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sense of self-esteem. It is suggested that these processes involve developing illusions. Such illusions are not necessarily in
contradiction to reality but are positive interpretations of this reality. For example, although theremaybelittleevidenceforthe
real causes ofcancer,orfortheabilityofindividualstocontrolthecourseoftheirillness,thosewhohavesufferedcancerwishto
hold their own illusions about these factors (e.g. I under- standwhatcausedmycancerandbelievethatIcancontrolwhetherit
comes back). Taylor and her colleagues argued that these illusions are a necessary and essential component of cognitive
adaptation and that reality orientation (as suggested by other coping models) may actually be detrimental to adjustment.
The need for illusions raises the problem of disconfirmation of the illusions(whathappenswhenthereoccurrenceofcancer
cannot be controlled?) Taylor argued that the need for illusions is sufficient to enable individuals to shift the goals and foci of
their illusions so that the illusions can be maintained and adjustment persist.

Implications for the outcome of the coping process

According to this model of coping, theindividualcopeswithillnessbyachievingcogni-tiveadaptation.Thisinvolvessearching
for meaning (I know what caused my illness), mastery (Icancontrolmyillness)anddevelopingself-esteem(Iambetteroff
than a lotofpeople).Thesebeliefsmaynotbeaccuratebuttheyareessentialtomaintainingillusionsthatpromoteadjustmentto
the illness. Therefore, within this perspective thedesiredoutcomeofthecopingprocessisthedevelopingofillusions,notreality
orientation.

THE POSITIVE INTERPRETATION OF ILLNESS

Most theories of coping emphasize a desire tore-establishequilibriumandareturntothestatusquo.Therefore,effectivecoping
would be seen as that which enables adjustment to the illness and a return to normality. Some research however,indicatesthat
some people perceive benefits from being ill and see themselves asbeingbetteroffbecausetheyhavebeenill.Thisapproachis
in line with positive psychology and its emphasis on positive rather than negative affect (see stress and positive psychology
Chapters 1011). For example, Laerum et al. (1988) interviewed84menwhohadhadaheartattackandfoundthatalthoughthe
men reported some negative consequences for their lifestyleandqualityoflife,33percentofthemenconsideredtheirlifetobe
somewhat or consider- ably improved. Similarly, Collins et al. (1990) interviewed 55 cancer patients and also reported some
positive shifts following illness. Sodergren and colleagues have explored positivity following illness and have developed a
structured questionnaire calledtheSilverLiningQuestionnaire(SLQ)(SodergrenandHyland2000;Sodergrenetal.2002).They
concluded from theirstudiesthatthepositiveconsequencesofillnessarevariedandmorecommonthanoftenrealized.Theyalso
suggest that positivity can be improved by rehabilitation.

70 HEALTH PSYCHOLOGY

USING THE SELF-REGULATORY MODEL TO PREDICT OUTCOMES

The self-regulatory model describes a transition from interpretation, throughillnesscog-nitions,emotionalresponseandcoping
to appraisal. This model has primarily been used in research to ask the questions How do different people make sense of
different illnesses? and How do illness cognitionsrelatetocoping?Research,however,hasalsoexploredtheimpactofillness
cognitions on psychological and physical health out- comes. Some research has addressed the links between illness cognitions
andadherencetotreatment.Otherresearchhasexaminedtheirimpactonrecoveryfromillnessesincludingstrokeandmyocardial
infarction (MI; heart attack).

