Liminality: a major category of the experience of cancer illness

'Getting through' not 'going under': a qualitative study of gender and spousal support after diagnosis with colorectal cancer

Many studies have found that people with cancer value family support. Feminist work suggests that women carry most responsibility for practical and emotional support in families, but few qualitative cancer studies explicitly incorporate a gender perspective. We undertook secondary analysis of in-depth interviews with 33 married or cohabiting respondents with colorectal cancer in the UK to compare men and women's accounts of 'spousal' support. Both men and women described the vital role that their partners played in providing emotional and practical support. Mutual support and reciprocity were also key features of narratives; both men and women reported controlling their emotions to protect spouses and preserve 'normal' household routines. Traditional gender roles had some influence; some women organised 'cover' for domestic work and childcare when they were ill, while some men focused on making sure that their families were financially secure and partners were 'protected' from the effects of their stomas. Our findings illustrate the complexity of gendered constructions and performances of 'care' and contribute to debates about gender and emotional labour.

The preoperative experience of patients undergoing surgery for colorectal cancer: a phenomenological study

Colorectal cancer is associated with significant morbidity and mortality; many patients undergo surgical resection following which they are discharged home to await adjuvant therapy. Using a phenomenological approach, patients' experiences during this period were investigated arising from a concern that their needs may be overlooked. However, though post-discharge experience was the primary focus, informants chose first to talk about their preoperative experiences; these are reported here. As this was not the primary focus, we cannot claim that the data is complete though the findings suggest that this area warrants further investigation. Preoperative experiences, characterised by fear, questions, isolation and uncertainty, exerted significant influence on the respondents. Some believed that cancer was 'their problem', no-one could help them with it although support from the Clinical Nurse Specialist was highly valued. Such reactions are not specific to colorectal disease and it was rarely evident that respondents had this form of cancer. Patients exhibited a desire to protect others from their diagnosis. The findings also show considerable variation in the requirement for information indicating that professionals should take their lead from the individual concerned. Patients with cancer are the 'experts' in living with the disease and their experiences can make a significant contribution to the planning and delivery of care. These findings have the potential to impact on the care received by those with colorectal cancer.

The challenge of fitting in: non-participation and withdrawal from an online self-help group for breast cancer patients

Online self-help groups multiply peoples' possibilities to exchange information and social support. Such possibilities are expected to be of crucial value for the 'new' healthcare user. However, similar to experiences from face-to-face based groups, studies of online self-help groups report high drop-out rates. Knowledge about why this happens is scarce. By means of qualitative interviews and participant observation, this article examines non-participation and withdrawal from an online self-help group for Norwegian breast cancer patients. Five conditions are identified as barriers to use; a need to avoid painful details about cancer, not being 'ill enough' to participate, the challenge of establishing a legitimate position in the group, the organisation of everyday life and illness phases that did not motivate for self-help group participation. I suggest that an adoption of the biomedical explanation model represents an important background for this pattern, an argument which contrasts prominent assumptions about the new healthcare user who does not accept the biomedical 'restitution story' in her efforts to make sense of an illness. A further suggestion is that experiences of self-help groups as arenas for successful coping need to be further considered as a barrier to use.

Liminality as a Descriptor for the Cancer Experience

Liminality has been used in medical anthropology to conceptualize the cancer experience (Little, Jordens, & Paul, 1998). This article discusses the results of a recent study that support this, that indeed having ovarian cancer can instill a sense of alienation from life as a person has known it. However, it is also suggested here that the term needs to be amended to include the social surround of a liminal experience, as well as the generative potential inherent in such an experience. The study is qualitative in nature and explores the subjectivity of nine women living with stage-three ovarian cancer. The recurrent nature of the disease with its poor survival rate was found to instill a kind of sustained trauma that is accentuated by experiences of suffering in connection to loss. Finally, a pressing need to speak with and find recognition from other women who shared the same site of cancer was found.

Cancer survivors' experience of time: time disruption and time appropriation

AIM

This paper reports a study to explore how cancer survivors talk about, experience and manage time in everyday life.

