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Regression, stress and readjustment in aging: A structured, bio-psychosocial perspective on coping and professional support
Sm. Sci. Med. Vol. 37, No. 3, pp. 437440, Printed in Great Britain
0277-9536/93 $6.00 + 0.00 Pergamon Press Ltd
1993
BOOK REVIEWS
Issues in Reproductive Technology I: An Anthology, edited by HELEN BEQUAERTHOLMES. Garland Publishing, New York, 1992. In the preface to her edited book, Dr Helen Bequaert Holmes notes that although reproductive technology has its roots in medicine, the nature of a technology that has as its subject the very essence of life and species survival needs to be analyzed from social, psychological, ethical, legal and political (as well as medical and technological) perspectives. Hence, she begins the ambitious task of piecing together a book with sections devoted to new contraceptives, the abortion debate, cryopreservation of embryos, psychosocial dimensions of in-vitro fertilization, and contract pregnancy, weaving the aforementioned perspectives into each section. Distinguishing this effort from others is her dual emphases on feminism and reproductive rights. She is to be applauded for generally having succeeded in this ambitious undertaking with this mostly well written and engaging volume. To be consistent with the overall theme of the book, some chapters make obligatory nods toward feminism (such as in the last paragraph of ‘Contraceptive vaccines: promises and problems’) while dealing with a technological or other topic area. In general, however, the chapters are strongly feminist, as is appropriate, and generally embrace various other sociopolitical points of view, as is natural. The chapter ‘Teen pregnancy among black women’ takes as its point of departure “the Moynihan doctrine and its sexist/racist analysis”, which although published one year after the Gulf of Tonkin Resolution is deemed by this author still to be highly influential among politicians-and policy makers. The author reviews the work of two ‘black authors’, a ‘black labor organizer’ and a ‘white woman’ to counterattack Sen. Moynihan’s prejudice and unevenness. Yet less convincing is the chapter ‘Slavery and contract motherhood: a radicalized objection to the autonomy arguments’, which seeks to draw an analogy and even direct historic roots of modern day contract motherhood with slavery in general and rape of slave women by their white male owners in particular. This author has overworked a fairly straightforward point: people with less money and/or power are forced to do things that people with more do not have to. While one may or may not agree with perspectives such as this, it is certainly important to be exposed to and
understand them. Using parallel standards, however, the reader in turn becomes worried about the narrowness of this book. Here I am not referring to ‘right to life’ or other politically conservative viewpoints; it is quickly apparent that such will receive no attention. In the preface, however, the editor acknowledges that although the bulk of the authors come from the U.S., an international perspective is gained through the inclusion of Europeans, Australians and Canadians. Yet among the chapters’ 31 authors there is only (apparently) one person who represents an underdeveloped country, and no chapter devotes itself uniquely to family planning and develdpment. The 1985 fertility rates for Africa. Asia and Latin America were 6.6, 4.2 and 3.9. respeciively, while the U.S. stabilized at 2.0 [l]. Since (a) reproductive technology and the suffering of women is least as pertinent to populations of less developed countries as it is to Americans, and (b) the feminism espoused in this volume is clearly derived from Western/Northern value systems, why is there not more of a truly international perspective? Nevertheless, reproductive technology in underdeveloped countries does get some attention (e.g. in ‘Norplant: conflicting views on its safety and acceptability’). In short, the title’s subheading “an anthology” is probably misemployed. Anthology connotes a less than totally systematic collection of essays. Such is clearly not the case here: a more appropriate trailer might have been “an American feminist perspective”. Nevertheless, the book includes excellent discussions of issues related to reproductive choice as well as straightforward technical presentations of reproductive technology. It will be a valuable addition to the libraries of scientists and technologists needing more information on the former topic as well as social scientists and policy makers who want to learn more about the latter. Graduate School of Public Health San Diego State University San Diego, CA, U.S.A.
JOHN P. ELDER
REFERENCE 1. Demographic Data for Development Project. Child Survival: Risks and Road to Health. Institute for Resource Development, Washington, DC, 1987.
Regression, Stress and Readjustment in Aging: A Structured, Bio-Psychosocial Perspective on Coping and Professional Support, by ZEEV BEN-SIRA. Praeger, New York, 1991. $45.00.
