problem-solving appraisal and psychological adjustment...

Cognitive Therapy and 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~Medical College of 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 in- cluded 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.

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0147-5916/91/1000-0387506.50/0 © 1991 Plenum Publishing Corporation

388 Elliott, Godshall, Ilerrick, Witty, and Spruell

The study of self-appraised problem-solving ability has provided valu- able 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 expres- sion, and by approaching rather than avoiding problematic situations (Hep- pner, 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 environ- mental resources (Neal & Heppner, 1986) and have been rated more in- terpersonally 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 (EI- liott, 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

Problem-Solving and SCI 389

therapeutic interventions in SCI rehabilitation (Frank et al., 1987). Conse- quently, 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 ques- tionnaires 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

390 Elliott, Godshail, llerrick, Witty, and Spruell

which are rated on a 6-point Likert scale (1 = strongly agree to 6 = strongly disagree). The PSI contains three previously identified factors: Problem- solving 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 ac- cumulated over several studies, revealing that the PSI total score and sub- scales 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. Anec- dotal 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. Tes t - re tes t reliability (0.98 over 2 days) and internal consistency coefficients (0.92) have been impressive; comparisons with interview systems and other self- report measures of depression have yielded acceptable correlations (rang- ing 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


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. Test- retest 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-

392 Elliott, Godshall, llerrick, Witty, and Spruell

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Problem-Solving and SC!

Table 1I. Dependent and Predictor Variables for Hierarchical Analyses a

Multiple-Regression

393

Dependent and predictor variables F R 2 p value

Depression Age, education, race, level of injury 2.37 .10 .059 Time since injury 1.18 .01 .28 PSI total score 21.18 .18 .0000 PSI x Time 2.52 .02 .116

Psychosocial impairment Age, education, race, level of injury 1.57 .07 .189 Time since injury 8.16 .08 .005 PSI total score 13.01 .12 .0005 PSI × Time 0.006 .00 .945

Assertion Age, education, race, level of injury 3.46 .14 .01 Time since injury 0.00 .00 .98 PSI total score 4.75 .05 .03 PSI x Time 0.14 .00 .71

aNote: Incremental change statistics are reported for F ratios and R 2 and p values for variables entered after the first step in each separate equation.

avoidance , 36.12 (SD = 11.05), and persona l control , 14.79 (SD = 6.05). T h e a v e r a g e d e p r e s s i o n score was 14.26 (SD = 10.48), the a v e r a g e psychosocia l impa i rmen t score was 16.41 (SD = 12.95), and the average asser t ion score was 57.8 (SD = 12.48). Cor re la t ions be tween the PSI, d e m o g r a p h i c variables, and the d e p e n d e n t var iables are p re sen ted in Tab le I. E a c h d e p e n d e n t variable was significantly cor re la ted with the PSI total score. All o f the problem-so lv ing appraisal var iables were Sig- nif icantly re la ted to par t ic ipant educa t ion . These cor re la t ions indicate tha t lower levels o f educa t ion were associa ted with h igher scores on the PSI, indica t ing se l f -appra ised ineffect ive p rob lem-so lv ing ability. Cor- r e l a t i ons r e v e a l e d h ighe r levels o f e d u c a t i o n to be s ign i f ican t ly as- soc ia ted with less depress ion (r = -0 .30, p < 0.002) and psychosocia l impa i rmen t (r = -0.20, p < 0.05), and with g rea te r assert iveness (r = -0.21, p < 0.05).

PSI scores were not significantly correlated with age, level of injury, or race. Several s ignif icant co r r e l a t i ons were f o u n d be tween specific demographic variables and the ou tcome measures. Therefore , a block o f clinically relevant demographic variables including patient level o f injury (coded as paraplegia = 1, quadriplegia = 2), race (coded as Caucasian = 1, Af r i c an -Amer i c a n = 2), age, and educat ion was entered at the first step in each o f the subsequent multiple-regression equations. Time since injury (TSI) was entered next, and the PSI total score was entered at the third step. A PSI Total Score × TSI interaction term was entered last. This pro-

394 Elliott, Godshall, llerrick, Witty, and Sprueil

cedure allowed for the systematic examination of the effects of these variables on each dependent variable, and the study of the effects of the PSI scores above and beyond the variance attributable to demographic variables (see Table II).

The first hierarchical multiple regression tested the hypothesis that problem-solving appraisal would be predictive of depressive behavior. The block of demographic variables was entered first, and was not significantly predictive of depression scores [F(4, 85) = 2.37, p = 0.059, R = 0.10]. Examination of individual beta weights revealed education to have a significant relationship with depression [beta = -0.31, t(85) = -2.93,p < 0.01], indicating that higher education levels were predictive of lower depression scores. TSI was entered at the second step, and this variable was not significantly predictive of depressive behavior, Finc(1, 84) = 1.18, n.s. Next, the PSI total score was entered and was significantly predictive of depression scores, Finc(1, 83) = 21.18, p < 0.0001, R2inc = 0.18. Self-appraised effective problem-solving ability was associated with lower depression scores. Therefore, the prediction that problem-solving appraisal would be predictive of depressive behavior was upheld. The PSI Total Score x TSI interaction term was then entered and this was not significant [Finc(1, 82) = 2.52, n.s.]. The final model accounted for 31% of the variance in the dependent variable.

