l s of homophobia and 103 lower s e l f - e s t e e m are a s s o c i a t e d with the r e l a t i v e l y g r e a t e r use of EAR coping. T h i s f i n d i n g i s c o n s i s t e n t with other r e s e a r c h which found t h a t p e r s o n a l i t y v a r i a b l e s are p r e d i c t o r s of emotion-focused coping ( c f . F e i f e l et a l . , 1987; Long, 1989). I t i s a l s o c o n s i s t e n t w i t h the work of P e a r l i n and Schooler (1978) who found t h a t a ne g a t i v e s e l f -e v a l u a t i o n was a more s i g n i f i c a n t p r e d i c t o r of coping than was a p o s i t i v e s e l f - e v a l u a t i o n . With r e s p e c t t o the combination of Seeking S o c i a l Support and P l a n f u l Problem S o l v i n g (SPS) coping, s t r e s s o r type was s i g n i f i c a n t i n e n t e r i n g the equation, f o l l o w e d by homophobia. A f t e r the e f f e c t s of these v a r i a b l e s had been accounted f o r , the e f f e c t of time s i n c e d i a g n o s i s became s i g n i f i c a n t and entered the equation. Together the th r e e v a r i a b l e s accounted f o r a modest 9% of the e x p l a i n e d v a r i a n c e , roughly d i v i d e d between the t h r e e . The p o s i t i v e a s s o c i a t i o n between s t r e s s o r and SPS coping i s somewhat c o n f u s i n g as i t suggests t h a t men who are worrying about t h e i r h e a l t h or the f u t u r e are more l i k e l y t o use a problem-focused form of coping. T h i s i s c o n t r a i n d i c a t e d by p r e v i o u s r e s e a r c h which suggests t h a t , p a r t i c u l a r l y i n the case of i l l n e s s concerns, the g r e a t e r the u n c e r t a i n t y or the l e s s an i n d i v i d u a l can do the more l i k e l y they are to use an emotion-focused form of cop i n g ( F e l t o n & Revenson, 1984; Folkman & Lazarus, 1980). This f i n d i n g i s c o n s i s t e n t with r e s e a r c h , however, which has found t h a t the s e r i o u s n e s s of an i l l n e s s i s p o s i t i v e l y 104 a s s o c i a t e d with g r e a t e r use of an a c t i v e , problem-focused ( c o n f r o n t i v e ) coping approach ( F e i f e l et a l . , 1987). Folkman, Lazarus, Dunkel-Schetter et a l . (1986) a l s o suggest t h a t the more changeable a s t r e s s o r i s a p p r a i s e d t o be the more l i k e l y an i n d i v i d u a l i s t o use a problem-focused form of coping. T h i s r e s u l t suggests t h a t HIV+ gay men who are worrying about t h e i r h e a l t h or the f u t u r e are more l i k e l y t o seek out support, medical help or ot h e r i n f o r m a t i o n ( p o s s i b l y because such s t r e s s would be p e r c e i v e d as more s e r i o u s ) , than would HIV+ gay men concerned with o t h e r types of s t r e s s o r s . I t does not e x p l a i n , however, why t h i s would not a l s o be the case with r e s p e c t t o s t r e s s o r s which can be d e a l t w i t h d i r e c t l y , such as t e l l i n g o t h e r s about one's d i a g n o s i s . The f a c t t h a t time s i n c e d i a g n o s i s i s n e g a t i v e l y a s s o c i a t e d with SPS coping i s c o n s i s t e n t w i t h F e i f e l et a l . (1987) who found t h a t g r e a t e r time s i n c e d i a g n o s i s was a s s o c i a t e d with g r e a t e r use of acceptance and r e s i g n a t i o n coping. I n i t i a l l y gay men may f e e l t h e i r s i t u a t i o n i s c o n t r o l l a b l e or managable, and hence they use more problem-focused forms of coping, but as time goes on these f i n d i n g s suggest t h a t the r e l a t i v e amount of problem-focused coping used w i l l decrease, perhaps i m p l y i n g an acceptance of the u n c e r t a i n t y and ambiquity a s s o c i a t e d w i t h HIV i n f e c t i o n . A second goal of the r e s e a r c h was to i n v e s t i g a t e the r e l a t i o n s h i p between coping s t r a t e g i e s and mood s t a t e . The zero-order c o r r e l a t i o n s suggested a s t r o n g c o r r e l a t i o n 105 between EAR coping and mood s t a t e . A h i e r a r c h i c a l stepwise r e g r e s s i o n a n a l y s i s was conducted i n c l u d i n g EAR and SPS coping and the other p r e d i c t o r v a r i a b l e s and mood s t a t e as the c r i t e r i o n v a r i a b l e . Time s i n c e d i a g n o s i s entered s i g n i f i c a n t l y a c c o u n t i n g f o r 4% of the t o t a l v a r i a n c e , i n d i c a t i n g t h a t the mood s t a t e of gay men g e n e r a l l y improved the g r e a t e r the time s i n c e d i a g n o s i s . EAR coping entered second and accounted f o r 32% of the t o t a l v a r i a n c e , a f t e r the e f f e c t of time s i n c e d i a g n o s i s was removed. T h i s f i g u r e i s s u b s t a n t i a l l y g r e a t e r than t h a t accounted f o r by coping s t r a t e g i e s i n other s t u d i e s ( c f . F e l t o n et a l . , 1984; Folkman, Lazarus, Gruen, & DeLongis, 1986), and suggests t h a t the use of EAR coping by HIV+ gay men i s s t r o n g l y a s s o c i a t e d with a poor mood s t a t e . Homophobia and s e l f -esteem entered a f t e r coping, with homophobia a c c o u n t i n g f o r an a d d i t i o n a l 3% and s e l f - e s t e e m a c c o u n t i n g f o r an a d d i t i o n a l 10% of the t o t a l v a r i a n c e , a f t e r the e f f e c t s of time s i n c e d i a g n o s i s and EAR coping were removed. The e n t i r e equation accounted f o r 50% of the e x p l a i n e d v a r i a n c e . Although t h i s study found a s i g n i f i c a n t p o s i t i v e a s s o c i a t i o n between the g r e a t e r use of A c c e p t i n g R e s p o n s i b i l i t y and a worsened mood s t a t e , d i f f e r e n t f i n d i n g s have been r e p o r t e d by p r e v i o u s r e s e a r c h . Bulman and Wortman (1977), f o r example, found t h a t blaming o n e s e l f f o r one's i n j u r y was p o s i t i v e l y a s s o c i a t e d with s u c c e s s f u l coping i n a group of p a t i e n t s p a r a l y z e d i n s e r i o u s a c c i d e n t s . S i m i l a r l y , Moulton et a l . (1987) found t h a t blaming o n e s e l f 106 f o r i n f e c t i o n was not a s s o c i a t e d with a worsened mood s t a t e i n a group of respondents w i t h ARC (although i t was i n a group of s u b j e c t s with AIDS), and t h a t a t t r i b u t i n g the cause of improvement t o o n e s e l f was n e g a t i v e l y a s s o c i a t e d with a worsened mood s t a t e i n the same group of i n d i v i d u a l s with ARC. Although SPS coping accounted f o r 23% of the t o t a l coping used by gay men i t i s important t o note t h a t i t was not s i g n i f i c a n t i n p r e d i c t i n g mood s t a t e . S i m i l a r l y , EAR coping accounted f o r 15% of the t o t a l coping ( i . e . , l e s s than the amount p r e d i c t e d by chance given s i x subscales summing t o 100% t o t a l c o p i n g ) , y e t i t was s t r o n g l y a s s o c i a t e d with a worsened mood s t a t e . Thus, even though i t i s not used as much r