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Chronic illness, stress and coping
Sm. Sci. Med. Vol. 18, No. 9, pp. 7X-736, F’rinted in Great Britain
CHRONIC
1984
0277-9536/84
S3.00 + 0.00
Pergamon Press Ltd
ILLNESS,
STRESS
AND COPING*
ZEEV BEN-SIRA The Hebrew University of Jerusalem, School of Social Work, Jerusalem 91905 and The Israel Institute of Applied Social Research, Jerusalem, Israel
Abstract-The study investigated the factors that may alleviate the emotional distress of chronically ill persons, enhance their coping capacity and prevent further acceleration of the deterioration in their condition. Based on recent approaches to breakdown and stress, the seriousness of a chronically ill person’s situation was hypothesized as resulting from the inadequacy of the individual’s and his primary group’s coping resources and inexpediency of the professional emotional support. A study carried out among a representative sample of Jewish Israeli adults gave support to the hypothesized insufficiency of
individual resources. Data highlighted the significance of the physician’s emotional support as the most sought for yet least attainable resource in alleviating distress. The study lends further support to previous evidence of the importance of the physician’s affective behavior in the patient’s wellbeing. It also ascertained the role that primary groups’ emotional support may have in the readjustment of the
chronically ill.
INTRODUCTION
This study focuses on the stress arousing factors that are inherent in chronic illness, and on the efficacy of individual resources, of primary social support and of professional assistance, in alleviating the emotional distress of a chronically ill person, thus reducing the risk of further acceleration in the deterioration of the patient’s physical and emotional condition. ANALYTICAL
CONSIDERATIONS
Stress, coping and disease
Recent approaches in the stress-illness relationship serve as a useful point of departure for the analysis of the health-deteriorating effect of the stress potential inherent in the nature of chronic illness. According to these approaches [l-7], illness constitutes an expression of ‘breakdown’ [3,4,7] due to a prolonged failure of restoring a person’s emotional homeostasis which has been disturbed due to inadequate coping with demands of life-demands to which an individual is constantly exposed and which require response (i.e. coping). In fact, exposure to and coping with demands comprise the essence of human life. Yet there are “demands that tax or exceed the resources of the system or to which there are no readily available or automatic adaptive responses” [8, p. *A different, less elaborate and shorter version of this study was presented by the author at the 11th International Congress on Suicide Prevention and Crisis Intervention, Paris, July 1981. My gratitude is extended to Professor Aaron Antonovsky of the Ben-Gurion University for his important comments to the initial version, and to Mrs Haya Gratch for her valuable and indispensable assistance in editing this paper. tThis approach is considered much more advanced and relevant than the earlier specific theories which flourished in the early 1950s (e.g. [l 11) according to which specific stresses produce specific diseases. These theories which did not gain empirical support are now considered outdated. 125
1091. Such demands cause ‘tension’, namely, disturb the individual’s emotional homeostasis. Demands to which there are no readily available or automatic responses and consequently disturb one’s emotional homeostasis are commonly defined as ‘stressors’ [S, p. 1091. At this stage it should be pointed out that demands as such may be physical (e.g. pain), social (e.g. behavior required by social environment) or psychological (e.g. satisfaction of psychological needs such as achievement). The impact of the demands on a person’s emotional homeostasis is predominantly at the perceptual level, namely, to a great extent it is not the demand per se, but rather the individual’s assessment of it that make a demand a stressor. The same experience may be highly threatening to one person yet harmless to another [9]. Undoubtedly, there may occur events which by far exceed the bounds of a normal course of life--events which impose upon an individual demands which are perceived insurmountable. Following the earlier delineated approach to stress and illness [3-71, such demands have the power of disturbing the individual’s emotional homeostasis (i.e. constitute stressors)--a disturbance which if not adequately resolved carries the danger of ‘breakdown’, disease being one of its expressions 13941. Inferentially, then, the greater the amount and the perceived severity of the demands which impinge upon an individual, the greater the severity of the disturbance and consequent increase in the danger of breakdown and illness. Thus, constant confrontation with perceptually insurmountable demands (i.e. stressors) will lead, according to this approach [3,4] to an accumulation of unresolved tensions, resulting in an increase in the severity of the disturbance of the emotional homeostasis (e.g. [lo]), thus increasing, and possibly accelerating, the danger of breakdown and consequent illness. It should be pointed out that according to this approach [3,4] any illness, acute or chronic, is conceived as an expression of breakdownt. However, the present state of art is still far from facilitating the assessment of the weight of
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stress compared to biological, physiological and other factors, as well as the mechanisms of interaction between the latter and emotional factors in the outbreak, severity and prognosis of an illness. Nevertheless however, clinical evidence points to the fact that emotional stress plays an important etiological role in any disease, including the development and severity of chronic conditions (e.g. [5-7, 12-141). Chronic illness: outcome and cause of breakdown
It follows then from the preceding analysis, and in particular Antonovsky’s recent advances [3,4] that chronic illness has to be conceived as an expression of ‘breakdown’ following a prolonged failure to restore one’s emotional homeostasis which has been disturbed due to inadequate coping with demands. In other words, in terms of these approaches, chronically ill persons failed both in coping with a variety of demands of life and in restoring the consequently disturbed emotional homeostasis. At this stage the irrevocable, impairing and suspected to be. progressively damaging characteristics of chronic illness-and particularly the uncertainty of its prognosis, namely, the constantly accompanying though not necessarily salient threat of the unpredictable occurrence of further damaging episodes should be pointed out. These characteristics impose new demands upon the chronically ill persondemands which, if not successfully coped with, will become stressors, with further homeostasis-disruptive effect. Following now the logic of the stress-illness relationship, further disruption of the person’s emotional homeostasis-which essentially is a consequence of an accumulation of unresolved tensions--carries the danger of further deterioration of that person’s health. Thus, coping with demands, and in particular minimizing the potential of demands imposed by the chronic condition of becoming stressors, is essential for reducing the risk or at least arresting the acceleration of further deterioration of a chronically ill person’s health condition. Resources and coping
What, then, are the factors that enhance successful coping? Relating to this issue undoubtedly directs the focus on the issue of resources as the fulcrum of homeostasis maintenance (e.g. [3, pp. 98-122, 4-7, 10, 15, 16-271). In the literature we may find classification of resources according to their ‘source’, namely, who controls the resources: the individual himself (e.g. education, SES), or his/her primary social network (e.g. social support) or secondary social environment (e.g. professional help) who place resources at the individual’s disposal. Empirical evidence clearly shows that in a variety of situations, self-controlled resources are frequently more effective than other-controlled resources. In particular the self-controlled resources seem to be by far more effective in coping with demands and restoring homeostasis than those from the environment [6, 10, 15-I 8,2 1,281. The predominant efficacy of the self-controlled over other-controlled resources conforms with the logic of the theories of stress and breakdown: whatever the demands, ultimately it is the individual himself who is constantly confronted by them, interprets them, assigns them a subjective 1
meaning, and constantly has to respond to them. Inferentially, then, the greater an individual’s control of resources, the greater will be the range of demands with which he will have the capacity to cope successfully. Conversely, the less the control of own resources, the greater the chances for either being unable to meet these demands, a state which may result in the demands becoming stressors or having to mobilize resources from the environment. However. dependence on the environment for meeting the demands has at least two disadvantages which make them less efficacious than self-controlled resources. On the one hand environmental support, whatever their proximity, is not omnipresent, hence chances are that one may be confronted with demands in the absence of the appropriate ‘environmental resources’. and thus be unable to meet them at the time of their occurrence-the inability having the earlier-described deleterious consequences. On the other hand, following the logic of classical exchange theory [29], getting help, hence ‘buying’ resources from the social environment incurs a ‘cost’ on the ‘buyer’, such as admission of his inferiority, or giving certain services in return for the help given. The ‘cost’ of this help (i.e. resources supplied by the environment) by definition imposes new demands on the recipient. Thus, this ‘help’, though assisting the recipient to overcome the initial demand, because of its ‘cost’ reduces, in terms of exchange theory [29], the net profit of the success. There will be, however, throughout one’s life, demands coping with which will require resources over and above those at one’s disposal, hence inevitably requiring other-controlled resources. In this respect, primary group support, if efficacious, has an advantage over that of the secondary social environment, in particular over professional support, by being to a great extent based on a reciprocal affective relationship: The mere membership of a person in a primary group, by definition implies a person’s value for that group, and the help given to him is in exchange for the rewarding value of his mere membership in that group. Indeed, the literature highlights the significant stress-buffering role of social support by a person’s primary social network such as family and friends 15, 21-25, 281. Yet with respect to secondary environmental help, data allude to a possible deleterious effect that dependence on this type of help, and in particular professional assistance, may have on a person’s emotional homeostasis [20, 21, 28). That has been explained as resulting from a sense of inferiority and powerlessness vis-ci-vis a ‘powerful professional’-a sense that is inherent in the dependence on the indispensable assistance, on the one hand (e.g. [30. p. 22, 31, pp. 72-80]), and the professional’s striving to maintain and enhance his power, on the other [32, pp. 52-53, 331. It should be pointed out that this line of argument does by no means imply that an individual who is in need of professional help has the alternative of choosing between the professional help and his primary group support. Rather, it means that the recognition of the indispensability of the professional help highlights his dependence on that help for responding to a vital demand, thus implying inferiority.
