Psychological Adaptation to Disability: Perspectives From Chaos and Complexity Theory

By Livneh, Hanoch; Parker, Randall M

The process of psychological adaptation to chronic illness and disability (CID) has been extensively studied by rehabilitation professionals for more than 50 years, yet it is still fraught with misunderstanding and often contradictory views. In this paper, the authors seek to expand on earlier suggestions by Parker, Schaller, and Hansmann (2003) and on recent applications in the field of psychology to demonstrate the potential usefulness of chaos and complexity theory (CCT) to understanding the psychosocial adaptation process to CID. In accordance, we (a) provide an overview of the most popular models of psychosocial adaptation to CID, (b) review the main elements of CCT, (c) discuss the current beliefs on the linkage between CCT and psychological reactions to stress and crisis, and (d) offer preliminary suggestions on the application of CCT to the adaptation process in CID and to rehabilitation-related interventions.

The onset of a physically traumatic event and the diagnosis of a chronic, life-threatening illness set into motion a chain of psychosocial experiences, reactions, and responses. The study of the nature, formation, structure, and temporal sequencing of these experiences has occupied the clinical and research interests of disability studies and rehabilitation professionals for the past 50 years. A database search of the available literature that focuses on psychosocial adaptation and adjustment to chronic illness and disability (CID) reveals hundreds of “hits,” strongly indicating the importance ascribed to understanding how individuals cope with the loss of body integrity and deteriorating health conditions.

In this paper, the authors will address the following areas: First, the various models of psychosocial adaptation to CID are briefly outlined. Second, the most salient elements of chaos and complexity theory (CCT) are described. Third, the convergent themes between CCT and psychosocial adaptation to CID are discussed. Finally theoretical and clinical applications of CCT to the understanding of the process and outcomes of adaptation to CID are suggested. The interested reader is referred to Barton (1994), Heiby (1995a, 1995b), and Parker, Schaller, and Hansmann (2003) for a succinct review of CCT’s main components, and to Abraham and Gilgen (1995), Butz (1997), Chamberlain and Butz (1998), Masterpasqua and Perna (1997), and Robertson and Combs (1995), for a more detailed discussion of the theory with specific applications to the fields of psychology and psychotherapy.

MODELS OF PSYCHOSOCIAL ADAPTATION TO CHRONIC ILLNESS AND DISABILITY

Four models, or more accurately, theoretical frameworks, of psychosocial adaptation to CID are frequently cited in the literature. These models share certain common views, most notably that (a) the experience of psychosocial adaptation to CID is a dynamic, unfolding temporal process; (b) the process of psychosocial adaptation integrates both intrapersonal elements (e.g., coping mechanisms, past experiences, cognitive appraisals) and transpersonal elements (e.g., influence of social networks, encountered environmental barriers, availability of medical and rehabilitation resources); and (c) irrespective of the structural and dynamic components of the model (e.g., linear, cyclical, random), most individuals appear to move toward renewed personal growth and functional adaptation. Of the four outlined models, two are essentially linear in nature and two are nonlinear.

Stage-Phase Models

The earlier models of psychosocial adaptation to CID emphasized the linearity of the adaptation process (see Cohn-Kerr, 1961; Dunn, 1975; Falek & Britton, 1974; Fink, 1967; Shontz, 1965). These models posited a generally predictable progression of stages (temporally nonoverlapping psychosocial experiences) and phases (partially overlapping experiences). Although the order of these mostly clinically postulated reactions or experiences differs slightly among the various models, they all argued for the existence of such psychosocial stages and phases as shock, denial, anxiety, anger, acceptance, and some form of reorganization or “final adjustment.”

Common to all these models is the assumption that more distal reactions-those temporally removed from the onset of the traumatic event-are predicated upon experiencing more proximal reactions- those occurring earlier in the adaptation process. For example, reaching the stage of acceptance or reorganization is conditional upon successful navigation of earlier stages such as anxiety or depression. Seldom did these earlier models consider the interaction of interpersonal or transpersonal factors with the internal psychodynamics that may have influenced the nature, formation, progression, or valence of the psychosocial adaptation process to CID.

Linear-Like Models

Although still conceptualizing psychosocial adaptation to CID as essentially a linear process, these more structurally complex models have paid greater attention to other determining factors. Included among these factors are (a) CID-related characteristics, for example, type, severity, and duration of condition; (b) personality attributes, for instance, coping style and self-concept; and (c) environmental influences, such as architectural barriers and societal attitudes (Livneh, 2001; Livneh & Antonak, 1997; Moos & Schaefer, 1984; Trieschmann, 1988). The role of these additional factors was typically viewed as either interactive or mediating. With interactive processes, the psychosocial adaptation process follows different trajectories at different levels of the operating factor. For example, the use of problem-focused coping vs. emotional- regulation coping acts to moderate psychosocial adaptation to CID. With mediating processes, the implicated factor (for example, coping strategies) is seen as directly caused or influenced by an earlier variable (for instance, level of pain) and, in return, directly influences psychosocial adaptation to CID.

