Social Problem-Solving Abilities and Adjustment to Recent

Rehabilitation Psychology
November 1999 Vol. 44, No. 4, 315-332
© 1999 by the Educational Publishing Foundation
For personal use only--not for distribution.
Social Problem-Solving Abilities and Adjustment to Recent-Onset
Spinal Cord Injury
Timothy R. Elliott
Department of Physical Medicine and Rehabilitation University of Alabama at
Objective: To examine the relation of social problem-solving abilities to
psychological and physical adjustment of persons with recent spinal cord injuries
(SCIs). Design: Correlational procedures were used. Participants: One hundred
eighty-six persons with recent SCI completed self-report measures during inpatient
rehabilitation; 94 returned for an annual evaluation. Main Outcome Measures:
Acceptance of disability, career needs, and pressure sore diagnoses. Results: Greater
negative problem orientation predicted each self-report outcome variable;
completeness of lesion was the best predictor of pressure sore diagnosis. Conclusions:
The problem orientation component appears to relate to self-reported adjustment
among persons with SCI in a theoretically consistent fashion.
Social problem solving entails the instrumental, cognitive—behavioral attitudes and
skills necessary for adjustment in everyday life and for coping effectively with events
encountered in living ( D'Zurilla & Nezu, 1982 ). Because most problems are
encountered within a social and interpersonal context, the emphasis on social problem
solving distinguishes these skills from the more purely cognitive abilities studied in
controlled laboratory situations ( D'Zurilla & Maydeu-Olivares, 1995 ). Contemporary
models stipulate that social problem-solving attitudes and skills are implicated in the
prevention, development, and maintenance of adjustment difficulties experienced by
people in general ( D'Zurilla & Nezu, 1990 ; Nezu & D'Zurilla, 1989 ).
D'Zurilla and colleagues conceptualized two components of social problem solving
labeled problem orientation and problem-solving skills (e.g., D'Zurilla & Nezu, 1990
). The problem orientation component is delineated into positive and negative
elements. A positive orientation entails beliefs, expectancies, and abilities that
motivate a person through problem solving and promote positive emotions that
facilitate effective problem solving. In contrast, a negative orientation is characterized
by pessimistic appraisals of the self and negative expectancies for future behavior and
events. Individuals who possess a negative orientation toward problem solving often
experience difficulties regulating their mood, and they are often pessimistic about
their abilities to solve both routine and complex problems of everyday life.
Consequently, these individuals have a lowered sense of competence when facing
problems and may lack the necessary motivation for adaptive and effective problem
solving. They then encounter difficulties in solving the problems that they face, in
turn reinforcing their negative problem orientation ( Nezu, 1987 ).
There is evidence that the problem orientation component possesses mood-regulatory
properties that predict the development and maintenance of depressive behavior (
Elliott, Shewchuk, Richeson, Pickelman, & Franklin, 1996 ). Prior research has
shown that a negative problem orientation is significantly associated with trait
negative affectivity ( Elliott, Herrick, MacNair, & Harkins, 1994 ), worry ( Dugas,
Letarte, Rheaume, Freeston, & Ladouceur, 1995 ), health complaints ( Elliott &
Marmarosh, 1994 ), depressive behavior ( Elliott, Godshall, Herrick, Witty, & Spruell,
1991 ), and the rate of cognitive errors committed in an objectively defined problemsolving task ( Shewchuk, Johnson, & Elliott, in press ).
The second component of the social problem-solving model encompasses the
cognitive—behavioral skills used in actual problem solving. These include abilities to
define a problem; generate alternatives; evaluate, implement, and monitor solutions;
and make rational decisions ( Nezu & D'Zurilla, 1989 ). The presumed properties of
this component have also received empirical scrutiny. Tendencies to avoid problem
solving are associated with greater sedentary leisure activity and increased alcohol
consumption ( Godshall & Elliott, 1997 ) and with irrational decision-making styles
among college students ( Chartrand, Rose, Elliott, Marmarosh, & Caldwell, 1993 ).
Moreover, tendencies to avoid problem solving are associated with the occurrence of
secondary complications among persons with severe physical disabilities, indicating
that problem-solving skills may be associated with health outcomes that are mediated
by behavioral mechanisms ( Herrick, Elliott, & Crow, 1994 ). In the Herrick et al.
study, greater avoidance of problem solving was associated with increased likelihood
of pressure sore occurrence 1 year after the initial assessment of problem-solving
Several issues remain unresolved in research on social problem-solving abilities. For
example, there is some concern that the relation of the problem orientation component
to emotional adjustment may be mediated by prior levels of distress or negative affect
(see Elliott, Sherwin, Harkins, & Marmarosh, 1995 , Study 4). Thus, cross-sectional
evidence linking problem solving with self-reported adjustment may be confounded
by ongoing levels of distress that contaminate both the measurement of problemsolving abilities and adjustment at the time of assessment. The need also exists to
replicate the results of the Herrick et al. (1994) study, which involved a rather small
sample of participants who varied considerably in chronicity.
