The Journal of The American Paraplegia Society
ISSN: 0195-2307 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/yscm19
Applying Functional Analysis to Psychological Rehabilitation Following Spinal Cord Injury Clive A. Glass To cite this article: Clive A. Glass (1992) Applying Functional Analysis to Psychological Rehabilitation Following Spinal Cord Injury, The Journal of The American Paraplegia Society, 15:3, 187-193, DOI: 10.1080/01952307.1992.11735872 To link to this article: http://dx.doi.org/10.1080/01952307.1992.11735872
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Applying Functional Analysis to Psychological Rehabilitation Following Spinal Cord Injury Clive A. Glass, BSc., M.Ciin.Psych., Ph.D., C.Ciin.Psych. ABSTRACT There have been numerous attempts to categorize the responses of individuals to spinal trauma on the basis of generalized stage theories of grief reaction, and personality theory. A number of these studies are critically appraised and a behavioral model, based on functional analysis, is proposed as a more constructive framework for future research. Such an approach is applied clinically to the activities and development of the Clinical Psychology Service provided to the Mersey Regional Spinal Injuries Centre in Southport, England. A number of examrles of clinical and research practice are included, highlighting the applicability of functional analysis to individual and systems level investigations.
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KEY WORDS: spinal injury, functional analysis, psychological intervention
INTRODUCTION
The physiological changes experienced by those who suffer spinal impairments are immense. While the majority of such persons are somewhat fortunate in not having experienced severe cognitive impairment, the corollary of such a situation is that individuals are able to examine and communicate their concerns over future functioning, usually involving close family members. The importance of relatives in such a situation cannot be stressed too highly. Considerable research1 has shown, for example, that children's reactions to parental injury are not related to severity of injury; rather, the parental support. and financial security of the family environment are seen as more important. The maintenance of family structure and open communication are therefore seen as fundamental to the success of the rehabilitation programs undertaken at the Centre. This paper deals with a number of responses to trauma at both the immediate and longer-term stages following disability, and outlines a clinical Address correspondence to: Dr. Clive A. Glass Consultant Clinical Psychologist, Mersey Regional Spinal Injuries Centre, Southport District General Hospital, Town Lane, Southport PR6 6NJ. England, U.K. (An earlier version of this paper appeared in Clinical Psychology Forum, a publication of the Division of Clinical Psychology, The British Psychological Society 1990:26;2-6.)
approach that has not only face validity, but situational reliability. LIMITATIONS OF STAGE THEORY RESPONSE TO TRAUMA
The experience of spinal trauma has been likened in the past (Kubler-Ross 2) to the responses to bereavement, but without the end result. Lindemann,3 reviewing the findings of Weller and Miller, 4 indicates that eventual adaptation to trauma involved the progression through a number of stages: shock, denial, anger, depression, and eventual acceptance. It has been suggested that denial may allow for the gradual acceptance of trauma into consciousness (Stewart5). It may be overt, such that patients refuse support on the basis that they will walk out of the unit, or more subtle. Many spinal cord injury (SCI) patients retain the hope that one day a cure will be found that will enable them to walk again. This view may assume great importance in their development of coping strategies to enable them to adapt to their trauma. Anger may occur at the same time as denial. The development of this feeling is understandable in non-blame situations. It may be tempting on occasion to return this hostility, though such a response would only serve to reinforce the frequency of such outbursts and should be avoided. Depression may result during any of the above stages, and may reflect guilt about the accident, if
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it involved others. The responses outlined above could impede progress through rehabilitation if maintained for long periods. There is, therefore, an understandable urge to want to stop such behaviors as soon as they occur. However, such responses are those which any person in that particular situation would be expected to experience. As such, they are essentially normal responses to an abnormal situation, and should require specialized intervention only if they seriously impede rehabilitation. Furthermore, some patients may not experience these behaviors, or will not experience them in the order presented, and may resent being seen by a psychologist. This is particularly true if the role of psychological intervention is not explained, and the person sees no direct benefits from the involvement. The responses listed above are equally applicable to the relatives of trauma victims who themselves need to begin to adapt to a new set of circumstances. Considerable time is spent during the early stages of an individuals admission, informing relatives of the likely behavioral responses which the injured person may experience. However, while the experiences of anger, depression, and denial are common, particularly during the immediate post-traumatic period, they tend to occur with less clarity and intensity in subsequent months, although in most cases an injured person could not be considered to have adapted to the situation by that time. Furthermore, while there appear to be certain times when patients are more likely to experience difficulties (immediately following admission, when they first start to get out of bed, immediately prior to discharge, and immediately following discharge) these are by no means universal. The applicability of a stage theory to account for behavioral change and adaptation following trauma would therefore appear questionable. While some people will exhibit such changes over time, it must be remembered that individual responses to trauma are essentially unique events, and attempts at broad categorizations of responses can prove inaccurate and problematic. For example, one nurse from another spinal unit, commenting on a specific case, stated that such a person would not be considered ready for discharge because he had not shown any evidence of denial.
