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Psychosomatics 41:235-244, June 2000
© 2000 The Academy of Psychosomatic Medicine

Multidimensional Investigation of the Structure of Coping Among People with Amputations

Hanoch Livneh, Ph.D., Richard F. Antonak, Ed.D., and John Gerhardt, M.D.

Received April 19, 1999; revised August 30, 1999; accepted September 15, 1999. From the Rehabilitation Counseling Program, Department of Special and Counselor Education, Portland State University, Portland, Oregon; the School of Education, Indiana State University, Terre Haute, Indiana; and Orthopedic and Rehabilitation Medicine, Oregon Health Sciences University, Portland, Oregon. Address reprint requests to Dr. Livneh, Department of Special and Counseling Education, Portland State University, P.O. Box 751, Portland, OR 97207.


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
In this study, the responses of 61 people with amputations to a measure of coping strategies were submitted to multidimensional scaling and cluster analysis. Interpretations of the three-dimensional solution, aided by the emergence of five coping clusters, suggested that respondents' perceptions of their coping with amputation-related stress were best explained by the following three dimensions: 1) active/confrontive versus passive/avoidance coping; 2) pessimistic/fatalistic versus optimistic/positivistic coping; and 3) social/emotional versus cognitive coping.

Key Words: Amputation • Coping • Psychosocial Adaptation

  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
The investigation of psychosocial adaptation to the traumatic loss of body functioning and body parts (e.g., amputation) has generated a plethora of clinical and empirical studies.1–4 Much of the literature to date that focuses on traumatic loss can be broadly viewed as falling into one of three categories: 1) clinical accounts of psychosocial reactions, experiences, and assumed phases of adaptation; 2) descriptive empirical studies that report the prevalence of certain psychosocial reactions and experiences (e.g., levels of depression or anger) among those with bodily losses; and 3) correlational and predictive investigations of the relationship between a host of sociodemographic, experiential, personality, environmental, and disability-related variables and selected psychosocial indices of adaptation to the traumatic loss.

Clinical accounts typically include discussions where traumatic loss of a limb is equated with loss of one's perception of wholeness,5 loss of a spouse,6,7 symbolic castration, and even death.8,9 Also included in this category are efforts to delineate a temporal sequencing of psychosocial phases of adaptation to the traumatic loss.1,10,11 The second group of studies, which are descriptive reports of the prevalence of common psychosocial reactions among people who sustained loss of body parts, generally provides empirical data on the frequency of emotional distress, neuroticism, depression, anxiety, and denial. Although inconsistent, research findings to date suggest the existence of higher prevalence of anxiety and depression among people with amputation compared with the general population.12–14 Finally, a growing body of empirical research has accumulated in recent years concerning the predictive power of an individual's sociodemographic characteristics (e.g., present age, age at time of amputation, marital status), disability-related variables (e.g., time since injury, degree of functional involvement), experiential and psychological variables (e.g., social discomfort, coping modes), and environmental context (e.g., perceived and actual social support) in the investigation of psychosocial adaptation to amputation.1,15–19

A theme shared by research efforts in the three categories is recognizing the cardinal role played by the individual's coping strategies during the process of psychosocial adaptation to amputation and determining its outcome. Defense mechanisms and coping strategies have been recognized as influencing one's body image and self-concept as well as contributing to the nature and temporal sequencing of the adaptation process to loss and disability.20–22 Similarly, these variables have been implicated as mediating the outcome of psychosocial adaptation to physical and personal loss. For example, maladaptive coping strategies may lead to deleterious effects such as emotional distress, whereas adaptive strategies may support salutary effects such as successful resolution of loss.21,23,24

More recently, data have been reported on the specific role played by coping in mediating psychosocial adaptation to amputation.3,25,26 In their study of people with amputations who experienced phantom limb pain, Hill and colleagues26 adopted the Coping Strategies Questionnaire (CSQ) as a measure of coping with pain and the Sickness Impact Profile (SIP) as a measure of physical and psychosocial adaptation. Hill and colleagues reported the following: 1) the coping factor of helplessness accounted for a significant proportion of the variance in both physical and psychosocial adaptation to amputation; 2) the specific coping strategy of catastrophizing explained the largest proportion of variance in both physical and psychosocial dysfunction, followed by that of behavioral activity and hoping/praying; and 3) the reinterpretation of pain sensations was positively linked to psychosocial dysfunction.