e l a t i v e t o other s t r a t e g i e s , EAR coping has a powerful negative a s s o c i a t i o n with mood s t a t e . These f i n d i n g s are somewhat d i f f e r e n t than those r e p o r t e d by Namir et a l . (1987) i n a study of gay men with AIDS. In a r e g r e s s i o n p r e d i c t i n g mood s t a t e Namir et a l . found t h a t an a c t i v e - b e h a v i o u r a l method of coping, s i m i l a r i n items t o SPS coping, was a s i g n f i c a n t p r e d i c t o r of and n e g a t i v e l y a s s o c i a t e d with the POMS-TMD score. S i m i l a r l y , avoidance coping was s i g n i f i c a n t l y p o s i t i v e l y a s s o c i a t e d with mood s t a t e . T h i s study f a i l e d t o f i n d the a s s o c i a t i o n between an a c t i v e - b e h a v i o u r a l coping s t r a t e g y and mood s t a t e , and whereas Namir et a l . found t h a t avoidance accounted f o r 8% of the t o t a l v a r i a n c e , t h i s study r e p o r t e d over 30% of the t o t a l v a r i a n c e being e x p l a i n e d by EAR coping. These 107 d i f f e r e n c e s may suggest t h a t the p a r t i c u l a r s i t u a t i o n of HIV+ gay men ( i . e . , g r e a t e r u n c e r t a i n t y and ambiquity) i s l e s s amenable t o the e f f e c t s of a problem-focused form of coping, w h i l e being h i g h l y s e n s i t i v e t o the form of emotion-focused coping c h a r a c t e r i z e d by EAR coping. O v e r a l l these f i n d i n g s support the e x p e c t a t i o n s of the post-hoc a n a l y s e s . L e v e l s of i n t e r n a l i z e d homophobia i n HIV+ gay men are s i g n i f i c a n t l y a s s o c i a t e d w i t h the g r e a t e r r e l a t i v e use of d i s t i n c t l y d i f f e r e n t approaches t o coping with i n f e c t i o n - r e l a t e d s t r e s s . The f i n d i n g t h a t a more p o s i t i v e a t t i t u d e towards homosexuality i s a s s o c i a t e d with g r e a t e r use of a problem-focused form of coping (SPS copin g ) , w h i l e a more ne g a t i v e a t t i t u d e i s a s s o c i a t e d with the greater'use of an emotion-focused form of coping (EAR copin g ) , demonstrates t h a t these two coping s t r a t e g i e s are p o l a r i z e d along the continuum of l e v e l of i n t e r n a l i z e d homophobia. As such, homophobia c o u l d be used as a p r e d i c t i v e measure of coping. S i m i l a r l y , the g r e a t e r use of EAR coping was shown t o be s t r o n g l y a s s o c i a t e d with a worsened mood s t a t e . The l a c k of a p o s i t i v e a s s o c i a t i o n between mood s t a t e and SPS coping suggests t h a t i n d e a l i n g w i t h H I V - r e l a t e d s t r e s s o r s , coping alone, and i n p a r t i c u l a r , problem-focused coping, does not have a s i g n i f i c a n t p o s i t i v e a s s o c i a t i o n with mood. The i m p l i c a t i o n of these f i n d i n g s i s t h a t an improvement i n mood may be more dependent on v a r i a b l e s such as s e l f - e s t e e m or i n t e r n a l i z e d homophobia, or merely on the p a s s i n g of time, 108 than on any p a r t i c u l a r s t y l e of coping. I t i s somewhat s u r p r i s i n g t h a t a problem-focused form of coping d i d not have a p o s i t i v e a s s o c i a t i o n w i t h mood. F u r t h e r r e s e a r c h i n t h i s area c o u l d help c l a r i f y what impact, i f any, problem-focused coping has on the mood and adjustment of HIV+ gay men. These f i n d i n g s suggest, t h a t c e r t a i n s t y l e s of coping are l i k e l y t o be a s s o c i a t e d w i t h a more negative mood. Whether d i s c o u r a g i n g the use of these s t r a t e g i e s would r e s u l t i n an improvement i n mood i s another q u e s t i o n f o r f u r t h e r r e s e a r c h . Although i t would be tempting t o s p e c u l a t e on the ca u s a l i m p l i c a t i o n s of these f i n d i n g s the c r o s s - s e c t i o n a l design of the study does not a l l o w f o r statements of d i r e c t i o n a l i t y t o be made. I f however, one assumes t h a t a p e r s o n a l i t y c o n s t r u c t such as i n t e r n a l i z e d homophobia i s l i k e l y t o p r e e x i s t d i a g n o s i s , i t would not be unreasonable to assume t h a t i t i s the homophobia which i n p a r t leads t o the g r e a t e r use of EAR coping, r a t h e r than the EAR coping which leads t o the homophobia. Whether or not the continued use of EAR coping leads t o the c r e a t i o n of a s i t u a t i o n i n the gay man's l i f e which f u r t h e r exacerbates h i s homophobia i s d i f f i c u l t t o s p e c u l a t e on. With r e s p e c t t o the r e l a t i o n s h i p between mood s t a t e , coping and s e l f - e s t e e m , there i s undoubtedly g r e a t e r b i d i r e c t i o n a l i n t e r a c t i o n . I f EAR coping i s not h e l p i n g the gay men s u c c e s s f u l l y d e a l with h i s s t r e s s (which has not been shown by t h i s study) he w i l l undoubtedly s u f f e r from a worsened mood. T h i s i n t u r n c o u l d 109 impact n e g a t i v e l y on s e l f - e s t e e m . Time s i n c e d i a g n o s i s appears t o a c t u n i d i r e c t i o n a l l y and i n such a way as t o r e s u l t i n an improvement of mood. The i n a b i l i t y f o r s o c i a l support to s i g n i f i c a n t l y enter any of the r e g r e s s i o n equations i s s u r p r i s i n g g i v e n t h a t s o c i a l support has been shown t o be a s s o c i a t e d w i t h the use of s p e c i f i c s t r a t e g i e s i n o t h e r s t u d i e s (Long, 1989; Parkes, 1986) and with poorer mood s t a t e i n gay men w i t h AIDS (Wolcott, Namir et a l . , 1986; Z i c h & Temoshok, 1987). I t may be t h a t the Revised Kaplan S c a l e i s not a v a l i d measure of s o c i a l support or t h a t the aspect of support t h a t i t does measure i s s u b s t a n t i a l l y d i f f e r e n t from or u n r e l a t e d t o t h a t assessed i n other s t u d i e s . There i s some support f o r t h i s c o n j e c t u r e given the s u r p r i s i n g l a c k of c o r r e l a t i o n between the s o c i a l support scores and the number of f r i e n d s and f a m i l y (r=.10), and the number of p r o f e s s i o n a l s (r=-.01) t h a t respondents had approached f o r support. I t i s a l s o p o s s i b l e t h a t t h e r e i s a high degree of c o l l i n e a r i t y between s o c i a l support and homophobia and/or s e l f - e s t e e m , although the c o r r e l a t i o n s are of a moderate s t r e n g t h (r=.45 and .56, r e s p e c t i v e l y ) and a c o r r e l a t i o n of s i m i l a r s t r e n g t h between homophobia and s e l f - e s t e e m (r=.52) d i d not suggest a high degree of o v e r l a p between the two v a r i a b l e s . A l s o of i n t e r e s t i s the l a c k of s i g n i f i c a n c e of the i n t e r a c t i o n terms. Previous r e s e a r c h has r e p o r t e d mixed r e s u l t s w i t h some f i n d i n g s s u g g e s t i n g t h a t i n t e r a c t i o n terms are s i g