BACKGROUND

There is an increasing interest in specific physical and psychosocial aspects of life after cancer diagnosis and treatment, but hardly any research follows cancer survivors over time to explore how perceptions and experiences change.

METHODS

An exploratory study was carried out in 2002-2004 with a purposive sample of adults who had experienced various forms of cancer. Data collection included 9 weeks of participant observation at a Cancer Rehabilitation Centre and ethnographic interviews with 23 informants. Ten men and 13 women were interviewed twice: 2 weeks after their stay and 18 months later.

FINDINGS

Data were analysed from a culture-analytical perspective. Three main themes regarding the survivors' handling and perception of time were found: (1) cancer disrupts time and life; (2) awareness of time increases, time is verbalized and reflected; and (3) the informants appropriate time. A diagnosis of cancer, even for a survivor, means a confrontation with death. It means a disruption of continuous clock and calendar time. Survivors appropriate time, and prioritize how and with whom they want to spend their time.

CONCLUSION

With an increasing number of people being cured following a cancer diagnosis, nurses and oncology nurse specialists who work with cancer survivors must be aware of the fact that time is a central theme in understanding cancer survivors' lives, and they must know how to guide these survivors in their new lives and take care of their well-being.

Recurrence of Ovarian Cancer-Living in Limbo

Few studies have shed light on women's life situation after being informed of having recurrent ovarian cancer. The present study aimed to elucidate women's experiences of living with this knowledge. Interviews were conducted with 12 women who were undergoing or had just completed chemotherapy, 5 to 10 months after learning of the recurrence. Data were collected and analyzed based on a life world perspective using a descriptive phenomenological method. The women's experiences are described via 3 key constituents: being denied one's future while simultaneously hoping to be able to delay the cancer's advancement, feeling alienated from both oneself and one's surroundings, and being responsible. The key constituents were integrated into the structure "living in limbo." The women lived on the threshold to the unknown. They were preparing themselves both for a continued life and for death. "Living in limbo" can be described as a phase of a health-illness transition characterized by loneliness. The vulnerable position and existential struggle of these women should be focused upon in nursing. The sensitive dialogue is essential in these cases.

‘What does it mean?’ uncertainty, trust and communication following treatment for pre-cancerous cervical abnormalities

The early detection of pre-cancerous cervical conditions has risen dramatically, prompting more in-depth investigations regarding psychological implications inherent within the diagnosis and treatment of this condition. This study aimed to identify factors that influence women's experience of diagnosis and treatment of cervical abnormalities and factors that facilitate positive adjustment. Using a semi-structured telephone interview, we interviewed 21 women (age 24-54) treated at a colposcopy clinic. Systematic recruitment of women with varying degrees of cervical abnormality (CIN 1-3) and time since treatment was undertaken to ensure representation of all relevant experiences and allow the identification of long-term factors. Coding of audio-taped, transcribed interviews and searching for themes was achieved by using NUD*IST software. The results identified uncertainty, trust and communication as the key factors for women following diagnosis and treatment. The primary concern following diagnosis was related to cancer but changed to a more prominent concern with future reproductive issues in the post-treatment period. The majority of women acknowledged the importance of the doctor's empathic communication style. These findings have important implications for future studies and clinical practice.

Helping patients with advanced cancer live with concerns about eating: a challenge for palliative care professionals

This paper reports findings of an exploratory study of the eating habits of people with advanced cancer living in the south of England in 2003. The purpose of the study was to develop an understanding of why eating can be experienced as troubling and examine the potential for helping people live with the changes in eating habits that often accompany advanced cancer. Semistructured interviews were conducted with 30 patients, 23 lay caregivers, and 14 specialist nurses. The data were analyzed thematically. It was found that patients experienced eating-related concerns when the reality of eating differed from the expectations of eating. Patient response to concern ranged from acceptance to self-action. A subgroup of participants believed that they could have been helped by support for taking self-action. Eating-related concerns present nurses and other health care professionals with the challenge of supporting differing patient preferences for living with the symptom, which can include the expectation of support for self-action.

