108 MW 312 Ill “MW W l l lllljlllflflllflll L ,3 R A R Y 006 6 Michigan State ”up.“ U . . This is to certify that the thesis entitled An Exploratory Study to Delineate Personal Meaning Categories of Chronic Physical Illness presented by Wendy Jean Fielder has been accepted towards fulfillment of the requirements for Master' 8 degree in Psychology 1M4 Major professor NW Elam saw 0-7639 OVERDUE FINES ARE 25¢ pER DAY PER ITEM Return to book drop to remove this checkout from your record. AN EXPLORATORY STUDY TO DELINEATE PERSONAL MEANING CATEGORIES OF CHRONIC PHYSICAL ILLNESS BY Wendy Jean Fielder A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF ARTS Department of Psychology 1979 ABSTRACT AN EXPLORATORY STUDY TO DELINEATE PERSONAL MEANING CATEGORIES OF CHRONIC PHYSICAL ILLNESS BY Wendy Jean Fielder One hundred fifty-three individuals with chronic lung disease or diabetes completed a 60 item questionnaire designed to measure illness perception. Factor analysis yielded five factors with good reliabilities. Correlations were carried out between these factors and various other demographic measures as well as with a measure of helpfulness of others develOped in this study, and the Holmes and Rahe Social Read- justment Rating Scale. The factors were compared to those prOposed and found in two other studies, and their relation- ship to coping strategies was discussed. Scale validation attempts and difficulties were discussed and suggestions for future study offered. TABLE OF CONTENTS List of Tables Introduction Generality vs. Specificity: Two Ways of Viewing Stress Threat and Its Appraisal Methods of Coping; Minimization, Vigilant Focusing and Capitulation Personal Meanings of Illness Experimental Work with COping Styles Method Subjects Diagnosis Materials Results DeveIOpment of Measures Helpfulness Scale The Social Readjustment Rating Scale Response to Illness Questionnaire: Factor Analysis Hypotheses Relating RIQ Factors to Other Measures Results Correlations of the Factor Scales with Help- fulness Scale and SRRS Relationship of Diagnostic Categories and Fac- tor Scales ii iv' 13 15 20 20 2a 2a 26 26 26 26 26 34 35 35 35 TABLE OF CONTENTS (cont'd.) Correlations of the Factor Scales with the Demographic Data Correlations of Demographic Data, Helpful- ness Scale and SRRS with Items which were Rejected in RIQ Factor Analysis Discussion Comparison with Lipowski's Meaning Categories: The Similarities Comparison with Lipowski's Meaning Categories: The Differences Comparison with Pritchard's Empirically Ob- tained Factors: The Similarities Comparison with Pritchard's Factors: The Dif- ferences Summary The Meaning of Illness and Coping Strategies The Problems with Validity Future Directions Conclusion Appendix A: Social Readjustment Rating Scale Appendix B: Response to Illness Questionnaire Bibliography Viii 37 38 41 42 46 49 54 55 56 58 62 63 65 67 69 LIST OF TABLES Demographic Information Final Scales Factor Loadings for the Final Items Intercorrelations for the Five Final Items Correlations of Factor Scales with SRRS, Helpfulness Scale, and Demographic Data Correlations of Rejected Items from RIQ with Demographic Data, Helpfulness Scale and SRRS Factors Identified by Pritchard iv 22 29 32 33 36 39 51 INTRODUCTION Facing the reality of having a chronic disease certain- ly ranks as one of the most stressful events a person can encounter during his lifetime. Aside from the possible life threatening implications, the very nature of a chronic ail- ment implies that a person has to re-evaluate the rest of his life in terms of the illness' effects. This may involve many changes: from day to day routines, lessening abilities to engage in activities, alterations in social relationships to changes in an individual's self concept. And when the disease is not only chronic but threatening to an individ- ual's life itself, the person's concept of what his life will be, in terms of length and achievements, is drastically challenged. These stressful changes are also made even more difficult to deal with because, due to the disease involved, the person's strength and resources are being drained. So, not only is the situation difficult to face in itself, but a person's resources for dealing with stress are likely to be lower than at other times in his life. Stress, and the individual's strategies for cOping with it, have been topics of increased interest in recent years. What types of events are the most stressful, what environ- mental configurations increase the likelihood that an event 2 will be seen as stressful, how do personality characteris- tics affect the appraisal of, and subsequent COping with, stress, what behavioral, physiological and emotional reac- tions are common to all in stressful encounters and what ones are specific to certain individuals? Generality vs. Specificity: Two Ways of Viewing Stregs There seem to be two main theoretical approaches to stress found in the literature. The first, illustrated best by the early work of Selye (I956), emphasizes the gen- erality of response to all kinds of stress. His popular concept of a General Adaptation Syndrome (GAS) explains all forms of threat as activating this general defense. An in- dividual is first in a state of alarm as the threat is rec- ognized, then goes into a stage of resisting the threat, and finally, as the situation continues, the system reaches a point of exhaustion. A person in this final stage is likely to have undergone some type of tissue damage as a re- sult of the struggle. The well known Holmes and Rahe social readjustment scale is based upon the concept of a general reaction to stress. In this, major life changes are given point values according to the amount of stress they produce (in any person) and a total of above 200 is an indication that the individ- ual's defensive resources are likely to be depleted, with the possibility of serious physical illness following. The_other approach to conceptualizing stress is that 3 of specificity. According to this viewpoint, different en- vironmental demands will result in differential stress dis- orders, depending on the nature of the demand, the character- istics of the individual facing that demand, and the ways in which that individual attempts to cope with the situation (Lazarus, 1966). Both approaches have given us valuable insights into the components and reactions to stress, but as Lazarus states, "...I find the specificity arguments richer in the range of potential factors that might account for var- iations in the degree and type of somatic illness in differ- ent individuals and under different environmental conditions." (1974) A concept that supports the idea that an individual plays an important role in determining his reaction to stress is that of threat being cognitively mediated. A study by Symington, Currie, Curran and Davidson (1955) showed that the physiological mechanisms of the GAS are not brought into play by an injured animal unless the organism is conscious during the injury. In other words, the activation of the GAS is psychologically determined, in that threat, or stress, is not reacted to without it being cognitively assessed as such. Theorists such as Ellis (1973) and Seligman (1975) also emphasize the causal chain as being from cognition to emotion, and not the other way around. Lazarus' major work on stress (1966) is based on the belief that cognitive ap- praisal of the situation leads to feelings of stress, an- xiety and fear: and that this appraisal is necessary to mo— bilize coping responses. L, This is not to say that these appraisals are necessar- ily rational or lead to particularly adaptive responses. In- dividuals' beliefs about the environment and themselves can run the gamit from being reasonable and reality oriented to delusional and fantasy based. It is to say that these ap- praisals of the situation will follow from these beliefs, and likewise be realistic and lead to reasonable responses, or be unrealistic and result in unadaptive and possibly even harmful coping reactions. Threat andets Appraisal Threat is by definition an anticipated harm, which pro- mises to hinder or prevent a personal goal. The more impor- tant the reaching of this goal is to a person, the more threat its demise presents. Some types of goals are more or less universal, e.g. good health and freedom from pain, and so reactions to threats of these goals will be somewhat similar for every person. Even so, some differences in re- sponse can be noted, and these relate to different COping mechanisms utilized by different individuals. The two major factors that affect how a threat is ap- praised are the situational factors involved and the person- ality characteristics of the person doing the appraising (Lazarus, 1966). In considering the situational factors, one must first assess the balance of power between the harm producing stimuli and the individual's own resources to coun- teract the potential danger. If the person can muster the power to overcome the harm, the threat is substantially 5 reduced; likewise if it seems that the harm will occur re- gardless of personal efforts, the threat grows. The person's resources include his knowledge of the objective danger, his environmental supports in the form of his family and other interpersonal relationships, and his beliefs about his own power. In this last aspect, it is important to note that it is the person's belief about his abilities, more than his actual power, that is the vital factor. One must also take into account the imminence of ex- pected confrontation with harm. If it is expected far in the future, the magnitude of the threat it presents is like- ly to be much less than if it is more immediate. This can be seen in Mechanic's study of graduate students facing doc- toral exams (1962). He found that the anxiety and preoccu- pation of the students with possible failure increased as the time for the exams grew closer. This can also be seen clearly in the attitudes found towards death in this country. Younger, healthier pe0ple rarely dwell on thoughts of their own deaths and therefore do not consider it much of a threat to their planned activities and goals for their lives. But as anyone who has visited an older, and/or quite ill person can see, death, and the threat it poses are much more imme- diate and great. The appraisal of threat is also influenced by the ambi- guity of clues about the anticipated harm. The more vague the danger seems, the less threat it will cause a person to feel, in general. However, ambiguous clues about harm allow personal idiosyncrasies to dominate the affective reaction. 6 That is, if a person is inclined to be pessimistic about his environment and his abilities to resist harm, even slight indications of harm can set this apparatus into mo- tion. Likewise, a more optimistic personal outlook will al- low an individual to overlook or minimize small possibil- ities of danger. In the case of dealing with physical illness, aspects of the illness itself are important considerations in how the situation will be appraised. The seriousness of the disease, its location in the body, degree of reversability and extent to which personal efforts can changeits course are all important variables. These variables must not only be viewed from their objective harm producing characteris- tics, but fOr the meaning they have to the person who is afflicted (Lipowski, 1970). As he states, "The more the impaired body part or function involves the individual's values, conflicts and sources of gratification, the more it challenges his c0ping resources". This brings us to the personality factors that have an effect on how threat will be appraised. As mentioned above, threat is the potential harm that will be done to a motive or goal. In the individual, a threat is only as strong as the motive it endangers is important. These goals may be quite individualistic, or more culturally determined. Whatever their source, a great deal of the meaning of an illness to a person relates to the importance and meaning of the goal it threatens to cut short or alter. This can be clearly seen in the case of mastectomies. The Reach for 7 Recovery program instituted by the American Cancer Society, for instance, focuses heavily on the emotional meanings and consequences of losing a breast as well as on physiological recovery from such a trauma (Lasser, 1972). Threat appraisal is also influenced by the individual's beliefs about his interaction with the environment. If he is inclined to see the environment as dangerous, hostile and untrustworthy he is more likely to appraise a threat as more serious than a person who has more positive trusting feelings about his surroundings and his ability to deal with them (Davids, I956, Lazarus, 1966). A final determinant of the way in which crises are viewed are personal characteristics of the individual, such as in- telligence, educational level and general s0phistication. These can have varied effects on appraisal, e.g. a person of lower intelligence may not recognize certain cues of threat and therefore not feel in danger, but he may also be less amenable to comforting efforts by others in his envir- onment and so may feel more threatened than the objective situation calls for. By the same token, a person of high education may be able to control his fear through his know- ledge of the situation, while another of comparable train- ing may know almost too much about the possible complica- tions and become overly worried. These factors, therefore, can not be examined in isolation from the other variables mentioned: importance of the goal in danger and the individ- ual's concept of the friendly or unfriendly nature of the environment. 