Abstract
Quality of life (QOL) has been one of the most commonly used constructs in the field of rehabilitation. More specifically, it has been viewed and studied as a process, measure, goal, and outcome in the domain of psychosocial adaptation to chronic illness and disability (CID). However, it has seldom been discussed in the contexts of community-level clinical interventive strategies or personal-level coping strategies. This article seeks to provide the reader with a better appreciation and understanding of (a) the temporal nature of QOL within both the community-level and personal-level contexts of interventions, (b) the temporal-oriented parallel nature of managing life stresses as viewed from both community- and personal-level perspectives, (c) the intricate nature of anticipating, managing, and coping with CID as viewed from three distinct temporal vantage points, and (d) the psychosocial benefits accrued from future-oriented, positively valenced, post-CID coping efforts and their salutary influence on QOL among people with CID. The article concludes with a brief review of several theoretical, clinical, and research implications, informed by the temporal nature of coping strategies and their effect on psychosocial adaptation to CID.
The concept of quality of life (QOL), as a psychosocial construct, process, measure, goal, and outcome, has gained much popularity in the rehabilitation literature during the past 35 years (Bishop, 2005; Crewe, 1980; Fabian, 1991; Hershenson, 1990; Livneh, 2001; Roessler, 1990). As both a goal (i.e., assisting clients with chronic illnesses and disabilities [CIDs] to attain a better QOL) and a process–outcome indicator (i.e., assessing both subjective and objective levels of QOL during and following rehabilitation interventions), QOL has become one of the most prominent and central concepts in the field of rehabilitation (Bishop, 2005; Bishop, Smedema, & Lee, 2009; Crewe, 1980; Renwick, Brown, & Nagler, 1996). Despite the numerous theoretical, clinical, and empirical perspectives from which it has been approached, the understanding of QOL has only seldom been addressed by using the dynamic, time-dependent, process-like perspective of its clinical underpinnings. That is, the link between QOL, as a rehabilitation goal and outcome, and its unfolding temporal link to the domains of (a) community-level clinical interventions (i.e., public health, mental health, crisis intervention, and rehabilitation services) and (b) personal-level coping strategies (i.e., psychosocial adaptation and, more specifically, coping with life stresses and disability-induced functional limitations) has only scarcely been explored by rehabilitation researchers and practitioners.
More specifically, within the context of improving and maintaining QOL, community-level interventions have sought to address the occurrence, among the public, of physical limitations (e.g., functional restrictions), psychological limitations (e.g., stressful life events), and social limitations (e.g., restricted social activities) through the establishment of a comprehensive network of interventions that are geared toward (a) prevention (future-oriented; reducing the risk variables that may affect the lives of community members), (b) early intervention (present-oriented, or crisis intervention; directed at people who actively experience a crisis by seeking to restore equilibrium and reduce distress), and (c) postvention (past-oriented; directed at people long after onset of stressful or crisis situation, by seeking to minimize residual impairments and limitations following resolution of crisis; Caplan, 1964; Janosik, 1984; Livneh, 1995; Slaikeu, 1990). In a similar vein, person-level (psychosocial) interventions, mostly internally driven, but, at times, also externally initiated, include the acquisition of individualized coping skills to combat the deleterious impact of disability-imposed functional limitations and associated stressful life events: (a) before crisis onset (i.e., preventive, proactive, and anticipatory coping; or future-oriented coping), (b) during or through currently experienced crisis situations (i.e., crisis intervention, or present-oriented coping), and (c) pursuant to the resolution of crisis (i.e., reactive and residual coping, or past-oriented coping; Aspinwall, 2005; Auerbach, 1992; Folkman & Moskowitz, 2004; Schwarzer & Knoll, 2003).
In line with these notions of community-level and personal-level strategies, the aims of the present article are to (a) familiarize the reader with the conceptual and temporal parallelism underlying the domains of community interventions and personal coping, of which rehabilitation services are an essential component, as part of their joint goal to improve QOL, and (b) provide examples from the field of psychosocial rehabilitation, and more specifically coping with CID, that address the temporal nature of QOL-improving coping strategies.
Community and Personal-Level Interventions: Managing Stressful Events and Coping With CID
As suggested earlier, an often observed parallelism exists between the temporal undergird of community-level human service interventions and personal-level coping efforts and strategies. First conceived by Caplan (1964), the so-called tripartite model of therapeutic modalities to combat health impairments as well as psychopathologies was developed to depict preventions and interventions (the two terms are often inexplicably used interchangeably; Auerbach, 1992; Janosik, 1984; Slaikeu, 1990) in the fields of public health, mental health, social services, medicine, nursing, physical therapy (PT), occupational therapy (OT), and rehabilitation (psychology and counseling). The model contains, both structurally and temporally, three distinct content domains, as well as time frames. These three intervention domains, as mentioned above, are time-dependent and customarily include preventive (i.e., primary prevention [PP] or crisis prevention), interventive (i.e., secondary prevention [SP] or crisis intervention), and postventive (i.e., tertiary prevention [TP] or rehabilitation) services. The three domains are also noted by their differential therapeutic goals, indicators, targeted service providers, and intervention strategies (for detailed treatment of various aspects of the tripartite model, the reader may also wish to consult Auerbach, 1992; Goodyear, 1976; Janosik, 1984; and Slaikeu, 1990, and more specifically the rehabilitation field; Hershenson, 1990; Hershenson et al., 1981; Livneh, 1995).
In contrast to the community-based, large-scale, broad-angle view on human health, functioning, and behavior, undertaken by fields such as community health, occupational health, medicine, and nursing, the concept of coping has traditionally been associated more specifically with individual-level processes, originated in the field of psychology and its derivatives (e.g., health psychology, medical psychology, and rehabilitation psychology and counseling). Furthermore, coping models seek to directly address the sources of life stresses by considering their “temporal ordering.” That is, they aim to explore the effectiveness of various coping strategies in minimizing physiological stress, emotional distress, cognitive distortions, and behavioral and psychological dysfunction, as they are anchored in a differentiated temporal fabric (Auerbach, 1992; Schwarzer & Knoll, 2003).
The concept of coping has been explored and described in numerous ways and has been studied in a wide range of contexts (Endler & Parker, 1990; Haan, 1977; Lazarus, 1966; Lazarus & Folkman, 1984; Martz & Livneh, 2007; Moos, 1986; Zeidner & Endler, 1996). Essential to the understanding of coping is the notion that it is a dynamic and sequential process in which various coping modalities operate, intersect, and aggregate their unique properties (Krohne, 1996; Lazarus & Folkman, 1984; Skinner, Edge, Altman, & Sherwood, 2003). Regardless of its definitional nuances, a common theme that has been, overtly or covertly, implied by these definitions is that coping efforts undertake different patterns and guises commensurate with the temporal orientation of the encountered stressful situation. Indeed, Auerbach (1992) argued more than two decades ago that time and temporality are intrinsic to the understanding of stress and coping. More specifically, he maintained that the two (temporality and coping) are intimately linked because (a) exposure to stressful life events varies in its duration, and as a result, coping outcomes vary as well; (b) stressful life events confront individuals at different developmental life stages, and, consequently, the nature, interpretation, and modes of coping with these events vary along the life cycle (see also McGrath & Beehr, 1990); and (c) life events that occur “off-time” (unexpectedly) typically result in higher levels of stress and less effective coping, as compared with those that occur “on-time” (age-associated) or at a “bad time” concurrent with other life events and stressors (see also Schlossberg, 1981). To this list, one could also add the following: (d) Coping (and its success) with stressful life events often hinges on the degree of predictability, certainty, and controllability of the encountered event, and these events differ as to their temporal properties (e.g., unlike a stressful event that has already been experienced, those anticipated are less predictable or controllable; Folkman & Moskowitz, 2004; McGrath & Beehr, 1990; Schwarzer & Knoll, 2003).