The present study examined the relation of social problem-solving abilities to
psychological adjustment and physical health among persons with recent-onset
physical disability. In line with the social problem-solving model, it was expected that
the problem orientation component would be significantly associated with personal
acceptance of disability reported by persons with recent-onset physical disability after
taking into consideration previous levels of distress measured on admission to a
medical rehabilitation program. Acceptance of disability involves a shift in personal
values after extreme physical loss, along with an elevation of intrinsic aspects of the
self and devaluation of the physique, and it often indicates that a person has found
meaning in his or her circumstances ( Wright, 1960 ). If the problem orientation
encompasses cognitive and motivational properties, as delineated in the D'Zurilla
model, greater acceptance of disability should be associated with a greater positive
and a lower negative orientation, regardless of previous levels of distress or the
objective impairment imposed by the disability.
Subjective well-being and optimal adjustment over time among persons with physical
disability are often higher among those with active and meaningful vocational and
leisure pursuits ( Krause, 1991 ). Unfortunately, little is known about the careerdecision-making needs of individuals with permanent health impairments. On the
basis of prior work (e.g., Chartrand et al., 1993 ), it was expected that the problem
orientation component would be associated with career decisional needs reported by
persons facing discharge from a medical rehabilitation program. A negative
orientation would be associated with more decisional needs, because individuals with
these characteristics are probably preoccupied with negative emotional reactions
when considering vocational options after their return to the community. In contrast,
effective problem-solving skills should be associated with more career informational
needs. Those with more instrumental, proactive problem-solving strategies would
probably seek out and request information that could facilitate career decision
making, consistent with the Chartrand et al. (1993) findings.
It is also important to examine the relation of the problem-solving skills component
with the occurrence of secondary complications mediated by behavioral pathways.
Individuals who incur disabilities that restrict mobility and disrupt central nervous
system function are at risk for developing skin ulcerations. These "pressure sores" are
usually prevented by adhering to recommended regimens for shifts in body weight
(ranging in 15-min to 45-min intervals), routine skin inspections, proper nutrition and
water intake, and avoidance of damaging stimuli (e.g., extreme heat or cold, jagged
edges, and ill-fitting equipment or clothing). Treatment of pressure sores is expensive
both to the person (in terms of lost productivity and "downtime" required for skin
healing) and to the health care system (in meeting the expense of treatment and
service delivery). Therefore, this study tested the hypothesis that problem-solving
skills predict occurrence of pressure sores 1 year after patient discharge from a
rehabilitation program.
One hundred eighty-six individuals admitted for inpatient medical rehabilitation were
consecutively referred for psychological assessment as part of their rehabilitation
program. All were admitted within 1 year of the initial onset of the condition.
Admission to the unit was predicated on the medical stability of the individual,
funding resources available to reimburse the facility for providing rehabilitation, and
willingness of the patient to be admitted and participate in a rigorous rehabilitation
program. Of those admitted and referred for assessment, 80 had incurred tetraplegia,
and 94 had sustained paraplegia. Twelve individuals had injuries to the lower regions
of the spine, resulting in cauda equina injuries or spinal stenosis, or had incurred
multiple fractures to the pelvis that affected cord functions. Ninety-seven had incurred
complete lesions to the spinal cord, resulting in a complete and measurable loss of
function and sensitivity to touch below the site of the lesions. Eighty-nine others had
sustained incomplete lesions of the cord (resulting in some sensitivity to touch or
some residual motor function below the site of the lesion). The sample included 140
men and 46 women. Participants were an average of 31.83 years of age ( SD = 11.72)
and had 11.91 years of formal education ( SD = 2.17). Participants averaged 6.10
weeks ( SD = 6.14) since the onset of injury at admission to the program. The sample
comprised Caucasians ( n = 123) and African Americans ( n = 63).
All participants were administered a measure of depressive behavior on referral for
psychological assessment. This information is used in staff consultations, in
developing clinical interventions for the patient, and in planning certain aspects of the
rehabilitation program. Before leaving the rehabilitation program, patients underwent
psychological evaluation to assess psychological adjustment, career-related concerns
and needs, and cognitive—behavioral characteristics (e.g., problem-solving abilities)
relevant to outpatient follow-up programs. At a later date, staff affiliated with the
clinic and the Model Systems database project set outpatient appointments with
eligible participants for an annual evaluation conducted by a board-certified
Measures Depressive behavior.