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PREDICTING RESPONSES TO TRAUMA Criticisms, similar to those outlined above, can be aimed at studies that have attempted to examine specific personality variables as predictive indicators of the likelihood of an individual to experience trauma, and the effects of personality on successful or unsuccessful adaptation to it. Weller and Miller4 in a study of 30 male and 7 female trauma victims noted: Over half the patients were young, emotionally immature, in the midst of rebelling or self-destructive acting out, with insecure, poor self-image, and low self-esteem; at a peak of physical and sexual activity, with investment in physical prowess far outweighing intellectual interests; with low levels of education and job opportunities; and with troubled families broken through marital discord, death, illness, and other crises. However, the authors give little information on both the selection procedures involved in the investigation and the characteristics of the other 50 percent of the cases studied, and it is the experience in Southport that while a certain number of patients could be considered to show some of these characteristics, the majority do not. It would appear, therefore, that while patients in this group are undeniably a subset of spinal trauma victims, they are not representative of trauma victims as a whole. In a similar study, Ducharme et al. 6 attempted to examine the role of self-destruction as a factor in spinal trauma mortality. They examined the hypothesis that a desire for self-destruction was a significant factor as a cause of death following spinal trauma, and used this to indicate the presence of an underlying character disorder, which predisposed such a person to experience an early death. They argued that a number of deaths resulted from violent accidents, and that for these persons traumatic injury had not been an isolated event, as it had occurred, for example, after a death in the family, or a divorce. As with the earlier Weller and Miller investigation, this study failed to examine the base rate of the incidence of selfdestructive acts as a precursor to establishing significance. Similarly, the reliance on retrospective analysis makes the findings somewhat open to question.
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The major criticisms which can be directed toward studies that have attempted to examine personality variables as predictors of acceptable and unacceptable adaptation, center on their lack of standardization data and their lack of premorbid assessment. It is difficult to assess whether a person's personality following trauma is a direct result of that trauma, or an extension of the pretrauma personality, unless some measure is taken of pre-trauma variables. It may be that certain psychological variables are predictive of successful adaptation but the current research evidence for this proposition is poor. A comprehensive, methodologically rigorous, examination of these issues is being conducted at Southport,7 with data also being provided by Craig Hospital in Colorado. More than 500 standardized questionnaires were completed by the injured persons and their closest relative. The aim of this investigation was to establish a standard technique for assessing adjustment to trauma. The initial findings indicate that the scale is significantly more reliable than any other scale produced to date. Once further examination is complete, it should be possible to provide a stable baseline from which to gauge behavioral change. This is particularly important in resource allocation since it enables those with greatest adaptation difficulties to be most effectively targeted. In summarizing the current literature, it must therefore be concluded that comparisons of a specific individual's behavioral responses to spinal trauma with textbook responses to trauma is essentially meaningless. Once specific problems are highlighted, the only way to examine non-adaptive behaviors objectively and begin to establish adaptation, is to apply a methodologically rigorous approach which takes individual variation into account. Such variation is accounted for in an individual functional analysis. APPLICATION OF FUNCTIONAL ANALYSIS IN SPINAL INJURY SETTINGS Individual Functioning and Difficulties
The essential characteristics of functional analysis have been described (Slade, 8 Owens and Ashcroft9) as have the applications of the theory to specific clinical populations (Jackson, Glass, and HopelO). Such an analysis demands the specification ofvari-
abies, of which any specific behavior shown is a function, and an examination of the relationship between this behavior and such variables. While such analysis sounds complex, it can be broken down into three simple stages. Antecedents are variables that bring about a specific behavior. While it would be trite to say that the spinal trauma has brought about any specific behavior, such as the person being withdrawn or irritable, there will be more specific variables which make certain behaviors more or less likely to occur. These include variables such as frequency of individual activity, whether particular nurses are in attendance, or whether families visit regularly or not. Similarly the consequences of the behavior may serve either to maintain it or reduce the likelihood of it occurring again; while in some cases constant attention to the problem by the psychologist, staff, or relatives may only serve to exacerbate the difficulty, in others it can lead to an adaptive alteration in the behavior. Such interactions can be expanded considerably to include, for example, the interactions between a specified individual and the family and community in which he lives. However, limitations are placed on the analysis to the point at which intervention could be considered to have an effect. The application of such an approach therefore requires comprehensive monitoring and adaptation of the intervention to take account of changes in the individual's circumstances. Within the context of spinal injuries, rehabilitation must be aimed at achieving the optimal level of independence and quality of life for each individual. The individual's role in assigning values to such independence and quality must be paramount, and the application of functional analysis is entirely compatible with such a philosophy. While the design and implementation of such a procedure is somewhat more complex, the explanation above outlines the basic tenets. The following examples are designed to indicate the usefulness of the application of functional analysis to commonly experienced difficulties in clinical practice. Secondary Impotence
Given the increased frequency with which men experience spinal trauma, the biomechanics associated with erection, and the cultural acceptance of male sexual expression, it is perhaps under-
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standable that they seek help with sexual difficulties more readily than women. Psychogenic erections, or those resulting from thoughts and feelings, are reported to occur less frequently following spinal trauma. Brindley 11 noted that those with complete lesions below T9 should be able to experience some degree of psychogenic erection, while those with lesions at TS cannot be discounted. The development of secondary impotence in otherwise physiologically potent males is a common phenomenon in a number of trauma groups (Glass 12). The following example highlights the development of such a difficulty in a man following spinal trauma. A 34-year-old man with a wedge fracture at TlO but no neurological damage was admitted for rehabilitation. He began to complain of sexual difficulties with his partner three months after discharge. Full vascular, hormonal, and neurological examination revealed no evidence of impairment. Interviews with the clinical psychologist led to the production of the functional analysis illustrated in Figure 1 which shows four major issues related to the maintenance of the central difficulty, involving both partners perceptions of sexual activity and sexuality. In this particular case therapy was based on utilizing the patient's awareness of medical usefulness by using the results of the physiological assessments of his potency in conjunction with his nocturnal tumescence results. His ability to achieve erections when alone was used in conjunction with home monitoring of erection levels to provide biofeedback and further reassurance of his erectile abilities. Following this section of treatment, the issues surrounding his partner's experiences of sexuality were explored. Attempts were made to increase her arousal using non-penetrative sexual activities and by gradual extension of foreplay. This had the effect of not only reducing her anxieties about further conception but reduced the patient's anxieties about sexual performance. Increased experimentation over time led to increased enjoyment for both partners and a gradual return to normal sexual functioning. The entire intervention required twelve sessions over a five-month period.
