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Psychological factors in work-related amputation: considerations for rehabilitation counselors.

Traumatic amputation is a catastrophic work injury and is often a major cause of disability. In the United States between 1992 and 1999, there were approximately 11,000 non-fatal workplace amputations each year (National Institute of Occupational Safety; [NIOSH], 2000). When compared to other workplace injuries, traumatic amputation is associated with among the highest work claim costs and days off work. This injury is most common in young to middle adult age males, and is most likely to occur within manufacturing industries. The workers at highest risk are industrial machine operators, fabricators, and labourers. Machinery is the major source of work-related amputation and the accidents typically involve being caught in, or compressed by equipment or objects. The vast majority (94%) of work-related amputation involve fingers (NIOSH, 2000) and are usually the result of crush or laceration injuries.

Depending on the severity and level of amputation, work-related amputation often requires intensive acute medical care as well as arduous and sometimes protracted rehabilitation. In addition to treating life-threatening injuries, initial trauma management may attempt to surgically reattach the amputated limb. When that is not possible, efforts are turned to the repairing the tissue at the site of the amputation, often referred to as the residual limb, or stump. The initial postoperative phase focuses on wound treatment and early physical reactivation, and the use of prostheses or other artificial devices may be recommended. Rehabilitation ideally includes a multi-disciplinary approach of physical and rehabilitation medicine, psychology, prosthetic services, and vocational rehabilitation. Ongoing care of the residual limb, prosthetic readjustments, follow-up evaluations, and even surgical revisions are all part of the long-term management of work-related amputation.

The process of adjusting to work-related amputation often involves ongoing cognitive, emotional, and behavioral adaptations. From the time of the accident, and through the acute and post acute rehabilitation phases, work-related amputation can evoke a complex range of psychological reactions. New psychological issues and coping challenges often emerge later, particularly as the worker attempts to adjust to the injury and its impact on daily life. This work injury can be associated with severe psychological sequelae including anxiety symptoms such as posttraumatic stress symptoms, depression, grief, body image disturbances, and chronic pain. Together, the physical and emotional effects of the injury can have devastating occupational, social, and interpersonal consequences.

The purpose of our paper is to provide a review of the literature on the psychological factors associated with the adjustment and outcome of work-related amputation. Considerations for rehabilitation counselors in promoting psychosocial adjustment, return to work, and quality of life are also discussed. We also provide suggestions for how cognitive behavior therapy can be used by counselors to effectively address the complex range of psychological difficulties that can arise following this injury. Lastly, directions for future research are suggested.

Psychological Factors in Work-Related Amputation

Despite the personal and economic toll of this work injury, the empirical research on work-related amputation is relatively sparse. Vocational functioning in work-related amputation has received some empirical investigation (Dasgupta, McCluskie, Patel, & Robins, 5997; Millstein, Bain, & Hunter, 1985), and only a handful of studies have specifically examined the psychological aspects of this injury (Cheung, Alvaro, & Colotla, 2003; Grunert, et al., 1988b, 1990a; Henniger, Saunders, & Efanda, 2001).

Research on accident-caused amputation, herein referred to as traumatic amputation, has generally found that psychological adjustment gradually occurs postinjury (Livneh, Antonak, & Gerhardt, 1999; Matsen, Malchow, & Matsen, 2000). However, a substantial number of people experience enduring physical and emotional difficulties (Dillingham, Pezzin, Mackenzie, & Burgess, 2001; Pezzin, Dillingham, Ellen, & MacKenzie, 2000). There are also significant individual variations in psychological sequelae and in the process of adaptation. Over the last several decades, the rehabilitation field has recognized the importance of psychosocial variables in adjustment from physical injuries (Shontz, 1975; Wright, 1960), and that these factors play a much more important role than objective physical injury variables. In traumatic amputation, for example, there is little relationship between the level of amputation and psychological adjustment. As a result, research efforts have turned to identifying the cognitive, emotional, and contextual variables that might be linked to adjustment (Gallagher & MacLachlan, 2000, 2001; Livneh, et al., 1999; Livneh, Antonak, & Gerhardt, 2000). A summary of the major psychological factors relevant to work-related amputation is described below.

Anxiety Reactions

Anxiety is a normal response to perceived stressors or threats, and is manifested by feelings of nervousness or fear, recurrent and uncontrollable frightening thoughts, and a variety of physical responses (e.g., increased heart rate, sweating, difficulty breathing, muscle tension). When anxiety symptoms are excessive and persistent, they are often debilitating, and do not usually remit without treatment (American Psychiatric Association; [APA], 2000). Anxiety can be generalized in nature, or can involve a specific constellation of anxiety symptoms that are diagnostically distinguishable across the various anxiety disorders, such as panic disorder, specific phobia, or social phobia (APA, 2000).