8 Methods of COping: Minimization, Vigilgnt Focgsing and Capi - ulgtion The appraisal of threat is only the first step a per— son facing a crisis will take. Following a concept of the amount and type of danger one is in, one must then formulate a method of dealing with, or coping with, the situation. Much has been written in recent years about the differ- ent methods of c0ping, their relative efficacy, and their effect on the adaptation of the individual to his situation. Different authors have titled methods differently, but one finds three major classifications emerging from most of the literature. The first, and the one which has received the most at- tention, is denial. Cohen and Lazarus (1973), Lipowski (1970) and Kiely (1972) refer to this as minimization, or avoiding, Verwoerdt (1972) as retreat from threat and sup- pression, and Hamburg, Hamburg and deGoza (1953) as constric- tion, but all are referring to a similar phenomenon. Min- imization is perhaps the most inclusive of these terms and is characterized by "...a tendency to ignore, deny or ra- tionalize personal significance of information input re- lated to one's illness and its consequences" (Lipowski, 1970). This mechanism is most likely to be seen in the ini- tial, emergency, phase of illness, and is very common and functional when displayed at the beginning (Hamburg et al., 1953, Visotsky, 1961). Visotsky, Hamburg, Goss and Lebovits (1961) offer a A 9 six part definition of the effectiveness of coping, and it would be well to keep this in mind when considering the ef- fects of any attempt to deal with illness. Coping is effec- tive when it serves one or more of the following functions: 1) keeping distress within manageable limits 2) enabling one to feel hope 3) maintaining a sense of personal worth 4) main- taining meaningful social relationships 5) enhancing pros- pects for physical recovery 6) enabling one to establish a satisfactory situation after maximum physical recovery has been reached. I One could look at denial, long perceived as a negative mechanism, in these terms. Work done with victims of cancer and cardiac illness has shown that denial can be quite ef- fective and useful for the cardiac patient, and, in fact, tends to be fostered by the staff and hospital atmosphere (Hackett and Weisman, 1969). For the patient with a good chance of recovery, denial enables him to keep his distress at a minimum, generate hOpe for recovered functioning, which in turn enhances possibilities for a good recovery, and main- tain a sense of personal worth and the quality of relation- ships with significant others. The picture is somewhat dif- ferent, however, for those with an incurable illness. Weisman and Hackett (1967) formulate the idea that the major function of denial is to preserve relationships with important others. Often, those close to a person are made so uncomfortable by a change in the relationship, i.e. the fact that one of them is dying, that they may be driven away 10 from closeness with that person. They hypothesize that the fear of abandonment, of isolation and loneliness. is greater among the dying than the fear of death itself. For this rea- son, many dying people will attempt to ignore the issue of death with those close to them, although they may make it clear to a relative stranger, e.g. a hospital aide, or a so- cial worker, that they are well aware of their situation (Weisman, 1972). While this, on the one hand, will keep those close from being driven away, it, on the other, often increases the individual's loneliness in that he has no one close to him with whom to discuss the vital changes that are occuring within him. This may be likened to the disturbing sensation we are all familiar with; feeling alone in a crowd. This often leads to depression and feelings of extreme alien- tion, as the person may feel rejected as the individual he truly is: a person with a predictably short life span. Minimization is but one way a person consistently deals with stress in his life. Another, also titled by Lipowski (1970), is vigilant focusing. These two forms of cognitive coping styles are, of course, on a continuum, with very few individuals falling on the extreme ends. However, there is some indication that, within limits, a person tends to use these mechanisms to the same degree in any stressful situa- tion, of which dealing with a chronic illness is only one instance (Shneidman, 1963). Vigilant focusing is characterized by obsessional, an- xiety prone attention to the problem, with attempts at 11 mastery and understanding. It too falls, at times, in the effective c0ping category, and at others, not. When anxiety is moderate, for example, before surgery, the post operative prognosis is generally good, as the person has had a chance to do his "worrying work" in advance and come to terms with his situation (Janis, 1958). On the other hand, those that are extreme vigilant c0pers may be so caught up in the need to master situations, that they have extreme difficulty in accepting the necessary dependent position of illness and therefore, hinder their chances for recovery (Cohen and Lazarus, 1973)- The third major coping mechanism, capitulation, has not received quite the interest and study that the other two have had, but is an important variable none the less. Per- haps the most influential discussion of giving up is offered by Seligman (1975), who puts forth the idea that those who have become convinced of their powerlessness in altering their lives tend to give up. This phenomenon has been nice- ly distinguished from hopelessness by Schmale (1972). Help- lessness, he says, is the feeling of powerlessness over the achievement of external sources of gratification. Hopeless- ness, while it may be generated by helplessness, is differ- ent in that.it represents a person's inability to satisfy his own standards. Both are detrimental to recovery, or effective acceptance of the situation. These mechanisms should not be confused with passivity in the service of letting the body rest and get better. 12 This type of passivity, which in the case of a curable ill- ness, is temporary, is an adaptive response to the reality of decreased bodily energy. Capitulation should also be differ— entiated from what Weisman and Hackett (1961) refer to as a predilection to death. This occurs when death is seen as appropriate, desirable, and accompanied by little anxiety or depression. The instance of this is somewhat rare, but gives us a model of what may be fostered in the terminally ill in order to make their death more acceptable and anxiety free. Conflict is reduced, compatibility with the ego ideal is achieved, important relationships are continued or re- stored, with death representing the fulfillment of a wish. Although these three mechanisms may continue for the duration of the illness, often the patient is able to move on from these towards recovery and/or acceptance. Visotsky et al. (1961) and Hamburg et al. (1953) have reported very interesting observations of the progress of polio and burn victims, respectively, and cite the aforementioned strate- gies of c0ping as emergency mechanisms for the most part. After the emergency phase has passed, they record the mecha-- nisms that aid in recovery. Important among these are re- newal of hope, sustaining family and other significant re- lationships, the use of humor, interaction with other pa- tients and the community, the setting of intermediate goals, the restoration of self esteem, and the perceived ability, as functioning is beginning to be recovered, of being able to master some of the situation. 13 Pergonal Meanings of Illness As mentioned above, a person's appraisal of threat re- sults from many situational and personal variables. The same is true for the type of c0ping strategy an individual adopts in the face of threat: it is based on the personal meaning an illness or injury has to an individual (Lipowski, 1970). Lipowski details eight major categories this meaning may fall into which are prevelant in our culture. The first is "illness as challenge". This meaning en- courages active participation in coping and generally in- spires adaptive behavior. In direct contrast to this is "ill- ness as enemy“, which, as the name implies, denotes attack, which leads to anxiety, fear and anger, and can promote the feelings of helplessness, desire to surrender, passivity, and in its extreme forms, blame towards others for "causing" the illness. In a slightly different vein, there is "illness as pun- ishment". This may be accompanied by depression, anger and anxiety and can represent the illness as just or unjust pun- ishment. Some patients may come to the conclusion that they have now paid for their wrongdoings, and can face the rest of their lives with renewed hope and vigor. Others, who feel unjustly afflicted, are likely to show signs of deep depression. A meaning especially related to our culture is "illness as weakness". This not only refers to physical weakness, but some flaw in moral character as well. This is likely to 14 lead to guilt feelings and the attempt to hide the fact of being ill. A particularly dangerous meaning in terms of the ability to recover is "illness as relief". Some patients may dis- cover that their illness gives them a welcome respite from responsibilities, and attempt to cling to their disabilities even when physiologically recovered. This phenomenon is akin to that of secondary gain in psychologically disturbed indi- viduals. Although the symptoms may develOp from many sources, - the person discovers, "secondarily", that these same symp- toms are giving him advantages and power he is reluctant to give up. This makes the treatment of these types of distur- bances much more difficult, because removal of the symptoms also means removal of the gains a person is getting from them. Parsons and Fox (1952), in their classic discussion of ill- ness in America, have taken the "illness as relief" idea one step further, saying that in many cases, the etiology of illness can be traced to the individual taking a "legit- imate", culturally approved way out of his life pressures, by becoming ill. Related to the relief patients may feel at being ill, is the meaning "illness as strategy". In this, the ill per- son may, through his dependence, attempt to manipulate those close to him. To the extent that this strategy is success- ful, this type of patient may also fight any improvement in his health. A meaning that is especially vital to discover early on 15 in the illness process is "illness as irreparable loss or damage". This relates strongly to the excessive emphasis our society places on physical vitality in men, and physical attractiveness in women. A patient who believes that he or she has lost something vitally important which can never be restored or replaced is a good candidate for severe depres- sion, and possibly attempts