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Spinal injury
.1. Initial impotence
.1. Increased anxiety about failure
t
.1.
Continued impotence
Erect in
Religious views on sex
Fig 1. Factors associated with the development and maintenance of a case of secondary impotence following spinal trauma. Suicide The occurrence of deaths by events other than natural causes were noted earlier. In Southport, six persons have tragically ended their own lives in the past seven years. There are a number of reasons why trauma victims might want to end their lives, and evidence from investigations in other areas (Tuckman and Youngman 13) shows that suicide occurs in most groups suffering physicalloss. It is important also to note that most completed suicides are by paraplegics, though it may be intuitively expected that quadriplegics would be most likely to take their own lives, given their greater degree of loss. Research data is unable to show, however, how many quadriplegics would commit suicide if they were able to do so. There is some evidence to support the notion of decreased coping ability correlated with increasingly higher lesion level (Gardner et al.l 4 ; Maynard and Muth 15), although more recent information presented at the First International Conference on Domiciliary Ventilation held in Southport begins to question this hypothesis, at least in the latter group of individuals (Glass 16).
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A further investigation conducted in Southport involved the retrospective analysis of cases where patients had taken their own lives, with data obtained using a structured interview completed during contacts with surviving relatives. While the trauma itself was seen as the major precipitating factor, other issues such as social isolation, feelings of hopelessness, and lack of awareness of rehabilitative options were also raised. Perceived hopelessness is seen by many researchers (Becket aL1 7) as a more comprehensive indicator of suicidal intent than, for example, assessment of depression. Upon admission to the Centre, all patients participate in a comprehensive analysis of both their perceptions of their disability and their perceptions of future activity. This is constantly followed-up during their stay at the Centre with particular emphasis placed on positive adaptation. Those who experience continual difficulties in adaptation are noted and provided with comprehensive support and follow-up once they return to the community. It is expected that such comprehensive analysis will enable the directing of resources to those who exhibit problems in adaptation. Given the relatively low frequency with which people commit suicide, analysis of the data will require the use of Bayes' theorem (Rorer et al. 18), rather than more traditional statistical analysis. However, effectiveness of intervention with a further specific difficulty is more amenable to analysis of change. Pressure Sores One of the most frequent causes of readmission following initial post-trauma hospitalization is the development of pressure sores. Patients are taught methods of regular skin examination before they learn to use their wheelchairs. While quadraplegics have less control over the development of sores, paraplegics should rarely experience such difficulties. From an examination of the situations that have brought about sores in paraplegics, a number appear to have arisen due to poor self-care. In each of these cases, functional assessment is based on the situation occurring immediately before the sore developed, and an examination made of the consequences of such an incident. Frequently, persons experienced difficulties with their partners, or were generally finding life at home
intolerable. Admission to the Centre often leads to an improvement in the family situation by taking away a primary source of stress, and gives the individual an improvement in social interaction through contact with staff and other people with some understanding of their requirements, as well as direct access to occupational and physiotherapy support. The development of pressure sores can, therefore, be seen in some cases as either a reaction to deterioration in psychosocial or environmental conditions, or a somewhat extreme method of gaining some degree of positive respite. In such cases, during the treatment of the sore, the patient is involved in a comprehensive examination of the factors that have lead to the development and maintenance of the difficulty, and a strategy is developed to reduce the likelihood of the related behavioral responses recurring following discharge. This may involve the arrangement of regular respite, closer coordination with community services, or further involvement with psychological services. It is a policy of the Centre that an open door to treatment prevails, encouraging individuals to contact the Centre for assistance whenever required. This service extends to the provision of a comprehensive community support program whereby individuals are routinely followed-up in their own homes after discharge. Systems Level Applications As noted earlier, spinal trauma not only affects the patients, but their relatives and friends. However, there is a third group of people whose lives are affected by the trauma, the staff within the centres. Functional analysis can therefore be applied not only at the level of the individual but also at a systems level. A review of the literature by Tucker 19 emphasized that emotional adjustment of both patient and staff is essential for successful rehabilitation. Gunther20 ·21 studied experiences of staff working with SCI and other severe injuries over a 20-year period and concluded that staff members working with SCI patients were often severely affected and disturbed by their experiences to a greater extent than those working with less severely ill patients. Further evidence was provided by Sadlick and Penta 22 who observed that students in a 10-week rehabilitation nursing
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course became acutely depressed and pessimistic about the prospect of working with quadriplegic SCI patients. A recent paper (Krishnan et al. 23) showed that inexperienced staff believed that work in an SCI unit engenders a greater degree of involvement and autonomy among the patients, than did the more experienced staff. This suggests that inexperienced staff display more optimism for both the extent to which trauma victims may be rehabilitated and the value of the rehabilitation program itself. This may in part explain the high turnover of experienced staff in most spinal injuries centres. Realistic goal setting has been suggested to be a major factor in job satisfaction (Locke et al. 24)_ Therefore under conditions where expectations of effectiveness are unrealistically high, it may be anticipated that greater experience may lead to disillusionment and lower morale. Staff members may try to accommodate the cognitive dissonance between expected and actual success by modifying their expectations, although the findings of this study argue against such a conclusion. The study in fact showed that it is important to select staff with realistic expectations from the start, which has implications for the selection procedures currently in operation. Furthermore, the ability to alter expectations depends upon continued reappraisal, and for this reason comprehensive in-service training is essential to maintain and expand not only the individuals knowledge base, but also morale. A follow-up study of the effect of system modification on staff-retention and morale was recently published (Glass et ai.2 5) indicating considerable improvements as a consequence of implementing system changes. Related to the issues of staff morale and involvement in care are issues concerned with the ergonomics and physical environment of care. The views of staff working in the Spinal Injuries Centre in Southport, based in old, general-purpose accommodations were compared (Nugent et ai.2 6) with the staff perceptions of a specially constructed Regional Head Injuries Centre and a refurbished General Medical Ward. The spinal injuries personnel were found to be most pessimistic about their work place, and while earlier studies (Krishnan et
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ai.2 3) indicated that the intensive nature of work in spinal injuries may be responsible for lower morale and high staff turnover, the high morale shown by the head injuries staff (controlling for the intensive nature of care) would not support this view. It remains unclear what causal relationship exists between individual, job-related and environmental factors in the development and maintenance of an optimal rehabilitation environment, although the application of functional paradigms provides, at least, a framework within such variables may continue to be examined. The aim of this brief paper has been to outline a number of areas where applied functional analysis leads not only to a more comprehensive understanding of the interaction between physiological and psychological variables, but is of paramount importance in establishing effective treatment options. The success of the suggested theoretical approach requires a clear understanding of the effects of interactions which occur within specified environments, between individual trauma victims, their families, and staff. The major advantages of utilizing such an approach is that all persons involved in rehabilitation have a clearer understanding of their roles, and clearly defined measures of effectiveness.
