Journal of Clinical Psychology in Medical Settings (2018) 25:485–496

https://doi.org/10.1007/s10880-018-9559-6

Active Coping and Perceived Social Support Mediate the Relationship

Between Physical Health and Resilience in Liver Transplant Candidates
Amelia Swanson1 · Jessica Geller2,3 · Kelly DeMartini2,4,5 · Anne Fernandez6 · Dwain Fehon2,4,5

Published online: 15 March 2018

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract
Without a transplant, end-stage liver disease is associated with significant morbidity and mortality. Transplant candidates
endure physical and psychological stress while awaiting surgery, yet little is known about the relationship between physical
health and psychological resilience during the wait-list period. This study examined predictors of psychological resilience
and mediators of the relationship between physical health and psychological resilience in liver transplant candidates. Wait-
listed candidates (N = 120) from a single Northeast transplant center completed assessments of physical functioning, coping,
perceived social support, and resilience. Findings revealed that physical functioning, active coping, and perceived social
support were positively associated with resilience; maladaptive coping was negatively associated with resilience. Perceived
social support and active coping partially mediated the relationship between physical functioning and resilience. Transplant
center care providers should promote active coping skills and reinforce the importance of effective social support networks.
These interventions could increase psychological resilience among liver transplant candidates.

Keywords Liver disease · Liver transplant · Resilience · Social support · Coping

Introduction Scaglione et al., 2015). Liver transplantation is the stand-

End-Stage Liver Disease (ESLD) is a progressive, chronic,
and fatal condition with multiple etiologies, including hepa-
titis C, alcohol use disorders, obesity, autoimmune hepa-
titis, and metabolic and genetic conditions (Razavi et al.,
2013; Rehm, Samokhvalov, & Shield, 2013; Rinella, 2015;
The contents of this research do not represent the views of the
Department of Veterans Affairs or the United States Government.
ard of care for patients with ESLD; however, the number of
available organs is insufficient to meet the current demand.
Of the nearly 13,000 Americans currently wait-listed for
liver transplantation, approximately 1500 will die annually
while waiting for a lifesaving transplant (United Network
for Organ Sharing, 2015). Researchers have largely focused
on post-transplant outcomes, but less is known about the
critical wait-list period. A better understanding of that may
facilitate resilience of patients awaiting liver transplant could

2
* Amelia Swanson Department of Psychiatry, Yale University School
amelia.swanson@umassmemorial.org of Medicine, New Haven, CT, USA
3
Jessica Geller Department of Veterans Affairs, Denver-Seattle Center
jessgeller@gmail.com of Innovation, Aurora, CO, USA
4
Kelly DeMartini Smilow Cancer Hospital at Yale-New Haven, New Haven,
kelly.demartini@yale.edu CT, USA
5
Anne Fernandez Yale-New Haven Transplantation Center, New Haven, CT,
annefernandez@gmail.com USA
6
Dwain Fehon Department of Psychiatry, University of Michigan,
dwain.fehon@yale.edu Ann Arbor, MI, USA
1
Department of Psychiatry, University of Massachusetts
Medical School, 55 Lake Avenue North, Worcester,
MA 01655, USA