Pendular Models

Developed to account for the often-reported swings between predisability and postdisability identities or between illness and health, pendular models have sought to portray the process of psychosocial adaptation to permanent disability as a series of gradual changes in selfidentity along a pendular trajectory (cf., Charmaz, 1991,1995; Kendall& Buys, 1998; Yoshida, 1993). For example, Charmaz (1983, 1995) posited that these changes among people with CID reflect a recognition of a loss of their former self- image. The process of adaptation for most people with CID, according to Charmaz, consists of a gradual evolution of an altered self reconstructed to accommodate bodily and functional losses. It also unifies the altered body and the adjusting self. Hence, adaptation is not a single, linear event but rather a repeated series of experiences as new losses are encountered and assimilated.

In a similar vein, Yoshida (1993) conceptualized the reemergence of the self following CID as a pendular representation of identity reconstruction. Following CID, the individual is seen as moving back and forth between the nondisabled, former self and the present, disabled aspects of the self. Identity reconstruction is, therefore, viewed as a dual-directional, nonlinear process whose outcome is never fully certain. After reviewing the research of Charmaz (1983, 1995) and Yoshida (1993), Kendall and Buys (1998) concluded that the pendular model aptly describes the constantly shifting self- perceptions of people with disabilities from their predisability self to their postdisability identity and back again. Similar dual- directional paradigms are found in the literature on coping with the death of a loved one, in which the bereaved person is described as oscillating between loss and restoration-oriented coping (see Stroebe & Schut, 1999).

Interactive Models

Interactive models of psychosocial adaptation (PA) to CID typically maintain that there is a reciprocal, iterative process of adaptation that involves both the individual and the environment. Commonly traced to the earlier work of Kurt Lewin and his students in the field of somatopsychology, such as L. Meyerson, T. Dembo, R. Barker, and B. Wright, these models suggest that PA proceeds in a complex manner that incorporates two sets of interactive variables, namely, those internal and those external to the individual. First, the intraindividual variables are those associated with physical aspects (e.g., type and severity of CID) and psychological aspects (e.g., self-concept) of the person. These variables interact with existing environmental conditions that include the physical, social, and vocational environments. Using Lewin’s formula, B = f (I,E), behavior (level of adaptive functioning) is a function of the interaction between the individual and the environment. According to this perspective, the individual’s overall degree of adaptation, following the onset of CID, may be mapped in a two-dimensional space, reflecting the joint “push and pull” of internal needs, motives and attributes, on the one hand, and external forces and barriers, on the other.

The foregoing four types of models, despite their time-honored contributions to the field of psychosocial adaptation to CID, are rather narrow in their focus. F\or example, all these models rely solely upon linear, homeostatic, or limited-cycle (disability as the center of mental gravity) notions that are often unfounded when applied to complex human systems (Butz, 1997; Cambel, 1993; Capra, 1996). In the following sections, therefore, a concerted effort is made to provide an overview of a relatively new framework for viewing psychosocial adaptation to CID that could greatly benefit our understanding of the process, dynamics, and complexity of life following the onset of disability.

CHAOS AND COMPLEXITY THEORY

Commensurate with the narrow aims of this paper, the authors provide a rather abbreviated review of the most essential concepts of CCT, followed by a discussion of their relevance to the field of psychosocial adaptation to CID. CCT has its origins in fields such as meteorology, mathematics, physics, biology, chemistry, geography, astronomy, and engineering. Because of its wide-ranging conceptual and empirical underpinnings, no unified theory of CCT exists. Many definitions have been undertaken, and most strive to highlight CCT’s nonlinear, dynamic, interactive, turbulent, unpredictable, self- organizing, and fractal nature (Capra, 1996; Chamberlain, 1998; Gleick, 1987; Parker et al., 2003).

Unlike the earlier Newtonian notions espoused in the fields of physics and mathematics, which emphasized linear, deterministic, and mostly quantitative concepts, CCT seeks to demonstrate the existence of discontinuous, nonlinear forces in many life domains. Using both qualitative and quantitative approaches to studying unstable phenomena, CCT is a collection of mathematical, numerical, and geometrical techniques that allow us to venture into nonlinear problems to which there are no explicit, general solutions (Cambel, 1993; Kellert, 1993). Furthermore, by focusing on complex systems and behaviors, CCT has succeeded in showing that chaos, despite initial perceptions of it as purely random, ill-organized sets of processes, has in fact an inherently ordered and deterministic set of rules (Chamberlain, 1998; Freeman, 1991). As such, CCT is one of the most popular approaches to the study of complexity, which Ls typically viewed as occupying a position along a continuum that ranges from perfect order to total randomness (Pagels, 1988).

