Perception of family competence and adaptation to illness among African Americans with disabilities.

Family involvement in the rehabilitation success of persons with disabilities has received greater attention in health and human services. For instance, several authors have suggested that family competence is a key factor of family influence on psychosocial adaptation to disability (Dew, Phillips, & Reiss, 1989; Herbert, 1989; English, 1983; Power & Dell Orto, 1980). Family competence can be described succinctly as the degree of familial support provided for individual as well as family growth and the ability of the family to adapt to new situations (Bochner & Eisenberg, 1987). As contended by Seligman (1991), healthy and competent family functioning can alleviate the psychological stresses as well as facilitate the life maintenance challenges associated with caring for a family member who has a disability. There is no one type, organizational structure, or relational configuration which typifies healthy family functioning (Rigazio-Digillo, 1991). The disposition of a family is largely defined by the culture from which it emanates. Therefore, it is necessary to recognize that the nature of the family and its concepts of health vary widely among cultures.

For example, the African American community contains cultural characteristics (e.g., extensive kinship networks) that influence the systemic functioning of families indigenous to the culture. Consequently, the issue of family competence becomes critical when examining the role of the family in psychosocial adjustment for African Americans with disabilities.

The functioning of any family, regardless of ethnicity, is affected by a traumatic life event such as the onset of disability and its complications. Consequently, the family system is generally reorganized because of the implications of disability (e.g., mobility limitations, dietary regimens). The reordering of system dynamics facilitates adjustment for both the family and the member who has a disability. The quality of family competence preceding the onset of a disability is a primary determinant of whether family members can expeditiously alter behaviors and attitudes to cope with the stress engendered by the disability. For instance, Morrison (1982) noted that a client's adjustment to loss of sight is closely related to the family's attitudes, behaviors, and perceptions about blindness. As suggested earlier, family traits such as attitudes are partly explained by the rules and norms of the family's ethnic culture.

According to Roberts and Magrab (1991), each family has patterns of interaction that are manifested during times of challenge such as adjustment to disability. These patterns consist of styles of conflict resolution and problem solving, processes of decision making, and role expectations for its members. In a study of cancer surgery patients and their spouses, Keitel, Cramer, and Zevon (1990) found that patterns of interaction characterized by escape and avoidance were positively correlated with psychological distress for both parties. Evans et al. (1987) investigated treatment adherence and family interaction after stroke. They found that patient adherence to treatment was significantly related to affective involvement, communication, and problem solving among family members. Vargo (1983) explored the coping patterns of men with spinal cord injury and their spouses. The author discovered that the wife assumed the role of protector. New routines were established and some order restored in their lives by the wife performing tasks previously reserved for the husband. The aforementioned studies are significant because credence is given to the suggestion that adjustment to disability is related to general family competence and patterns of interaction.

Several authors have examined the patterns of functioning in African American families (Hill, 1972; Hines & Boyd-Franklin, 1982; McAdoo, 1983; and Ho, 1987). These authors have suggested that the African American family has evolved unique patterns of competence that serve as buffers to the stressors and crises (e.g., racism, high unemployment, and extreme poverty) commonly faced by its members. Moreover, these buffers are utilized to manage the typical crises that all families may confront (e.g., divorce, death, and disability). Hill (1972) and Hines and Boyd-Franklin (1982) labeled three of these unique patterns of African American family competence as extended family constellations, adaptability of family roles, and intense religious orientation. Alston and Turner (1994) asserted that the African American family strengths and coping strategies identified by Hill (1972) and Hines and Boyd-Franklin (1982) can enhance the chance of success for African American clients participating in rehabilitation services. Moreover, they contended that the "family" is an essential element of healthy psychosocial adjustment for African Americans who are disabled. In a study of psychosocial adjustment to disability among rehabilitated African Americans, Alston, McCowan, and Turner (1994) found that the African American family patterns of strong kinship bonds, role flexibility, and religious orientation were perceived by the former clients as being significant factors in acceptance of their disabilities. Miller (1986) reported similar findings in a study of adjustment among African American patients receiving medical services for hypertension, diabetes, or epilepsy at a community hospital. She found that adjustment was significantly related to expressiveness, cohesion, and cooperation among family members.