The Inventory to Diagnose Depression (IDD; Zimmerman & Coryell, 1987 ) is a 22item measure of depressive behavior ( Zimmerman, Coryell, Corenthal, & Wilson,
1986 ). Acceptable test—retest reliability (.98 over 2 days) and internal consistency
(.92) coefficients have been reported; correlations with interview systems and other
self-report measures of depression have also been adequate (ranging from .80 to .87;
Zimmerman & Coryell, 1987 ; Zimmerman, Coryell, Corenthal, & Wilson, 1986 ;
Zimmerman, Coryell, Wilson, & Corenthal, 1986 ). Each item is rated on a 5-point
scale ranging from no presence of the symptom (0) to severe symptomology (4). The
sum of the responses provides a total severity score. Higher scores reflect the
endorsement of more depressive behaviors. The IDD is recommended as a useful tool
in the assessment of people with spinal cord injuries ( Elliott & Frank, 1996 ). It was
administered at admission to the program.
Social problem-solving abilities.
The Social Problem Solving Inventory—Revised (SPSI-R; D'Zurilla, Nezu, &
Maydeu-Olivares, in press ) is a 52-item self-report measure of social problem
abilities. Each item is rated on a 5-point Likert-type scale ranging from not very true
of me (0) to extremely true of me (4). The SPSI-R is based on a five-dimensional
model of problem solving and includes five scales ( Maydeu-Olivares & D'Zurilla,
1996 ). Two of the SPSI-R scales measure problem orientation dimensions: Positive
Problem Orientation and Negative Problem Orientation. The remaining three scales
are considered problem-solving skills scales: Rational Problem Solving,
Impulsive/Careless Style, and Avoidance Style (AS).
The Positive Problem Orientation scale assesses a general cognitive set that includes
the tendency to view problems in a positive light, to see them as challenges rather
than threats, and to be optimistic regarding the existence of a solution and one's ability
to detect and implement effective solutions. The Negative Problem Orientation scale
assesses a cognitive—emotional set that hinders effective problem solving. The
Rational Problem Solving scale assesses the tendency to systematically and
deliberately use effective problem-solving techniques that include defining the
problem, generating alternatives, evaluating alternatives, and implementing solutions
and evaluating outcomes. The Impulsive/Careless Style scale measures a tendency to
implement skills in an impulsive, incomplete, and haphazard manner. The Avoidance
Style scale assesses dysfunctional patterns of problem solving characterized by
putting the problem off and waiting for problems to solve themselves.
Internal consistency estimates (alphas) for the scales in a sample of college students
ranged from .76 (Positive Problem Orientation) to .92 (Rational Problem Solving),
and test—retest (3 weeks) reliability ranged from .72 (Positive Problem Orientation)
to .88 (Negative Problem Orientation; D'Zurilla et al., in press ). Criterion-referenced
validity is evidenced by significant correlations with relevant scales on the Problem
Solving Inventory (PSI; Heppner, 1988 ) and with other theoretically related
constructs as stress, somatic symptoms, anxiety, depression, hopelessness, and
suicidality ( Chang & D'Zurilla, 1996 ; D'Zurilla et al., in press ). The SPSI-R scales
have been predictably associated with self-esteem, life satisfaction, extraversion,
social adjustment, and social skills ( D'Zurilla et al., in press ). The SPSI-R was
administered in the discharge evaluation.
Acceptance of disability.
The Acceptance of Disability scale (AD; Linkowski, 1971 ) is a 50-item measure of
adjustment among persons with disability according to the dimensions defined by
Wright (1960) . Specifically, the scale assesses the degree to which people are able to
find meaning in their circumstances, value their selfhood, and maintain positive
beliefs about themselves ( Linkowski, 1971 ). Each item is rated on a 6-point Likerttype scale ranging from disagree very much (1) to agree very much (6). The measure
has evidenced adequate internal consistency ( Linkowski, 1986 ). Several studies have
found the scale to be a sensitive index of adjustment among persons with a variety of
debilitating and chronic conditions ( Linkowski, 1986 ). The AD scale was
administered at discharge from the program.
Career decisional and informational needs.
The Career Factors Inventory (CFI; Chartrand & Robbins, 1997 ) is a 21-item
instrument designed to assess antecedents of career indecision. The CFI includes four
scales: Career Choice Anxiety (6 items), Generalized Indecisiveness (5 items), Need
for Career Information (6 items), and Need for Self-Knowledge (4 items). The
response format for each item ranges from 1 ( strongly disagree ) to 5 ( strongly agree
). The CFI subscales have evidenced adequate internal consistency coefficients
(ranging from .73 to .86), and 2-week test—retest reliability estimates have ranged
from .79 to .84 ( Chartrand & Robbins, 1997 ). Because the CFI scales are essentially
hypothetical constructs, evidence of construct validity is particularly important. The
manual reports several important correlates of the two separate CFI factors with
established measures of career decision making, career development patterns, and
career-related adjustment ( Chartrand & Robbins, 1997 ).