During the past two decades, preliminary work has been reported in the literature on possible applications of CCT to the behavioral and social sciences. Butz (1992) provided some general guidelines for applying CCT concepts to analytical (i.e., Jungian) psychotherapy. Viewing chaos as a state of overwhelming anxiety, Butz proceeded to suggest how psychologically experienced chaos could be transcended and harnessed into human growth. Heiby (1995a), suggested preliminary guidelines for applying CCT to intensive, single-subject, time-series research designs. Her approach placed particular emphasis on continuous assessment of self-reported depression in one’s natural environment and on the search for nonlinearity as exemplified by unstable (e.g., bifurcated), irreversible transitional points. Goldstein (1995) explored the role of CCT in the context of psychoanalytical theory. He argued cogently that Freud’s regulatory principles that include equilibrium-seeking systems (e.g., the pleasure principle) could be modified to include more complex, nonequilibrium, nonlinear, and self-organizing changes. In that context, the traditional clinical understating of equilibrium is viewed as only a phase within the more nonlinear dynamics of the human psyche. Moran (1998) further suggested that psychoanalytic interpretations and increased insight into unconscious material combine to create perturbations that “alter the trajectory of the patient’s mental phenomena” (p. 35), thus paving the way to potentially improved emotional states.

Brabender (1997) drew attention to several similar lines between CCT and the life of psychotherapeutic groups. She identified parallels between the foregoing complex systems (CCT and group psychotherapy), such as irreversibility, constant exchange of information with the environment, and self-organization, and stressed the important role that chaos, as manifested in group members’ unconscious-driven behaviors, plays in the life of the group. Warren, Franklin, and Streeter (1998) maintained that CCT is highly suitable to understanding system theory and related complex human systems. They went on to illustrate how a number of concepts advocated by CCT can be applied to the field of social work, with particular emphasis on brief therapies. These therapies initially trigger in the client small behavioral changes that later could mushroom into more fundamental and lasting changes in behavioral repertoires and personality structure. Finally, Duffy (2000) discussed the application of CCT to career plateau. She provided, albeit sketchily, a case study in which five CCT concepts, namely, trigger event, chaotic transition, order in chaos, order from chaos, and selforganization, are used to deal with stagnated careers. Further efforts to apply CCT to human behavior can be found in the literature and have included understanding of family dynamics (Butz, 1997; Hudgens, 1998), exploring religion and spirituality (Butz, 1997; Swinney, 1998), and analyzing the dynamics of substance abuse (Hawkins & Hawkins, 1998).

CCT may be conveniently perceived as a broad effort to describe and understand systems that are nonlinear, dynamic, self- organizing, and self-similar. In the following paragraphs these concepts are briefly reviewed.

Nonlinearity

Nonlinear systems are those in which input does not equal output. Stated differently, cause and effect are not proportional, so that minor initial changes may result in large consequences (Cambel, 1993; Capra, 1996). This phenomenon is often referred to as “sensitive dependence on initial conditions.” Even barely noticeable differences or changes in initial conditions might initiate a sequence of events that can culminate in a massively chaotic outcome (Butz, 1997; Lorenz, 1963). The behavior of nonlinear systems is, therefore, nonrepetitive, unpredictable, aperiodic, and unstable. Nonlinear systems typically contain as part of their operational space, referred to as phase space, critical junctions of instability that are termed bifurcation points (Abraham, 1995; Capra, 1996). A bifurcation point is located where the system encounters two separate choices (often portrayed as a fork in the road). When a system reaches a bifurcation point, its earlier stability has already been compromised because of internal or external forces. Immediately beyond this point, the system’s properties undergo abrupt and seemingly unpredictable changes (Chamberlain, 1998; Coveney & Highfield, 1990,). Following the bifurcation, or crisis point, the system increasingly adopts new behaviors and gradually becomes more stable as it reaches more adaptive levels of functioning, until the next bifurcation point (Chamberlain, 1998; Prigogine, 1980). A bifurcation is, therefore, that critical juncture where order and chaos are joined. It is also the point where order emerges from the shadows of chaos. Bifurcation has also been described as that point where, following a system’s increasing unrest, quantitative changes transform into qualitative changes (Abraham, 1995). Finally, bifurcation is observed only in open systems operating far from equilibrium states (Prigogine, 1980).

A related concept frequently posited by CCT is that of attractors. An attractor is a pattern of behavior within a phase space toward which dynamic, nonlinear systems gravitate (Masterpasqua & Perna, 1997). Several types of attractors have been recognized.

Fixed-Point Attractors. These attractors portray predictable, stable, equilibrium-type points (in a phase space). When a fixed- point attractor operates (e.g., a pendulum at rest), the system gravitates to a single centering point and remains there (therefore the term fixed). The system’s trajectory, then, spirals inwardly toward a central location (the reader may visualize waters approaching a drain or a whirlpool). In this homeostatic state, the system does not manifest any indications of change and is assigned a dimension of zero (a point in space has no dimensions) (Cambel, 1993; Capra, 1996).

Limited-Cycle (Periodic, Cyclic) Attractors. These attractors are represented by predictable loops, both closed and open. These periodic circle-, or ellipse-shaped trajectories are reflections of oscillatory behaviors (Butz, 1997; Cambel, 1993). Periodic attractors typically follow donut-shaped (at times referred to as torus) trajectories. The system, therefore, approaches two different points periodically but does not escape that cycle (Abraham, 1989). Examples include a pendulum in motion and the beating human heart (Cambel, 1993). Torus-shaped cyclic attractors represent first- order change and have a dimension of 2 (a surface). As a torus continues to move farther away from its periodic, ellipsoid cycle, it collapses into two or more tori, creating two outcome basins and taking the shape of a butterfly. This constitutes a secondorder change.