Occupation as a vehicle to surmount the psychosocial challenges of cancer

Research indicates that cancer presents challenges to one's social relationships, identity, and ability to live each day to the fullest. Occupation can be a powerful vehicle that one can use to respond to and cope with these psychosocial challenges. However, literature also suggests that occupation can be a problematic vehicle because many persons with cancer report frustration with their ability to engage in daily occupations. This paper synthesizes the research describing these psychosocial challenges and explores the nature of occupational engagement for persons with the life-threatening illness of cancer. Interpreting the research from the standpoint of the Person-Environment-Occupation Model suggests that variations in the congruence between person, environment, and occupation is an intuitively plausible explanation for differing perceptions of the quality of occupational engagement for persons with cancer.

At home in hospital? Interaction and stigma in people affected by cancer

Social research conducted in cancer hospitals has tended to focus on interaction between patients and staff, and studies of interaction amongst people with cancer often centre on group therapy and patient-patient support mediated by health professionals. Informal interaction between patients and fellow patients, and their carers/visitors, occurs in cancer hospitals every day but has remained largely unanalysed, particularly in the case of visitors. In this paper, based on data from 71 in-depth interviews, we compare patient and carer perceptions of interacting with fellow patients/visitors in a cancer centre with their perceptions of interacting in the outside world. We apply Erving Goffman's theories on stigma to the data and argue that these theories have both relevance and currency. The outside world can be seen as a 'civil place' where people with cancer often encountered difficulties such as undue admiration, uneasiness, avoidance and lack of tact, whereas the cancer centre appears to have been a 'back place' where, for most patients, stigmatisation was not an issue, and they could 'get on with it' in the company of fellow patients and their visitors. However, some groups of patients experienced social isolation in the hospital or seemed to be assigned to the lower strata of cancer patient society. We conclude that patients who are outside the informal support system in cancer hospitals may have psychosocial difficulties that might be recognised and addressed by healthcare staff, and that patients and their carers might benefit from enhanced support following discharge from hospital.

Desperately seeking “normal”: the promise and perils of living with kidney transplantation

Organ transplantation offers a dramatic example of the promises for health held out by biomedicine-and thus, a productive vantage point from which to interrogate those promises. Drawing on ethnographic research on kidney transplantation in Guadalajara, Mexico, this article examines the version of "health" offered to patients through transplantation. The paper explores patients' transplant trajectories as they move from learning to desire a transplant to actually receiving one and living with it over the long term, all within particular structuring sociocultural and political economic conditions. The article analyzes how transplanted patients are forced to come to terms with the contingent states of "health" and "normality" wrought by transplantation as they carve out an existence in the persistently liminal spaces between the roles of "sick" and "healthy," dependent patient and fully contributing family member.

Boundary breaches: the body, sex and sexuality after stoma surgery

People with limited or no bladder or bowel control, who have had a stoma to manage elimination, have a particular awareness of the proximity of the sites of pleasure and excretion. Drawing on interviews and related ethnography conducted in Australia from 1998 to 2001, this paper explores how men and women with permanent continence problems negotiate their sexuality around their bodily unreliability. Pleasurable sex, idealized, involves losing control. People who are incontinent or rely on a stoma, however, must monitor their bladder and bowel, disguising the stoma and bag and controlling their body in sex as in other circumstances. The need to negotiate bodily boundaries with established partners, or to disclose to new sexual partners, results in self-consciousness and social unease, and people need to reconstruct notions of privacy and dignity so that breaches in bodily control do not undermine the sexual relationship. For many, the stoma undermines self-esteem and body image, while its management confuses the status of the individual as "normal" and the partner as carer or lover.