n i f i c a n t (Parkes, 1986) w h i l e other f i n d i n g no 110 s i g n i f i c a n c e (Long, 1989). The r e s u l t s of t h i s study suggest t h a t the combined e f f e c t s of homophobia wi t h s e l f -esteem and s o c i a l support do not s i g n i f i c a n t l y c o n t r i b u t e t o the t o t a l v a r i a n c e p r e d i c t i n g coping s t r a t e g i e s . T h i s i n t u r n suggests t h a t the v a r i a b l e s operate r e l a t i v e l y independently of each o t h e r . These f i n d i n g s suggest t h a t i n t e r n a l i z e d homophobia, as a p s y c h o l o g i c a l r e a c t i o n or as p a r t of a p s y c h o l o g i c a l p r o c e s s , i s a s p e c i f i c a l l y d e f i n e d v a r i a b l e which does not i n t e r a c t w i t h other more s t a b l e p e r s o n a l i t y c o n s t r u c t s , such as se l f - e s t e e m , nor a f f e c t an i n d i v i d u a l ' s i n t e r a c t i o n s w i t h o t h e r s . F u r t h e r r e s e a r c h i n t h i s area would help c l a r i f y the r e l a t i o n s h i p between homophobia, s e l f - e s t e e m and the way an i n d i v i d u a l p e r c e i v e s and i n t e r a c t s with h i s environment. This study hypothesized t h a t l e v e l s of i n t e r n a l i z e d homophobia, s e l f - e s t e e m and s o c i a l support would be a s s o c i a t e d with the use of d i f f e r e n t coping s t r a t e g i e s i n HIV+ gay men, and t h a t the use of d i f f e r e n t s t r a t e g i e s i s a s s o c i a t e d with mood s t a t e . Although the p a t t e r n of coping s t r a t e g i e s o r i g i n a l l y a n t i c i p a t e d was not found t o be present, the r e s u l t s based on the new coping s t r a t e g i e s d i d support the hypotheses. These f i n d i n g s have i m p l i c a t i o n s f o r agencies and i n d i v i d u a l s working with HIV+ gay men. Although i t may not be more p r e v a l e n t i n i n f e c t e d gay men than n o n i n f e c t e d gay men, i n t e r n a l i z e d homophobia i s c l e a r l y a s i g n i f i c a n t f a c t o r i n the coping and adjustment of HIV+ gay men. General s e l f - e s t e e m i s a l s o an important I l l v a r i a b l e . C o u n s e l l o r s should be aware of the l e v e l s of s e l f - e s t e e m and homophobia i n t h e i r c l i e n t s . Given t h a t t h e r e i s some i n d i c a t i o n t h a t b i s e x u a l men may experience g r e a t e r d i s t r e s s than homosexual men, c o u n s e l l o r s working with HIV+ gay men should make themselves aware of the o r i e n t a t i o n of t h e i r c l i e n t s so as t o be a b l e t o be s e n s i t i v e t o b i s e x u a l men who may be e x p e r i e n c i n g d i f f i c u l t y . In d e a l i n g w i t h these problems i n d i v i d u a l or group work f o c u s i n g on improving s e l f - e s t e e m and examining a t t i t u d e s towards homosexuality may prove u s e f u l . T h i s type of work may be p a r t i c u l a r l y important f o r b i s e x u a l men. A t t e n t i o n should a l s o be p a i d t o the types of coping i n f e c t e d gay c l i e n t s use. C l i e n t s who e x h i b i t a g r e a t d e a l of self-blame r e g a r d i n g t h e i r i n f e c t i o n , l i f e s t y l e or c u r r e n t problems i n t h e i r l i f e should be noted. A psychoeducational approach examining the nature of HIV i n f e c t i o n and l i f e s t y l e i s s u e s may be an important way to help these men d e a l with t h e i r f e e l i n g s of g u i l t and blame. I t i s a l s o important to note i f c l i e n t s tend t o cope through escape i n t o f a n t a s y or avoidance. E f f o r t s might focus on more concrete, problem-focused coping s t r a t e g i e s which would help the i n d i v i d u a l d e a l w i t h the i s s u e d i r e c t l y . There are a number of l i m i t a t i o n s i n t h i s study which p o t e n t i a l l y weaken the r e l i a b i l i t y of the f i n d i n g s . F i r s t , as with any s e l f - r e p o r t q u e s t i o n n a i r e survey, t h e r e i s the p o s s i b i l i t y of response b i a s i n completing p a r t or a l l of the package. The f a c t , however, t h a t the means and standard 112 d e v i a t i o n s obtained f o r the p r e d i c t o r and c r i t e r i o n measures are comparable t o those found i n other s t u d i e s with gay men with AIDS, as w e l l as s t u d i e s on other p o p u l a t i o n s , suggests t h a t the r e s u l t s of t h i s study are r e l i a b l e . Second, as the method of data g a t h e r i n g i s through the v o l u n t a r y completion of the g u e s t i o n n a i r e package i t cannot be hoped t o have a r e p r e s e n t a t i v e sample of the HIV i n f e c t e d gay p o p u l a t i o n , l e t alone the gay p o p u l a t i o n as a whole. B a t c h e l o r (1984) and Joseph, Emmons et a l . (1984) address t h i s i s s u e by acknowledging t h a t i t i s never p o s s i b l e t o gain a t r u l y r e p r e s e n t a t i v e sample of the gay community because of i t s d i v e r s e nature and because of a r e l u c t a n c e f o r members t o take p a r t i n h e t e r o s e x u a l l y promoted r e s e a r c h . T h i s i s l i k e l y t o be p a r t i c u l a r l y t r u e i n the case of HIV+ i n d i v i d u a l s , as g e n e r a l h e a l t h concerns, as w e l l as concerns about c o n f i d e n t i a l i t y , would i n h i b i t people from p a r t i c i p a t i n g . Nonetheless, the demographic d e s c r i p t i o n of t h i s sample i s comparable t o those of ot h e r A I D S - r e l a t e d s t u d i e s i n v o l v i n g gay men (Joseph, Montgomery et a l . , 1987; Moulton et a l . , 1987; S t u l b e r g & Smith, 1988, Wolcott, Namir et a l . , 1986). As such, the p o p u l a t i o n represented i n these s t u d i e s i s p r i m a r i l y Caucasian, middle-aged, educated and middle-c l a s s . I t i s c l e a r , t h e r e f o r e , t h a t the sample i n t h i s study and i n the others i s not t r u l y r e p r e s e n t a t i v e , as c e r t a i n members of the homosexual community are not be i n g accessed. Gay men from other e t h n i c groups such as the 113 A s i a n or Native Indian community are not be i n g a c c u r a t e l y represented, nor or gay men from lower socio-economic or education backgrounds. S i m i l a r l y , t h i s sample i s l a r g e l y an urban sample. As such, gay men from a suburban or r u r a l s e t t i n g are not repr e s e n t e d . Although i t i s u n c l e a r what impact the responses of men from these d i f f e r e n t groups might have on the f i n a l r e s u l t s , i t i s ev i d e n t t h a t the r e s u l t s o b tained i n t h i s study must be viewed with some r e s e r v a t i o n . People working with HIV+ gay men should t h e r e f o r e be s e n s i t i v e t o the p a r t i c u l a r s i t u a t i o n s of c l i e n t s who do not f a l l i n t o the demographic p o p u l a t i o n d e s c r i b e d by t h i s and other s t u d i e s . T h i r d , HIV+ gay men