Despite the encouraging findings of Miller (1986) and Alston, McCowan, and Turner (1994), considerable inquiry of African American family competence and adjustment to disability is needed. African Americans comprise a substantial percentage of persons with disabilities (Bowe, 1983; Walker, Akpati, Roberts, Palmer, & Newsome, 1986). Thus, rehabilitation research involving the identification and exploration of African American cultural factors that can facilitate adaptation to disability for African Americans is imperative. The purpose of this study is to explore the influence of family competence factors such as cohesion, expressiveness, leadership, and conflict on adjustment to disability for African Americans. Implications for rehabilitation counseling and recommendations for rehabilitation research will be provided.

Method

Participants

All of the participants were former African American clients of either the Department of Vocational Rehabilitation or the Department of the Blind in a Southeastern state. Furthermore, the rehabilitation case file of each participant had been closed with the designation of "successful closure" by the agencies. A total of 64 African Americans with disabilities comprised the participant group. Demographic information was collected pertaining to age, disability type, age-of-onset of disability, educational level, and marital status. Table 1 contains a detailed description of the participants.

Table 1
Demographic Variables of Participants (N = 64)

                                   Frequency    Percentage

Sex              Male                   31        48.4
                 Female                 33        51.6

Age             Below 20                 4         6.3
                20 - 29                 18        28.0
                30 - 39                 19        29.7
                40 - 49                 17        26.6
                50 - 59                  6         9.4
Disability      Visual Impairment       15        23.4
                Substance Abuse         12        18.8
                Hearing Impairment       9        14.1
                Back Injury              8        12.5
                Spinal Injury            8        12.5
                Epilepsy                 5         7.8
                Emotional Impairment     4         6.2
                Carpal Tunnel            3         4.7

Education       9 - 11                   9        14.1
                Diploma/GED             34        53.1
                2 YR. College           12        18.8
                4 YR. College            7        10.9
                Above 4 YR. College      2         3.1

Marital Status  Single                  27        42.2
                Married                 18        28.1
                Divorced                14        21.9
                Separated                5         7.8

Instruments

The investigators used the following three instruments in the study: (1) personal data sheet, (2) Self-Report Family Inventory (Beavers, Hampson, & Hulgus, 1986), and (3) Acceptance of Disability Scale (Linkowski, 1971). A personal data sheet was developed by the investigators to collect basic demographic information about the participants. The data sheet was completed by the subjects in the study.

Family competence was measured by Beavers, Hampson, and Hulgus's (1985) Self-Report Family Inventory (SFI). The SFI is designed to assess an individual's perception of family functioning. The response format of the SFI is comprised of a five-point Likert scale ranging from "Fits our family well", to "Does not fit our family well". The SFI measures the following five dimensions of family competence believed to be significant in therapeutic treatment and planning: (1) Cohesion, (2) Expressiveness, (3) Leadership, (4) Conflict and (5) Health Competence. The specific family characteristics defined by each dimension are as follows:

1. Cohesion -- satisfaction and happiness through togetherness and closeness versus more distant and expelling relations.

2. Expressiveness -- feelings of physical and verbal expression and the ease with which warmth and caring are expressed by family members.

3. Leadership -- strong and consistent patterns of directed leadership in the family.

4. Conflict -- low levels of unresolved conflict, fighting, blaming, and arguing with higher levels of problem-solving and acceptance of personal responsibility.

5. Health/Competence -- global indicators such as happiness optimism, family love, listening, problem-solving, and adult coalitions. (Beavers, Hampson, Hulgus, 1985)

Internal consistency for the subscales of the SFI has been estimated between .84 and .88 (Hulgus & Hampson, 1986). Moreover, test-retest reliability for the SFI was determined over 30 and 90 day periods. Average correlations across time revealed that the SFI possesses adequate test-retest reliability for most scale dimensions, thereby supporting the temporal stability of the scales (Beavers, Hampson, & Hulgus, 1985).

