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

"It is not possible to step twice into the same river." Heraclitus. 540-480 B.C.

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 good or not. Anxiety goes with a need to react to and manage change. With a change, whether for better or worse; 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. The ability to deal with change is probably determined by several factors including age, education, experience, and family (environmental) support as noted in Part 1 of this article (The Transverse Myelitis Association Newsletter, Volume 2, Issue 1).

What happens when an individual is confronted with an overwhelming change? First we should note, as we did in Part 1, that each individual finds his or her own way to adapt to new situations and problems. 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. (Note, in Part 1, we described behavior as resulting from three complex factors: Physiology, Personality, and 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. Much has been written about each of these issues; and because of limitations of space and time, we will not attempt to address the full list. Instead, we will focus on the General Tasks; because, as noted, these appear to describe best the long-term issues of living with disability. According to the Moos/Shaefer model, the 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.

In the next installment of this article we will consider the adaptive task of planning for an uncertain future. We will address the issues surrounding planning for and returning to work.

Reference:

Moos, R.H. (Ed.). (1989). Coping With Physical Illness. (2^nd ed.). New York: Plenum Medical Book Co.