REFERENCES 1. Buck F. The influence of parental disability on children: an exploratory investigation of the adult children of spinal cord injured fathers. University of Arizona; 1980. Dissertation. 2. Kubler- Ross E. On death and dying. New York: Macmillan; 1969. 3. Lindemann JE. Psychological and behavioral aspects of physical disability. New York: Plenum; 1981. 4. Weller DJ, Miller PM. Emotional reactions of patients, family and staff in acute care period of spinal cord injury. Soc Wk Health Care 1977;3(1):7-17. 5. Stewart TD. Coping behaviour and the moratorium following spinal cord injury. Paraplegia. 1977;15:338-342. 6. Ducharme SH, Freed MM. The role of self destruction in spinal cord injury mortality. SCI Digest. 1980;2(4):29-38. 7. Jackson HF, Glass CA, Hopewell CA, Warberg R, Dewey M, Ghadiali E. The Katz social adjustment scale: modification for use with victims of head and spinal trauma. Brain Injury (In Press)
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8. Slade PD. Towards a functional analysis of anorexia nervosa and bulimia nervosa. J Exp Psych 1982;38:168-172. 9. Owens RG, Ashcroft ,JB. Functional analysis in applied psychology. Brit J Clin Psych 1982;21:181-189. 10. Jackson HF, Glass CA, HopeS. A functional analysis of recidivistic arson. Brit J Clin Psych 1987;26: 175185. 11. Brindley GS. Reflex ejaculation under vibratory stimulation in paraplegic men. Paraplegia 1981; 19:300-303. 12. Glass CA, Fielding DM, Evans CM, Ashcroft JB. Factors related to sexual functioning in male patients undergoing haemodialysis and with kidney transplants. Arch Sex Beh 1988;16:189-207. 13. Tuckman J, Youngman WF. Identifying suicide risk groups among attempted suicides. Pub Health Rep 1963;78:763-766. 14. Gardner BP, Theocleous F, Watt JWH, Krishnan KR. Ventilation or dignified death for patients with high tetraplegia. Brit Med Jour 1985;291:1620-1622. 15. Maynard FM, Muth AS. The choice to end life as a ventilator dependent quadriplegic. Arch Phys Med Rehab 1987;68:862-864. 16. Glass CA. The impact of home based ventilator dependence on family life. Proceedings of the first international conference on domiciliary ventilation 1992, Mersey Spinal Injuries Centre, Southport, England, UK: (In Press). 17. Beck AT, Weissman A, Lester D, Trexler L. The measurement of pessimism: The hopelessness scale. J Consul Clin Psych 1974;42:861-865. 18. Rorer LG, Hoffman PJ, Hsei HK. Utilities as base rate multipliers in the determination of cutting scores. Oregon Res Inst Res Bull 1966. 19. Tucker SJ. The psychology of spinal cord injury: patient staff interaction. Rehab Lit 1980;41(56):114-121. 20. Gunther MS. Psychiatric consultation in a psychiatric hospital: a regression hypothesis. Comp Psychiat 1971;12(6):572-585.
21. Gunther MS. The threatened staff: a psychoanalytic contribution to medical psychology. Comp Psychiat 1977;18(4):385-397. 22. Sadlick M, Penta F. Changing student nurse attitudes towards quadriplegics through the use of television. Chicago, Ill: Univ. Illinois Coll Nurs; 1972. 23. Krishnan KR, Glass CA, Jackson HF, Bingley J. Patient and nursing staff perceptions of living and working on a spinal injuries unit. Paraplegia 1988;26:287 -292. 24. Locke EA, Shaw KN, Sarri LM, Latham GP. Goal setting and task performance: 1969-1980. Psych Bull 1981;90:125-152. 25. Glass CA, Krishnan KR, Bingley JD. Spinal injuries rehabilitation: Do staff and patients agree on what they are talking about? Paraplegia 1991;29:343-349. 26. Nugent 0. An investigation of the relationship between environmental factors and job satisfaction in intensive nursing, with particular reference to spinal trauma. Paraplegia 1992 (In Press).