The present volume was authored during a sabbatical at Rutgers University, and represents an attempt to develop a new paradigm for aging, based on the stress-outcome model. This new paradigm characterizes aging as bio-psychosocial regression. Ben-Sira defines age-related regression as “the product of a damaging cycle of reciprocally activating deleterious stimuli” (p. 10). He contrasts this view with traditional views of aging, such as disengagement theory, and proposes this new paradigm as a means to identify and remediate individual and environmental factors that interfere with successful adaptation in aging. The strength of Ben-Sira’s model is two-fold: its basis in the theoretically and empirically sound stress-outcome
Zeev Ben-Sira is the director of the School of Social Work at the Hebrew University in Jerusalem, with an appointment to the Louis Guttman Israel Institute of Applied Social Research. With interests in the areas of both aging and disability, Ben-Sira has the ideal background to author a volume relating the two topics. Further, his extensive publication record, in this journal and others, suggests a social and political sensitivity that are evident throughout. 437
438
Book Reviews
model, and its systematic identification of the many changes associated with aging. A wealth of literature exists to support and elaborate the notion that stress has deleterious effects on the human organism, and that certain filters exist to buffer or modify these harmful effects. Ben-Sira enumerates many of the stressors associated with aging, including health problems, disability, risk of falling, organic mental disorders, negative attitudes, retirement, residential relocation, institutionalization, limited self-control and widowhood. He states that: Disability, despair . ., apprehension . . ., and increasing dependence are apt to crush the aging individual’s self-concept and self-esteem (p. 31). While this is not a particularly positive view of aging, Ben-Sira’s review leaves little doubt that it is accurate and empirically supported. With regard to buffers of the potential negative effects of these stressors, two categories are considered: coping and resources. Within coping, particular emphasis is placed on the concept of ‘potency’, first advanced by Ben-Sira himself, in a 1985 article in this journal. Potency is defined as a belief in one’s own coping potential and in the potential of one’s social network to provide the necessary. Resources are classified as either intrapersonal or extrapersonal. Intrapersonal resources include health, gender, socioeconomic status, experience and mastery; extrapersonal resources include formal and informal social supports. Thus the model is conceived as an equation, where the diminution of resources and the expansion of stresses that inevitably accompany aging, have predictable effects on the outcome of adjustment. Finally, Ben-Sira proposes a model of practice, aimed primarily at physicians and social workers, to guide intervention against the march toward disability, dependence and despair. The model is summarized in an extremely complex and not terribly helpful figure on p. 95. Ben-Sira suggests that the “damaging cycle . . of age-related bio-psychosocial regression” can be interrupted at two points. First, the sense of potency may be enhanced, through a number
Health for AU? Evaluation and Monitoring in a Comprehensive Primary Health Care Project in Colombia, by P. E. M. ENGELKES. Royal Tropical Institute, Amsterdam, 1989. 205 pp. During the 1980s when much of the developed realm scaled back development assistance, the Dutch quietly moved forward in typical fashion on a number of projects in the developing world. P. E. M. Engelkes painstakingly describes one such project in the Choco region on the Pacific coast of Colombia. This is a remote corner of South America comprised of scattered African-Amerindian fishing people and remains one of the great last frontiers of tropical settlements remaining. In twenty-one tightly organized chapters, Engelkes guides the reader on a detailed safari of the region, primary health-care monitoring methods, and the outcome of this four-year grassroots project. Her experience with development work in Africa affords her with a broad disciplinary approach to primary health care which complements her medical and public-health training in the Netherlands. Because this monograph is based on her Ph.D. thesis, it reveals some of the strengths and weaknesses of making the transition from a closed committee of a few select scholars, to a tome of general interest to a wider audience. In other words, it may be a bit too ambitious, trying to satisfy too many disciplines. Even