Chronic illness, stress and coping Chronic illness and the relative eficacy resources
of coping
Coming back now tb the situation of the chronically ill person, in terms of the precedingly delineated approaches to stress [l+, illness, and consequently chronic illness, is conceived as an expression of breakdown resulting from inefficacy of the afflicted individual’s resources to prevent that illness and/or enhance recovery from it. Thus, if chronic illness is an expression of breakdown, then by definition we may expect that individual’s resources to be particularly ineffective in the alleviation of the imbalance which they were unable to prevent. Indeed, they may even be less effective in restoring homeostasis of a chronically ill person, considering the greater effort required for restoring than for maintaining homeostasis. In addition to the above, the chronically ill person has to cope with new demands which may arise from his permanent incapacitation, which is frequently accompanied by stigma and the constant fear of a possible occurrence of additional episodes with further damaging results, and with the potential of depriving him abruptly or gradually of his control over his entire life. The afflicted individual and his primary lay network may feel entirely helpless and incompetent to interpret the patient’s sensations and to affect his physical condition substantially. Moreover, the chronically ill person and the members of his primary network will generally be explicitly aware of their incompetence of coping also with the patient’s emotional disturbance which may result from his physical and medical problems. It follows, then, that any effort at improving, or at least arresting deterioration of the physical and emotional state, may point to the’ need for additional, more proficient resources, namely, the help of professionals such as physicians, psychologists or clergy (if the latter is compatible with the individual’s beliefs and recognized as being experienced in such conditions). As indicated earlier, the indispensability of professional assistance highlights the patient’s inadequacy in coping, and hence his dependence on the professional for the satisfaction 0f.a vital need. As indicated above, dependence suggests inferiority and powerlessness, which have been found to be deleterious to wellbeing, and consequently contradictory to the restoration of emotional homeostasis [ 19,20, 34, p. 301, 351, to readjustment to disability [36,37] and even predictive of psychiatric disorders [38,39]. The eficacy
of professional assistance
To what extent can professional
assistance, and in particular that of the medical profession be regarded as efficacious in restoring a chronically ill person’s emotional homeostasis? In the light of the irreversibility of that person’s somatic disturbance, emo-
*The importance of the doctor’s emotional support in reducing stress even among patients in their terminal stage may be inferred from the study of Friedman et al. [49]. The study carried out among children dying from leukemia and their parents, showed the potential of the doctor’s support in reducing stress among parienzs and their parents at the time of death.
727
tional support will be highly pertinent, frequently even more than bio-medical instrumental help. Yet from the ill person’s viewpoint, the most appropriate source of support is the physician specializing in his type of somatic disturbance. He expects that physician to intervene clinically in order to restore his physical health, or at least to arrest further detioration. Yet, in light of the esotericity of medical activity and the lay incompetence in judging the content and outcome of a physician’s professional activities, medical intervention per se may frequently be inefficacious in alleviating the patient’s anxiety which results from the subjectively perceived seriousness of his condition and its prognosis. It has been shown that patients judge to a great extent the quality of the treatment and the physician’s competence, and gain reassurance from the physician’s affective behavior toward them [U3]. These conclusions seem particularly applicable with respect to chronic illness where the capacity of substantially affecting the condition by medical clinical procedures is minimal, thus stressing even more the necessity for affective (i.e. humane) behavior toward the patient*. However, in light of the dominance of the bio-medical model in medical practice, which focuses on physical disturbance rather than on the emotional state of the afflicted individual, (e.g. [44, pp. 1l-121) the practitioner’s inclination to demonstrate such behavior seems rather dubious. Indeed, as Balint argues, doctors can be profoundly hindered, by some askcts of their professional training, in understanding and paying attention to the therapeutic significance of coping with a patient’s emotional problems [45]. Moreover, the dominance of the bio-medical model in medical practice causes the physician to view the patient’s anxiety as an outcome of the disease, which will ‘naturally’ be alleviated upon recovery from the illness, hence a priori rejecting the therapeutic importance of affective behavior [46, p. 251. Consequently, then, the limited ability of a physician to provide an effective medical solution to a chronically ill person’s somatic needs, on the one hand, and failure to assign the necessary importance to the affective component of his behavior, on the other hand, makes his capacity to alleviate a chronically ill person’s emotional disturbance rather dubious. Indeed, as Brown [47, p. 4171 maintains, emotional support is not seen by doctors as professionally challenging. Moreover, the physician’s recognition of his inability to help the patient medically (i.e. curing him) with the help of his technical abilities and knowledge, hence unable to respond to the patient’s plea for help, may constitute a sense of failure to live up to his role [47, pp. 1961971. That in turn may lead to defensive behavior by avoiding as much as possible confronting the patient-a behavior which is frequently justified by the necessity to allocate the scarce resources (the doctor’s time) mainly to those who are likely to benefit the most from the doctor’s intervention [48]. However, the patient may interpret the physician’s inability to meet his most basic needs, and in particular the physician’s avoidance of him, as indifference, and consequently may feel deserted by the most appropriate and most sought for agent for support.
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Double vulnerability of the chronically ill and ineficacy of resources: anomie
In summary, then, a chronically ill person appears to be highly vulnerable to further deterioration of his condition, not merely because of possible inherent progressive damage caused by the illness itself, but even more so because of the concomitant inability to alleviate emotional disturbance owing to the recognized inefficacy of the person’s individual and primary group resources and the perceived indifference of and desertion by the allegedly most competent support agent, namely, the physician. The sense of helplessness (due to his own and his primary group’s inability to cope with the demands) and powerlessness (dependence on the physician), on the one hand, and a sense of being abandoned by the only competent support agent in a state of despair, on the other hand, concomitant with the accumulation of unresolved emotional distresses, and the unpredictability of the health condition, reflect a state of anomie [SO, pp. 241-276,50, pp. 161-194), and in particular Srole’s conceptualization of it [57, pp. 712-7131. According to these approaches, anomie is conceived as a sensation of powerlessness and inefficacy in achieving one’s goals, of unpredictability of environment, indifference of social contacts and finally surrender to the inevitable, hence highlighting a sense of futility of life. Consequently, anomie, in itself a health hazard [3,4, 161, and in addition to the final recognition of the inefficacy of even the most relied upon resources (medical profession), may by definition result in an aggravation of the breakdown, and, following the logic of the approach of the coping-stress-breakdown relationship [3,4], accelerate the further deterioration of the condition. At this stage it should be pointed out that, following the earlier-discussed state of art, there is no intention of suggesting an exact weight of anomie in affecting deterioration, and neither of claiming that anomie is the only factor that may affect deterioration. On the other hand, following the precedingly delineated coping-stress-breakdown relationship, an anomie*hronic illness relationship should be expected.
particularly primary social networks; (b) illness, and particularly chronic illness, is an expression of a breakdown following a prolonged failure to restore homeostasis due to the inadequacy of these resources; (c) individual and primary social resources will be only of a limited efficacy in restoring homeostasis; unrestored homeostasis increases the risk of anomie of a chronically ill person; (d) consequently, an interactive relationship between chronic illness and anomie should be expected, each of these factors predicting aggravation of the other; thus (e) chronic patients will draw on professional assistance for the satisfaction of emotional and physical needs; but (f) professional assistance will be of limited value in restoring emotional homeostasis and reducing anomie. Hypotheses
In operational terms, verification of these arguments will require an empirical structure of interrelationship among the variables-a structure where homeostasis on the one hand, and breakdown and chronic illness on the other, have to be conceived as a product of the interrelationship among the various resource variables. In this respect, empirical verification of the following hypothesized relationships seems essential for the support of the suggested analytical framework: (a) Emotional homeostasis is positively correlated with the control of individual and primary social resources. (b) Emotional homeostasis is negatively correlated with chronic illness. (c) Chronic illness is negatively correlated with individual and primary social resources. (d) Chronic illness is positively correlated with anomie, and anomie is negatively correlated with emotional homeostasis. (e) Chronic illness is positively correlated with the employment of professional resources (professional assistance). (f) Professional assistance is negatively correlated with emotional homeostasis.
Summary
The preceding analysis may be summarized as follows: (a) emotional homeostasis will be maintained with the help of one’s individual and social resources,
*The sample was drawn systematically from the Israeli voting register, which is the relatively most reliable updated listing of the Israeli population. The sample is representative of the heterogeneous character of the Israeli, Jewish, urban adult (age 20+) population: 41% were Israeli born (16% of North-African or Asian origin, 18% of European or American origin and 7% at least second generation Israelis), and 59% were born abroad (19% in North African or Asian countries, 40% in Europe or America). 45% of the latter immigrated after the establishment of the State of Israel (in 1948). 26% in the years 1948-1954 and only 7% after 1968. A quarter (25%) had no, some or complete elementary schooling, 18% some high school, 27% completed high school, 31% studied I3 years or more (12% completed university); 47% were male, 53% female.
