The Process Of Adaptation To Effects Of Severe Injury And Illness

The process of adaptation to severe injury and illness is complex and highly individualized. Any attempt to understand this process must start with an examination of the basics of human behavior. Questions about how humans adapt to severe injury and illness are really part of a larger question about what causes human behavior, and it is these questions which have occupied the minds of great thinkers throughout history. Despite so much being written on this subject, there are no simple answers. There are a variety of explanations for behavioral and psychological problems; however, in studying the process of adaptation to disabling illness, most theories fall short, because they do not account for all factors affecting behavior. Probably the biggest problem most theories of human behavior have is that they are limited only to the psyche or psychological makeup of the individual. While this is important, the internal psychological makeup of an individual is only one part or one factor that goes into the determination of behavior.

A better approach to understanding human behavior is described by Trieschmann, who suggests that human behavior is the result of three interacting factors. These factors are best described as an organic factor, a person and personality factor, and an environmental factor. Trieschmann describes behavior as including health and rehabilitation adjustment; and she deals mostly with adjustment and adaptation in rehabilitation. The behavior that we see in others, and the way we ourselves behave can be viewed as a result of an interaction of these three factors. Put another way, we do what we do because of: 1) what we are physically capable of doing, 2) our personality and our unique way of looking at the world, and 3) the environment in which we find ourselves.

For the purpose of this article, we will define personality as a unique complex set of attitudes, expectations, beliefs, coping strategies, decision rules, and behavioral style. This may sound complicated, but these are really some of the personal qualities that make each of us unique individuals. We expect these personal and personality qualities to be relatively stable over time, including before and after onset of a major illness.

In studying the reaction to severe injury and illness, it is useful to consider Treishmann’s view of human behavior. We know, for example, that individuals react in different ways to severe injury or an illness such as Transverse Myelitis (TM). We know that individuals are unique before the onset of the illness, so it should not be surprising that reactions to illness and the process of adaptation are also unique. We know that each individual finds their own way to adapt to the changes brought on by illness and injury. Any attempt to describe a detailed, step-by-step process of adaptation fails because it does not allow for unique qualities of the disease, individual personal differences, and unique environmental factors. It is impossible to study the process of adaptation without dealing with the differences in degree of injury, unique personal factors, and the variety of environments (life situations) among persons who are struggling with adaptation.

We will now take a closer look at the three factors of behavior, as they might apply to adaptation to TM or illness involving significant limitations of function.

First consider the organic, or physiological, factor. This factor includes all that an individual is capable of doing based on organic function. Organic function would be determined by level of spinal cord lesion, with resulting impairment of muscle function. It includes muscle strength. It includes the basic senses plus coordination, sense of balance, and tactile sense. The organic factor includes how the body reacts to stress. It includes how much sleep one needs in order to feel good. Note that medication affects body chemistry, and in a sense, changes what the physical body is capable of doing. Within the physical body — without regard to personality issues – – the effects of illness and injury vary greatly. TM has a great variety of effects depending on size and location of damage. TM can affect different amounts of both gray and white matter of the spinal cord in one or more adjacent thoracic segments. The degree and severity of the injury determines functional capability of the body, and this physical capability affects the process of adaptation. The question, “what will I do?” is usually followed closely by “what can I do?”

Next, consider the personality factor. This factor includes all the things that make us unique as individuals. We may be shy or outgoing, quick or slow to make decisions, even and steady or up and down. We may be liberal or conservative, or we may be someone who doesn’t want to be considered as either. When making a decision, we may look for all the facts, make lists, and try to think logically, or we may prefer to use our intuition or feelings. We may take risks or we may prefer not to. We may attack a problem directly or we may prefer to avoid a direct attack. We differ from one another in a great many ways. Of course, we differ in how we react to change and loss. What is the individual’s reaction to a serious syndrome like TM? How one reacts to such a problem depends on many personal qualities. Consider the reactions to loss of physical ability by two different people, one who greatly enjoys physical activities and the outdoors, and one who does not. Limited mobility could easily represent a greater problem for one person than for another. Note also that education and work experience often play a part in adaptation to illness, again because of the different physical demands of various jobs. How one adapts to uncertainty, uncertain prognosis, and course of disease is especially important with TM because so much about the syndrome is unclear.

Finally, let us examine the effect of environmental factors on behavior and adjustment. Obviously, the family is an environmental factor that plays a major role in adjustment. Imagine the effects on behavior of a family that is caring, reassuring, and supportive and a family that is withdrawn and tentative in their support. Likewise, imagine the effects on behavior caused by a sympathetic and an unsympathetic employer. Consider also the possible effects on an individual of health care agencies, hospital environments, hospital staff, and work environments. Consider the differences between physically accessible buildings and those that are not, or only minimally accessible. The reactions of friends, spouses, family members, health care workers, and coworkers are all part of the environmental effect.

In summary, there are many ways of adapting to the effects of a severe injury or illness. It is impossible to describe a standard process of adaptation because humans do not all act the same in response to a specific injury or illness. Human behavior is complex, and any attempt to describe the process of adaptation must account for the great variety of behavior and experience. Human behavior is best described as a complex interaction of physiology (what the physical body can do), environment (the physical environment and the support of others), and person and personality (the kind of person I am, including the ways I solve problems and manage my needs). Each individual will find their own way of adapting to the effects of illness.

What one must remember above all is that change is part of life: it is inevitable and unavoidable. We cannot avoid the changes related to aging, work, illness, birth and death, nor can we avoid changes brought on by advances in science and technology. We cannot stop the river of change. As functional, effective, and imaginative human beings, we must be able to deal with change. We might expect that, because we live with continuous change, we are equipped to deal with it – or at least a certain amount of it. We may even be expecting and planning for certain changes, such as a wedding, a graduation, a new job, a new baby, or retirement.