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486
be particularly useful to not only reduce stress, but improve
well-being.
Positive psychology is increasingly recognized as an
important perspective to consider when evaluating health
outcomes. Positive psychology helps refocus research and
theory from decreasing physical or psychological symptoms
to improving well-being and quality of life (Kobau et al.,
2011). A central tenant of positive psychology is that well-
being and psychological and physical illness are not two
points on the same continuum; instead, well-being and ill-
ness are separate concepts that are not mutually exclusive
(Kobau et al., 2011). Indeed, people can live with severe
medical conditions and experience good quality of life and
demonstrate psychological resilience (Mitmansgruber et al.,
2015; Viggers & Caltabiano, 2012). This concept is directly
applicable to people waiting for transplant who are suffering
from a myriad associated health problems. A better under-
standing of how to promote and maintain resilience in the
liver transplant population could help improve psychological
well-being and overall quality of life for these patients.
Resilience
Resilience occurs when a person is faced with adversity
but is able to adapt and thrive despite the circumstance in
order to preserve a better quality of life (Connor & David-
son, 2003; Windle, 2011). Components of resilience include
perceiving goals as achievable, persistence in the face of
adversity, knowing how to ask for help, and having a strong
sense of purpose (Connor and Davidson 2003). Resilience is
not a fixed character trait but rather a process that involves an
interaction between an individual and his/her environment
(Ungar, Ghazinour, & Richter, 2013). For those with ESLD
awaiting transplant, many aspects of their circumstances
may affect psychological adjustment and emotional well-
being. Some of these factors may include long and unpre-
dictable wait times coupled with challenging and severe
medical comorbidities.
Higher levels of resilience have been associated with
lower levels of psychiatric symptoms (e.g., depression and
anxiety) and improved quality of life in patients who are
post-renal transplant, pre- and post-stem cell transplant,
and in other cancer patient groups at various points in their
treatment (Cuhadar, Tanriverdi, Pehlivan, Kurnaz, & Alkan,
2016; Matzka et al., 2016; Tian et al., 2016). Resilience has
been found to be positively associated with quality of life
for patients with chronic pain (Viggers & Caltabiano, 2012).
Although there are known associations with resilience and
lower levels of distress and psychiatric symptoms in medi-
cal patients, less is known about psychological and environ-
mental factors that may influence this relationship. Better
understanding of the factors which promote and maintain
resilience in ESLD patients could help inform development
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Journal of Clinical Psychology in Medical Settings (2018) 25:485–496
of evidence-based programs to promote resilience and qual-
ity of life. Given that resilience is due to an interaction of
contextual and individual factors, it may be important to
consider the combined impact of physical functioning and
the ability to complete important life tasks, with contextual
factors such as social support, and internal variables such as
coping styles on resilience among ESLD candidates.
Physical Functioning
Individuals with ESLD experience a progressive decline in
physical health; symptoms can include refractory ascites,
encephalopathy, variceal bleeding, thrombocytopenia, infec-
tious complications, dysalbuminemia, pneumonia, renal
failure, hyponatremia, reduced heart rate variability, and
eventually death (Lefton, Rosa, & Cohen, 2009; Scaglione
et al., 2015; O’Leary, Orloff, Levitsky, Martin, & Foley,
2015; Vernon, Baranova, & Younossi, 2011). Many patients
with ESLD also experience equally detrimental malnutrition
and muscle atrophy, which can further impede functional
status (De Lima et al., 2015; Lai et al., 2014). The progres-
sive physical symptoms of ESLD are often outside of the
patient’s control and affect day-to-day functioning, leading
to an inability to work, sustain family roles and responsibili-
ties, and can result in psychological distress and impairment.
The Karnofsky Performance Status (KPS), and Model of
End-Stage Liver Disease (MELD) severity are frequently
used clinical measures of liver disease. The KPS is a sub-
jective physician rating of physical functioning, while the
MELD score is based on a patient’s serum bilirubin, serum
creatinine, and the international normalized ratio for pro-
thrombin time (INR) (Karnofsky & Burchenal, 1949;
Kamath & Kim, 2007). The KPS relies on the rating of a
physician and therefore may not fully assess the patient’s
perspective of their functioning. The MELD is an objective
score, but does not always predict objectively or subjectively
measured physical functioning for ESLD patients (Lai et al.,
2014). These limitations in measuring patient’s perception of
their functioning by standard measures has lead researchers
to increasingly use patient’s own report of their functioning
as an important focus (Corruble et al., 2011).
Due to the many physical complications of ESLD,
researchers have focused on physical functioning outcomes
or on understanding the impact of these physical symptoms
on quality of life (Corruble et al., 2011; Eftekar & Pun,
2016; Younossi & Henry, 2015). Less is known about how
physical functioning impacts patients’ ability to cope with
their illness and benefit from social support. Although resil-
ience is the process of responding to a stressful event, such
as limitations in physical functioning due to liver disease,
less in known in this population about how the level of phys-
ical functioning relates to resilience. This is of particular
Journal of Clinical Psychology in Medical Settings (2018) 25:485–496
importance to ESLD patients awaiting transplant as they
may benefit from interventions during their wait-list period.
Coping
Coping encompasses a variety of behaviors and cognitive
strategies that attempt to reduce the distress that accompa-
nies negative experiences (Carver & Vargas, 2011). Coping
strategies can vary by individual, type of stressor, person-
ality, and context (Carver & Vargas, 2011). Whereas the
impact and effectiveness of the coping strategy determines
its appropriateness, active coping (e.g., taking action, or
exerting efforts to remove or circumvent the stressor) has
been associated with positive health outcomes (Stilley et al.,
2010; Telles-Correia, Barbosa, Mega, Barroso, & Monteiro,
2011, Telles-Correia, Barbosa, Mega, & Monteiro, 2009b).
Other types of coping, including avoidant, passive, and pes-
simistic coping, have been associated with negative health
outcomes (Stilley et al., 2010).
Active coping has been found to be positively associated
with a number of important health-related factors that could
be particularly salient for ESLD patients. Treatment adher-
ence is crucially important for this population, both before
and after transplant, to avoid serious medical complications
and death (Stilley et al., 2010). In a study of patients who
had undergone liver transplant, active coping was positively