Strange Attractors. These attractors indicate chaos, complexity, and unpredictability. Their trajectories are said to show “sensitive dependence on initial conditions.” Put differently, the slightest initial difference between two systems will mushroom into an extremely large difference over time and space, demonstrating the so- called butterfly effect (Cambel, 1993; Capra, 1996). Strange attractors, because of their unfolding and stretching properties, display noninteger or fractal dimensions generally between two and three dimensions. As indicators of chaotic systems, they are said to exhibit third-level changes, since the periods of these systems have bifurcated for the third time (Cambel, 1993; Young, 1995).

Dynamic Systems

Real-life, complex systems a\re dynamic and are neither fully random nor fully deterministic. They exhibit properties of both qualities (Cambel, 1993). The components of the system are synergistically linked to one another. The degree of complexity inherent in a system depends on several factors, including the system itself, the context (or environment) that engulfs it, and the nature of the interaction between the two.

Complex systems, therefore, are open systems because they exchange energy, material, and information with their immediate environment; closed systems do not (Cambel, 1993: Prigogine, 1980). Furthermore, complex systems are dissipative because they experience energy losses over time; to survive, they must reduce internal disorder, referred to as entropy, and at the same time, receive energy and information from the environment (Cambel, 1993; Capra, 1996). This set of conditions is described by the second law of thermodynamics. The level of entropy in a system is, therefore, indicative of its degree of randomness, noise, and irreversibility; in other words, it is a measure of chaos (Cambel, 1993; Prigogine & Stengers, 1984). Unlike open systems, closed systems proceed from order to disorder. Hence, the entropy of closed systems continuously increases as this irreversible process results in dissipation of unrecoverable energy. Closed, environmentally isolated systems, then, are at equilibrium or a state of maximum entropy (Kossmann & Bullrich, 1997; Prigogine & Stengers, 1984).

Consistent with these views, dynamic systems typically proceed from a phase of stable, orderly functioning through, first, an unstable, bifurcation phase, and second, a chaotic period. The chaotic period culminates in a phase of new and more complex order (Butz, 1997; Kossmann & Bullrich, 1997). Hence, chaos is the necessary phase before reorganization of previously malfunctioning components within a system. Upon the dissipation of chaos a new and adaptive pattern (higher order) is likely to emerge as the system successfully, and creatively, reorganizes itself. From the dynamic perspective, therefore, chaos serves two primary purposes. First, it facilitates adaptive functioning. Chaotic activity propels the dissipation of disturbance (or disorder) in a system. second, through its openness to environmental interactions and increased probability of change, chaos creates the system potential for creativity and evolution (Perna, 1997).

Self-Organization

Self-organizing, open systems possess certain unique characteristics, which include (a) nonlinear trajectories, (b) leap- like changes following a gradual aggregation of stresses, (c) spontaneous emergence of new structures and behavioral forms, and (d) internal feedback loops (Capra, 1996; Prigogine & Stengers, 1984). According to CCT, turbulent activity often appears random and irregular on a macroscopic level, but when viewed microscopically, it demonstrates a high degree of organization. Self-organization, then, is the process by which a chaotic system attains a new level of order, stability, and adaptation (Butz, 1997; Maturana & Varela, 1988).

The term autopoiesis (self-generating or “of the living”) has been applied to describe the self-organizational proclivity of living systems (Maturana & Varela, 1980). Autopoiesis is a mode of autonomous organization within organic structures. It both creates and renews itself by virtue of its own processes and their interaction with the surrounding environment, referred to as “structural coupling with the environment” (Varela, 1989).

Self-Similarity

Chaotic systems frequently give rise to a peculiar phenomenon in which similar structures-including those in naturally occurring objects, such as snowflakes, coastlines, tree branches, and cloud formations-may be observed at consecutive levels of magnification. This phenomenon is called self-similarity (Butz, 1997; Mandelbrot, 1977). Certain self-similar patterns, termed fractals by Benoit Mandelbrot (1977), have been extensively studied because of their chaotic nature. Fractals are best explained as deterministic, self- similar formations that are defined by their similar shapes across a wide range of scales (Masterpasqua & Perna, 1997; Parker et al., 2003). Strange attractors (discussed earlier) are viewed as “trajectories in phase space that exhibit fractal geometry” (Capra, 1996, p. 139). Complex fractal structures can be generated mathematically by repeatedly solving certain iterative equations (Parker et al., 2003; Sabelli, Carlson-Sabelli, Patel, Levy, & DiezMartin, 1995). Fractals exhibit noninteger dimensions (e.g., 1.84, 2.65), and they may be found in between traditional, integer- based Euclidian dimensions.