In work-related amputation, heightened anxiety is often precipitated by an array of injury- and postinjury-related stressors. In a study of 170 workers with hand injuries (either amputation or crush injuries), Grunert et al. (1992) reported generalized anxiety symptoms in 48.2% of the workers at an evaluation completed five days postinjury. These symptoms decreased over time and only 5.9% continued to have prominent anxiety symptoms at an 18-month follow-up assessment. The general research on traumatic amputation has also shown that general anxiety reactions tend to remit with time, and that these responses are more pronounced in younger than older adults (Livneh et al., 1999).

There are numerous precipitating factors of anxiety in work-related amputation. One major stressor for injured workers includes uncertainty about the extent of their physical recovery and apprehension about future vocational functioning. Financial difficulties as a result of being unable to work, and protracted involvement with insurance companies, litigation, and the Workers' Compensation Board can be ongoing cumulative sources of stress. Surgical revisions, prosthetic fittings, ongoing medical investigations, and rehabilitation training can also be anxiety-provoking events. Disfigurement caused by the amputation can elicit fears of being negatively evaluated by others and embarrassment about one's physical appearance (Breakey, 1997; Rybarczyk, Nyenhuis, Nicholas, Cash, & Kaiser, 5995). Another source of anxiety includes apprehension about physical vulnerability and fears of potential victimization due to one's physical disability (Behel, Rybarczyk, Elliot, Nicholas, & Nyenhuis, 2001; Rybarczyk, Szymanksi, & Nicholas, 2000). Additionally, the fear of reinjury can be very common in the initial months after a work-related amputation, and this fear may persist over time. To illustrate, Grunert et al. (1992) found that more than one-third of their sample of severe work-related hand injuries continued to have this fear at an 18-month follow-up evaluation.

Work-related amputation is also associated with an increased risk of developing another specific type of anxiety problem--posttraumatic stress symptoms (Alvaro, Colotla, & Cheung, 1998; Cheung et al., 2003; Grunert et al., 1992; Hennigar, et al., 2001). Given the traumatic nature of work-related amputation, it is understandable that these symptoms can develop. Acute posttraumatic stress reactions often develop shortly after the accident, involving intrusive reexperiencing of the trauma through repetitive memories, flashbacks, and nightmares. Heightened physical and emotional reactivity to trauma cues and reminders are commonly experienced. For example, returning to the accident site, seeing the accident machine or hearing machine noises can elicit marked anxiety responses. Persistent pain, functional restrictions, and disfiguring injuries can also serve as ongoing potent reminders of the trauma.

Posttraumatic stress symptoms also involve deliberate attempts to avoid thinking about and talking about the traumatic event. Objects, situations, and activities that serve as reminders of the accident may be avoided for example; the worker may deliberately avoid returning to the accident site. Another cluster of symptoms includes emotional numbing, restricted range of affect, and a sense of a foreshortened future. Heightened arousal, involves another group of posttraumatic stress symptoms, which can be manifested through sleep disturbances, increased feelings of anger and irritability, concentration difficulties, startle reactions, and hypervigilance. If posttraumatic symptoms meet a set of criteria, including a duration of more than one month, and cause clinically significant distress or functional interference, a diagnosis of posttraumatic stress disorder (PTSD) would be rendered (APA, 2000).

Although the exact prevalence of PTSD in work-related amputation is unknown, it appears to be a common clinical problem. In a Canadian study, Hennigar et al. (2001) found that over 50% of a work-related hand injury sample experienced PTSD symptoms. In Grunert et al.'s study (1992), prominent PTSD symptoms were reported by workers who were assessed five days postinjury; 81% reported flashbacks, 70% reported nightmares, 38% reported startle reaction, 20% reported behavioral avoidance, and 44% reported gaze aversion to the injured hand. At 3-, 6-, 12-, and 18-month follow-ups, many of these symptoms had abated. However, some symptoms persisted, particularly flashbacks and behavioral avoidance. Furthermore, Grunert et al. (1988) found flashbacks to be a significant predictor of long-term maladjustment and reemployment difficulties.