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ISSN: 0195-2307 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/yscm19
Applying Functional Analysis to Psychological Rehabilitation Following Spinal Cord Injury Clive A. Glass To cite this article: Clive A. Glass (1992) Applying Functional Analysis to Psychological Rehabilitation Following Spinal Cord Injury, The Journal of The American Paraplegia Society, 15:3, 187-193, DOI: 10.1080/01952307.1992.11735872 To link to this article: http://dx.doi.org/10.1080/01952307.1992.11735872
Published online: 02 Jun 2016.
Submit your article to this journal
Article views: 1
View related articles
Citing articles: 2 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=yscm19 Download by: [University of Calgary]
Date: 06 August 2017, At: 09:48
Applying Functional Analysis to Psychological Rehabilitation Following Spinal Cord Injury Clive A. Glass, BSc., M.Ciin.Psych., Ph.D., C.Ciin.Psych. ABSTRACT There have been numerous attempts to categorize the responses of individuals to spinal trauma on the basis of generalized stage theories of grief reaction, and personality theory. A number of these studies are critically appraised and a behavioral model, based on functional analysis, is proposed as a more constructive framework for future research. Such an approach is applied clinically to the activities and development of the Clinical Psychology Service provided to the Mersey Regional Spinal Injuries Centre in Southport, England. A number of examrles of clinical and research practice are included, highlighting the applicability of functional analysis to individual and systems level investigations.
Downloaded by [University of Calgary] at 09:48 06 August 2017
KEY WORDS: spinal injury, functional analysis, psychological intervention
INTRODUCTION
The physiological changes experienced by those who suffer spinal impairments are immense. While the majority of such persons are somewhat fortunate in not having experienced severe cognitive impairment, the corollary of such a situation is that individuals are able to examine and communicate their concerns over future functioning, usually involving close family members. The importance of relatives in such a situation cannot be stressed too highly. Considerable research1 has shown, for example, that children's reactions to parental injury are not related to severity of injury; rather, the parental support. and financial security of the family environment are seen as more important. The maintenance of family structure and open communication are therefore seen as fundamental to the success of the rehabilitation programs undertaken at the Centre. This paper deals with a number of responses to trauma at both the immediate and longer-term stages following disability, and outlines a clinical Address correspondence to: Dr. Clive A. Glass Consultant Clinical Psychologist, Mersey Regional Spinal Injuries Centre, Southport District General Hospital, Town Lane, Southport PR6 6NJ. England, U.K. (An earlier version of this paper appeared in Clinical Psychology Forum, a publication of the Division of Clinical Psychology, The British Psychological Society 1990:26;2-6.)
approach that has not only face validity, but situational reliability. LIMITATIONS OF STAGE THEORY RESPONSE TO TRAUMA
The experience of spinal trauma has been likened in the past (Kubler-Ross 2) to the responses to bereavement, but without the end result. Lindemann,3 reviewing the findings of Weller and Miller, 4 indicates that eventual adaptation to trauma involved the progression through a number of stages: shock, denial, anger, depression, and eventual acceptance. It has been suggested that denial may allow for the gradual acceptance of trauma into consciousness (Stewart5). It may be overt, such that patients refuse support on the basis that they will walk out of the unit, or more subtle. Many spinal cord injury (SCI) patients retain the hope that one day a cure will be found that will enable them to walk again. This view may assume great importance in their development of coping strategies to enable them to adapt to their trauma. Anger may occur at the same time as denial. The development of this feeling is understandable in non-blame situations. It may be tempting on occasion to return this hostility, though such a response would only serve to reinforce the frequency of such outbursts and should be avoided. Depression may result during any of the above stages, and may reflect guilt about the accident, if
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it involved others. The responses outlined above could impede progress through rehabilitation if maintained for long periods. There is, therefore, an understandable urge to want to stop such behaviors as soon as they occur. However, such responses are those which any person in that particular situation would be expected to experience. As such, they are essentially normal responses to an abnormal situation, and should require specialized intervention only if they seriously impede rehabilitation. Furthermore, some patients may not experience these behaviors, or will not experience them in the order presented, and may resent being seen by a psychologist. This is particularly true if the role of psychological intervention is not explained, and the person sees no direct benefits from the involvement. The responses listed above are equally applicable to the relatives of trauma victims who themselves need to begin to adapt to a new set of circumstances. Considerable time is spent during the early stages of an individuals admission, informing relatives of the likely behavioral responses which the injured person may experience. However, while the experiences of anger, depression, and denial are common, particularly during the immediate post-traumatic period, they tend to occur with less clarity and intensity in subsequent months, although in most cases an injured person could not be considered to have adapted to the situation by that time. Furthermore, while there appear to be certain times when patients are more likely to experience difficulties (immediately following admission, when they first start to get out of bed, immediately prior to discharge, and immediately following discharge) these are by no means universal. The applicability of a stage theory to account for behavioral change and adaptation following trauma would therefore appear questionable. While some people will exhibit such changes over time, it must be remembered that individual responses to trauma are essentially unique events, and attempts at broad categorizations of responses can prove inaccurate and problematic. For example, one nurse from another spinal unit, commenting on a specific case, stated that such a person would not be considered ready for discharge because he had not shown any evidence of denial.