Dunn25 sought to examine the effects of three generalized coping strategies on two indices of psychosocial well-being—depression and self-esteem—among people with amputations: finding positive meaning following amputation, adopting an optimistic outlook, and perceiving control over amputation. Dunn's findings indicated that, in general, discerning positive meaning in one's amputation, being more optimistic, and perceiving more control over the resultant disabling condition were associated with lower levels of depressive symptomatology (as measured by the CES-Depression Scale) and a higher degree of self-esteem (as measured by the Rosenberg Self-Esteem Scale). Finally, Livneh and Antonak3 found that active problem solving (as measured by the abbreviated COPE Inventory) may be inversely related to depression and internalized anger [as measured by the Reactions to Impairment and Disability Inventory (RIDI)] but positively related to adjustment (as measured by the RIDI) and acceptance of disability [as measured by the Acceptance of Disability Scale (AD)]. Emotion-focusing and cognitive disengagement, in contrast, were positively linked to anxiety, depression, and externalized hostility (RIDI), and negatively to acceptance of disability (AD).

Despite the growing interest in the role played by coping efforts during the process of adaptation to loss and disability, the extant literature strongly suggests disagreements among researchers, theoreticians, and clinicians as to the nature, function, classification, and measurement of coping.3,27 Coping has been differentially conceived in several ways: 1) both a personality (i.e., intrapsychic) trait or style and a situationally determined response; 2) a dynamic process as well as a static construct; 3) a mature, adaptive, and flexible strategy (coping) but also a neurotic, maladaptive, and rigid reaction (defense mechanism); and 4) a global, generally dichotomous concept (emotion-focused versus problem-focused, passive versus active), but also an intricate, hierarchically structured, multilevel concept (global coping styles, intermediate coping strategies, specific coping acts).28–33 Although such disagreements on the nature and function of coping are also prevalent in the literature on coping with physical loss and disability,21,24,34 more conspicuous is the absence of research that seeks to examine the dimensional structure of coping among people with disabilities. The available research relies heavily on preexisting, general population-based, factor-analytic-derived scales with little attention paid to the dimensional properties inherent in the structure of coping derived directly from people with disabilities. To this end, the purpose of this study is to provide initial empirical data on the dimensional structure of coping with disability-related stress among adults with amputations. It is anticipated that, when asked to indicate their typical modes of coping with amputation-related stressful situations, respondents would reveal coping modes that could be collapsed into an interpretable multidimensional space, thus providing an initial database on the transcontextual structure of their coping efforts.


  METHOD

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
RESULTS
 DISCUSSION
 REFERENCES
 
Participants
The sample consisted of 61 members of the Outreach Amputee Support Education Services (OASES) of Oregon. Participants were mainly white (n=59; 97%) men (n=36; 59%) age 15 to 84 [mean 54.6±16.9(SD) years]. Marital status of participants included married (58%), divorced (20%), single (18%), and widowed (4%). Years of formal education ranged from 8 to 18 (12.05±3.1 years).

Participants reported various types of amputation and these included single lower extremity (69%), single upper extremity (13%), double lower extremities (8%), double upper extremities (1.5%), and a combined single lower and upper extremities (3.5%). The remaining 5% were unspecified. Causes of amputation were described as attributed to illness (e.g., diabetes) (44.5%), accidents (42.5%), and birth disorders (10%). The remaining 3% were unspecified. Approximately 70% of the participants were prosthesis users. Age at onset of amputation ranged from birth to 78 years (37.4±21.8 years; median=38.5 years). Duration of amputation, at the time of the study, ranged from 2 months to 64 years (15.8±16.1 years; median=11 years).

