This article was downloaded by: [McMaster University] On: 21 December 2014, At: 10:53 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of Human Stress Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vzhs20
Stress, Illness, and Illness Behavior Dr. David Mechanic Ph.D. a
a b
University of Wisconsin , Madison, Wisconsin, USA
b
Center for Medical Sociology and Health Services Research , University of Wisconsin , Madison, Wisconsin, USA Published online: 09 Jul 2010.
To cite this article: Dr. David Mechanic Ph.D. (1976) Stress, Illness, and Illness Behavior, Journal of Human Stress, 2:2, 2-6, DOI: 10.1080/0097840X.1976.9936061 To link to this article: http://dx.doi.org/10.1080/0097840X.1976.9936061
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
STRESS, ILLNESS, AND ILLNESS BEHAVIOR
Downloaded by [McMaster University] at 10:53 21 December 2014
DAVID MECHANIC. Ph.D.
This paper examines adaptation as a transactive process involving the skills and capacities of individuals and their supporting groups on the one hand, and the types o f challenges thqy .face on the other. Many di@ulties in under standing stress processes in illness result j - o m the con-fusion between illness and illrivss behavior. I t is argued that the medical record is as much a history of the individual's behavior and social selection processes as it is a reflection oj. levels of physical health. Various examples are discussed. illustrating how medical records can be misleading in research examining the relationship between stress and illness. and how injluences attributed to stress may be the result of illness behavior. The paper concludes b-y examining alternative conceptual models .for studying t h e relationships between l i f e challenges. illness behavior and illness. The pages that follow contain a discussion of some of the conceptual difficulties in the definition and measurement of stress, and an exploration of some alternative perspectives for continued research on the relationships between life events and life changes and the health status of populations. I n a previous discussion' I reviewed some alternative conceptions that might explain observed correlations between life change and illness. Here I wish to give greater attention to various intervening factors that help explain why persons facing comparable stressors react clifferently.
Although it is desirable, in order to meet necessary methodological standards, to h,ave
measures of stressors that are independent of people's reactions, it is important theoretically to view adaptation as a transactive process between people and their life situations. We cannot adequately predict the response of a person while only knowing the dimensions of the challenges he faces; we also must know a good deal about his capabilities to deal with these situations. The process of adaptation depends on the degree of fit between the skills and capacities of individuals and their relevant supporting group structures on the one hand, and the types of challenges with which they are confronted on the other. To the extent that capacities and relevant social supports are fitted well to characteristic challenges, the flow of events is routine and ordinary. The maintenance and development of mastery requires that individuals face demands that are somewhat challenging but not so challenging as to defeat their coping resources. To the extent that individuals are involved and motivated, their capacities to meet challenging life demands depend on inborn and acquired skills, the material and interpersonal resources available to them in their environment, and their psychological capacities to handle anxieties and discomfort as they carry out various tasks. It is useful to conceive of the exercise of skills and capacities as coping, in contrast to defense (those intrapsychic processes that control negative arousal). Coping and defense, however, are highly interdependent processes. Successful application of skills and capacities requires that inadequacy and uncertainty and protect against a sense of futility. Defense processes must be sufticientlv effective to keeD DeoDle from being distracted from tasks thev can reasonablv Derform, but sufficiently so that persons can gauge their environment and its attendant dangers. If defense processes en.
Dr. Mechanic is John Bascom Professor of Sociology and Director of the Center for Medical Sociology and Health !$ervices Research at the University of Wisconsin at Madison, Wisconsin.
2 Journal of Human Stress
-
&
_ I I
June, 1976
MECHANIC courage aspirations that individuals cannot possibly achieve, they inevitably lead to difficultY It is worth emphasizing that the conception of the transaction of the person and his environment can be dealt with in objective terms, by measuring attributes of situations and persons' adaptive capacities independently of their reports concerning the situation. Although we must move in this direction, the reluctance to do so is understandable. When we exclude persons' perceptions as data to allow more rigorous tests of important hypotheses, we obviously lose a great deal of information that is not easily obtainable when using more objective approaches. Also, our methodologies for measuring important dimensions of situations and adaptive capacities of people are very much underdeveloped and seem incomplete relative to the richness of perception we obtain from the subjects themselves. A reasonable compromise is to work at both levels, making sure that we do not confuse the development of more objective indicators with people's perceptions and reactions.