The role of temporality in the context of coping with stressful situations was first suggested by Lazarus and colleagues (Lazarus, 1966, 1991; Lazarus & Folkman, 1984; Lazarus & Launier, 1978). In their model of coping with stressful life events, Lazarus and his colleagues viewed coping as consisting of a range of psychological and behavioral efforts, undertaken to manage, minimize, overcome, or defuse stressful events. The deployment of coping efforts follows the individual’s appraisal of the situation, which determines whether the potential threat is viewed as stressful, irrelevant, or even possibly beneficial for future well-being. These appraisals are further classified as (a) loss and harm (implying events that occurred in the past), (b) crises and ongoing stresses (indicating events of the present), and (c) challenges and threats (implying anticipated or future events). These time-associated stressful experiences further suggest that the temporal location of the stressful event may be associated with certain emotional manifestations such that, for example, appraisals of loss or harm (past orientation) may trigger feelings of depression (and possibly anger), those of threat (future orientation) may be more directly associated with apprehension and anxiety, whereas appraisals of challenge (also future orientation) may be linked to feelings of hope and benefit finding.
In the context of life following the onset of CID, coping efforts, at first glance, seem to suggest that, because CID has already occurred (i.e., the event leading to loss, damage, or injury is anchored in the past), these efforts to mitigate the event’s impact should be directed toward the aftermath of the CID. That is, coping efforts should target overcoming the experience of lost bodily parts, functions, abilities, and so on. In reality, however, this is a rather myopic, indeed misleading, perspective because people who have sustained CID, by necessity, must deal with continuous, presently experienced crises and realizations, as well as coping with future consequences and vicissitudes of their physical and psychological conditions. Furthermore, the linear, universal, and objective passage of time in which future events gradually and uniformly mold into the present and then proceed to become part of the past (i.e., Newtonian time) is not reflective of human subjective passage of time (i.e., private or “felt” time) in which time is often experienced through cyclical, pendular, episodic, or epochal perception of events, including stressful events, crisis situations, or traumatic onset of CID (McGrath & Beehr, 1990; McGrath & Tschan, 2004; Slife, 1993). For example, a person who sustained spinal cord injury (SCI), in addition to having to cope with losses (e.g., mobility), and imposed life changes (e.g., use of transportation) and psychological stresses necessitated by the onset of the injury (i.e., the past), in reality must cope with present, continuous stressful situations (e.g., neurological pain, respiratory difficulties, spasticity, urinary complications, inaccessible settings, architectural barriers), as well as anticipated future events (e.g., further medical complications, decreased employment opportunities, increased insurance premiums, and other financial hardships). In a somewhat similar vein, the diagnosis of life-threatening and chronic medical conditions (lung cancer, congestive heart disease) could, likewise, trigger a set of temporally influenced coping efforts, commensurate with the nature, severity, stability, and functionality of the experienced symptoms. For instance, present coping efforts may focus more squarely on mitigating the debilitating effect of anxiety, the impact the condition has on other family members, the changes required in daily activities, and the time and energy constraints imposed by the treatment regimen. In contrast, future coping efforts may be differentially applied and focus on long-term implications of the condition, its prognosis, level of (un)certainty, and (un)controllability, as well as issues revolving around anticipated long-term functional abilities and restrictions, financial burden, employability considerations, and future level of QOL. Finally, individuals with early life–induced disabling conditions (e.g., Type I diabetes mellitus, cerebral palsy, epilepsy) may be, altogether, more likely to apply a different set of coping efforts, typically termed proactive coping. Individuals with diabetes must regularly proactively cope with such issues as continuous dietary restrictions, worries about future physical complications, fear of diabetic coma and insulin shock, and the anxiety associated with a hidden disability, unpredictable symptoms, and uncertain future. Those with cerebral palsy must also cope, proactively, with such areas as progressively worsening mobility and speech deficits, involuntary muscle spasms (e.g., contractures), feelings of shame and embarrassment, and negative public attitudes triggering social rejection. Finally, people with epilepsy find it necessary to proactively cope with concerns emanating from anxiety linked to the unpredictability and often uncontrollability of seizures, the wide range of side effects associated with many anti-epileptic medications, social restrictions (on alcohol consumption and driving), and the shame and embarrassment triggered by the seizure itself and the associated public stigma. The use of coping modalities to manage these issues is marked by an early acquisition and organization of those personal and environmental resources needed to facilitate successful coping with the imminent challenges of life with CID and its anticipated, yet often unpredictable, consequences (Aspinwall, 2005; Schwarzer & Knoll, 2003).
In light of the above considerations, the following sections seek to provide the reader with a more thorough review of (a) the role of temporality within community-anchored strategies to combat both physical and psychopathologies, (b) the role of temporality in coping with life stresses, and (c) selected examples from the CID literature on how temporality has been conceived in assessing coping with, and adaptation to, CID-induced life stresses (see Table 1).
CID-Oriented Community Interventions and Coping Strategies as Viewed From a Temporal Perspective.
Note. QOL = Quality of Life; CID = chronic illness and disability; rehab. = rehabilitation; PTs = physical therapists; OTs = occupational therapists.
The Temporal Aspects of Community-Based Stress and Crisis
Although Caplan’s (1964) original tripartite model of community-based medical and psychiatric pathology prevention has been conceived half a century ago, applications of its clinical acumen and practical versatility have been surprisingly lacking in the fields of rehabilitation psychology and counseling. In this section, we provide an overview of the model’s three-pronged temporal nature (i.e., PPs, SPs, and TPs/interventions) and essential features.
PP
PP encompasses those strategies that seek to reduce, harness, and, if possible, prevent the occurrence of physical disabilities, chronic illnesses, and psychiatric disorders among members of the public, with particular emphasis on those who represent high-risk groups, thus ensuring a sustained positive QOL. They are, therefore, applied prior to event occurrence. Viewed from a different angle, as espoused by the prevailing positive psychology framework, these interventions may also be said to represent attempts at promoting physical and psychological health, as well as positive QOL (e.g., subjective well-being, life satisfaction). The professions that best represent the type of interventions within the PP domain include, among others, public/community health, public education, occupational health, public safety, and preventive medicine. Specific intervention strategies most commonly used by proponents of PP, therefore, include public education and political campaigns to inform the public of health threats and hazards; environmental modifications to ensure the reduction, control, or elimination of detrimental environmental stimuli and stressors; and the teaching and promotion of behaviors that are known to be successfully linked to warding off future stressful situations and physical impairments and diseases. On a more constricted scale, PP strategies focus on teaching problem-solving and decision-making skills and the fostering of personal strengths, resources, and coping modalities that serve to immunize people to stress and minimize the future risk of physical and psychiatric conditions (Caplan, 1964; Hershenson, 1990; Livneh, 1995; Slaikeu, 1990).