of mechanisms specifically outlined in the text. Second, resources may be marshalled, either through compensation/substitution or enhancement. In the final two chapters, Ben-Sira directs a number of remarks specifically to physicians and social workers, with the intent of overcoming common professional biases and belief systems that militate against effective service to aging individuals. Many of the ideological critiques of professional health services advanced in Ben-Sira’s earlier works are evident in these remarks, however, a true structural analysis is still lacking of the problems experienced by aging individuals uis-ri-uis the health care system. The critique stops short of analysing maladjustment as a function of the environment in any substantive sense. Instead, the author considers the system’s response to problems residing in individual aging persons. In this context, he raises crucial issues like professional dominance, orientation toward cure, and the supremacy of the biomedical model as significant deterrents to interrupting bio-psychosocial regression. In conclusion, “Regression, Stress and Readjustment in Aging”, by Zeev Ben-Sira, serves as a useful review of age-related changes, while presenting these changes in a new context; that is, as a function of stress. Further, this volume outlines the potential for intervention by at least two health disciplines, according to a well-developed and empirically supported model. However, although almost indisputable, the model proposed unfortunately presents aging in a distinctly negative light, with emphasis on losses and deterioration As the structure of Western populations change to include an ever-greater proportion of aging individuals, positive constructive models of aging are sought. In this instance, the reader is left to perform this philosophical conversion to re-interpret the changes that Ben-Sira describes as regression, to read progression toward an ultimately more complete and mature self. Queen’s University Kingston, Ontario Canada K 7L 3N6
MARY ANN MCCOLL
though the author’s introduction to the project was that of “project manager in Colombia, not a researcher” (p. 36), she defends herself capably in reviewing the evaluation research literature. The goals of this development project “were ambitious: to provide community-based primary care for at least 80% of the rural population of the province” (p. xxii) through the use of health workers @romotoras), an auxiliary health center staff, community participation, and an enhanced rural sanitation and water system. The program aims to cast light on the ongoing debate about the merits and detriments of selective versus comprehensive primary care. The former relies, for example, on UNICEF’s GOBIFFF activities (Growth monitoring, Oral rehydration, Breast feeding, Immunizations, Food supplements, Family planning, Female education), while the latter emphasizes the principles of appropriate technology, prevention, intersectoral approach, community participation, and equity. The conclusions of this study are directed to evaluation methods used in comprehensive primary health care. They also suggest that the comprehensive versus selective debate may be a conceptual device that is more relevant in the boardrooms of WHO and PAHO than the stark reality of a destitute sparsely populated tropical forest of Latin America. The twenty-one chapters are divided among five sections: General introduction; Background; Methods; Results; and
0277-9536/93 $6.00 + 0.00 Pergamon Press Ltd
1993
BOOK REVIEWS
Issues in Reproductive Technology I: An Anthology, edited by HELEN BEQUAERTHOLMES. Garland Publishing, New York, 1992. In the preface to her edited book, Dr Helen Bequaert Holmes notes that although reproductive technology has its roots in medicine, the nature of a technology that has as its subject the very essence of life and species survival needs to be analyzed from social, psychological, ethical, legal and political (as well as medical and technological) perspectives. Hence, she begins the ambitious task of piecing together a book with sections devoted to new contraceptives, the abortion debate, cryopreservation of embryos, psychosocial dimensions of in-vitro fertilization, and contract pregnancy, weaving the aforementioned perspectives into each section. Distinguishing this effort from others is her dual emphases on feminism and reproductive rights. She is to be applauded for generally having succeeded in this ambitious undertaking with this mostly well written and engaging volume. To be consistent with the overall theme of the book, some chapters make obligatory nods toward feminism (such as in the last paragraph of ‘Contraceptive vaccines: promises and problems’) while dealing with a technological or other topic area. In general, however, the chapters are strongly feminist, as is appropriate, and generally embrace various other sociopolitical points of view, as is natural. The chapter ‘Teen pregnancy among black women’ takes as its point of departure “the Moynihan doctrine and its sexist/racist analysis”, which although published one year after the Gulf of Tonkin Resolution is deemed by this author still to be highly influential among politicians-and policy makers. The author reviews the work of two ‘black authors’, a ‘black labor organizer’ and a ‘white woman’ to counterattack Sen. Moynihan’s prejudice and unevenness. Yet less convincing is the chapter ‘Slavery and contract motherhood: a radicalized objection to the autonomy arguments’, which seeks to draw an analogy and even direct historic roots of modern day contract motherhood with slavery in general and rape of slave women by their white male owners in particular. This author has overworked a fairly straightforward point: people with less money and/or power are forced to do things that people with more do not have to. While one may or may not agree with perspectives such as this, it is certainly important to be exposed to and