Downloaded by [McMaster University] at 10:53 21 December 2014
-
ILLNESS AND ILLNESS BEHAVIOR
The persistent confusion between illness and illness behavior (i.e., the processes of definition and response to symptoms) has been a major weakness in the stress literature. It is one thing to demonstrate that stress influences the occurrence of morbidity; it is quite another to show that stress may result in different responses to the occurrence of symptoms and different patterns of seeking assistance. This confusion results, in part, from the types of populations clinical researchers usually study, and from the types of perspectives that guide their assumptions. In the section below, I discuss the problem of research populations. Varying perspectives for studying stress and illness are reviewed in the final section of the paper. Most studies of illness are based on clinical populations who have selected themselves from a population at risk on the basis not only of illness but also of a variety of sociocultural, psychological and situational characteristics. June. 1976
Thus, patients with a particular diagnosis may be more or less representative of all those in the population who have the same disorder. Although the onset of some disorders is sufficiently acute to minimize selective factors other than those associated with the illness, this is not typically the case and much of the research on human stress involves samples of illness that are preselected because of a variety of social, psychological and situational factors. The foregoing also suggests why even conventional studies of human stress in relation to disease usually must depend on clinical assessment in a community population. The record of use of medical services is constructed from the totality of events and reactions of individuals in their life situations and reflects not only evident physical morbidity but also cultural patterns, peer pressures, life difficulties, attitudes toward the value of medical care, and the like. Thus, the medical record is as much a history of the individual's social behavior as a reflection of the level of physical health. The consequences of using records to identify specific illnesses can be illustrated by considering viral respiratory conditions, the single most frequent problem found in ambulatory medical care practices. Despite the frequency of symptoms of viral respiratory disease as presenting complaints, only a minority of such conditions are brought to the attention of physicians. Such conditions, further, are reported to be a major cause of restriction of normal activity, work absenteeism and loss of human productivity. While I do not debate that such conditions cause considerable discomfort and inconvenience, I contest the casual interpretation of the association between such conditions and social outcomes. Viral respiratory conditions rarely make it impossible to carry out normal activities, and the fact that persons respond differently suggests that we should look further for other variables of importance. Restriction of occupational and social activity occurs because persons often find the activities themselves distasteful, unsatisfying or frustrating. While viral respiratory diagnoses may excuse the failure to report for work or to meet other social obligations, we would do well not to accept the usual assumption that their elimination would conJournal of Human Stress 3
Downloaded by [McMaster University] at 10:53 21 December 2014
STRESS AND ADAPTATION tribute in a major way to diminished work absenteeism and increased human productivity. Individuals who face adverse circumstances certainly would find other medical excuses to justify their failure to meet responsibilities that are distasteful or burdensome. The links between discomforting life events and viral respiratory complaints are more complex than the above suggests. The possibilities include: (1) that stress contributes in some fashion to the incidence of infectioq3(2) that the condition, itself, is a significant source of distress and weakens the person's incentive; ( 3 ) that the condition serves as an excuse to relieve distressful obligations and helps avoid social sanctions for nonperformance of respon~ i b i l i t i e s(4) ; ~ that the condition allows the person to justify to himself his failure to adequately meet social responsibilities;s (5)that the distress of the condition becomes merged and confused with other existing feelings of distress so that the individual cannot differentiate clearly the souirce of his distress and attributes causality to ithe viral respiratory condition;6or all of these. Some of these possibilities further imply varying processes of occurrence. Thus, stress may affect rhe reported incidence of infection by lowering bodily resistance; or it may affect the person's behavioral patterns including exposure to infection, eating and sleeping; or it may affect the person's threshold to recognize discomfort, or his reactions to it. The diagnosis on the medical record fails to inform us as to which of these hypotheses is the more valid one, and a successful study would be designed so as to provide confirmation or refutation of varying alternative hypotheses. Some years ago, we abstracted the clinic records of a population of students we were studying from an epidemiological standpoint. If one examines the population of persons from such a record system who have particular diagnostic entries, one finds that they are distinctive not only in their propensity to be so labeled, but also in a variety of other social, cultural and situational characteristics that differentiate them from the population from which they have come.' Looking at the more common diagnoses - such as viral respiratory conditions - indicates that such an entry is a measure of a behavioral pattern perhaps more than a