at suicide. Therefore, the ear- ly identification of this meaning may be necessary to save a patient's life. The final meaning Lipowski lists is "illness as value". Whether one wishes to classify this as a "defence" or not, there are individuals who firmly believe that the experience of being ill has enabled them to deepen their personalities and has given them extra sensitivity to life. This is not a prevalent vieWpoint in our society, but certainly enables the person who can believe this to develop a much more pos- itive outlook on himself and his experience than many of the preceeding meanings. Egperimentgl Work with Cooing Styles Some work has been done trying to link meanings and c0ping styles to observable differences in recovery rate and emotional reactions to illness and surgery. Janis' classic work on stress (1958) studied the connection between pre-Operative defense mechanisms, or ways of COping, with post-operative reactions. He found that very low levels of pre-operative fear, or high degrees of denial, were 16 linked with poor recovery rates coupled with anger and re- sentment. He hypothesized that this was the result of lack of preparation for the ordeal, while those that had a medium level of pre-operative fear were able to do the "work of wor— rying" prior to their operations. This enabled them to take the frightening aspects of the experience and develop some reassuring attitudes which carried them through recovery with a minimum of emotional disturbance. Andrew (1970) worked with prospective surgery patients also, giving them information on their upcoming Operations. She found that people with different customary coping styles (i.e. avoiders, sensitizers, which correspond to vigilant focusers, and neutrals) reacted differently to her "helpful" tactics, with only the neutrals being able to use the infor- mation to cut their recovery time. In another study on surgery reactions, Cohen and Lazarus (1973) found that neutral and avoidant groups recovered the quickest, with vigilant focusers having the most difficulty. They theorized that vigilant cOpers are, by nature, people to Whom mastery is important, and the dependent and helpless aspects of undergoing surgery were very difficult for them to accept. They also postulated that denial, or avoidance, is the most effective way of dealing with surgery, especially if the prognosis is good. This conclusion is at odds with that of Janis, and illustrates the relatively small degree of knowledge that is available in this area at the present time. . Using a different group of subjects, Bulman and Wortman 17 (1977) studied the reactions of accident victims who were now quadroplegic or paraplegic. They found that the best c0pers were those who blamed themselves for the accident, but at the same time felt that they could not have done any- thing to avoid it. They interpret these findings as indi- cating a need for an orderly and meaningful world, rather than a controllable one. It could also be seen as an effort on the part of the victim to reason that if it was his fault he would have the power to make it better somehow. This is reminiscent of a vigilant form of coping, of a person who feels somehow responsible for what happens to him, and consequently, responsible for his reactions to the event of being injured. The authors do warn, however, that these re- sponses are those of peOple who were healthy one day, and permanently crippled the next, and these may differ signi- ficantly from the dynamics of peOple whose illnesses pro- gress at a more gradual rate. Another offshoot of the theorizing on meaning dimen- sions of illness are attempts to empirically document im- portant dimensions of disease, by collecting responses to items about illness perception and then conducting factor analyses on the resulting data. Most of these studies have been conducted on patients with chronic pain (Pilowsky and Spence, 1975, Timmermans and Sternback, 1974), and while these are interesting, they have doubtful generalization to populations with illnesses that do not have the obvious psychosomatic components chronic pain does. 18 One series of studies has been done on patients in haemodialysis (Pritchard, 1974a, 1974b, 1974c) which lends some support to the meaning categories proposed by Lipowski. Pritchard found the following factors emerging from his study: disease seen as enemy vs. seen as a challenge, feel- ing self responsible vs. disease as unjust punishment, help appreciated vs. dependence resented, anger vs. depression, information desired vs. worry, fight vs. escape and a dimen- sion of loss and failure. Unfortunately, this study was conducted on a very small group of patients, which casts extreme doubt on the validity of conducting a factor analy- sis, and therefore, on the factors identified. Work in this area is obviously, however, of importance in the treatment of people with illnesses. If a method of identifying both the factors in disease meaning, and an in- dividual's scores on those factors, can be devised, it could be possible to pinpoint early in treatment those high risk patients, as well as finding which methods of c0ping are the most effective for various types of illness. There is some indication that attempts to help patients c0pe effec- tively will have varying consequences depending upon the pre- ferred c0ping mechanisms of the person involved, so that if his customary outlook could be identified early, the most effective method of reaching him to aid in speedy recovery could be used. The specific areas of an individual's concern could be located, and emphasis, therefore, could be concen- trated on these aspects. Doctors have long noted that 19 different patients with the same prognosis have different rates of recovery and differing degrees of co-operation with therapY: this area of research could eventually give us an empirical method of identifying and helping those with less than Optimal attitudes. The current study prOposes an initial attempt to iden- tify the relevant factors of disease perception, using as a basis the questionniare devised by Pritchard (with some modifications) and using a much larger pepulation so that a factor analysis of the results will have a chance of re- sulting in some valid dimensions. METHOD Subjectg The subjects were patients who were participating in outpatient clinics for chronic disorders at two medical facilities in the Lansing area. These clinics required regular visits (anywhere from once a week to once every six months, depending on the patient's condition) during which time each patient met with his doctor and reviewed his pro- gress, problems and any relevant medical tests that had been done. Subjects were asked about participating in the study when they made this regular visit, and questionnaires were generally completed in the waiting room, or other rooms made available by the clinic. Data were collected over a ten .month period, during which time 238 peOple were approached about participating. They were informed of the voluntary nature of participating, assured of confidentiality regarding their responses and promised that general results of the study would be sent to the clinic where they could pick up a c0py on a subsequent visit. One hundred fifty-three individuals completed the questionnaires, 36 declined participation, 45 took the materials home and did not return them, and four questionnaires were returned incomplete and therefore were not used. In these four cases, the materials were not completed because the subject was too ill to 20 21 continue. An attempt was made to approach everyone who met the criteria of having a chronic illness, so there would not be a biased selection procedure. 0f the completed questionnaires, 92 were from men and 61 were from women. The subjects covered a wide age range, from 20 years to 86 years with a mean of 55. All education levels were represented, the largest group being that with a high school diploma (43 individuals). Over 60% had a high school education or schooling beyond that level. (See Table 1.) ' The subjects used in the present study, and in Pritchard's (1974b), the only other study to date to employ the Response to Illness Questionnaire, all had chronic illnesses, but the type of illness varied, and this may have had an impact on the results of both these studies. The subjects used by Pritchard were 14 (5 male, 9 female) patients with chronic renal failure, undergoing haemodialysis. No other demograph- ic data was given, other than that six of these subjects had been seen by Pritchard for psychiatric consultation in the past. This is a type of illness and treatment that, one might surmise, is quite obvious in the day to day life of the patient, and which requires active monitoring and intervention, as well as, quite possibly, concern about further complications which might be life threatening. The patients used in the current study were for the most part (86%) taken from a clinic population of persons with chronic lung disorders: emphysema, chronic bronchitis, chronic obstructive pulmonary disease, asthma, chronic 22 “Table 1 Demographic Information Male Subjects 92 Female Subjects 6; N=153 Diaggosis Frequency Diabetes 21 Emphysema . 63 COPD 25 Asthma 17 Chronic Bronchitis 24 Misc. .1 153 Educational Level - Freguencv More than 4 years college 7 College degree 17 Partial college 21 High school degree 43 10th or 11th grade 16 7th, 8th, 9th grade 36 Less than 7 years schooling 4 Missing data 23 shortness of breath and chronic respiratory infection. The remaining 21 subjects had diabetes. There was a large range in these patients as to how physically debilitating the ill- ness was, how much it affected their lives and plans for the future, and how much time and effort had to be outlayed in maintaining and caring for their conditions. While some of the lung patients carried oxygen tanks with them at all times, most of them did not require equipment to keep them alive, unlike the haemodialysis patients. Also, the life threat- ening aspects of these illnesses had a greater range than those of Pritchard's patients, in that some of the older pa- tients in the lung clinic sample had to be concerned about the increased rate of infections, while many of them and the younger patients did not have a reduced life expectancy due to the disease. This same range was evident in the diabetic patients, with those who had develOped the disease earlier in life likely to develOp more serious complications than those who had deveIOped it later. Because no demographic data was included in Pritchard's publication, one has no information as to the differences between these two populations in terms of length of illness, age and education level. There may also have been a differ- ence in terms of voluntary participation, as several of Pritchard's patients had a previous association with him, and no data is given to indicate how many patients declined to participate. 