Fukunishi (1999) compared traumatic digit amputation (not limited to work injuries) and burn injury groups, and reported that PTSD was more common in the burn group (35%) as compared to the amputation group (18.5%). However, a number of variations in the PTSD symptom profiles between the two groups were observed. In particular, flashbacks, hypervigilance, and heightened physical reactivity to trauma cues were considerably greater in the amputation group as compared to the burn group. The authors also found that the degree of cosmetic disfigurement following digit amputation in females was related to the development of PTSD symptoms, particularly avoidance and emotional numbing.

In a recent study of 30 injured workers who attended a hand and amputee clinic in an outpatient rehabilitation program, Cheung et al. (2003) found that upper limb amputation (mostly hand and finger injuries) was associated with a greater frequency of posttraumatic stress symptoms than lower limb work-related amputation. They concluded that workers with upper limb amputations are at a heightened risk of developing PTSD and should be given additional psychological attention during their rehabilitation.

In the general PTSD literature, there has been growing interest in determining the predictors of PTSD. Subjective variables at the time of the trauma, such as the perceived threat appraisals, peritraumatic dissociation, as well as acute avoidance symptoms and avoidant coping strategies are risk factors for developing PTSD across a range of traumatic events (McFarlane, 2000; McNally, 2003; Ozer, Best, Lipsey, & Weiss, 2003). Posttrauma cognitive variables are particularly important risk factors for chronic PTSD (PTSD lasting more than 3 months). Specifically, negative interpretations of the traumatic memories and the PTSD symptoms, rumination about the trauma, and anger cognitions are highly predictive of chronic PTSD (Ehlers & Clark, 2000). Ongoing medical complications, such as persistent pain symptoms and physical injuries also appear to contribute to its chronicity (Burgess, Hibler, Keegan, & Everly, 1996). There is some evidence to suggest that perceived social support is an important protective buffer for PTSD (Ozer et al., 2003). Empirical research is needed to determine whether these findings can be generalized to PTSD arising from work-related amputation.

Depressive Reactions

Depressive symptoms are another common reaction to work-related amputation. Symptoms of major depression include depressed mood, loss of interest, appetite disturbance, loss of energy, sense of worthlessness, sleep difficulties, concentration problems, and suicidal ideation or recurrent thoughts of death. When depressive symptoms persist and cause clinically significant distress or functional interference, a diagnosis of major depressive disorder is made (APA, 2000).

Onset of these reactions can occur shortly after the work injury and may remit over time. In the study of work-related hand injury by Grunert et al. (1992), 62.4% reported depression at the initial assessment. Over time, these symptoms gradually decreased and 14.1% continued having prominent depressive symptoms at the 18-month follow-up. It is also likely that depressive episodes can be precipitated by critical events during the rehabilitation process, such as being fitted for a prosthesis, reaching maximal physical recovery, or being unable to return to one's preinjury employment.

The prevalence rate of major depressive disorder in work-related amputation is unknown and a few studies suggest that these symptoms may be less prominent than PTSD symptoms (Cheung et al., 2003; Fisher & Hanspal, 1998; Fukunishi, 1999). Fukinishi (1999) reported that 7.4% of the traumatic digit amputation sample met criteria for major depression, in contrast to the 18.5% who met criteria for PTSD. Similarly, Cheung et al. (2003) found lower levels of depression than PTSD symptoms in their sample of work-related amputation, and that the workers with upper limb amputations experienced more symptoms of depression than persons with lower limb amputations.

There is some evidence (Fisher & Hanspal, 1998a; Livneh, et al., 1999) to suggest that young adults with traumatic amputation may be at higher risk for major depression as compared to individuals with vascular- or disease-related amputations. Other risk factors that have been shown to predict depression after amputation due to disease or traumatic injury include perceived social stigma, negative body image, and poor social support (Breakey, 1997; Rybarczyk et al., 1995). Buffers to depression appear to be perceived control over one's life, optimistic attitude, active problem solving strategies, and finding positive meaning following the amputation (Dunn, 1997; Livneh et al., 1999). However, the extent to which these findings apply to work-related amputation is not known.

Grief

Grief is a normative and universal reaction to loss. In work-related amputation, the loss not only involves a part of one's physical self and body image, it also results in numerous secondary and cumulative losses over time (Alvaro et al., 1998). These secondary losses can involve major life roles and identity, employment, avocational activities, and future goals. These losses may go unacknowledged by heath care professionals and the injured workers themselves.