SP
SP, or crisis intervention (also referred to as direct or real-time intervention), refers to those interventions that attempt to directly, immediately, and intensely reduce the effects of an ongoing life (non-chronic) crisis, and, concomitantly, promote personal resilience and growth through the crisis experience itself. Through these early interventions efforts, SP aims at restoring life equilibrium and reducing the severity and frequency of debilitating affective, cognitive, and behavioral distress experienced by community members. Crisis intervention, therefore, is equated with those efforts more traditionally referred to as short-term (crisis) therapy, intensive psychotherapy, and psychiatric first aid (Auerbach, 1992; Caplan, 1964), which aim to restore previously experienced QOL. The professional schools that most clearly represent SP interventions are medicine and nursing (i.e., urgent care), and psychiatry and psychotherapy, all seeking to reverse or curtail physical pathology (medicine and nursing), and psychiatric symptomatology (psychiatry and psychotherapy). Unlike PP, where the focus is on the community at large, SP targets selected individuals directly (i.e., those affected by the crisis experience), as well as their immediate environments (Hershenson, 1990; Livneh, 1995).
TP
TP, also known as postvention or rehabilitation, is the third and final domain (as well as therapeutic phase) of community-based intervention. It encompasses those interventions that are geared toward minimizing, and if possibly reversing, the residual impact on people (typically patients or ex-patients) of long-standing and severe physical and psychiatric CIDs, whose onset has been associated with an earlier experience of crisis and its aftermath. TP is implemented long after crisis resolution (although it may be initiated relatively early following successful attainment of physical and/or psychosocial equilibrium), and its overarching goal is the restoration of pre-CID QOL. Put differently, TP focuses on the provision of supportive and ameliorative services to individuals with CID and the promotion of a better QOL (Bishop, 2005; Hershenson et al., 1981; Janosik, 1984; Livneh, 1995; Slaikeu, 1990; Wright, 1980). Among the professions that are associated with TP, the most prominent ones are medicine (for chronic conditions; physiatry, cardiology, neurosurgery, oncology, pain medicine), long-term psychotherapy, PT, OT, speech and hearing therapy (S&HT), rehabilitation engineering, and (psychosocial, vocational) rehabilitation psychology and counseling (Hershenson, 1990; Livneh, 1995).
Further analysis of the goals of TP, as mostly espoused by the fields of rehabilitation psychology and counseling, indicates that they could be further categorized into the following three domains.
CID minimization
This goal is best reflected in those efforts that seek to minimize the CID impact on the individual by reversing the course of the CID and restoring functional capacity, including affected life skills. Typical interventions include the use of assistive technologies to improve sensory functioning, surgical procedures to correct neuromuscular and orthopedic impairments, the use of orthotic and prosthetic devices to improve mobility and manipulative functioning, and a host of CID-specific PT, OT, and S&HT procedures (Hershenson, 1990; Livneh, 1995).
Skill acquisition
This goal is normally associated with rehabilitation efforts to compensate for the functional limitations imposed by CID through the enhancement of other, not directly implicated abilities and skills, thus often necessitating modification and reformulation of earlier life goals. More specifically, the goal is to teach and practice specific coping skills and a broad range of life skills, through the adoption of psychosocial and vocational rehabilitation (VR)–based strategies that include educational, career, vocational (job-specific), and personal adjustment skills. Among the wide spectrum of coping skills training modules available, the following appear to be the most widely used: managing anxiety, depression, frustration, and anger; self-assertiveness; stigma reduction; self-concept/efficacy improvement; job searching, interviewing, and performance; time management; decision making; problem solving; money management; and medical/symptom management. Rehabilitation (postvention) services are commonly provided by rehabilitation counselors and psychologists, special educators, social workers, and recreational therapists (Hershenson, 1990; Livneh, 1995).
Environmental manipulation
This goal is normally implemented through efforts directed at modifying and restructuring the environment to minimize the impact of CID-imposed functional restrictions. These efforts are aimed at both the physical environment (i.e., restructuring features of one’s home, work and leisure activities environments, and eliminating community-based architectural barriers) and the social/attitudinal environment (i.e., combating and eliminating the stigma, prejudice, and discrimination stemming from the existence of CID). Included among these target groups are family members, employers, and members of the public whose negative attitudes often foster additional barriers to positive QOL maintenance (Hershenson, 1990; Livneh, 1995).
In sum, the community-based primary, secondary, and tertiary interventions are mostly externally driven strategies (i.e., applied by trained professionals) geared toward preventing or minimizing the likelihood of occurrence, or reducing the impact of certain medical and psychiatric conditions prior to, during, or following their onset. In addition, although a logical temporal sequencing is often assumed for strategy applications (i.e., prevention → intervention → postvention), strategies normally applied later on in this model are not necessarily bound by these clinical features. That is, people who sustained CID (by definition, function in a postvention or rehabilitation stage) are not excluded from using, and are just as likely to benefit from, preventive and interventive services for QOL enhancement that may stem from anticipated future medical complications and encountered crisis situations that may still be experienced by the person with CID.
The Temporal Aspects of Coping With Stress and CID
Only scarce literature is presently available on the temporal aspects of coping efforts. Nevertheless, this body of literature suggests that these efforts to improve QOL following stressful situations (e.g., onset of CID) could be conveniently organized into three broad categories. These include (a) pre-emptive, or pre-impact, coping efforts that are directed at potential future stressful live events (threats, challenges) that range from those whose occurrence spans from unlikely but possible to likely or probable; (b) crisis-experienced coping efforts directed at presently experienced, or ongoing (dynamic), stressful events and crises (including various physical injuries, bodily insults, and psychiatric crises); and (c) post-impact or post-event coping efforts directed at stressful life events (losses, harms) of the past whose impact still plays a significant role in influencing present physical, psychological, and social activities (Aspinwall, 2005; Auerbach, 1992; Livneh & Martz, 2007; McGrath & Beehr, 1990; Schwarzer & Knoll, 2003).
Pre-Emptive or Pre-Impact Coping
Pre-emptive coping can be viewed as the person-level analogue of community-anchored PP, which, as outlined earlier, aims to reduce the likelihood of future occurrence of both physical and psychiatric CIDs. Pre-impact coping strategies have been classified into the following: (a) preventive coping, regarded as the most temporally distal from future event occurrence; (b) proactive coping; and (c) anticipatory coping (most proximal to future event occurrence). Put differently, the extended pre-impact period can be, somewhat arbitrarily, subdivided into distal anticipatory (preventive), mid-range anticipatory (proactive) and proximal anticipatory (or just anticipatory) “time zones” (Auerbach, 1992; McGrath & Beehr, 1990; Schwarzer & Knoll, 2003). As a group, all pre-emptive coping efforts present a rather elusive and uncertain picture because the impact or stressful experience has not occurred as of yet and is, therefore, not directly familiar to the person. These efforts, then, may be conceived as attempts to cognitively scan possible future scenarios and the scope of their potential impact and implications, and gradually build up (psychologically and behaviorally) those necessary resources to combat stressful life events.
Preventive coping
Preventive coping, as its name suggests, focuses on those long-term, distant future-anchored, yet broadly anticipated events well before these events are to be encountered (e.g., retirement, age-related illnesses, expected functional losses, long-term medical insurance). These efforts, therefore, reflect coping strategies that seek to address uncertain and mostly unpredictable threats located within a distant future. The function of preventive coping, according to Auerbach (1992), is to ideally delay or, when feasible, prevent the likelihood of (a) the event occurring, (b) the impact of the event on the individual, and (c) the potential damage that the impact of such an event may impose on the individual. In the context of the health domain, Auerbach further argues that activities undertaken by the individual during preventive coping typically include (a) prevention of the occurrence of these potentially stressful or damaging events (e.g., the use of problem-focused coping); (b) prevention of exposure to those potentially aversive events, such as the use of problem-focused and action-oriented coping to avoid such exposure (e.g., carcinogenic agents, pulmonary pollutants, hearing loss-inducing environments); and (c) prevention or, at the very least, significant minimization of the detrimental consequences of such potentially damaging and stressful events, again, through the employment of mostly problem-focused efforts that seek to eliminate or reduce anticipated harmful conditions, various life losses, functional limitations, and experienced pain.