4 Journal of Human Stress
measure of morbidity. The different social profile, of course, may also be associated with varying risks of developing such a medical problem, but there is no current evidence to suggest this is the case. More recently, we have carried out an epidemiological investigation of students seeking assistance for psychological distress and the relationship between the magnitude of distress and the student's sociocultural context.8 Although level of distress is the single most important factor predicting use of psychological helping services - including the use of a psychiatry clinic, a counseling center, and religious counseling services - sociocultural factors differentiate importantly between those using and not using a particular service. In this investigation we attempted to address a variety of issues: (1) the role of distress levels in seeking assistance; (2) the sociocultural determinants of distress; (3) the role of sociocultural factors in seeking assistance, controlling statistically for the magnitude of distress; and (4)the role of sociocultural factors in seeking assistance from particular sources of care. We find in the population studied that sociocultural selection generally occurs at varying levels of distress and is relatively independent of distress in initiating care. Although sociocultural factors are important in accounting for help-seeking at a particular source such as psychiatry, we found little evidence in this case that such factors were important in whether some kind of formal assistance was sought or not. In short, the portrait of the epidemiology of distress obtained from solely examining patients of any single agency gives a highly distorted view of persons with distress in general. or the character of all of those who seek help. SOCIAL CHANGE, ADAPTATION, AND MODELS OF ILLNESS
Although there is a large clinical research literature on the role of stress in relation to a variety of diseases, only rarely are attempts made to specify the processes through which life events affect specific diseases. Despite many years of research, we know too little about the conditions under which stress has more or less impact, or why it may manifest itself in illness June. 1976
Downloaded by [McMaster University] at 10:53 21 December 2014
MECHANIC when it does. To the extent that it is assumed that stress can manifest itself in any of the body systems, or in any physical or behavioral dysfunction, without further elaboration of relevant processes or conditions, there is little direction for further research. The traditional approach to the problem of stress and illness would suggest that we move toward greater refinement in dependent variables, and for each disease attempt to understand the etiological significance of stress as it interacts with a variety of genetic, physiological and psychosocial variables. Such studies, if they are to be carried out successfully, require reliable and valid measurement of the dependent variable, a sizable representative sample of persons suffering from the condition under study, and a relevant comparison group. Because these conditions are often difficult to meet, the clinical researcher frequently falls back on the study of cases obtained from his particular clinic or hospital. But as noted earlier, the extent of illness behavior and disability, which may vary substantially for any level of objective dysfunction, may hopelessly confound his observations and conclusions. Because physicians tend to view illness in terms of relatively discrete entities and assume that the medical record is an adequate measure of these, they may misperceive or underestimate the significance of variations in behavior surrounding illness, or incorrectly attribute to the illness reactions that are more appropriately accounted for by other factors. John Casse19 has noted serious difficulties with the traditional approach and suggests an alternative perspective: Logically, then, the problem can be formulated as two interrelated, but from a research point of view separate, questions. First would be the identification of situations that are likely to evoke inappropriate adaptive responses. Populations exposed to such situations would be expected to manifest a wide spectrum of disease consequences which may or may not “fit” the existing clinical classificatory schemes. The nature or form of these manifestations would be the second type of question. Answers to this will not come from the identification of the processes involved in the situation alone, but must take into account June, 1976
the determinants of the particular adaptive devices utilized by various segments of the population . . . .Such a formulation, by allowing for multiple alternative options to any particular situation and by indicating a need to identifysituations likely to evoke inappropriate adaptive responses,can provide leads as to what it is that needs to be quantified and what sorts of relationships would be acceptable as evidence of importance of these situations. (pp. 203-2041 Although events causing maladaptive response may contribute to traditional disease entities, Cassel urges that we take a broader view than those suggested by existing classifications. Such an effort appears worthwhile, particularly since the conditions of living have been changing rapidly and will continue to change in dramatic ways. There is reason to anticipate that people will find social change difficult, and that adaptations harmful to health will take many forms. In recent years there has been a marked shift in the study of human adaptation from concern with intrapsychic defense mechanisms to much greater emphasis on the skills and supports req u i r e d t o m e e t t y p i c a l l i f e c h a l l e n g e s . ’’ Associated with this shift is a growing realization that the medical