In general, little research has been conducted on grief reactions in amputation (MacGuire & Parkes, 1998; Parkes, 1975, 1998) and none to date has specifically examined this issue in work-related amputation. In a landmark study from England, Parkes (1975) compared the experience of loss of a limb (mostly due to vascular-related disease) to the loss of a spouse and demonstrated a number of similarities in the grief process. Individuals in both groups described an immediate reaction of emotional numbness. This reaction was followed by a sense of longing and yearning, particularly for the widow group, and to a lesser degree for the amputation group. In contrast, the longing reaction in the amputation group focused more on the secondary losses associated with the amputation. Both groups reported intrusive memories, avoidance of reminders, and sense of presence. A year after the loss, symptoms in both groups had decreased and return to work appeared to be related to this improvement. The amputation group had lower rates of returning to work and continued to be more preoccupied with their losses than the widow group.

The grief experience encompasses a range of emotional, behavioral, and cognitive reactions involving depression, generalized anxiety, and PTSD symptoms (Raphael & Martinek, 1997). However, there is significant individual and cultural variation in the subjective experience and expression of grief, it is also recognized that pathological forms of grief can arise. Although, there is no consensus on the defining features that would distinguish normal and pathological grief, it is generally accepted that grief becomes pathological when the reactions are excessive, prolonged, or unresolved (APA, 2000). However, the grief experience and process, the influence of mediating variables, and predictors of pathological grief has yet to be empirically investigated in work-related amputation.

Body Image Disturbances

Body image is a complex construct that is defined by our "perceptions, thoughts, and feelings about the body and bodily experience" (Pruzinsky & Cash, 1990, p. 337), and is embedded and shaped within our sociocultural context. It not only provides a sense of "self," our body image also affects how we think, act, and relate to others. The abrupt change in one's physical appearance as a result of a work-related amputation can present significant and complex psychological challenges (Alvaro et al., 1998).

The general literature on traumatic amputation has shown that body image disturbances and cosmetic concerns as a result of disfiguring injuries are common reactions, and this issue seems to be particularly prevalent in young adults (Fisher & Hanspal, 1998a,b; Fukinishi, 1999). Body image disturbances typically involve distorted and negative perceptions about their physical appearance. Strong feelings of embarrassment, self-consciousness, and social discomfort often accompany these interpretations. A number of avoidance behaviors are often used to suppress negative emotions and thoughts, such as avoiding visual contact with the residual limb, neglecting self-care needs of residual limb, and concealing the residual limb from others. In turn, these negative reactions can interfere with the rehabilitation process and contribute to increased social isolation. Breakey (1997) reported that negative body image in traumatic amputation is associated with lower life satisfaction, reduced self-esteem, and higher levels of anxiety and depression. Body image difficulties have also been shown to be a significant predictor of negative psychosocial adjustment (Rybarczyk et al., 1995). Fisher and Hansapal (1998b) have suggested that facilitating prosthetic use and prosthetic satisfaction can reduce body image disturbances.

There is very little research on body image disturbances specific to work-related amputation. Grunert et al. (1992) found prominent cosmetic concerns in their sample of work-related hand injury. At the initial evaluation, 65.9% reported cosmetic concerns and over half reported difficulties regarding self-acceptance and social acceptability. Although these reactions declined postinjury, almost one-third of the sample reported persistent cosmetic and social acceptability concerns at the 18-month follow-up. These significant findings suggest that further research is needed to delineate the nature of body image disturbances in work-related amputation, and its impact on rehabilitation and return to work.

Chronic Pain

Pain is a subjective multi-dimensional construct that involves sensory, affective, cognitive, autonomic, and behavioral components (Melzack, 1999). It is widely accepted that there are considerable individual variation in the pain experience, and that psychological, social, contextual, and biological factors contribute to these differences (Gasma, 1994; Gatchel & Turk, 1999, Melzack, 1999). As a result of these findings, there is current consensus that pain is best understood through a biopsychosocial perspective.

The two most common pain reactions following an amputation include phantom limb and residual limb pain (Hill, 1999; Sherman, 1997). Phantom limb sensations, or non-painful sensations in the lost limb, are experienced almost immediately following an amputation. These sensations will feel like the missing limb was actually present in its full representation by shape, length, and position in space. These sensations are almost always experienced and gradually diminish over time. Many people also experience phantom limb pain, or pain sensations that commonly involve burning, cramping, and piercing sensations in the absent limb. Although the exact prevalence of phantom pain is unknown, it appears to be quite common and tends to subside with time (Ehde, et al., 2000; Hill, 1999, Sherman, 1997). Residual limb pain, or stump pain, involves painful sensations at the site of the amputation (Hill, 1999). This form of pain is typically the most intense during the acute postoperative period and often decreases thereafter.