Measures
As part of a larger study, participants responded to a measure of coping modes and to a questionnaire requesting sociodemographic and disability-related information. For the purpose of this study, coping was measured with an abbreviated version of the COPE Inventory.28 The original COPE Inventory consists of 14 scales, each addressing a unique mode of coping. Thirteen of the 14 scales are measured by 4 items and the remaining scale (Alcohol and Drug Disengagement) consists of a single item. Respondents are instructed to indicate how they generally feel and what they generally do when experiencing a stressful event. For the purposes of this study, we requested that respondents indicate how they deal with stress that is related to their amputation.

Items are endorsed on a 4-point scale, ranging from 1 ("I usually do not do this at all") to 4 ("I usually do this a lot"). The items/responses are then summed up separately for each scale to yield 14 separate coping scores. Carver et al.28 have reported test-retest reliability coefficients for the 14 scales over a period of 2 months ranging from 0.42 to 0.89, with a median coefficient of 0.63. Internal reliability estimates (Cronbach's alpha) ranged from 0.45 to 0.92, with a median coefficient of 0.71. Interscale correlations among the 14 scales ranged from -0.28 to 0.69. The authors also reported COPE Inventory correlations with a number of personality measures (e.g., optimism, self-esteem, anxiety, social desirability) that lend support to its convergent and discriminant validities.

For the purpose of this study, an abbreviated version of the COPE Inventory was used. Carver et al.35 reduced the number of items to three per scale and successfully measured coping among women with early-stage breast cancer. Internal reliabilities for 10 of the 13 three-item scales proved adequate (alphas ranging from 0.65 to 0.90). Because of the exploratory nature of the present study and after careful reviews of the existing literature on coping and the 10 currently available coping measures, we decided to include additional items to reflect coping strategies not directly addressed by the COPE Inventory. To that end, items from the Tobin et al.33 Coping Strategies Inventory (CSI) were added to provide a broader perspective on the structure of coping. In its final format, the coping measure used in this study included the following: 1) Carver et al.'s35 abbreviated COPE Inventory (39 items tapping the following 13 coping scales—Active Coping, Planning, Suppression of Competing Activities, Restraint, Seeking Social Support—Instrumental, Seeking Social Support—Emotional, Positive Reframing, Acceptance, Religion, Venting Emotions, Denial, Behavioral Disengagement, and Mental Disengagement); 2) Carver et al.'s28 original 1-item scale (Alcohol and Drug Disengagement), here split into 2 items addressing alcohol and drug use separately; and 3) 3 additional scales, each measured by 2 or 3 items from Tobin et al.'s33 CSI, reflecting Wishful Thinking, Self-Criticism, and Social Withdrawal.

Procedure
Members of OASES (n=200) were mailed the study's instrument packet that included a brief personal questionnaire, the composite measure of coping strategies, and two measures of acceptance and adaptation to disability (these two instruments are not the focus of the present study). Each packet included a cover letter describing the intent of the study, which emphasized the voluntary nature of participation in the study and assured participants of complete response anonymity. Of the 200 mailed packets, 64 were returned (32% return rate) and of these, 61 contained usable data that served as a subsequent basis for all our statistical analyses.

Statistical Analyses
In accordance with the primary goal of this descriptive study, data obtained from the abbreviated COPE Inventory and the three selected CSI scales were submitted to a multidimensional scaling (MDS) analysis. Unlike metric factor analysis, which is typically limited to analysis of correlation coefficient matrices, nonmetric MDS offers more flexibility and can be applied to a wider range of proximity data sets.36 The following are among the most commonly cited advantages of MDS: 1) MDS provides a more parsimonious representation of a data set structure;37 2) MDS is readily interpretable because the MDS notion of interpoint distances is easier to conceive than the factor analysis notion of intervector angles;38 3) MDS does not assume linear relationships among variables yielding solutions of lower dimensionality compared with factor analysis;38 and 4) MDS enables the researcher to represent respondents' reactions and perceptions spatially, therefore deepening the insight into their cognitive-perceptual systems.39