model as a mode of studying adaptations is very much limited, and an increasing interest in exploring alternative educational and transactional models of human behavior. The challenge is to define those variables on both an individual and community level that are identifiable and measurable and that can be linked to health behavior and health levels in populations. The individual’s motivations, skills and defensive capacities do not develop in a vacuum but, rather, reflect the social context in which he is reared and in which he develops his social experience. Psychological stress does not occur without the individual facing a threat of failure or loss; yet the meaning of failure or loss is dependent on social values and the acceptance of cultural definitions of what is valuable. It is the cultural meanings in any subgroup that determine what events will be experienced as stressful. The types of skills people acquire also depend on how well fitted both formal and informal experience is for dealing with likely challenges. Part of the difficulty of a rapidly Journal of Human Stress 5
Downloaded by [McMaster University] at 10:53 21 December 2014
STRESS AND ADAPTATION changing society is that experience may only poorly prepare persons for the types of life challenges they must face, or so inappropriately structure expectations so that people are inevitably frustrated and disappointed. The rapidity of communication and the exposure to diverse living styles, so facilitated by television and rapid travel, have resulted in certain instabilities in expectations and satisfactions. The constant barrage of alternative possibilities and the pace of change bring into question the longterm usefulness of what has been learned in the family, the youth peer group, or in even more formal institutions such as schools. The adequacy of defensive processes, those that allow people to maintain their sense of equilibrium and esteem as they go about meeting ordinary demands, is very much dependent on the types of social supports available lo people in their families, kinship groups, work contexts, or in the community more general1.y. With increasing geographic and social mobilit,y, many of the traditional support systems have been weakened, and a wide variety of formal agencies have assumed some of these responsibilities. The importance of intimacy is reflected in a recent study by Brown” of depression in women, in which he notes that an intimate relationship often insulates women against depression despite significantly stressful life events. It seems unlikely that more formal agencies of support, however important, can reasonably substitute for the breakdown in more intimate, informal support systems. One of the most dramatic evidences of the search for group meaning is in the proliferation of encounter groups of all kinds.’I While these groups are mostly temporary and frequently recreational in nature, they reflect a search for intimacy and meaning which many people find lacking in more usual life experiences. Similarly, there is some evidence that much of the utilization of more formal helping agencies also reflects a loss of meaning and commitment that drains the vitality and excitement of people’s lives. In our concern for diminishing stresses that tax the coping abilities of individuals, we must recall that much of human activity involves seeking out stress and searching for the exhilaration of new experience. Stress is a condli-
6 Journal of Human Stress
tion for growth, and it is through successful exercise of mastery that people develop a sense of worth and competence. Thus, the task for society may not be to diminish the sense of challenge that contributes to life and growth, but to better facilitate the ability of individuals and groups to develop the competence to deal successfully with challenges and strain. Studies of stress must give greater attention to people’s adaptive struggles, and how personal and group effectiveness can be enhanced. This work was supported in part by a grant from the Robert Wood Johnson Foundation.
INDEX TERMS stress,
ulaess behavior, dnptation, coping, defense, social
change.
REFERENCES 1. Mechanic, D. “Some Problems in the Measurement of Stress and Social Readjustment,” J. Hum. Stress. Vol. 1. No. 3, September, 1975, pp. 43-48. 2. S t u d e n t s Under Stress: A Study in the Social Psychology Of’Adaptation. Free Press, New York, 1962. 3. Meyer. R. J.. and R. Haggerty. “Streptococcal Infections in Families,” Pediatrics. Vol. 29. 1962, pp. 539-549. 4. Field, M. Doctor and Patient in Sovier Russia. Harvard University Press, Cambridge, 1957. 5. Cole, S., and R. Lejeune. “Illness and the Legitimation of Failure,’’ A m . Sociol. Rev., Vol. 37, 1972, pp. 347356. 6. Imbcden. J. B.. A. Canter, and L Cluff. “Symptomatic Recovery from Medical Disorders,” J.A. M.A.. Vol. 178, 1%1, pp. 1182-1184. 7. Mechanic, D. “Some Implications of Illness Behavior for Medical Sampling.” N. Engl. J. Med.. Vol. 269. 1%3. pp. 244-247. 8. Greenley, 1.. and D. Mechanic. “Patterns of Seeking Care for Psychological Problems,” in D. Mechanic, The Growth Of‘BureaucraticMedicine: A n Inquiry into the Dynamics of Patient Behavior and the Organization ofMedical Care. Wiley-Interscience. New York, 1976. 9. Cassel, John. “Physical Illness in Response to Stress,’’ Social Stress. S . Levine. and N. Scotch, eds Aldine, Chicago, 1970. 10. Mechanic, D. “Social Structure and Personal Adaptation: Some Neglected Dimensions.” Coping and A d a p tation, G. Coelho. D. Hamburg. and J. E. Adams. eds. Basic Books, New York. 1974. 11. Brown, G. “Social Class and Psychiatric Disturbance Among Women in an Urban Population,” Department of Sociology. Bedford College, University of London, 1974. 12. Back, K.Beyond Words: The Story ofSensitivity Training and the Encounter Movement. Russell Sage, New York.1972.