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PREDICTING RESPONSES TO TRAUMA Criticisms, similar to those outlined above, can be aimed at studies that have attempted to examine specific personality variables as predictive indicators of the likelihood of an individual to experience trauma, and the effects of personality on successful or unsuccessful adaptation to it. Weller and Miller4 in a study of 30 male and 7 female trauma victims noted: Over half the patients were young, emotionally immature, in the midst of rebelling or self-destructive acting out, with insecure, poor self-image, and low self-esteem; at a peak of physical and sexual activity, with investment in physical prowess far outweighing intellectual interests; with low levels of education and job opportunities; and with troubled families broken through marital discord, death, illness, and other crises. However, the authors give little information on both the selection procedures involved in the investigation and the characteristics of the other 50 percent of the cases studied, and it is the experience in Southport that while a certain number of patients could be considered to show some of these characteristics, the majority do not. It would appear, therefore, that while patients in this group are undeniably a subset of spinal trauma victims, they are not representative of trauma victims as a whole. In a similar study, Ducharme et al. 6 attempted to examine the role of self-destruction as a factor in spinal trauma mortality. They examined the hypothesis that a desire for self-destruction was a significant factor as a cause of death following spinal trauma, and used this to indicate the presence of an underlying character disorder, which predisposed such a person to experience an early death. They argued that a number of deaths resulted from violent accidents, and that for these persons traumatic injury had not been an isolated event, as it had occurred, for example, after a death in the family, or a divorce. As with the earlier Weller and Miller investigation, this study failed to examine the base rate of the incidence of selfdestructive acts as a precursor to establishing significance. Similarly, the reliance on retrospective analysis makes the findings somewhat open to question.
Journal of the American Paraplegia Society
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Downloaded by [University of Calgary] at 09:48 06 August 2017
The major criticisms which can be directed toward studies that have attempted to examine personality variables as predictors of acceptable and unacceptable adaptation, center on their lack of standardization data and their lack of premorbid assessment. It is difficult to assess whether a person's personality following trauma is a direct result of that trauma, or an extension of the pretrauma personality, unless some measure is taken of pre-trauma variables. It may be that certain psychological variables are predictive of successful adaptation but the current research evidence for this proposition is poor. A comprehensive, methodologically rigorous, examination of these issues is being conducted at Southport,7 with data also being provided by Craig Hospital in Colorado. More than 500 standardized questionnaires were completed by the injured persons and their closest relative. The aim of this investigation was to establish a standard technique for assessing adjustment to trauma. The initial findings indicate that the scale is significantly more reliable than any other scale produced to date. Once further examination is complete, it should be possible to provide a stable baseline from which to gauge behavioral change. This is particularly important in resource allocation since it enables those with greatest adaptation difficulties to be most effectively targeted. In summarizing the current literature, it must therefore be concluded that comparisons of a specific individual's behavioral responses to spinal trauma with textbook responses to trauma is essentially meaningless. Once specific problems are highlighted, the only way to examine non-adaptive behaviors objectively and begin to establish adaptation, is to apply a methodologically rigorous approach which takes individual variation into account. Such variation is accounted for in an individual functional analysis. APPLICATION OF FUNCTIONAL ANALYSIS IN SPINAL INJURY SETTINGS Individual Functioning and Difficulties
The essential characteristics of functional analysis have been described (Slade, 8 Owens and Ashcroft9) as have the applications of the theory to specific clinical populations (Jackson, Glass, and HopelO). Such an analysis demands the specification ofvari-
abies, of which any specific behavior shown is a function, and an examination of the relationship between this behavior and such variables. While such analysis sounds complex, it can be broken down into three simple stages. Antecedents are variables that bring about a specific behavior. While it would be trite to say that the spinal trauma has brought about any specific behavior, such as the person being withdrawn or irritable, there will be more specific variables which make certain behaviors more or less likely to occur. These include variables such as frequency of individual activity, whether particular nurses are in attendance, or whether families visit regularly or not. Similarly the consequences of the behavior may serve either to maintain it or reduce the likelihood of it occurring again; while in some cases constant attention to the problem by the psychologist, staff, or relatives may only serve to exacerbate the difficulty, in others it can lead to an adaptive alteration in the behavior. Such interactions can be expanded considerably to include, for example, the interactions between a specified individual and the family and community in which he lives. However, limitations are placed on the analysis to the point at which intervention could be considered to have an effect. The application of such an approach therefore requires comprehensive monitoring and adaptation of the intervention to take account of changes in the individual's circumstances. Within the context of spinal injuries, rehabilitation must be aimed at achieving the optimal level of independence and quality of life for each individual. The individual's role in assigning values to such independence and quality must be paramount, and the application of functional analysis is entirely compatible with such a philosophy. While the design and implementation of such a procedure is somewhat more complex, the explanation above outlines the basic tenets. The following examples are designed to indicate the usefulness of the application of functional analysis to commonly experienced difficulties in clinical practice. Secondary Impotence
Given the increased frequency with which men experience spinal trauma, the biomechanics associated with erection, and the cultural acceptance of male sexual expression, it is perhaps under-
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standable that they seek help with sexual difficulties more readily than women. Psychogenic erections, or those resulting from thoughts and feelings, are reported to occur less frequently following spinal trauma. Brindley 11 noted that those with complete lesions below T9 should be able to experience some degree of psychogenic erection, while those with lesions at TS cannot be discounted. The development of secondary impotence in otherwise physiologically potent males is a common phenomenon in a number of trauma groups (Glass 12). The following example highlights the development of such a difficulty in a man following spinal trauma. A 34-year-old man with a wedge fracture at TlO but no neurological damage was admitted for rehabilitation. He began to complain of sexual difficulties with his partner three months after discharge. Full vascular, hormonal, and neurological examination revealed no evidence of impairment. Interviews with the clinical psychologist led to the production of the functional analysis illustrated in Figure 1 which shows four major issues related to the maintenance of the central difficulty, involving both partners perceptions of sexual activity and sexuality. In this particular case therapy was based on utilizing the patient's awareness of medical usefulness by using the results of the physiological assessments of his potency in conjunction with his nocturnal tumescence results. His ability to achieve erections when alone was used in conjunction with home monitoring of erection levels to provide biofeedback and further reassurance of his erectile abilities. Following this section of treatment, the issues surrounding his partner's experiences of sexuality were explored. Attempts were made to increase her arousal using non-penetrative sexual activities and by gradual extension of foreplay. This had the effect of not only reducing her anxieties about further conception but reduced the patient's anxieties about sexual performance. Increased experimentation over time led to increased enjoyment for both partners and a gradual return to normal sexual functioning. The entire intervention required twelve sessions over a five-month period.