Career Choice Anxiety and Generalized Indecisiveness scores are summed to provide
a single index of career decisional needs, and Need for Career Information and Need
for Self-Knowledge scores are combined to provide a single index of career
informational needs ( Chartrand & Robbins, 1997 ). These two indexes were used as
criterion variables. The CFI was a part of the discharge psychological evaluation.
Pressure sore diagnosis at annual evaluation.
The presence of any pressure sore was determined by the physiatrist who conducted
the yearly medical evaluation of a returning participant. These sores are diagnosed by
visual inspection in a manner consistent throughout the cooperating Model Systems
centers ( Enis & Sarmiento, 1973 ). Although pressure sores can be rated in terms of
severity, it was sufficient, for our purposes, to code pressure sores as absent (coded as
0) or present in any number (coded as 1). This information is archived in the national
Model Systems database for use in clinical research projects.
Statistical Analyses
Hierarchical regression equations were computed to test each hypothesis about the
relation of social problem-solving abilities to adjustment at discharge. An alpha level
of p < .05 was used to determine significance. Following recommendations for using
regression procedures for hypothesis testing with the social problem-solving variables
( Elliott et al., 1995 ; Godshall & Elliott, 1997 ), conservative procedures were used to
enter the problem-solving variables in separate steps based on a priori predictions.
Thus, in the equation to predict acceptance of disability, it was expected that the
problem orientation variables would be uniquely predictive of acceptance, according
to the presumed properties of this particular component. A block of relevant
demographic characteristics was entered in the first step to control for any variance in
the criterion variable attributable to these characteristics. Specifically, level of spinal
cord injury (coded as tetraplegia [1 or 0], paraplegia [1 or 0], or cauda equina [1 or
0]), lesion (coded as 1 [incomplete] or 2 [complete]), years of education, and age were
entered as a block in the first step of the equation. Depressive behavior (as reflected in
the IDD total score) was then entered in the second step. The three problem-solving
skill subscales (Rational Problem Solving, Impulsive/Careless Style, and Avoidance
Style) were then entered in the third step of the equation. In the final step, the two
problem orientation variables were entered (Negative Problem Orientation and
Positive Problem Orientation). This permitted a stringent test of the presumed
relationship between problem orientation and acceptance of disability.
A similar approach was used to predict career decisional needs at discharge. The
problem orientation variables should be uniquely predictive of career decisional
needs. The four demographic variables were entered as a block in the first step of the
equation. In the second step, the depression and acceptance of disability scores were
entered as a block to control for any variance in the criterion variable attributable to
these indexes of adjustment at admission and at discharge from the program. As a
means of testing the presumed and unique relationship between the problem
orientation component and career decisional needs, the three problem-solving skills
subscales were entered in the third step of the equation, followed by the two problem
orientation variables in the final step. However, in the equation to predict career
informational needs at discharge, prior research suggests that problem-solving skills
should have a unique relationship with informational needs ( Chartrand et al., 1993 ).
Therefore, in this final regression equation, the problem orientation variables were
entered in the third step, and the three problem-solving skill variables were entered in
the final step to test this presumed association.
Logistic regression was used to predict pressure sore diagnosis at the annual medical
evaluation. Predictor variables entered simultaneously into the equation included the
four demographic variables and the five problem-solving subscale variables.
Means and standard deviations on the self-report variables are presented in Table 1 .
Correlations used in the regression equations are presented in Table 2 , and results of
the three hierarchical regression equations are shown in Table 3 . Unequal amounts of
participant data were available for statistical tests. This was due primarily to missing
and incomplete data across the different measures. A few persons ( n < 15) were
discharged before assessment, declined to complete all of the instruments, or did not
complete the battery because of a lack of time. Statistical tests were conducted for
each criterion variable on the available number of participants after listwise deletion
of missing data.
Acceptance of Disability
Of the block of four demographic variables entered in the first step of the equation,
education,  = .16, t (181) = 2.20, p < .05, emerged as a significant predictor (see
Table 3 ). In the second step, higher levels of depressive behavior at admission were
significantly associated with lower acceptance of disability scores at discharge, and
this accounted for an additional 15% of the variance in this variable. Of the three
problem-solving skills entered in the third step of the equation, two were significantly
associated with the criterion measure. Impulsive and careless problem-solving skills
were associated with less acceptance of disability,  = .29, t (177) = 3.32, p < .01;
better rational problem-solving skills were also significantly associated with greater
acceptance of disability,  = .15, t (177) = 2.39, p < .05. In the final step of the
equation, a negative problem orientation was associated with less acceptance of
disability,  = .23, t (175) = 2.09, p < .05; a positive problem orientation was
associated with greater acceptance of disability,  = .17, t (175) = 2.03, p < .05. As
predicted, the problem orientation component maintained a unique association with
acceptance of disability after initial levels of distress at admission had been
Career Decisional and Informational Needs
The block of demographic variables entered in the first step of the equation was
unrelated to career decisional needs at discharge. In the second step of the equation,
higher levels of depressive behavior,  = .23, t (160) = 2.94, p < .01, and less
acceptance of disability,  = .38, t (160) = 4.93, p < .001, were significantly
associated with greater decisional needs. Unexpectedly, greater tendencies to use
rational problem-solving skills were associated with fewer career decisional needs at
the next step of the equation,  = .17, t (157) = 2.37, p < .05. Consistent with
predictions, a greater negative problem orientation was significantly associated with
heightened career decisional needs,  = .49, t (155) = 4.01, p < .001, in the final step
of the equation.