To further illustrate the spatial mapping (i.e., dimensional structure) afforded by the MDS solution, it has been suggested that combining this solution with a cluster analytic (CA) grouping of the variables (i.e., a qualitative categorical structure) aids in interpreting the obtained results.36,40 For this reason, both the MDS (i.e., ALSCAL) and CA analyses (i.e., Average Link and Ward's hierarchical clustering) procedures were performed using the SPSS for Windows program.41


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
DISCUSSION
 REFERENCES
 
Before conducting the MDS and CA analyses, the internal reliability (Cronbach's alpha) of each of the 17 coping strategy scales was assessed. It should be recalled that 13 of the coping scales were measured with 3 items (abbreviated COPE Inventory) while the remaining 4 scales (Drug and Alcohol Disengagement, Wishful Thinking, Self-Criticism, and Social Withdrawal) comprised 2, 3, 2, and 2 items, respectively. Considering the small number of items depicting each coping scale, the majority of scales demonstrated acceptable reliability coefficients. Alpha coefficients for 14 of the scales ranged from 0.50 to 0.89, with a median coefficient of 0.67. The remaining three scales yielded lower internal reliability estimates (0.41, 0.37, 0.37 for the Restraint, Denial, and Behavioral Disengagement scales, respectively).

MDS analyses were, first, conducted on both the entire sample of participants (n=61) and a reduced sample of those participants with a single lower extremity (n=42). The results of these analyses (and of the cluster analyses, see following pages) were virtually identical. To increase sample size and improve dimensional and cluster stabilities, we decided to retain the original sample for purposes of statistical analyses. Results reported are, therefore, based on data obtained from the entire sample (n=61).

MDS analyses were performed on the following: 1) the full set of 17 coping scales; 2) the full set of 17 coping scales but including only the highest correlated 2 items for each of the 3 poorly defined scales; and 3) a reduced set of 14 scales (eliminating the 3 poorly defined scales). The resultant MDS solutions yielded only minor structural deviations between the 2 sets of 17 coping scales (full and truncated range of items). Deleting the 3 poorly defined scales also revealed only modest changes in the MDS solution. Therefore, because this was an exploratory study of the structure of coping among people with amputations, we felt it was appropriate to focus on the results obtained from the more comprehensive set of analyses, namely, the MDS solution obtained from the inclusion of the original 17 coping scales.

Two- through six-dimensional solutions for the set of 17 coping scales were explored. Based on Kruskal and Wish's42 stress value and a judgment of the meaningfulness of these solutions, a three-dimensional MDS solution was selected for interpretation. The three-dimensional solution yielded a stress value of 0.04 and R2 of 0.99. Table 1 illustrates this three-dimensional solution and includes the coordinates of each of the coping strategies as anchored in these three dimensions.


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TABLE 1. Three-dimensional multidimensional scaling solution (MDS) and cluster membership of coping strategies



The first derived MDS dimension contrasts active or confrontive with passive or escapist/avoiding coping. The scales of Active Coping, Planning, Positive Reframing, and Acceptance, on the positively scored pole, are contrasted with Alcohol and Drug Disengagement, Self-Criticism, and Social Withdrawal, on the negatively scored pole. Alternatively, the former pole suggests traditionally regarded adaptive coping efforts, whereas the latter points to those efforts considered maladaptive.33,43,44 The second dimension contrasts to a lesser extent (i.e., smaller absolute negative coordinate values and fewer coping scales) Religion with Mental Disengagement (Planning and Social Support—Instrumental, also clustered on the latter pole). This dimension suggests two interpretations for the two poles: 1) optimistic or positivistic (hope and comfort stemming from religious convictions) versus pessimistic or fatalistic (trying to take one's mind off things, going to movies, watching TV, and daydreaming to think less about problems, all inherent in mental disengagement) coping strategies; and 2) abstract (i.e., religion) versus concrete (i.e., simple substitute activities, making action plans, getting direct advice from others) coping strategies.