correlated with treatment adherence, whereas avoidant cop-
ing was a significant predictor of several clinical indicators
of transplant rejection (Stilley et al., 2010; Telles-Correia
et al., 2009b). Furthermore, active coping prior to liver
transplant also has been found to predict shorter length of
hospital stay post-transplant (Telles-Correia et al., 2011).
Active coping is also associated with psychological and
physical quality of life in liver transplant patients post-
transplant (Lasker, Sogolow, Short, & Sass, 2011), and has
been found to specifically predict higher levels of quality of
life related to physical functioning after transplant (Telles-
Correia, Barbosa, Mega, Barroso, & Monteiro, 2009a,
Telles-Correia, Barbosa, Mega, Monteiro, 2009c). Active
coping, therefore, may be an important strategy that trans-
plant patients can utilize to improve their well-being and
thrive despite ESLD.
Social Support
Social support, particularly when it is perceived as available
in response to a specific need, is especially important for
patients experiencing stressful medical conditions (Helge-
son, 1993, 2003). Types of social support may include emo-
tional, instrumental, and informational support and may be
provided by family, friends, medical personnel, and others
in the lives of patients. Perceived social support has been
associated with lower levels of psychiatric symptoms and
487
improved quality of life in medical populations including
pre- and post-stem cell transplant, kidney transplant, liver
transplant, and HIV-positive patients (Helgeson, 2003; Lim
& Zebrack, 2006; Smith, Crespi, Petersen, Zimmerman, &
Ganz, 2010).
In a sample of kidney transplant recipients, high levels of
social support were particularly effective in reducing anxiety
for patients with high transplant-related stress (Pisanti et al.,
2014). Transplant-related stress included stress related to
physical limitations, compliance to medical regimen, and
medication side-effects. In stem cell transplant patients,
higher perceived social support and stable pre-transplant
social support have been associated with lower levels of
post-transplant distress, anxiety, post-traumatic stress symp-
toms, and depression when controlling for initial levels of
depression (Bevans et al., 2011; Fife et al., 2000; Grassi,
Rosti, Albertazzi, & Marangolo, 1996; Jacobsen et al., 2002;
Jenks Kettmann & Altmaier, 2008; Syrjala et al., 2004).
High levels of social support also have been shown to reduce
the negative impact of HIV stigma on resilience (Earnshaw,
Lang, Lippitt, Jin, & Chaudoir, 2015).
In a descriptive study of the social support networks of
patients who underwent kidney, liver, and pancreas trans-
plants, high levels of social support were correlated with
high levels of post-transplant quality of life (Cetingok, Hath-
away, & Winsett, 2007). Social support may also play a par-
ticularly important role as a “stress-buffer” for minimizing
the impact of negative and stressful life events on individu-
als with chronic liver disease who are awaiting transplant
(Cohen & Wills, 1985). These findings suggest that social
support may be particularly important for patients managing
the uncertainty of waiting for a liver transplant. However,
the specific impact of social support on resilience of patients
awaiting liver transplant has not yet been clearly identified.
Study Aims
As previous research has shown that perceived social sup-
port can help promote resilience in various populations of
medical patients (Cetingok et al., 2007), the first aim of this
study was to evaluate the association between perceived
social support and resilience while controlling for physi-
cal functioning. We predicted that both perceived social
support and active coping, after controlling for physical
functioning, would have a positive association with resil-
ience. Furthermore, research has found that coping can
have both a positive and negative impact on resilience in
medical patients based on the type of coping used (Stilley
et al., 2010; Telles-Correia et al., 2009c), the second aim of
this study was to evaluate the association between coping
styles and resilience while controlling for physical function-
ing and perceived social support. We predicted that active
coping would have a positive association with resilience,
13
488
while maladaptive coping would have a negative associa-
tion with resilience, after controlling for physical function-
ing and perceived social support. Finally, given the paucity
of research investigating other variables that may partially
explain the relationship between physical functioning and
resilience, the third aim of the study was to evaluate if either
perceived social support or active coping partially explained
the relationship between physical functioning and resilience
in patients with ESLD awaiting liver transplantation. We
predicted that both social support and active coping would
partially explain the relationship between physical function-
ing and resilience.
Methods
Participants and Procedures
All English-speaking patients at least 18 years of age and
currently on the United Network for Organ Sharing (UNOS)
wait-listed for liver transplantation at a single Northeast
transplant center were screened for eligibility to participate.
A total of 270 UNOS wait-listed patients were screened for
eligibility. Screened patients were not invited to participate
if their primary language was not English, as some meas-
ures utilized were only validated in English, or their disease
severity prevented participation (e.g., those patients who
were hospitalized and critically ill, removed from transplant
wait-list due to other medical comorbidities, and those who
died or were transplanted during the study period). Potential
participants were informed of the study during routine clinic
appointments and/or by telephone invitations to participate.
Of the 270 patients screened for the study, 223 met inclu-
sion criteria and a total of 125 agreed to participate and
consented to the study. Fifty-six percent of patients that met
inclusion criteria participated in the study. See Fig. 1 for a
flowchart detailing this process.
Participants were asked to complete a battery of brief
self-report assessments at a single time point to assess cop-
ing styles, psychological resilience, perceived social sup-
port, and health-related quality of life including physical
functioning. Demographic and medical history information
was recorded and verified through the electronic medical
records system. All participants provided written informed
consent prior to participation. This study was approved by
the institution’s Human Investigations Committee.
Measures
Demographic and Medical Variables
Demographic information, including gender, race/ethnic-
ity, and age, was collected through self-report and verified
13
Journal of Clinical Psychology in Medical Settings (2018) 25:485–496
Screened for
eligibility
Ineligible
N = 270
Non-English speaking: N = 22
Deceased: N = 11
Removed from list: N = 10
Received transplant during recruitment: N = 4
Eligible
N = 223
Could not contact: N = 60
Refused: N = 31
Other: N = 7
Recruited
N = 125
Incomplete assessment data: N = 5
Obtained complete
case data
N = 120
Fig. 1  Flowchart of participant recruitment and outcome
through the patient’s medical record. Medical information,