who are u s i n g more avoidance and withdrawal i n coming t o terms with t h e i r d i a g n o s i s might be r e l u c t a n t t o come forward t o p a r t i c i p a t e i n a study. Since the primary means of r e a c h i n g p o t e n t i a l s u b j e c t s was through agencies or i n d i v i d u a l s who were o f f e r i n g h e a l t h , e d u c a t i o n a l or s u p p o r t i v e s e r v i c e s t o i n f e c t e d i n d i v i d u a l s , the p o p u l a t i o n was a l r e a d y skewed i n favour of those people who had sought help i n d e a l i n g w i t h t h e i r d i a g n o s i s . Thus, the sample might underestimate the number of gay men who are, or the degree t o which they are, e x p e r i e n c i n g i n t e r n a l i z e d homophobia and/or u s i n g avoidant forms of coping. F i n a l l y , time s i n c e d i a g n o s i s was an important v a r i a b l e being c o n s i d e r e d and proved s i g n i f i c a n t i n a number of the r e g r e s s i o n equations. I t i s important t o note, however, 114 t h a t the m a j o r i t y of respondents had been l i v i n g with t h e i r i n f e c t i o n f o r n e a r l y two y e a r s . The i n i t i a l stages of d e a l i n g with a traumatic event are o f t e n q u i t e profound ( c f . Kubler-Ross, 1969; Worden, 1982). T y p i c a l l y , r e a c t i o n s can i n c l u d e d i s b e l i e f , shock and d e n i a l . As such, t h e r e i s reason t o suspect t h a t the time immediately f o l l o w i n g d i a g n o s i s c o u l d be s i g n i f i c a n t f o r HIV+ gay men. U n f o r t u n a t e l y , t h i s group was l a r g e l y unrepresented i n the present study. Although i t i s not expected t h a t the a d d i t i o n of a g r e a t e r number of newly diagnosed respondents would d i m i n i s h the observed e f f e c t s , i t should be kept i n mind t h a t the experiences and r e s u l t s f o r newly diagnosed gay men may be d i f f e r e n t than f o r men who have been l i v i n g with i n f e c t i o n f o r a g r e a t e r l e n g t h of time. The r e s u l t s of t h i s study suggest a number of areas f o r f u r t h e r r e s e a r c h , some of which have a l r e a d y been mentioned. This study has r e v e a l e d some of the v a r i a b l e s a s s o c i a t e d with the use of c e r t a i n c o p i n g s t r a t e g i e s , but i t i s c l e a r t h a t i n the case of problem-focused types of c o p i n g such as SPS coping, other v a r i a b l e s are a l s o a t work which were not e v a l u a t e d . P o s s i b l e f a c t o r s which have been examined i n p r e v i o u s coping r e s e a r c h i n c l u d e h a r d i n e s s , optimism and one's sense of p e r s o n a l e f f i c a c y . F u r t h e r r e s e a r c h should be conducted to p r o v i d e g r e a t e r c l a r i f i c a t i o n of the p s y c h o s o c i a l f a c t o r s a s s o c i a t e d with, not o n l y the coping s t r a t e g i e s examined i n t h i s study, but those subscales which were not examined. As w e l l , r e s e a r c h of a l o n g i t u d i n a l 115 nature would p r o v i d e i n f o r m a t i o n on the process of coping with i n f e c t i o n , and the r o l e of v a r i o u s p s y c h o s o c i a l over the course of time. T h i s study and other s t u d i e s suggest t h a t the experiences of gay men wi t h HIV+ may be d i f f e r e n t from those of gay men with AIDS. F u r t h e r , t h i s study has shown t h a t t h e r e are d i f f e r e n c e s between men wi t h HIV and men with ARC. F i r s t , gay men with ARC experience more mood d i s t u r b a n c e than men who are HIV+. The most l i k e l y e x p l a n a t i o n f o r t h i s i s t h a t the presence of e a r l y A I D S - r e l a t e d symptoms makes the h e a l t h t h r e a t more r e a l and hence causes g r e a t e r d i s t r e s s . T h i s d i s t i n c t i o n between men with ARC and men with HIV i s important as w r i t e r s (Moynihan et a l . , 1988) had suggested t h a t men who were HIV+ experienced more d i s t r e s s ( i n the form of hopelessness and a n x i e t y ) than men with AIDS. Future r e s e a r c h should be done to c l a r i f y not on l y the d i f f e r e n c e s between those w i t h HIV and AIDS, but a l s o the s i m i l a r i t i e s . As w e l l , g i v e n the g e n e r a l l a c k of i n f o r m a t i o n , f u r t h e r r e s e a r c h s t i l l needs t o be conducted t o examine the a s s o c i a t i o n between the p s y c h o s o c i a l f a c t o r s i d e n t i f i e d i n t h i s study and the use of coping s t r a t e g i e s and mood s t a t e i n gay men with AIDS. Although the MANOVA r e v e a l e d no o v e r a l l s i g n i f i c a n t group e f f e c t between gay men who c o n s i d e r e d themselves homosexual and those who c a l l e d themselves b i s e x u a l , the d i f f e r e n c e s i n the means on the p r e d i c t o r and c r i t e r i o n measures suggest t h a t t h i s may be an important p o i n t of 116 d i s t i n c t i o n which needs f u r t h e r r e s e a c h i n g . E a r l i e r s t u d i e s of gay men with AIDS have not d i s t i n g u i s h e d between homosexuals and b i s e x u a l s , but t h i s d i s t i n c t i o n may w e l l be s i g n i f i c a n t . Although the d i s p a r a t e c e l l s i z e s weaken the s t r e n g t h of the d i f f e r e n c e s , b i s e x u a l men r e p o r t e d g r e a t e r homophobia, lower s e l f - e s t e e m and s o c i a l support and g r e a t e r mood d i s t u r b a n c e . There are a number of p o s s i b l e e x p l a n a t i o n s f o r these d i f f e r e n c e s . B i s e x u a l men may be men who have been l e a d i n g double l i v e s . They may be o p e r a t i n g as though they were h e t e r o s e x u a l w h i l e m a i n t a i n i n g some degree of a s e c r e t homosexual l i f e s t y l e . T h i s b e i n g the case they are a group which may not have come f u l l y t o terms with t h e i r sexual o r i e n t a t i o n and as such, they are l i k e l y t o have higher l e v e l s of i n t e r n a l i z e d homophobia. As b i s e x u a l s they may f i n d themselves caught between two c u l t u r e s , and not f u l l y a p a r t of e i t h e r . Thus, they may be unable or u n w i l l i n g t o seek s o c i a l support f o r f e a r of r e v e a l i n g a s i d e of themselves which they themselves have t r o u b l e a c c e p t i n g and which they have attempted t o h i d e . Whatever the reason, t h e r e i s evidence t o suggest t h a t b i s e x u a l men may be at g r e a t e r r i s k than homosexual men. F u r t h e r r e s e a r c h needs to be conducted t o c l a r i f y t h i s i s s u e . One of the u n d e r l y i n g p o s i t i o n s of t h i s study was t h a t the pervading s o c i a l homophobia c o u l d p o t e n t i a l l y impact on gay men and t h e i r adjustment t o the AIDS c r i s i s . The s i g n i f i c a n t r o l e of i n t e r n a l i z e d homophobia i n t h i s study's 117 f i n d i n g s p r o v i d e s some e v i d e n c