Stereotactic radiosurgery: the patient's experience

Stereotactic radiosurgery (SRS), a highly technical treatment for life-threatening brain tumors and vascular malformations, is provided at one site (Dunedin Hospital) for all New Zealand. The full-day procedure begins with the surgical attachment by bone screws of a metal helmet, followed by computerized tomography with or without angiography, and concludes with focused irradiation of the lesion. Previous SRS research has focused on therapeutic indications and outcomes; we report here patients' experiences of this procedure using both qualitative and quantitative methods. Participants (n = 12) uniformly described SRS as unusual and highly significant, a pivotal event shaping the future. For most, the procedure symbolized relief of symptoms, hope, reduction of risk, and recovery. Descriptions of the disruption produced by the onset of symptoms, diagnostic procedures and SRS, followed by a period of uncertain prognosis, also signaled experiences of liminality. Although patients experienced anxiolysis and described status changes following SRS, their lives are not returned to normal; they continue to inhabit a liminal state between health and normality on one hand, illness and disability on the other. Our findings indicate aspects of the experience of SRS for patients and their families that could assist in technically informing and emotionally supporting patients through this unusual treatment.

While there's life ... hope and the experience of cancer

Hope is the subjective probability of a good outcome for ourselves or someone close to us. During mortal extreme experience, observers and participants in the experience hope for life over death. In cancer, the illness/treatment experience is similar to the experience of dying, but with the redeeming element of hope for cure, for life over death. If cure is not obtained, hope for the participant moves to a 'good death'. If the outcome is cure, however, the hope for life has been realised for both participant and observer. Hope, which is always for the future, may now diverge between participant and observer. Observers hope for a return to normality, and use a discourse of normality which emphasises such things as 'getting over it', 'moving on' and 'getting back to normal'. Survivors may not find the realisation of hope for life to be as comfortable as might be expected. After the euphoria of being declared free of disease, about 30% of survivors develop post-cancer distress with death salience. They recognise, whether they want to or not, that they have confronted their own annihilation, and that they will at some stage have to do so again. We all know that we will die, but there is a greater vividness and proximity in that knowledge for someone who has been through mortal extreme experience. Death salience provokes a confrontation with meaning in a person's life. Thus survivors turn inward to their deep selves in order to establish an understanding of what their life projects might become. Observers, on the other hand, find death salience hard to live with, and may turn away from the distressed survivor. The hopes and discourses of survivors and those close to them may have different structures and different objects. These differences may help to explain the frequency with which stress and disruption affect close relationships after cancer and other life-threatening experiences.

Liminality as biographical disruption: unclassifiability following hormonal therapy for advanced prostate cancer

The hormonal treatment of advanced prostate cancer involves life disruptive side-effects, such as impotence, libido loss and bodily feminisation. Conflicting views on the weight of the disruption they cause as against the therapy's survival benefits currently underlie debates over its appropriate mode of administration and its optimal timing in cases that do not necessitate immediate intervention. On the basis of a study of the disruptions caused to various life domains of 15 Israeli patients receiving such treatment, the present paper illustrates an integrated approach to their analysis that sheds new light on their intensity. The study was conducted by means of in-depth interviews and its data were processed according to the constant comparative analysis method. Its findings indicate that the therapy allowed the patients to regain their strength, to retain their need of love, basic masculine self-identification and spousal ties, and to renew their past social contacts. On the other hand they could no longer define themselves as healthy, sexually competent and 'male' in all respects, and their pre-treatment relationships with partners and friends lost the sense of closeness. Further psychosocial costs that were detected include patients' deprivation of their sense of continuity, excitements, hopes and coping capabilities. An integrated analysis of the concurrent normalisation and deviantisation processes undergone by them yielded the conclusion that the therapy subjects them to a liminal state, that is, the inability to classify themselves into culturally available categories. The difficulties entailed in this state highlight the need to take them into consideration when patients' condition allows a choice between alternative forms of hormonal therapy and between its early or deferred commencement. The interpretation of the disruption to their lives in terms of liminality also clarifies former studies' confusing reference to this subject and points to issues that still await investigation.

Women's experiences of cervical cellular changes: an unintentional transition from health to liminality?

