they have bome them for some time previously, consulting a doctor when the accommodation of ... usual activities (Apple, 1960). However, it has been argued ...
Alan Radley and Ruth IUness as adjustn^nt: a methodology and conceiitiial framework
Abstract This paper describes a method for studying individual adjustment to illness. The methodology draws upon the conceptual framework offered by Herzlich (1973) and defines four modalities of adjustment - accommodation, active-denial, secondary gain and resignation. The relevance of these modalities for understanding how people come to terms with illness is indicated with reference to a variety of studies of chronic illness describing such adjustments. The technique, which invites free responses to a series of questions, engages responctents on a number of issues which have been designated salient in the literature on illness behaviour and is intended to be used (a) to distinguish between individuals in their adaptation to their condition, and (b) to relate personal experience of iUne^ to changing sodal situations and relationshii^. TTie methodology is offered as a way of de«:ribing, within a sii^e conceptual scheme, the ways in which incttviduals resolve the dual demands of bodily change and of cultural constraint during chronic illness.
The question of how individuals leam to live with chronic illness in their everyday Uves h ^ supplemented the concept of the sick role as that which rtant reasons for this, which if subjected to the assumptions of positivist methodology would be regarded as severe weaknesses of the technique as presented. Firstly, the adjustment of individuals to illness or disability is not independent of context: different people have varying demands and opportunities as a consequence of their sodal situation. In a position of limited re-employment possibilities, small finances, heavy family responsibilities and poor support networks resignation may be a more usual and, therefore, predictable response. In a recent study we have found that male coronary patients' styles of adjustment to illness are parallelled by the form of relationship with their wives (Radiey & Green, 1986). Furthermore, those couples for whom social resources were limited and economic difficulties were prevalent appeared more often to be engaged in a fruitless stmggle with the illness, and sometimes with each other within the marital relationship. Assessing adjustment to illness is therefore not an exerdse in personality testing or behaviour-typing: it is the exploration of the patient's individual experience coordinated within the exerdse of these modalities in his/her relationships with others. Therefore, while it is tme to say that one aspect of concem is the individual's relationship to illness - how s/he has come to terms with it - the method is not aimed at assessing how tiie person copes with the illness as if it were a ready-made object. The illness or condition is itself defined through the mode of adjustment described, so that even in bro^ud terms being 'healthy' or 'ill' are differrai^ judgemoits from the petspec&ve of individuks eiqiresang different modsdities. To take this further, it is pebble for an asymptomic {^rson to appraise hk/her situation, in the light of his/her illne^ history, from the per^jeclive of acconunodation or active-denial. Hie
wo Mm Radtey asd Rutii Green
paradox of designating 'asserted good health' as active-denial (what is being denied if no symptom is experienced?) is resolved if it is emphasised again that the methodology is designed to tap the resolution of health and illness in {^rsonal experience. Onc^ the impiidt (and inojrrect) assumption that active-denial is in essence 'patihogenic' is exposed, then it can be acknowledged that 'battling on' might be, for some people in certain situations, an effective way of resolving symptoms and sodal life together, remembering that health is only one issue in people's lives (Gannik, 1983); An additional example can be fumished by considering the accommodation modality. This carries connotations of good adaptation, defined as it is as an acceptance of limitations and the integration of the disease into the lifestyle. And yet, as Cross has pointed out, hidden a^umptions may mean that this capacity to accept one's disability 'actually means accepting the social environment that exists for people who are disabled, rather than accepting the disability itself (1981). Rather than searching for conditions in the annmunity and environment to account for differences in ad^>tation, one seeks instead to locate the causes of such differences in tiie individuals themselves. This is the basis of what has been termed 'blaming the victim' which, with its accent on individual responsibility and intervention, 'atomises both causation and solution to illness' (Crawford, 1977). The methodology presented here is not intended to detract from sodal analysis through focusing upon adjustment as simply an individual affair. Although we have not set out to examine systematically such differences, use of the questionnaire revealed for three separate cohorts (each, N = 40) no significant differences in adjustment style between sodal classes Non-manual (I, II, III [N.M.]) and Manual (III [M], IV, V). However, in a second interview (as yet unpublished) with one of these cohorts just before admission for surgery, ocxupants of these two socioeojnomic groupingss (all men) were significantly distinguished in that (i) nonmanual re^xmdents accommodated more to their illness, and reported more secondary gain, (ii) mutual workers showed greater active-denial, (there was no difference in resignation). While re^ons for this finding might relate to the particular time of interview, this result is consistent with previous indkations that 'indifference to symptoms increases as one descends the sodal scale' (Baumann, 1961). M Koo& (1954) also pointed out, higher levels of education provide tiie benefidaries with the means to communicate with meiUcal personnel, and to g r a ^ aincepts of medical thinking.
