Adjustment to spinal cord injury: a review of coping styles contributing to the process.
Malec and Neimeyer (1983) have suggested that difficulties adjusting to spinal cord injury may lead to decreased quality of life, poor self care and costly multiple medical problems. Even more distressing is the estimate that persons with spinal cord injury commit suicide two to six times more frequently than the general population (Frisbie & Kache, 1983; Geisler, Jousse, Wynne-Jones, & Breithaupt, 1983; Judd & Brown, 1992).
The scientific literature has yet to explain why some people effectively adjust and others do not (Krause & Crewe, 1990). Early investigators sought to explain individual differences in response to spinal cord injury by examining personality constructs (Guttmann, 1976; Harris, Patel, Greer, & Naughton, 1973; Mueller & Thompson, 1950; Roberts, 1972; Siller, 1969; Wittkower, Gingras, Mergler, Wigdor, & Lepine, 1954).
The role of depression also received a good deal of attention for many years (Trieschmann, 1980). Proponents of "stage" theories of adjustment insisted that patients must experience depression as one of a sequence of emotional reactions leading to improved adjustment (Bracken & Shepard, 1980; Cook, 1979; Hohman, 1975; Kerr & Thompson, 1972). Others have shown however, that despite treatment efforts aimed at fostering depressed affect many patients do not become depressed and still cope effectively with their injury (Bodenhamer, Achterberg-Lawlis, Kevorkian, Belanus, & Cofer, 1983; Ernst, 1987).
Depression is typically assumed by treatment staff even in the absence of behavioral manifestations. If patients do not appear depressed, they are "in denial" and concern about them is expressed. Investigators using objective criteria over the course of treatment indicate that patients may experience sadness or depressed mood, but not meet the DSM-IIIR definition of major depression (Judd, Brown, & Burrows, 1991). The frequency of major depression in acute injury, regardless of level, reaches about 20% measured by objective psychological testing (Howell, Fullerton, Harvey, & Klein, 1981; Judd, Burrows, & Brown, 1986; Nestoros, Demers-Desrosiers, & Dalicandro, 1982; Richards, 1986). These findings caution treatment specialists that to assume most suffer depression may place an unnecessary and excessive burden on patients as well as treatment resources (Frank, Van Valin, & Elliot, 1987; Hammell, 1992; Judd, Stone, Webber, Brown, & Burrows, 1989).
An effective method of early diagnosis and treatment of clinically depressed patients must be inherent to any rehabilitation effort since acutely injured patients who experience major depression do poorly in rehabilitation (Bracken & Bernstein, 1980; Trieschmann, 1980). It is essential that objective measures be used since staff, no matter what their discipline (psychology included), overestimate levels of depression in their patients when relying on clinical impressions (Cushman & Dijkers, 1990).
Although depression may lead to difficulties in rehabilitation and adjustment, the absence of depression may not necessarily bode that all is well. Hence, finding out what's wrong with the patient is one goal. Finding out what's right is another. The charge to treatment specialists is to identify variables relevant to the adjustment process, and develop valid and reliable measures. The study of cognitive mediating factors such as coping style may make this task easier.
Feifel, Strack, and Nagy (1987) used a three-factor model of coping (confrontation, avoidance, and acceptance-resignation) and found patients with life threatening illness who used "avoidance" or "acceptance-resignation" did not cope well. Those with non-life-threatening illness using the same coping styles were more effective.
Elliott, Witty, Herrick, and Hoffman (1991), relying on a two-factor coping model proposed by Snyder (1989), reported that patients in the acute phase of traumatic spinal cord injury, with a strong desire to achieve goals (factor 1), had lower scores on measures of depression and distress. Those injured longer, who had well developed strategies for goal attainment (factor 2), also scored lower on measures of depression and distress.
In a review of coping models, Frank et al. (1987) and Frank and Elliott (1987) suggested that style used to cope with spinal cord injury, regardless of time since onset, may dramatically affect the adjustment process. Certain coping styles may lead to depression, others to non-compliance or to anxiety, and yet others may lead to successful adjustment (Ray & West, 1984).