The third and final dimension, also revealing only moderate differentiation of coping modes along its axis, contrasts Social Support for Emotional Reasons and Venting of Emotions with Acceptance and, to a lesser degree, Denial. The former pole conveys social-affective coping modes while the latter reflects cognitive ones. This continuum can also be interpreted as marked by external-oriented (i.e., social- or people-oriented) versus internal-oriented (i.e., personal- or self-oriented) coping.

The cluster analysis of the same data set was adopted to facilitate the interpretation of the MDS solution. A 5-cluster solution was deemed most meaningful after exploring 2- to 6-cluster solutions. The reasoning behind the choice of a 5-cluster solution was as follows: 1) it was the most psychologically interpretable solution (i.e., it was consistent with most theoretical models on the structure of coping), and 2) it allowed for sufficient differentiation among clusters without being overly dissected. Because of the relatively small sample size, a cross-validation by randomly assigning participants into two halves was deemed psychometrically inappropriate. The application of two distinct cluster analyses (average-link or between-groups, and Ward's method) resulted in an identical structure, thus lending additional support for the 5-cluster solution.

The 5 clusters and the coping scales making up each cluster are depicted in the fourth column of Table 1. Cluster 1 consists of 5 scales (Social Withdrawal, Self-Criticism, Alcohol and Drug Disengagement, Behavioral Disengagement, and Denial) and clearly reflects maladaptive or global disengagement coping efforts. Cluster 2 includes a single scale, Religion. Cluster 3 contains 2 scales, Seeking Social Support–for both Instrumental and Emotional Reasons. Cluster 4 comprises five scales (Wishful Thinking, Venting Emotions, Mental Disengagement, Restraint, and Suppression of Competing Activities). It suggests a cluster of indirect (or passive) coping efforts where the individual attempts to avoid, rather than confront, the impact of the stressful event by seeking cognitive and affective outlets or by subterfuge. The fifth and final cluster, depicted by 4 coping scales (Acceptance, Positive Reframing, Planning, and Active Coping) reflects positive, direct, or engagement-like coping efforts with the possible exception of Acceptance, which signifies a more passive yet realistic perception (e.g.,"I learn to live with it").

Clusters 1 and 5 occupy the opposing poles of the first MDS-generated dimension with most scales representing Cluster 3 and Cluster 4 occupying intermediate positions. This dimension strongly suggests a contrast between accepting the eventuality of the loss while making direct and active plans to cope with it, and resorting to behavioral (i.e., using drugs, socially withdrawing) or cognitive (i.e., criticizing oneself) efforts of disengaging its impact. The second dimension is less clearly defined and contrasts Cluster 2 (Religion) on the positive pole with Cluster 5 (only slightly positioned toward the negative pole of this axis) and a single coping scale of Cluster 4 (Mental Disengagement). This dimension, therefore, appears to represent one of hope, optimism, or spirituality versus realism, concreteness, and even shades of fatalism. The third and final dimension, also not sharply demarcated by cluster homogeneity, contrasts Cluster 3 (Social Support) and the single scale of Venting Emotions (in Cluster 4) on the positive pole with Clusters 1 and 5 (both only slightly positioned toward the negative pole of this axis). This dimension, therefore, suggests affective/social coping (i.e., seeking social support, focusing on emotions) versus cognitive coping (i.e., accepting an unchanged reality, denial of occurrence) orientation, but it also suggests an externally oriented versus internally oriented approach to coping with the impact of the loss.


  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
REFERENCES
 
This study sought to explore the dimensional structure of coping with stressful situations among people with amputations. The results from the multidimensional scaling suggest that three dimensions of coping most cogently explain the variance in the responses obtained from the present sample of respondents. The three dimensions appear to reflect the following: 1) active/confrontive versus passive/avoiding or adaptive versus maladaptive coping modes; 2) optimistic/positivistic versus pessimistic/fatalistic or possibly abstract versus concrete forms of coping; and 3) social/emotional versus cognitive or externally oriented versus internally oriented coping strategies.