Iitiwss as wiiw^m^Bt 201
Not only tiiis, but in being afflicted by chronic illness the better educated and the economically advantaged are those whose situation is buffered against the consequences of ill-health and who, in being able to retain intrinsic rewards in other areas of life, are best set to cope with the difficulties involved. (Pearlin and Schooler, 1978). The possibility that these sodo-economic groupings might differ in their styles of adjustment to illness can be related to two distinguishing class features; (a) the experience of the body, and (b) the system of beiiefe conceming how illness should be borne. For manual workers, particularly those who are unskilled, the body is the very instmment through which their labours are achieved. Tliis stands in contrast to the 'work of the hands' of the skilled worker (Arendt, 1959), or that 'of the mind' of the professional. It is not just that the body serves in different ways in the occupational life of these groupings but that, in its conduct and deportment, it stands in a different relation within the experience and practice of working and middle class people. For this reason, chronic illness may affect the working class patient not only directly, incapadtating him/her in his/her work, nor only through affecting him/her in his/her role as wage-eamer, but also by interfering with the distinctive and stylistic bodily comportment by which working class men, in particular, distinguish themselv^. (Bourdieu, 1984). (The heart patient who cannot chastise his child, for fear of bringing on chest pain, is an example). By contrast the middle class patient afflicted by chronic illness has a different relationship to his/her body, on which s/he relies in a different way, such that not only are other non-physical areas of life less affected but the idea of one's body as something to be maintained and monitored is a familiar one. If we address ourselves to the idea of health beliefs, the working and middle class patients might be distinguished in terms of the scheme introduced by Bernstein, and augmented by Douglas (1973) in order to show how bcdies are subject to, and act as a medium for sodal control. To the extent that (working class) patients find themselves in 'positional' role stmctures, illness which interferes with their roles k likely to be seen as a deviation from group norms. Families in which members cannot recoi^tmct their relationshif^ around sudi caises need every member to play his/her part. In these context, in spite of good will on dl sides, the patient is likely to experience both the impact of illness most fordbly and also the guilt which accompmiies it. v^ainst this backpound, it is to be expected that where patients omiiot change the situation they will fight
202 Alan Radiey and Ruth Green
against it (active-denial), asserting ^x)d health when pos^ble through the medium characteristic of its expres»on in their group the body itself. By contrast, the middle dass family, which can be described as having a more 'personal' system of control, engages iUness and its treatment as something for which the individual remains responsible; attention to changes in activity and diet are not only consistent with this attitude, but are moral requirements expressive of the relationship to the body which the middle cla% enjoys. Coupled with a greaterflexibilityof oinjugal roles, it is to be expected that accommodations might be e^ier for these individuate. Furthermore, there has been for some time within middle cls^ ideology the idea that iUness (be it ulcxrs, or heart disease) is in some way an honourable scar. This is evidenced in the popular (and wholly mistaken) notion of stress being a middle-class affUction (Stewart, 1950), so that when an executive suffers a heart attack his colleagues and employer have a health belief system in which that event is comprehensible - i.e. can be accommodated - and even offers gains. ^ Given the above arguments, the sdieme which we have described refers beyond the individual to the sodal context in which health beliefs are practised, and aUows questions of cultural cx)nstraint to be referred to the individual's situation. The potential of this approach lies predsely in the simultaneous treatment of illness/health as sodal practic;e and as formed within personal experience and conduct. The modalities describing the experience of the iU people are summaries of a process of adjustment pr^umed to take place between them and significant others. In revealing the outcomes of the meeting of lay and medical ideologies the methodology relates to the issue of multiple worlds of meaning. It is nec^sary to consider this in order to indicate the position with regard to what might otherwise be considered a further methodological weakness; that the technique is not intended primarily as a tool for prediction. The aim of linking sodal, and more particularly psychological measurement to outcome has been widespread in the application of sodal sdence to medidne. There is, from the medical perspective, a ftinctional need for assessment relating mdividual characteristics to both diagnc^is and prognosis. However, the employment of sodal sdence concepts in the service of mecUcaUy-oriented assessment led, in certain spheres, to the {voduction of typologies and which do not bear upon problems of sodal meaning, though proliferating emi»rical findings (Radiey, 1982). While igxeme measurement of personality or coping style may enable compioisooS
as adjustment :D3
to be made across d^mrate groupii^, the abstracticm erf phen