e o f t h i s . A I D S , h o w e v e r , i s n o t e x c l u s i v e l y a d i s e a s e o f g a y men. I V d r u g u s e r s a n d h a e m o p h i l i a c s a r e a l s o a t r i s k f o r c o n t r a c t i n g t h e v i r u s a n d i n c i d e n c e o f i n f e c t i o n i s i n c r e a s i n g i n m i n o r i t y e t h n i c g r o u p s i n N o r t h A m e r i c a ( i . e . , n a t i v e p e o p l e s , b l a c k s a n d h i s p a n i c s ) . T h e s e g r o u p s a r e a l s o s u b j e c t t o s o c i a l b i a s w h i c h w i l l u n d o u b t e d l y i m p a c t on t h e i r a b i l i t y t o a d j u s t t o an HIV i n f e c t i o n . R e s e a r c h , t h e r e f o r e , n e e d s t o f o c u s on t h e i m p a c t o f s o c i a l b i a s on o t h e r i d e n t i f i e d m i n o r i t i e s , s u c h as t h e n e g a t i v e s t i g m a a s s o c i a t e d w i t h I V d r u g u s e r s o r p r o s t i t u t e s , o r t h e r a c i a l b i a s d i r e c t e d t o w a r d s o t h e r e t h n i c g r o u p s . A t t h e same t i m e , r e s e a r c h must a l s o f o c u s on ways t o b e t t e r e d u c a t e s o c i e t y s o a s t o c o u n t e r a c t o r e l i m i n a t e t h e s e b i a s e s . AIDS i s a d i s e a s e w h i c h w i l l n o t q u i c k l y go away. R a t h e r , t h e f u t u r e w i l l l i k e l y s e e a n i n c r e a s i n g number o f p e o p l e b e c o m i n g HIV+ a n d , u l t i m a t e l y , a n i n c r e a s i n g number o f p e o p l e w i t h A I D S . A l t h o u g h m e d i c a l r e s e a r c h may e v e n t u a l l y f i n d a c u r e o r i m p r o v e d methods o f t r e a t m e n t f o r t h e d i s e a s e , c o p i n g w i l l c o n t i n u e t o p l a y a n i m p o r t a n t r o l e i n t h e d a y t o d a y a d j u s t m e n t o f HIV+ p e o p l e s . 118 References Acevedo, J.R. (1986). Impact of r i s k r e d u c t i o n on mental h e a l t h . In L. McKusick (Ed.), What to do about AIDS (pp. 95-102). 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A t t r i b u t i o n s of blame and r e s p o n s i b i l i t y i n r e l a t i o n t o d i s t r e s s and h e a l t h behavior change i n people with AIDS and A I D S - r e l a t e d complex. J o u r n a l  of A p p l i e d S o c i a l Psychology, 17, 493-506. Moynihan, R., C h r i s t , G., & S i l v e r , L.G. (1988). AIDS and t e r m i n a l i l l n e s s . S o c i a l Casework: The J o u r n a l of  Contemporary S o c i a l Work. 69, 380-387. Namir, S. (1986). Treatment i s s u e s c o n cerning persons with AIDS. In L. McKusick (Ed.), What t o do about AIDS (pp. 87-94). Berkeley: U n i v e r s i t y of C a l i f o r n i a P r e s s . Namir, S., Wolcott, D.L., Fawzy, F. I . , & Alumbaugh, M.J. (1987). Coping with AIDS: P s y c h o l o g i c a l and h e a l t h i m p l i c a t i o n s . J o u r n a l of A p p l i e d S o c i a l Psychology, 17, 309-328. N i c h o l s , S.E. (1984). 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P i e r c e & D. VanDeVeer (Eds.), AIDS: E t h i c s and  p u b l i c p o l i c y (pp. 39-48). Belmont, C a l i f . : Wadsworth. Ross, M.W., & Rosser, B.S. (1988). P s y c h o l o g i c a l i s s u e s i n AIDS-re l a t e d syndromes. P a t i e n t Education and  Counseling, 11, 17-28. S i l v e r , R.L., & Wortman, C.B. (1980). Coping with u n d e s i r e a b l e l i f e events. In J . Garber & M.E.P. Seligman (Eds.), Human h e l p l e s s n e s s : Theory and  a p p l i c a t i o n s (pp. 279-340). New York: Academic P r e s s . Simmons, R.G., K l e i n , S.D., & Simmons, R.L. (1977). G i f t of  l i f e : The s o c i a l and p s y c h o l o g i c a l impact of organ  t r a n s p l a n t a t i o n . New York: John Wiley & Sons. Solomon, G.F., & Temoshok, L. (1987). A psychoneuroimmunologic p e r s p e c t i v e on AIDS r e s e a r c h : Questions, p r e l i m i n a r y f i n d i n g s , and sugge s t i o n s . J o u r n a l of A p p l i e d S o c i a l Psychology, 17, 286-308. S t u l b e r g , I., & Buckingham, S.L. (1988). P a r a l l e l i s s u e s f o r AIDS p a t i e n t s , f a m i l i e s , and o t h e r s . S o c i a l  Casework: The J o u r n a l of Contemporary S o c i a l Work, 69., 355-359. S t u l b e r g , I., & Smith, M. (1988). P s y c h o s o c i a l impact of the AIDS epidemic on the l i v e s of gay men. S o c i a l  Work, 33/ 277-281. Tennen, H., & Herzberger, S. (1985). Ways of cop i n g s c a l e . In D.J. Keyser & R.C. Sweetland (Eds.), Test C r i t i q u e s  V o l . 3 (pp. 686-697). Kansas C i t y , Mo.: Tes t C o r p o r a t i o n of America. Turner, R.J. (1981). Experienced s o c a l support as a contingency i n emotional w e l l - b e i n g . J o u r n a l of Health  and S o c i a l Behaviour, 22., 357-367. Turner, R.J. (1983). D i r e c t , i n d i r e c t , and moderating e f f e c t s of s o c i a l support on p s y c h o l o g i c a l d i s t r e s s and a s s o c i a t e d c o n d i t i o n s . In H.B. Kaplan (Ed.), 125 P s y c h o s o c i a l s t r e s s : Trends i n theory and r e s e a r c h (pp. 105-155). New York: Academic P r e s s . Turner, R.J., F r a n k e l , B.G., & L e v i n , D.M. (1983). S o c i a l Support: C o n c e p t u a l i z a t i o n , measurement, and i m p l i c a t i o n s f o r mental h e a l t h . Research i n Community  and Mental Health, 3, 67-111. Turner, R.J., & Noh, S. (1988). P h y s i c a l d i s a b i l i t y and d e p r e s s i o n : A l o n g i t u d i n a l a n a l y s i s . J o u r n a l of Health  and S o c i a l Behavior, 29, 23-27. V a l d i s e r r i , R.O. (1987). Epidemics i n p e r s p e c t i v e . J o u r n a l  of M e d i c a l Humanities and B i o e t h i c s , 8., 95-100. Van Den bout, J . , van Son-Schoones, N., Schipper, J . , fit G r o f f e n , C. (1988). A t t r i b u t i o n a l c o g n i t i o n s , coping behavior, and s e l f - e s t e e m i n i n p a t i e n t s w i t h severe s p i n a l cord i n j u r i e s . J o u r n a l of C l i n i c a l Psychology, 44# 17-22. Vingerhoets, A.J.J.M., & F l o h r , P.J.M. (1984). Type A behaviour and s e l f - r e p o r t s of coping p r e f e r e n c e s . B r i t i s h J o u r n a l of M e d i c a l Psychology, 57., 15-21. V i t a l i a n o , P.P., Maiuro, R.D., Russo, J . , & Becker, J . (1987). Raw versus r e l a t i v e scores i n the assessment of coping s t r a t e g i e s . J o u r n a l of B e h a v i o r a l Medicine, 10, 1-18. Weckowicz, T.E. (1978). P r o f i l e of mood s t a t e s . In O.K. Buros (Ed.), The e i g h t h mental measurements yearbook, ( V o l . 1, pp. 1018-1019). Highland Park, New J e r s e y : Gryphon. Wolcott, D.L., Fawzy, F.I . , Landsverk, J . , & McCombs, M. (1986). AIDS p a t i e n t s ' needs f o r p s y c h o s o c i a l s e r v i c e s and t h e i r use of community s e r v i c e o r g a n i z a t i o n s . J o u r n a l of P s y c h o s o c i a l Oncology, 4, 135-146. Wolcott, D.L., Namir, S., Fawzy, F.I . , G o t t l i e b , M.S., & Mitsuyasu, R.T. (1986). I l l n e s s concerns, a t t i t u d e s towards homosexuality, and s o c i a l support i n gay men with AIDS. General H o s p i t a l P s y c h i a t r y , 8, 395-403. Worden, J.W. (1982). G r i e f c o u n s e l i n g and g r i e f therapy. New York: Sp r i n g e r . Z i c h , J . , & Temoshok, L. (1987). P e r c e p t i o n s of s o c i a l support i n men with AIDS and ARC: R e l a t i o n s h i p s with d i s t r e s s and h a r d i n e s s . J o u r n a l of A p p l i e d S o c i a l  Psychology, 17, 193-215. 