24 Diagnosig The subjects were drawn from a clinic for diabetics and a clinic concerned with chronic lung disease. No patient ‘ with cancer or a progressive fatal disease was included, as were none who had temporary disorders. Twenty-one subjects were gathered from the diabetes clinic and the remaining 132 subjects attended the chest clinic. Among the latter group, several diagnoses were included. The largest group was 64 people with emphysema, followed by 26 with chronic bronchitis, 25 with chronic obstructive pulmonary disease (COPD), 19 with asthma and three in a miscellaneous category (two with chronic shortness of breath and one with chronic respiratory infection). Across all groups, the average duration of the disease was 6.808 years, with a range of .75 years to 40 years. Materials The questionnaires consisted of several parts. The first part was concerned with demographic data: diagnosis, length of illness, whether or not the doctor had given the patient all the information he had desired, age, sex, education level and employment information ( job of primary wage earner, or major source of support). The person was asked, if work- ing, whether or not the illness had affected his or her job. The subject was also asked to rate his or her current feeling state (worse than usual, about average, or better than usual) at the beginning and end of the questionnaire. Several of these indices were not used in the final analysis, due to lack of variation (feeling state, information from doctor) or ‘- 25 insufficient numbers of respondants (employment information). The next five questions dealt with the support systems available to the patient and the extent to which these had been found to be helpful during the illness. These asked the patient to rate on a five point scale, from very unhelpful to very helpful, his or her spouse, children, co-workers, and members of any clubs or religious organizations to which he or she belonged. The next part of the questionnaire was the Social Readjustment Rating Scale (SRRS) developed by Holmes and Rahe (1967)r This scale is reproduced in Appendix A. These instructions asked the patient to check any event listed which had taken place in the last two years of his life. The final section of the questionnaire was a variation of the Response to Illness Questionnaire (RIQ) developed by Pritchard (1974a). This scale is shown in Appendix B. It consisted of 60 statements, each followed by five possible responses, ranging from strongly disagree to strongly agree. Following these statements was a sentence inviting the patient to add any feelings about his or her illness that the 60 items had not covered. The questionnaire was administered in this total form to 81 patients. The remaining 72 subjects completed only the RIQ, and indicated their age, sex, and education level. RESULTS Develogment of Measgges Helpfulness Scale. The five items which asked subjects to rate the helpfulness of people around them (spouse, children, fellow club members, fellow members of a religious congregation and if employed, co-workers) were correlated with each other. These correlations ranged from .2985 to .6878 and all were significant at the .001 level. The reliability (coefficient alpha) for these five items was found to be .79542. It was decided to treat these five items as a cohesive scale, and scale scores for individuals were calculated by adding up the responses on each of the items. The Social Readjustment Rating Scale. The scale was scored according to the method described by Holmes and Rahe (1967). Each checked item was given the apprOpriate number of points according to the weighting system and these points were added together to compute the final score for each individual. The mean score for this sample was found to be 180.95, with a score range of 53 to 688, and a standard deviation of 95.82. figgpgnse to Illpesgrguestionngire: Factgijnalysi . A classical or common factor factor analysis was performed on the items in the RIQ. Squared multiple correlations were 26 27 used as initial communality estimates.‘ Varimax orthoginal rotation was used throughout these procedures. Use of the scree criterion suggested that seven or eight factors be rotated. The eight factor solution was chosen as the basis for further scale develOpment, since it had the most conceptually meaningful factors. The last two factors in this solution were judged to be meaningless, and the items which composed these factors were drOpped (#30, 38, 8, and 12) as were all items that had loaded less than .4 on their respective factors in the seven and eight factor solu- tions (#2, 4, 7, 15, 16, 20, 29, 33, 35, 36, 37, 43, 44, and 55). The remaining 42 items were refactored specifying the rotation of six factors. The items making up these six fac- tors were further scrutinized by comparing the corrected item- total correlations for each item with the scale to which it belonged with its correlation with the other five scales. Any item which correlated higher with another scale than with the one of which it was a part was dropped from the scale (#52, 54, 10, 19, and 51). The remaining 37 items were factor analyzed again speci- fying the rotation of six factors. Reliabilities (coefficient alpha) were calculated on these six factors and two items which lowered the reliabilities of their factors were dropped (#21 and 23). Of these six remaining factors, the sixth consisted of only two items (#22 and 31) and had a reliability of .4651? and so was not used in any further analyses. 28 The items in the five remaining factors are listed in Table 2, and were interpreted in the following way. The first, a more general factor, contained 12 items relating to alienation from others, e.g. Others do not understand how being ill is for me, It makes me feel I am alone, My illness is worse than others realize: concern with the consequences of the illness, e.g. I feel threatened by it, I don't worry much about my illness (reflected), I feel depressed about it: and feelings of being depleted, e.g. I feel it indicates that I am inferior, My illness has taken something from me, It is a sign of weakness in me. The reliability of this factor was .87954 and it will be referred to as Alienation in the follow- ing. The second factor was named Responsibility and contained seven items dealing with personal responsibility and partici- pation in contracting the illness. Representative of this scale are items like: I feel I am in some way responsible for being ill, I must have done something to deserve it, and It is a punishment for something I have done. Reliability for this factor was found to be .83721. Factor three was named Defeat and contained four items that dealt with loss of control over one's life and feelings of helplessness. Examples are: It defeats me and There is nothing I myself can do about my illness. The reliability found for this scale was .78064. Fourth was a five item scale that dealt with increased dependence on others, resentment of this dependence, and 29 Table 2 Final Scales Alienatiog Others do not understand how being ill is for me I feel depressed about it I feel resentful about it I feel threatened by it I feel it indicates that I am inferior My illness is worse than others realize I feel frightened about it It makes me feel I am alone I feel angry about it I don' t worry much about my illness (reflected) My illness has taken something from me It is a sign of weakness in me Regponsibility I feel I am in some way responsible for being ill I must have done something to deserve it It is a punishment for something I have done I do not think there is anythin I've done that explains why I' ve become ill (reflected I cannot think of any reason having to do with me that explains why I should have it (reflected) This shows that I have somehow failed I feel guilty about it liaise: It defeats me There is nothing I myself can do about my illness I am defenseless against it Being ill has made me feel I have little control over what happens to me Illness as Enemy It makes me more dependent than I'm used to being I feel it is something that has come and attacked me My illness is like an enemy I resent the way it makes me dependent on others I feel I have to resist it 30 Table 2 (cont'd.) Denigl It is a punishment which I do not deserve It is wrong that I should have to suffer this I feel it's like a dream: that it's not really happening to me Others are responsible for it 31 viewing the illness as an attacking force that must be resisted. This included items like: I feel it is something that has come and attacked me, I feel I have to resist it, and I resent the way it makes me dependent on others. The reliability for this scale was .72181 and it was named Ill- ness as Enemy. The final, fifth scale contained four items dealing with the wrongness of having the illness, externalization of re- sponsibility, and denial of the situation. These items were: It is‘a punishment which I do not deserve, It is wrong that I should have to suffer this, I feel it's like a dream: that it's not really happening to me, and Others are responsible for it. The reliability for this scale, called Denial, was .70277. Scale scores for each subject on each scale were computed by adding the responses made by an individual to each item (ranging from strongly disagree = 1 to strongly agree = 5) on a scale. The factor loadings for the items on the five factors are presented in Table 3. A Pearson correlation coefficient was calculated for each scale with each other scale. These correlations ranged from .3458 between Denial and Illness as Enemy to .6860 between Illness as Enemy and Alienation. The correlations are pre- sented in Table 4. Factor , Factor 1 .42788 .23226 .13739 .39969 .25721 .71731 .62681 .63060 ~35587 .11023 .28803 .22931 .03557 .52130 .42921 .43201 .74770 .65869 .62024 ~03589 .43869 .25208 " c 603,4'9 .04624 .51675 .45720 -.O90lO .20100 .35535 .52500 .04725 32 Table 3 Loadings for the Final Items W .13991 .70106 .14078 -34597 .06240 .08448 .22944 .83388 .14897 .08550 ~03552 .76074 .54584 .31969 .13025 .00531 .10584 .10797 -49933 .57561 - 0 02449 .07466 .10612 .49365 .22145 .09449 .11501 ~09590 Factorg3 .08103 .02199 .04473 .21305 .02875 .05268 -06539 .10343 .05684 .35318 .16442 .08351 .1322? .25830 .16458 .26678 .02971 .24169 .10043 .14419 .15618 .23074 .52822 .22294 .69932 .68375 -57679 .20002 .01964 Factor 4 " 0 12276 .13633 .32455 .19366 .25353 .06756 .19450 .15973 .41647 .42527 .62212 .61875 .11863 .01260 ~09179 .50019 .09838 .13535 .19372 .08848 .01694 .05777 .07481 -.O3513 .09822 " I 03687 .06747 .04590 .12229 .37317 .35284 Easier; .03106 ‘ c 02277 .52271 .21168 .60804 .1182? .37248 .07113 .07253 -.10430 .26794 .32690 .21399 .13955 .28915 .01442 .18010 .03520 .15342 .27035 .10043 .24696 .60238 --03971 .45955 .05280 .30020 .13773 .15203 - 0 03901 .22092 33 names. mama. wmdm. some. swam. Hmacaa Hwfimu. sass. Heam. comm. hsmcm mm mmmGHHH myopomm Hoo. may #6 psmowmflswflm 6pm msoHpmHmnpoo HH< . t. * madam mpCoHOflhMmoo mam mosam> Honowmflo* Hm>oa seems. smms. Hmsmm. :Hmm. «ammmm. ssmmsm. pmommm Apfiaflnflmcommom :oflPMSme< amCHm m>fim one uoh mcowpmamnuoonoch a manna amazon hamcm mm mmwQHHH pastas apaaanamcoamam soapmcmflam 34 HypotheseggRelating RIQ_Factors to Other Measuggg, Three hypotheses were generated on the basis of the fac- tors which were found. It was thought that there might be a significant relationship found between the scale Responsibil- ity and the category of diagnosis: specifically that there would be a difference between the diabetic and chest clinic patients on this scale, with the chest clinic patients scoring higher. This hypothesis was based on the experimenter's ob- servation that while many of the chest clinic subjects spon- taneously expressed the belief that some of their actions, e.g. cigarette smoking and working in atmospherically hazard- ous jobs, were responsible for their current condition, none of the diabetic group mentioned this idea. These observations were based on both verbal comments made to the experimenter and on the written comments subjects were invited to make at the end of the RIQ. It was also hypothesized that a significant negative correlation would be found between the level of helpfulness experienced and the scores found on the scale Alienation. If the factor Alienation did, as thought, measure some degree of social isolation and loneliness, it would follow that this would vary inversely with the level of helpfulness experienced by an individual, i.e. that if people felt helped by relatives and friends they would experience less loneliness and social alienation around the illness. The third hypothesis was that a significant positive correlation would be found between the amount of change 35 recorded on the Social Readjustment Rating Scale and the score on the scale of Defeat. The SRRS measures the amount of change, or potential stress,_in a person's recent life. Holmes and Rahe (1967) have found that a score above 200 indicates that a person's defenses are likely to be depleted, leaving them Open to illness. Selye's GAS theory (1956), in correspondence with Holmes and Rahe's ideas, postulates that after resistence to stress is depleted, the individual reaches a point of exhaustion and gives up. These are theories based on physical phenomena, and it was thought that it might follow that the physical exhaustion would be accompanied by emotional defeat, as measured by the Defeat scale develOped in this study. Resultg Correlations of the Fagtor Sgales with Helpfulnesg Scale agd SRRS. The hypotheses concerning these correlations were not confirmed. The correlation between Alienation and Help- fulness was —.0984, not found to be significant at the .05 level in a one-tailed test. The correlation between the scores on the SRRS and the scores on Defeat was found to be -.1721, also not significant at the .05 level in a one-tailed test. The Helpfulness scale and the SRRS also did not show significant correlations with any of the other scales derived from the factor analysis (see Table 5). Relagionshipof Diagnostic Categories and Factor Scales. One way analyses of variance were computed for each of the scales with the six categories Of diagnosis. No significant 36 mmoo.n mooo.