The first dimension strongly resembles the first facet of coping with life stresses argued in the model proposed by Billings and Moos.52,53 Their coping facet contrasts cognitive and behavioral active coping with avoidance. Similarly, the first dimension reflects the highest level (i.e., tertiary) in Tobin et al.'s33 model that classifies coping efforts into engagement versus disengagement. The first dimension is consistent with Krohne's45 model that distinguishes between approach and avoidance strategies at the higher-order level. In an earlier study of Australian university students without disabilities, Westbrook46 also reported a Confrontation versus Avoidance dimension. As in the present study, the positive pole was marked by coping modes that indicated direct plan- and action-taking efforts, mastery, and in general, an adaptive-instrumental coping with encountered problems. In contrast, the opposite pole reflected avoiding, escaping, or disengaging oneself from confronting the problem.

Attempts to classify coping strategies obtained from responses of people who sustained personal losses and severe traumas or those with disabilities are scarce. Mikulincer and Florian,24 for instance, have proposed a model of coping with trauma and loss. They argue that four higher-order categories best explain these coping efforts and include the following: 1) problem-focused strategies (cognitive and behavioral responses to eliminate external sources of stress); 2) reappraisal (positive reinterpretation of external events and partial denial of negative aspects of reality); 3) reorganization (accommodation of existing intrapsychic steps, such as acceptance to reality constraints); and 4) avoidance (cognitive efforts to prevent threatening thoughts, and behavioral attempts to disengage from the stressful situation). On the basis of an extensive review of the coping literature regarding trauma, bereavement, and chronic physical conditions, these authors concluded that the use of problem solving, reappraisal, and reorganization (which demonstrate striking resemblance to the positive pole found in the present study) is associated with more effective or successful adaptation to life stresses and challenges. On the other hand, relying more heavily on avoidance was linked to less beneficial (more ineffective) adaptation to consequences triggered by these conditions. Empirical investigations of the role played by direct, active, problem-focused coping strategies in fostering successful psychological adaptation to life-threatening chronic illnesses (e.g., cancer, heart condition) and disabilities (e.g., spinal cord injury), indeed, strongly suggest their beneficial effects.47–49

The second dimension, as previously argued, reflects both positivism/optimism versus fatalism/pessimism and abstract/spiritual versus concrete/substantive modes of coping. The former pole reflects turning to God and religion (i.e., finding spiritual comfort) when encountering a stressful situation. Coping modes placed at the latter pole, in contrast, focus on disengaging or substituting activities (e.g., activities used to take one's mind off the stressful situation, watching movies and TV) and also focus on instrumental efforts to actively engage the situation (e.g., making plans of action, seeking social support for instrumental reasons). This dimension appears to combine two of Westbrook's46 dimensions: optimism versus realism (e.g., hoping for a better future versus attempting to deal with the problem) and fatalism/pessimism versus positive orientation (e.g., expecting the worse, anticipating problems versus seeking cheerful company, reducing tension).

It is also noteworthy that embedded in this dimension may be the notion of temporal sequencing of the adopted coping modes. It could possibly be argued that immediately after a crisis or stressful situation (e.g., amputation), some individuals resort to hope and even unrealistic solutions to their problems, thus, optimistically anticipating a better future. As time passes, however, and the problem has not been successfully resolved, the person may be compelled to seek more realistic or concrete solutions to the problem or even resort to a more pessimistic outlook. A time-reversed argument is equally plausible. Some people might first attempt to actively confront the source of their problems via planning and directly seeking to defuse its impact. However, with the passage of time and with the problem still looming large, they may lose hope and develop a fatalistic outlook. Similar notions could be found in Aldwin and Ravenson,50 Folkman and Lazarus,51 and Heim et al.,48 who argue that when coping strategies are both problem-focused (i.e., instrumental) and perceived to be successful, reduction of stressful symptoms follow. When these strategies are not perceived as efficacious, however, respondents resort to other, often more emotion-focused strategies to minimize the impact of prolonged stress.