Cervical cancer screening is a preventive intervention directed towards women to both detect cervical cancer and identify those at risk for developing this disease. It has been argued that participation in screening programmes and early detection situations may lead to new kinds of sickness experiences. This article is based on qualitative phenomenological hermeneutical analysis of interviews with women who have received abnormal Pap smear test results through a population-based outreach screening programme in urban Sweden. The aim of this article is to illuminate the meaning, for the participating women, of the lived experience of receiving notification about an abnormal Pap smear result. The data are presented in terms of two themes: Pap smear for routine and recurrent confirmation of health and unexpected and ambiguous communication about Pap smear results. The findings are discussed as an unintentional transition from confirmation of health to liminality. Whereas medical diagnosis has been discussed as structuring the inchoate, an abnormal Pap smear did not create order for the interviewed women. On the contrary, the notification of an abnormal Pap smear created disorder as the women had expected to be confirmed as healthy but instead neither health nor disease were confirmed or excluded. Even 'simple' technology is shown to have an ontological dimension, with the ability to transform daily taken-for-grantedness of ourselves as primarily healthy to (potentially) unhealthy.

Expressions of loss of adulthood in the narratives of people with colorectal cancer

The diagnosis and treatment of colorectal cancer entail detailed discussions of bodily functions, invasive procedures, and a reorientation of life around bowel habit. Furthermore, people with stomas undergo a second experience of toilet training in adulthood. For these reasons, colorectal cancer is sometimes considered an embarrassing disease. Narrative interviews with colorectal cancer patients indicate the inadequacy of the concept of embarrassment in describing the loss of dignity, privacy, independence, and sexual confidence as well as a compromised ability to work, travel, and socialize. The link between bowel control and the constitution of adult identity must be acknowledged if health professionals and carers are to offer the most appropriate forms of information and support to people affected by colorectal cancer.

Haematological cancer patients: achieving a sense of empowerment by use of strategies to control illness

BACKGROUND

The role that empowerment plays through involving haematological cancer patients and their families in their treatment and care is undeniable. It encompasses the implementation of various strategies to achieve a sense of empowerment.

AIMS AND OBJECTIVES

This phenomenological study sought to identify core strategies used by cancer patients regardless of their illness stage and prognosis who exhibited a strong sense of empowerment in coping with their condition.

DESIGN

A phenomenological approach using an in depth interviewing technique was used to identify the common factors which patients and spouses believed could enable them to achieve a measure of control in managing their illness. These measures were referred to as coping strategies.

METHODS

It was decided to conduct a purposive study and re-interview seven of 12 patients who had previously participated in a pilot Haematology Shared Care project and who had developed a high level of ability in coping with their illness. At the patient's discretion, spouses were invited to participate and to contribute to the interview. Three spouses participated in the interviewing process.

RESULTS

Common strategies emerged regardless of the patient's stage of illness and prognosis. Informants identified the determination to remain in control of the illness and treatment side effects, having the support of family and significant others, illness acceptance and maintaining hope as crucial to their sense of empowerment.

RELEVANCE TO CLINICAL PRACTICE

It is hoped that clinicians will gain a deeper understanding of the varied and numerous strategies used by cancer patients in coping with their illness. This understanding will ensure that by encouraging these strategies, patients and their families will be supported by health professionals to achieve a greater sense of empowerment. As this and other studies have shown, working alongside health professionals contributes to empowerment for both the cancer patient and significant others in their lives.

Disability rites: the cultural shift following impairment

Persons with disabilities experience barriers to health within a culture. The local culture assigns meanings to those with impairments and their activities. In order to understand the experience of disability as influenced by culture, anthropological models of rites of passage and liminality have been used, but these can be extended further. The authors posit that local cultures should be the context for studying disability, and thus extend on previous work by Murphy on the rites of passage for persons with disabilities. This article will: (1) review how disability has been culturally created and defined, (2) provide additional evidence for the argument regarding the existence of disability culture, and (3) extend the work on rites of passage for persons with disabilities. A brief discussion of how this expanded model might guide the understanding of disability and the understanding of barriers to health follows.