- ammo. ammo. smao.- #1:. Ass u zv mmmcazmmao: ©N+~OO I some. HNNH.I * ammo. mmmfi. Ans u zv mama mpmmp mocmOflmficmHm pmafimpnmco * mo. V.Q * fizz. .8. commas mmonp you paooxm nmawmpsozp mum mpmmp moCmOHmacmHm Ham * mfism. mmem. mmfim. Humm. * *3. ***+~N.®m . Amm n zv amaa.- mmfio. m:mo.: mmmo.u Caro. Anna u 22 snow weapommu< xam ammo. swoo. Hosfi. * ** mooH. @000. Assfi u zv CoHPmOzpm :HHH. mmmo.- ammo. mmso. mmma.n fifimfi n mw< zv wmmo. sumo. NNHH. Ndao.| ammo. Ame u zv Cowpmhza hamcm mm mmmcHHH hzmm pastas spaaanaacoamaa CowmeOHH< *mpmn owngmpmosmm ppm .oamom mmocasmaaom .mmmm new; mmamom popomm mo msowpmampuoo m manna 37 F ratio was found for the scale Responsibility (DF of 5 and 147: F ratio = .4162: probability = .8369). While no other hypotheses about diagnostic categories were made, one was ANOVAs showed significant effects for the analyses involving the scales of Defeat and Illness as Enemy. The F ratio for the ANOVA between Defeat and categories of diagnosis was 2.4119, with DF of 5 and 147, significant at the .05 level. Contrasting all means against all others using the Scheffe methods showed no significant differences. The F value for the ANOVA between Illness as Enemy and the six diagnostic categories with DF of 5 and 147 was found to be 2.1760, significant at the .059 level. Again using the Scheffe method to contrast all means with all other means, no significant differences were found. Correlations of the Factor Scales with the Demoggaphig Data. The scores on the factors were correlated with the demographic items of duration of illness, age, level of educa- tion, sex, and the effect of the illness on the individual's job (see Table 5). Using two-tailed significance tests, positive correlations (p <:.05) were found between the factor scales of Alienation and Responsibility, and the job of the individual being affected by the illness. A correlation (p < .05) was also found between the level of education and the factor scale of Defeat, with the scores on Defeat increas- ing as education level decreased. 38 Correlations of Demoggaphic Data, Helpfulness Scale aad §RRS with Items which were Rejected in RIQ Factor Analysi . In an attempt to extract full information from the data set, the items which were drOpped during the factor analysis were correlated with the demographic information, as well as with the Helpfulness scale and the SRRS. The correlation matrix and significant correlations are listed in Table 6. pmafimvnosp mam mpmmp mocmowmwnwwm HH< 8o. V of... H0. v 9...... wo.nv ma H mooa. maso. oomm. *ammmm.- momo. *soom. ooma. mm smma. mooa. mosa. mosa.- mmoo. aoaofi. smma.- an msmo. *mmmm. moan. mmoo. mooo. mooo. omoo.- om Haso. mooa.- omsm.- *mmma.- aammom. swamsmm. maoo. om ammo. mmoH.- mono. osmo.- mood. aamaam. mmmfi. mm omoo.- omma.- oomfi. omoo.- mmam. soda. oHHo. mm momo.- ommo.- omao. ommo. maao. omao.- ommm.- Hm ammo.- maoo.- aoamo. mmoa.- mooo. mmmo. oomo. om momma. mmmo. oamm.- aaomom.- momo. muss. ooHH.- as sooo.- oooo. sumo. mono. ommo. ammo. ammo. oa somo.- mmmo.- somom. aaaomom.- mmsH. Rosa. ammo. ma ammo. mmmo.- omoa. mmma.- mHHm. ommH. mmoa.- ma Homa.- mmoH.- aaamms. momo.- aammom. moms. msoo.- oa 00N0.| stowfim.n ONNM. NMN0.I *tmmmm. *Hmma. mmfia.l m mmao. ammo.- oomm.- mmfio.- mmma. mmmo.- ammom. m momo.- oooo. mmmm. moaa.- somfi. momo. mooo.- : 0030.1 wmmo. *tmfimr. mmma.n ***5Hmm. 3:30. m000. m oofio. ommo.- zoo”. amomfi.- aammmm. moao.. ammo. m mmocaammmom mmmm mmooxmcapoomwm mum coapmmaom mum coapaaoo sopH Hmmmm can .Oamom mmoCHsmmamm .mvma Ofizamnwoeon spa: on scam meOPH pmvomwmm mo meowvmaonpoo o «Home 40 mmao. mooo. oomo.- omoo. ammo. owns. oomo.- mmmo.- omma.- oaso.- mafio. mmmo. omoo. :Hso. omso. ooma. moam. mmmo. mooo.- ammo. ammo. somoa.- mmmo.- omsm. mooo. mmmo.- momo.- mmoo. oHoH. flosa. HHoH. mmmo.- *omoa.- ammo. moma. ommo. *ommm.- oooo. *smoo.- mamo.- aaaomm. ooma. mNHO. mmoo. *wam.l humo. a00a.l m0®0.| ##050H. omoH.- mHHo. moom.- wonoa. mooo.- Hooo.- ammo. mmoo.- mono. sows. oomo.- mafia. oaso.- moma. mmmo.: *tdmmm. moma. *tommm. *tm:mm.: *moom.l Hmoo. mascaammaom mmmm once weapooomm mow coapaoaom. mam compaaso A.o.pcooo o mamas DISCUSSION The Response to Illness Questionnaire was administered to 153 medical patients, drawn from chronic care clinics for chest diseases and diabetes. This questionnaire was factor analyzed, resulting in five meaningful factors, with reliabil- ities ranging from .87954 to .70277. Correlations were carried out between these factors and various other demographic measures as Well as with a helpfulness scale develOped in this study, and the Holmes and Rahe Social Readjustment Rating Scale. In the discussion, these factors will be compared to the theoretical dimensions prOposed by Lipowski (1970) and to the factors found in the one other study using this scale done by Pritchard (1974b). Fairly close correspondence was found between the factors identified in this study and the dimensions proposed and found in the other two publications. The dimensions not found in this study which were represented in the other two will be discussed, and several hypotheses will be Offered to account for their lack of representation in the current investigation. The factors found in this study will be then compared with three major coping strategies: vigilant focusing, min- imization, and capitulation. The possible consequences of 41 42 these various coping strategies with regard to illness-will also be discussed. The attempts to validate the factors will be described, and the problems with validating these factors discussed. Primary among these problems in the high intercorrelation of all the factors, leading to the suggestion that the items retained in this analysis tend to measure one broad aspect of illness perception, that being depression and discontentment. Suggestions for further inquiry will be offered, among these being subject pOpulations which might endorse items which measure the other, more "positive" outlook on illness. Correlations of the rejected items in this analysis with high education level and younger age indicate that these positive items are salient to some individuals, and in an expanded study, these dimensions might be represented. Compagison with Lipowski's Meaaing Categories: Ths Similarities. The illness meaning categories postulated by Lipowski in his 1970 theoretical article were substantiated to some degree by this study. Two of his meanings were found to be the central component in two of the factors found. These were Illness as Enemy and Illness as Punishment. Three of his other meaning categories: Illness as Weakness, Illness as Irreparable Loss, and Illness as Strategy were represented to some degree, and three categories were not represented in any of the factors found. Illness as Enemy, a meaning which regards the illness as as an invading force which should be fought, corresponds 43 closely to the factor named Illness as Enemy, which, in ad- dition to the items relating closely to feeling attacked, also contained two items having to do with acknowledgement and resentment of the increased dependency resulting from being sick. The other meaning that closely corresponds to the factors found in the present study was Lipowski's category of Illness as Punishment. In this category, the patient explains the illness as being related to some of his or her own actions. Lipowski includes in this meaning a patient's judgement about whether the illness is just or unjust. Statements about this judgement were not included in the factor labeled Responsibility, but items explaining the illness as a punish- ment and/or a responsibility of the patient were included. Combined with this feeling of responsibility was a feeling of guilt and failure. This factor seems to reflect beliefs that the person had, at one time at least, control over contracting the disease, and because he or she did not avoid it, or through his or her actions encouraged it: the resulting feelings are of failure and guilt. There was also some correspondence between the factor of Denial and Lipowski's theorizing. In his explanation of the category Illness as Weakness, Lipowski states that while there is responsibility felt here also, the resulting affect is shame, and therefore attempts to hide the illness from Others, or to escape the situation through denial are found. The factor labeled Denial contains, in addition to the denial 44 item, two items which express the idea that the illness is wrong, that the person should not have to suffer this. These two items could be seen as a denial of weakness, and the neg- ative moral implications that accompany this perception of the cause of the illness. The fourth item in this factor puts the cause of the illness outside the individual, to oth- ers. This factor is not only the denial of the consequences, but the denial of the responsibility for the contraction of the disease. Lipowski states in his explanation of Illness as Enemy that "In its extreme pathological form this attitude may be frankly paranoid and others may be blamed for having caused or aggravated the illness." (1970) The factor labeled Denial then seems to have connections to illness seen as weak-H ness, as well as to this specific consequence of illness seen as enemy. It may be that the meaning of illness as enemy is not felt merely on a continuum, from a little to a great deal, but that the upper limits of this meaning are actually of a different quality, perhaps a defense against feeling weak and out of control. Rather than admitting a belief of being out of control personally, the control is believed to be in others' hands and therefore, while the individual still lacks control, it is not seen as a personal failing, but as a pun- ishment from without. Lipowski's meaning of illness that he calls irreparable loss or damage seems fairly close in meaning to the factor of Defeat. In this outlook, the belief is that what has been lost is irreplaceable and the loss is felt to be overwhelm- ing. While none of the items that addressed these feelings 45 specifically were retained in this analysis, the feelings that result from this belief, depression and resistance to rehabilitative assistance, are expressed in the items in De- feat. This factor expresses a hopeless outlook. in which the individual feel defenseless, defeated and without control over his or her life. It is not a long way from these feelings to depression and to beliefs that any rehabilitative measures are worthless and unlikely to lead to improvement. The fifth factor found in the present study, called Alien- ation, is a more general factor, and contains components of several meaning categories. Most of the retained items which described feelings: depression, anger, resentment and fright, are in this factor and could apply to many of the meaning categories. Also contained in this factor are two items having to do with inferiority and weakness, which would apply to Illness as Weakness. Most of the other items have to do with being misunderstood and alone. These items do not cor- respond closely to any meaning category, but may have some connection with the Illness as Strategy meaning, which deals directly with the impact of the illness on the patient's re- lationship with others. For patients who score low on this factor, the illness may represent a successful attempt to gain more attention and involvement from others, which in turn could alleviate their feelings of being inferior and weak, as they do not perceive themselves as powerless in gaining;or maintaining important relationships. At the Oppo- site pole, feeling alone and misunderstood could exacerbate 46 the feelings of depression, resentment and fear. Comparison with Lipowski's Meaping Categories: The Differences. While all the factors which resulted from this analysis correspond with variable closeness to the meaning categories proposed by Lipowski, three of his meanings were not represented to any degree in the present sample. These areas were those he labels illness as relief, illness as value, and illness as challenge. There are several plausible explan- ations as to why the items expressing these feelings did not load highly enough on a factor to be retained. The correla- tions between the demographics and the responses to the re- jected items can help to account for this. None of the items that characterize the illness as a relief from responsibilities or those that expressed direct gains from the illness were retained. It may be that the so- cial undesirability of responding to these items in the af- firmative prevented an accurate measurement of these percep- tions.1 It must also be recalled that Lipowski includes in this meaning category relief through unconscious strategies and unconscious resolutions of inter and intra personal con- flicts. It is possible that this type of questionnaire would have difficulty in measuring these feelings in a direct way. It is also possible that the particular population used in this study generally disagreed with these items because of 1Inspection showed that the mean of each of these items fell below the average mean of all the items. 