Predicting adherence to treatment

Beliefs about illnessintermsofthedimensionsdescribedbyLeventhalandcolleagues(1980,1997)havebeenshowntorelateto
coping. They have also been associated with whether or not a person takes their medication and/or adheres to other suggested
treat- ments. For example, Brewer et al. (2002) examined the relationship between illness cognitions and both adherence to
medication and cholesterol control in patients with hypercholesterolaemia (involving veryhighcholesterol).Theresultsshowed
that a belief that the illness hasseriousconsequenceswasrelatedtomedicationadherence.Inaddition,actualcholesterolcontrol
was related to the belief that the illness was stable, asymptomaticwithseriousconsequences.Someresearchhasalsoincludeda
role for treatment beliefs. For example, Horne and Weinman (2002) explored the links between beliefs about both illness and
treatment and adherence totakingmedicationforasthmain100community-basedpatients.Theresultsshowedthatnon-adherers
reported more doubts about the necessity of their medication, greater concerns about the consequences of the medication and
more negative beliefs about the consequences of their illness. Overall, the analysis indicated that illness and treatment beliefs
were better predictors of adherence than both clinical and demographic factors. In a similar study, Llewellyn et al. (2003)
explored the interrelationships between illness beliefs, treatment beliefsandadherencetohometreatmentinpatientswithsevere
haemophilia. The results showed that poor adherence was related to beliefs about thenecessityofthetreatment,concernsabout
the consequences of treatment and beliefs about illness identity.

Predicting recovery from stroke

Research has also explored links between illness cognitions and recovery from stroke. For example, Partridge and Johnston
(1989) used a prospective study and reported that individuals beliefs abouttheirperceivedcontrolovertheirproblempredicted
recovery from residual disability in stroke patients at follow-up. The results showed that this relationship persisted even when
baseline levels of disability were taken into account. In line with this, Johnston et al. (1999a) also explored the relationship
between perceived control and recovery from stroke and followedup71strokepatientsoneandsixmonthsafterdischargefrom
hospital. In addition, they examined the possible mediating effects of
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coping, exercise and mood. Therefore, they asked the questions Does recoveryfromstrokerelatetoillnesscognitions?andIf
so, is this relationshipdependentuponotherfactors?Theresultsshowednosupportforthemediatingeffectsofcoping,exercise
and mood but supported earlier work to indicate a predictive relationship between control beliefs and recovery.

Predicting recovery from MI

Research has also explored the relationship betweenillnesscognitionsandrecoveryfromMI.Fromabroadperspectiveresearch
suggests that beliefs about factorssuchastheindividualsworkcapacity(MaelandandHavik1987),helplessnesstowardsfuture
MIs (called cardiac invalidism) (Riegel 1993) and general psychologicalfactors(Diederiksetal.1991)relatetorecoveryfrom
MI as measured by return to work and general social and occupational functioning. Using a self-regulatory approach, research
has also indi- cated that illness cognitions relatetorecovery.Inparticular,theHeartAttackRecoveryProject,whichwascarried
out in New Zealand and followed 143 first time heart attack patients aged 65 or under for 12 months following admission to
hospital.Allsubjectscompletedfollow-upmeasuresat3,6and12monthsafteradmission.Theresultsshowedthatthosepatients
who believed that their illness had less serious consequences and would lastashortertimeatbaseline,weremorelikelytohave
returned to work by six weeks (Petrie etal.1996).Furthermore,thosewithbeliefsthattheillnesscouldbecontrolledorcuredat
baseline predicted attendance at rehabilitation classes (Petrie et al. 1996). In a recent study authors did not only explore the
patients beliefs about MI but also the beliefs of their spousetoaskwhethercongruencebetweenspouseandpatientsbeliefswas
related to recovery from MI (Figueiras and Weinman 2003). Seventy couples in which the man had had an MI completed a
baseline measure of the illness cognitions which were correlated with follow-up measures of recovery taken at 3, 6 and 12
months. The results showed that in couples who had similar positive beliefs about the identity and consequences oftheillness,
the patients showed improved recovery in terms of better psychological and physical functioning, bettersexualfunctioningand
lower impact of the MI on social and recreational activities. In addition, similar beliefs about time line were related to lower
levels of disability and similar cure/control beliefs were associated with greater dietary changes. Beliefs about illnesstherefore
seem to be associated with recovery. Further, congruence in beliefs also seems to influence outcomes.
A self-regulatory approach may be useful for describing illness cognitions and for exploring the relationship between such
cognitions and coping, and also for understanding and predicting other health outcomes.