126 Appendix A: I n t r o d u c t o r y L e t t e r The U n i v e r s i t y of B r i t i s h Columbia F a c u l t y of Education Department of C o u n s e l l i n g Psychology 5780 Toronto Road Vancouver, B.C. V6T 1L2 COPING WITH HIV Dear P a r t i c i p a n t : Thank you f o r b e i n g w i l l i n g t o p a r t i c i p a t e i n t h i s study. The aim of t h i s p r o j e c t i s to examine the d i f f e r e n t ways gay men come to terms wi t h an HIV+ d i a g n o s i s , and some of the f a c t o r s t h a t might a f f e c t the types of coping they use. I t i s hoped t h a t the i n f o r m a t i o n gained through t h i s r e s e a r c h w i l l enable people t o be more s e n s i t i v e t o the needs and concerns of homosexual men who t e s t p o s i t i v e f o r HIV and t h a t i t w i l l h e lp i n d e s i g n i n g c o u n s e l l i n g programs t h a t w i l l b e s t meet those needs. Your p a r t i c i p a t i o n i n t h i s study i s completely v o l u n t a r y and w i l l i n no way a f f e c t the care or treatment you are p r e s e n t l y r e c e i v i n g nor your e l i g i b i l i t y t o p a r t i c i p a t e i n any other U.B.C. s t u d i e s . A l l i n f o r m a t i o n i s s t r i c t l y c o n f i d e n t i a l . In o r d e r t o secure anonymity, I ask t h a t you do not s i g n your name anywhere on t h i s q u e s t i o n n a i r e package. Your package i s i d e n t i f i e d s o l e l y by the number at the top of the f i r s t page. The q u e s t i o n n a i r e w i l l take approximately one hour t o complete. There are no r i g h t or wrong answers, o n l y p e r s o n a l c h o i c e s . Some of the g u e s t i o n s t h a t you w i l l be asked may seem i r r e l e v a n t or perhaps o f f e n s i v e . I t i s important t o remember t h a t t h i s r e s e a r c h i s t r y i n g t o g a i n i n f o r m a t i o n on h e a l t h and c o p i n g and t h a t i t makes no moral or p o l i t i c a l judgements. Your answers w i l l h e l p p r o v i d e an o v e r a l l p i c t u r e of how gay men are responding t o b e i n g HIV+. You are f r e e , of course, to no answer s p e c i f i c q u e s t i o n s . Because of the q u a l i t y of the r e s e a r c h depends on the q u e s t i o n n a i r e b e i n g f u l l y completed, though, I urge you t o answer a l l q u e s t i o n s . I f you do complete the q u e s t i o n n a i r e and r e t u r n i t i n the stamped, s e l f - a d d r e s s e d envelope which i s s u p p l i e d , t h i s w i l l i n d i c a t e t h a t you have consented to your p a r t i c i p a t i o n i n the study. Appendix B: Demographic Information Please read a l l i n s t u c t i o n s c a r e f u l l y . There are no r i g h t or wrong answers t o these q u e s t i o n s , o n l y p e r s o n a l c h o i c e s . Answer a l l the q u e s t i o n s . C i r c l e the number which be s t d e s c r i b e s your s i t u a t i o n . 1. Age: •  2. Highest education completed: Less than Grade 12 1 High s c h o o l graduate 2 Some u n i v e r s i t y 3 Bachelors degree 4 Masters degree 5 D o c t o r a l degree 6 3. Current employment s t a t u s : F u l l - t i m e 1 Part-ti m e 2 Unem p l o y e d / D i s a b i l i t y . . . . . . . 3 R e t i r e d 4 4. Occupation ( i f unemployed, your l a s t o c c u p a t i o n ) : P r o f e s s i o n a l 1 Managerial 2 C l e r i c a l 3 T e c h n i c a l 4 Sales 5 S e r v i c e 6 Manual 7 Student 8 Other 9 Please s p e c i f y : 5. Approximate y e a r l y income, b e f o r e t a x e s : Under $10,000 1 $10,000 t o $19,999 2 $20,000 t o $29,999 3 $30,000 t o $49,999 4 $50,000 t o $100,000 5 Over $100,000 6 6. E t h n i c background: Black ' . . 1 Caucasian 2 East Indian 3 Native Indian 4 O r i e n t a l . 5 Other 6 Please s p e c i f y : 129 7. R e l i g i o n : C a t h o l i c 1 Jewish 2 P r o t e s t a n t 3 None 4 Other 5 Please s p e c i f y : 8. R e l a t i o n s h i p s t a t u s : S i n g l e 1 In committed r e l a t i o n s h i p , but not l i v i n g with l o v e r . . . . 2 L i v i n g w i t h l o v e r 3 Separated/divorced/widowed . . . 4 M a r r i e d 5 9. How long have you c o n s i d e r e d y o u r s e l f homosexual or b i s e x u a l ? (Check one) Years Months 10. P r i o r t o your d i a g n o s i s , how comfortable were you with your sexual o r i e n t a t i o n ? Not at a l l Moderately Very 11. How a c t i v e are you as a member of the gay community? Not a t a l l Moderately Very 12. How long ago d i d you r e c e i v e your HIV+ d i a g n o s i s ? Years Months 13. To the b e s t of your knowledge how d i d you become i n f e c t e d ? Homosexual c o n t a c t with i n f e c t e d p a r t n e r . . . 1 Heterosexual c o n t a c t with i n f e c t e d p a r t n e r . . 2 Sharing IV drug needles 3 Blood t r a n s f u s i o n 4 Don't know/ Other 5 Please s p e c i f y : 14. What i s your present d i a g n o s t i c s t a t u s ? HIV+: ARC (AIDS-related complex): AIDS: 15. How l i k e l y do you f e e l i t i s t h a t you w i l l develop AIDS? Not a t a l l Moderately Very 130 16. How many f r i e n d s or f a m i l y members have you t o l d about or gone t o f o r help w i t h regards your d i a g n o s i s ? 17. How many d o c t o r s , h e a l t h p r o f e s s i o n a l s , c o u n s e l l o r s , support groups or other h e l p e r s have you t o l d about or gone t o f o r help with regards your d i a g n o s i s ? 18. Are you aware of programs or groups designed t o p r o v i d e ongoing support and educa t i o n t o HIV+ gay men? Yes No Have you attended any? Yes No 131 A p p e n d i x C : R o s e n b e r g S e l f - E s t e e m S c a l e ( R S E S ) A n s w e r t h e f o l l o w i n g g u e s t i o n s b y c i r c l i n g t h e number w h i c h b e s t r e p r e s e n t s how y o u f e e l . S t r o n g l y d i s a g r e e . . . 1 D i s a g r e e 2 A g r e e 3 S t r o n g l y a g r e e . . . . 4 1. On t h e w h o l e , I am s a t i s f i e d w i t h m y s e l f . . 1 2 3 4 2 . A t t i m e s I t h i n k I am no g o o d a t a l l . . . . 1 2 3 4 3 . I f e e l t h a t I h a v e a number o f g o o d g u a l i t i e s 1 2 3 4 4 . I am a b l e t o do t h i n g s a s w e l l a s mos t p e o p l e 1 2 3 4 5 . I f e e l I do n o t h a v e much t o b e p r o u d o f . . 1 2 3 4 6. I c e r t a i n l y f e e l u s e l e s s a t t i m e s 1 2 3 4 7 . I f e e l t h a t I am a p e r s o n o f w o r t h , a t l e a s t on a n e q u a l p l a n e w i t h o t h e r s . . . 1 2 3 4 8 . I w i s h I c o u l d h a v e more r e s p e c t f o r m y s e l f 1 2 3 4 9 . A l l i n a l l , I am i n c l i n e d t o f e e l t h a t I am a f a i l u r e 1 2 3 4 1 0 . I t a k e a p o s i t i v e a t t i t u d e t o w a r d m y s e l f . . 