47 the organization of the clinic which they attend, resulting in a restriction of range.2 Part of the objective of this clinic is to involve the family of the patient, and a family member attends all clinic visits with the patient whenever possible. This is to encourage family assistance in care, and to discourage the transmission of distorted information to the family from the patient. In other words, one of the ob- jectives of this clinic is to prevent the patient from develOp- ing strategies with which to manipulate those around him or her, or to gain unduly by being ill. In describing the view of illness as value, Lipowski states, "This belief is not prevalent in our hedonistic society. On the contrary, illness tends to have a negative value and everything is done to counteract it" (1970). It may very well be that because of this, the items having to do with seeing illness as a valuable experience, one that facil- itates growth and understanding, may not have been salient items for this population. This is also a vieWpoint that requires some perspective on the experience, as well as a pro- pensity for abstract and philos0phical thought, so the failure of these items to load highly on any factor may be related to the educational level of this population.3 For example, originally a semantic differential scale was planned, to be given along with the RIQ, but it was discovered very quickly 2Two out of the three items clearly related to relief through illness had variances that fell below the average variance of all the items. * 368% of the subjects had a high school education, or less. 48 that the level of abstraction involved in that kind Of instru- ment was experienced as too confusing and vague for many of the subjects, even with extensive explanation. The final meaning category, illness as challenge, was represented in this questionnaire by items having to do with seeing the illness as a problem to be tackled, as a challenge, and to this end, desiring all pertinant details and informa- tion about the illness process. Again, a restriction of range may have contributed to none of these items being retained.“ The first 81 subjects answered a question which asked if their doctor had told them all they wished to know about their illness, and of the 78 who responded to this (question, only 6% (five individuals) answered no. It may be, too, that people participating in these clinics, which require regular attendence, are for the most part, those that are interested in complete information. It also may be that for this pOpulation, the words "challenge" and perhaps "tackle" were somewhat confusing, as the experimenter was asked to define many simpler words for subjects, such as "defeat" and "inferior." Again, these items may be found to be more meaningful to a better educated pOpulation. In addition, 'items which dealt with challenge and wanting to know details were positively correlated with education level: the higher the education, the greater the desire to know. This would be ”Four of five Of these items had variances below the average variance of all the items. One was over one S.D. below and one item fell over two S.D.s below this average. 49 a quite understandable coping device for better educated indi- viduals as their outlook would be likely to regard knowledge, information, and detailed understanding as methods of problem solving. In a population with a higher education level, there- fore, there are several reasons to hypothesize that the challenge items would be retained. There is also some evidence that age may have been a factor in the exclusion of the challenge items. Age was found to be significantly positively correlated with items expres- sing a desire not to know details, and a desire not to think about the illness. Age was also correlated with education, with the younger person more likely to have had more years of schooling. Both these subject variables suggest that the person most likely to endorse challenge and information seek- ing items may be the one who feels better equipped to deal with the illness, through youth and schooling. Comparison with Pritchapd's Empirically Obtained Factors: The Similarities. One previous attempt has been made to factor analyze the RIQ to result in illness meaning categories (Pritchard, 1974b). There were 14 subjects undergoing haemo— dialysis for chronic renal failure in his study, and with this (few subjects, the possibility of capitalizing on chance comb- inations of items should be kept in mind when examining these factors. Also, no reliability data was given so there is no indication of the stability of these factors in the pOpulation used. To complicate matters, the 22 variables Pritchard chose to use in his factor analysis were not all seperate items. 5O Fourteen of these "variables" consisted of the sum of two items and his basis for creating these variables was subjec- tive rather than empirical. Therefore, some of these combin- ations have even a lower chance of being replicated when the composition of factors is computed using each item as a seper- ate variable. In spite of these rather serious methodological problems, there is some correspondence between the factors found by (Pritchard (see Table 7), and those which resulted from the current analysis. Four out of the seven factors identified in Pritchard's study have similar meanings to four of the five factors reported here. The meaning which is clearly defined in both studies is Illness as Enemy. Three of the items are identical. The other two items in Pritchard's factor of this name were dropped from the current study because their factor loadings were less than .4. The items in this study which were not inclu- ded in Pritchard's were two items which acknowledged the in- creased dependency and resentment of the same. The fact that there is such close correspondence between the two studies on this factor, in spite of the methodological problems mentioned above and the different pOpulations used, is a strong support for this being a dependable, consistent and stable factor in illness perception. The factor Pritchard named Helpless Loss is similar to the Defeat factor found in this inquiry. Both express a sense of helplessness in the face of the illness, and a sense 51 Table 7 Factors Identified by Pritchard Hopeless Defeat I do not think others realize that because of it I cannot OOpe ( with responsibilities I am worried that because of it I am not meeting my responsi- bilities as I should (I feel depressed about it I feel miserable about it (I want to escape from it I want to run away from it (I have to give in to it It defeats me I resent the way it makes me dependent on others Anxious Preoccupation vs. Denial I think a good deal about it (I feel anxious about it I feel frightened about it (I am not told enough about it I am kept too much in the dark about it Outwagd Hostility (I cannot think of any reason to do with me why I should have it I do not think there is any explanation on my part why it oc- cured (I feel angry about it I feel resentful about it Helpless Loss (I am defenseless against it I do not think I can resist it (It has taken something from me I will never be the same again because of it There is nothing I can do myself about it ( - Indicates that item above and below were combined and used as a single variable 52 Table 7 (cont'd.) Challenging Appraisal (I look on it as a challenge I think of it as a problem to be tackled I want to find out all I can about it Illness as Enemy (It is like an enemy I feel it is something that has come and attacked me I appreciate the help and sympathy it has brought me (I must fight it I feel I have to resist it Paranoid Withdrawal vs. Involvement It is worse than others realize (It is wrong that I should have to suffer this It is a punishment which I do not deserve It is something I must overcome myself (reflected) 53 that the illness has prevailed and the individual must give up in defeat. Two items match, a third found by Pritchard was included in his analysis because it was subjectively com- bined with one of these matching items into one of his vari- ables. In addition, Pritchard's Helpless Loss includes feel- ings of being permanently and negatively changed because of the illness experience. While there are, then, a few items which do not appear in both factors, there is little doubt in the eXperimenter's mind, because of the content of the items, that these two factors are expressing the same mean- ings and feelings. A third area which both studies tapped were feelings Pritchard titled Paranoid Withdrawal and this study called Denial. Both these factors contained items having to do with the unfairness of the illness. It seems, though, that the resulting additional feelings associated with unfairness were slightly different in the two studies. In Pritchard's, the unfairness was coupled with feeling powerless and mis- understood by others, as if the experience of developing an unexpected and seemingly unfair illness had seriously eroded the individual's faith in his or her own power to change and control his or her life. There is a somewhat different fla- vor to the Denial factor in the present study. In these re- sults, included along with the unfairness items are an item that expresses a desire not to think about the illness, and an item placing the responsibility for the illness on others. This has a sense of, instead of admitting a personal lack Of 54 control, making an attempt to place that control outside the individual. This may have been a consequence of the differ- ent populations involved in these two studies. Pritchard's subjects, in having to spend substantial amounts of time on dialysis machines may have not been able to externalize the situation, or ignore it, as much as the patients in the cur— rent study, whose illnesses did not require such a visable rehabilitation regime. Finally, the reflection of Pritchard's factor Outward Hostility has some similarity to this study's factor named Responsibility. Pritchard associates this factor with the Just Punishment meaning suggested by Lipowski, which may make it more clear as to why it is also associated with Responsi- bility. The present factor Responsibility is, however, much more extensively defined than Pritchard's factor, and this may be due to the pOpulations tested. Many of those included in the present study had a realistic basis for feeling re- sponsible, citing cigarette smoking, living in polluted sur- roundings and working in atmospherically hazardous jobs. There is no indication that Pritchard's subjects had any iden- tifiable actions that they could connect with the onset of their conditions. This factor, then, may be more stable and meaningful for populations to whom the concept of personal responsibility is most salient. Comparison with Pritchard's Factors: Lghe Differences. Three