CCT AND PSYCHOSOCIAL ADAPTATION TO CHRONIC ILLNESS AND DISABILITY

Adaptation to Stress

Before considering the potential usefulness of CCT within the context of adaptation to CID, we briefly review its recent applications within psychology, focusing on coping with stress and crisis situations. During the past decade, concerted efforts have been made to elucidate the applicability of CCT-generated concepts to the psychodynamics of such diverse conditions as substance abuse, depression, anxiety, phobias, neurosis, disassociative identity disorder, and criminal behavior (Butz, 1997; Chamberlain, 1998; Masterpasqua & Perna, 1997; Robertson & Combs, 1995). Five themes, jointly linking CCT and psychology, are reviewed below.

Psychic System as a Nonlinear System. The psychic system is viewed by CCT proponents as operating at increasingly more complex levels (i.e., it is influenced by more intricate sets of attractors), as conditions of farfrom-equilibrium present themselves (Goldstein, 1995). Under everyday conditions, human cognitions and behaviors can accommodate both linear (e.g., time) and nonlinear (e.g., space) themes. In contrast, under stressful conditions, they manifest more complex, unpredictable, and ultimately increased nonlinear dynamics.

Psychic System as Self-Organizing (Autopoietic). Unlike noncomplex, closed systems, the psychic system structures itself through a dissipative exchange of energy and information with the external environment. The complex, dynamic psychic processes, with their inherent chaotic properties, serve an adaptive function in the long run (Perna, 1997). This adaptive function, it is argued, is manifested through activities that demonstrate creativity, spontaneity, and risk taking.

Human Behavior as Capable of Fractal Dimensionality. Human behavior, under stressful conditions, loses its integrative balance and attains fractional dimensionality. Examples of the self’s fractional dimensionality include obsessions, compulsions, phobias, and, most likely, dissociative reactions (Marks-Tarlow, 1995). Pathological conditions, therefore, often function as attractors that reduce the system’s dimensionality (or complexity) and propel it toward more stereotypical (or less adaptive) forms (Chamberlain, 1998). In a similar vein, Sabelli et al. (1995) have argued that the presence of chaotic (as opposed to rigidly structured) conditions may serve a role in increasing the dimensionality of homeostatic human functioning.

Defense Mechanisms and Coping Strategies as Special Types of Attractors. As unique attractors, defensive and coping strategies function to attain and maintain psychic stability (Butz, 1997; Torre, 1995). With repeated stressful encounters, individuals appear to regress to earlier forms of behavior. These more primitive (i.e., regressive) efforts to manage stress mirror what psychodynamic proponents refer to as repetition compulsion. Individuals also display self-similar forms in what is now a reduced dimensional space of human functioning (MarksTarlow, 1995). Indeed, the process of regression itself is capable of producing psychological and behavioral chaos in the self-system that is parallel to chaotic behavior in complex, nonlinear dynamic systems (Perna, 1995). Even more ostensibly adaptive and mature coping strategies, such as problem solving and cognitive restructuring, are not immune from gradually deteriorating into nonadaptive behavioral patterns (attractors). The reason for this is that over time they become more rigid and fail to transition or bifurcate into more situationally appropriate behaviors (Torre, 1995).

Chaos as an Indication of Overwhelming Anxiety. Psychic chaos, mostly equated with debilitating anxiety, is also capable of triggering a mixture of related emotions that include depression and anger (Butz, 1997; Chamberlain & Butz, 1998; Sabelli, 1989). The experience of profound heightened anxiety, as of other pathological psychic conditions, is likely to result in changes in the level of behavioral complexity (dimensionality). A psyche confronted with overwhelming anxiety transforms into a series of chaotic mental processes that serves both (a) the need to dissipate energy (i.e., decrease levels of anxiety) arid (b) the pursuit of adaptive forms of behavior and reconstructed self-organization (Chamberlain, 1998; Conrad, 1986; Perna, 1997). The progression from the initial core anxiety state, through the chaotic turbulence, to a renewed stable and adaptive functioning constitutes a phase transition “as the original attractor becomes repellent and forces trajectories outward” (Lewis & Junyk, 1997, p. 60).

Adaptation to Chronic Illness and Disability

From the perspective of CCT, psychosocial adaptation to CID is nonlinear, unpredictable, and discontinuous. Similar opinions were voiced by Butz (1997) and Chamberlain and Butz (1998) regarding human adaptation to most stressful life events. The process of adaptation, then, is essentially a process of self-organization that unfolds through experiences of chaos (i.e., emotional turmoil) and complexity (i.e., cognitive and behavioral reorganization) to increased functional dimensionality and renewed stability, even if temporary.

Understanding the psychosocial self-organi\zation that follows CID may benefit from adopting the applied models of chaotic dynamics posited by Lewis and Junyk (1997), Derrickson-Kossmann and Drinkard (1997), and Torre (1995). These models share the following elements with theories of self-organization, and their relevance to PA to CID is evident:

* Three components interact to play a dynamic role in the process of psychosocial self-organization following the onset of CID. These include cognitive appraisals, such as appraisals of loss; emotional experiences, such as experiences of anxiety and sadness; and behavioral responses, such as retreat from social encounters.