including liver disease etiology, Karnofsky Performance Sta-
tus (KPS), and Model of End-Stage Liver Disease (MELD)
score were gathered from the medical record from the most
recent visit with the hepatologist, typically within two weeks
of completing the measures. The KPS is a physician rating of
general physical functioning between 100 = perfect health to
0 = death (Karnofsky & Burchenal, 1949). The MELD score
is based on a patient’s serum bilirubin, serum creatinine,
and the international normalized ratio for prothrombin time
(INR); it is used as a marker of liver disease severity with
higher scores indicating a greater probability of mortality
(Kamath & Kim, 2007). Scores range from 6 = less ill to
40 = gravely ill and are used to assess the severity of liver
disease for patients age 12 and older.
Brief COPE (BCOPE; Carver, 1997)
The BCOPE is a 28-item self-report measure designed to
assess 14 conceptually different styles of coping. For this
study, six factors previously validated on liver transplant
patients were used including active, maladaptive, emo-
tional support, humor, religious, and substance use coping
(Amoyal, Fernandez, Ng, & Fehon, 2016). Respondents are
asked to indicate “What you generally do and feel when you
experience stressful events.” Response scales ranged from
0 = not at all to 4 = a lot Typical active coping items are
“You concentrate your efforts on doing something about the
situation you are in” and “You think hard about what steps
to take.” Scores on the active coping subscale can range
from 0 to 24, with higher scores indicating higher levels of
active coping. Typical maladaptive coping items are “You
criticize yourself” and “You give up trying to deal with it.”
Journal of Clinical Psychology in Medical Settings (2018) 25:485–496
Scores on the maladaptive coping subscale can range from
0 to 32, with higher scores indicating higher levels of mala-
daptive coping. Typical emotional coping items are “You
get emotional support from others” and “You get comfort
and understanding from someone.” Scores on the emotional
coping subscale can range from 0 to 20, with higher scores
indicating higher levels of emotional coping. The two humor
coping items are “You make fun of the situation” and “You
make jokes about it.” Scores on the humor coping subscale
range from 0 to 8, with higher scores indicating higher levels
of humor coping. Typical religious coping items are “You
pray or meditate” and “You try to find comfort in your reli-
gion or spiritual beliefs.” Scores on the religious coping
subscale range from 0 to 12, with higher scores indicating
higher levels of religious coping. The two substance abuse
coping items are “You use alcohol or other drugs to make
yourself feel better” and “You use alcohol or other drugs to
help you get through it.” Scores on substance abuse coping
subscale range from 0 to 8, with higher scores indicating
higher levels of substance abuse coping. Cronbach’s alpha in
the current study was 0.77 for active coping, 0.76 for mala-
daptive coping, 0.68 for religious coping, 0.90 for substance
use coping, and 0.88 for humor coping. As humor coping
and substance use coping are two item scales, spears coef-
ficient was also calculated. Spearman–Brown for substance
use scoring was 0.90 and for humor coping was 0.88.
Connor–Davidson Resilience Scale (CD–RISC; Connor &
Davidson, 2003)
The CD-RISC is a 25-item, 5-factor self-report measure
assessing psychological resilience. The scale’s original five-
factor structure reflects the factors of personal competence,
trust in one’s instincts, tolerance of negative affect, posi-
tive acceptance of change, control, and spirituality. For this
study, we used a single factor, 20-item version of the scale
that has been validated for use with ESLD patients (Fernan-
dez, Fehon, Treloar, Ng, & Sledge, 2015). Respondents are
asked to indicate “how true the following statements are of
you.” Typical items are “You are able to adapt to change eas-
ily” and “You feel that coping with stress strengthens you.”
Response scales ranged from 0 = not true at all to 4 = true
nearly all the time. Scores range from 0 to 80 and higher
scores are associated with better resilience. Cronbach’s alpha
in the current study was 0.96.
Medical Outcome Study Social Support Survey (MOS‑SSS;
Sherbourne & Stewart, 1991)
The MOS-SSS is a 20-item, self-report measure assess-
ing perceived social support. The measure assesses the
contributions of network size and four major categories
of support (instrumental, emotional, informational, and
489
companionship). For this study, we only utilized the overall
score for perceived social support. For each item, patients
indicate “How often are the following kinds of support avail-
able to you if you need it?” Typical items are “Someone
you can count on to listen to you when you need to talk”
and “Someone whose advice you really want.” Response
scales ranging from 0 = none of the time to 4 = all of the time.
Scores range from 0 to 8 and higher scores reflect higher
levels of perceived social support. Cronbach’s alpha in the
current study was 0.96.
Medical Outcome Study Short‑Form 36 Health Survey
(SF‑36; Ware & Sherbourne, 1992)
The SF-36 is a 36-item well-known and widely used self-
report measure of health-related quality of life assess-
ing eight areas. This study utilized the 10-item physical
functioning subscale that assesses limitations in physical
activities due to health problems. The physical function-
ing subscale was used for theoretical and statistical reasons
including that physical functioning is not always accurately
represented by scores such as MELD or KPS (Lai et al.,
2014). Respondents are asked about activities they might
do in a typical day and “Does your health now limit you
in these activities? If so, how much?” Typical items are
“Lifting or carrying groceries” and “Bending, kneeling, or
stooping.” Response scales ranged from 1 = yes, limited a
lot to 3 = no, not limited at all and higher scores indicate
participants perform all type of physical activities without
limitations due to health. Scores are reported as t scores,
ranging from 0 to 100. The SF-36 has shown evidence of
validity across diverse participant groups (McHorney, Ware,
Lu, & Sherbourne, 1994). Cronbach’s alpha for the physical
functioning subscale, the only subscale used in the current
study, was 0.82.
Data Analysis
Analyses were performed using IBM SPSS Statistics (ver-
sion 22). One hundred twenty-five responses were inspected
for outliers, normality, and missing data. One participant had
more than 90% of questions incomplete and was excluded
from analyses. Four additional cases were missing key
demographic information and were also excluded. The final
sample of 120 participants were included in all analyses.
All variables had < 6% missing data. To determine whether
missingness impacted the results, expectation/maximization
(i.e., E/M algorithm) was utilized to impute missing values
for resilience, physical functioning, social support, active cop-
ing, maladaptive coping, humor coping, religious coping, and
emotional support coping. Final statistical models were run
with pairwise deletion methods for handling missing data and
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490 Journal of Clinical Psychology in Medical Settings (2018) 25:485–496