of Pritchard's factors were not replicated to any degree by the current study. The first he named HOpeless Defeat, and 55 associated this with Lipowski's meaning category of weakness. As was indicated in the discussion of Lipowski's categories, the feelings that he associates with weakness were found to be distributed among several factors in this study, and the same is true for the items in this factor of Pritchard's. This Hopeless Defeat factor was the general factor found in Pritchard's study, and simply does not correspond closely to any one factor found in the current investigation. The other two factors Pritchard found that were not included in the present study were those he titled Anxious Preoccupation vs. Denial and Challenging Appraisal. Both of these factors related closely to Lipowski's Illness as Chal- lenge category, in that they included items directly labeling the illness as a challenge, a problem to be tackled (these two items were, however, used together as a variable) and many items concerned with information gathering and thinking. The possible explanations for why these types of items were not retained in the current inquirywere discussed above in the comparison with Lipowski's categories. Summapy. In spite of the above mentioned discrepancies in factors, and the very different types of patients and stat- istical reliabilities involved in these two studies, the .similarities are striking. In fact, they are even more striking when one does keep in mind the many differences between the studies. Definite credence is lent to the ques- tionnaire being used with different patient pOpulations, and additional support is given (beyond the acceptable 56 reliabilities) to the stability of the majority of the factors found in the present study. Ths;Meapipg of Illness and COping Strategiss Deliniating the different meanings of chronic illness is merely an intellectual exercise unless this inquiry is taken as the first step in linking these meanings with COping strategies, with behaviors that directly affect the course and outcome of an illness. Some attempts to connect meaning categories with cOping strategies will be described below. Lipowski states, "It is the writer's thesis that cOping strategies are directly related to the individual's personal meaning of and attitudes towards his illness, injury, or dis- ability" (1970). Taking the meaning categories deliniated in this study, it may be useful to trace these back to the involved COping strategies they may represent or be part of. The first major cOping strategy of interest here is that of vigilant focusing (Lipowski, 1970). It may be remembered that this was described as involving obsessional, anxiety prone attention to the problem with the objective being under- standing and mastery of the situation. There is a large range of intensity found in these types of feelings, and they may not always lead to effective COping or mastery. The two factors found in this study that seem to relate to this COping strategy are Illness as Enemy and Responsibility. Illness as Enemy seems to represent an extreme form of vigil- ant c0ping, one in which attention is clearly focused on the 57 illness, and the attempts at mastery are in the form of conscious resistance and counterattacks. It should be noted that this may not be an effective way of dealing with the ill- ness, due to the inflexibility implied in these feelings. This may represent the mastery component of vigilance, while Responsibility seems more closely linked to the effort to understand the illness and its causes. A person who scores high on Responsibility would be someone who has actively explored what the illness might mean about him or her, and come to some conclusions about his or her levels of responsi- bility in contracting the illness, and consequently, to a greater personal understanding of the condition. Another COping mechanism which has received a great deal of attention is denial, or to use a more inclusive term, minimization (Cohen and Lazarus, 1973: Lipowski, 1970: and Kiely, 1972). Involved in this are attempts to rationalize, ignore or deny the significance of the illness, its causes and its consequences. The factor Denial found in this study corresponds to this strategy, primarily in the rationaliza- tion expressed in the items. Most of the items that directly expressed denial or lack of awareness of the illness were not retained in this factor for reasons discussed above. However, it is plausible that a person scoring high on this factor, especially someone who has had the illness for some time (as denial is a common initial response to an injury or illness), would have trouble adhering to a rehabilitation schedule, and therefore might be a person to whom extra attention should be 58 paid by the helping professions. It should also be kept in mind, however, that this mechanism can be adaptive and use- ful in some conditions, like cardiac illness (Hackett and Weisman, 1969). The final major COping mechanism is capitulation, which can be particularly harmful to the individual, as this way of viewing the illness can.preclude adaptive acceptance of the condition or effective resistance. The factor Defeat closely corresponds to this coping strategy, expressing as it does the belief that the individual can do nothing about his or her illness, and on a more inclusive level, that the ill- ness experience has resulted in a felt loss of control over many events in the person's life. This can be a particularly crucial set of beliefs_in a chronic illness, where some level of constant attention and personal effort is required to keep the condition under control. The Problems with Validity Although there is fairly good theoretical support for the content of the factors found in this study, there is a less clear empirical base, in terms of validity. Although no concerted effort was made in this study to validate the dimensions found, the ANOVA performed between the factor Responsibility and the diagnostic categories and the correla- tion carried out between the Helpfulness scale and the factor Alienation, and between the factor Defeat and the SRRS, were a first step in this direction. The lack of significant 59 findings on these hypothesized combinations therefore, does not offer any positive evidence for the validity of these meaning dimensions, either the theoretical dimensions, or the ones found in practice through this investigation, but on the other hand, it seems far too soon to take these as an indication that no validity of such does exist. Part of the difficulty in establishing significant and/ or important relationships between any one of these factors and any other measure employed lies in the fact that all the factors were significantly and highly correlated with each other. This could be a by product of lack of precision in the measuring instrument, as very little empirical work has been performed on this scale up to now. It does seem clear that the items retained in this study are those that could be termed more "negative" ones, which, as discussed in rela- tion to particular dimensions above, could be the result of those particular items being more salient to the population sampled, and/or a consequence of the greater variability of answers to these items.5 These intercorrelations of meaning categories may have the greatest part in explaining the lack of association found between the scale of Responsibility and the diagnostic cate- gories. They may also partially explain the lack of connec- tion between the scale of Alienation and the Helpfulness scale, 5The average variance Of the retained items was 1.1962, as compared to the average variance of the rejected items, which was 1.0737. 60 as the factor named Alienation contained items which ex- pressed other feelings. Also, since the Helpfulness scale was formed during this study, and has no validity data it is possible that, although reliable, it has little validity. The Social Readjustment Rating Scale also was not found to be significantly associated with any of the factors. This may be a function of its measuring, as explained in the introduc- tion, a general factor of stress, assuming as it does that the value of stress will affect different peOple in the same ways. It is possible, however, that the specificity theory of stress has more application in this instance, so that two different individuals who scored the same amount of change in their lives actually see this in different ways, and it has a different impact on their outlook on themselves and their illnesses. If this is the case, it would not be sur- prising that the SRRS would not correlate highly with mea— sures of meaning of illness, as the stress assessment would differ from person to person. In looking at the correlations between demographic data and the factor scales, it was found that if a person's job had been affected by the illness, that person was signifi- cantly more likely to score higher on Alienation and on Re- sponsibility. The positive correlations of this item with the other factors were not significant, but definite trends were found. This may be related to the previously mentioned observation that the items retained in these factors were primarily "negative" ones, measuring discontent, depression, 61 and dissatisfaction with the situation. That these correlate highly with problems on the job due to the illness is another support for the factors measuring something significant, albeit similar from one factor to another. Additional support for the Defeat factor measuring that concept is found in the significant correlation found between this factor and the level of education, with persons scoring higher on Defeat as their education level decreases. This could relate to the resources a person feels he can.muster to deal with the illness: as these resources, in the form of education, decrease, he is likely to feel more helpless in the face of an illness. This could be the Opposite side of the coin to the correlation between higher education and en- dorsement of the challenge items discussed previously. It might be noted that no significant relationship was found between the sex of the individual and any of the factors. This would support the concept that the factors are measuring something related to subject characteristics other than sex. The problem of good criterion variables has to be con- sidered in this area of research. When.we are assuming that COping strategies are directly related to the behaviors of the patient, we are making a statement about the importance of identifying these strategies, in an effort to provide bet- ter care, and to predict the behavior that has relevance to the illness process. The difficulty arises when one tries to clearly define the behaviors that are adaptive and maladap- tive, and this seems to vary depending on the illness 62 considered. Once the behaviors have been identified, there is the additional problem of Operationalizing these behaviors so they can be accurately measured. This seems especially hard when dealing with illnesses which are not usually fatal, so the degrees of adaptive COping are just that, a matter of degrees, and nothing concrete like life or death. Also to be considered are other inter-patient variables which could affect the progress and seriousness of the disease, like age or previous illnesses. Future Directions In spite of the criterion variable problem, there are possibilities for future exploration of this area. In a more long term validation study, one might be interestedin trying to link these meaning factors to some measure of re- lapse, like admittance to the hospital, demonstrable deter- ioration in physical status, or contraction of other physical ailments. Since the variable of adaptive COping is often a subjective judgement, one might want to seriously consider develOping reliable scales of this, tapping the judgements of medical personnel and/or the family. Aside from the sub- .jective nature of these measures, however, one has the dif- ficulty of validating a meaning scale with a level of COping scale, which in turn would have to be validated using some kind of stable behavioral measure. It seems clear that a vital area of exploration for the future involves establish- ing these measurable behavioral