Demographic variables were entered as a block in the equation to predict career
informational needs. Higher levels of education were associated with fewer career
informational needs,  = .27, t (162) = 3.45, p < .01. In the second step of the
equation, greater acceptance of disability was associated with fewer career
informational needs,  = .22, t (160) = 2.70, p < .01. A greater negative problem
orientation was unexpectedly associated with more career information needs,  = .24,
t (158) = 2.72, p < .01, in the third step of the equation. Contrary to theoretical
expectations, problem-solving skills did not significantly augment the equation at the
final step.
Prediction of Pressure Sore Diagnosis at Follow-Up
Ninety-four individuals returned to the outpatient clinic for the annual medical
evaluation. Comparisons between returnees and those who were not seen for the 1st
year annual evaluation revealed no significant differences between the two groups on
any of the self-report measures (problem solving, IDD, CFI, or AD), nor were
differences found in terms of age, education, race, gender, or cord lesion (level or
Of the individuals who returned for the annual evaluation, 69 had no pressure sores
and 25 had one or more pressure sores. A logistic regression equation including the
four demographic variables and the five social problem-solving variables as predictors
was computed, with a 27% classification cutoff (to reflect the actual distribution). The
resulting model was significant,  2 (10, N = 94) = 19.07, p < .05. As depicted in
Table 4 , completeness of lesion was the only variable that significantly contributed to
the prediction of pressure sore diagnosis ( B = 2.27, p < .01). Inspection of the partial
contribution of this variable–in the context of the other predictor variables–revealed
that persons with a complete lesion were 9.38 times more likely to have a positive
pressure sore diagnosis than persons with an incomplete lesion. The final model
correctly classified 65% of the sample assessed for pressure sores at the evaluation.
Forty-one persons were correctly classified as having no sore, and 20 persons were
correctly classified as having at least one sore. Twenty-eight persons were incorrectly
classified as having at least one sore, and 5 persons were incorrectly classified as
having no sore.
Post Hoc Analyses
Hierarchical regression procedures are preferred when testing theoretical assertions,
particularly when conservative approaches are used to maximize the falsifiability of a
predicted relationship. However, results from these procedures may be misinterpreted
with respect to the overall effect of a given relationship. For example, the problem
orientation component was significantly predictive of disability acceptance after
several demographic and self-report variables had been controlled, and this
association accounted for 4% of the unique variance in acceptance of disability
scores. This finding supports the theoretical properties of the problem orientation
component; however, it might inadvertently convey that such a result is somewhat
trivial in terms of clinical importance.
For a post hoc procedure, it may be useful to conduct forward-entry regression
equations for each criterion variable. This procedure permits the equation to select the
best and unique predictors of each criterion variable from a group of predictor
variables. Such procedures are not recommended for hypothesis testing, but they are
useful for identifying the best predictors from an array of variables and obtaining
some indication of the relative variance unique to the selected predictor variables.
Nevertheless, results from forward-entry equations should be interpreted with caution,
because they are associated with an increased likelihood of chance findings and
statistical artifacts.
In applying the forward-entry method to predict acceptance of disability from the selfreport and demographic variables contained in Table 2 , negative problem orientation
was selected as the best single predictor, F (1, 184) = 57.26, accounting for 24% of
the variance. Positive problem orientation, F inc (1, 183) = 13.38, R inc 2 = .05;
depression, F inc (1, 182) = 12.84, R inc 2 = .05 ; and impulsive—careless problem
solving, F inc (1, 181) = 8.13, R inc 2 = .03 , were selected into the equation as
predictors of unique variance in the criterion variable. No other variables were
significant predictors of acceptance of disability scores.
Similarly, negative problem orientation was the single best predictor of career
decisional needs, F (1, 165) = 53.66, accounting for 25% of the variance in the
criterion variable. Other significant predictors of career decisional needs included
acceptance of disability, F inc (1, 164) = 15.40, R inc 2 = .07 ; rational problem solving,
F inc (1, 163) = 8.13, R inc 2 = .03 ; and avoidant problem solving, F inc (1, 162) = 3.99,
R inc 2 = .02 . Lower acceptance of disability and lower scores on the rational and
avoidant problem-solving scales were associated with more career decisional needs.
No other variables were selected as significant contributors to this equation.