In some individuals, both pain conditions can become chronic and disabling, evolving into an entrenched and vicious cycle of psychological distress and suffering, physical deconditioning, withdrawal from activities, behavioral dysfunction, as well as dependence on medication and health care services (Eimer & Freeman, 1998). Chronic pain can also interfere with rehabilitation, prosthetic adjustment, and return to work (Dillingham et al., 2001; Millstein et al., 1985). Chronic phantom and residual limb pain can be difficult to treatment, as they may not respond to pharmacological or physiotherapy management (Halbert, Crotty, & Cameron, 2002; Sherman 1997).

It appears that no published studies have yet to examine chronic pain specific to work-related amputation, and much of our knowledge about chronic pain is drawn from the general amputation literature. Early research (Parkes, 1972, 1984) suggested that particular personality styles and defense mechanisms, such as denial of grief, played a role in phantom pain's etiology and maintenance. Recent research (Fisher & Hanspal, 1998b: Hill 1999) has shown that there is little evidence to substantiate these hypotheses. Rather, psychosocial variables appear to play a much important role in the etiology and maintenance of phantom pain. Specifically, research findings have suggested that chronic phantom pain is exacerbated by factors, such as increased stress, fatigue, and limited social support (Arena, Sherman, Bruno, & Smith, 1990). Similarly, Jensen et al. (2002) also found that higher levels of catastrophizing cognitions, lower levels of perceived social support, and higher levels of solicitous responses from family members predicted phantom limb pain intensity, pain-related interference, and depression.

Summary

Work-related amputation is associated with an array of psychosocial adjustment challenges. This type of injury involves coping with the traumatic nature of the accident, adapting to the impact of the amputation, and coping with the array of secondary stressors that emerge over time. The adaptation process is multidimensional and unique, and is highly influenced by the interaction between individual and contextual factors. In particular, coping strategies, social support, attitudinal variables, litigation factors, and workplace factors appear to be closely linked with adjustment. Workers with this injury at are an increased risk of psychological symptoms including anxiety, PTSD, depression, grief, body-image disturbances, and chronic pain. These reactions are not likely to occur in isolation and in many cases multiple psychosocial difficulties may be present in varying degrees. To facilitate adjustment and outcome, rehabilitation programs must be able to effectively address these issues.

The Rehabilitation of Work-Related Amputation: Implications for Rehabilitation Counselors

Given the complex physical and psychological issues involved in work-related amputation, a comprehensive and holistic rehabilitation approach is recommended. Psychological services provided by psychologists and rehabilitation counselors play an important role in the multi-disciplinary team by facilitating psychosocial and vocational adjustment. An overview of the rehabilitation process and considerations for rehabilitation counselors working with this population are described in the following paragraphs.

Postacute Psychosocial Assessment and Intervention Strategies

Early medical information, rehabilitation services, and prosthetic fitting have been shown to be predictors of positive rehabilitation outcome from traumatic amputation (Pezzin et al., 2000). Education about the rehabilitation and recovery process has also been shown to be extremely beneficial (Watanbe, McCluskie, Asami, & Watanbe, 1999). These findings suggest that individuals with work-related amputations should begin an integrated and holistic rehabilitation program as soon as possible. This program typically begins with a multi-disciplinary assessment to identify rehabilitation issues and goals. Ideally, this would include medical, physical therapy, occupational therapy, and psychological assessments.

Rehabilitation counselors can be instrumental in identifying early psychosocial difficulties that may arise. Such information is ideally obtained using multiple assessment methods, which include a clinical interview, self-report measures, and if appropriate collateral interviews with a spouse or family member. During the interview, information about the accident and its aftermath from the worker's perspective can be obtained. Questions should examine the nature of the accident, emotional reactions during and after the accident, secondary traumas (e.g., negative reactions of witnesses, treatment rendered by rescue and medical personnel), and attributions of blame over the cause of the accident. Counselors should ask questions about the presence of the psychological symptoms described in the above section. Additionally, information about the worker's perceptions of functional limitations, disability, and expectations of recovery should be gathered. Other factors that might be influencing the worker's psychological functioning, such as concurrent stressors, coping strategies, personality style, and family and social support should also be assessed. To better understand the worker's context, it is also critical to examine vocational, educational, family, cultural, and spiritual background. Substance abuse, suicidality, psychiatric, and trauma history are other important areas of inquiry. Lastly, concerns and questions regarding compensation, rehabilitation, and return to work issues should be discussed.