understand them. Using parallel standards, however, the reader in turn becomes worried about the narrowness of this book. Here I am not referring to ‘right to life’ or other politically conservative viewpoints; it is quickly apparent that such will receive no attention. In the preface, however, the editor acknowledges that although the bulk of the authors come from the U.S., an international perspective is gained through the inclusion of Europeans, Australians and Canadians. Yet among the chapters’ 31 authors there is only (apparently) one person who represents an underdeveloped country, and no chapter devotes itself uniquely to family planning and develdpment. The 1985 fertility rates for Africa. Asia and Latin America were 6.6, 4.2 and 3.9. respeciively, while the U.S. stabilized at 2.0 [l]. Since (a) reproductive technology and the suffering of women is least as pertinent to populations of less developed countries as it is to Americans, and (b) the feminism espoused in this volume is clearly derived from Western/Northern value systems, why is there not more of a truly international perspective? Nevertheless, reproductive technology in underdeveloped countries does get some attention (e.g. in ‘Norplant: conflicting views on its safety and acceptability’). In short, the title’s subheading “an anthology” is probably misemployed. Anthology connotes a less than totally systematic collection of essays. Such is clearly not the case here: a more appropriate trailer might have been “an American feminist perspective”. Nevertheless, the book includes excellent discussions of issues related to reproductive choice as well as straightforward technical presentations of reproductive technology. It will be a valuable addition to the libraries of scientists and technologists needing more information on the former topic as well as social scientists and policy makers who want to learn more about the latter. Graduate School of Public Health San Diego State University San Diego, CA, U.S.A.
JOHN P. ELDER
REFERENCE 1. Demographic Data for Development Project. Child Survival: Risks and Road to Health. Institute for Resource Development, Washington, DC, 1987.
Regression, Stress and Readjustment in Aging: A Structured, Bio-Psychosocial Perspective on Coping and Professional Support, by ZEEV BEN-SIRA. Praeger, New York, 1991. $45.00.
The present volume was authored during a sabbatical at Rutgers University, and represents an attempt to develop a new paradigm for aging, based on the stress-outcome model. This new paradigm characterizes aging as bio-psychosocial regression. Ben-Sira defines age-related regression as “the product of a damaging cycle of reciprocally activating deleterious stimuli” (p. 10). He contrasts this view with traditional views of aging, such as disengagement theory, and proposes this new paradigm as a means to identify and remediate individual and environmental factors that interfere with successful adaptation in aging. The strength of Ben-Sira’s model is two-fold: its basis in the theoretically and empirically sound stress-outcome
Zeev Ben-Sira is the director of the School of Social Work at the Hebrew University in Jerusalem, with an appointment to the Louis Guttman Israel Institute of Applied Social Research. With interests in the areas of both aging and disability, Ben-Sira has the ideal background to author a volume relating the two topics. Further, his extensive publication record, in this journal and others, suggests a social and political sensitivity that are evident throughout. 437
438
Book Reviews
model, and its systematic identification of the many changes associated with aging. A wealth of literature exists to support and elaborate the notion that stress has deleterious effects on the human organism, and that certain filters exist to buffer or modify these harmful effects. Ben-Sira enumerates many of the stressors associated with aging, including health problems, disability, risk of falling, organic mental disorders, negative attitudes, retirement, residential relocation, institutionalization, limited self-control and widowhood. He states that: Disability, despair . ., apprehension . . ., and increasing dependence are apt to crush the aging individual’s self-concept and self-esteem (p. 31). While this is not a particularly positive view of aging, Ben-Sira’s review leaves little doubt that it is accurate and empirically supported. With regard to buffers of the potential negative effects of these stressors, two categories are considered: coping and resources. Within coping, particular emphasis is placed on the concept of ‘potency’, first advanced by Ben-Sira himself, in a 1985 article in this journal. Potency is defined as a belief in one’s own coping potential and in the potential of one’s social network to provide the necessary. Resources are classified as either intrapersonal or extrapersonal. Intrapersonal resources include health, gender, socioeconomic status, experience and mastery; extrapersonal resources include formal and informal social supports. Thus the model is conceived as an equation, where the diminution of resources and the expansion of stresses that inevitably accompany aging, have predictable effects on the outcome of adjustment. Finally, Ben-Sira proposes a model of practice, aimed primarily at physicians and social workers, to guide intervention against the march toward disability, dependence and despair. The model is summarized in an extremely complex and not terribly helpful figure on p. 95. Ben-Sira suggests that the “damaging cycle . . of age-related bio-psychosocial regression” can be interrupted at two points. First, the sense of potency may be enhanced, through a number