In a similar vein, Schwarzer and colleagues (Schwarzer, 2000; Schwarzer & Knoll, 2003; see also Aspinwall, 2005) have maintained that preventive coping is noted for its efforts to prepare the individual for adverse or stressful events through the gradual building and use of generalized resources (e.g., development of psychological strengths, accumulation of wealth, attainment of social resources and skills). These future-oriented efforts are directed at nullifying (or, at times, mostly minimizing) the severity of the potential impact and maximizing the probability of successful stress-reducing strategies.
Proactive coping
Whereas preventive coping, ideally, seeks to avoid or neutralize the occurrence of potentially threatening stressful life events, proactive coping efforts focus more on minimizing or reducing the impact of such future-anchored events (i.e., events that are likely to occur). The available literature, however, is not always clear about such a distinction and presents a rather overlapping view of the two coping modalities. For example, Aspinwall and colleagues (Aspinwall, 2005; Aspinwall & Taylor, 1997) offer only marginal distinction between proactive and preventive coping efforts and regard both as active behavioral efforts to prevent, eliminate, reduce, or modify impending stressful events. The latter encompass events such as threatening environmental situations or taxing psychological demands, which are likely to culminate in harm, loss, or damage.
As compared with anticipatory coping (discussed in the next section), proactive coping can be best described as (a) temporally removed from the threatening event (i.e., they are used earlier in the chain of coping efforts); (b) invoking aggregation of personal and environmental resources, including the mastery of skills needed to confront threatening events; and (c) necessitating a different set of coping skills; that is, whereas proactive coping is normally better served through the use of more active coping modes, such as planning, information gathering, skill development, and goal management, anticipatory coping may, quite often, be better served through the use of more affective and social coping modes, such as emotional regulation, emotional support, and positive reappraisal to manage the upcoming stressful event (Aspinwall, 2005; Aspinwall & Taylor, 1997).
A somewhat diverging perspective was advanced by Schwarzer and Knoll (2003; see also Folkman & Moskowitz, 2004). These authors view proactive coping as coping efforts that involve future challenges that are “potentially self-promoting” (Folkman & Moskowitz, 2004, p. 757; see also Schwarzer & Knoll, 2003). In contrast, they regard preventive coping as coping efforts that portend “an uncertain threat potential in the distant future” (p. 757). Proactive coping, therefore, serves as the prototype of positive coping efforts, in which the individual builds up resources that facilitate promotion of challenging future goals and personal growth, as well as goal management and the attainment of meaningful life pursuits (Schwarzer & Knoll, 2003). These efforts, then, serve a different purpose than the one promoted by preventive coping, the latter seeking to avoid or largely minimize potential negative occurrences, such as damage to one’s physique or psyche.
Anticipatory coping
As its name implies, anticipatory coping refers to these coping efforts that are triggered by environmental and physical (e.g., bodily) cues that indicate that the individual is on a course of confronting, in the near future, an aversive life event (e.g., anxiety-provoking doctor appointment, forthcoming diagnostic test or surgery, job interview, important exam, upcoming retirement) with a high degree of certainty (Auerbach, 1992; Folkman & Moskowitz, 2004; Schwarzer & Knoll, 2003). Here, too, the individual may be more likely to use problem-focused coping to avoid such an encounter or, if this is impossible, to minimize the risk or damage (including level of stress) that such an encounter may produce (Auerbach, 1992; Janis, 1958).
Anticipatory coping is further subdivided into those efforts that confront avoidable and unavoidable life stressors (Auerbach, 1992). A somewhat similar subclassification may also be useful here, in which future life stressors are grouped into controllable and uncontrollable, changeable and non-changeable, certain and uncertain events (Krohne, 1993; Maes, Leventhal, & de Ridder, 1996; McGrath & Beehr, 1990; Mishel, 1988; Perrez & Reicherts, 1992). Avoidable (or potentially controllable) stressors according to Auerbach and others (e.g., Aspinwall & Taylor, 1997; Schwarzer & Knoll, 2003) are those stressors whose potential harm can be modified, minimized, or postponed. This can be accomplished through vigilant attention, preparation for the stressful event’s eventual occurrence, acquisition of necessary information, assessment of useful alternatives, and selection of an appropriate course of action to confront those upcoming stressors. Unavoidable, or uncontrollable, stressors, however, such as eventual retirement, physical deterioration, death of spouse or oneself, and even the risk of invasive medical and surgical procedures, are those stressors that most, if not all, individuals will be ultimately facing. According to Auerbach (1992), successful coping efforts with these imminent stressors include both cognitive-behavioral-focused modalities (e.g., information use, planning, behavior modeling) and emotional-focused modalities (e.g., seeking social support, venting emotions in a supportive environment) used to reduce apprehension, anxiety, and further stress.
Dynamic or Impact-Experienced Coping
Coping with ongoing crises may be considered the individual-level analogue of community-aimed SP, the latter seeking to mitigate the psychic toll mounted by a presently experienced crisis situation (e.g., injury, life-threatening diagnosis). Dynamic coping, or coping with presently experienced stressors or crises, includes those coping efforts where the individual is said to actively manage the stressful event. They are also described as coping efforts undertaken during (at the present, or at real time) directly experienced, or ongoing, stressful event, often also termed crisis or crisis situation. Ironically, crisis is often viewed as that period where coping, including problem-solving ability, has broken down, and, therefore, normal coping and cognitive processes are no longer capable of achieving the goal of returning the individual to a state of psychological equilibrium (Roberts, 2000; Slaikeu, 1990). The redeployment of organized and balanced coping efforts is not an instantaneous and automatic occurrence and may, therefore, require additional time to successfully detect, interpret, process, and eventually recover from the crisis experience (McGrath & Beehr, 1990). Notwithstanding this theoretical contradiction, one of the primary aims of coping efforts that ostensibly still serves the individual in crisis is to defuse or minimize the felt (emotional) impact (Hodgkinson & Stewart, 1991; James & Gilliland, 2001).
Historically, the field of coping with crisis situations has its roots in the seminal bodies of work of Eric Lindemann (1944) and Gerald Caplan (1961, 1964). Lindemann studied reactions of acute grief and bereavement among both non-psychiatric and psychiatric patients, describing them as reflecting wave-like processes of panic and anxiety reactions that alternate with those of denial and avoidance. In his Crisis Prevention/Intervention model, Caplan extended this body of work by developing a crisis-oriented brief psychotherapy to help individuals who experience a crisis to better confront and defuse their stress reactions during this time-limited period.
It is beyond the scope of this article to address the plethora of contributions made by crisis (and crisis intervention) clinicians and researchers. Briefly, however, it could be argued that to better understand crisis-experienced coping, one needs to (a) provide a broad description (rather than the formal, yet linguistically rigid, use of a succinct definition) of the term crisis that includes its main components and clinical features, (b) understand the initial and extended reactions to crisis, and (c) describe the primary types of crisis. These are summarized in the following paragraphs for the benefit of readers who are not well-acquainted with the literature on crisis intervention.