METHOD Sample and jieldwork
A representative systematic random sample* of the adult Israeli Jewish urban population (N = 523) that was drawn systematically from the Israeli voting register was investigated by means of a closed questionnaire presented to the respondents by interviewers in the respondents’ homes during November 1980. Measures (a) Chronic illness. Similar to other studies on the behavioral aspects of disease (e.g. [l&53]), the respondents’ report of physician-diagnosed, chronic episodes was applied as a measure of chronic illness. We confined the report only to chronic episodes that were diagnosed by a physician (see Appendix I). Based on these reports, each respondent was assigned a score based on the number of reported diagnosed
Chronic illness, stress and Table 1. Chronic illness scores SCOR
1 2 3 4 5 6 7
Number of reported medical diagnoses 8+ 5-l 4 3 2
I
0
Distribution of respondents N % 9 2 6 I 10 2 41 8 51 10 106 20 297 57 520 100
episodes. Table 1 indicates the distribution of respondents according to this chronic illness score. (b) Emotional homeostasis. As in a great number of studies (e.g. [13, 54-56]), we found Langner’s [57] 22 item index (MIH) to be an appropriate indicator of homeostasis (or lack of it-frequently defined as psychological distress). (c) Anomie. Based on the logic of the analysis, Srole’s [52] conceptualization was found as the most appropriate indicator of anomie. The following Srole’s five original items were operationalized: (1) indifference of community leaders; (2) unpredictability of social order; (3) impossibility of realization of life goals; (4) sense of meaninglessness of life; (5) immediate personal relationships no longer predictive or supportive (cannot count even on closest friends). The items were presented to respondents in the form of statements and they were requested to indicate their agreement on a scale of 6 (1 = ‘strongly agree’ . . . 6 = ‘strongly disagree’). In order to allow for scaling, they were dichotomized as follows: categories l-3 were scored 1, 4-6 (disagree) were assigned a score of 0. The responses to the five items formed a Guttman scale with a coefficient of reproducibility (COR) of 0.85, which still may be considered to be a reasonable indication that the items relate to the same content universe. The
*Pearlin and Schooler’s [ 191comprehensive study serves as an illustration of the difficulty of differentiating between resource and outcome measures. They defined ‘Marriage does not give the opportunity to hecome a person I’d like to he’ as an outcome measure, ‘A feeling of control over things’ as a resource, and ‘How would you compare your marriage to that of most people like yourself as a coping response [19, pp. 18-211. We think that each of these items could serve equally as a resource or outcome measure. tAge categories are ordered from young to old. Thus, a negative correlation between age and chronic disease indicates that younger people have lesser chances than
older people of being chronically ill. A positive correlation between homeostasis and age indicates the greater chances of older individuals of suffering from psychological distress. :The formula for p2 is as follows [58, 591. Given n pairs of observations on numerical variables (x. y), (.x,..r,)(i = 1,2,. . , n), then
coping
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order of the items was the following: meaninglessness (‘most serious’wn’t count on people-life goalsleaders’ indifference-unpredictability (‘least serious’). (Interestingly this order reflects greatly the logic of viewing anomie as an indication of accumulation of unresolved emotional disturbances.) The scale was applied as a measure of anomie where the score of 1 represented the highest level of anomie, namely, agreeing with all five statements, 6 the lowest = disagreeing with all five. (d) Resources. Any attempt at operationalizing the concept of resource is confronted by the problem of a conceptual differentiation between initial resource and outcome measures +. Income or education may be both a resource and the outcome of coping with the help of other resources. Frequently an achievement (e.g. occupational status or satisfaction of catharsis needs) or a successful activity (e.g. frequent leisure time) may constitute both a resource in itself or an indirect evidence of the existence of another resource which facilitated that achievement. Thus an item was defined as a measure of resource if it indicates either a potential of enhancing coping or successful coping. Following the logic of the analytical section of this paper, resources may be classified according to the source of the resource (the individual himself, his primary group, or secondary environment) and the modality (type: instrumenta1-e.g. education, income, or afictiue-emotional support, e.g. catharsis). Based on this classification, the following resource items were applied: With respect to resources which the individual has at his/her disposal, afictive resources focused on his/her coping with catharsis needs, family and other primary relationships and leisure activities; the instrumental resources focused on education, employment, income dwelling density and aget. Since this study concerns enhancement of emotional homeostasis, the focus of the other-controlled resources was on the affective modality, particularly on the extent to which the individual’s catharsis needs are met with the help of primary and professional agents. Meeting with others.(visiting friends, visiting physicians) was defined as a resource, ‘unspecified’ from the viewpoint of modality. In total, the schedule contained 30 measure items of resources. For a total listing of resource items see Appendix II. Data analysis
(a) Correlations. Data analysis was intended to identify the predictive power of resource variables with respect to the restoration of homeostasis. Correlation coefficients were conceived as useful measures for identifying the relationships (hence predictive power) among items. A weak monotonicity coefficient 012) where linearity is not assumed, was used$ [58, 591. (b) SSA-smallest space analysis. The multidimensionality of the content universe requires a technique that facilitates simultaneous perception of the relative power of the variables (in particular resource variables) in predicting homeostasis as well as breakdown and chronic illness, and gives an overall picture not merely of the relative predictive power but also, and even more so, their interrelationships, revealing an overall structure of coping
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particularly highlights the efficacy of individual resources in enhancing homeostasis and concomitantly it reflects their ineffectiveness in alleviating the anomit situation of a chronically ill person. It also reflects the professionals’ ineffectiveness in enhancing homeostasis. On the other hand, the intervening position of primary group support should be noted. These general conclusions may be inferred from the location of the variables on the SSA map: On the extreme left side of the map is the variable indicating emotional homeostasis; on the extreme right, in a polar opposite position, we find chronic illness and anomie, indicating close interrelationship between them and concomitantly their strong negative relationship with homeostasis. Indeed, as shown in Table 2, chronic illness has the relatively strongest negative association with homeostasis (-0.72). The farther an item is to the left, the greater its power to predict homeostasis; the farther its location to the right, the less it is positively predictive of homeostasis. Close to chronic illness are the items which specify professional assistance. Their proximity reflects, on the one hand, their being the most sought for coping resources by the chronically ill (e.g. pZ between chronic illness and physician as agent of catharsis = 0.64). On the other hand, their great distance from homeostasis indicates their lack of efficacy in alleviating the afflicted individual’s distress (e.g. p2 between physician as catharsis agent and homeostasis is -0.60). (If the physician’s assistance were effective in the restoration of homeostasis, the relationship would have been positive). On the left side of the map we find individual resources, indicating their efficacy in predicting homeostasis. Thus the data lend support to the first part of hypothesis (a) by showing the positive relationship of individual resources to homeostasis, but seem to
and homeostasis maintenance. A portrayal of the structure is particularly important in light of the essence of the hypothesized framework according to which a person’s coping capacity and consequent homeostasis has to be understood in the framework of a structure being a product of the interrelationship and the variables comprising the hypothesized content universe of coping. A practical technique is the SSA-I--Smallest Space Analysis [60,61], where the computer locates each variable as a point on a map according to the strength of the correlations among them: the stronger the positive correlation, the smaller the distance between two points; the stronger the negative correlation, the greater the distance between points. This technique has been found useful in a variety of studies on coping with various stress arousing situations-such as readjustment of disabled [21], or bereaved persons [28] or of hospitalized patients [62], in revealing the relative weight of and complementarity among various factors in the restoration of homeostasis following traumatic life change episodes. Thus the utility of further application of this technique is not merely in its potential or arriving at meaningful conclusions, but in particular in facilitating an accumulation of comparable empirical evidence on the structure of coping in various stress arousing situations which may allow in the future to arrive at an overall empirically verified model of coping. RESULTS
Structure of the homeostasislchronic lationship The SSA-I map (Fig. 1) which displays the relationship among the items on the intercorrelations among them as shown
illness
re-
graphically basis of the in Table 2,
Education 15
12 Marned /
I
19 Hospltollzatvzn
I
Physicmn Vlslts 16
9 Physnans CafharsIs
Family. catharsis
6
CalharsIs
Work campanfians 8 cathaws
11 Rabbi cathaws
7 Fnends: catharsis Parents: cotharsls
Fig.
I. The structure
5
of the homeostasis, illness and resources (smallest space analysis) of intercorrelations
relationship: of Table
two-dimensional 2.
SSA-I
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Chronic illness, stress and coping
give only weak support to the hypothesized effectiveness of primary group resources: On the one hand, most of the individual resources have relatively strong relations with homeostasis (correlations coefficient p2 with catharsis: 0.43; with leisure: 0.46; with education: 0.26; with age: 0.38; with income: 0.50; with employment: 0.47; with occupational status: 0.48). [Exceptions are: being married (- 0.15) and dwelling density (OM), which can hardly be conceived as effective resources for predicting homeostasis.] On the other hand, with respect to the primary group resources, only ‘meeting with friends’ has a meaningful monotonic relationship with homeostasis (0.36) whereas all other primary social support items are unrelated to homeostasis @I varies from 0.02 to 0.15). The data support hypothesis (b) by revealing an extreme negative correlation between homeostasis and chronic illness & = -0.74) thus supporting the contention that illness is an expression of breakdown. The positive correlation of chronic illness with anomie (0.35), which is located on the most extreme right alludes to the risk of further psychological deterioration of the chronically ill person’s condition, thus supporting hypothesis (d). The distance of individual resources from chronic illness and anomie reflects their limited effect as coping resources for the chronically ill, thus supporting the first part of hypothesis (c). Yet the location of the primary social group support items on the center of the map alludes to their intervening capacity. The fact that primary group emotional support is not, as hypothesized in (c), negatively related to chronic illness and anomie but rather showed no relationship Q.L~varies between -0.02 and -0.06) does not give unequivocal support to the expected inefficacy of primary groups as a distress relieving agent for chronically ill persons. Indeed, this result alludes to the possibility that under certain circumstances they may have some anomie relieving capacity. The negative correlation between homeostasis and anomie (-0.46) supports the second part of hypothesis (d). The data clearly support hypothesis (e), showing reasonably strong positive correlations between chronic illness and the perception of professionals as agents of emotional support (correlation with physician: 0.64; with psychologist: 0.52; with Rabbi: 0.45). The way the question was posed (“With whom do you talk when feeling tense, nervous and unable to carry on?“) highlights the possible significance of professionals and particularly the physician as emotional support agents. To what extent do they actually satisfy these expectations? As hypothesized in (f), data reveal negative correlations between professional emotional support and homeostasis (physician: -0.60; psychologist: -0.35; Rabbi: -0.15). indicating that turning to a physician or psychologist does not predict alleviation of distress. The situation of those who turn to a Rabbi seems somewhat better, in view of the weakness of the negative association. DISCUSSION
AND SUMMARY
This study was aimed at elucidating the factors that may enhance the coping capacity of a chronically ill
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person with the demands imposed upon him by his condition, and hence restore his emotional homeostasis. Considering the stress-potential of chronic illness, with its power of aggravating anomie, alleviating the emotional disturbance seems vital for preventing further deterioration of the person’s condition. As hypothesized, the person’s individual resources were found insufficient for such an endeavour, and professional emotional support, particularly that of a physician, is the most sought for, yet least attainable for alleviating the individual’s distress. This highlights the importance of the physician’s affective behavior toward the patient as a powerful therapeutic tool. In fact, recent evidence [40-43] ascertained the importance of the physician’s affective behavior toward the patient in the latter’s assessment of the efficacy of the medical treatment and in his gaining a feeling of reassurance. That has to be understood in the light of the fact that the patient’s emotional state is to a great extent determined by his perception of the seriousness of his condition and prognosis. Hence, the expected solution is mainly from the physician, a fact that indeed gains support from the strong association of chronic illness with perceiving the practitioner as the most preferred agent of catharsis, his weight being greater than that of all other agents. However, the physician seems not to be sufficiently aware of these expectations, assuming probably that the therapeutic success of the physical disturbance would concomitantly also alleviate the emotional disturbance, thus viewing affective behavior as either an ineffective therapeutic tool, or altogether superfluous. Such an approach may sometimes lead to a feeling that the physician believes that any further investment. with respect to a chronically ill person will be ineffective, and any further attention to him may deprive other, more promising cases. However, since chronically ill persons conceive, as we have seen, the physician as the most relevant support agent, such a behavior on the part of the physician may ultimately contribute to the acceleration of the deterioration of his condition. Further study is needed to ascertain the extent to which physicians are indeed unaware of the possible compensatory function of affective behavior. A peculiar position occupy primary group emotional support agents (‘agents of catharsis’). Their intermediate position between homeostasis on the one hand, and chronic illness and anomie, on the other, seems to indicate both their low weight in promoting homeostasis and in serving as support agents for the chronically ill. Yet this position may also be interpreted as indicating the possible success they may have in alleviating distress, if the chronically ill would find their support efficacious. We are aware that these conclusions have to be viewed as tentative, considering several shortcomings of the present study. The fact that the study is not a longitudinal one and reflects the situation at one point of time, may be considered as the most serious shortcoming. Yet, in light of the great limitations (material and other) involved in conducting a longitudinal study on this topic, the inferences drawn from the present data may be considered as an important empirically based baseline and as insight for under-
standing the factors that may promote a chronically ill person’s wellbeing or predict further deterioration of his/her condition. However, followup studies will be required for confirming our conclusions. The fact that our conclusions are based on correlations may be considered as an additional shortcoming and in particular with regard to the direction of prediction. Yet in this respect the present study does not differ from other studies in the social sciences, in view of the limitations imposed on such studies by the present state of art in the realm of data analysis. However, in contrast to many other studies. the advantage of the present one is that many of the resource variables reflect activities that occurred in the past, whereas the person’s level of homeostasis and his state of health relate to the present. Thus, the time sequence may give some support to our argument. Additional support may be gained from the pattern that emerges from looking at the structure as a whole, which is facilitated by the method of multivariate data analysis (SSA) employed here. In this respect this method makes an invaluable contribution in furthering the understanding of the condition of the chronically ill. Another critique that could be raised is the underlying logic of the demands-coping-breakdowndisease relationship. The suggestion that an expression of breakdown (which has been conceptualized here in terms of anomie and disturbed homeostasis) could be any disease, may be questioned. Yet this exactly is the essence of the stress-illness theory [3,4], though it requires still further elaboration. In fact, it is precisely in this respect that the present study contributes a further support to the accumulating evidence on stress-illness relationship (e.g. [6, 12-14, 63,641 by showing the associations described here, which are independent of the type of chronic condition. Finally, the fact that the present study relates to the Jewish Israelis requires further investigation for ascertaining the applicability of its conclusions to other cultural contexts with other schemes of medical services. Despite these reservations, I think that the present study may be considered as an important contribution to the understanding of the factors that may enhance or impede a chronically ill person’s wellbeing and arrest, or at least reduce the risk of further deterioration of his condition. REFERENCES 1. Selye H. The Stress of Lye. McGraw-Hill. New York. 1956. 2. Janis I. L. SIWSS and Frusmztion. Harcourt. Brace Jovanovich, New York, 1971. 3. Antonovsky A. Health, Stress and Coping. Jossey Bass, San Francisco, 1979. 4. Antonovsky A. Breakdown: a needed fourth step in the conceptual armamentarium of modern medicine. Sot. Sci. Med. 6, 537-544,
1972.