A negative problem orientation was also the best single predictor of career
informational needs, F (1, 165) = 22.75, and this accounted for 12% of the variance in
the criterion variable. Education was selected as the second best predictor, F inc (1,
164) = 13.34, R inc 2 = .07 . Lower levels of education were associated with more
career informational needs. No other variables were selected as significant predictors
in this equation.
Consistent with the predictions of this study and with prior research, the problem
orientation component was significantly predictive of disability acceptance and career
decisional needs among persons with spinal cord injury at discharge from inpatient
rehabilitation. The relationship of problem orientation to disability acceptance and
career decisional needs was not mediated by prior distress, injury severity, or
demographic characteristics. The problem orientation component may have
considerable motivational and cognitive properties, as posited in the D'Zurilla model,
and correlations between the problem orientation scales and outcomes variables may
not be solely attributable to prior distress observed at admission to the program.
It is possible that the problem orientation variables are associated with acceptance of
disability because of the unique features of these particular constructs. Acceptance of
disability encompasses more than emotional reactions to a physical disability. It
involves several cognitive and affective elements believed to be important in optimal
adjustment among those with chronic and debilitating health conditions. An
individual with a higher level of acceptance may experience a shift in values that
deemphasizes the more transitory and superficial aspects of physique and
attractiveness and elevates the values placed on spiritual and characterological
attributes of the individual ( Wright, 1983 ). This reflects a type of reality negotiation
as individuals come to terms with their condition and find meaning in their
circumstances ( Dunn, 1994 ). Conversely, individuals who are preoccupied with the
negative aspects of permanent disability and who are susceptible to ongoing bouts of
negative mood may evidence a greater negative orientation and experience subsequent
difficulties in coming to terms with their disability.
An intriguing association occurred between the social problem-solving variables and
the dimensions culled from the CFI. Past research has shown negative orientation to
be associated with greater decisional needs and effective problem-solving skills to be
associated with more informational needs among college students ( Chartrand et al.,
1993 ). A similar pattern was expected in this study. However, less education, lower
acceptance of disability scores, and a negative problem orientation were associated
with more career informational needs at discharge. The pattern of correlations (see
Table 2 ) suggests that greater informational needs were associated with a more
distressed profile on all self-report measures. This finding indicates that greater career
informational needs among these individuals might reflect a level of current
psychological distress exacerbated by a negative problem orientation. A desire for
more career information and training opportunities might not represent a proactive
approach to career issues, particularly among those with fewer psychological and
educational resources. Perhaps these individuals see themselves as possessing fewer
resources for making vocational decisions. Alternatively, it is possible that
interventions that address career-decision-making needs early in the rehabilitation
process also serve to allay some distress and provide a sense of direction. Generally,
this finding suggests that results from undergraduate samples concerning career
development processes–particularly with respect to the CFI and other decisionmaking variables in the career development literature–may not readily generalize to
those who incur severe and debilitating conditions that threaten or disrupt their
The lack of a relationship between social problem-solving variables and pressure sore
diagnosis merits some comment. Although earlier research showed an association
between problem solving and the occurrence of a pressure sore, this work involved a
sample of individuals who had been injured from several months to many years (
Herrick et al., 1994 ). It may be that social problem-solving abilities do not influence
adherence to self-care regimens in the 1st year after the onset of severe physical
disability. It is also possible that studies of health outcomes among people with severe
disabilities may be sensitive to the vagaries of clinic catchment areas. For example,
many individuals admitted to the facility in the present study were without insurance
coverage, and most held semiskilled and skilled jobs. Other clinics often refuse this
type of patient and admit only those who have adequate third-party coverage to pay
the costs of inpatient rehabilitation; such individuals often have higher levels of
education, work in professional ranks, and are admitted to inpatient rehabilitation
programs with fewer coexisting medical problems ( Stover, Whiteneck, & DeLisa,
1995 ). The unique nature of the sample from the present facility may have had an
influence on this study's inability to find a relationship between problem solving and
pressure sore occurrence.
There was also some indication that problem-solving skills are instrumental in the
adjustment process following disability in a manner unanticipated. A greater tendency
to solve problems in an impulsive, careless manner and a disinclination to use
rationale problem-solving skills were associated with less acceptance of disability at
discharge. Lower rational problem-solving skills scores were also associated with
greater career decisional needs. Apparently, effective problem-solving skills are
associated with less distress in general; one cannot infer from the present data
possible mechanisms by which these skills influence self-reported adjustment. These
findings may reflect the influence of a positive problem orientation. Theoretically,
those who have a more positive orientation are motivated to solve problems in a
proactive fashion. The problem orientation component appears to have considerable
motivational and cognitive properties, as posited in the D'Zurilla model.
The present results imply that individual differences may characterize those who are
more inclined to have difficulty in finding meaning following severe disability. Others
have commented on the lack of critical inquiry and rigorous empirical scrutiny of this
concept in the extant literature ( Dunn, 1994 ; Keany & Glueckauf, 1993 ).