The third and final dimension was marked by its contrast of social/emotional and cognitive modes of coping, or alternatively by externally oriented and internally oriented coping. The former pole reflected the following efforts: 1) seeking social support (Cluster 3) for both emotional (e.g., sharing feelings with others) and instrumental (e.g., asking others for advice) reasons, and 2) venting emotions (e.g., letting feelings out when becoming emotionally distressed). In contrast, the opposing pole focused on accepting or denying the eventuality of the condition. These cognitive processes, in themselves, suggest a continuum marked by passive acceptance versus denial of the disabling condition; however, they fall short of indicating specific instrumental or active efforts to confront directly the stressful situation. As suggested, this dimension can also be interpreted as externally versus internally oriented coping. Seeking social support and releasing one's emotions require the presence of others. Accepting or denying the existence of the disabling condition, or its permanency, is typically a personal choice, conscious or otherwise, made by the individual and, therefore, may be regarded as internally oriented. A distinction between cognitive and social/emotional modes of coping is consistent with the extant coping literature. Billings and Moos,52,53 for instance, in their tripartite coping model recognized cognitive appraisal and emotional modes of coping as two of three higher-order coping classes (the third being behavioral- or problem-focused). Westbrook46 identified a coping dimension that she termed Seeking versus Not Seeking Interpersonal Help. The former pole was marked by getting involved with others for the purpose of seeking help and comfort, whereas the latter was seen as relying largely upon oneself to defuse worries about the future.

The findings of this study suggest two conclusions. First, consistent with most views on the structure of coping,30,33,45,52–54 coping may indeed be conceptualized as hierarchical in nature. At the highest level, coping reflects those generalized coping styles, dispositions, or intentions such as approach versus avoidance, monitoring versus blunting, repression versus sensitization, problem-focused versus emotion-focused, and coping versus succumbing, all previously identified in the coping literature.30,45,54–60 At the intermediate level, coping can be conceptualized as encompassing global coping strategies or modes. These typically include strategies such as those outlined in the COPE Inventory's 14 scales, the Coping Strategies Inventory, or the Ways of Coping Questionnaire's scales (e.g., Confrontive Coping, Distancing, Self-Controlling).45,58

Finally, at the lowest level, coping may be regarded as consisting of specific behaviors, cognitions, responses, and reactions to stressful situations. Examples of the latter include the numerous items commonly listed on coping measurement scales (e.g., "I try to come up with a strategy about what to do," "I hope a miracle will happen," "I stood my ground and fought for what I wanted"). The present study sought to empirically investigate how relationships among 17 coping strategies (intermediate level), obtained from responses of people with amputations, could be meaningfully collapsed into higher-order dimensions (highest coping level). As such, our results provide additional support to existence of global coping styles, or more accurately, dimensions of higher-level coping (i.e., approach or confrontation versus avoidance, positivistic versus fatalistic, social/emotional versus cognitive).

A second conclusion that may be drawn from the results of this study is that coping efforts of people with disabilities, or at least those who sustained bodily losses in the form of amputation, are not meaningfully different from coping efforts of those who are not physically disabled. The higher-level structure of coping strategies among participants of the present study was remarkably consistent with studies that relied exclusively on analyses of data obtained from nondisabled populations.33,50,52,61 Indeed, empirical research on coping efforts among people with cancer,62–65 heart disease,66–69 rheumatoid arthritis,70–73 and spinal cord injury47,74 has consistently reported coping styles (top level) and strategies (intermediate level) reflecting the following: 1) problem-focused versus passive (or avoidant) emotion-focused versus active emotion-focused coping; 2) denial versus realism; 3) active versus passive coping; 4) adaptive versus maladaptive coping; and 5) confrontive coping versus resignation.3,21,24

The results of this study also raise several points of interest. For instance, do specific types of amputation (e.g., upper extremity vs. lower extremity) or causes for the amputation (e.g., diabetic vascular insufficiency vs. a farming accident) result in differential coping strategies? Unfortunately, the descriptive nature of the data obtained in this study does not allow for cause-and-effect conclusions. One may speculate, however, based on the extant coping literature,19,21,27 that factors such as 1) functional limitations involved (e.g., mobility, manipulation), 2) degree of experienced pain, 3) onset of amputation- precipitating cause (e.g., sudden, gradual), 4) type of amputation-precipitating cause (e.g., congenital, chronic disease, injury), 5) chronological/developmental age and age at amputation, 6) educational and vocational background, 7) nature and extent of social support network, 8) prior life experiences with losses, 9) time since injury, and 10) general psychological make-up could all contribute to a unique constellation of adopted coping strategies and ultimately, psychosocial adaptation to amputation.

