The Process Of Adaptation To Effects Of Severe Injury And Illness
James A. Arnett and Denise S. Rabold

We are please to present the first installment in a series of articles written by James A. Arnett, Ph.D. and Denise S. Rabold, Ph.D. Drs. Arnett and Rabold are faculty members in the Division of Rehabilitation Psychology, Department of Physical Medicine and Rehabilitation at The Ohio State University. Rehabilitation Psychology is a specialty of psychology that serves individuals with disabilities as they adjust, adapt, and progress toward healthy and satisfying lifestyles. Psychologists working in rehabilitation use education, remediation, counseling, and advocacy to minimize effects of impairments due to disabling medical conditions and promote wellness through optimal psychological and social functioning. Dr. Arnett has a broad base of experience with a range of disabling conditions, and specializes in evaluation of mental performance and adjustment issues associated with impaired brain function. Dr. Rabold is licensed as both a psychologist and speech-language pathologist. She specializes in counseling and cognitive remediation for work, school, and community re-entry after acquired brain injury.

Introduction

We are very pleased to have this opportunity to present our ideas about ]the process of adaptation to the effects of injury and illness. After some preliminary discussion, we realized this project involved many important issues, and adequate treatment would probably require more than one article. The process of adjusting to, and living with, a disabling illness is complex, and to treat it fairly will require giving attention to many issues and concerns. Because every person is unique, it is impossible to discuss the adaptation process without attending to the problem of individual differences. Analysis becomes even more complicated when we consider that each unique individual also lives in a unique environment, and has -- within a range -- unique effects of a disease. In considering these problems, we elected to begin our presentation with a general discussion of human behavior, as applied to illness, impairment, and adjustment. We will then present ideas about the adaptation process, and move to more specific factors and problems related to impairments and adaptation. We plan to deal with specific topics including community and work re-entry, relationships, sexuality, and issues of psychological distress. Finally, although we intend to address specific problems related to Transverse Myelitis, we recognize that many of the ideas presented here probably have utility for a broader range of disabling injury and illness. We welcome your questions, suggestions, and comments, as we prepare future articles.

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. Before attempting a study of the process of adaptation, we must take a more general look at human behavior.

Questions about human behavior and human nature, or about what makes us do the things we do, have occupied the minds of great thinkers throughout history. The fact that so much has been written on this subject, and there are so many different theories, should lead us to believe there are no simple answers. There is 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. Most theories of behavior and personality are either incomplete or they do not offer adequate explanation for all of the great variety of human behavior we see around us. 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 affect of environmental factors on behavior and adjustment. Obviously, the family is an environmental factor that plays a major role in adjustment. Imagine the affects 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 affects on behavior caused by a sympathetic and an unsympathetic employer. Consider also the possible affects 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. Although there is no one sure way to go about it, the process of adaptation to disability does involve certain standard tasks, a review of which will make up our next article.

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