June, 1976
Journal of Human Stress Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vzhs20
Stress, Illness, and Illness Behavior Dr. David Mechanic Ph.D. a
a b
University of Wisconsin , Madison, Wisconsin, USA
b
Center for Medical Sociology and Health Services Research , University of Wisconsin , Madison, Wisconsin, USA Published online: 09 Jul 2010.
To cite this article: Dr. David Mechanic Ph.D. (1976) Stress, Illness, and Illness Behavior, Journal of Human Stress, 2:2, 2-6, DOI: 10.1080/0097840X.1976.9936061 To link to this article: http://dx.doi.org/10.1080/0097840X.1976.9936061
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
STRESS, ILLNESS, AND ILLNESS BEHAVIOR
Downloaded by [McMaster University] at 10:53 21 December 2014
DAVID MECHANIC. Ph.D.
This paper examines adaptation as a transactive process involving the skills and capacities of individuals and their supporting groups on the one hand, and the types o f challenges thqy .face on the other. Many di@ulties in under standing stress processes in illness result j - o m the con-fusion between illness and illrivss behavior. I t is argued that the medical record is as much a history of the individual's behavior and social selection processes as it is a reflection oj. levels of physical health. Various examples are discussed. illustrating how medical records can be misleading in research examining the relationship between stress and illness. and how injluences attributed to stress may be the result of illness behavior. The paper concludes b-y examining alternative conceptual models .for studying t h e relationships between l i f e challenges. illness behavior and illness. The pages that follow contain a discussion of some of the conceptual difficulties in the definition and measurement of stress, and an exploration of some alternative perspectives for continued research on the relationships between life events and life changes and the health status of populations. I n a previous discussion' I reviewed some alternative conceptions that might explain observed correlations between life change and illness. Here I wish to give greater attention to various intervening factors that help explain why persons facing comparable stressors react clifferently.
Although it is desirable, in order to meet necessary methodological standards, to h,ave
measures of stressors that are independent of people's reactions, it is important theoretically to view adaptation as a transactive process between people and their life situations. We cannot adequately predict the response of a person while only knowing the dimensions of the challenges he faces; we also must know a good deal about his capabilities to deal with these situations. The process of adaptation depends on the degree of fit between the skills and capacities of individuals and their relevant supporting group structures on the one hand, and the types of challenges with which they are confronted on the other. To the extent that capacities and relevant social supports are fitted well to characteristic challenges, the flow of events is routine and ordinary. The maintenance and development of mastery requires that individuals face demands that are somewhat challenging but not so challenging as to defeat their coping resources. To the extent that individuals are involved and motivated, their capacities to meet challenging life demands depend on inborn and acquired skills, the material and interpersonal resources available to them in their environment, and their psychological capacities to handle anxieties and discomfort as they carry out various tasks. It is useful to conceive of the exercise of skills and capacities as coping, in contrast to defense (those intrapsychic processes that control negative arousal). Coping and defense, however, are highly interdependent processes. Successful application of skills and capacities requires that inadequacy and uncertainty and protect against a sense of futility. Defense processes must be sufticientlv effective to keeD DeoDle from being distracted from tasks thev can reasonablv Derform, but sufficiently so that persons can gauge their environment and its attendant dangers. If defense processes en.
Dr. Mechanic is John Bascom Professor of Sociology and Director of the Center for Medical Sociology and Health !$ervices Research at the University of Wisconsin at Madison, Wisconsin.
2 Journal of Human Stress
-
&
_ I I
June, 1976
MECHANIC courage aspirations that individuals cannot possibly achieve, they inevitably lead to difficultY It is worth emphasizing that the conception of the transaction of the person and his environment can be dealt with in objective terms, by measuring attributes of situations and persons' adaptive capacities independently of their reports concerning the situation. Although we must move in this direction, the reluctance to do so is understandable. When we exclude persons' perceptions as data to allow more rigorous tests of important hypotheses, we obviously lose a great deal of information that is not easily obtainable when using more objective approaches. Also, our methodologies for measuring important dimensions of situations and adaptive capacities of people are very much underdeveloped and seem incomplete relative to the richness of perception we obtain from the subjects themselves. A reasonable compromise is to work at both levels, making sure that we do not confuse the development of more objective indicators with people's perceptions and reactions.