* Through the process of adaptation, these components interact with and activate each other recursively, proceeding from less harmonious to more harmonious coexistence.

* Experiences immediately following the onset of CID can be best understood within the context of sensitive dependence on initial conditions. Even minor, ostensibly insignificant, influences within the initial postCID psychological, social, or environmental contexts could have powerful long-term implications (both salutary and detrimental) on psychosocial adaptation. Similar reasoning could be applied to rehabilitation interventions following the onset of CID. During this crisis-like period, minor changes in one’s behavior or use of newly acquired coping strategies could quickly transform into long-term and more fundamental behavioral changes and life pursuits.

* Earlier in the process of adaptation (during the chaotic phase), substantial discrepancies, and even antagonistic trends, are likely to exist among the trajectories of these three components (cognitions, emotions, behaviors) in both scope and valence. Put differently, the normal and continuous convergence of feelings, thoughts, and behaviors that signifies the adaptive functioning under most life conditions becomes disrupted and disjointed.

* During the adaptation process, certain recurrent states, such as negative appraisals, hyperarousal, blaming others, and guilt, may be formed and may exert a powerful influence on the individual’s thought processes and behaviors. These recurrent states are indicators of attractors in the self’s phase space map.

* Throughout the adaptation process, as chaotic and complex conditions gradually give way to reorganization, self-correcting and self-stabilizing relations among the three sets of experiential components (cognitions, emotions, and behaviors) slowly converge to reestablish a unified functional front.

* Following a traumatic event, such as CID, the normal patterns of coping with manageable life stressors are no longer capable of containing the overwhelming anxiety and other distressing emotions. As a result, adaptation to CID leads to a series of bifurcations in the individual’s customary life experiences. The impact of the CID, then, gives rise to newly formed attractors in the individual’s perceptions, cognitions, level of affectivity, and daily activities. As some of these attractors transform into strange attractors, they draw into the CID-operating region (phase space) a wide range of behaviors (Francis, 1995). With time, chaotic perceptions and disorganized behaviors flood the psyche and gradually interfere with normal activities. Following a period of psychic decompensation, new patterns of selforganization gradually emerge, and these result in restoration of psychic balance and increased differentiation of mental processes.

* Psychosocial adaptation following CID may be perceived as a “dialectical interaction” (Perna, 1995) between the self- organization processes of the internal world made up of the postchaotic psyche-mending self and the prevailing social-physical context of the external world.

* Many natural phenomena and human experiences are cyclical. Natural phenomena are frequently gauged with references to seasons, period, and so on. A wide range of human activities and milestones are timed using cyclical-repetitious, albeit artificial, indicators (e.g., minutes, hours, days, months, years, anniversaries). Much of life, therefore, evolves around both fixed and limited-cycle attractors. These somewhat predictable continuous cycles are disrupted following the onset of life-altering, traumatic experiences such as CID. The trajectories of these mostly stable attractors (e.g., spending time at a work site, engaging in leisure time activities) are then transformed into those resembling unpredictable, turbulent strange attractors (life experiences that now follow highly irregular patterns).

Exploratory Suggestions for Rehabilitation Interventions

The CCT-based literature on psychotherapeutic interventions with clients who manifest clinical symptomatology (e.g., anxiety, depression, personality disorders, or disassociative reactions) or are confronted with stressful life events is only beginning to emerge (Butz, 1997; Chamberlain & Butz, 1998; Masterpasqua & Perna, 1997; Robertson & Combs, 1995). Moran (1998), adopting a psychodynamic perspective, argues that neurotic behaviors and the experiences of anxiety, depression, and stress act as attractors that reduce the psychic system’s dimensionality. Neurotic behaviors, thus, result in a less complex and creative behavior, or alternatively, more rigid and stereotypical activities. With its emphasis on interpretations, gaining insights, and the therapeutic alliance, psychodynamic therapy introduces a series of perturbations that alter the trajectory of the client’s cognitive schemata and gradually increase behavior complexity, leading to more adaptive levels of functioning. In a similar vein, Goldstein (1995) maintains that psychotherapy can be viewed as a “system transformation.” From a linearfocused, rigid, and equilibrium-operated psychic system, the client is helped to attain a nonlinear, nonequilibrium, and more complex mode of functioning. Psychotherapy is, therefore, the transition work into more complex attractors and increased dimensionality.

The rehabilitation and disability studies literatures have yet to adopt the principles and insights of CCT to understanding psychosocial adaptation to CID. In the concluding section of this paper, possible applications of CCT to those fields are suggested. More specifically, we draw upon two interrelated concepts derived from CCT, namely, complexity/dimensionality and self-organization, to assist us in these efforts.