The second hierarchical multiple-regression equation tested the prediction that problem-solving appraisal would be significantly predictive of psychosocial impairment. The block of demographic variables was entered first, and was not significantly predictive of SIP scores, F(4, 85) = 1.57, n.s. TSI was entered at the second step and found to be significantly predictive of psychosocial impairment, Finc(1, 84) = 8.16, p = 0.005, R2inc = 0.08. More recent onset of injury was associated with greater impairment. The PSI total score was entered next and this was significantl)~ predictive of psychosocial impairment [Finc(1, 83) = 13.01, p = 0.0005, R'inc = 0.12]. Self-appraised effective problem-solving ability was associated with less psychosocial impairment, as expected. The PSI Total Score × TSI interaction was entered at the final step, and this interaction was not significantly predictive of impairment, [Finc(1, 82) = 0.006, n.s.]. The final model accounted for 27% of the variance in the psychosocial impairment scores.

The final multiple-regression equation tested the prediction that problem-solving appraisal would be significantly predictive of assertiveness. The block of clinically relevant demographic variables was entered first and found to be significantly predictive of assertion, F(4, 85) = 3.46, p = 0.01, R 2 = 0.14. Examination of individual beta weights revealed a significant effect for level of injury [beta = -0.22, t(85) = -2.12, p < 0.05], indicating that quadriplegia was associated with more assertiveness. TSI was entered


at the second step and was not significantly predictive of assertion [Finc(1, 84) = 0.00, n.s.]. PSI total scores were entered at the third step. As predicted, PSI total scores were significantly predictive of assertion, Finc(1, 83) = 4.75, p 0.03, R2inc = 0.05, above and beyond that accounted for by level of injury. Self-appraised effective problem-solving ability was associated with a greater inclination to act in an assertive manner. The PSI Total Score x TSI interaction, entered at the final step, was not significantly predictive of assertion [Finc(1, 82) = 0.14, n.s.]. The final model for predict- ing assertiveness accounted for 19% of the total variance.

DISCUSSION

Problem-solving appraisal was significantly predictive of depression, psychosocial impairment, and assertiveness, as hypothesized. These rela- tions were evidenced after controlling for the effects of important demographic characteristics and chronicity. Self-appraised effective problem-solving ability was significantly associated with lower depression and psychosocial impairment scores, and a greater willingness to act assertively. Chronicity was significantly predictive of psychosocial impairment, but not depressive behavior. Pearson correlations between the PSI subscale and the dependent variables indicated that the three components of problem-solving appraisal were significantly related to each index of psychological adjustment.

The results of the present study are consistent with other psychological investigations of adjustment following SCI. Previous research has related patient locus of control to psychological distress regardless of the time since the onset of injury or the type of coping strategies utilized (Frank, Umlauf et al., 1987; Shadish, Hickman, & Arrick, 1981). Goal-directed, problem-focused orientations appear to be important characteristics of persons who report fewer problems with depression and social adjustment after acquiring SCI (Elliott, Witty, Herrick, & Hoffman, in press).

Several issues concerning the assessment of depression in this study should be considered. The measurement of depression among patients with certain physical disorders is a controversial enterprise given the confound- ing effects of somatic problems that accompany physical problems like SCI. Endorsement of items tapping somatic features of depression may reflect concomitants of disease or disability (Kathol, 1985). The applicability of standardized criteria of depression to patients with degenerative and chronic physical disorders has received much attention and more systematic, conclusive research is needed in this area (House, 1988). Other data suggest that while somatic items on depression scales may bias the

396 Elliott, Godshall, Ilerrick, Witty, and Spruell

prevalence of depression among medical patients, correlations between depression scores and other psychological variables are not likely to be ad- versely inflated (Blalock, DeVellis, Brown, & Wallston, 1989).

The correlational and cross-sectional nature of the study precludes definitive causal interpretations of relationships between the independent and dependent variables. Empirical relationships between many independent variables and measures of depression often dissipate in prospective designs (Barnett & Gotlib, 1988). It is possible that persons who were ex- periencing more negative mood reported their problem-solving skills in a more pessimistic direction. The IDD and SIP scores may have been similar- ly affected by participant mood. Further, depression scores in this popula- tion could reflect the stable personality dimension of neuroticism or negative affectivity, rather than emotional disorder or distress. Negative affectivity is often embedded in psychological measures of distress (Watson & Clark, 1984).

Other shortcomings of the present research should be considered. This study relied extensively on self-report measures and scores may not be indicative of actual behavior. The need exists to examine behavioral outcome measures, particularly with indices germane to rehabilitation (e.g., self-care behaviors, social mobility, incidence of decubitus ulcers). The im- balance between men and women may obfuscate possible gender differences in psychological adjustment following SCI. Despite these limitations, the results are consistent with current theory and past research regarding problem-solving appraisal, and imply that current perspectives in problem- solving therapy are relevant for psychological interventions in SCI rehabilitation.

Implications of the Present Study

The findings of this study have several implications for psychological interventions in rehabilitative settings. Persons who perceive themselves as capable of regulating their emotions and systematically approaching problems may be able to cope more effectively with physical disability. Theoretically, effective self-appraised problem-solvers would demonstrate more appropriate behavioral strategies as they actively cope with situations imposed by their condition. Following SCI, for example, a person must ad- here to self-care regimens such as conducting routine skin checks, monitor- ing urinary and bowel functions, regulating fluid intake, and observing regular out-patient visits. Failure to comply with these regimens can con- tribute to urinary tract infections and decubitus ulcers that can culminate in extended hospitalizations at cost to the physical health of the person


and the resources o f the heal th-care system. In addition, the inability to effectively access and utilize environmenta l and social suppor t systems (i.e., vocat ional rehabili tation, social service and medical agencies, independen t living centers) can also contr ibute to psychological and physical maladjust- ment . Psychological interventions in SCI rehabili tation based on problem- solving principles may be helpful in alleviating distress, augment ing existing coping skills, and developing systematic approaches in defining and solving day- to-day social and medical problems imposed by disability.

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