compared to the results of the dataset with estimated values. Table 1  Demographic and medical characteristics of sample
The missing items did not impact the findings of the study. (N = 120)
Descriptive statistics (mean and standard deviations) were Patient characteristic N %
examined to characterize participants’ demographic informa-
Gender
tion and response to measures (e.g., BCOPE, CD-RISC, MOS-
Male 73 60.8
SSS, and SF-36). Pearson’s correlations assessed whether
Female 47 39.2
there were significant relationships between each predictor
Race/ethnicity
variable and the main outcome variable (e.g., psychological
White 91 75.8
resilience). Variables significantly related to resilience were
Black 12 10.0
used to build hierarchical regression models to evaluate the
Hispanic 11 9.2
effect of each variable on resilience. Physical functioning, per-
Other 4 3.3
ceived social support, and all styles of coping were evaluated
Missing 2 1.7
for multicollinearity. If they were found to have multicollin-
Marital status
earity, they were excluded. Variables that were included had a
Single 19 15.8
tolerance > 0.1 and variance inflation factor < 10, suggesting
Married 61 50.8
that multicollinearity was not an issue.
Separated 4 3.3
An initial hierarchical multiple regression analysis was
Divorced 29 24.2
run with resilience as the dependent variable. The hierar-
Widowed 5 4.2
chical multiple regression then added one variable to each
Missing 2 1.7
new block with a total of seven blocks. The variables were
Employment status
entered in the following order: physical functioning, per-
Full-time 20 16.7
ceived social support, active coping, maladaptive coping,
Part-time 5 4.2
humor coping, religious coping, and then substance abuse
Unemployed 34 28.3
coping. We chose this order to first consider physical func-
Disability 59 49.2
tioning and physical impact of illness, followed by the
Missing 2 1.7
contextual factor of perceived social support, and finally
Liver disease etiology
all styles of coping. All styles of coping were added after
HCV 62 51.7
physical functioning and perceived social support in order to
ALD 18 15.0
determine which styles of coping were significant predictors
HCC alone 2 1.7
of resilience when physical functioning and perceived social
NASH 11 9.2
support, as well the other forms of coping, were controlled
Other diagnoses 26 21.7
for. A final hierarchical regression model was run with only
Missing 1 0.8
the significant predictors.
HCC status
A parallel, multiple mediator model was built via PRO-
Yes 30 25.0
CESS modeling (Hayes, 2013) to examine the interrelation-
No 90 74.2
ships among physical functioning, active coping, perceived
Missing 1 0.8
social support, and resilience. The goal of this multiple
mediator model was to examine both the direct and indirect ALD Alcoholic Liver Disease, HCC Hepatocellular Carcinoma,
effects of physical functioning on resilience, while modeling HCV Hepatitis C Virus (HCV), NASH Non-alcoholic Steatohepati-
a simultaneous process in which physical functioning oper- tis; ‘Other Diagnoses’ includes genetic, metabolic, autoimmune, and
other unknown etiologies of liver disease
ated through active coping and perceived social support. All
indirect effects were estimated as the product of regression
weights linking X to Y through at least one mediator (M). with a mean age of 56.0 years (SD = 8.70). Many of the par-
Bootstrap confidence intervals were calculated for indirect ticipants were on a public stipend for individuals with docu-
effects. mented disability (49.2%; n = 59) and 50.0% of the sample
had an income below $35,000 a year. The majority (51.7%;
n = 62) had ESLD due to hepatitis C, and had a mean native
Results MELD score of 12.5 (SD = 4.47) and mean Karnofsky score
of 84.58 (SD = 8.97) indicating moderate disease severity.
Sample Descriptives See Table 1 for more information about demographic and
medical characteristics of the sample.
The sample was primarily male (60.8%; n = 73), Caucasian Participants reported moderate to high levels of resil-
(75.8%; n = 91), married or cohabitating (50.8%; n = 61), ience (M = 58.92, SD = 13.91) and high levels of perceived