The skull beneath the skin: Cancer survival and awareness of death

Terror management theory predicts that people made aware of their own mortality (mortality salience) will seek to boost their self-esteem in order to buffer the anxiety they feel. One common resource to achieve this is strengthening social bonds with an admired in-group. It would also seem to predict that cancer survivors and those close to them would be driven to a greater closeness. A similar closeness might be predicted between those with terminal illness and their families and other supporters. Some empirical observations suggest that there are other forms of death-related salience which do not conform to the predictions of terror management theory. We suggest that some of those who have recovered from cancer may be made death salient, while those close to them remain mortality salient. Death salience seems to turn people inward to the resources and challenges of their deep (subconscious and unconscious) minds, and confronts them with the realities of their deep identities. A third form of salience, dying salience, affects those who have terminal illness. Distinguishing between death salience and mortality salience provides one explanation for the frequency with which close relationships break down after recovery from cancer. The distinctive nature of dying salience raises important questions about the inappropriateness of survivors as providers of support for the dying.

Future directions in research on consumer-provider communication and adherence to cancer prevention and treatment

The goal of this paper is to examine emerging issues in consumer-provider communication and patient adherence to cancer prevention, screening, diagnosis, treatment, and coping with survivorship. Many factors that have been shown to affect adherence can be supported or hindered by provider-patient communication, including the provider-patient relationship, patients' beliefs, social and cultural norms, family and social support, mood, and behavioral management. Six research questions are posed, and substantive and methodological recommendations are offered for empirical research on the measurement and achievement of patient adherence.

'Better than numbers...' A gentle critique of evidence-based medicine

Evidence-based medicine (EBM) has achieved cult status in the last 10 years or so. It is an altogether admirable movement in medicine, capable of a great deal of good. Its privileged status, however, has prevented critics from being heard, and there are problems with EBM. Eight features need further discussion if EBM is not to be discredited and superseded. They are its reductionism; its unwitting paternalism; its privileging of restricted kinds of evidence; its dependence on the questionable concept of equipoise; the instability of the 'truths' it produces; its capacity to eliminate individuals in favour of categories; its historical arrogance; and its contempt for the wisdom and integrity of our predecessors. Evidence-based medicine is here to stay; for the moment, at least. It is sufficiently well established to withstand critique. It needs criticism if it is to survive and flourish.

Discourse in different voices: reconciling N = 1 and N = many

When groups are convened to discuss the making of policy, people are chosen to represent particular interests because they have relevant experience. Different stakeholders, however, may use differing discourses, and particular discourses may be privileged in particular contexts. This means that important contributions to the discussion may not be reflected in final reports. Discursive incommensurability is particularly seen when individual, personal experience is presented in meetings where quantification or "numbers talk" is privileged. While pooled personal experience may carry some weight in such a context, individual anecdote does not. The inclusion of 'consumers' in policy making groups may result in their dysempowerment. Their presence promises that they will have influence, but their voices disappear from the final document. The promise of empowerment is not realised. Dysempowerment may translate into empowerment with time, as it has done with feminism and the HIV/AIDS lobby. In order to speed the process, we suggest some practical means whereby mixed discourses may be generated and monitored. For constructive interchange, each party to the discourse needs to express the interests and arguments relevant to the group he or she represents. Supporting this principle of representation are principles of implicature and radical respect. Implicature is the act of implying what is relevant to others involved in the discourse. Radical respect is a fundamental and foundational respect for others in their roles as representatives of stakeholders with legitimate interests in the topic of the discourse.