Downloaded by [McMaster University] at 10:53 21 December 2014
-
ILLNESS AND ILLNESS BEHAVIOR
The persistent confusion between illness and illness behavior (i.e., the processes of definition and response to symptoms) has been a major weakness in the stress literature. It is one thing to demonstrate that stress influences the occurrence of morbidity; it is quite another to show that stress may result in different responses to the occurrence of symptoms and different patterns of seeking assistance. This confusion results, in part, from the types of populations clinical researchers usually study, and from the types of perspectives that guide their assumptions. In the section below, I discuss the problem of research populations. Varying perspectives for studying stress and illness are reviewed in the final section of the paper. Most studies of illness are based on clinical populations who have selected themselves from a population at risk on the basis not only of illness but also of a variety of sociocultural, psychological and situational characteristics. June. 1976
Thus, patients with a particular diagnosis may be more or less representative of all those in the population who have the same disorder. Although the onset of some disorders is sufficiently acute to minimize selective factors other than those associated with the illness, this is not typically the case and much of the research on human stress involves samples of illness that are preselected because of a variety of social, psychological and situational factors. The foregoing also suggests why even conventional studies of human stress in relation to disease usually must depend on clinical assessment in a community population. The record of use of medical services is constructed from the totality of events and reactions of individuals in their life situations and reflects not only evident physical morbidity but also cultural patterns, peer pressures, life difficulties, attitudes toward the value of medical care, and the like. Thus, the medical record is as much a history of the individual's social behavior as a reflection of the level of physical health. The consequences of using records to identify specific illnesses can be illustrated by considering viral respiratory conditions, the single most frequent problem found in ambulatory medical care practices. Despite the frequency of symptoms of viral respiratory disease as presenting complaints, only a minority of such conditions are brought to the attention of physicians. Such conditions, further, are reported to be a major cause of restriction of normal activity, work absenteeism and loss of human productivity. While I do not debate that such conditions cause considerable discomfort and inconvenience, I contest the casual interpretation of the association between such conditions and social outcomes. Viral respiratory conditions rarely make it impossible to carry out normal activities, and the fact that persons respond differently suggests that we should look further for other variables of importance. Restriction of occupational and social activity occurs because persons often find the activities themselves distasteful, unsatisfying or frustrating. While viral respiratory diagnoses may excuse the failure to report for work or to meet other social obligations, we would do well not to accept the usual assumption that their elimination would conJournal of Human Stress 3
Downloaded by [McMaster University] at 10:53 21 December 2014
STRESS AND ADAPTATION tribute in a major way to diminished work absenteeism and increased human productivity. Individuals who face adverse circumstances certainly would find other medical excuses to justify their failure to meet responsibilities that are distasteful or burdensome. The links between discomforting life events and viral respiratory complaints are more complex than the above suggests. The possibilities include: (1) that stress contributes in some fashion to the incidence of infectioq3(2) that the condition, itself, is a significant source of distress and weakens the person's incentive; ( 3 ) that the condition serves as an excuse to relieve distressful obligations and helps avoid social sanctions for nonperformance of respon~ i b i l i t i e s(4) ; ~ that the condition allows the person to justify to himself his failure to adequately meet social responsibilities;s (5)that the distress of the condition becomes merged and confused with other existing feelings of distress so that the individual cannot differentiate clearly the souirce of his distress and attributes causality to ithe viral respiratory condition;6or all of these. Some of these possibilities further imply varying processes of occurrence. Thus, stress may affect rhe reported incidence of infection by lowering bodily resistance; or it may affect the person's behavioral patterns including exposure to infection, eating and sleeping; or it may affect the person's threshold to recognize discomfort, or his reactions to it. The diagnosis on the medical record fails to inform us as to which of these hypotheses is the more valid one, and a successful study would be designed so as to provide confirmation or refutation of varying alternative hypotheses. Some years ago, we abstracted the clinic records of a population of students we were studying from an epidemiological standpoint. If one examines the population of persons from such a record system who have particular diagnostic entries, one finds that they are distinctive not only in their propensity to be so labeled, but also in a variety of other social, cultural and situational characteristics that differentiate them from the population from which they have come.' Looking at the more common diagnoses - such as viral respiratory conditions - indicates that such an entry is a measure of a behavioral pattern perhaps more than a
