Adjustment to spinal cord injury: a review of coping styles contributing to the process

Journal of Rehabilitation, Oct-Dec, 1993 by Douglas Cairns, John Baker

The coping process following spinal cord injury is not well understood despite nearly fifty years of study. Today's climate of increasing costs and decreasing length of hospital stay, lends an urgency to understanding the process so early identification of patients at risk for disturbed adjustment can occur.

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).