The experience of crisis
There have been many, and often inconsistent, definitions of the term crisis. It may, therefore, be beneficial to provide first a more general description of the term. Briefly, then, crisis can be described as a subjective reaction to an acute and intense variant of a stressful or hazardous life event or experience. By its very nature, it has an identifiable beginning (a precipitating event, or an adverse stimulus or catalyst) and is a time-limited (i.e., temporary) state (see Note 1); a state most commonly associated with cognitive and emotional disorganization, psychological disequilibrium, extreme vulnerability, reduced functional capacity, and ultimately a failure to cope with the stressful situation using previously familiar and successful strategies. Crisis, then, reflects the experience of a highly stressful situation or event that creates an obstacle to the attainment of meaningful life goals, and whose resolution exceeds the individual’s presently available resources and coping (i.e., problem-solving) strategies (Collins & Collins, 2005; James & Gilliland, 2001; Janosik, 1984; Roberts, 2000; Slaikeu, 1990). Other models of crisis can be found in Selye’s (1976) general adaptation syndrome (Alarm, Resistance, Exhaustion), and Horowitz’s (1986) stages of normal response (outcry, denial, intrusion, working through, and completion) versus pathological response (overwhelmed, panic, exhaustion, avoidance, flooded psyche, and psychosomatic response) to crisis situations.
Reactions to crisis
The clinical literature has generated an exhaustive list of chaotic psychosocial reactions that are associated with the onset of crisis. Among the most frequently discussed are those that indicate cognitive and emotional distortions and behavioral malfunctioning. More specifically, the literature strongly indicates that acute reactions to crisis situations strongly parallel those observed among individuals who sustained a sudden and severe onset of CID, and that have traditionally been referred to as shock, alarm, and anxiety “phases” (alternatively referred to as reactions or responses; Hodgkinson & Stewart, 1991; Horowitz, 1986; Livneh & Antonak, 1997; Shontz, 1975). These include reactions such as disbelief, numbness, confusion, disorientation, incoherency, feeling overwhelmed, disorganized thinking and speech (all regarded as indicators of a shock response), intense fear, panic, tension, distress, subjective discomfort, and dread (all viewed as indicators of an anxiety response; Caplan, 1964; Cavaiola & Colford, 2006; Collins & Collins, 2005; James & Gilliland, 2001; Janosik, 1984; Roberts, 2000; Slaikeu, 1990). These reactions are perceived among “crisis theory” proponents as further clinical proof that during the immediate aftermath of a crisis experience, the person is temporarily unable to cope. This eventuality is believed to follow the breakdown of the network of previously used coping strategies that are now incapable of thwarting off crisis-triggered cognitive and affective disorganization.
Types of crisis
Crisis situations are commonly subdivided into the following types:
Developmental crises
These are crises that are associated with those life stages or phases (the life cycle; for example, Erikson’s psychosocial stages of development) that the individual undergoes, rather predictably, during the normal course of his or her growth and maturation. They reflect changes perceived in the individual’s inner sense of self as he or she transitions through these life milestones (James & Gilliland, 2001; Janosik, 1984; Slaikeu, 1990). Examples include high school or college graduation, marriage, career change, “midlife crisis,” and retirement.
Situational crises
These are crises that are directly linked to sudden onset, random, unexpected, unpredictable, uncommon, and environmentally triggered episodes, where the individual faces external events that may alter his or her life considerably and even permanently (James & Gilliland, 2001; Janosik, 1984; Slaikeu, 1990). Examples include (a) health-related crises, such as loss of body part or function, major surgery, physical injury, automobile accident, and life-threatening illness (or its diagnosis); (b) death-related crises, such as the death (by natural causes or fatal accidents), homicide, or suicide of a spouse or a loved one; (c) crime-related crises, such as physical or sexual assault, domestic violence, and any other form of victimization; (d) financial crises, such as job loss, bankruptcy, and loss of one’s home; and (e) crises associated with natural or man-made disasters, such as earthquakes, floods, hurricanes, fires, and wars (James & Gilliland, 2001; Janosik, 1984; Slaikeu, 1990).
Existential crises
These crises are the result of personal anxieties and inner conflicts that are associated with significant and unresolved human issues and uncertainties. These experienced crises typically reflect subjective concerns that include, among others, the purpose and meaning (or alternatively, futility) of one’s life and existence, personal responsibility, issues of dependency versus independency, freedom and freedom of choice, alienation, commitment (to others or an important cause), and connectedness to others (Cavaiola & Colford, 2006; James & Gilliland, 2001).
Post-Impact Coping
Post-impact coping can best be seen as the person-level analogue of community-based TP, which embodies rehabilitation philosophy and processes, and focuses on reducing and altering functional limitations acquired in the most recent as well as remote past, and therefore, their resolution culminates in enhanced QOL. Post-impact, or post-crisis, coping has been traditionally viewed as including two temporally variant coping efforts. These are (a) proximal or reactive coping efforts (where the impact of harm, damage, loss, or onset of CID has been sustained within recent time), and (b) distal or residual coping efforts (where these events occurred more remotely in time; Auerbach, 1992; Folkman & Moskowitz, 2004; Livneh & Martz, 2007; Schwarzer & Knoll, 2003). No clear demarcating boundary between what is regarded as “recent” or “short-termed” and what is referred to as “remote” or “long-termed” has ever been proposed in the literature. Despite the fact that reactive coping is directed toward experiences of the immediate (short-term) past, and residual coping toward experiences long after the stressful event has occurred, in both cases, primary coping strategies often include (a) problem-focused coping to manage the consequences of the event (e.g., task-oriented), (b) cognitive-focused coping to rationally assess and prioritize available alternatives (e.g., cognitive reappraisal, belief-control, meaning finding, and benefit finding), (c) social-emotional coping to defuse or moderate emotional distress and heightened anxiety (e.g., seeking social support, expressing emotions constructively), and (d) avoidance coping to divert or remove oneself from a stressful situation (e.g., social avoidance, denial, emotional venting; Amirkhan, 1990; Endler & Parker, 1994; Martz & Livneh, 2007; Moos & Holahan, 2003; Pearlin & Schooler, 1978).
Traditionally, therefore, post-impact coping can be viewed as coping efforts directed at stressful events whose aftermath resulted from physical harm or bodily injury, personal loss (e.g., marital breakup, job loss, loss of home), and, in general, chronic illnesses or disabling conditions, which were experienced in the immediate or remote past, and that, consequently, served to mitigate against negative affect and restore functioning and pre-impact QOL (Bishop, 2005; Kennedy, Lude, Elfstrom, & Smithson, 2012; Livneh, 2001; Moos & Holahan, 2007; Smedema, Catalano, & Ebener, 2010). The goal of post-impact coping efforts is, accordingly, to compensate for those sustained losses and injuries and gradually restore psychological equilibrium, leading to an improved QOL (Bishop, 2005; Bishop et al., 2009; Schwarzer & Knoll, 2003). Post-impact coping efforts could, therefore, be regarded as more realistic and tangible in nature, as compared with pre-impact efforts, because the impact has already been experienced, perceived, and cognitively and emotionally processed. In the context of life following the onset of CID, these efforts could also, at first glance, be viewed as dealing with shattered plans and hopes, and essentially with the discrepancy created between “having had” (the past) and “no longer having” (present and presumably future).