4 Journal of Human Stress
measure of morbidity. The different social profile, of course, may also be associated with varying risks of developing such a medical problem, but there is no current evidence to suggest this is the case. More recently, we have carried out an epidemiological investigation of students seeking assistance for psychological distress and the relationship between the magnitude of distress and the student's sociocultural context.8 Although level of distress is the single most important factor predicting use of psychological helping services - including the use of a psychiatry clinic, a counseling center, and religious counseling services - sociocultural factors differentiate importantly between those using and not using a particular service. In this investigation we attempted to address a variety of issues: (1) the role of distress levels in seeking assistance; (2) the sociocultural determinants of distress; (3) the role of sociocultural factors in seeking assistance, controlling statistically for the magnitude of distress; and (4)the role of sociocultural factors in seeking assistance from particular sources of care. We find in the population studied that sociocultural selection generally occurs at varying levels of distress and is relatively independent of distress in initiating care. Although sociocultural factors are important in accounting for help-seeking at a particular source such as psychiatry, we found little evidence in this case that such factors were important in whether some kind of formal assistance was sought or not. In short, the portrait of the epidemiology of distress obtained from solely examining patients of any single agency gives a highly distorted view of persons with distress in general. or the character of all of those who seek help. SOCIAL CHANGE, ADAPTATION, AND MODELS OF ILLNESS
Although there is a large clinical research literature on the role of stress in relation to a variety of diseases, only rarely are attempts made to specify the processes through which life events affect specific diseases. Despite many years of research, we know too little about the conditions under which stress has more or less impact, or why it may manifest itself in illness June. 1976
Downloaded by [McMaster University] at 10:53 21 December 2014
MECHANIC when it does. To the extent that it is assumed that stress can manifest itself in any of the body systems, or in any physical or behavioral dysfunction, without further elaboration of relevant processes or conditions, there is little direction for further research. The traditional approach to the problem of stress and illness would suggest that we move toward greater refinement in dependent variables, and for each disease attempt to understand the etiological significance of stress as it interacts with a variety of genetic, physiological and psychosocial variables. Such studies, if they are to be carried out successfully, require reliable and valid measurement of the dependent variable, a sizable representative sample of persons suffering from the condition under study, and a relevant comparison group. Because these conditions are often difficult to meet, the clinical researcher frequently falls back on the study of cases obtained from his particular clinic or hospital. But as noted earlier, the extent of illness behavior and disability, which may vary substantially for any level of objective dysfunction, may hopelessly confound his observations and conclusions. Because physicians tend to view illness in terms of relatively discrete entities and assume that the medical record is an adequate measure of these, they may misperceive or underestimate the significance of variations in behavior surrounding illness, or incorrectly attribute to the illness reactions that are more appropriately accounted for by other factors. John Casse19 has noted serious difficulties with the traditional approach and suggests an alternative perspective: Logically, then, the problem can be formulated as two interrelated, but from a research point of view separate, questions. First would be the identification of situations that are likely to evoke inappropriate adaptive responses. Populations exposed to such situations would be expected to manifest a wide spectrum of disease consequences which may or may not “fit” the existing clinical classificatory schemes. The nature or form of these manifestations would be the second type of question. Answers to this will not come from the identification of the processes involved in the situation alone, but must take into account June, 1976
the determinants of the particular adaptive devices utilized by various segments of the population . . . .Such a formulation, by allowing for multiple alternative options to any particular situation and by indicating a need to identifysituations likely to evoke inappropriate adaptive responses,can provide leads as to what it is that needs to be quantified and what sorts of relationships would be acceptable as evidence of importance of these situations. (pp. 203-2041 Although events causing maladaptive response may contribute to traditional disease entities, Cassel urges that we take a broader view than those suggested by existing classifications. Such an effort appears worthwhile, particularly since the conditions of living have been changing rapidly and will continue to change in dramatic ways. There is reason to anticipate that people will find social change difficult, and that adaptations harmful to health will take many forms. In recent years there has been a marked shift in the study of human adaptation from concern with intrapsychic defense mechanisms to much greater emphasis on the skills and supports req u i r e d t o m e e t t y p i c a l l i f e c h a l l e n g e s . ’’ Associated with this shift is a growing realization that the medical model