Complexity/Dimensionality. Immediately following the onset of CID, psychic disequilibrium ensues. Previously adhered-to emotional, cognitive, and behavioral processes are disrupted, and the generally stable preCID functional complexity is shattered and reduced to lower dimensionality. The reduction to lower dimensionality is evidenced as life’s focus shifts into the “here and now,” physiological survival, and deflection of impending psychosocial crises. Time and space are constrained to the present and the immediate surroundings (e.g., hospital and home). The role of the rehabilitation professional, under these circumstances, could be conceptualized as addressing the following broad goals:

* Helping the client to regain the “lost” core of functional complexity. This could be accomplished by shifting the focus from the present-oriented, space-restrained framework of the individual to future-oriented, goal-oriented, skill acquisition activities and ::; to community-oriented participatory efforts. Moreover, as the external environment gradually assumes increased importance in , the life of the individual with CID, rehabilitation efforts are directed not merely at environmental mastery but equally at modifying the person’s home, work, and commu- .; nity environments. Since the impact of disability can best be understood as a con. , ; tinuous interaction among functional limitations and residual abilities (both stemming from the nature of the medical condition) and barriers imposed by both the physical and social-attitudinal environments, it is imperative that the rehabilitation professional incorporate the influences generated by these environments (i.e., dimensions) into a well-balanced rehabilitation plan.

* Working with the client to extend functional dimensionality. This could be pursued by gradually introducing into the client’s life space additional domains (i.e., dimensions) that are likely to elevate functioning from its present health- and survival-oriented modes to include social, spiritual, vocational, and environmental mastery modes.

* Working through and gaining insight into nonfunctional defenses. Because of regressive tendencies that could follow the trauma of CID, the client may resort to adopting earHer (past- oriented) and no longer adaptive (rigid) defense mechanisms such as projection, splitting, and displacement (see, for example, Haan, 1977). Increased dimensionality, within the context of coping with stress, may take the form of increasing the individual’s repertoire of future-oriented, flexible, and situationally adaptive coping strategies. These strategies could draw from both emotional- and cognitive-oriented approaches to regulate unremitting stress, and behavioral and problem-solving efforts to manage and directly address changeable circumstances (Devins & Binik, 1996; Zeidner & Saklofske, 1996). In addition, a wide range of environmental-based coping resources (e.g., financial, educational, vocational, social- supportive) should be made readily available to the individual.

* Increasing the client’s recognition of spontaneous, creative, and even risk-taking efforts, Following sudden-onset CID, cognitive processes and daily activities are reduced to more rigid, risk- avoiding, and predictable patterns (lower dimensionality). Limited- cycle (periodic) attractors often emerge, and, as a result, many life experiences revolve around nonadaptive foci such as negative emotionality, resignation, succumbing to external barriers, social withdrawal, feelings of \anger, and so on. It is incumbent upon the rehabilitation professional to arrange for or create perturbations that would open up additional life options, increase flexible and creative modes of problem solving, and expand the range of available experiences and behaviors for the client. These strategies seek to allow the client to reach higher dimensionality of cognition, emotion, and behavior, thus facilitating the process of psychosocial adaptation to CID.

Self-Organization. The seeds of self-organization may already be found in humanistic-existential theories, such as Rogers’s person- centered therapy and Maslow’s self-actualization approach. Rogers’s concepts of the self-actualization tendency and organismic trusting and Maslow’s concepts of self-actualization and growth motivation strongly indicate that these and other humanistic writers (e.g., Frankl and Peris) were well aware of the self-healing processes inherent in all human activities with the processes’ innately self- organizing and self-regulating properties (Ford & Urban, 1998; Maddi, 1989). Relatedly, Mahoney and Moes (1997) argued that human patterns of personal-experiential development reflect lifelong selforganizing processes. Inherent in Mahoney and Moes’s approach is the belief that life maintains its balance through dynamic and recurrent phases. Although periodic perturbations (e.g., stresses, crises, challenges) may occasionally disrupt this balance, these perturbations are usually accommodated in a successful manner. More severe perturbations (such as CID) may create turbulent cycles that result in disequilibrium, but, with time, life balance is typically restored.

Rehabilitation professionals who adopt this view may find the following broad strategies for promoting self-reorganization useful:

* Providing the client with the quintessential Rogerian conditions of change (e.g., empathie understanding, warmth, unconditional positive regard, genuineness) may be a necessary but certainly not a sufficient strategy required to induce change in the lives of people who have undergone the experience of CID. A derailment, albeit temporary, from the path of self-actualization and growth may necessitate an additional “jolt to the system” (such as a direct confrontation to or challenging of one’s faulty cognitions and entrenched misperceptions). A temporary derailment may help the client resume the innate drive toward selforganization and self-constructing. Gestalt therapy and cognitive-behavioral strategies that seek to challenge the individual’s psychological defensiveness, denial of affective involvement, and unrealistic cognitions regarding the CID and its impact may more effectively facilitate the client’s movement toward a new order of adaptation.

