KEY WORDS: problem-solving appraisal; spiral cord injury. 1Gratitude ... personal dissatisfaction and evidence a higher mortality rate than those who are more ...
Cognitive Therapyand Research, Vol. 15, No. 5, 1991, pp. 387-398
Problem-Solving Appraisal and Psychological Adjustment Following Spinal Cord Injury 1 Timothy R. EUiott 2
Virginia Commonwealth University~MedicalCollegeof Virginia Frank J. Godshall, Stephen M. Herrick, and Thomas E. Witty
kirginia Commonwealth University Michael Sprueli McGuire Veteran's Administration Medical Center
This study examined the effects of problem-solving apprabal on psychological adjustment following spinal cord injury. It was predicted that self-appraised effective problem-solvers would evidence less depressive behavior and psychosocial impairment and would be more assertive than self-appraised ineffective problem-solvers regardless of time since the onset of injury. Participants included 90 persons receiving either in-patient or out-patient services for spinal cord injury at one of three rehabilitation facilities. Results indicated that problem-solving appraisal was significantly predictive of all three dependent measures, confirming the hypotheses. The findings are discussed as they pertain to theoretical implications for current models of problem-solving appraisal, and in relation to applications of problem-solving in rehabilitation. KEY WORDS: problem-solving appraisal; spiral cord injury.
1Gratitude is expressed to Erlyne Mangum, Kevin West, Paul Caulkins, and Anne Patti for their assistance in collecting and scoring protocols, and also to Jim Hoffman, Ph.D., and Bruce Coplin, M.D., for their cooperation in the recruitment of participants. This research was supported in part by a grant to the first author from the American Association of Spinal Cord Injury Psychologists and Social Workers. 2Address all correspondence to Timothy R. Elliott, Department of Psychology, Virginia Commonwealth University, Richmond, Virginia 23284. 387 0147-5916/91/1000-0387506.50/0 © 1991 Plenum Publishing Corporation
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The study of self-appraised problem-solving ability has provided valuable information for conceptualizing and developing therapeutic interventions. Persons who appraise their problem-solving skills as being effective are characterized by a high degree of confidence in their ability to address day-to-day problems, by regulating their emotional experience and expression, and by approaching rather than avoiding problematic situations (Heppner, 1988). Self-appraised effective problems-solvers evidence less distress under general conditions (Heppner, Kampa, & Brunning, 1987; Nezu, 1985) and stressful conditions (Nezu, Nezu, Saraydarian, Kalmar, & Ronan, 1986). Self-appraised effective problem-solvers are more aware of environmental resources (Neal & Heppner, 1986) and have been rated more interpersonally skilled than self-appraised ineffective problem-solvers (Heppner, Hibel, Neal, Weinstein, & Rabinowitz, 1982). Self-appraised effective problem-solvers also display fewer irrational beliefs, more internal expectancies of control, more adaptive study skills, and higher levels of confidence in their decision making ability than ineffective problem-solvers (EIliott, Godshall, Shrout, & Witty, 1990; Heppner, Reeder, & Larson, 1983; Larson & Heppner, 1985). Treatment modules incorporating problem-solving principles underpinning the study of problem-solving appraisal have demonstrated effectiveness in decreasing depressive behavior (Nezu & Perri, 1989). Problem-solving appraisal may play a role in the psychological adjustment of persons with debilitating physical conditions, such as spinal cord injury (SCI). Many persons with SCI meet diagnostic criteria for affective disorders, and depressive behavior is predictive of longer hospitalizations, medical complications, and decreased self-care among these patients (Frank, Elliott, Corcoran, & Wonderlich, 1987). Persons with SCI reporting more psychosocial impairment secondary to the disability display greater personal dissatisfaction and evidence a higher mortality rate than those who are more socially adept (Krause & Crewe, 1987). Psychosocial impairment is often triggered by physical stigma, which can disrupt relationships with significant others, acquaintances, health-care staff, and people in general (Dunn & Herman, 1982). Persons with SCI who are unable to interact effectively with others encounter difficulties in social interactions (Elliott & Frank, 1990). Unfortunately, the psychological study of adjustment following SCI has been plagued by several problems. Popular anecdotal models of adjustment that maintain a systematic progression through various psychological stages have traditionally guided clinical efforts over the years, despite the theoretical and empirical shortcomings of these models (Frank et al., 1987). The lack of theory-based empirical research of psychological adjustment after SCI has hindered the development and implementation of
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therapeutic interventions in SCI rehabilitation (Frank et al., 1987). Consequently, the demonstrated relevance of theory-driven variables such as problem-solving appraisal on adjustment following SCI would have clear implications for interventions in rehabilitation efforts. The present study examined the effects of problem-solving appraisal on psychological adjustment following SCI. Specifically, it was predicted that self-appraised effective problem-solving would be associated with lower levels of depression and psychosocial impairment, and more assertiveness, regardless of the time since the onset of the injury.
