What is the difference between chemical coping and active coping behaviors in psychiatry?

Chemical Coping vs Active Coping Behaviors in Psychiatry

Core Distinction

Chemical coping refers to the maladaptive use of medications (particularly opioids or sedatives) to manage psychological or spiritual distress rather than for their intended therapeutic purpose, falling on a spectrum between appropriate medication use and addiction. 1 In contrast, active coping behaviors involve patients taking personal responsibility and using behavioral strategies to manage their symptoms and distress. 2

Chemical Coping: Definition and Characteristics

What It Is

• Chemical coping describes patients' intake of medications on a scale spanning from normal therapeutic use to addiction, with most patients falling somewhere in the middle by using medications to cope with psychological or spiritual distress rather than physical symptoms. 1
• This represents a "vast middle ground" between completely compliant drug-taking behavior and frank addiction, characterized by periodic aberrant behaviors and mixed therapeutic responses. 3
• The Health Care Financing Administration defines chemical restraint specifically as "a drug used to control behavior or restrict a patient's freedom of movement and is not standard treatment for the patient's medical or psychiatric condition." 2

Key Features

• Patients display aberrant medication-taking behaviors periodically, with overall results that are less than satisfying in the domain of functionality. 3
• When no obvious medical causes exist for increased symptom intensity, chemical coping should be considered alongside delirium, somatization, and depression. 1
• This pattern makes patients susceptible to drug toxicity and harm through maladaptive medication use. 1

Active Coping Behaviors: Definition and Characteristics

What It Is

• Active coping involves patients assuming personal responsibility for attempting to control their own symptoms and behaviors through self-management strategies rather than relying solely on medication. 2
• This approach emphasizes that staff control should only be used when patient self-control is unavailable, underdeveloped, or insufficient. 2

Key Features

• Patients use behavioral techniques, environmental modifications, and therapeutic skills to manage distress and prevent symptom escalation. 2
• Active coping requires patients to participate in the therapeutic program and work toward self-control even when at risk of symptom exacerbation. 2
• This approach promotes personal responsibility and self-control as the foundation of treatment. 2

Clinical Implications and Management

Identifying Chemical Coping

• Use brief screening tools such as the CAGE questionnaire during initial evaluation to identify patients at risk for chemical coping. 1
• Look for patterns where medication use increases without corresponding changes in objective symptoms or medical conditions. 1
• Monitor for signs of using medications to manage emotional distress rather than physical symptoms. 1

Managing Chemical Coping

• Adopt a structured approach including standardized documentation, opioid treatment agreements, urine drug screens, frequent visits, and restricted quantities of breakthrough medications. 1
• Provide brief motivational interviewing with an objective, nonjudgmental, and empathic style that includes personalized feedback about markers of risk or harm. 1
• For patients approaching the addiction end of the spectrum with evidence of compulsive use and destructive behavior, refer to substance abuse specialists. 1

Promoting Active Coping

• Beginning with intake, hospital staff should promote personal responsibility and self-control with patients to establish a therapeutic environment. 2
• Explain clearly the purpose of treatment, expectations for participation, expected behaviors, and unit rules to defuse potential crises caused by misperceptions. 2
• Teach patients aggression management skills and self-control strategies so that restrictive interventions can be minimized or rendered unnecessary. 2

Critical Pitfalls to Avoid

• Do not ignore chemical coping patterns, as they lead to unnecessary medication toxicity, poor pain control, and reduced quality of life. 1
• Avoid placing the burden of symptom management entirely on staff or medications rather than engaging patients in active self-management. 2
• Do not use chemical restraint as punishment, for staff convenience, to compensate for inadequate staffing, or by untrained personnel. 4
• Recognize that the ability and desire to control symptoms varies among patients and within individual patients depending on multiple factors including mental state and substance influence. 2