A second point of interest suggested by the present and related findings17,25,26,76 pertains to their clinical implications. It may be argued that clinicians who work with individuals following the aftermath of amputation may wish to assess their patients' coping styles so as to draw a sharper picture of their coping capability with loss and their level of psychosocial adaptation. For example, coping strategies traditionally regarded as disengaging in nature, including helplessness, catastrophizing, and cognitive disengagement, were found to be linked to poorer psychosocial adaptation to amputation.26,77 These maladaptive coping strategies can be typically recognized through the use of verbal responses and overt activities that include 1) giving up efforts to obtain personal goals and wishes because of the amputation, 2) viewing the amputation as the worst thing that could have happened, 3) resorting to alcohol and other drugs to relieve frustrations, 4) blaming or criticizing oneself and others for what has happened, 5) waiting for amputation-associated difficulties to somehow take care of themselves, and 6) daydreaming about things other than present situations.

With the help of psychometrically sound coping measures (COPE Inventory, Coping Strategies Inventory, Ways of Coping Questionnaire) clinicians may wish to assess the presence of these maladaptive coping strategies and their impact on their patients' everyday living. Cognitive-behavioral therapeutic techniques may be implemented to foster a more realistic perspective on how the loss (i.e., amputation) affects one's well-being and functional ability and to assist in the acquisition of specific skills required to successfully operate within one's living and working environments.

Furthermore, these coping strategies often conceived as engaging in nature, such as finding positive meaning, perceiving control over the disability, and active problem-solving, were found to be associated with better psychosocial adaptation to amputation.25,77 These adaptive coping strategies are typically being manifested by the use of verbal responses and overt behaviors that include 1) finding purpose in one's life, 2) believing that one can still function and compete successfully in most life endeavors, 3) demonstrating the ability to confine the effects of the amputation to only those domains directly influenced by the loss (e.g., working at occupations that require continuous ladder climbing), and (4) focusing efforts on action-taking and problem-solving of disability-linked issues. Clinicians may wish to investigate the existence of these ostensibly successful coping strategies among their patients with amputation and capitalize on their salutary effects; clinicians, if needed, may provide short-term therapy to assist the patient in recognizing their benefits, practice coping strategies during treatment sessions, and gradually generalize these coping skills to their patients' daily activities.

The findings of this study should be interpreted with caution. First, the sample consisted mainly of older, white men who sought help. Additionally, the sample's relatively small size and potential responding bias (32% return rate) limits the generalizability of the study's findings. Second, the measure used in this study (the COPE Inventory) relies exclusively on participants' self-reports and therefore is subject to biased responses (e.g., social desirability) or may be affected by the degree of respondents' self-awareness or cognitive functioning. An additional caution relates to the stability of the MDS solution. Because data analyses were based on one sample, and not cross-validated on an independent sample, the results should be considered sample-specific. Finally, the low internal consistency of three of the coping strategies (i.e., Restraint Coping, Denial, and Behavioral Disengagement) must be considered. Despite the similarities of the MDS solutions when these three strategies were removed from analysis or rescored (two highest correlated items on each scale), the instability introduced by these scales must be recognized.

Future research should not only seek to replicate these preliminary findings, with larger and more representative samples of people who are amputees, but it should also focus on other psychometrically sound coping measures and other-rated (e.g., family members, peers) instruments. Also, because coping strategies are often regarded as situation-specific and time-dependent efforts to diffuse stressful conditions,31,75 future research should consider adopting longitudinal research designs to ensure that coping is not regarded strictly as a stable disposition but rather as a flexible and dynamic effort to relieve emotional stress, gain knowledge of the situation, and engage in behaviors that seek to thwart the source of vicissitudes of the stressful event.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 

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