In sum, then, the person-based pre-emptive, dynamic and post-impact coping efforts are mostly internally derived strategies (i.e., applied by the individual himself or herself) geared toward preventing or minimizing anticipated future stressful events, confronting ongoing crisis situations, and managing the aftermath of past stressful occurrences and related CID-triggered losses. In addition, although a logical temporal sequencing is often assumed for the application of these coping modalities (i.e., pre-emptive → crisis-experienced → post-impact), strategies normally applied later on in this model are not necessarily restricted to this order. That is, people who sustained personal losses, including CID (by definition, engage in post-impact coping) are not excluded from using, and are just as likely to benefit from, pre-emptive and crisis-experienced coping strategies that may stem from anticipated future stressful events, and ongoing crisis situations that may still confront the person with CID. Indeed, research findings have shown that past-oriented coping efforts (or “getting stuck” in the past, focusing on the negative content of the past) and foreshortened future time coping (failure to project into the future) are often associated with negatively valenced coping and increased levels of psychological distress (e.g., Buckelew, Baumstark, Frank, & Hewett, 1990; Holman & Silver, 1998; Livneh & Martz, 2007; Malcarne, Compas, Epping-Jordan, & Howell, 1995; Martz, 2004). Similar findings were obtained from the literature on the relationships between negative past-oriented appraisals and psychosocial outcomes following the onset of CID. For example, appraisals of loss, including overwhelming disbelief of SCI occurrence and related negative perceptions of its impact on one’s life, have been associated with higher levels of depression and anxiety, poorer social integration, and lower QOL perceptions (Dean & Kennedy, 2009; Kennedy et al., 2012; Kennedy et al., 2010). Other indicators of negative and past-oriented appraisals, including feelings of helplessness (lack of control over the future) and self-blame (focusing on self in the past), have also been found to be correlated with perceived lower QOL and life satisfaction, and even self-reported poorer mental health (Schulz & Decker, 1985; van Leeuwen et al., 2012). In a similar vein, a bourgeoning body of literature has now been amassed to document the beneficial consequences, including the salutary influences on various QOL indicators, of future- and positive-oriented coping on the lives of people with CID. These are reviewed next.
Coping: Gaining From Adversity
As was argued above, the more traditional view of coping fails to fully recognize two important issues. First, post-impact coping is not necessarily bound by a past-oriented psychological framework, and second, it does not indubitably originate from a “loss and grief” mentality. To wit, post-impact coping efforts are not necessarily constricted in their focus to negative perceptions, cognitions, and feelings that are tied to lost past abilities and unfulfilled dreams. Indeed, adopting a future-oriented, positively valenced coping framework, rather than a past-oriented, negatively valenced approach to coping, negates focusing not only on the immutable past and therefore losses incurred, but also, and most importantly, on the future and its many opportunities for personal growth and improvement in one’s QOL. A growing body of literature has now conclusively documented that the onset of CID often gives rise to positive perceptions and beliefs that, alternatively, are linked to new hopes, aspirations, and challenges. These latter positive appraisals and adaptive coping modalities have been shown to be associated with such psychosocial outcomes as psychological and social QOL, life satisfaction, and perceived well-being, and negatively linked to depression and anxiety. They have been studied and observed under terms such as maintaining hope (Elliott, Witty, Herrick, & Hoffman, 1991; Kennedy, Evans, & Sandhu, 2009; Kortte, Stevenson, Castillo, Hosey, & Wegener, 2012; Snyder, Lehman, Kluck, & Monsson, 2006); benefit finding (from adversity in general and CID, more specifically; Helgeson, Reynolds, & Tomich, 2006; Kortte, Gilbert, Gorman, & Wegener, 2010; Pakenham, 2005; Tennen & Affleck, 2002; van Leeuwen et al., 2012); meaning searching, making, restoring, or finding (Davis & Morgan, 2008; Davis, Nolen-Hoeksema, & Larson, 1998; deRoon-Cassini, de St Aubin, Valvano, Hastings, & Horn, 2009; Janoff-Bulman & Yopyk, 2004; Pakenham, 2007; Park, Edmondson, Fenster, & Blank, 2008; Park & Folkman, 1997); purpose or meaning in life (deRoon-Cassini et al., 2009; Reker, 1977; Thompson, Coker, Krause, & Henry, 2003); posttraumatic growth (or growth and resilience through adversity; Joseph & Linley, 2006; Kennedy et al., 2010; Pollard & Kennedy, 2007; Tedeschi & Calhoun, 2004; Tedeschi, Park, & Calhoun, 1998); and challenge (used as a generic term for Lazarus-derived, future-oriented, primary appraisal concept; Kennedy et al., 2009; Kennedy et al., 2012).
These coping efforts demonstrate that post-impact coping, despite its origination from a stressful and loss-associated past event, nevertheless, is not bound by past orientation and, frequently, spans the entire range of the human temporal experience. Put differently, the post-CID experience often necessitates the engagement of both proactive (e.g., anticipating future barriers, transcending life constraints) and presently active (e.g., confronting ongoing stresses and restrictions, defusing negative affective states) sets of coping efforts to restore perceived pre-CID QOL, or any QOL level commensurate with one’s present abilities, skills, plans, and hopes. Indeed, research focusing on future-oriented, positive post-impact coping, as manifested by the engagement of the earlier mentioned coping strategies of (a) sustaining hope, (b) finding benefits in the experience of CID, (c) searching and making meaning and purpose in one’s life following the onset of CID, (d) sustaining self-efficacy beliefs, and, in general (e) experiencing post-CID growth, has documented that positively valenced post-impact coping is uniquely meritorious in overcoming past losses and seeking to achieve positive and satisfying level of future QOL (e.g., Carver et al., 1994; deRoon-Cassini et al., 2009; Dunn, 1996; Kortte et al., 2010; Schou, Ekeberg, Sandvik, Hjermstad, & Ruland, 2005; Smedema et al., 2010). For example, post-impact, future-oriented, positive coping modalities, such as those outlined earlier, have demonstrated their positive influence on improved QOL in a wide range of CIDs including, but not limited to, SCI (Pollard & Kennedy, 2007), traumatic brain injury (Moore, Stambrook, & Gill, 1994), multiple sclerosis (Pakenham, 2005), epilepsy (Amir, Roziner, Knoll, & Neufeld, 1999), heart disease (Garnefski, Kraaij, Schroevers, & Somsen, 2008), cancer (Manne et al., 2004), limb amputation (Oaksford, Frude, & Cuddihy, 2005), and general rehabilitation populations (Kortte et al., 2012). The recognition that positive and future-oriented coping efforts exert a powerful influence on the QOL of people with CID ushers several important implications to the field of rehabilitation. Several of these are addressed in the following paragraphs.