5. Norbeck J. S. and Peterson-Tilden V. Life-stress, social support, and emotional disequilibrium in complications of pregnancy: a’prospective multivariate study. J. HIth sot. Be/mu. 24, 30-46,
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6. Kobasa S. C., Maddi S. R. and Courington S. Personality and constitution as mediators in the stress-illness relationship. J. Hlfh sot. Behuu. 22, 368-378, 1981.
Chronic illness, stress and coping 7. Ben-Sira Z., Aviram U., Stern I. and Shoham I. A facet theoretical approach to psychosomatic complaints. Isr. Annls Psychiat. 16, 219-231, 1978. 8. Lazarus R. S. and Cohen J. B. Environmental stress. In Human Behavior and Environment (Edited by Altman I. and Wohlwill J. F.), Plenum Press, New York, 1977. Stress and the Coping 9. Lazarus R. S. Psychological Process. McGraw-Hill, New York, 1966. 10. Ben-Sira Z. The interrelationship and the dynamics of the symptoms of psychological distress: an additional approach to the theory of readjustment and breakdown. In Research in Psychology and Medicine (Edited by Obome D. J., Gruneberg M. M. and Eiser J. R.), pp. 117-124. Academic Press, London, 1979. Medicine. Norton, New 11. Alexander F. Psychosomatic York, 1950. 12. Gunderson E. K. and Rahe R. (Eds) Life Stress and Illness. Thomas, Springfield, 1979. 13. McFarlane A. H., Norman G. R., Streiner D. L., Roy R. and Scott D. A longitudinal study of the inlhrence of the psychosocial environment on health status: a preliminary report. J. Hfth sot. Behao. 21, 129-133, 1980. 14. Cohen J. et al. (Eds) Psychological Factors in Cancer. Raven Press, New York, 1982. 15. Ben-Sira Z. A scale of psychological distress. Res. Commun. Psychol. Psychiat. Behav. 4, 337-356, 1979. 16. Askenasv A. R., Dohrenwend B. P., Dohrenwend B. S. Some effects of social class and ethnic group on judgemerits of the magnitude of stressful life events. J. Hlth sot. Behac. 18, 432-439. li. Dohrenwend B. S. and Dohrenwend B. P. Class and race as status-related sources of stress. In Social Stress (Edited by Levine S. and Scotch N. A.), pp. 111-140. Aldine, Chicago, 1970. 18. Kessler R. C. and Cleary P. D. Social class and psychological distress. Am. social. Rec. 45, 463478, 1980. 19. Pearlin L. I. and Schooler C. The structure of coping. J. Hlth sot. Behac. 19, 2-21, 1978. 20. Smith R. T. and Midanik L. The eliect of social resources on recovery and perceived sense of control among disabled. Social. Hlth Illness 2, 48-63, 1980. 21. Ben-Sira Z. The structure of readjustment of the disabled. An additional perspective on rehabilitation. Sot. Sci. Med. 15A, 565-581, 1981. 22. San A. and Lin N. The stress buffering role of social support: problems and prospects for -systematic investigation. J. nerv. ment. Dis. 165, 403-417, 1977. 23. Lin N., Simeone R. S., Ensel W. M. and Kuo W. Social support, stressful life events and illness: a model and empirical test. J. Hlth sot. Behav. 20, 108-l 19, 1979. 24. Miller P. M. C., Ingham J. G. and Davidson S. Life events, symptoms and social support. J. Psychosomat. Res. 20, 515-522, 1976. 25. Thoits P. A. Conceptual, methodological and theoretical problems in studying social support as a buffer aeainst life stress. J. Hlth sot. Behav. 23. 145-156. 1982. 26. Piarlin L. I., Lieberman M. A., Menaghan E. G. and Mullin J. T. The stress process. J. HIth sot. Behav. 22, 337-356. 1981. 27. Folkman S. and Lazarus R. S. An analysis of coping in a middleaged community sample. J Hlth sot. Behao. 21, 219-239, 1980. 28. Ben-Sira Z. Loss, stress and readjustment: the structure of coping with bereavement and disability. Sot. Sci. Med. 17, 1619-1632, 1983. 29. Homans G. C. Social Behaaior; Its Elementary Forms. Routledge & Kegan Paul, London, 1961. 30. Blau P. M. Exchange and Power in Social Life. Wiley, New York. 1969. 31. Freidson E. Profession of Medicine. Dodd, Mead. New York, 1972. 32. Blau P. and Scott R. Formal Organizations. Routledge & Kegan Paul. London. 1970.
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33. Johnson T. J. Profissions and Power. Macmillan, New York, 1972. 34. Mechanic D. Medical Sociology, Second Edition. The Free Press, New York, 1978. 35. Shontz F. C. The Psychological Aspects of Physical Ilbtess and Disabilitv. Macmillan. New York. 1975. 36. Stotsky B. A. Social psychological factors in dependency. Rehab. Record 4, g-9,1963. 37. Goldin G. S.. Perrv S. L.. Mareolin R. J. and Stotskv B. A. Dependency and its Implicitions for Rehabilitation. Heath, Lexington, 1972. 38. Roth J. A. and Eddy E. M. Rehabilitation for the Unwanted. Atherton, New York, 1962. 39. Fried M. Social differences in mental health. In Poverty and Health (Edited by Kosa J., Antonovsky A. and Zola I. K.), pp. 113-167. Harvard University Press, Cambridge, MA, 1969. 40. Ben-Sira Z. The functions of the professional’s affective behavior in client satisfaction: a revised approach to social interaction theory. J. Hlth sot. Behau. 17, 3-l 1, 1976. 41. Ben-Sira Z. Affective and instrumental components in the physician-patient relationship: an additional dimension of interaction theory. J. Hlth sot. Behav. 21, 170-180, 1980. 42.. Ben-Sira Z. Stresspotential and esotericity of health problems: the significance of the uhvsician’s affective behavior. Med. Care 20, 4lc1424,*1982. 43. Ben-Sira Z. Lay evaluation of medical treatment and competence: Development of a model of the function of the physician’s affective behavior. Sot. Sci. Med. 16, 1013-1019, 1982. 44. Eisenberg L. and Kleinman A. (MS) Clinical social science. In The Relevance of Social Science for Medicine, pp. 7-20. Reidel, Dordrecht, 1981. 45. Balint M. The Doctor. Patient and the Illness. Tavistock. London, 1957. 46. Leigh H. and Reiser M. F. The Patient. Plenum Press, New York, 1980. 47. Brown G. W. The mental hospital as an institution. Sot. Sci. Med. 1, 407424, 1973. 48. Tuckett D. (Ed.) Doctors and Patients. In Medical Sociology, pi. l&224. Tavistock, London, 1976. 49. Friedman S. B.. Chodoff P.. Mason J. W. and Hamburg D. A. Behavioral observations on parents anticipating the death of a child. Pediatrics 32, 610-625, 1963. 50. Durkheim E. Suicide. Routledge & Kegan Paul, London, 1966. 51. Merton R. K. Social Theory and Social Structure. The Free Press, New York, 1965. 52. Srole L. Social integration and certain corrolaries: an exploratory study. Am. social. Rev. 21, 709-716, 1956. 53. Melick M. E. Life change and illness: illness behavior of males in the recovery period of a natural disaster. J. Hlth sot. Behav. 19, 355-342, 1978. 54. Dohrenwend B. S. Life events as stressors: a methodological inquiry. J. Hlth sot. Behav. 14, 167-175, 1973. 55. Mueller D. P., Edwards D. W. and Yarvis R. M. Stressful life events and psychiatric symptomatology: change or undersirability. _J. Hlth sot: Behap. ii, 307-317,
1977.
56. Wildman R. C. and Johnson D. R. Life change and Langner’s 22&m Mental Health Index: a study and partial replication. J. Hlth sot. Behau. 18, 197-198, 1977. 57. Langner T. S. A twenty-two item screening score of psychiatric symptoms indicating impairment. J. HIth Hum. Behav. 3, 269-276, 1962. 58. Guttman L. and Levy S. Structure and dynamics of worries. Sociometry 38, 448-473, 1975. 59. Rave A. Finding periodic patterns in time series with monotonic trend: a new technique. In Theory Construc-
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tion and Data Analysis in the Behavioral Sciences (Edited by Shye S.), pp. 371-390. Jossey Bass, San Francisco, 1978. 60. Ben-Sira Z. and Guttman L. A Facet Theoretical Approach to Research. The Israel Institute of Applied Social Research, Jerusalem, 1971. 61. Bloombaum M. Doing smallest space analysis. J. Conflict Resol. 14, M16,
1970.
