Discussion
Adapting to SCI-related challenges and overcoming emotional and psychosocial problems is a time and energy-intensive process. Persons with SCI need sufficient time to develop effective coping strategies and to learn to funnel personal resources in order to optimally confront new and often multiple stressors following SCI.
Overcoming Stressors
This case study of Ingrid emphasises the importance of adapting interventions to evolving and fluctuating stress and coping. Stressors as well as the ability to activate personal resources and supports, and coping strategies can fluctuate with a person’s circumstances – requiring at times less, more or different interventions. In Ingrid's case, she had difficulties accepting her health condition and her new life situation, especially the dependency that was associated with being a patient and a person with SCI. Ingrid's difficulty in accepting her new life situation compounded other factors, including emotional instability, blocking her from achieving many of the rehabilitation goals she and her rehabilitation team set.
From a stress appraisal model perspective, the underachievement of rehabilitation goals and minimal improvement in Ingrid's functioning reflected a low capacity for overcoming specific stressors i.e. living with complete tetraplegia and corresponding impairments and limitations in functioning, and uncertainty about her prognosis and prospects for community integration. The inability to overcome these stressors exacerbated her emotional instability, and in turn, her emotional instability further inhibited her progress – creating a vicious circle.
Another stressor that underscored the uncertainty she experienced about her future was the break-up with her boyfriend; this was one source of support she was no longer able to depend on. Luckily, Ingrid possessed other sources of support – a network of friends, a supportive family and a skilled and knowledgeable team of rehabilitation professionals – who were available to help Ingrid cope with her situation. Having available supports is not enough – key is activating these supports as well as personal resources in implementing coping strategies and in stabilising emotional functioning. In Ingrid's case, expanded knowledge about SCI and implications for her daily life was one personal resource that may have contributed to increasing her acceptance of her situation (even if the increase is only slight).
Appraising Stressors
The appraisal of the stressors i.e. how stressors are perceived, can impact the strategies employed and the steps taken in overcoming the stressors. In Ingrid's case, her negative perception of her uncertain prognosis and prospects for further improvement in functioning became an obstacle to her psychological well-being.
Addressing the Impact of Stressors
Findings of a 21-year longitudinal study on psychological impact, coping strategies and cognitive appraisal in persons with SCI showed that coping strategies a person with SCI employs early on after injury is predictive of long-term psychological status (distress). The investigators emphasised the need for early screening of possible psychological impact.14 This supports previous findings.13 Therefore, it is essential that members of the rehabilitation team are aware of the signs and symptoms that indicate possible emotional and other psychosocial problems, possibly even anxiety and/or depression.
In the same longitudinal study the investigators found that higher depression levels were associated with more frequent use of maladaptive coping strategies rather than coping strategies that reinforce positive interpretation of situations, growth and active coping. The investigators highlighted the importance of providing support and services, including peer counselling, in rehabilitation settings and in the community.14 Given this, it would also be important that the rehabilitation team implements approaches and interventions that could help persons with SCI to develop and employ positive and adaptive coping strategies, as well as plan for possible interventions after discharge from the rehabilitation institution.5713{cs15-fn24}
""...important that the rehabilitation team implements approaches and interventions that could help persons with SCI to develop and employ positive and adaptive coping strategies...""
In Ingrid's case, the rehabilitation team recognised early on that psychological support was essential for rehabilitation success, and planned interventions accordingly. Moreover, they tailored the interventions to adjust to Ingrid’s changing psychological needs. Despite these efforts, improvements in Ingrid's functioning was shown to be marginal at the end of the Rehab-Cycle®. Nevertheless this Rehab-Cycle® was the starting point for further assessments and interventions to support Ingrid on her long road to psychological well-being, independence in daily living, and community reintegration.
This case study illustrated the importance of addressing psychological issues throughout the rehabilitation process and adapting the rehabilitation process to the individual needs and resources of the person with SCI.