Several investigations have supported the validity of the SFI. Green, Fuller, and Hopkins (1986) reported that the subscales of the SFI reflect face validity with the items of the Beavers-Timberlawn Family Evaluation Scale (BTFES). Convergent validity has been demonstrated between the SFI and Bloom Family Evaluation Scale, Moos Family Environment Scale, and Family Assessment Device (Hulgus & Hampson, 1986). In addition, moderate correlations of concurrent validity were found between the SFI and the BTFES (Green et al., 1986; Hulgus & Hampson, 1986).

Psychosocial adjustment was measured by using the Acceptance of Disability Scale (ADS). The ADS was developed by Linkowski (1971,1981) and contains 50 items based on Beatrice Wright's (1983) constructs of psychosocial adjustment. The scale was designed to assess psychosocial adjustment in relation to the client's self-perception of the handicapping effects of disability. Wright conceptualized psychosocial adjustment as a process of value shifts. According to Wright, value shifts are characteristic of individuals with disabilities who have come to accept their disability. In the process of value shifts, one's scope of values are enlarged; physique is subordinated relative to other values; disability effects are contained realistically; and one focuses on personal valuable attributes.

The response format of the ADS is comprised of a six-point Likert scale ranging from "I disagree very much," to "I agree very much". A total score between 50 and 300 can be received by respondents. Greater acceptance of disability and adjustment are indicated by higher scores. After completing a split-half correlation (r = .86) of the scale, Linkowski (1971) reported the full-scale reliability of the ADS as r = .93. Linkowski's findings suggest high reliability for the scale. Construct validity was found between the ADS and Butler and Haigh's (1954) Self Ideal Q-Sort measure of self-esteem (r = .52). The strong correlation (r = .64) found between the ADS and Dunn's (1967) Satisfaction with Social Relationships scale provided further evidence of construct validity (Linkowski, 1971). Moreover, a concurrent correlation coefficient of r = .81 (Linkowski, 1971) was attained between the ADS and Attitude Toward Disabled Persons scale developed by Yuker, Block, and Campbell (1960).

Procedures

The data collection format of the study consisted of a voluntary mail survey. Administrators from the Department of Vocational Rehabilitation and the Department of the Blind were consulted for guidance and approval. The study was endorsed by the administrators, and they instructed their field counselors throughout the state to assist in the generation of participants. The counselors proceeded to identify former African American clients whose cases had been closed successfully. The clients were contacted by the counselors to inquire about their willingness to participate. The clients expressing an interest were asked to sign an interest form which included their mailing address. The counselors forwarded the interest forms to the investigators.

After receiving the interest forms, the investigators mailed a packet containing the instruments used in the study along with a postage-free return envelope to the potential respondents. A cover letter explaining the study and emphasizing their right to not participate was included in the packet. Respondents were instructed to avoid signing their name on the instruments or return envelope, thereby ensuring anonymity. A total of 64 surveys were returned to the investigators.

Results

In order to analyze the relationship between family competence and adjustment to disability, two statistical procedures were utilized. First, a Pearson product-moment correlation analysis revealed high coefficients between the ADS and SFI's Cohesion (r = -.73), Expressiveness (r = -.67) and Health/Competence (r = -.64) subscales. Moderate correlations were found between the ADS and the SFI's Conflict (r = -.59) and Leadership (r = -.44) subscales.

To determine whether the dimensions of family competence are predictive of adjustment, a multiple regression analysis was performed. When the shrinkage estimate was applied, it was found that 76% of the variance overall could be explained by three of the dimensions [F(3,60) = 65.99). Specifically, the Cohesion subscale appeared to be the strongest predictor by accounting for 54% of the variance. Whereas, the Health/Competence and Expressiveness subscales accounted for 14% and 9% respectively. The Conflict and Leadership subscales did not make a significant contribution to the model. Table 2 contains a summary of the regression.