Implications to Rehabilitation Theory
The distinction between past-oriented, negatively valenced and present- and/or future-oriented, positively valenced approach to post-impact (e.g., CID) coping is also implicitly, even if not always explicitly, portrayed in several of the leading models of psychosocial adaptation to CID. For example, two of the leading models of psychosocial adaptation to CID are those of Devins (Illness Intrusiveness model; Devins, Bezjak, Mah, Loblaw, & Gotowiec, 2006; Devins et al., 1993) and Bishop (Disability Centrality model; Bishop, 2005; Bishop, Stenhoff, & Shepard, 2007). Although both models share a common core of concepts and mechanisms (Bishop, by his own admission, even argues that his model is an extension of the Devins’s model), and one would be hard-pressed to identify any glaring discrepancies between the two, they nevertheless intimate two distinct philosophical underpinnings that are rooted in discrepant views of human nature and time perspectives. Devins’s model is spawned by a traditional medical model that suggests the supremacy of concepts such as psychopathological processes, sickness, passivity, and functional deficits. These notions are clearly evidenced in the use of terms such as intrusiveness of disease, disruption of global lifestyle, burden of illness, and diminished participation in valued life functions. This philosophical framework is also anchored in the model’s overarching mostly, but not inclusively, unidimensional outcome measure of adaptation to post-impact CID, that of emotional distress–emotional well-being, as reflected in indicators of QOL such as mood disturbance, depressive symptoms, pessimism, and global psychopathological symptoms (Devins et al., 1993). The Illness Intrusiveness model, therefore, focuses mostly on the impact of past losses on present functioning and the “negative” aspects of the human CID experience, including lack of personal control over positive outcomes (which indicates truncated future possibilities) and perceptions of decreased capacity to influence such life outcomes (again suggesting that future options are limited). In contrast, Bishop’s model, despite recognizing some of these aspects, including the initial decrease in perceived personal control and the role played by negative emotions, nevertheless, incorporates a more positive, present- and future-oriented, and holistic rehabilitation philosophy. In this model, greater emphasis is placed on the person with CID’s ability to maintain satisfaction in, and positive control over, central life domains and reprioritize domain centrality to close existing gaps between present levels of experienced QOL and desired or expected (i.e., future-oriented) QOL (Bishop, 2005). Bishop’s positive, future-oriented notions are clearly evidenced by his emphasis on the use of processes that increase perceived control and rearrange domain importance, such as self-management, environmental accommodations, and rehabilitation interventions, all indicating a dynamic approach to changes in centrally important domains. Furthermore, Bishop’s model adopts a broader and more inclusive view of the QOL concept, as exemplified in its multidimensional view on various life domains (e.g., physical health, mental health, work, leisure activities, social relationships, spirituality) and their role in psychosocial adaptation to CID.
Implications to Rehabilitation Practice
Unlike their disengagement, mostly past-oriented post-impact coping modalities (e.g., avoidance, escape, denial, wish fulfillment, self- or other-blame), post-impact engagement coping (e.g., problem focusing, planning, positive reframing, active acceptance, seeking social support) and coping resources (e.g., hope, optimism, benefit finding, meaning making) are mostly future-oriented. Disengagement coping efforts are, in general, oriented toward past events. For example, blaming self or others for CID onset focuses on irrevocable past losses and the reasons for their occurrence. Wish fulfillment can be equated with attempts to negate or nullify the reality of CID and avoiding confrontation with a realistic CID-experienced future. In contrast, engagement coping and the use of positive coping resources are, in general, squarely anchored in present experiences and, likewise, view the future more favorably and as realistically changeable (e.g., hope, optimism, planning, seeking social support). Furthermore, whereas the former modalities largely dwell on the sustained losses and functional deficits (e.g., CID) or seek to negate their reality by adopting subterfuge mechanisms, the latter modalities focus on efforts that seek to build on remaining functions and available skills and resources.
Adoption of future-oriented post-impact engagement coping strategies and tapping into available positive coping resources have been, indeed, repeatedly documented to promote higher levels of perceived QOL among a wide range of people with CID (Elfstrom & Kreuter, 2006; Livneh & Wilson, 2003; McMillen & Cook, 2003; Pakenham, 2006; Sears, Stanton, & Danoff-Burg, 2003). In contrast, when post-impact coping has been limited to past-oriented (or, separately, future-truncated) disengagement coping strategies, the literature has conclusively shown decreased reports of QOL by people with CID, as indicated by higher levels of post-CID depression and anxiety, and lower levels of perceived well-being and life satisfaction (e.g., Kemp & Krause, 1999; McCabe, Stokes, & McDonald, 2009; M. K. Wagner, Armstrong, & Laughlin, 1995). Rehabilitation practitioners, therefore, would benefit from promoting client awareness of their available coping resources and use of future-oriented, engagement coping strategies. In addition, discouraging client use of past-oriented, disengagement, loss-dominated coping strategies should be identified and discouraged. Post-impact, future-oriented coping intervention modules that address CID-related psychosocial adaptation have been developed and successfully implemented by Radnitz (2000), Kennedy and colleagues (Kennedy, 2008; Kennedy, Duff, Evans, & Beedie, 2003), and Sharoff (2004). These coping interventions rely, largely, on the use of cognitive restructuring and reframing skills, problem-solving skills, planning for future eventualities, and related cognitive-behavioral interventions, all seeking to bolster engagement coping skills.
Another temporally based clinical intervention that provides fruitful implications to serving individuals who sustained CID can be found in the work of Zimbardo and colleagues (Sword, Sword, Brunskill, & Zimbardo, 2014; Zimbardo & Boyd, 2008). Derived from Zimbardo’s temporal theory (Zimbardo & Boyd, 2008), the authors developed an intervention modality known as Time Perspective Therapy (TPT). In this theoretical and clinical approach, time is perceived as psychological time, that is, a subjective, flexible, and dynamic concept, rather than an objective, rigid, scientifically measured duration of time. In this approach, the rehabilitation professional is concerned with the perception of experienced past and present events (including CID-triggering situations and currently held beliefs and perceptions), and their impact on future goals and plans, rather than with their actual temporal unfolding.
Among TPT’s essential operating principles are the following: (a) Human time experience or perception can best be compartmentalized into six (originally five) time zones that include past positive (focusing on “good experiences”), past negative (focusing on failure and losses), present hedonistic (focusing on pleasurable experiences), present fatalistic (focusing on inability to control life situations), future (focusing on goals and objectives), and (more recently) future transcendental (for a detailed discussion of each zone the reader is referred to Zimbardo & Boyd, 2008); (b) TP is a learned human experience and latently influences most cognitions, decisions, and behaviors; (c) humans develop time zone biases, such that they tend to over- or under-employ certain time zones when they engage in action-based judgments and decisions; (d) overuse of any time zone(s), especially past negative (“getting stuck in the past”) could have dire consequences to one’s psychological well-being; and (e) individuals function best when they develop and implement a balanced and flexible TP, adapted to their current, dynamic, and continuously unfolding life situations (Sword et al., 2014; Zimbardo & Boyd, 2008). The clinical thrust of TPT, therefore, rests on the premise that past-oriented people make decisions and act according to both negative and positive (even if no longer appropriate) memories of similarly encountered situations. Future-oriented individuals, in contrast, reach their decisions and initiate behaviors based on rational assessment of anticipated consequences and probability of success.
In the context of adaptation to CID, TPT can be best implemented through both making the negative past (onset of CID, the functional losses incurred, and the experienced psychological impact) more manageable and extending the perceived timeline further into the future, a zone where the pursuit of positive goals, the use of coping resources such as hope and optimism, and the employment of future-oriented engagement coping skills, all serve to balance out the time zone bias of the negative past. To keep this balance intact, the rehabilitation professional seeks to continuously juggle efforts to minimize reliance on the past negative zone (e.g., the use of past-oriented, disengagement-like coping strategies and negative thoughts), leveraging the present (mostly hedonistic) zone to initiate new and realistic life goals and plans, as well as bolstering self-confidence/efficacy, and ultimately ensuring that the positively valenced future time zone gains supremacy in the client’s life (Sword et al., 2014; Zimbardo & Boyd, 2008). Although TPT is a relatively nascent therapeutic intervention, and requires additional supportive documentation of its merits, preliminary documentation of the association between time perception and psychosocial adaptation to CID (i.e., cardiac disease, diabetes) has been reported in the literature (e.g., Hamilton, Kives, Micevski, & Grace, 2003; Livneh & Martz, 2007).