The assessment not only serves to gather relevant information but also provides a therapeutic setting for discussing psychological and vocational concerns. To address these issues, rehabilitation counselors are also in the position to offer psychoeducation, provide information about community resources, and discuss the role of counselling within the rehabilitation context. Counselors should also encourage the worker to take an active role in the assessment and rehabilitation process. Findings and recommendations from the psychological assessment can then be integrated into the overall rehabilitation plan to facilitate injury adjustment and outcome.

Not all injured workers with amputation injuries need or have an interest in receiving psychological treatment. Whether or not psychosocial counselling is provided, it still important for rehabilitation counselors to continue building rapport with the worker during the rehabilitation phase. This can be accomplished by regular and non-obtrusive contact, such as talking with the worker in the rehabilitation center a few minutes each day. Not only does this provide a valuable source of additional support and encouragement, it helps establish the rehabilitation counselor's credibility and expertise as a rehabilitation team member. As the individual proceeds with their rehabilitation, it is important to regularly inquire about psychosocial adjustment challenges that may emerge over time. For example, Grunert et al. (1992) reported a gradual increase of marital distress, alcohol and drug problems, and sexual difficulties with time postinjury, and their findings suggest the importance of repeated assessments during rehabilitation.

Rehabilitation counselors also function as a consultant with other rehabilitation start, health care specialists, and employers. At times, workers will need to be referred to a psychologist or psychiatrist for specialized treatment of PTSD, major depression, and other serious psychological disturbances. Psychiatric or physician consultation will be necessary for psychotropic medication management. Neuropsychological consultations are recommended for individuals who have also sustained a concurrent brain injury in their work accident. Injured workers with substance abuse issues may require a more intensive chemical dependency treatment program. Referral to a pain management program may be helpful for persons with severe chronic pain associated with their work-related amputation.

Cognitive Behavioral Strategies

Although supportive counseling is an important tool in facilitating psychosocial adjustment, there are a number of specific psychological approaches that can also contribute to this process. In particular, cognitive behavior therapy (CBT) is highly effective in treating a range of clinical problems including depression, anxiety, posttraumatic stress disorder, chronic pain, interpersonal difficulties, and body image disturbances (Barlow, 2002; Cash, 1996; Elmer & Freeman, 1998; Foa, Keane, & Friedman, 2000; White, 2001). This therapeutic approach includes a number of different interventions (behavioral and cognitive therapies) that are used to modify maladaptive thoughts or behaviors that contribute to, and maintain, current psychological problems and symptoms. CBT is a collaborative, problem focused, time limited, and empirically supported approach that is highly appropriate for rehabilitation settings. Readers can find additional professional resources on CBT, such as Bourne (2000), Burns (1999), Davis, Eshelman, and McKay (2000), and Philips and Rachman (1996). A summary of CBT interventions that may be helpful for treating the psychosocial difficulties in work-related amputation is presented below.

Cognitive interventions may be particularly useful given that attitudinal processes appear to be critical variables in the adjustment process. Research on amputation caused by trauma or disease, have found that perceived life control, finding "positive meaning," an optimistic attitude, and active coping strategies, such as seeking social support have been linked with psychosocial adjustment (Dunn, 1997; Gallagher & MacLachlan, 1999, 2000; Livneh, et al., 1999, 2000). In contrast, avoidance strategies, catastrophizing, emotional venting, hostility, a pessimistic outlook, and negative religious coping (e.g., anger towards God), has been shown to be associated with poorer adjustment and higher levels of emotional distress (Gallagher & MacLachlan, 1999, 2000; Hill, et al., 1995; Livneh, et al., 1999, 2000).

Cognitive restructuring is commonly used to identify and replace maladaptive and self-defeating beliefs and attitudes that people hold about themselves, the world, and their future. To illustrate, assumptions about safety, control, and danger are often shattered following a traumatic injury. Exaggerated, catastrophic, and negative appraisals may be described, such as "I am a totally worthless person now," "The world is a dangerous place," or "1 can't stop bad things from happening to me." Cognitive therapy entails a process of collaborative guided questioning to encourage clients to identify and replace their cognitive errors with more realistic and adaptive beliefs.

Coping skills training is comprised of different CBT techniques, in which clients are taught new coping behaviors through education, rehearsal, and application to real life problem situations. These techniques can be particularly effective in helping clients with general anxiety and stress management, as well as for alleviating sleep disturbances, and chronic pain. The specific strategies include relaxation training, coping self-statements, thought stopping, modelling, and role-playing. Furthermore, there are a variety of other CBT strategies, such as graded activity scheduling, activity pacing, and goal setting that can be incorporated into the counselling process.