62. Ben-Sira Z. The structure of a hospital’s image. Med. Care 21, 943-954, 1983. 63. Bommer K. and Newberry B. H. (Eds) Stress and Cancer. Hogrefe, Toronto, 1981. 64. Hollis J. F., Conner W. E. and Materazzo J. D. Lifestyle, behavioural health and heart disease. In Handbook of Psychology and Health (Edited by Gatchel R. J., Baum A. and Singer J. E.). Lawrence-Elbaum, Hilldaly, NJ, 1982.
APPENDIX
I
Here is a list of diseases or other conditions. Have you been told by a physician that such a condition has been diagnosed? 1. High blood pressure 2. Heart disease 3. Other disease of blood circulation 4. Diabetes 5. Disease of the nervous system 6. Rheumatism 7. Ulcer of stomach 8. Chronic eye disease 9. Cancer 10. Liver disease 11. Kidney disease 12. Other chronic condition of the digestive system 13. Bone disease 14. Other chronic condition 15. Permanent disability because of injury.
Measures
14
12 13
9 10 II
3
Identification No. of item?
Resource
Modality
.
.
.
.
.
Self
Resource
. . . . . .
Marital status Meeting with friends
Physician Psychologist Rabbi
Spouse Parents Other family members Friends Work companions
Agents of catharsis:
.
Satisfaction: catharsis
Leisure activities
. . . . . . . .
Primary group
.
Professionals
.
Primary groups
. .
Self
Agent of control of resource
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
I. Spontaneous response* (For those not spontaneously mentioned, after probing) 2. Very often 3. often 4. Rarely 5. Never 6. (Not relevant, e.g. not married)
.
~~___ ~~~ _..__ 5. Very often, 3. often, 3. rarely, 2. very rarely. I. never
Response options
.
How often do you usually meet with friends . . . . . . . . . . . How often do you spend your leisure out of your home, e.g. visit movies, theatre, night club, cafe, excursions
.____
1. Married, 2. Not married I. Several times a week. 2. Once a week. 3. 2-3 times a month, 4. Once a month. 5. Once in several months, 6. Once a year. 7. More rarely, 8. Never
__~__
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
When you feel tense and nervous and you can’t carry on any longer, with whom do you usually talk?*
. . . . . . . . . . . .
Question
II
During the past year, did it happen that you felt that you have nobody to talk to about your worries, about being lonely, tense or nervous?
APPENDIX
3 B & a s .U 8’ 09
.r
8
n
3 _.
3 ti
L
A
Education
Numberof years of schooling
_‘I.
I. Completed university, 2. l3+ years of schooling (no university diploma) 3. 12 years, 4. 11 years, 5. 9-10 years, 6. 5-8 years, 7. 4 and less, 8. no schooling Youne-l old Age . ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Physician visits In the past two years, how 1. Every week, 2. 2-3 Times a month, Professionals 3. Once a month. 4. Once every 2-3 months, often did you see a physician 5. Once in half a’ year, 6. Once-a year, about your health 7. once, 8. not during the recent two years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes: How long was your last term of Hospitalization Have you been hospitalized hospitalization? in the recent two years I. More than a month, 2. 34 weeks, 3. Two weeks, 4. One week or less, No: have you been hospitalized before that? 5. Yes, 6. No . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Self Income , ., .., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., . . 1. Employed, 2. Unemployed Employment status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. Professionals and scientific, Occupational status 2. High ranking administrators and political leaders 3. Business owner 4. Nonacademic professionals (e.g. elementary school teacher) 5. White collar 6. Technicians 7. Skilled blue collar 8. Unskilled 9. Unemployed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rooms per individual in Dwelling density apartment
Self
*Interviewer waited for spontaneous response and coded 1 any of the ‘agents’ mentioned. For those not mentioned, the interviewer probed: “To what extent did you also talk with tltem No. 1 = emotional homeostasis, No. 2 = anomie, No. 3 = chronic illness.
23
N
22
T
E
M
R
T
S
N
I
21
20
19
18
I6
IS
B vl z
CHRONIC
1984
0277-9536/84
S3.00 + 0.00
Pergamon Press Ltd
ILLNESS,
STRESS
AND COPING*
ZEEV BEN-SIRA The Hebrew University of Jerusalem, School of Social Work, Jerusalem 91905 and The Israel Institute of Applied Social Research, Jerusalem, Israel
Abstract-The study investigated the factors that may alleviate the emotional distress of chronically ill persons, enhance their coping capacity and prevent further acceleration of the deterioration in their condition. Based on recent approaches to breakdown and stress, the seriousness of a chronically ill person’s situation was hypothesized as resulting from the inadequacy of the individual’s and his primary group’s coping resources and inexpediency of the professional emotional support. A study carried out among a representative sample of Jewish Israeli adults gave support to the hypothesized insufficiency of
individual resources. Data highlighted the significance of the physician’s emotional support as the most sought for yet least attainable resource in alleviating distress. The study lends further support to previous evidence of the importance of the physician’s affective behavior in the patient’s wellbeing. It also ascertained the role that primary groups’ emotional support may have in the readjustment of the
chronically ill.
INTRODUCTION
This study focuses on the stress arousing factors that are inherent in chronic illness, and on the efficacy of individual resources, of primary social support and of professional assistance, in alleviating the emotional distress of a chronically ill person, thus reducing the risk of further acceleration in the deterioration of the patient’s physical and emotional condition. ANALYTICAL
CONSIDERATIONS
Stress, coping and disease
Recent approaches in the stress-illness relationship serve as a useful point of departure for the analysis of the health-deteriorating effect of the stress potential inherent in the nature of chronic illness. According to these approaches [l-7], illness constitutes an expression of ‘breakdown’ [3,4,7] due to a prolonged failure of restoring a person’s emotional homeostasis which has been disturbed due to inadequate coping with demands of life-demands to which an individual is constantly exposed and which require response (i.e. coping). In fact, exposure to and coping with demands comprise the essence of human life. Yet there are “demands that tax or exceed the resources of the system or to which there are no readily available or automatic adaptive responses” [8, p. *A different, less elaborate and shorter version of this study was presented by the author at the 11th International Congress on Suicide Prevention and Crisis Intervention, Paris, July 1981. My gratitude is extended to Professor Aaron Antonovsky of the Ben-Gurion University for his important comments to the initial version, and to Mrs Haya Gratch for her valuable and indispensable assistance in editing this paper. tThis approach is considered much more advanced and relevant than the earlier specific theories which flourished in the early 1950s (e.g. [l 11) according to which specific stresses produce specific diseases. These theories which did not gain empirical support are now considered outdated. 125
1091. Such demands cause ‘tension’, namely, disturb the individual’s emotional homeostasis. Demands to which there are no readily available or automatic responses and consequently disturb one’s emotional homeostasis are commonly defined as ‘stressors’ [S, p. 1091. At this stage it should be pointed out that demands as such may be physical (e.g. pain), social (e.g. behavior required by social environment) or psychological (e.g. satisfaction of psychological needs such as achievement). The impact of the demands on a person’s emotional homeostasis is predominantly at the perceptual level, namely, to a great extent it is not the demand per se, but rather the individual’s assessment of it that make a demand a stressor. The same experience may be highly threatening to one person yet harmless to another [9]. Undoubtedly, there may occur events which by far exceed the bounds of a normal course of life--events which impose upon an individual demands which are perceived insurmountable. Following the earlier delineated approach to stress and illness [3-71, such demands have the power of disturbing the individual’s emotional homeostasis (i.e. constitute stressors)--a disturbance which if not adequately resolved carries the danger of ‘breakdown’, disease being one of its expressions 13941. Inferentially, then, the greater the amount and the perceived severity of the demands which impinge upon an individual, the greater the severity of the disturbance and consequent increase in the danger of breakdown and illness. Thus, constant confrontation with perceptually insurmountable demands (i.e. stressors) will lead, according to this approach [3,4] to an accumulation of unresolved tensions, resulting in an increase in the severity of the disturbance of the emotional homeostasis (e.g. [lo]), thus increasing, and possibly accelerating, the danger of breakdown and consequent illness. It should be pointed out that according to this approach [3,4] any illness, acute or chronic, is conceived as an expression of breakdownt. However, the present state of art is still far from facilitating the assessment of the weight of
126
ZEEVBEN-SIRA
stress compared to biological, physiological and other factors, as well as the mechanisms of interaction between the latter and emotional factors in the outbreak, severity and prognosis of an illness. Nevertheless however, clinical evidence points to the fact that emotional stress plays an important etiological role in any disease, including the development and severity of chronic conditions (e.g. [5-7, 12-141). Chronic illness: outcome and cause of breakdown
It follows then from the preceding analysis, and in particular Antonovsky’s recent advances [3,4] that chronic illness has to be conceived as an expression of ‘breakdown’ following a prolonged failure to restore one’s emotional homeostasis which has been disturbed due to inadequate coping with demands. In other words, in terms of these approaches, chronically ill persons failed both in coping with a variety of demands of life and in restoring the consequently disturbed emotional homeostasis. At this stage the irrevocable, impairing and suspected to be. progressively damaging characteristics of chronic illness-and particularly the uncertainty of its prognosis, namely, the constantly accompanying though not necessarily salient threat of the unpredictable occurrence of further damaging episodes should be pointed out. These characteristics impose new demands upon the chronically ill persondemands which, if not successfully coped with, will become stressors, with further homeostasis-disruptive effect. Following now the logic of the stress-illness relationship, further disruption of the person’s emotional homeostasis-which essentially is a consequence of an accumulation of unresolved tensions--carries the danger of further deterioration of that person’s health. Thus, coping with demands, and in particular minimizing the potential of demands imposed by the chronic condition of becoming stressors, is essential for reducing the risk or at least arresting the acceleration of further deterioration of a chronically ill person’s health condition. Resources and coping
What, then, are the factors that enhance successful coping? Relating to this issue undoubtedly directs the focus on the issue of resources as the fulcrum of homeostasis maintenance (e.g. [3, pp. 98-122, 4-7, 10, 15, 16-271). In the literature we may find classification of resources according to their ‘source’, namely, who controls the resources: the individual himself (e.g. education, SES), or his/her primary social network (e.g. social support) or secondary social environment (e.g. professional help) who place resources at the individual’s disposal. Empirical evidence clearly shows that in a variety of situations, self-controlled resources are frequently more effective than other-controlled resources. In particular the self-controlled resources seem to be by far more effective in coping with demands and restoring homeostasis than those from the environment [6, 10, 15-I 8,2 1,281. The predominant efficacy of the self-controlled over other-controlled resources conforms with the logic of the theories of stress and breakdown: whatever the demands, ultimately it is the individual himself who is constantly confronted by them, interprets them, assigns them a subjective 1
meaning, and constantly has to respond to them. Inferentially, then, the greater an individual’s control of resources, the greater will be the range of demands with which he will have the capacity to cope successfully. Conversely, the less the control of own resources, the greater the chances for either being unable to meet these demands, a state which may result in the demands becoming stressors or having to mobilize resources from the environment. However. dependence on the environment for meeting the demands has at least two disadvantages which make them less efficacious than self-controlled resources. On the one hand environmental support, whatever their proximity, is not omnipresent, hence chances are that one may be confronted with demands in the absence of the appropriate ‘environmental resources’. and thus be unable to meet them at the time of their occurrence-the inability having the earlier-described deleterious consequences. On the other hand, following the logic of classical exchange theory [29], getting help, hence ‘buying’ resources from the social environment incurs a ‘cost’ on the ‘buyer’, such as admission of his inferiority, or giving certain services in return for the help given. The ‘cost’ of this help (i.e. resources supplied by the environment) by definition imposes new demands on the recipient. Thus, this ‘help’, though assisting the recipient to overcome the initial demand, because of its ‘cost’ reduces, in terms of exchange theory [29], the net profit of the success. There will be, however, throughout one’s life, demands coping with which will require resources over and above those at one’s disposal, hence inevitably requiring other-controlled resources. In this respect, primary group support, if efficacious, has an advantage over that of the secondary social environment, in particular over professional support, by being to a great extent based on a reciprocal affective relationship: The mere membership of a person in a primary group, by definition implies a person’s value for that group, and the help given to him is in exchange for the rewarding value of his mere membership in that group. Indeed, the literature highlights the significant stress-buffering role of social support by a person’s primary social network such as family and friends 15, 21-25, 281. Yet with respect to secondary environmental help, data allude to a possible deleterious effect that dependence on this type of help, and in particular professional assistance, may have on a person’s emotional homeostasis [20, 21, 28). That has been explained as resulting from a sense of inferiority and powerlessness vis-ci-vis a ‘powerful professional’-a sense that is inherent in the dependence on the indispensable assistance, on the one hand (e.g. [30. p. 22, 31, pp. 72-80]), and the professional’s striving to maintain and enhance his power, on the other [32, pp. 52-53, 331. It should be pointed out that this line of argument does by no means imply that an individual who is in need of professional help has the alternative of choosing between the professional help and his primary group support. Rather, it means that the recognition of the indispensability of the professional help highlights his dependence on that help for responding to a vital demand, thus implying inferiority.