* Self-organization entails efforts by the rehabilitation professional to move the person with CID past the chaos and complexity phases. This could be accomplished through facilitating realignment of the disrupted synchronicity among the cognitive, affective, and behavioral components of life experiences. Moreover, the pre-CID adaptive homeostasis between the self (internal world) and the environment (external reality) is also frequently disrupted following a traumatic physical or psychological event. To help the client reach a restored functionally adaptive state, the rehabilitation professional should consider garnering the combined facilitative influences of both experiential (e.g., Gestalt) and cognitive (e.g., cognitive-behavioral) interventions. In this search for restoration of functional adaptation, rehabilitation professionals should, likewise, pay particular attention to the immediate (proximal) and broad (distal) environments within which the person with CID functions. Examples of proximal selforganization- associated domains include, but are not limited to, family influences, financial resources, the local community (e.g., medical, rehabilitation, educational, transportation, vocational, and recreational resources), and attitudinal barriers and facilitators at each of these local settings. Distal self-organization-linked domains include, among others, prevailing sociocultural influences (including cultural beliefs, values, and perceptions), political climate, technological and medical advances, and the availability of federal and state funding for modifying environmental barriers and creating job opportunities for people with disabilities. Although beyond the scope of this paper, the rehabilitation professional should make every reasonable effort to consider these environmental influences as they may facilitate or hinder the process of selforganization and the attainment of person-environment congruence.

* If, indeed, after periods of chaos such as evidenced following the onset of CID, old patterns of cognitions and behaviors (e.g., earlier problem-solving and coping strategies) no longer succeed in their adaptive roles, the individual may be nearing a crucial psychic bifurcation point. This is the point of maximum potential that is required to undertake the necessary leap into adopting new behaviors (Chamberlain, 1998). This point also signifies what has been described as operating at the “edge of chaos” (Kauffman, 1995; Waldrop, 1992). This point reveals the complex Janus-faced phenomenon (or region) that retains residues of old and orderly patterns of behavior, but at the same time lays the ground for a system transformation, the emergence of a new order, openness to experience, alternative states of viewing the world, and the adoption of adaptive cognitive schemas and behaviors.

This is where the role of the rehabilitation professional becomes significant. The rehabilitation professional is in an excellent position to be a catalyst to guide the client’s behavior toward new and adaptive patterns of cognition and behaviors, and ultimately to help in propelling the emergence of these patterns toward reorganization of the client’s future hopes and goals.

SUMMARY

From the perspective of CCT, psychosocial adaptation to CID can be construed as a dynamic, nonlinear, and mostly unpredictable process in which the individual undergoes the following four transitions:

1. The initial poverty of the complexity/ dimensionality of previously established behavioral, cognitive, and coping patterns following the impact of CID is followed by a gradual increase in dimensionality/ complexity of behavior, as the process of identity reconstruction and self-reorganization unfolds.

2. The pre-CID life space, which typically included relatively stable period attractors (i.e., daily vocational, educational, familial, and avocational tasks and responsibilities), gradually shifts to include strange attractors or aperiodic, unpredictable experiences (emotional states, cognitive schemata) to which many life activities gravitate, leading to chaotic psychic experiences.

3. Following CID, the impact of physiological and biochemical elements (often triggered by the anatomical insult of the condition), new psychological and behavioral experiences, and environmental conditions (family reactions, social attitudes, architectural barriers) is filtered through the ingrained pre-CID personality attributes and demographic characteristics. As these many influences converge, the chaotic patterns evidenced in one’s life space intensify through a series of turbulent bifurcations, ultimately resulting in more intricately adaptive cognitive and behavioral patterns.

4. The adaptive behavioral patterns, as evidenced in a reconstructed self-identity, are manifested in several ways. These include increased spontaneity, creativity, cognitive flexibility, risk-taking behaviors (albeit within limits), pursuits that transcend rigid obligations and goals, appreciation of diverse activities and life goals, and a dynamic balance of vocational and avocational pursuits. These new and adaptive patterns recognize not only CID-influenced activities of daily living but also the many nonaffected spheres of life. In fact, some of the earlier propositions of Beatrice Wright and her coworkers on value transformation following CID demonstrate uncanny insight into this facet of CCT (Wright, 1983).

Finally, although CCT does not directly indicate which rehabilitation interventions are best suited for increasing psychosocial adaptation to CID, it does offer a general framework for interventions. Mostly, it suggests the supremacy of an eclectic approach that incorporates multifaceted, yet nonrigid, views of the human experience and its change following adverse physical and psychological conditions. Such an approach recognizes the complexity, uncertainty, transformation, and ever evolving dynamics of the human spirit, especially as it seeks to transcend the constraining barriers imposed by chronic illness and disability.

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Hanoch Livneh

Portland State University

Randall M. Parker

University of Texas at Austin

ABOUT THE AUTHORS

Hanoch Livneh, \PhD, is a professor and the coordinator of the Rehabilitation Counseling Program at Portland State University. He teaches and writes about the topics of psychosocial adaptation to chronic illness and disability. Randall M. Parker, PhD, is the Melissa Elizabeth Stuart Centennial Professor of Education and the director of Rehabilitation Counseling Education in the Department of Special and Counselor Education at the University of Texas at Austin. He teaches and writes on the topics of adjustment to disability, research design, and data analysis. Address: Hanoch Livneh, Rehabilitation Counseling Program, Department of Special and Counselor Education, Portland State University, PO Box 751, Portland, OR, 97207; e-mail: [email protected]

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