Experience of Stress after SCI
The degree to which a stressor i.e. anything that causes stress impacts on a patient with SCI depends upon a number of factors including an inability to perform many activities in the same way as before the injury, dependence on others, social demands that can include work and family obligations, and all of the bodily changes associated with SCI.2 Additionally, feelings and perceptions (or lack thereof) of dignity, value and importance – essential aspects of an individual’s quality of life - can contribute to a person’s emotional state.3 Other factors, both internal and external, can also impact a patient’s emotional well-being. Some of them, such as pain, medication, isolation, medical complications, body image, feelings of helplessness and humiliation and cognitive problems have been reported in the literature.34
The response to stressors vary among individuals and over the course of recovery; it can also fluctuate during a SCI patient's course of life. An early emotional reaction to an SCI is often some degree of denial, a reaction that prevents a patient from confronting the dramatic changes that he or she is faced with. Other responses may include withdrawal, regression, anger, depression, anxiety and grief.3 There is a widely-accepted view that those emotional responses are ‘normal’ reactions to an abnormal situation, resulting in confusing and even conflicting emotions.4 Furthermore, the extent and degree of such responses can vary from a “wide range of behavioural problems and psychological symptoms” in the days following admission to a health care facility to a number of problems and disorders that can afflict patients in the subsequent months and years following injury.3
The effectiveness of a patient’s response to stress or set of stressors has much to do with coping. Coping can be viewed “as a protective factor that facilitates adaptation to stressful life events”.5 Strategies for coping are either behavioural or psychological efforts that are used to overcome, lower or minimize stress related to events through problem-solving or emotion-focused strategies.6 Problem-solving strategies work to ease stressful circumstances, whereas strategies that are emotion-focused seek to control the emotional effects of stressful situations. The degree to which each of these strategies is employed will depend upon the individual’s personality and the nature of the stress, and may even change over time.2
Box 1 | Coping
Two of the pioneering researchers on stress, Lazarus and Folkman, defined coping as “constantly changing cognitive and behavioural efforts to manage a specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person”.2 A number of studies have demonstrated that coping is an important mediator of emotional adjustment to SCI.2 The Stress Appraisal and Coping Model helps describe and elaborate the capacity to cope with and adjust to stress. The model interrelates the following factors 2:
- Resources health, education, age, social support;
- Coping-information seeking, denial of disability, positive reframing, behavioural disengagement, religion, drug use;
- Stressors–work, family, physical symptoms;
- Primary and secondary appraisals–threat to livelihood, challenges to be over come, perceived ability to meet demands;
- Outcomes relating to life satisfaction–depression, anxiety, decreased self-esteem, acceptance of disability, satisfaction with life.
Modified theoretical model of the coping process
Within this model, mediators alter or alleviate the effect that stressors can have on an individual. These include appraisals, coping and resources. Appraisals involve an initial “primary” non-objective assessment of a situation, resources and stressors. In the secondary appraisal, a complex decision-making process is undertaken to confront a stressful circumstance.
Coping often includes a range of aspects such as “acceptance”, “social reliance”, “a fighting spirit”, “self-trust”8, “social trust”, “problem-reducing actions”, “change of values”9, as well as “an internal locus of control”, “social support” and “problem solving” capacities.10 By contrast, an early study of coping strategies found that SCI patients using certain strategies such as wishful thinking and self-blame had greater levels of depression and perceived life stress.5 How patients cope with a given stress will depend to some degree on the resources available in individuals.
Stressful life events increase the risks of secondary conditions such as depression and anxiety.2 However, while SCI patients remain at greater risk for depression and anxiety, it must also be noted that these disorders are by no means inevitable outcomes of an SCI.11
Box 2 | Anxiety and Depression
While mood disorders associated with SCI are not a given11, it is estimated that 30-40% of SCI patients will develop a depressive and 20-25% may experience an anxiety disorder up to two years after the incident.3 In the general population, rates of depression are estimated to be 4-10%. As recently as the mid-1980’s, depression in SCI patients was even considered to be a normal process of psychological adjustment – an absence of a depressive phase was thought indicative of an “unhealthy denial of the concomitants and finality of the injury”.2 One study estimated a prevalence of post-traumatic stress disorder (PTSD) in 20% of patients with spinal cord lesions.11 However, these conditions are often underdiagnosed in patients with serious health conditions (with detection rates estimated at fewer than 10%) due to the perceived normalization of mood disorders by health care professionals.4
Two important factors that contribute to these mood disorders include pain and a patient’s feelings of a lack of control before being discharged. Additionally, a prior history of psychological disorders (including substance abuse) can increase the likelihood of suffering from a post-injury mood disorder.12 The wide range of mood disorders that can affect a patient and the fact that such disorders often go undetected, clinicians need to distinguish “between the physiological and the pathological” and “determine who is actually clinically depressed”.13 To do this a number of scales have been developed to evaluate patients for post-traumatic psychological problems.
Successful coping often requires psychological support and interventions from rehabilitation professionals over the course of a patient’s recovery and at times even longer. Therefore, key responsibilities of health care professionals include the promotion of emotional well-being and the prevention or detection of depression and/or anxiety.
Beyond detecting these disorders, interventions in a sub-clinical stage may also mitigate the risks of acquiring them. Immediately after an SCI patient’s physical condition has been stabilized, such interventions should begin. Missed diagnoses can obviously have detrimental consequences. Interventions and therapies aimed at successful coping with SCI will contribute to emotional well-being and quality of life of a patient and his family not only in the short-term.
From the very early stages of an SCI patient’s rehabilitation, general approaches can be undertaken to promote his or her emotional well-being and minimize the risks of developing depression or anxiety. Such measures may include:
- Treatment of pain
- Early, but structured, opportunities for family visits
- Maintaining the day/awake, night/sleep cycle
- Social support for financial problems
- A supportive atmosphere with respect to the health care team; this should include identification and simple explanations of procedures.13
Once an evaluation has been undertaken, specific interventions to support the patient’s emotional well-being can be implemented. For SCI patients, such interventions should help to support patients in their search for coping strategies that correspond to their needs and the stresses they confront in their specific situation.8
Psycho-social and emotional interventions can be undertaken utilizing a range of approaches:
- Group-based interventions - including coping effectiveness training that teaches appraisal skills and cognitive behavioural coping skills.17 Additionally, group activities such as “learning by doing” courses and city trainings can be beneficial.
- Individual counseling, such as cognitive behavioural therapy (see Box), and additionally for cases of PTSD, hypnotherapy and psychodynamic treatment3
- Pharmacotherapy, generally for treating Posttraumatic Stress Disorder (PTSD)3
Once an evalutation has been undertaken, specific interventions to support the patient's emotional well-being can be implemented.
This case study aims to illustrate one patient’s experience of stress in relation to her emotional well-being and the overall impact of individual coping styles in the rehabilitation process. The stressful experience of future uncertainty following a traumatic SCI and the challenges for the health care team in their efforts to support her emotional well-being during post-acute rehabilitation will also be described.