Chronic illness, stress and coping Chronic illness and the relative eficacy resources
of coping
Coming back now tb the situation of the chronically ill person, in terms of the precedingly delineated approaches to stress [l+, illness, and consequently chronic illness, is conceived as an expression of breakdown resulting from inefficacy of the afflicted individual’s resources to prevent that illness and/or enhance recovery from it. Thus, if chronic illness is an expression of breakdown, then by definition we may expect that individual’s resources to be particularly ineffective in the alleviation of the imbalance which they were unable to prevent. Indeed, they may even be less effective in restoring homeostasis of a chronically ill person, considering the greater effort required for restoring than for maintaining homeostasis. In addition to the above, the chronically ill person has to cope with new demands which may arise from his permanent incapacitation, which is frequently accompanied by stigma and the constant fear of a possible occurrence of additional episodes with further damaging results, and with the potential of depriving him abruptly or gradually of his control over his entire life. The afflicted individual and his primary lay network may feel entirely helpless and incompetent to interpret the patient’s sensations and to affect his physical condition substantially. Moreover, the chronically ill person and the members of his primary network will generally be explicitly aware of their incompetence of coping also with the patient’s emotional disturbance which may result from his physical and medical problems. It follows, then, that any effort at improving, or at least arresting deterioration of the physical and emotional state, may point to the’ need for additional, more proficient resources, namely, the help of professionals such as physicians, psychologists or clergy (if the latter is compatible with the individual’s beliefs and recognized as being experienced in such conditions). As indicated earlier, the indispensability of professional assistance highlights the patient’s inadequacy in coping, and hence his dependence on the professional for the satisfaction 0f.a vital need. As indicated above, dependence suggests inferiority and powerlessness, which have been found to be deleterious to wellbeing, and consequently contradictory to the restoration of emotional homeostasis [ 19,20, 34, p. 301, 351, to readjustment to disability [36,37] and even predictive of psychiatric disorders [38,39]. The eficacy
of professional assistance
To what extent can professional
assistance, and in particular that of the medical profession be regarded as efficacious in restoring a chronically ill person’s emotional homeostasis? In the light of the irreversibility of that person’s somatic disturbance, emo-
*The importance of the doctor’s emotional support in reducing stress even among patients in their terminal stage may be inferred from the study of Friedman et al. [49]. The study carried out among children dying from leukemia and their parents, showed the potential of the doctor’s support in reducing stress among parienzs and their parents at the time of death.
727
tional support will be highly pertinent, frequently even more than bio-medical instrumental help. Yet from the ill person’s viewpoint, the most appropriate source of support is the physician specializing in his type of somatic disturbance. He expects that physician to intervene clinically in order to restore his physical health, or at least to arrest further detioration. Yet, in light of the esotericity of medical activity and the lay incompetence in judging the content and outcome of a physician’s professional activities, medical intervention per se may frequently be inefficacious in alleviating the patient’s anxiety which results from the subjectively perceived seriousness of his condition and its prognosis. It has been shown that patients judge to a great extent the quality of the treatment and the physician’s competence, and gain reassurance from the physician’s affective behavior toward them [U3]. These conclusions seem particularly applicable with respect to chronic illness where the capacity of substantially affecting the condition by medical clinical procedures is minimal, thus stressing even more the necessity for affective (i.e. humane) behavior toward the patient*. However, in light of the dominance of the bio-medical model in medical practice, which focuses on physical disturbance rather than on the emotional state of the afflicted individual, (e.g. [44, pp. 1l-121) the practitioner’s inclination to demonstrate such behavior seems rather dubious. Indeed, as Balint argues, doctors can be profoundly hindered, by some askcts of their professional training, in understanding and paying attention to the therapeutic significance of coping with a patient’s emotional problems [45]. Moreover, the dominance of the bio-medical model in medical practice causes the physician to view the patient’s anxiety as an outcome of the disease, which will ‘naturally’ be alleviated upon recovery from the illness, hence a priori rejecting the therapeutic importance of affective behavior [46, p. 251. Consequently, then, the limited ability of a physician to provide an effective medical solution to a chronically ill person’s somatic needs, on the one hand, and failure to assign the necessary importance to the affective component of his behavior, on the other hand, makes his capacity to alleviate a chronically ill person’s emotional disturbance rather dubious. Indeed, as Brown [47, p. 4171 maintains, emotional support is not seen by doctors as professionally challenging. Moreover, the physician’s recognition of his inability to help the patient medically (i.e. curing him) with the help of his technical abilities and knowledge, hence unable to respond to the patient’s plea for help, may constitute a sense of failure to live up to his role [47, pp. 1961971. That in turn may lead to defensive behavior by avoiding as much as possible confronting the patient-a behavior which is frequently justified by the necessity to allocate the scarce resources (the doctor’s time) mainly to those who are likely to benefit the most from the doctor’s intervention [48]. However, the patient may interpret the physician’s inability to meet his most basic needs, and in particular the physician’s avoidance of him, as indifference, and consequently may feel deserted by the most appropriate and most sought for agent for support.
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Double vulnerability of the chronically ill and ineficacy of resources: anomie
In summary, then, a chronically ill person appears to be highly vulnerable to further deterioration of his condition, not merely because of possible inherent progressive damage caused by the illness itself, but even more so because of the concomitant inability to alleviate emotional disturbance owing to the recognized inefficacy of the person’s individual and primary group resources and the perceived indifference of and desertion by the allegedly most competent support agent, namely, the physician. The sense of helplessness (due to his own and his primary group’s inability to cope with the demands) and powerlessness (dependence on the physician), on the one hand, and a sense of being abandoned by the only competent support agent in a state of despair, on the other hand, concomitant with the accumulation of unresolved emotional distresses, and the unpredictability of the health condition, reflect a state of anomie [SO, pp. 241-276,50, pp. 161-194), and in particular Srole’s conceptualization of it [57, pp. 712-7131. According to these approaches, anomie is conceived as a sensation of powerlessness and inefficacy in achieving one’s goals, of unpredictability of environment, indifference of social contacts and finally surrender to the inevitable, hence highlighting a sense of futility of life. Consequently, anomie, in itself a health hazard [3,4, 161, and in addition to the final recognition of the inefficacy of even the most relied upon resources (medical profession), may by definition result in an aggravation of the breakdown, and, following the logic of the approach of the coping-stress-breakdown relationship [3,4], accelerate the further deterioration of the condition. At this stage it should be pointed out that, following the earlier-discussed state of art, there is no intention of suggesting an exact weight of anomie in affecting deterioration, and neither of claiming that anomie is the only factor that may affect deterioration. On the other hand, following the precedingly delineated coping-stress-breakdown relationship, an anomie*hronic illness relationship should be expected.
particularly primary social networks; (b) illness, and particularly chronic illness, is an expression of a breakdown following a prolonged failure to restore homeostasis due to the inadequacy of these resources; (c) individual and primary social resources will be only of a limited efficacy in restoring homeostasis; unrestored homeostasis increases the risk of anomie of a chronically ill person; (d) consequently, an interactive relationship between chronic illness and anomie should be expected, each of these factors predicting aggravation of the other; thus (e) chronic patients will draw on professional assistance for the satisfaction of emotional and physical needs; but (f) professional assistance will be of limited value in restoring emotional homeostasis and reducing anomie. Hypotheses
In operational terms, verification of these arguments will require an empirical structure of interrelationship among the variables-a structure where homeostasis on the one hand, and breakdown and chronic illness on the other, have to be conceived as a product of the interrelationship among the various resource variables. In this respect, empirical verification of the following hypothesized relationships seems essential for the support of the suggested analytical framework: (a) Emotional homeostasis is positively correlated with the control of individual and primary social resources. (b) Emotional homeostasis is negatively correlated with chronic illness. (c) Chronic illness is negatively correlated with individual and primary social resources. (d) Chronic illness is positively correlated with anomie, and anomie is negatively correlated with emotional homeostasis. (e) Chronic illness is positively correlated with the employment of professional resources (professional assistance). (f) Professional assistance is negatively correlated with emotional homeostasis.