as a mode of studying adaptations is very much limited, and an increasing interest in exploring alternative educational and transactional models of human behavior. The challenge is to define those variables on both an individual and community level that are identifiable and measurable and that can be linked to health behavior and health levels in populations. The individual’s motivations, skills and defensive capacities do not develop in a vacuum but, rather, reflect the social context in which he is reared and in which he develops his social experience. Psychological stress does not occur without the individual facing a threat of failure or loss; yet the meaning of failure or loss is dependent on social values and the acceptance of cultural definitions of what is valuable. It is the cultural meanings in any subgroup that determine what events will be experienced as stressful. The types of skills people acquire also depend on how well fitted both formal and informal experience is for dealing with likely challenges. Part of the difficulty of a rapidly Journal of Human Stress 5
Downloaded by [McMaster University] at 10:53 21 December 2014
STRESS AND ADAPTATION changing society is that experience may only poorly prepare persons for the types of life challenges they must face, or so inappropriately structure expectations so that people are inevitably frustrated and disappointed. The rapidity of communication and the exposure to diverse living styles, so facilitated by television and rapid travel, have resulted in certain instabilities in expectations and satisfactions. The constant barrage of alternative possibilities and the pace of change bring into question the longterm usefulness of what has been learned in the family, the youth peer group, or in even more formal institutions such as schools. The adequacy of defensive processes, those that allow people to maintain their sense of equilibrium and esteem as they go about meeting ordinary demands, is very much dependent on the types of social supports available lo people in their families, kinship groups, work contexts, or in the community more general1.y. With increasing geographic and social mobilit,y, many of the traditional support systems have been weakened, and a wide variety of formal agencies have assumed some of these responsibilities. The importance of intimacy is reflected in a recent study by Brown” of depression in women, in which he notes that an intimate relationship often insulates women against depression despite significantly stressful life events. It seems unlikely that more formal agencies of support, however important, can reasonably substitute for the breakdown in more intimate, informal support systems. One of the most dramatic evidences of the search for group meaning is in the proliferation of encounter groups of all kinds.’I While these groups are mostly temporary and frequently recreational in nature, they reflect a search for intimacy and meaning which many people find lacking in more usual life experiences. Similarly, there is some evidence that much of the utilization of more formal helping agencies also reflects a loss of meaning and commitment that drains the vitality and excitement of people’s lives. In our concern for diminishing stresses that tax the coping abilities of individuals, we must recall that much of human activity involves seeking out stress and searching for the exhilaration of new experience. Stress is a condli-
6 Journal of Human Stress
tion for growth, and it is through successful exercise of mastery that people develop a sense of worth and competence. Thus, the task for society may not be to diminish the sense of challenge that contributes to life and growth, but to better facilitate the ability of individuals and groups to develop the competence to deal successfully with challenges and strain. Studies of stress must give greater attention to people’s adaptive struggles, and how personal and group effectiveness can be enhanced. This work was supported in part by a grant from the Robert Wood Johnson Foundation.
INDEX TERMS stress,
ulaess behavior, dnptation, coping, defense, social
change.
REFERENCES 1. Mechanic, D. “Some Problems in the Measurement of Stress and Social Readjustment,” J. Hum. Stress. Vol. 1. No. 3, September, 1975, pp. 43-48. 2. S t u d e n t s Under Stress: A Study in the Social Psychology Of’Adaptation. Free Press, New York, 1962. 3. Meyer. R. J.. and R. Haggerty. “Streptococcal Infections in Families,” Pediatrics. Vol. 29. 1962, pp. 539-549. 4. Field, M. Doctor and Patient in Sovier Russia. Harvard University Press, Cambridge, 1957. 5. Cole, S., and R. Lejeune. “Illness and the Legitimation of Failure,’’ A m . Sociol. Rev., Vol. 37, 1972, pp. 347356. 6. Imbcden. J. B.. A. Canter, and L Cluff. “Symptomatic Recovery from Medical Disorders,” J.A. M.A.. Vol. 178, 1%1, pp. 1182-1184. 7. Mechanic, D. “Some Implications of Illness Behavior for Medical Sampling.” N. Engl. J. Med.. Vol. 269. 1%3. pp. 244-247. 8. Greenley, 1.. and D. Mechanic. “Patterns of Seeking Care for Psychological Problems,” in D. Mechanic, The Growth Of‘BureaucraticMedicine: A n Inquiry into the Dynamics of Patient Behavior and the Organization ofMedical Care. Wiley-Interscience. New York, 1976. 9. Cassel, John. “Physical Illness in Response to Stress,’’ Social Stress. S . Levine. and N. Scotch, eds Aldine, Chicago, 1970. 10. Mechanic, D. “Social Structure and Personal Adaptation: Some Neglected Dimensions.” Coping and A d a p tation, G. Coelho. D. Hamburg. and J. E. Adams. eds. Basic Books, New York. 1974. 11. Brown, G. “Social Class and Psychiatric Disturbance Among Women in an Urban Population,” Department of Sociology. Bedford College, University of London, 1974. 12. Back, K.Beyond Words: The Story ofSensitivity Training and the Encounter Movement. Russell Sage, New York.1972.
June, 1976