METHOD
Participants Participants were 87 men (mean age = 40.54; SD = 13.65, range 19 to 66 years) and three women (mean age = 24.67; SD = 4.04, range 20 to 27 years) receiving treatment for spinal cord injuries at one of three rehabilitation facilities. Seventy-four patients were serviced by a Veteran's Administration medical center, ten were treated at a rehabilitation unit in a large urban medical school, and six were receiving treatment in a rural rehabilitation facility. Fifty-seven patients were caucasian and 33 were African-American. The average time since the onset of the injury was 99.78 months (SD = 134.05, range 1 month to 490 months). Fifty-three participants were paraplegic and 37 were quadriplegic. The average years of education for the sample was 12.61 (SD = 2.65, range of 6 years to 19 years of education). Patients were approached by a member of the research team and told that the study examined the relationship between interpersonal behavior and adjustment to SCI. Sixteen persons declined to participate in the study. Informed consent was obtained from interested participants. The measures were administered in a random order. Trained interviewers verbally administered the measures to patients, since many patients with high-level injuries required or requested assistance. Interviewers were sensitive to the possible effects of undetected closed head injuries secondary to SCI, and one patient who evidenced obvious difficulties in comprehending the questionnaires was dropped from study.
Independent Variables The Problem-Solving Inventory (PSI; Heppner, 1988) was used to measure self-appraised problem-solving ability. The PSI contains 32 items
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which are rated on a 6-point Likert scale (1 = strongly agree to 6 = strongly disagree). The PSI contains three previously identified factors: Problemsolving confidence, approach-avoidance, and personal control (Heppner, 1988). Separate scores are derived for these factors and a total score is computed by summing the factor scores. Reliability estimates reveal that these constructs are internally consistent (alpha coefficients from 0.72 to 0.90; N = 150) and stable over a 2-week period (test-retest correlations from 0.83 to 0.89; N = 31; Heppner, 1988). Validity estimates have accumulated over several studies, revealing that the PSI total score and subscales are significantly related in predicted directions with a variety of self-report and observational measures (Heppner, 1988). Lower PSI scores denote a more positive appraisal of personal problem-solving skills. A second independent variable was derived from the number of months that had transpired since the onset of injury for each patient. Anecdotal models of adjustment following SCI maintain that the longer a person is injured, the more emotionally accustomed the person becomes to the injury. Subsequently, depression is usually expected by clinicians in the early months of injury (e.g, Siller, 1969). According to this line of reasoning persons who have recently sustained injuries should evidence higher levels of depression and psychosocial impairment than those who have been injured for longer periods of time, and these differences should be detectable in cross-sectional analyses.
Dependent Measures The Inventory to Diagnose Depression (IDD; Zimmerman & Coryell, 1987) was used as a criterion variable. The IDD is a 22-item self-report instrument developed to measure depressive behavior. T e s t - r e t e s t reliability (0.98 over 2 days) and internal consistency coefficients (0.92) have been impressive; comparisons with interview systems and other selfreport measures of depression have yielded acceptable correlations (ranging from 0.80 to 0.87; Zimmerman, Coryell, Corenthal, & Wilson, 1986; Zimmerman, Coryell, Wilson, & Corenthal, 1986; Zimmerman & Coryell, 1987). Each item requires a respondent to indicate the severity of a depressive behavior on a 5-point Likert scale. A total score is derived from the sum of the responses. Higher scores reflect the endorsement of more depressive behaviors. The Sickness Impact Profile (SIP; Gilson et al., 1975) was used to measure psychosocial impairment. The SIP is a 136-item questionnaire measuring health-related impairment in physical and psychological dimen sions. The psychosocial subscale was utilized in this study. Items on this
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subscale tap functioning across categories of social interaction (e.g., "I am doing fewer social activities with groups of people"), alertness ("I do not keep my attention on any activity for long"), emotional behavior ("I laugh or cry suddenly"), and communication ("I do not speak clearly when I am under stress"). Respondents are asked to endorse only those items that describe their personal experience within the preceding 24 hours. Testretest correlations of the SIP across several studies and time intervals have been consistently high (0.75 to 0.92) for the total score, and moderate (0.45 to 0.60) for items endorsed (Bergner et al., 1981; Gilson et al., 1975). Validity coefficients resulting from comparison with other measures of health-related dysfunction have ranged from 0.30 to 0.85 (Bergner, Bobbitt, Carter, & Gilson, 1981). Higher scores denote greater psychosocial dysfunction. The Spinal Cord Injury Assertion Questionnaire (SCIQ; Herman, Van Horn, & Dunn, 1977), was used to measure patient assertiveness. The SCIQ consists of 26 potentially sensitive social situations specific to SCI. A respondent rates on a 1 (all of the time) to 5 (never) Likert scale the degree to which the person would respond assertively in specific social situations. Test-retest reliabilities over a 2-week period averaged 0.60 and odd-even reliability was 0.67 (Herman et al., 1977). A total score is obtained by summing the responses. This index denotes the likelihood the person would behave assertively. The total score has been significantly correlated with conventional self-report and observational measures of assertiveness (Dunn & Herman, 1982). Lower scores denote greater willingness to act assertively.
Statistical Analysis Pearson correlations were computed between the PSI variables, the dependent variables, and relevant demographic variables to examine possible relationships. Separate multiple-regression equations were computed using the PSI total score and time since injury as independent variables to predict depression, psychosocial impairment, and assertiveness, respectively.
RESULTS Participant mean scores on the PSI (mean = 72.46, SD = 20.79) were comparable to mean scores observed among adult men (mean = 76.9, SD = 22.9; Heppner, 1988). The mean PSI factor scores were as follows: problem-solving confidence, 21.67 (SD = 7.48), approach-
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