TO CONCLUDE
In the same way that people have beliefs about health they also have beliefs about illness. Such beliefsareoftencalledillness
cognitions or illness representations. Beliefs about illness appear to follow a pattern and are made up of: (1) identity (e.g. a
diagnosis and symptoms); (2) consequences (e.g. beliefs about seriousness); (3) time line (e.g. how long

72 HEALTH PSYCHOLOGY
it will last); (4) cause (e.g. caused by smoking,causedbyavirus);and(5)cure/control(e.g.requiresmedicalintervention).This
chapter examined these dimensionsofillnesscognitionsandassessedhowtheyrelatetothewayinwhichanindividualresponds
to illness via theircopingandtheirappraisaloftheillness.Further,ithasdescribedtheself-regulatorymodelanditsimplications
for understanding and predicting health outcomes.

? QUESTIONS
1 How do people make sense of health and illness? 2 Discuss the relationship between illness cognitions and coping. 3 Why is
LeventhalLs model Oself-regulatoryL? 4 Discuss the role of symptom perception in adapting to illness. 5 Illusions are a central
component of coping with illness. Discuss. 6 Illness cognitions predict health outcomes. Discuss. 7 Design a research project to
evaluate the role of coping in adaptation to illness.

FOR DISCUSSION
Think about the last timeyouwereill(e.g.headache,flu,brokenlimb,etc.).Considerthewaysinwhichyoumadesenseofyour
illness and how they related to your coping strategies.

ASSUMPTIONS IN HEALTH PSYCHOLOGY

The literature examining illness cognitions highlights some of the assumptions in health psychology:
1 Humans as information processors. The literature describing the structure of ill- nesscognitionsassumesthatindividualsdeal
with their illness by processing thedifferentformsofinformation.Inaddition,itassumesthattheresultingcognitionsareclearly
defined and consistent across different people. However, perhaps theinformationisnotalwaysprocessedrationallyandperhaps
some cognitions aremadeupofonlysomeofthecomponents(e.g.justtimelineandcause),ormadeupofothercomponentsnot
included in the models.
2 Methodology as separate to theory. The literature also assumes that the structure of cognitions exists priortoquestionsabout
these cognitions. Therefore, it is assumed that the data collected are separate from the methodology used (i.e. the different
components of the illness cognitions pre-date questions about time line, causality, cure, etc.). However, it is possible that the
structure of these cognitions is in part an artefact of the types of questions asked. In fact, Leventhal originally argued that
interviews should be used to access illness cognitions as this methodology avoided contaminating the data. However, even
interviews involve the interviewers own
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preconceived ideas that may be expressed through the structure of theirquestions,throughtheirresponsestotheinterviewee,or
through their analysis of the transcripts.

FURTHER READING
Bird, J.E. and Podmore, V.N. (1990) ChildrenLs understanding of health and
illness, Psychology and Health, 4: 175-85. This paper examines how children make sense of illnesses and discusses the possible
developmental transition from a dichotomous model (ill versus healthy) to one based on a continuum.
de Ridder, D. (1997) What is wrong with coping assessment? A review of conceptual and methodological issues, Psychology
and Health, 12: 417-31. This paper explores the complex and ever-growing area of coping and focuses on the issues surrounding
the questions OWhat is coping?L and OHow should it be measured?L
Leventhal, H., Meyer, D. and Nerenz, D. (1980) The common sense representa- tion of illness danger, in S. Rachman (ed.),
Medical Psychology, Vol.2, pp. 7-30. New York: Pergamon Press. This paper outlines the concept of illness cognitions and
discusses the implica- tions of how people make sense of their illness for their physical and psycho- logical well-being.
Petrie, K.J. and Weinman, J.A. (1997) Perceptions of health and illness.
Amsterdam: Harwood Academic Publishers. This is an edited collection of projects using the self-regulatory model as their
theoretical framework.
Taylor, S.E. (1983) Adjustment to threatening events: A theory of cognitive
adaptation, American Psychologist, 38: 1161-73. This is an excellent example of an interview based study. It describes and
analyses the cognitive adaptation theory of coping with illness and emphasizes the central role of illusions in making sense of the
imbalance created by the absence of health.