Exposure therapy, a specific type of behavior therapy, has been shown to be one of the most effective psychological approaches in treating PTSD and traumatic phobias (Foa et al., 2000). This type of therapy provides a gradual and systematic method for allowing the worker to face trauma-related cues. This therapy can be administered as imaginal exposure that involves the systematic confrontation of distressing memories of the trauma using the client's imagination. In vivo, or live exposure, involves confronting feared but harmless reminders of the trauma that are avoided in daily life. Ideally, exposure therapy is done in a graded and prolonged manner over a number of sessions and as homework exercises between sessions. This intervention should be administered and supervised by mental health professionals who have expertise in this treatment.

Interpersonally focused cognitive behavioral interventions, such as assertiveness training, couples and family interventions, and social skills training may be helpful in addressing relational and social issues in work-related amputation. Rybarczyk et al. (1995) found that approximately half of their sample expressed an interest in receiving group treatment. Group interventions, such as cognitive behavioral therapy groups and support groups, can also be very beneficial in promoting psychosocial adjustment, and provide a source of additional social support and mentoring by other amputees who have made positive adjustments (Page & Rowe, 1998).

Very little research has examined the effectiveness of psychosocial interventions for work-related amputation. In the only published treatment study on work-related PTSD in severe hand injuries, Grunert et al. (1992) conducted an uncontrolled consecutive series. The study examined the efficacy of four different CBT interventions: (1) imaginal exposure and coping skills training, (2) an in vivo exposure exercise of returning to the accident worksite, (3) graded work exposure, (4) visiting the worksite and practicing learned coping skills on the job. The authors reported that 60.9% (74 of 122 workers) had returned to work after treatment and remained working at a six-month follow-up. Graded work exposure was found to be the most effective approach in helping injured workers return to work. This strategy involved an early return to work, in which the numbers of hours per week at work were gradually increased. These findings suggest that CBT interventions can be effective in both reducing PTSD and facilitating return to work, and more controlled treatment research in work-related amputation is needed.

Return to Work Issues and Interventions

As rehabilitation progresses, counselors will need to begin to address return to work issues. The goal is typically to help workers return to their employers, either in their preinjury job or in a modified position as soon as possible. A structured and individually tailored return to work plan developed by the rehabilitation team, employer, and worker is essential. It is also critical that the return to work plan addresses both physical and psychological issues. Furthermore, a successful return to work is often contingent on being able to adequately resolve any of the psychosocial difficulties that may have arisen postinjury.

Although many individuals eventually return to work after their accidents, a significant number of individual experience vocational difficulties. Reemployment rates of traumatic lower limb amputation have ranged from 59% (Dasgupta, et al., 1997) to 66% (Fisher et al., 2003). In the only published study on vocational outcomes in work-related amputation, Millstein et al. (1985) also found that although the majority (74%) returned to work in some capacity, and in most cases this involved changing jobs. Overall, these studies have consistently found that many individuals with traumatic amputation face a range of reemployment barriers, such as inadequate workplace accommodations, a delay between time of injury and return to work, and reduced opportunities for advancement or promotion. Furthermore, Fisher et al. (2003) suggested that psychological factors play a more important role in predicting return to work than variables of physical status, such as level and cause of amputation, age, and prosthetic comfort.

Fisher et al. (2003) and Millstein et al. (1985) suggested the potential benefits of vocational counselling in improving rates of return to work. In the study by Millstein et al., the authors also noted that one of the key factors related to reemployment was the availability of vocational services. In addition to utilizing vocational expertise and knowledge, rehabilitation counselors will also play an important role in providing ongoing supportive counselling and monitoring of psychosocial difficulties that may emerge during the reemployment phase. Furthermore, the integration of CBT interventions with vocational interventions has been gaining interest (Grunert et al., 1992; Marhold, Linton, & Melin, 2001). This approach involves practicing learned coping skills at the workplace, to help the worker perform their job duties and manage job-related stressors.

To facilitate the return to work process, rehabilitation counselors will also need to address workplace and organizational factors. Key workplace factors include the employer-employee relationship, job demands, job security, safety concerns and hazards, co-worker relationships, potential discrimination, and workplace accommodations (Tschopp, Bishop, & Mulvihill, 2001). To address these factors, Gates (2000) proposed a social model of accommodation that involves psychoeducational training of both the worker and employer. Strategies also include facilitating communication skills between clients and supervisors, negotiating and securing workplace accommodations, and educating supervisors and co-workers on disability issues. Also, from an ergonomic perspective, Girhdar, Mital, Kephart, and Young (2001) emphasized the importance of workplace accommodations, such as modifiying various aspects of the physical work environment, to better "fit" the worker's functional needs and limitations.