Table 2
Disability Adjustment

Predictor Variance     B     Partial [R.sup.2]   Model [R.sup.2]
Cohesion            -1.35        .54                   .54
Health/Competence   -.47         .14                   .68
Expressiveness     -1.15         .09                   .77

Predictor Variance     [R.sup.2]       [F.sup.2]
Cohesion                  .53          72.37(**)
Health/Competence         .66          63.31(**)
Expressiveness            .76          65.99(**)

[MATHEMATICAL EXPRESSION NOT REPRODUCIBLE IN ASCII]

(**) p < .01

Discussion

The high and moderate correlations observed between psychosocial adjustment and each of the family competence dimensions suggest that African Americans have the resources needed to flourish during a trauma event such as onset of disability. Thus, several interpretations of the findings are noteworthy. First, the strong relationship found between adjustment and both family cohesion and expressiveness indicates that African Americans who adjust to their disabilities emerge from close and supportive families in which feelings are openly shared both verbally and physically. The significant association observed in this study supports Alston and Turner's (1994) assertion that the African American family strength of strong kinship bonds can increase the chances of successful adaptation to disability for African American clients. Another inference of the findings is that the emotional support of the African American kinship network provides a sense of connectedness and knowledge that the challenge of adjustment is not being met alone. Also, the strong family cohesion reported by the participants suggests the presence of family members who are willing to assist in managing the tasks (e.g., activities of daily living) surrounding adjustment to disability for the family member who has the disability.

Second, the strong relationship found between level of adjustment and perception of general family health and competence indicates that a sense of family well being and happiness can be a key contributor to psychosocial adaptation of African Americans with disabilities. It can be inferred from this finding that the homeostasis of an African American family is not easily disrupted by events such as onset-of-disability. As contended by Minuchin (1974), families strive for homeostasis in which a steady, operational, and nonchaotic atmosphere is established, and trust, enjoyment, and group concern are maintained. Judging from the perceptions of the participants in this study, African American families can accommodate disability while continuing to demonstrate healthy and homeostatic behaviors such as humor, stability, and lack of preoccupation with selfish issues.

Third, the findings pertaining to the family competence dimensions of leadership and conflict illustrate some culture specific traits of the African American family and suggest how it may handle an occurrence such as diagnosis of serious illness. The moderate relationship found between adjustment and the lack of clearly defined leadership patterns reflects the tendency of African Americans to ignore rigidly prescribed roles in society. As noted by Alston and Turner (1994), African American families are likely to redefine the role responsibilities of various members for adaptation and survival. For example, the leadership responsibilities traditionally ascribed to the father in mainstream families may be shared by several members in an African American family. Alston and Turner suggested that flexibility in role definition and assignment is a strength that can serve as a vehicle for family adjustment to role restructuring necessitated by a family member incurring a disability.

The moderate correlation found between adjustment and conflict suggest that the participants in this study are members of families with few unresolved disagreements, propensity for problem solving, and minimum blaming and arguing. Although this finding may be accurate, a safer interpretation is that the participants in the study did not consider family conflict a hindrance to surmounting the handicapping effects of disability. The African American culture encourages expression of feelings and emotions, particularly in cases of disagreement (Staples, 1985). Consequently, expression of conflict is perceived as a natural part of family life rather than an obstacle to problem solving or adjustment. The findings in this study indicate that African Americans with disabilities learn to negotiate family conflict while managing the psychosocial demands of disability.

Finally, findings of this study which concern predictions indicate that several indicators of family competence may predict adjustment to disability. The strongest predictor, cohesion, suggests that the existence of a close family unit in which the members feel a sense of satisfaction and love will likely yield successful adaptation to disability for African Americans. As suggested by expressiveness and general health/competence predictors, accurate prediction of adjustment will be further increased by a possession of problem-solving skills, optimism, and an environment where family members are comfortable expressing themselves with words as well as through physical means. The absence of conflict and leadership from the prediction model may suggest that these dimensions of family competence hold little promise for predicting psychosocial adjustment or other important psychological outcomes for African Americans with disabilities.