Survivorship and discourses of identity

Personal identity is self-evidently important to us all. Identity is a philosophically complex subject, but there is some agreement that memory, embodiment and continuity are essential components. The sense of memory includes 'future memory', the kind of memory we would like to construct for ourselves as our lives proceed. While the sense of personal identity is internal to the individual, a sense of that person's identity exists in the minds of others. Extreme experiences threaten the element of continuity, because they may bring bodily changes as well as cognitive changes that challenge central values. Restoring or preserving continuity is a major task for survivors. The ways in which people experience discontinuity because of cancer illness, and the ways in which they manage this experience emerges from the narratives of the survivors of cancer and in the narratives of health care workers who look after them. People manage discontinuity by reference to stable 'anchor points' in their beliefs and values; by re-constructing versions of their pre-experience identities, drawing on past memory and finding ways to preserve a continuity between past memory, present experience and constructions of the future; by using the experience to develop established facets of identity; and by imbuing the experience with meaning and recognising the enlarged identity made possible by survival. Those who cannot achieve a sense of continuity may feel alienated from themselves, their friends and family. All these methods of management may be used by one person to negotiate the post-experience identity in its different social interactions. The experience of the survivor can be further understood by recognising the challenge posed by extreme experience to the sense of continuity of both embodied self and memory. A satisfactory discourse of survival has yet to enter the public domain. This lack adds to the burdens of survivors, including those who have survived cancer.

The psychosocial needs of cancer patients: findings from an observational study

The objectives of this study were to identify the prevalence of psychosocial need, and the contributory factors to need, among cancer patients, using a descriptive cross-sectional questionnaire survey of adult cancer patients. The participants were 1,000 patients from four hospitals in the north west of England with the following characteristics: tumour type (breast, colorectal, lymphoma, lung), being 1 month from a 'critical moment' in the cancer journey (i.e. (i) diagnosis, (ii) end of first treatment, (iii) recurrence, (iv) move from active treatment to palliative care), and aged over 18 years. The main outcome measure was a psychosocial needs inventory comprising seven needs categories (48 need items). A sample of 402 was achieved (40% response rate). Psychosocial needs relating to the need categories 'health professionals', 'information' and 'support networks' are commonly expressed and strongly felt by cancer patients. Needs relating to 'identity', 'emotional and spiritual' issues and 'practical' issues are less commonly expressed but are also strongly felt. Particular needs are related to tumour type, illness 'critical moment', age, gender, health status, socioeconomic and other social factors. This information should increase awareness among cancer care professionals about a range of psychosocial needs and may help them target particular patient groups for particular support interventions.

Life disruption and generic complexity: a social linguistic analysis of narratives of cancer illness

This paper draws on social linguistics to inquire into the meaning and function of complexity in illness narratives. According to social linguists, five different story-type genres occur in spoken English. These are illustrated and differentiated using examples drawn from 10 interviews with people who have undergone colectomy for colorectal cancer. In order to test a hypothesis that complexity in illness narratives is related to life disruption, the 10 accounts were ranked in terms of their generic complexity. Measures of life disruption were based on rankings furnished independently by two readers from different disciplines who were blind to the hypothesis being tested. These two rankings showed a high level of agreement (r(s) = 0.85, p<0.01). When the two life disruption rankings and the generic complexity ranking were compared, a high degree of concordance between the three rankings was observed (W = 0.91, p<0.01). No evidence was found of associations between generic complexity and gender, interviewer, surgical outcome in terms of stoma (p>0.05), age (p>0.7) nor time since diagnosis (p>0.1). We conclude that in this study, generic complexity was strongly and significantly related to life disruption. To explain the function of complexity in interaction, we characterise the illness narrative as a genre in its own right, and argue that illness narratives need to be considered both in terms of the work they do both on the listener and for the narrator. In the former case, complexity opens up a discursive space for the dynamic positioning of the interlocutor. In the latter case, we propose that complexity reflects the degree to which the process of re-ordering life by assigning meaning is occurring as the interaction unfolds. In both cases, complex narratives can thus be understood as "hard working" narratives.

A model for a culture-sensitive assessment of patients in health care settings

The need for a cultural formulation in the healthcare setting is demonstrated. A process is delineated for assessing the ethnically-diverse patient. A sensitive assessment provides recognition of how the patient's cultural roots affect their healing process. Cooperation and compliance to the advice given by healthcare professionals may be enhanced by understanding the patient's cultural perceptions. Case examples are given from Navajo, Laotian, and Cambodian cultures. The assessment and cultural formulation process can assist the social worker in their interventions with the patient and their recommendations to the other members of the treatment team.