1 2 3 4 132 Appendix D: Nungesser Homosexual A t t i t u d e s Inventory (NHAI) Please read the f o l l o w i n g statements and c i r c l e the number which b e s t r e p r e s e n t s your a t t i t u d e . I f the statement d e p i c t s a s i t u a t i o n you have not experienced, imagine how you might r e a c t t o the s i t u a t i o n . S t r o n g l y d i s a g r e e . . . 1 S t r o n g l y agree . . . . 5 1. When I t e l l my f r i e n d s about my homosexuality, I do not worry t h a t they w i l l t r y t o remember t h i n g s about me t h a t would make me appear t o f i t the ster e o t y p e of a homosexual 1 2 3 4 5 2. I am g l a d t o be gay 1 2 3 4 5 3. Male homosexuality i s a n a t u r a l e x p r e s s i o n of s e x u a l i t y i n human males 1 2 3 4 5 4. When I am s e x u a l l y a t t r a c t e d t o a c l o s e male f r i e n d , I f e e l uncomfortable 1 2 3 4 5 5. When I am i n a c o n v e r s a t i o n w i t h a homosexual man and he touches me i t does not make me uncomfortable 1 2 3 4 5 6. I would not mind i f my boss found out th a t I was gay 1 2 3 4 5 7. Whenever I t h i n k a l o t about b e i n g a homosexual, I f e e l depressed 1 2 3 4 5 8. Homosexuality i s not as good as h e t e r o s e x u a l i t y 1 2 3 4 5 9. I am proud t o be a p a r t of the gay community 1 2 3 4 5 10. Male homosexuals do not d i s l i k e women any more than h e t e r o s e x u a l males d i s l i k e women 1 2 3 4 5 11. Marriage between two homosexuals should be l e g a l i z e d 1 2 3 4 5 12. My homosexuality does not make me unhappy 1 2 3 4 5 13. Male homosexuals are o v e r l y promiscuous. . 1 2 3 4 5 When I am s e x u a l l y a t t r a c t e d t o another gay man, I do not mind i f someone e l s e knows how I f e e l 1 Most problems t h a t homosexuals have come from t h e i r s t a t u s as an oppressed m i n o r i t y , not from t h e i r homosexuality per se. . . . 1 When women know of my homosexuality, I am a f r a i d they w i l l not r e l a t e to me as a man 1 Homosexual l i f e s t y l e s are not as f u l f i l l i n g as h e t e r o s e x u a l l i f e s t y l e s . . . 1 I would not mind i f my neighbors knew t h a t I am gay . . 1 I t i s important f o r me t o conceal the f a c t t h a t I am gay from most people 1 Whenever I t h i n k a l o t about b e i n g a homosexual, I f e e l c r i t i c a l about myself . 1 Choosing a gay l i f e s t y l e should be an o p t i o n f o r c h i l d r e n 1 I f my s t r a i g h t f r i e n d s knew of my homosexuality, I would be uncomfortable. . 1 If men knew of my homosexuality, I am a f r a i d they would begin t o a v o i d me. . . . 1 Homosexuality i s a sexual p e r v e r s i o n . . . 1 If i t were made p u b l i c t h a t I am a homosexual, I would be extremely unhappy . 1 If my peers knew of my homosexuality, I am a f r a i d t h a t many would not want to be my f r i e n d s 1 A d u l t homosexual males who have sex with boys under 18 years of age should be punished by law 1 If o t h ers knew of my homosexuality, I would not be a f r a i d t h a t they would see me as effeminate 1 I wish I were a h e t e r o s e x u a l 1 134 30. When I t h i n k about coming out to a peer, I am a f r a i d they w i l l pay more a t t e n t i o n t o my body movements and v o i c e i n f l e c t i o n s 1 2 3 4 5 31. I do not t h i n k I w i l l be a b l e t o have a long-term l o v e r e l a t i o n s h i p with another man. 1 2 3 4 5 32. I am c o n f i d e n t t h a t my homosexuality does not make me i n f e r i o r 1 2 3 4 5 33. I am a f r a i d t h a t people w i l l harass me i f I come out more p u b l i c l y 1 2 3 4 5 34. When I t h i n k about coming out t o a heteros e x u a l male f r i e n d , I do not worry t h a t he might watch me t o see i f I do t h i n g s t h a t are s t e r e o t y p i c a l l y homosexual 1 2 3 4 5 135 Appendix E: Revised Ways of Coping Scale (WOCS) For the next set of q u e s t i o n s p l e a s e c o n s i d e r the p a s t month. Below are some problems t h a t many HIV+ gay men f i n d they must d e a l with. C i r c l e the category t h a t you have found to be the most s t r e s s f u l t o d e a l with t h i s p a s t month i n terms of coping with your d i a g n o s i s ? F e e l i n g badly about b e i n g i n f e c t e d 1 Worrying about my h e a l t h and/or the f u t u r e . . 2 T a l k i n g with other people or t e l l i n g o t her people about my d i a g n o s i s 3 D e a l i n g with the changes i n my l i f e s t y l e t h a t my d i a g n o s i s has caused 4 Other 5 Please d e s c r i b e Describe i n more d e t a i l what you have found t o be s t r e s s f u l . Now read each item below and i n d i c a t e , by c i r c l i n g the a p p r o p r i a t e number, to what extent you used i t i n d e a l i n g w i t h the s i t u a t i o n you have j u s t d e s c r i b e d . Not used a t a l l . . . . 0 Used somewhat 1 Used q u i t e a b i t . . . 2 Used a g r e a t d e a l . . . 3 1. Concentrated on what I had to do next -the next step 0 1 2 3 2. T r i e d t o make myself f e e l b e t t e r by e a t i n g . 0 1 2 3 3. Did something which I d i d n ' t t h i n k would work, but a t l e a s t I was doing something . . 0 1 2 3 4. Talked t o someone t o f i n d out more about the s i t u a t i o n 0 1 2 3 5. C r i t i c i z e d or l e c t u r e d myself 0 1 2 3 6. T r i e d not to c l o s e o f f my o p t i o n s , but leave t h i n g s open somewhat 0 1 2 3 7. Hoped a m i r a c l e would happen 0 1 2 3 136 8. Went al o n g with f a t e ; sometimes I j u s t have bad l u c k 0 1 2 3 9. Went on as i f n o t h i n g had happened 0 1 2 3 10. T r i e d t o keep my f e e l i n g s t o myself 0 1 2 3 11. Looked f o r the s i l v e r l i n i n g , so t o speak; t r i e d t o look on the b r i g h t s i d e of t h i n g s . 0 1 2 3 12. S l e p t more than u s u a l 0 1 2 3 13. Accepted sympathy and understanding from someone 0 1 2 3 14. Was i n s p i r e d t o do something c r e a t i v e . . . . 0 1 2 3 15. T r i e d t o f o r g e t the whole t h i n g 0 1 2 3 16. T r i e d to get p r o f e s s i o n a l help 0 1 2 3 17. Changed or grew as a person i n a good way. . 0 1 2 3 18. T r i e d to make myself f e e l b e t t e r by smoking, d r i n k i n g or t a k i n g drugs 0 1 2 3 19. Made a p l a n of a c t i o n and f o l l o w e d i t . . . . 0 1 2 3 20. I l e t my f e e l i n g s out somehow 0 1 2 3 21. Came out of the experience b e t t e r than when I went i n 0 1 2 3 22. Talked t o someone who c o u l d do something concrete about the problem 0 1 2 3 23. T r i e d to make myself f e e l b e t t e r by having sex 0 1 2 3 24. Took a b i g chance or d i d something r i s k y . . 0 1 2 3 25. T r i e d not to a c t too h a s t i l y or f o l l o w my f i r s t hunch 0 1 2 3 26. Found new f a i t h 0 1 2 3 27. Rediscovered what i s important i n l i f e . . . 0 1 2 3 28. Changed something so t h i n g s would t u r n out a l l r i g h t 0 1 2 3 29. Avoided b e i n g with people i n g e n e r a l . . . . 