02 - 2. Sick role and illness behaviour

2. Sick role and illness behaviour

© SPMM Course 2. Sick role and illness behaviour The sick role is a concept described by the American sociologist Talcott Parsons with 4 characteristics: The sick person is freed or exempted from carrying out normal social roles. The more severe the illness, the more is the freedom from normal social roles. This is granted to everyone in society irrespective of social status. People who are ‘sick’ are not directly responsible for their disease. They are not blamed or expected to take the blame, and if one takes self-blame, this is viewed as odd behaviour. It is necessary that a sick person tries to get well. The sick role is regarded as a temporary stage that should not be prolonged if at all possible. A sick person must seek competent help and cooperate with medical care to get well. This implies that a doctor is an agent of social control – one that restores people’s social roles. The concept of disease: Disease: refers to actual pathology (e.g. a process that results in illness) Illness refers to personal experience (a set of symptoms suffered by a patient) Sickness refers to social consequences (e.g. absence from work) Health behaviours are seen in healthy people who try to maintain their health – these are related to primary prevention of disease and are intended to reduce susceptibility to disease in the first place. Mechanic and Volkart, 1961, proposed the concept of illness behaviour which refers to any behaviour undertaken by an individual who feels ill to relieve that experience or to better define the meaning of the illness experience. Illness behaviour is an active process “that involves interpreting symptoms, evaluating possible responses and, finally, deciding whether to try to alleviate those symptoms or simply to ignore them”. Abnormal illness behaviour (Issy Pilowsky, 1969) is an extension of the concept of illness behaviour; it is defined as the persistence of a maladaptive mode of experiencing, perceiving, evaluating, and responding to one’s own health status, despite the fact that a doctor has provided a lucid and accurate diagnosis and management plan (if any), with opportunities for discussion, negotiation, and clarification, based on adequate assessment of all relevant bio-psycho-socio-cultural factors. These can be excessive illness affirming (e.g. somatoform or malingering) or denying behaviours (e.g. loss of insight in psychosis). Factors influencing individual response to illness  Symptom visibility & their perceived importance  Assessment of symptom’s significance  Potential for symptoms to disrupt community  Symptom denial for fear of confirmation of serious illness  Deferring response to symptoms because of competing social demands  Assessment of social & economic costs of responding to symptoms versus potential health-related benefits

© SPMM Course  Available information knowledge & cultural assumptions & understandings  Symptom frequency & persistence  Competing interpretations of symptoms International Classification of Impairments, Disabilities and Handicaps (ICIDH) provided a descriptive conceptual framework of consequences of illnesses. Impairment: interference with structural or psychological functions (that is, parts of the whole person e.g. loss of an arm’s function due to fracture). Disability is interference with activities of the whole person in relation to the immediate environment (simply ‘activities of daily living' e.g. not able to cook for oneself due to the fracture) Handicap is the social disadvantage resulting from disability (e.g. loss of work and inability to meet friends due to restricted driving secondary to fracture) Health Beliefs Model: The health beliefs model was developed with the observation that patients have their own beliefs about disease risks and treatment benefits. According to HBM patients’ beliefs about their disease states may be more influential than medically determined disease information. The health beliefs model identifies several factors for which patients’ beliefs may affect their treatment participation: (1) Patient’s beliefs about the severity of their condition, (2) Patient’s beliefs about their susceptibility of acquiring the disease or complications of the disease, (3) Patient’s beliefs about cost of treatment adherence (including costs in inconvenience, effort, time, and money), (4) Patient’s beliefs about benefits of treatment adherence, and (5) Patient’s beliefs regarding the environmental and social cues to action that may assist in their treatment adherence. The Transtheoretical Model (TTM) was developed by Prochaska and DiClemente (1982). This was developed largely in response to increasing divergence in the practice of psychotherapy, and the authors attempted a (transtheoretical) synthesis among the various therapeutic systems. They identified five common processes of change that are applicable to how individuals can be motivated to change their illness-related behaviours. These processes are (1) Consciousness raising – helping the patient gather information about self and the problem (2) Choosing – increasing awareness of healthy alternatives, (3) Catharsis – emotional expression of the problem behaviour and the process of change,

© SPMM Course (4) Conditional stimuli – includes stimulus control and counterconditioning, a. Stimulus control: Avoidance of stimuli associated with the problem behaviour and the operant extinction cueing effect of the stimulus on behaviour. b. Counterconditioning: Training an alternative, healthier response to the cue stimuli. (5) Contingency control: Positive reinforcement from others and self-appraisal and improving self-efficacy by self-reinforcement. From these five processes of change, Prochaska and DiClemente identified six stages of change. These are (1) precontemplation, (2) contemplation, (3) Preparation, (4) action, (5) maintenance, and (6) relapse. In the precontemplation stage, a person is not even considering changing his or her behaviour, does not see the behaviour as a problem, minimizes and denies associated risks, and avoids information to the contrary. In the contemplation stage, the person has become aware of why the behaviour is a problem but is ambivalent about changing, and likely sees equal or more benefits than costs from the behaviour. During preparation, the person has made a decision to change, and is planning a strategy for change, but has not yet taken action. In action, the person has implemented a plan and is changing the behaviour. In maintenance, the person has been able to sustain the change and avoid reverting to problem behaviour for a significant period of time. In relapse, the person does revert to problem behaviour, ‘back to square one’.  These stages are not linear in sequence but rather cyclical, in that a person can relapse and reenter at a later stage such as preparation.  The stages do not operate in an invariant sequence (unlike Piaget’s models).  Each stage can be moved into back and forth (reversibility).  The stages are not qualitatively different. Motivational Interviewing (Miller & Rollnick, 1991) is often used together with TTM and stages of change.