Although change is expected, it still causes stress. We feel anxiety about change whether or not the change is for the better or not. Anxiety goes with a need to react to and manage change; we must rely on our coping and problem solving strategies, and our defenses, until we have restored a sense of stability and understanding. Is there a limit to how much change a person can deal with? More appropriately, is there a limit to the amount of change a person can deal with at a given time? There probably is such a limit; and this limit is probably different for each individual.

What happens when an individual is confronted with an overwhelming change? If the process of adapting is unique, then we must look beyond the individual to make observations about how a person deals with a health crisis. Following a health crisis – a serious disabling illness or injury — there is probably a period of confusion and distress. There may be many different emotions experienced during this time. This time might be described as a period of disorganized thinking. The individual will be trying to understand what has happened, why it has happened, and what it means. Why did this happen to me? Did I do something that caused this to happen? Is someone responsible? If I cannot play tennis, can I still play golf? I don’t know what it is, but I believe this happened for a reason. Will I get better? Will I get worse? Will I be able to make love? Will anyone love me? Will I be able to work again? Will I be able to drive?

All of these and many similar questions are common during the early stage of dealing with effects of severe injury or illness. An individual may spend a lot of time thinking about the disease process, and trying to learn more about the disease. There may be problems of pain, which further limit concentration and the ability to think in organized and constructive ways. During this early period of adjustment, there is often considerable emotional distress and turmoil. This distress may be evident to others as anger, depression, anxiety, or guilt. The period of confusion varies in length according to characteristics of the individual, characteristics of the illness and physical abilities, and features of their support system, family, and home environment.

With time, adequate care and support, the individual will move from the period of confused thinking to a period of organized thinking. Movement from confused thinking to organized thinking means that after a period of confusion and distress, the individual begins to think in constructive and productive ways about their situation and problems. This is a time when old methods of problem solving and familiar ways of dealing with the world are expected to return. With this time of organized thinking come thoughts about the problems one faces and the beginning of planning for the future. What can be said about the period of organized thinking? This is the time when a person, who is dealing with a crisis of change, begins to look more objectively at his or her situation, and begins to make attempts at problem solving and planning. A useful model of adjustment and adaptation has been developed by Rudolf Moos and Jeanne Schaefer. Drs. Moos and Schaefer suggest that regardless of individual and environmental differences, persons faced with a health crisis all have the same problems to solve. Called adaptive tasks, these are problems that all individuals must deal with after serious, disabling illness or injury. Moos and Schaefer suggest there are seven common adaptive tasks that must be addressed in adjusting to the effects of serious illness. The seven adaptive tasks appear as follows:

Illness Related Tasks:

1. Dealing with pain, incapacitation, and other symptoms.
2. Dealing with the hospital environment and special treatment procedures.
3. Developing and maintaining adequate relationships with health care staff.

General Tasks:

4. Preserving a reasonable emotional balance.
5. Preserving a satisfactory self-image and maintaining a sense of competence and mastery.
6. Sustaining relationships with family and friends.
7. Planning for an uncertain future.

The first three adaptive tasks relate specifically to illness, hospitalization, and dealing with health care providers. The last four tasks are called general tasks because they apply not just to illness and injury related problems, but to any sort of crisis (loss of home, loss of a job, or natural disaster, such as a flood or tornado). In studying the adaptation model presented by Moos and Shaefer, it occurs to us that tasks 1, 2, and 3 (Illness related) might tend to be the focus of effort earlier in the adaptation process, while addressing the four general tasks would tend to come later. Of course, there are probably many exceptions to this. It would appear, however, that demands for dealing with pain, the hospital, medical procedures, and health care staff would occur early in an illness process. It would also appear that demands for dealing with these issues would occur at a time when the injured or ill person is most vulnerable, and most in need of assistance and support from family and health care workers. With the passage of time, the person will become more effective at using abilities and resources. The need for assistance and support is expected to decrease with time as functional skills are restored.

We have found this to be a useful model in guiding a person as they begin to deal with their problems following injury or illness. Long-term adaptation to a functional impairment or disability would involve maintaining emotional stability, maintaining a positive self-image and sense of competency, maintaining relationships, and planning for the future. Adjustment can be described as the process of dealing with these adaptive tasks. It should be noted that the adaptive tasks can be dealt with effectively, or they can be avoided or dealt with in destructive or negative ways. Probably the best example of destructive coping is the use of alcohol and drugs to ease depression and anxiety following a disruptive crisis. There is evidence that an injury that limits mobility and independence increases the risk of depression; and increased depression contributes to greater risk of abuse of alcohol and other drugs.

As a simple example, more effective coping might involve finding a way to increase mobility, which in turn would lower the risk of depression. Moving the focus of attention from the individual and placing it on the problems at hand leads to the interesting implication that all persons dealing with a crisis face common problems. Moos and Shaefer are suggesting that both the person with a disabling illness and the person who has lost a home through fire or natural disaster have much in common. Both must maintain an emotional balance. Both must maintain a positive self-image – one of self-worth, competence, and dignity. Both must attend to their relationships with family and friends. Both must make plans.

Reference: Moos, R.H. (Ed.). (1989). Coping With Physical Illness. (2nd ed.). New York: Plenum Medical Book Co. The following information is offered as a general response to questions related to Transverse Myelitis and is not to be construed as a specific medical recommendation for any individual. This information is based on the information provided in a brief question and is without the benefit of a complete history or an examination.

Reference: Trieschmann, R.B. (1988) Spinal Cord Injuries, Psychological, Social, and Vocational Rehabilitation, 2nd ed. New York: Demos Publications.