Implications for Rehabilitation Counseling

Delineation of factors which can contribute to disability adjustment for African Americans has important implications for the practice of counseling in rehabilitation settings. As suggested in this study, the strength and resourcefulness of the African American family is crucial to successful psychosocial adaptation for African Americans with disabilities. Exclusion of the family in rehabilitation treatment may ignore an important motivational component for the African American client. Thus, it is imperative for rehabilitation counselors to include the family in the initial assessment stages of therapeutic treatment with African American clients. The rehabilitation counselor can administer a family competence scale (e.g., Family Environment Scale) to assess level of family cohesion and problem solving. If poor family cohesion and problem solving are discovered, significant family members can be interviewed to gain an understanding of their assigned family responsibilities and their perspective on the nature of family functioning. Moreover, the rehabilitation counselor can ascertain the contributions that each family member is willing to make towards managing the daily living needs of the person with a disability. Specifically, family members can be assisted in the reordering of their family system to enhance adjustment to the disability for the family and the member who is disabled.

To further understand the competence of an African American client's family, rehabilitation counselors can use analogue techniques (e.g., role play and problem solving exercises) in family therapy sessions (Shapiro & Skinner, 1990). Family members can be presented hypothetical scenarios pertaining to adjustment situations and asked to respond as if at home. These methods would enable the rehabilitation counselor to observe family interaction in a simulated environment and make inferences regarding family competence in their natural environment. Information collected from the observations could be used to help the client and the family develop problem solving strategies for responding to challenging situations surrounding the disability.

Utilization of symbolic/experiential family therapy by the rehabilitation counselor can help the African American family become aware of the underlying symbolism that may influence family competence and adjustment to disability (Whitaker, 1967; Napier, 1978). How one feels end thinks about the family unit and individual members is of utmost importance to family competence. The symbolic meaning or image that family members attach to the family member with a disability influences behavior and emotions. To help the African American family uncover some of the images assigned to the member with a disability, the rehabilitation counselor ear instruct the family to draw images of their family. Along with the family, the rehabilitation counselor can explore individual or joint drawings for interpretation of meaning. The aim of symbolic techniques is to help the family redefine images, express emotions and perceptions, and to ultimately feel and work more powerful as a team in disability adjustment.

Recommendations for Future Research

It is important to note that this study involved a small sample size with varied disability types. Consequently, generalizations should be made with prudence. Additional studies of African American family competence and disability adjustment are warranted. Future investigations can include controls for family size and family constellation. Moreover, factors such as age-of-onset of disability and duration of adjustment should be contained to minimize effect. Researchers are encouraged to use other measures of adjustment such as the Katz Adjustment Scale for comparison to the scale used in this study. Similarly, a different scale which measures family competence, such as the Beavers-Timberlawn Family Evaluation Scale (Beavers, 1985), is recommended for future investigations.

The diverse disability composition of the participants in this study may have influenced outcome. In future studies, researchers should consider utilizing an African American participant group comprised of a single disability type (e.g., diabetes). Another research consideration is the differences between individuals in the public versus private rehabilitation system. This study utilized African Americans served by the public system. In future studies, African American clients from proprietary rehabilitation settings can be recruited to determine if differences exist between settings. Lastly, many types of ethnic minority clients are served by rehabilitation counseling. Researchers are encouraged to examine the cultural variables specific to minority client populations other than African Americans and determine how the variables contribute to psychosocial adjustment for those populations (e.g., Hispanic Americans).

Conclusion

Understanding the endemic cultural assets that can be utilized when serving ethnic minority consumers is highly beneficial to rehabilitation counseling. The findings of this study offer insights into how the African American family structure can serve as a source of support in meeting the challenges of adjustment to disability for African Americans. Providing counseling services to African Americans without attention to their cultural characteristics is problematic. Therefore, rehabilitation counselors are challenged to continually examine the cultural influences that African Americans bring to the rehabilitation process. As demonstrated in this study, African Americans who have adjusted to their disabilities perceive family competence as a crucial factor in managing the demands of adaptation.

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Received: February 1994 Acceptance: June 1994