13
Journal of Clinical Psychology in Medical Settings (2018) 25:485–496 491

social support (M = 77.89, SD = 14.48). Participants reported
some limitations with physical functioning (M = 39.19,
SD = 10.19). Participants also reported high levels of active
coping (M = 19.46, SD = 19.16) and a low to moderate level
of maladaptive coping (M = 13.83, SD = 4.22). Table 2
shows the mean, standard deviation, and Pearson’s cor-
relations for variables included in the analyses. As shown
in Table 2, physical functioning, perceived social support,
active coping, maladaptive coping, humor coping, and reli-
gious coping were all significantly correlated with resilience.
Hierarchical Regression Models
In order to properly specify the hierarchical regression
model, all demographic variables, MELD score, and KPS
were evaluated for their relationship to resilience. All vari-
ables but KPS were excluded because they did not have a
significant relationship with the outcome variable assessed
either by Pearson’s correlation or ANOVA. The KPS did
have a significant correlation with the SF-36 physical func-
tioning subscale (r = .20, p = .04), and therefore was not
included due to concerns of multicollinearity and for rea-
sons of parsimony. An initial hierarchical multiple regres-
sion analysis was conducted as an exploratory analysis, as
the BCOPE for ESLD patients has not been studied with
resilience previously. An initial hierarchical multiple regres-
sion analysis was run with resilience as the dependent vari-
able and included physical functioning, perceived social
support, active coping, maladaptive coping, humor coping,
religious coping, and substance abuse coping as independ-
ent variables, as previously clarified in "Methods" section.
Although the initial model was significant, humor coping
(β = 0.10, b = 0.62, SE = 0.44, p = .16), religious coping
(β = 0.03, b = 0.18, SE = 0.42, p = .65), and substance abuse
coping (β = 0.01, b = 0.10, SE = 0.1.49, p = .95) were not
significant predictors. These blocks did not add significant
variance to the model (ΔR2 = 0.01, p = .17; ΔR2 = 0.001,
p = .65; ΔR2 < 0.001, p = .95 , respectively). These three
blocks and predictors were removed from the final model
for parsimony. Emotional support coping was not included
in the model due to significant conceptual overlap with per-
ceived social support and high correlation with perceived
social support (r = .20, p = .04).
A final hierarchical multiple regression model was run
with the significant predictors. The final block was signifi-
cant, F (4,114) = 29.83, p < .001, R2 = 0.51 (see Table 3).
Both active coping (ΔR2 = 0.18, p < .001) and maladap-
tive coping (ΔR2 = 0.14, p < .001) significantly explained
additional variance in resilience. More than half (51%) of
the total variance in resilience was associated with physi-
cal functioning, perceived social support, active coping,
and maladaptive coping. Physical functioning (β = 0.18,
b = 0.24, SE = 0.10, p = .02), perceived social support
(β = 0.19, b = 0.18, SE = 0.07, p = .009), and active coping
(β = 0.39, b = 1.52, SE = 0.26, p < .001) were all positively
associated with resilience when controlling for other vari-
ables. Maladaptive coping (β = − 0.38, b = − 1.25, SE = 0.22,
p < .001) was negatively associated with resilience after con-
trolling for other variables. This indicates that lower levels
of maladaptive coping were associated with higher levels
of resilience.
Mediation Model
A parallel multiple mediation model was used to assess the
indirect effect of physical functioning on resilience through
active coping and perceived social support (See Fig. 2 for
a diagram including effects and significance values and
Table 4 for model summary). Patients who reported better
physical functioning also reported higher levels of active

Table 2  Means, standard deviations, and Pearson’s correlations between continuous variables included in preliminary analyses
M (SD) 2. 3. 4. 5. 6. 7. 8. 9.

1. Resilience 58.92 (13.91) 0.37** 0.33** 0.52** − 0.47** 0.02 0.26* 0.32** − 0.05
2. Physical functioning 39.19 (10.19) – 0.27* 0.23* − 0.13 0.12 0.13 0.15 − 0.13
3. Social support 77.89 (14.48) – 0.18* − 0.07 0.42** 0.07 0.10 − 0.02
4. Active coping 19.46 (3.60) – − 0.13 0.20* 0.35** 0.42** − 0.02
5. Maladaptive coping 13.83 (4.22) – 0.01 0.02 − 0.21* 0.07
6. Emotional support coping 15.36 (3.05) – 0.08 0.26* 0.02
7. Humor coping 4.77 (2.27) – 0.09 − 0.01
8. Religious coping 8.75 (2.51) – 0.02
9. Substance use coping 2.11 (0.63) –