During the reemployment process, the impact of psychological disabilities on work performance will also need to be considered (Strauser & Lustig, 2001). Psychiatric symptoms, such as PTSD or major depression can negatively affect work performance in a variety of ways. For example, people with anxiety or depression will likely experience difficulties in coping with stressful circumstances. The ability to maintain attention and concentration for extended periods, make simple work-related decisions, and perform at a consistent pace in the workplace may be impaired. Social functioning at work may also be impaired in a number of ways, such as has being more irritable or angry towards co-workers or customers, or being less able to cope with interpersonal conflicts in the workplace. However, the presence of psychological difficulties may not necessarily preclude individuals from returning to work. With ongoing psychological treatment of the difficulties and implementing workplace modifications (e.g., flexible or reduced work hours, structured work environment), it may be possible that the worker can return to work in some capacity.

In situations, where workers are unable to return to their preinjury work duties because of permanent physical or psychological impairment, they can benefit from more comprehensive vocational rehabilitation services. In these cases, vocational rehabilitation would typically begin with a comprehensive vocational assessment using interviews, standardized psychometric tests, and career exploration exercises. This assessment is a collaborative process in which the rehabilitation counselor and injured worker examine job interests, values, aptitudes, and abilities. The worker should be an active participant in choosing tests, discussing test results, and making vocational decisions, with the goal of matching the worker with suitable and personally satisfying employment. Necessary workplace modifications will also need to be considered, and gaining the employer's cooperation in implementing these accommodations is critical.

Future Research Directions

There has been relatively limited research on the psychosocial and vocational factors in work-related amputation. Much of our knowledge about the adjustment and outcome of work-related amputation is extrapolated from the general literature on traumatic amputation. However the extent to which these findings can be accurately generalized to work-related amputation is not known. Furthermore, research studies that specifically focus on work-related amputation may identify unique issues and needs in this population. Prospective descriptive research is needed to identify salient cognitive, affective, and contextual processes as mediating variables in the adjustment process and outcome specific to this population.

Specifically, further research is needed to delineate the nature and extent of psychological difficulties in work-related amputation. Secondly, given the important role of cognitive variables in adjustment and outcome from amputation, it makes sense that this issue should be examined in work-related amputation. Another research direction is to examine the role of contextual factors, such as social support, cross-cultural differences, and workplace factors. A fourth research question is to identify the risk factors and resiliency factors for developing specific psychosocial and vocational difficulties. Lastly, controlled treatment research is needed to establish empirically supported and cost-effective psychosocial and vocational rehabilitation interventions.

Conclusion

Our aim of this paper was to review the literature on the common psychosocial difficulties in work-related amputation, including anxiety reactions such as PTSD, depression, grief, body image disturbances, and chronic pain. Early recognition and intervention of these difficulties can facilitate the adjustment process and outcome from this work injury. Rehabilitation counselors can contribute to the worker's psychosocial and vocational adjustment, and overall quality of life in a number of ways. Specifically, they can provide education about potential psychological difficulties and the rehabilitation process. Counselors can also identify psychosocial problems through psychosocial and vocational assessments as well as provide counselling interventions. The incorporation of cognitive behavioral strategies into the counselling process can be particularly effective. These include cognitive therapy, graded exposure therapy, coping skills training, and interpersonally focused interventions. Rehabilitation counselors are also instrumental in promoting positive vocational outcomes. Successful vocational outcomes can be facilitated by structured and graduated return to work plans that address both individual and contextual factors. Identifying and reducing reemployment barriers, and implementing workplace accommodations are critical. Furthermore, teaching the worker how to apply learned coping skills "on the job" can promote job retention. Ongoing support through the transition from rehabilitation and job placement phases can also contribute to a successful, sustained, and productive work life. Lastly, there is much more to be learned about psychosocial and vocational factors in work-related amputation, and more empirical research is needed to enhance our understanding of these issues.

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Jaye Wald

University of British Columbia

Rosemarie Alvaro

Compensation Board of British Columbia

Jaye Wald, Ph.D., Department of Psychiatry, University of British

Columbia, 2255 Wesbrook Mall, Vancouver, B.C., V6T 1A1,

Canada. E-mail: jwald@interchange.ube.ca
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Author:Alvaro, Rosemarie
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Date:Oct 1, 2004
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