Acceptance of disability may not necessarily be a process that evolves over time as a
person lives with the condition, as originally theorized (Wright, 1960 , 1983 ).
Converging evidence suggests that this variable may be a sensitive indicator of
current psychological adjustment, and it may reflect enduring social—cognitive
characteristics of the individual, regardless of time since injury onset and severity of
Alternatively, it should be noted that the problem-solving measure and the acceptance
of disability measure were administered at the same time, so one cannot rule out
potential circularity between these constructs as a function of distress at the time of
assessment. Post hoc analyses revealed that negative orientation was the most salient
predictor of each self-report criterion variable. Individuals who were experiencing
greater distress at discharge may have given more negative responses to the separate
questionnaires administered at discharge. It should be noted, however, that the
findings concerning negative orientation and distress are theoretically consistent with
the present understanding of social problem-solving abilities, and thus cognitive—
behavioral interventions can be used to address these issues from a problem-solving
perspective (e.g., Nezu & Perri, 1989 ).
It is possible that training in problem orientation and problem-solving skill
components, as delineated by D'Zurilla and Nezu (1990) , is beneficial to persons
receiving inpatient medical rehabilitation services. Training in the problem orientation
component appears to be particularly effective in addressing problems presented by
those who are diagnosed with depressive disorders ( Nezu & Perri, 1989 ). There is
other evidence to indicate that social problem-solving interventions are effective in
enhancing self-management skills ( Richards & Perri, 1978 ), which could facilitate
adherence to self-care behavioral regimens after patients return to the community.
These interventions can be suited to the inpatient setting, and they can be delivered to
those residing in the community (e.g., telephone counseling; Roberts et al., 1995 ).
Chang, E. C. & D'Zurilla, T. J. (1996). Relations between problem orientation and
optimism, pessimism, and trait affectivity: A construct validation study. Behavior
Research and Therapy, 34, 185-194.
Chartrand, J. & Robbins, S. (1997). The Career Factors Inventory: Manual. ( Palo
Alto, CA: Consulting Psychologists Press)
Chartrand, J., Rose, M., Elliott, T., Marmarosh, C. & Caldwell, S. (1993). Peeling
back the onion: Personality, problem solving, and decision making correlates. Journal
of Career Assessment, 1, 66-83.
Dugas, M. J., Letarte, H., Rheaume, J., Freeston, M. H. & Ladouceur, R. (1995).
Worry and problem solving: Evidence of a specific relationship. Cognitive Therapy
and Research, 19, 109-120.
Dunn, D. S. (1994). Positive meaning and illusions following disability: Reality
negotiation, normative interpretation, and value change. Journal of Social Behavior
and Personality, 9(5), 123-138.
D'Zurilla, T. J. & Maydeu-Olivares, A. (1995). Conceptual and methodological issues
in social problem solving assessment. Behavior Therapy, 26, 415-438.
D'Zurilla, T. J. & Nezu, A. M. (1982). Social problem solving in adults.( In P. C.
Kendall (Ed.), Advances in cognitive-behavioral research and therapy (Vol. 1, pp.
201—274). New York: Academic Press.)
D'Zurilla, T. J. & Nezu, A. M. (1990). Development and preliminary evaluation of the
Social Problem Solving Inventory. Psychological Assessment, 2, 156-163.
D'Zurilla, T. J., Nezu, A. M. & Maydeu-Olivares, A. Manual for the Social Problem
Solving Inventory-Revised (SPSI-R). ( North Tonawanda, NY: Multi-Health
Systems.(in press))
Elliott, T. & Frank, R. G. (1996). Depression following spinal cord injury. Archives of
Physical Medicine and Rehabilitation, 77, 816-823.
Elliott, T., Godshall, F., Herrick, S., Witty, T. & Spruell, M. (1991). Problem-solving
appraisal and psychological adjustment following spinal cord injury. Cognitive
Therapy and Research, 15, 387-398.
Elliott, T. R., Herrick, S. M., MacNair, R. R. & Harkins, S. W. (1994). Personality
correlates of self-appraised problem solving ability: Problem orientation and trait
affectivity. Journal of Personality Assessment, 63, 489-505.
Elliott, T. & Marmarosh, C. (1994). Problem solving appraisal, health complaints, and
health-related expectancies. Journal of Counseling and Development, 72, 531-537.
Elliott, T., Sherwin, E., Harkins, S. & Marmarosh, C. (1995). Self-appraised problem
solving ability, affective states, and psychological distress. Journal of Counseling
Psychology, 42, 105-115.
Elliott, T., Shewchuk, R., Richeson, C., Pickelman, H. & Franklin, K. W. (1996).
Problem-solving appraisal and the prediction of depression during pregnancy and in
the postpartum period. Journal of Counseling and Development, 74, 645-651.