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Spinal injury
.1. Initial impotence
.1. Increased anxiety about failure
t
.1.
Continued impotence
Erect in
Religious views on sex
Fig 1. Factors associated with the development and maintenance of a case of secondary impotence following spinal trauma. Suicide The occurrence of deaths by events other than natural causes were noted earlier. In Southport, six persons have tragically ended their own lives in the past seven years. There are a number of reasons why trauma victims might want to end their lives, and evidence from investigations in other areas (Tuckman and Youngman 13) shows that suicide occurs in most groups suffering physicalloss. It is important also to note that most completed suicides are by paraplegics, though it may be intuitively expected that quadriplegics would be most likely to take their own lives, given their greater degree of loss. Research data is unable to show, however, how many quadriplegics would commit suicide if they were able to do so. There is some evidence to support the notion of decreased coping ability correlated with increasingly higher lesion level (Gardner et al.l 4 ; Maynard and Muth 15), although more recent information presented at the First International Conference on Domiciliary Ventilation held in Southport begins to question this hypothesis, at least in the latter group of individuals (Glass 16).
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A further investigation conducted in Southport involved the retrospective analysis of cases where patients had taken their own lives, with data obtained using a structured interview completed during contacts with surviving relatives. While the trauma itself was seen as the major precipitating factor, other issues such as social isolation, feelings of hopelessness, and lack of awareness of rehabilitative options were also raised. Perceived hopelessness is seen by many researchers (Becket aL1 7) as a more comprehensive indicator of suicidal intent than, for example, assessment of depression. Upon admission to the Centre, all patients participate in a comprehensive analysis of both their perceptions of their disability and their perceptions of future activity. This is constantly followed-up during their stay at the Centre with particular emphasis placed on positive adaptation. Those who experience continual difficulties in adaptation are noted and provided with comprehensive support and follow-up once they return to the community. It is expected that such comprehensive analysis will enable the directing of resources to those who exhibit problems in adaptation. Given the relatively low frequency with which people commit suicide, analysis of the data will require the use of Bayes' theorem (Rorer et al. 18), rather than more traditional statistical analysis. However, effectiveness of intervention with a further specific difficulty is more amenable to analysis of change. Pressure Sores One of the most frequent causes of readmission following initial post-trauma hospitalization is the development of pressure sores. Patients are taught methods of regular skin examination before they learn to use their wheelchairs. While quadraplegics have less control over the development of sores, paraplegics should rarely experience such difficulties. From an examination of the situations that have brought about sores in paraplegics, a number appear to have arisen due to poor self-care. In each of these cases, functional assessment is based on the situation occurring immediately before the sore developed, and an examination made of the consequences of such an incident. Frequently, persons experienced difficulties with their partners, or were generally finding life at home
intolerable. Admission to the Centre often leads to an improvement in the family situation by taking away a primary source of stress, and gives the individual an improvement in social interaction through contact with staff and other people with some understanding of their requirements, as well as direct access to occupational and physiotherapy support. The development of pressure sores can, therefore, be seen in some cases as either a reaction to deterioration in psychosocial or environmental conditions, or a somewhat extreme method of gaining some degree of positive respite. In such cases, during the treatment of the sore, the patient is involved in a comprehensive examination of the factors that have lead to the development and maintenance of the difficulty, and a strategy is developed to reduce the likelihood of the related behavioral responses recurring following discharge. This may involve the arrangement of regular respite, closer coordination with community services, or further involvement with psychological services. It is a policy of the Centre that an open door to treatment prevails, encouraging individuals to contact the Centre for assistance whenever required. This service extends to the provision of a comprehensive community support program whereby individuals are routinely followed-up in their own homes after discharge. Systems Level Applications As noted earlier, spinal trauma not only affects the patients, but their relatives and friends. However, there is a third group of people whose lives are affected by the trauma, the staff within the centres. Functional analysis can therefore be applied not only at the level of the individual but also at a systems level. A review of the literature by Tucker 19 emphasized that emotional adjustment of both patient and staff is essential for successful rehabilitation. Gunther20 ·21 studied experiences of staff working with SCI and other severe injuries over a 20-year period and concluded that staff members working with SCI patients were often severely affected and disturbed by their experiences to a greater extent than those working with less severely ill patients. Further evidence was provided by Sadlick and Penta 22 who observed that students in a 10-week rehabilitation nursing
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course became acutely depressed and pessimistic about the prospect of working with quadriplegic SCI patients. A recent paper (Krishnan et al. 23) showed that inexperienced staff believed that work in an SCI unit engenders a greater degree of involvement and autonomy among the patients, than did the more experienced staff. This suggests that inexperienced staff display more optimism for both the extent to which trauma victims may be rehabilitated and the value of the rehabilitation program itself. This may in part explain the high turnover of experienced staff in most spinal injuries centres. Realistic goal setting has been suggested to be a major factor in job satisfaction (Locke et al. 24)_ Therefore under conditions where expectations of effectiveness are unrealistically high, it may be anticipated that greater experience may lead to disillusionment and lower morale. Staff members may try to accommodate the cognitive dissonance between expected and actual success by modifying their expectations, although the findings of this study argue against such a conclusion. The study in fact showed that it is important to select staff with realistic expectations from the start, which has implications for the selection procedures currently in operation. Furthermore, the ability to alter expectations depends upon continued reappraisal, and for this reason comprehensive in-service training is essential to maintain and expand not only the individuals knowledge base, but also morale. A follow-up study of the effect of system modification on staff-retention and morale was recently published (Glass et ai.2 5) indicating considerable improvements as a consequence of implementing system changes. Related to the issues of staff morale and involvement in care are issues concerned with the ergonomics and physical environment of care. The views of staff working in the Spinal Injuries Centre in Southport, based in old, general-purpose accommodations were compared (Nugent et ai.2 6) with the staff perceptions of a specially constructed Regional Head Injuries Centre and a refurbished General Medical Ward. The spinal injuries personnel were found to be most pessimistic about their work place, and while earlier studies (Krishnan et
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ai.2 3) indicated that the intensive nature of work in spinal injuries may be responsible for lower morale and high staff turnover, the high morale shown by the head injuries staff (controlling for the intensive nature of care) would not support this view. It remains unclear what causal relationship exists between individual, job-related and environmental factors in the development and maintenance of an optimal rehabilitation environment, although the application of functional paradigms provides, at least, a framework within such variables may continue to be examined. The aim of this brief paper has been to outline a number of areas where applied functional analysis leads not only to a more comprehensive understanding of the interaction between physiological and psychological variables, but is of paramount importance in establishing effective treatment options. The success of the suggested theoretical approach requires a clear understanding of the effects of interactions which occur within specified environments, between individual trauma victims, their families, and staff. The major advantages of utilizing such an approach is that all persons involved in rehabilitation have a clearer understanding of their roles, and clearly defined measures of effectiveness.