Resilience: CD-RISC score, Physical functioning: physical functioning subscale of SF-36; Social Support: MOS-SSS score; Active Coping:
subscale of Brief COPE; Maladaptive coping: subscale of Brief COPE; Emotional support coping: subscale of Brief COPE; Humor coping: sub-
scale of Brief COPE; Religious coping: subscale of Brief COPE; Substance use coping: subscale of Brief COPE;
*p < .05; **p < .001

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492 Journal of Clinical Psychology in Medical Settings (2018) 25:485–496

Table 3  Hierarchical multiple Block Variable 𝛽 b (SE) R2 ΔR2 F

regression coefficients and
model summary Block 1 Physical functioning 0.37** 0.50 (0.12) 0.13** 0.13** 18.27**
Block 2 Physical functioning 0.30* 0.41 (0.12) 0.20** 0.06* 14.13**
Perceived social support 0.26* 0.25 (0.08)
Block 3 Physical functioning 0.21* 0.29 (0.11) 0.37** 0.18** 22.63**
Perceived social support 0.20* 0.19 (0.07)
Active coping 0.43** 1.68 (0.30)
Block 4 Physical functioning 0.18* 0.24 (0.10) 0.51** 0.14** 29.83**
Perceived social support 0.19* 0.18 (0.07)
Active coping 0.39** 1.52 (0.26)
Maladaptive coping − 0.38** − 1.25 (0.22)

Dependent variable is resilience, N = 120, *p < .05, **p < .001

Active Coping The bias-corrected bootstrap confidence interval for the

indirect effect of physical functioning on resilience through
b1 = 1.67**
a1 = .08* perceived social support and controlling for active coping
c’ = .29* (a2b2 = 0.07) based on 1,000 bootstrap samples was entirely
Physical Functioning Resilience above zero (CI 0.02, 0.17). There was no significant differ-
ence in the indirect effects of physical functioning on resil-
a2 = .38* b2 = .19* ience through active coping versus perceived social support
Perceived Social
(CI − 0.06, 0.21).
Support

Fig. 2  Parallel multiple mediation diagram of the effect of physical Discussion

functioning on resilience through active coping and perceived social
support
coping (a1 = 0.08) and higher perceived levels of social sup-
port (a2 = 0.38). Patients who reported higher levels of active
coping also had higher levels of resilience (b1 = 1.68), and
patients who perceived higher levels of social support also
reported higher resilience (b2 = 0.19). The bias-corrected
bootstrap confidence interval for the indirect effect of phys-
ical functioning on resilience through active coping and
controlling for perceived social support (a1b1 = 0.14) based
on 1000 bootstrap samples was above zero (CI 0.04, 0.27).
This is the first study, to our knowledge, to examine the
relationship between physical functioning, coping, per-
ceived social support, and psychological resilience in ESLD
patients awaiting liver transplantation. Studies that focus on
factors that may enhance resilience for patients awaiting
transplant are important as they may provide clues into the
underlying mechanisms that help patients remain resilient in
the face of significant and life-threatening physical illness.
The results of this study indicate that physical function-
ing, perceived social support, active coping, and maladap-
tive coping explained over half of the variance in resilience
in this sample. More specifically, physical functioning,

Table 4  Regression coefficients, standard errors, and model summary information for the Parallel Multiple Mediator Model Depicted in Fig. 2

Independent variable Outcome variable

Active coping Perceived social support Resilience
b SE p b SE p b SE p

Physical functioning a1 0.08 0.03 0.01 a2 0.38 0.13 0.003 c’ 0.29 0.11 0.007
Active coping – – – – – – b1 1.67 0.30 < 0.001
Perceived social support – – – – – – b2 0.19 0.07 0.01
Constant iM1 16.22 1.28 < 0.001 iM2 63.17 5.10 < 0.001 iγ 0.10 7.46 0.99
R2 = 0.06 R2 = 0.07 R2 = 0.37
F (1,118) = 6.81, p = .01 F (1,118) = 9.00, p = .003 F (1,116) = 22.63, p < .001