Summary
The preceding analysis may be summarized as follows: (a) emotional homeostasis will be maintained with the help of one’s individual and social resources,
*The sample was drawn systematically from the Israeli voting register, which is the relatively most reliable updated listing of the Israeli population. The sample is representative of the heterogeneous character of the Israeli, Jewish, urban adult (age 20+) population: 41% were Israeli born (16% of North-African or Asian origin, 18% of European or American origin and 7% at least second generation Israelis), and 59% were born abroad (19% in North African or Asian countries, 40% in Europe or America). 45% of the latter immigrated after the establishment of the State of Israel (in 1948). 26% in the years 1948-1954 and only 7% after 1968. A quarter (25%) had no, some or complete elementary schooling, 18% some high school, 27% completed high school, 31% studied I3 years or more (12% completed university); 47% were male, 53% female.
METHOD Sample and jieldwork
A representative systematic random sample* of the adult Israeli Jewish urban population (N = 523) that was drawn systematically from the Israeli voting register was investigated by means of a closed questionnaire presented to the respondents by interviewers in the respondents’ homes during November 1980. Measures (a) Chronic illness. Similar to other studies on the behavioral aspects of disease (e.g. [l&53]), the respondents’ report of physician-diagnosed, chronic episodes was applied as a measure of chronic illness. We confined the report only to chronic episodes that were diagnosed by a physician (see Appendix I). Based on these reports, each respondent was assigned a score based on the number of reported diagnosed
Chronic illness, stress and Table 1. Chronic illness scores SCOR
1 2 3 4 5 6 7
Number of reported medical diagnoses 8+ 5-l 4 3 2
I
0
Distribution of respondents N % 9 2 6 I 10 2 41 8 51 10 106 20 297 57 520 100
episodes. Table 1 indicates the distribution of respondents according to this chronic illness score. (b) Emotional homeostasis. As in a great number of studies (e.g. [13, 54-56]), we found Langner’s [57] 22 item index (MIH) to be an appropriate indicator of homeostasis (or lack of it-frequently defined as psychological distress). (c) Anomie. Based on the logic of the analysis, Srole’s [52] conceptualization was found as the most appropriate indicator of anomie. The following Srole’s five original items were operationalized: (1) indifference of community leaders; (2) unpredictability of social order; (3) impossibility of realization of life goals; (4) sense of meaninglessness of life; (5) immediate personal relationships no longer predictive or supportive (cannot count even on closest friends). The items were presented to respondents in the form of statements and they were requested to indicate their agreement on a scale of 6 (1 = ‘strongly agree’ . . . 6 = ‘strongly disagree’). In order to allow for scaling, they were dichotomized as follows: categories l-3 were scored 1, 4-6 (disagree) were assigned a score of 0. The responses to the five items formed a Guttman scale with a coefficient of reproducibility (COR) of 0.85, which still may be considered to be a reasonable indication that the items relate to the same content universe. The
*Pearlin and Schooler’s [ 191comprehensive study serves as an illustration of the difficulty of differentiating between resource and outcome measures. They defined ‘Marriage does not give the opportunity to hecome a person I’d like to he’ as an outcome measure, ‘A feeling of control over things’ as a resource, and ‘How would you compare your marriage to that of most people like yourself as a coping response [19, pp. 18-211. We think that each of these items could serve equally as a resource or outcome measure. tAge categories are ordered from young to old. Thus, a negative correlation between age and chronic disease indicates that younger people have lesser chances than
older people of being chronically ill. A positive correlation between homeostasis and age indicates the greater chances of older individuals of suffering from psychological distress. :The formula for p2 is as follows [58, 591. Given n pairs of observations on numerical variables (x. y), (.x,..r,)(i = 1,2,. . , n), then
coping
729
order of the items was the following: meaninglessness (‘most serious’wn’t count on people-life goalsleaders’ indifference-unpredictability (‘least serious’). (Interestingly this order reflects greatly the logic of viewing anomie as an indication of accumulation of unresolved emotional disturbances.) The scale was applied as a measure of anomie where the score of 1 represented the highest level of anomie, namely, agreeing with all five statements, 6 the lowest = disagreeing with all five. (d) Resources. Any attempt at operationalizing the concept of resource is confronted by the problem of a conceptual differentiation between initial resource and outcome measures +. Income or education may be both a resource and the outcome of coping with the help of other resources. Frequently an achievement (e.g. occupational status or satisfaction of catharsis needs) or a successful activity (e.g. frequent leisure time) may constitute both a resource in itself or an indirect evidence of the existence of another resource which facilitated that achievement. Thus an item was defined as a measure of resource if it indicates either a potential of enhancing coping or successful coping. Following the logic of the analytical section of this paper, resources may be classified according to the source of the resource (the individual himself, his primary group, or secondary environment) and the modality (type: instrumenta1-e.g. education, income, or afictiue-emotional support, e.g. catharsis). Based on this classification, the following resource items were applied: With respect to resources which the individual has at his/her disposal, afictive resources focused on his/her coping with catharsis needs, family and other primary relationships and leisure activities; the instrumental resources focused on education, employment, income dwelling density and aget. Since this study concerns enhancement of emotional homeostasis, the focus of the other-controlled resources was on the affective modality, particularly on the extent to which the individual’s catharsis needs are met with the help of primary and professional agents. Meeting with others.(visiting friends, visiting physicians) was defined as a resource, ‘unspecified’ from the viewpoint of modality. In total, the schedule contained 30 measure items of resources. For a total listing of resource items see Appendix II. Data analysis
(a) Correlations. Data analysis was intended to identify the predictive power of resource variables with respect to the restoration of homeostasis. Correlation coefficients were conceived as useful measures for identifying the relationships (hence predictive power) among items. A weak monotonicity coefficient 012) where linearity is not assumed, was used$ [58, 591. (b) SSA-smallest space analysis. The multidimensionality of the content universe requires a technique that facilitates simultaneous perception of the relative power of the variables (in particular resource variables) in predicting homeostasis as well as breakdown and chronic illness, and gives an overall picture not merely of the relative predictive power but also, and even more so, their interrelationships, revealing an overall structure of coping
ZEEV BEN-SIRA
730
particularly highlights the efficacy of individual resources in enhancing homeostasis and concomitantly it reflects their ineffectiveness in alleviating the anomit situation of a chronically ill person. It also reflects the professionals’ ineffectiveness in enhancing homeostasis. On the other hand, the intervening position of primary group support should be noted. These general conclusions may be inferred from the location of the variables on the SSA map: On the extreme left side of the map is the variable indicating emotional homeostasis; on the extreme right, in a polar opposite position, we find chronic illness and anomie, indicating close interrelationship between them and concomitantly their strong negative relationship with homeostasis. Indeed, as shown in Table 2, chronic illness has the relatively strongest negative association with homeostasis (-0.72). The farther an item is to the left, the greater its power to predict homeostasis; the farther its location to the right, the less it is positively predictive of homeostasis. Close to chronic illness are the items which specify professional assistance. Their proximity reflects, on the one hand, their being the most sought for coping resources by the chronically ill (e.g. pZ between chronic illness and physician as agent of catharsis = 0.64). On the other hand, their great distance from homeostasis indicates their lack of efficacy in alleviating the afflicted individual’s distress (e.g. p2 between physician as catharsis agent and homeostasis is -0.60). (If the physician’s assistance were effective in the restoration of homeostasis, the relationship would have been positive). On the left side of the map we find individual resources, indicating their efficacy in predicting homeostasis. Thus the data lend support to the first part of hypothesis (a) by showing the positive relationship of individual resources to homeostasis, but seem to
and homeostasis maintenance. A portrayal of the structure is particularly important in light of the essence of the hypothesized framework according to which a person’s coping capacity and consequent homeostasis has to be understood in the framework of a structure being a product of the interrelationship and the variables comprising the hypothesized content universe of coping. A practical technique is the SSA-I--Smallest Space Analysis [60,61], where the computer locates each variable as a point on a map according to the strength of the correlations among them: the stronger the positive correlation, the smaller the distance between two points; the stronger the negative correlation, the greater the distance between points. This technique has been found useful in a variety of studies on coping with various stress arousing situations-such as readjustment of disabled [21], or bereaved persons [28] or of hospitalized patients [62], in revealing the relative weight of and complementarity among various factors in the restoration of homeostasis following traumatic life change episodes. Thus the utility of further application of this technique is not merely in its potential or arriving at meaningful conclusions, but in particular in facilitating an accumulation of comparable empirical evidence on the structure of coping in various stress arousing situations which may allow in the future to arrive at an overall empirically verified model of coping. RESULTS
Structure of the homeostasislchronic lationship The SSA-I map (Fig. 1) which displays the relationship among the items on the intercorrelations among them as shown
illness
re-
graphically basis of the in Table 2,
Education 15
12 Marned /
I
19 Hospltollzatvzn
I
Physicmn Vlslts 16
9 Physnans CafharsIs
Family. catharsis
6
CalharsIs
Work campanfians 8 cathaws
11 Rabbi cathaws
7 Fnends: catharsis Parents: cotharsls
Fig.
I. The structure
5
of the homeostasis, illness and resources (smallest space analysis) of intercorrelations
relationship: of Table
two-dimensional 2.