REFERENCES 1. Buck F. The influence of parental disability on children: an exploratory investigation of the adult children of spinal cord injured fathers. University of Arizona; 1980. Dissertation. 2. Kubler- Ross E. On death and dying. New York: Macmillan; 1969. 3. Lindemann JE. Psychological and behavioral aspects of physical disability. New York: Plenum; 1981. 4. Weller DJ, Miller PM. Emotional reactions of patients, family and staff in acute care period of spinal cord injury. Soc Wk Health Care 1977;3(1):7-17. 5. Stewart TD. Coping behaviour and the moratorium following spinal cord injury. Paraplegia. 1977;15:338-342. 6. Ducharme SH, Freed MM. The role of self destruction in spinal cord injury mortality. SCI Digest. 1980;2(4):29-38. 7. Jackson HF, Glass CA, Hopewell CA, Warberg R, Dewey M, Ghadiali E. The Katz social adjustment scale: modification for use with victims of head and spinal trauma. Brain Injury (In Press)
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8. Slade PD. Towards a functional analysis of anorexia nervosa and bulimia nervosa. J Exp Psych 1982;38:168-172. 9. Owens RG, Ashcroft ,JB. Functional analysis in applied psychology. Brit J Clin Psych 1982;21:181-189. 10. Jackson HF, Glass CA, HopeS. A functional analysis of recidivistic arson. Brit J Clin Psych 1987;26: 175185. 11. Brindley GS. Reflex ejaculation under vibratory stimulation in paraplegic men. Paraplegia 1981; 19:300-303. 12. Glass CA, Fielding DM, Evans CM, Ashcroft JB. Factors related to sexual functioning in male patients undergoing haemodialysis and with kidney transplants. Arch Sex Beh 1988;16:189-207. 13. Tuckman J, Youngman WF. Identifying suicide risk groups among attempted suicides. Pub Health Rep 1963;78:763-766. 14. Gardner BP, Theocleous F, Watt JWH, Krishnan KR. Ventilation or dignified death for patients with high tetraplegia. Brit Med Jour 1985;291:1620-1622. 15. Maynard FM, Muth AS. The choice to end life as a ventilator dependent quadriplegic. Arch Phys Med Rehab 1987;68:862-864. 16. Glass CA. The impact of home based ventilator dependence on family life. Proceedings of the first international conference on domiciliary ventilation 1992, Mersey Spinal Injuries Centre, Southport, England, UK: (In Press). 17. Beck AT, Weissman A, Lester D, Trexler L. The measurement of pessimism: The hopelessness scale. J Consul Clin Psych 1974;42:861-865. 18. Rorer LG, Hoffman PJ, Hsei HK. Utilities as base rate multipliers in the determination of cutting scores. Oregon Res Inst Res Bull 1966. 19. Tucker SJ. The psychology of spinal cord injury: patient staff interaction. Rehab Lit 1980;41(56):114-121. 20. Gunther MS. Psychiatric consultation in a psychiatric hospital: a regression hypothesis. Comp Psychiat 1971;12(6):572-585.
21. Gunther MS. The threatened staff: a psychoanalytic contribution to medical psychology. Comp Psychiat 1977;18(4):385-397. 22. Sadlick M, Penta F. Changing student nurse attitudes towards quadriplegics through the use of television. Chicago, Ill: Univ. Illinois Coll Nurs; 1972. 23. Krishnan KR, Glass CA, Jackson HF, Bingley J. Patient and nursing staff perceptions of living and working on a spinal injuries unit. Paraplegia 1988;26:287 -292. 24. Locke EA, Shaw KN, Sarri LM, Latham GP. Goal setting and task performance: 1969-1980. Psych Bull 1981;90:125-152. 25. Glass CA, Krishnan KR, Bingley JD. Spinal injuries rehabilitation: Do staff and patients agree on what they are talking about? Paraplegia 1991;29:343-349. 26. Nugent 0. An investigation of the relationship between environmental factors and job satisfaction in intensive nursing, with particular reference to spinal trauma. Paraplegia 1992 (In Press).
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