Health for AU? Evaluation and Monitoring in a Comprehensive Primary Health Care Project in Colombia, by P. E. M. ENGELKES. Royal Tropical Institute, Amsterdam, 1989. 205 pp. During the 1980s when much of the developed realm scaled back development assistance, the Dutch quietly moved forward in typical fashion on a number of projects in the developing world. P. E. M. Engelkes painstakingly describes one such project in the Choco region on the Pacific coast of Colombia. This is a remote corner of South America comprised of scattered African-Amerindian fishing people and remains one of the great last frontiers of tropical settlements remaining. In twenty-one tightly organized chapters, Engelkes guides the reader on a detailed safari of the region, primary health-care monitoring methods, and the outcome of this four-year grassroots project. Her experience with development work in Africa affords her with a broad disciplinary approach to primary health care which complements her medical and public-health training in the Netherlands. Because this monograph is based on her Ph.D. thesis, it reveals some of the strengths and weaknesses of making the transition from a closed committee of a few select scholars, to a tome of general interest to a wider audience. In other words, it may be a bit too ambitious, trying to satisfy too many disciplines. Even
of mechanisms specifically outlined in the text. Second, resources may be marshalled, either through compensation/substitution or enhancement. In the final two chapters, Ben-Sira directs a number of remarks specifically to physicians and social workers, with the intent of overcoming common professional biases and belief systems that militate against effective service to aging individuals. Many of the ideological critiques of professional health services advanced in Ben-Sira’s earlier works are evident in these remarks, however, a true structural analysis is still lacking of the problems experienced by aging individuals uis-ri-uis the health care system. The critique stops short of analysing maladjustment as a function of the environment in any substantive sense. Instead, the author considers the system’s response to problems residing in individual aging persons. In this context, he raises crucial issues like professional dominance, orientation toward cure, and the supremacy of the biomedical model as significant deterrents to interrupting bio-psychosocial regression. In conclusion, “Regression, Stress and Readjustment in Aging”, by Zeev Ben-Sira, serves as a useful review of age-related changes, while presenting these changes in a new context; that is, as a function of stress. Further, this volume outlines the potential for intervention by at least two health disciplines, according to a well-developed and empirically supported model. However, although almost indisputable, the model proposed unfortunately presents aging in a distinctly negative light, with emphasis on losses and deterioration As the structure of Western populations change to include an ever-greater proportion of aging individuals, positive constructive models of aging are sought. In this instance, the reader is left to perform this philosophical conversion to re-interpret the changes that Ben-Sira describes as regression, to read progression toward an ultimately more complete and mature self. Queen’s University Kingston, Ontario Canada K 7L 3N6
MARY ANN MCCOLL
though the author’s introduction to the project was that of “project manager in Colombia, not a researcher” (p. 36), she defends herself capably in reviewing the evaluation research literature. The goals of this development project “were ambitious: to provide community-based primary care for at least 80% of the rural population of the province” (p. xxii) through the use of health workers @romotoras), an auxiliary health center staff, community participation, and an enhanced rural sanitation and water system. The program aims to cast light on the ongoing debate about the merits and detriments of selective versus comprehensive primary care. The former relies, for example, on UNICEF’s GOBIFFF activities (Growth monitoring, Oral rehydration, Breast feeding, Immunizations, Food supplements, Family planning, Female education), while the latter emphasizes the principles of appropriate technology, prevention, intersectoral approach, community participation, and equity. The conclusions of this study are directed to evaluation methods used in comprehensive primary health care. They also suggest that the comprehensive versus selective debate may be a conceptual device that is more relevant in the boardrooms of WHO and PAHO than the stark reality of a destitute sparsely populated tropical forest of Latin America. The twenty-one chapters are divided among five sections: General introduction; Background; Methods; Results; and