Implications to VR
The field of VR has traditionally focused on helping people with CID seek and secure employment commensurate with their functional level, skills, and abilities. Two pivotal concepts that have undergirded much of the success incurred by VR are those of strengthening client (functional) life skills and motivation level. As viewed from a post-impact, future-oriented, positively valenced coping perspective, both concepts acquire additional meaning that can serve to further elucidate their importance and usefulness. Life skills have been operationalized as skills that include self-direction and determination skills, self-care skills, employment skills, work tolerance skills, and communication skills (Chan, Rubin, Lee, & Pruitt, 2003; da Silva Cardoso, Blalock, Allen, Chan, & Rubin, 2004). These skills, when acquired post impact, exemplify future-oriented, engagement-like coping modalities, and have been shown to be positively associated with subjective well-being. Furthermore, VR services geared toward improving these life skills were also found to improve reported QOL (da Silva Cardoso et al., 2004). These findings, demonstrating the benefits accrued by the use of future-oriented vocationally adaptive skills and life-functioning skills within the world of work, and their impact on clients’ QOL, have prompted rehabilitation researchers (Rubin, Chan, Bishop, & Miller, 2003; Rubin, Chan, & Thomas, 2003) to maintain that QOL may be a better predictor of long-term rehabilitation success, because life-functioning skills, in general, and employability skills, more specifically, require extended time to be fully internalized and successfully processed. It can, therefore, be argued that when applied to VR services, the careful implementation of programs that focus on future-oriented (both proximal and distal), adaptive life coping skills that seek to comprehensively instill physical (i.e., self-care), psychological (i.e., self-direction and determination), social (i.e., communication), and vocational (i.e., work tolerance, performance of specific job activities) is likely to promote higher perceived QOL and, relatedly, long-term vocational success. This assumed link of post-impact engagement coping strategies→ functional life skills→ improved QOL→ successful vocational outcomes certainly merits further exploration and verification.
The importance of the second concept, that of client motivation level, has been well recognized by practitioners in the field of VR for more than half a century, but has experienced a renewed clinical and empirical interest with the advent of the therapeutic approach known as motivational interviewing (MI; Miller & Rollnick, 2002; C. C. Wagner & McMahon, 2004). It is beyond the scope of this article to faithfully address the many features and innovations of the MI approach to VR, but its shared elements with post-impact, future-oriented coping skills must be recognized. MI can be best understood as a goal- (i.e., future-) oriented, self-determination- (i.e., adaptive coping-) enhancing, and change-of-life seeking approach to promote client motivation, explore and resolve ambivalence, and ultimately change maladaptive cognitions and behaviors and replace them with adaptive ones (Chou, Ditchman, Pruett, Chan, & Hunter, 2009; Miller & Rollnick, 2002). The MI approach emphasis on empathic listening; seeking, planning, and implementing specific goals (e.g., health-related, vocational); and committing oneself to needed changes, is akin to that undertaken by rehabilitation professionals who seek to train their clients in the use of engagement-type, adaptive coping skills that focus on the judicial and proficient use of such coping strategies as using emotional and instrumental support, cognitive reframing, and active planning to enhance successful psychosocial adaptation to CID. Both approaches share a common, overarching mission that focuses on (a) promoting autonomy and responsibility in implementing changes and adaptation to life both pre-CID (e.g., health maintenance, disease prevention; see earlier discussion on PP, and pre-impact and preventive coping) or following CID onset (e.g., substance abuse, SCI, cardiovascular disease); (b) relying on decision-making and problem-solving skills to chart one’s therapeutic course while implementing life (e.g., health-oriented, psychosocial, vocational) changes; (c) boosting self-efficacy/confidence during the process of adaptation to CID, including the acquisition of job skills and increasing employment opportunities; and (d) encouraging hope and optimism, both perceived as future-oriented motivational tools and coping resources, when seeking behavioral changes, psychosocial adaptation, and successful employment (Chou et al., 2009; C. C. Wagner & McMahon, 2004). Bolstering client motivation and enhancing future-oriented life changes, as envisioned by proponents of the MI approach, are highly commensurate with the future-oriented, engagement coping–type therapeutic framework advocated by psychosocial rehabilitation professionals. Both approaches have amassed an impressive body of clinical and empirical literature to support their usefulness, although they have followed separate professional routes. It is hoped that by recognizing both approaches’ underlying theoretical and clinical commonalities, rehabilitation professionals from both camps will seek to cross-fertilize the bodies of knowledge and strengths inherent in both approaches, thus benefitting the rehabilitation field as a whole.
Implications to Rehabilitation Research
As was observed earlier in this article, although post-impact coping strategies emanate from past traumatic events (e.g., injuries, life-threatening diagnoses), they are by no means exclusively past-oriented and, in fact, often focus on presently encountered obstacles and barriers, as well as anticipated future issues. Indeed, it is the latter coping orientation that has been often associated with successful psychosocial adaptation, better QOL, and positive rehabilitation outcomes. One area that rehabilitation researchers may wish to address, and further clarify, is the nature of the relationships between these coping strategies and psychosocial adaptation. For example, do these strategies directly influence perceived QOL (e.g., life satisfaction, well-being) and other, more objective indicators of QOL (e.g., community integration, occupational success) among people with CID, or are these relationships further mediated or moderated by (a) specific psychological mechanisms such as cognitive processes, appraisal, (control) belief system, motivational level, flexibility, and range of coping modes; (b) various situational determinants; and (c) degree, duration, or severity of the stress itself (Folkman & Lazarus, 1988; Folkman & Moskowitz, 2004; Mattlin, Wethington, & Kessler, 1990; Moos & Holahan, 2003; Terry, 1994). Furthermore, it would be of interest to learn what mechanisms and post-CID experiences may exist, which differentiate between these successful future-oriented coping strategies and those that are past-oriented and typically associated with poorer adaptation.
Another fruitful area for research efforts includes the study of how the use, nature, and dynamics of these post-CID future-oriented (e.g., proactive, anticipatory) coping strategies differ from future-oriented coping in the absence of CID, that is, coping strategies that are not triggered by traumatic onset but rather by mere anticipation and wish to prevent future events (the more traditional future-oriented coping). Researchers may also wish to consider another potential venue that focuses on investigating whether the scope, frequency, and clinical efficacy of post-CID coping strategies differ according to such CID-related characteristics as nature of onset (e.g., gradual, sudden), time of onset, duration of condition, severity of the CID, its course (e.g., stable vs. variable; predictable vs. unpredictable), and so on.
Finally, in certain situations, it is expected that both pre-emptive (e.g., anticipatory) and post-CID coping will occur. These situations involve medical procedures such as planned surgery (e.g., limb amputation, mastectomy, open heart surgery) and side effects of administered medication (e.g., chemotherapy, radiation therapy) among others. Research could shed light on such intriguing questions as what transitions in coping strategies, from pre event to post event, predict better psychosocial adaptation and reported QOL. Put differently, is there an “ideal” or beneficial coping transition (e.g., a particular pattern of pre-event to post-event set of coping strategies) that can predict better psychosocial adaptation, as indicated by such outcome measures as assessed QOL, perceived well-being and life satisfaction, level of depression and anxiety, and even non-psychological outcomes such as level of experienced pain, degree of functional abilities, extent of social pursuits, and community integration.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.