aspects of illness maintenance 63 or recovery, for only using these could a scale be adequate- ly validated, and therefore, of use in identifying those in- dividuals who are most likely to have difficulty in cOping with an illness. Future work on this scale might also include giving it to individuals with other diseases, both chronic and more time limited. It may be that certain of the meanings of ill- ness would be more salient to a pOpulation with a non-chronic condition and this could only be determined by giving these items to such a pOpulation. A more extensive data base would also go a long way to furthering the reliability data on any of the scales, as well as determining which are stable across populations, and which have variable applicability. A greater population with higher education level, and of younger age, could also give information on items which were drOpped in the current analysis, and give a better indication of whether or not these would be salient to a different pOpulation. Conclusion This was an exploratory study, an attempt to discover if there were identifiable meaning and illness perception cate- gories, on which there would be variable scoring by different individuals. There is certainly the indication from this in- quiry that this is so, and it remains the task of future ex- plorations to discover if these categories can be expanded and new categories added, as well as to establish empirical links to observable and measurable behaviors which affect 64 recovery from, and/or adequate maintenance of, illness. This could add not only to the general information about the pro- cess of recovery, and the emotional components of physical illness, but give health care professionals a tool with which to identify problem patients early on in the illness process, when the chances of effective intervention are the greatest. APPENDICES APPENDIX A Social Readjustment Rating Scale Here is a list of things that happen in peOple's lives. Please check any of the events that have happened to you in the last two years. Death of a spouse Divorce Marital separation Jail term Death of close family member Personal injury or illness Marriage Fired at work Marital reconciliation Retirement Change in health of family member Pregnancy Sex difficulties Gain of new family member (e.g., through birth, adoption, parent moving in, etc.) Business readjustment (e.g., merger, reorganization, bankruptcy, etc.) Change in financial state (e.g., a lot worse off or a lot better off than usual) Death of a close friend Change to a different line of work Change in number of arguments with spouse (e.g., either a a lot more or a lot less than usual regarding childrearing, personal habits, etc.) Mortgage over $10,000 (e.g., purchasing a home, business, etc. Foreclosure of mortgage or loan Change in responsibilities at work (e.g., promotion, demo- tion, lateral transfer) ‘ Son or daughter leaving home (e.g., marriage, attending college, etc.) ,Trouble with in-laws Outstanding personal achievement Wife begin or stOp work Begin or end school Change in living conditions (e.g., building a new home, remodeling, deterioration of home or neighborhood) 65 66 APPENDIX A (cont'd.) Revision of personal habits (e.g., dress, manners, asso- ciations, etc.) Trouble with boss Change in work hours or conditions Change in residence Change in schools Change in recreation Change in church activities (e.g., a lot more or a lot less than usual) Change in social activities (e.g., clubs, dancing, movies, visiting, etc.) Mortgage or loan less than $10,000 (e.g., purchasing a car, T.V., freezer, etc.) Change in sleeping habits (e.g., a lot more or a lot less sleep, or change in part of day when asleep) . Change in number of family get-togethers (e.g., a lot more or a lot less than usual) Change in eating habits (e.g., a lot more or a lot less food intake, or very different meal hours or surroundings) Vacation Christmas Minor violations of law (e.g., traffic tickets, jaywalking, disturbing the peace, etc.) NH OWQVO’WJ‘IFWNH HRH H K...) 14. 23. 24. . 25. 26. 27. 28. 29. 30. 31. 32. 33. 34- APPENDIX B Response to Illness Questionnaire Others do not understand how being ill is for me. It is a real threat to my health. I feel miserable about it. It threatens to change my life in ways I don’t like. I feel I am in some way responsible for being ill. It is a punishment which I do not deserve. I do not like others knowing about it. I am not told enough about my illness. It is a sign of weakness in me. Because of my illness I feel I cannot c0pe with my responsibilities. It is wrong that I should have to suffer this. It is hard for my family and friends to refuse me things because of it. I feel depressed about it. I feel resentful about it. I have to give in to it. I think of my illness as a problem to be tackled. I must have done something to deserve it. I feel threatened by it. Being ill has brought me closer to my family and friends. I do not think I can resist it. Having it has made me more aware of some of the good things in my life. It is kind of a relief not to have to do some of the things being ill prevents me from doing. I would rather not think about it and when these thoughts come to mind I push them away. It makes me more dependent than I'm used to being. I feel it is something that has come and attacked me. My illness is like an enemy. It is a punishment for something I have done. I do not think there is anything I've done that explains why I've become ill. I don't want to know any details of it. It is something I must overcome myself. My illness has given me some control over those close to me. I feel it indicates that I am inferior. I have lost some things through this that I can never get back. My illness is worse than others realize. 67 35- 360 37- 38. 39. (4'0. 41. 42. 43. 44. [4’50 46. 47. 48. 49. 50. 51. 52. 53- 54. 55- 56. 57- 58. 59. 60. 68 APPENDIX B (cont'd.) I want to find out all I can about it. I feel ashamed of it. I feel I can accept my illness and go on from there. It is not as serious as others make out. I resent the way it makes me dependent on others. I feel frightened about it} It makes me feel I am alone. I feel angry about it. I appreciate the help and sympathy my illness has brought me. I look on it as a challenge. I cannot think of any reason having to do with me that explains why I should have it. This shows that I have somehow failed. I feel it's like a dream: that it's not really happening to me. I-don't worry much about my illness- Others are responsible for it. It defeats me. I feel like running away from it. I have learned something from being ill. I feel guilty about it. I want to escape from it. I must fight it. There is nothing I myself can do about my illness. I am defenseless against it. Being ill has made me feel I have little control over what happens to me. My illness has taken something from me. I feel I have to resist it. BIBLIOGRAPHY BIBLIOGRAPHY American Cancer Society. 1922 Cancer Facts and Figppes. American Cancer Society, Inc., 197 . Andrew, J. M. Recovery from surgery, with and without preparatory instruction, for three coping styles. Journal of PersOpa;ipy apd Social Psychology, 1970, 151, 223-22 . Bulman, R. J., & Wortman, C. B. Attributions of blame and COping in the "Real World": Severe accident victims react to their lot. Journal of PersopaIity and Social Psychol- 2813 1977: 251 351-3 3- Cohen, F., & Lazarus, R. S. Active COping processes, COping dispositions, and recovery from surgery. Psychosomatic MEQQQEEQ: 1973..15: 375-389- Davids, A. Past experience and present personality dispo- sitions as determinants of selective auditory memory. Ellis, A. Humanistic Psychotherapy. New York: McGraw-Hill, 1973- Engel, G. L. Psychological DevelOpment in Health apd Disease. Philadelphia: W. B. Saunders, 19 2. Goffman, E. Sti a: Note on M ement of S oiled Identit . Englewood Cliffs: Prentice-Hall, 1963. Hackett, T. P., & Weisman, A. D. Reactions to the imminence of death. In G. H. Grosser, H. Wechsler, & M. Greenblat (Eds.), The Thre t of Im endi Disaster. Cambridge, MA: M.I.T. Press, 1924. Hackett, T. P., & Weisman, A. D. Denial as a factor in patients with heart disease and cancer. Appals of the New Igpk Academ of Science, 1969, 164, 802-817. Hamburg, D. A., Hamburg, B., & deGoza, S. Adaptive problems and mechanisms in severely burned patients. Ps chiatr , 19539 lé. 1‘200 . ' 69 7O BIBLIOGRAPHY (cont'd.) Holmes, T. H., & Rahe, R. H. The social readjustment rating scale. Journal of Psychosomatic Researsh, 1967, ;1, 213. Janis, I. L. Psychological Stress. New York: Wiley, 1958. Kiely, W. F. Coping with severe illness. Advapces in Psysho— Kissen, D. M., Brown, R. F., & Kissen, M. A further report on personality and psychosocial factors in lung cancer. Annals of the New York Academ of Science, 1969, 153, 535-5 5- ' Lasser, J. What is Reach to Recovepy? American Cancer :6; Society, Inc., 1972. Lazarus, R. 8. Ps cholo ic 1 Stress and the CO in Proces . New York: McGraw-Hill, 1966. Lazarus, R. S. Psychological stress and cOping in adaptation and illness. International Journal of Psychiatry in Medicine. 1974: 5. 321-333- Levine, J., & Zigler, E. Denial and self-image in stroke, lung cancer, and heart disease patients. JO 1 of Consultin and Clinical P cholo , 1975, _3, 751-757. Lipowski, Z. J. Psychosocial aspects of disease. Annals of Lipowski, Z. J. Physical illness, the individual, and the coping process. Psychiatric Medicine, 1970, 1, 91-102. Mechanic, D. Students Under Stres . New York: The Free Press of Glencoe, 1962. ' Parsons, T., A Fox, R. Illness, therapy and the modern urban Amefiican family. Journal of Social Issues, 1952, 8, 31" o Peck, A. Emotional reactions to having cancer. ’ . qurnal of Reontogenol Radiup_Therapeutic Nuclear Mega- cine, 1972, 114, 591-599. Pilowsky, I., & Spence, N. D. Patterns of illness behavior in patients with intractable pain. qurnal of Psychosomatic Research, 1975, as, 279-287.} 71 BIBLIOGRAPHY (cont'd.) Pritchard, M. Reaction to illness in long term haemodialysis. Journal of Ps chosomatic Research, 1974, pg, 55-67. Pritchard, M. Dimensions of illness behavior in long term haemodialysis. Journal of Psychosomatic Research, 1974, .lé: 351-356- Pritchard, M. Meaning of illness and patients' response to long term haemodialysis. Journal of Psychosomatic Rese Ch, 197“, Lg, 457-14'6 o Schachter, D., & Singer, J. CognitiVe, social and physiolog- ical determinants of emotional state. Psychological R__e_v___.lewv 19629 699 379-399- Schmale, A. H. Giving up as a final common pathway to chan es in health. Advances in Psychosomatic Medicine, 1972, _, 20. Seligman, M. Hslplsssness: On Dspression, Devlepment apd Death. San Francisco: W. H. Freeman and Company, 1975. Seyle, H. The Stress of Life. New York: McGraw-Hill, 1956. Shneidman, E. S. Orientations toward death: A vital aspect of the study of lives. In R. White (Ed.), Study of Lives. New York: Atherton Press, 1963. Symington, T., Currie, A. R., Curran, R. C., & Davidson, J. N. The reaction of the adrenal cortex in conditions of stress. In Ceba Foundation Colloquia in Endocrinology (Vol. 8), The Human Adrenal Cortex. Boston: Little, Brown and C0mpanY9 1955- Timmermans, G., & Sternback, R. A. Factors of’human chronic pain: An analysis of personality and pain reaction variables. Science, 1974, 184, 806. Tourney, G. Emotional reactions to chronic disease with emphasis on patients suffering from cancer. North- western.Meg;cine, 1969, as, 938-943. Verwoerdt, A. Psychopathological responses to the stress of physical illness. Advances in Psychosomatic Medicine, 1972: §; 119-_‘ 72 BIBLIOGRAPHY (cont'd.) Visotsky, H. M., Hamburg, D. A., Goss, M. E., & Lebovits, B. Z. COping behavior under extreme stress. Archives of General Ps chi tr , 1961, 5, 423-448. Waitzkin, H., & Stoeckle, J. D. The communication of informa- tion about illness. Advances in Psychosomatic Medicin , 1972 9 _8_’ 180’215 o Weisman, A. On Dying and Denyipg. Behavioral Publications, 1972. Weisman, A. D., & Hackett, T. P. Predilection to death: Death and dying as a psychiatric problem. Psychosomatic Weisman, A. D., & Hackett, T. P. Denial as a social act. In S. Levin, & R. Kahana (Eds.), PsyOAOgypapic Studiss op Aging: Creativity, Reminiscin and D in . New York: International Universities Press, 1967.