0 1 2 3 137 30. Didn't l e t i t get t o me; r e f u s e d t o t h i n k about i t too much 0 1 2 3 31. Asked a r e l a t i v e or f r i e n d I r e s p e c t f o r advice 0 1 2 3 32. Kept others from knowing how bad t h i n g s were 0 1 2 3 33. Made l i g h t of the s i t u a t i o n ; r e f u s e d t o get too s e r i o u s about i t 0 1 2 3 34. Talked t o someone about how I was f e e l i n g . . 0 1 2 3 35. I expressed anger to the person(s) who caused the problem 0 1 2 3 36. Stood my ground and fought f o r what I wanted 0 1 2 3 37. Knew what had to be done, so redoubled my e f f o r t s t o make t h i n g s work 0 1 2 3 38. Refused t o b e l i e v e i t had happened 0 1 2 3 39. Came up with a couple of d i f f e r e n t s o l u t i o n s t o the problem 0 1 2 3 40. T r i e d t o keep my f e e l i n g s from i n t e r f e r i n g with other t h i n g s too much 0 1 2 3 41. T r i e d t o get the person r e s p o n s i b l e t o change h i s or her mind 0 1 2 3 42. Wished t h a t the s i t u a t i o n would go away or somehow be over with 0 1 2 3 43. Had f a n t a s i e s or wished about how t h i n g s might t u r n out 0 1 2 3 44. Prayed 0 1 2 3 45. R e a l i z e d I brought the problem on myself . . 0 1 2 3 46. Went over i n my mind what I would say or do. 0 1 2 3 47. Thought of how a person I admire would handle t h i s s i t u a t i o n and used t h a t as a model. . . 0 1 2 3 48. I a p o l o g i z e d or d i d something t o make up . . 0 1 2 3 49. Made a promise to myself t h a t t h i n g s would be d i f f e r e n t next time 0 1 2 3 138 50. Took i t out on other people 0 1 2 3 51. Drew on ray past experiences; I was i n a s i m i l a r p o s i t i o n b e f o r e 0 1 2 3 52. I changed something about myself 0 1 2 3 53. I t r i e d something e n t i r e l y d i f f e r e n t from any of the above 0 1 2 3 Please d e s c r i b e : Appendix F: Revised Kaplan S c a l e (RKS) For the f o l l o w i n g questions read each set of v i g n e t t e s and check the box which best d e s c r i b e s how you f e e l . RONNIE People are devoted lo Ronnie and love him. They always support him, listen lo him, and sympathize with him. They care about him a lot. Check one box. 'STUART People are usually fond of Stuart. They can be sympathetic, but do not always listen lo him nor support him. PETER People are not devoted to Peler. They do nol support him, listen lo him, or sympathize with him. They do not care about him or love him. • • • • • I'm like Ronnie I'm halfway' between Ronnie and Stuart I'm like Cm halfway I'm like Stuart between Stuart Peter and Peter JOHN People rarely let John know thai he it want-ed. He does not really make a difference lo them and they are rarely concerned about him. He does not mat-ter lo ihem. Check one box. DAVID People sometimes let David know that he matters. Sometimes they think that he makes a difference to them. ANDY People constantly let Andy know that he is wanted. He really makes a difference to them. They are con-cerned about him and he matters. • • . • • .• I'm like I'm halfway I'm like I'm halfway I'm like John between John David between David Andy and David and Andy JONATHAN 3. People alwayi think that Jonathan ii a friend. They like talk-ing with him and spending a lot of time with him. He always haa lots of people around. He it seldom alone. Check one box. U1LL Li ill has friends and in a guod penuri to be with, but he isn't always sur-ruunded by people. ALLHN Allen is mostly alone. He rarely sees.people or spends time with them. He is most often by himself. • • • • • I'm like I'm hallway Jonathan between Jonathan and Bill I'm like U ill I'm llallwjy between Uill and Allen I'm like Allen S T E V E Sieve rarely has a close friend that he can count on. He does IKM know that they will always be there for him to lean on, and he does not support them. Check one box. • • I'm like Steve. G R E G O R Y Gregory sometimes has a close friend who is there for him and who he can count on. C H A R L E S Charles always has a close friend that he can count on. He does not have to worry a-boul whether they will be there for him to lean on. He gives them the same sup-port. • I'm halfway I'm like between Sieve Gregory, and Gregory. • • I'm halfway I'm like between Charles. Gregory and Charles. DENNIS People believe thai Dennis will make the right decisions and do the right things. They have confidence and faith in him. Check one box. BRIAN Some people have con-fidence and faith in Brian. Sometimes they think thai ne will make the right decisions and do (he right things. E D W A R D People rarely believe that Edward will make the right decisions or do the right things. They hardly ever have confidence in him. • • • • • I'm like Dennis I'm halfway between Dennis and Brian I'm like I'm halfway I'm like Brian between Brian Edward and Edward RONNIE Ronnie rarely spends time with other people. When he wants to do things, he hardly ever has anyone to do things with him. Check one box. RICHARD Richard sometimes spends lime wiih oilier people. When he wants to do things, some-times there are other people around lo do things with him. JEFFERY Jeffrey is almost al-ways with other peo-ple. Whenever he wants lo do things, he knows that one or an-other of his friends will be there to do things with him. • • • • • I'm like . I'm halfway I'm like Ronnie between Richard Ronnie and I'm halfway I'm like between Jcffery Richard and Jefferv 141 H A N K Hank knows that peo-ple care a lot about him. He has their at-tention and support. Check one box. M I C H A E L Michael sometimes has people's attention and support, He sometimes feels that they care about him. A N T H O N Y Anthony is uncertain that people care about him. He gets little at-tention or support. • • • • • I'm like Hank I'm halfway between Hank and Michael I'm like Michael I'm halfway between Michael and Anthony I'm like Anthony PATRICK 8. Patrick is rarely ad-mired and praised. There are very few people who think Pa-trick is important and worthy. Check one box. G O R D O N Gordon is sometimes admired and praised by some people. He is not always being reminded of his worth. JOEL Joel is consundy be-ing admired by peo-ple. They always praise him and think that he is important and worthy. I'm like Patrick I'm halfway between Patrick and Gordon I'm like Gordon I'm halfway between Gordon and Joel I'm like Joel R I C K Y 9. Ricky does not have a lot of different people lo lean on. He does not belong to a group of people who know each other and who would help one an-other when needed. Check one box. H A R O L D Harold sometimes has people he can lean un. He belongs lo a group of people who some-times help one another when needed. JASON Jason knows that there are a lot of different people he can lean on. He belongs to a group of many people who know each other and who always help one another out when needed. • • • • • I'm like I'm halfway I'm like Ricky between Ricky Harold and Harold I'm halfway I'm like between Jason Harold and Jason 

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