Lazarus and his colleagues (Coyne, Aldwin, & Lazarus, 1981; DeLongis, Folkman, & Lazarus, 1988; Folkman & Lazarus, 1980), developed the Ways of Coping scale (WOC), one of numerous published coping scales in the past several years (Aldwin & Revension, 1987).
Felton, Revension, and Hinrichsen (1984) reported a modest relationship between (WOC) scores and adjustment to chronic illness. Choice of coping strategy was not related to medical diagnosis, but was related to adjustment. Frank et al. (1987) and Folkman, Lazarus, Gruen, and DeLongis (1986) found patients who attempted fewer coping strategies reflected by low scores on the WOC were not as distressed or depressed as those attempting more coping. Perhaps even more thought provoking was the finding reported by Silver and Wortman (1980) that unrealistic beliefs among spinal injury patients regarding their potentials for improvement lead to better emotional functioning and adjustment.
Regarding specific coping strategies, Buckelew, Frank, Elliot, Chaney, and Hewett (1991) defined three groups of spinal injury patients (high, medium and low distress) by scores on the SCL-90-R. Using the WOC, they found the "high distress" group scored higher on Wish-Fulfilling Fantasy, Emotional Expression, Self Blame, and Threat Minimization subscales. The authors concluded that these strategies may not be effective in managing the psychological distress associated with spinal cord injury. There were no specific coping styles related to the "low distress" group.
Coca (1991) found support for choice of one strategy over another. She related scores on the revised WOC (Folkman & Lazarus, 1988) to scores on the Acceptance of Disability Scale. High scores on the Planful Problem-Solving subscale of the WOC were associated with successful adjustment, and high Escape-Avoidance subscale scores were predictive of poor adjustment. Implications for treatment suggest promoting specific coping strategies and discouraging others. Before such efforts are attempted, research into coping scales as well as the adjustment processes must continue if meaningful data are to be distilled.
Further studies are needed which employ sequential objective measures of coping, distress and depression, to include the full range of patients in acute phases of injury as well as the growing numbers of aging spinal cord injury patients (Eisenberg & Saltz, 1991; Trieschmann, 1987). It would not be surprising to find that the adjustment process and variables related to success in the acute phase may be quite different from those in the long term. Also, young acutely injured patients may employ coping strategies that are quite different from those used by an older acutely injured patient (Krause & Crewe, 1991; Shulz & Decker, 1985).
Prerequisite to progress in these areas, staff must first accept the patient's emotional expressions as genuine and relevant instead of interpreting them as denial, depression, anger, or some other transient emotion representing pre-ordained stages of adjustment. Research has demonstrated that people may show optimism, and not necessarily be "in denial". They may be sad and express grief, yet not suffer major depression. Behaviors such as substance abuse and acting-out may not be excused as reactions to the injury, but may reflect faulty coping with life in general. Behaviors associated with independence, often cited as examples of non-compliance, may be exacerbated by the confrontive and often restrictive rehabilitation environment.
Patients bring into the rehabilitation setting all of their collective persona and coping history. Some are successful at coping with the changes, while others rely on coping styles that have been marginally successful in the past. One definition of mental health is "the ability to adapt to change." When patients with poor coping skills are faced with rapid change associated with an injury, they may exhibit poor adjustment.
Once individual behaviors are accepted and objectively measured, instead of interpreted by clinical intuition, the focus on coping style may be sharpened for study. If research identifies a relationship between scores on certain coping measures and successful adjustment, treatment may be planned to increase behaviors associated with these coping styles (Nieves, Charter, & Aspinall, 1991). For example, Elliott, Herrick, et al. (1991) reported a relationship between assertion skills and depression in spinal cord injury patients. As a result, they recommend assertion training for people with disabilities. Trieschmann (1992) outlines several areas for research such as teaching alternate coping skills to patients with substance abuse, examining the coping style of women with spinal cord injury and older adults who have lived many decades with spinal cord injury.
Costs for rehabilitation alone (i.e., not including acute care) at the authors' facility is $96,000 for paraplegics and $144,000 for quadriplegic patients. Failure to maximize this investment adds inestimable burdens to the patient and
family as well as the health care system.
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Douglas Cairns, Ph.D., Head Clinical Psychologist, Rancho Los Amigos Medical Center, 7601 E. Imperial Hwy., Downey, Ca. 90242