13
Journal of Clinical Psychology in Medical Settings (2018) 25:485–496
perceived social support, and active coping had positive
associations with resilience, meaning that higher levels of
these variables were related to higher levels of resilience.
Likewise, maladaptive coping had a negative association
with resilience, meaning that lower levels of maladaptive
coping were related to higher levels of resilience. Mediation
analyses were used to examine the hypothesis that social
support and active coping partially mediate the association
between physical functioning and resilience. The results
indicated that the indirect coefficients of active coping and
perceived social support were significant, meaning that the
positive relationship between physical functioning and resil-
ience was explained, in part, by higher levels of active cop-
ing and perceived social support.
This study found that physical functioning, active cop-
ing, and perceived social support had significant, positive
associations with resilience, while maladaptive coping was
negatively associated with resilience. This finding is consist-
ent with previous research that better physical functioning,
as well as the active ways patients and families approach
medical issues, can impact a person’s ability to adapt and
thrive despite medical illness (Eftekar & Pun, 2016; Lasker,
Sogolow, Short, & Sass, 2011; Telles-Correia et al., 2009a,
c). It is also consistent with previous research that demon-
strates maladaptive coping is related to poor outcomes, such
as post-transplant non-adherence (Stilley et al., 2010).
Our results indicate that not all types of coping were
associated with resilience, including humor coping, reli-
gious coping, and substance abuse coping after controlling
for physical functioning, perceived social support, active
coping, and maladaptive coping. It is possible that humor
coping and religious coping were not associated with resil-
ience because they can have varied impact depending on the
context and how flexibly they are utilized (Amoyal et al.,
2011; Lawrence & Fauerbach, 2003). For example, coping
using humor may be effective to improve mood, while at
other times it could interfere with learning new information
or making positive lifestyle changes. Furthermore, substance
abuse coping may be difficult to measure in this population
when sobriety is a mandated requirement for active trans-
plant wait-listing and therefore a socially desirable response
style may influence self-report data.
In this study, physical functioning was a significant pre-
dictor of active coping and perceived social support, and
both active coping and perceived social support were signifi-
cant predictors of resilience among patients. These results
support a partial mediation hypothesis, that active coping
and perceived social support partially mediate the relation-
ship between physical functioning and resilience. The posi-
tive relationship between physical functioning and resilience
was in part explained by higher levels of active coping and
perceived social support. While we cannot infer causality,
this suggests that for many patients who may not be able
493
to control their level of physical functioning and may have
limited ability to improve their social support, increasing
active coping skills may be an effective way of improving
their resilience. This is consistent with previous research
indicating that patients with severe medical illness may show
resilience and positive adaptation to their illness (Cuhadar
et al., 2016; Matzka et al., 2016; Tian et al., 2016).
Limitations and Future Directions
Limitations of the current study include recruitment of an
ESLD patient sample from a single transplant center, reli-
ance on self-report data, the lack of a social desirability
assessment, and the use of cross-sectional data. There was
a 56% response rate to the study which limits the generaliz-
ability of the findings to the general population. It is possible
that participants that responded to this study had signifi-
cant differences on key variables such as resilience, active
coping, and physical functioning. Reliance on self-report
data limits the interpretation of this study as a patient’s fam-
ily and medical team may have a different perspective on
their functioning, social support, coping, and resilience.
Although the self-report measures used are well-known and
psychometrically sound, a qualitative study would provide
additional detail regarding the relationships between these
constructs and the processes which patients view as impor-
tant to resilience. Furthermore, due to the cross-sectional
research design, causal interpretations cannot be made. A
longitudinal research design in the future would be better
able to clarify causal relationships between physical health
and psychological resilience. Future research should include
the investigation of patients’ coping strategies at various
time points throughout the transplant process. In addition,
research surrounding intervention development should
investigate the efficacy of teaching active coping strategies
and methods of strengthening social support to enhance
pre-transplant functioning and potentially post-transplant
outcomes.
Clinical Implications
Despite physical limitations, previous researchers have
found that psychosocial interventions during hospitaliza-
tion (Georgiou et al., 2003), in the transplant center (Craig,
Miner, Remtulla, Miller & Zanussi, 2017), and by phone
(Bailey et al., 2017) are all acceptable modalities to use with
patients awaiting liver transplant. Patients awaiting trans-
plant often have frequent medical visits; therefore, psycho-
social interventions integrated into their standard care are
likely to be most efficient and less cumbersome.
Previous research has focused on psychosocial inter-
ventions for patients awaiting liver transplant targeting
increasing social support and preventing alcohol relapse
13
494
after transplant (Georgiou et al., 2003; Khan et al., 2016).
A meta-analysis of interventions to reduce alcohol recidi-
vism in post-transplant liver patients found that an integrated
approach including motivational enhancement therapy, cog-
nitive behavioral therapy, and comprehensive medical care
increased abstinence from alcohol (Khan et al., 2016). There
is still limited research to show a significant impact of inter-
ventions for improving social support (Georgiou et al., 2003)
or positive coping (Bailey et al., 2017).
The findings of this study suggest that a number of fac-
tors impact patient resilience, including the direct impact
of the disease on physical functioning, the extent to which
the patient perceives support from family and friends, and
the patient’s ability to engage in active coping behaviors
and avoid the use of maladaptive coping skills that could
possibly have a negative impact their health. Further devel-
opment and research related to psychosocial interventions
that not only treat symptoms but also promote resilience
could further support patient recovery and well-being pre-
and post-transplant. Transplant centers are therefore encour-
aged to develop and evaluate patient-centered programs to
promote the use of active coping skills and to reinforce
the importance of strong social networks to help ESLD
patients remain psychologically resilient while awaiting liver
transplantation.
Compliance with Ethical Standards
Conflict of interest The authors Amelia Swanson, Jessica Geller, Kelly
DeMartini, Anne Fernandez, and Dwain Fehon declare that they have
no conflict of interest.
Ethical Approval All procedures performed in studies involving human
participants were in accordance with the ethical standards of the insti-
tutional and/or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.
Statement of Human and Animal Rights and Informed Con‑
sent Informed consent was obtained from all individual participants
included in the study.
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