SSA-I
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Chronic illness, stress and coping
give only weak support to the hypothesized effectiveness of primary group resources: On the one hand, most of the individual resources have relatively strong relations with homeostasis (correlations coefficient p2 with catharsis: 0.43; with leisure: 0.46; with education: 0.26; with age: 0.38; with income: 0.50; with employment: 0.47; with occupational status: 0.48). [Exceptions are: being married (- 0.15) and dwelling density (OM), which can hardly be conceived as effective resources for predicting homeostasis.] On the other hand, with respect to the primary group resources, only ‘meeting with friends’ has a meaningful monotonic relationship with homeostasis (0.36) whereas all other primary social support items are unrelated to homeostasis @I varies from 0.02 to 0.15). The data support hypothesis (b) by revealing an extreme negative correlation between homeostasis and chronic illness & = -0.74) thus supporting the contention that illness is an expression of breakdown. The positive correlation of chronic illness with anomie (0.35), which is located on the most extreme right alludes to the risk of further psychological deterioration of the chronically ill person’s condition, thus supporting hypothesis (d). The distance of individual resources from chronic illness and anomie reflects their limited effect as coping resources for the chronically ill, thus supporting the first part of hypothesis (c). Yet the location of the primary social group support items on the center of the map alludes to their intervening capacity. The fact that primary group emotional support is not, as hypothesized in (c), negatively related to chronic illness and anomie but rather showed no relationship Q.L~varies between -0.02 and -0.06) does not give unequivocal support to the expected inefficacy of primary groups as a distress relieving agent for chronically ill persons. Indeed, this result alludes to the possibility that under certain circumstances they may have some anomie relieving capacity. The negative correlation between homeostasis and anomie (-0.46) supports the second part of hypothesis (d). The data clearly support hypothesis (e), showing reasonably strong positive correlations between chronic illness and the perception of professionals as agents of emotional support (correlation with physician: 0.64; with psychologist: 0.52; with Rabbi: 0.45). The way the question was posed (“With whom do you talk when feeling tense, nervous and unable to carry on?“) highlights the possible significance of professionals and particularly the physician as emotional support agents. To what extent do they actually satisfy these expectations? As hypothesized in (f), data reveal negative correlations between professional emotional support and homeostasis (physician: -0.60; psychologist: -0.35; Rabbi: -0.15). indicating that turning to a physician or psychologist does not predict alleviation of distress. The situation of those who turn to a Rabbi seems somewhat better, in view of the weakness of the negative association. DISCUSSION
AND SUMMARY
This study was aimed at elucidating the factors that may enhance the coping capacity of a chronically ill
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ZEEV BEN-SIRA
person with the demands imposed upon him by his condition, and hence restore his emotional homeostasis. Considering the stress-potential of chronic illness, with its power of aggravating anomie, alleviating the emotional disturbance seems vital for preventing further deterioration of the person’s condition. As hypothesized, the person’s individual resources were found insufficient for such an endeavour, and professional emotional support, particularly that of a physician, is the most sought for, yet least attainable for alleviating the individual’s distress. This highlights the importance of the physician’s affective behavior toward the patient as a powerful therapeutic tool. In fact, recent evidence [40-43] ascertained the importance of the physician’s affective behavior toward the patient in the latter’s assessment of the efficacy of the medical treatment and in his gaining a feeling of reassurance. That has to be understood in the light of the fact that the patient’s emotional state is to a great extent determined by his perception of the seriousness of his condition and prognosis. Hence, the expected solution is mainly from the physician, a fact that indeed gains support from the strong association of chronic illness with perceiving the practitioner as the most preferred agent of catharsis, his weight being greater than that of all other agents. However, the physician seems not to be sufficiently aware of these expectations, assuming probably that the therapeutic success of the physical disturbance would concomitantly also alleviate the emotional disturbance, thus viewing affective behavior as either an ineffective therapeutic tool, or altogether superfluous. Such an approach may sometimes lead to a feeling that the physician believes that any further investment. with respect to a chronically ill person will be ineffective, and any further attention to him may deprive other, more promising cases. However, since chronically ill persons conceive, as we have seen, the physician as the most relevant support agent, such a behavior on the part of the physician may ultimately contribute to the acceleration of the deterioration of his condition. Further study is needed to ascertain the extent to which physicians are indeed unaware of the possible compensatory function of affective behavior. A peculiar position occupy primary group emotional support agents (‘agents of catharsis’). Their intermediate position between homeostasis on the one hand, and chronic illness and anomie, on the other, seems to indicate both their low weight in promoting homeostasis and in serving as support agents for the chronically ill. Yet this position may also be interpreted as indicating the possible success they may have in alleviating distress, if the chronically ill would find their support efficacious. We are aware that these conclusions have to be viewed as tentative, considering several shortcomings of the present study. The fact that the study is not a longitudinal one and reflects the situation at one point of time, may be considered as the most serious shortcoming. Yet, in light of the great limitations (material and other) involved in conducting a longitudinal study on this topic, the inferences drawn from the present data may be considered as an important empirically based baseline and as insight for under-
standing the factors that may promote a chronically ill person’s wellbeing or predict further deterioration of his/her condition. However, followup studies will be required for confirming our conclusions. The fact that our conclusions are based on correlations may be considered as an additional shortcoming and in particular with regard to the direction of prediction. Yet in this respect the present study does not differ from other studies in the social sciences, in view of the limitations imposed on such studies by the present state of art in the realm of data analysis. However, in contrast to many other studies. the advantage of the present one is that many of the resource variables reflect activities that occurred in the past, whereas the person’s level of homeostasis and his state of health relate to the present. Thus, the time sequence may give some support to our argument. Additional support may be gained from the pattern that emerges from looking at the structure as a whole, which is facilitated by the method of multivariate data analysis (SSA) employed here. In this respect this method makes an invaluable contribution in furthering the understanding of the condition of the chronically ill. Another critique that could be raised is the underlying logic of the demands-coping-breakdowndisease relationship. The suggestion that an expression of breakdown (which has been conceptualized here in terms of anomie and disturbed homeostasis) could be any disease, may be questioned. Yet this exactly is the essence of the stress-illness theory [3,4], though it requires still further elaboration. In fact, it is precisely in this respect that the present study contributes a further support to the accumulating evidence on stress-illness relationship (e.g. [6, 12-14, 63,641 by showing the associations described here, which are independent of the type of chronic condition. Finally, the fact that the present study relates to the Jewish Israelis requires further investigation for ascertaining the applicability of its conclusions to other cultural contexts with other schemes of medical services. Despite these reservations, I think that the present study may be considered as an important contribution to the understanding of the factors that may enhance or impede a chronically ill person’s wellbeing and arrest, or at least reduce the risk of further deterioration of his condition. REFERENCES 1. Selye H. The Stress of Lye. McGraw-Hill. New York. 1956. 2. Janis I. L. SIWSS and Frusmztion. Harcourt. Brace Jovanovich, New York, 1971. 3. Antonovsky A. Health, Stress and Coping. Jossey Bass, San Francisco, 1979. 4. Antonovsky A. Breakdown: a needed fourth step in the conceptual armamentarium of modern medicine. Sot. Sci. Med. 6, 537-544,
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tion and Data Analysis in the Behavioral Sciences (Edited by Shye S.), pp. 371-390. Jossey Bass, San Francisco, 1978. 60. Ben-Sira Z. and Guttman L. A Facet Theoretical Approach to Research. The Israel Institute of Applied Social Research, Jerusalem, 1971. 61. Bloombaum M. Doing smallest space analysis. J. Conflict Resol. 14, M16,
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62. Ben-Sira Z. The structure of a hospital’s image. Med. Care 21, 943-954, 1983. 63. Bommer K. and Newberry B. H. (Eds) Stress and Cancer. Hogrefe, Toronto, 1981. 64. Hollis J. F., Conner W. E. and Materazzo J. D. Lifestyle, behavioural health and heart disease. In Handbook of Psychology and Health (Edited by Gatchel R. J., Baum A. and Singer J. E.). Lawrence-Elbaum, Hilldaly, NJ, 1982.
APPENDIX
I
Here is a list of diseases or other conditions. Have you been told by a physician that such a condition has been diagnosed? 1. High blood pressure 2. Heart disease 3. Other disease of blood circulation 4. Diabetes 5. Disease of the nervous system 6. Rheumatism 7. Ulcer of stomach 8. Chronic eye disease 9. Cancer 10. Liver disease 11. Kidney disease 12. Other chronic condition of the digestive system 13. Bone disease 14. Other chronic condition 15. Permanent disability because of injury.
Measures
14
12 13
9 10 II
3
Identification No. of item?
Resource
Modality
.
.
.
.
.
Self
Resource
. . . . . .
Marital status Meeting with friends
Physician Psychologist Rabbi
Spouse Parents Other family members Friends Work companions
Agents of catharsis:
.
Satisfaction: catharsis
Leisure activities
. . . . . . . .
Primary group
.
Professionals
.
Primary groups
. .
Self
Agent of control of resource
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
I. Spontaneous response* (For those not spontaneously mentioned, after probing) 2. Very often 3. often 4. Rarely 5. Never 6. (Not relevant, e.g. not married)
.
~~___ ~~~ _..__ 5. Very often, 3. often, 3. rarely, 2. very rarely. I. never
Response options
.
How often do you usually meet with friends . . . . . . . . . . . How often do you spend your leisure out of your home, e.g. visit movies, theatre, night club, cafe, excursions
.____
1. Married, 2. Not married I. Several times a week. 2. Once a week. 3. 2-3 times a month, 4. Once a month. 5. Once in several months, 6. Once a year. 7. More rarely, 8. Never
__~__
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
When you feel tense and nervous and you can’t carry on any longer, with whom do you usually talk?*
. . . . . . . . . . . .
Question
II
During the past year, did it happen that you felt that you have nobody to talk to about your worries, about being lonely, tense or nervous?
APPENDIX
3 B & a s .U 8’ 09
.r
8
n
3 _.
3 ti
L
A
Education
Numberof years of schooling
_‘I.
I. Completed university, 2. l3+ years of schooling (no university diploma) 3. 12 years, 4. 11 years, 5. 9-10 years, 6. 5-8 years, 7. 4 and less, 8. no schooling Youne-l old Age . ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Physician visits In the past two years, how 1. Every week, 2. 2-3 Times a month, Professionals 3. Once a month. 4. Once every 2-3 months, often did you see a physician 5. Once in half a’ year, 6. Once-a year, about your health 7. once, 8. not during the recent two years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes: How long was your last term of Hospitalization Have you been hospitalized hospitalization? in the recent two years I. More than a month, 2. 34 weeks, 3. Two weeks, 4. One week or less, No: have you been hospitalized before that? 5. Yes, 6. No . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Self Income , ., .., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., . . 1. Employed, 2. Unemployed Employment status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. Professionals and scientific, Occupational status 2. High ranking administrators and political leaders 3. Business owner 4. Nonacademic professionals (e.g. elementary school teacher) 5. White collar 6. Technicians 7. Skilled blue collar 8. Unskilled 9. Unemployed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rooms per individual in Dwelling density apartment
Self
*Interviewer waited for spontaneous response and coded 1 any of the ‘agents’ mentioned. For those not mentioned, the interviewer probed: “To what extent did you also talk with tltem No. 1 = emotional homeostasis, No. 2 = anomie, No. 3 = chronic illness.
23
N
22
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E
M
R
T
S
N
I
21
20
19
18
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IS
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