Enis, J. E. & Sarmiento, A. (1973). The pathophysiology and management of pressure
sores. Orthopaedic Review, 2(10), 25-34.
Godshall, F. & Elliott, T. (1997). Behavioral correlates of self-appraised problemsolving ability: Problem-solving skills and health-compromising behaviors. Journal of
Applied Social Psychology, 27, 929-944.
Heppner, P. P. (1988). A manual for the Problem Solving Inventory. ( Columbia:
University of Missouri)
Herrick, S., Elliott, T. & Crow, F. (1994). Self-appraised problem solving skills and
the prediction of secondary complications among persons with spinal cord injuries.
Journal of Clinical Psychology in Medical Settings, 1, 269-283.
Keany, K. C. & Glueckauf, R. L. (1993). Disability and value change: An overview
and reanalysis of acceptance of loss theory. Rehabilitation Psychology, 38, 199-210.
Krause, J. S. (1991). Survival following spinal cord injury: A fifteen-year prospective
study. Rehabilitation Psychology, 36, 89-98.
Linkowski, D. C. (1971). A scale to measure acceptance of disability. Rehabilitation
Counseling Bulletin, 14, 236-244.
Linkowski, D. C. (1986). The Acceptance of Disability scale. ( Washington, DC:
George Washington University)
Maydeu-Olivares, A. & D'Zurilla, T. J. (1996). A factor analytic study of the Social
Problem Solving Inventory: An integration of theory and data. Cognitive Therapy and
Research, 20, 115-133.
Nezu, A. M. (1987). A problem solving formulation for depression: A literature
review and proposal of a pluralistic model. Clinical Psychology Review, 7, 121-144.
Nezu, A. M. & D'Zurilla, T. J. (1989). Social problem solving and negative affect.( In
P. Kendall & D. Watson (Eds.), Anxiety and depression: Distinctive and overlapping
features (pp. 285—315). San Diego, CA: Academic Press.)
Nezu, A. M. & Perri, M. G. (1989). Social problem solving therapy for unipolar
depression: An initial dismantling investigation. Journal of Consulting and Clinical
Psychology, 57, 408-413.
Richards, C. S. & Perri, M. G. (1978). Do self-control treatments last? An evaluation
of behavioral problem solving and faded counselor contact as treatment maintenance
strategies. Journal of Counseling Psychology, 25, 376-383.
Roberts, J., Brown, G. B., Streiner, D., Gafni, A., Pallister, R., Hoxby, H.,
Drummond-Young, M., LeGris, J. & Meichenbaum, D. (1995). Problem-solving
counselling or phone-call support for outpatients with chronic illness: Effective for
whom? Canadian Journal of Nursing Research, 27(3), 111-137.
Shewchuk, R., Johnson, M. & Elliott, T.Self-appraised social problem solving
abilities, emotional reactions, and actual problem solving performance. Behaviour
Research and Therapy., , (in press)
Stover, S. L., Whiteneck, G. G. & DeLisa, J. A. (1995). Spinal cord injury: Clinical
outcomes from the model systems. ( Gaithersburg, MD: Aspen)
Wright, B. A. (1960). Physical disability: A psychological approach. ( New York:
Harper & Row)
Wright, B. A. (1983). Physical disability: A psychological approach ( (2nd ed.). New
York: Harper & Row)
Zimmerman, M. & Coryell, W. (1987). The Inventory to Diagnose Depression (IDD):
A self-report scale to diagnose major depressive disorder. Journal of Consulting and
Clinical Psychology, 55, 55-59.
Zimmerman, M., Coryell, W., Corenthal, C. & Wilson, S. (1986). A self-report scale
to diagnose major depressive disorder. Archives of General Psychiatry, 43, 10761081.
Zimmerman, M., Coryell, W., Wilson, S. & Corenthal, C. (1986). Evaluation of
symptoms of major depressive disorder: Self-report vs. clinician ratings. Journal of
Nervous and Mental Disease, 174, 150-153.
This study was supported by a grant from the National Institute on Disability and
Rehabilitation Research (H133N5009). Appreciation is extended to Andrew Palmatier
for his assistance in collecting and managing data and to Michael DeVivo for his
statistical advice.
Correspondence may be addressed to Timothy R. Elliott, 530 Spain Rehabilitation
Center, University of Alabama, 1717 Sixth Avenue South, Birmingham, Alabama,
Electronic mail may be sent to [email protected]
Received: October 10, 1998
Revised: April 19, 1999
Accepted: April 20, 1999
Table 1. Means and Standard Deviations for Predictor and Criterion Variables
Table 2. Correlations Used in Regression Analyses
Table 3. Multiple Regressions of Social Problem Solving on Acceptance of Disability,
Career Decisional Needs, and Career Informational Needs
Table 4. Pressure Sore Predictive Model