The more a patient has evolved socially and psychologically, the better he or she will be at using adaptive methods to deal with crises. Hence, a patient with a healthy premorbid personality but a severe physical disability may do better in rehabilitation than one with a less severe disability and a pathological premorbid personality.44 When aware of their patients' personality styles, physical therapists will be more adept at strategizing interventions, developing a plan of care (POC), and motivating and guiding patients through rehabilitation.
Although each personality is unique, personalities have been categorized into different types, such as type A, perfectionistic, authoritative, and passive-aggressive. These personality types are nonpathological and develop in response to one's environment when young.
Individuals with type A personalities have a compulsive need to be achievers in all aspects of life. They are extremely independent and productive. These qualities also serve as defenses against low self-esteem and interpersonal conflicts. These people usually derive satisfaction from being strong individuals who can help others. If they can no longer participate in this role, they may become depressed because of a perceived inability to confirm their worth through altruistic activities. Physical therapists can use these qualities in patients with type A personalities to motivate their interest in rehabilitation. Because they are often self-starters and take initiative for their own learning, they can usually be depended on to independently practice home exercise programs (HEPs).
Individuals with perfectionistic personalities uphold high standards in order to maintain self-esteem. These individuals judge themselves by inflexible and possibly unachievable criteria and may not be able to tolerate slow progress during rehabilitation. Physical therapists may aid these patients by helping them derive pleasure from simple things, such as a meal, a sunset, a new shirt, or interesting information. Helping them discover value in these things offers them sources of self-esteem other than meeting impossibly high standards.
Individuals with authoritative personalities need to be in control and need things to be done in a particular way because of rigid perceptions regarding values, rules, and the manner in which others should behave. They are often concerned with status, tend to be judgmental, and have difficulty empathizing with others. During rehabilitation, these patients may try to dictate their treatment and engage in a power struggle with their physical therapists. Patients with authoritative personalities have difficulty adapting to disability, which often requires acceptance and compromise. They may require alternative strategies to solve what may have been perceived as an unsolvable problem. Physical therapists should engage patients in problem solving to generate strategies to meet their goals.
Individuals with passive-aggressive personalities express hostility by using passive techniques such as procrastination, resistance, stubbornness, and intentional inefficiency. These personalities react to authority negatively and have difficulty working with others. Physical therapists may work more efficiently with passive-aggressive patients by placing the responsibility for progress onto them. Patients can be instructed to make decisions about their treatment whenever possible and then summarize their progress after each session. This deemphasizes the physical therapist's role as an authority figure, and therefore the need for a passive-aggressive response.
When an individual's personality style deviates from cultural norms over a long period of time, is inflexible or pervasive, causes distress to oneself and others, and leads to activity limitations, that personality style is considered to be dysfunctional.9 Personality disorders have been thoroughly classified. They include paranoid, antisocial (also referred to as sociopath or psychopath), borderline, histrionic, narcissistic, avoidant, dependent, obsessive-compulsive, schizoid, and schizotypal personalities. Freidman and Booth-Kewley45 state that disability exacerbates preexisting pathology, meaning that the stress of dealing with a physical illness can make personality disorders even more pronounced.
Patients with paranoid personality disorder interpret the motives of others as malevolent when they may not be. This results from a pattern of suspiciousness and distrust. These patients believe that others are trying to exploit, deceive, or harm them. Because of such mistrust, they may discharge themselves from treatment. Physical therapists should look for behaviors that indicate paranoid thoughts such as hostile reactions, guardedness, argumentation, and stubbornness, and encourage patients to express their thoughts at that moment. If the patient seems paranoid, the physical therapist should help him or her to better understand the reality of a specific situation. For instance, if the patient complains about being forced to participate in an elaborate intervention so that, in his or her view, the therapist can make more money, the therapist should review the pros and cons of various treatments and discuss the clinical reasoning involved. Literature can be very convincing since it does not come directly from the therapist.
Patients with antisocial personality frequently engage in deceit and manipulation. In rehabilitation, they may use an alias, lie to the staff, or malinger. They are irresponsible and often fail to comply with self-care procedures such as hygiene and home maintenance. They seek out and take advantage of weaker staff members, often using wit and charm. When they do not receive what they want, they commonly become irritable and violent, especially when staff members attempt to impose restrictions. They frequently cause disruption to others in rehabilitation. These patients require a cohesive team approach with immediate and strong intercommunication to minimize disruptive behaviors and refocus on rehabilitation goals.
Patients with borderline personality disorder have instability in emotions, relationships, and self-image; are impulsive; use primitive defense mechanisms such as splitting (Box 26.2) and devaluation; and tend to engage in self-destructive behaviors such as abusing drugs or self-mutilation. On the surface, they may appear critical of others but these are signs of deep vulnerability and should be treated as such. Therapists should respond with understanding and empathy instead of anger, and should emphasize strengths and strategies for ongoing work. Self-mutilating behaviors, such as repetitive cutting with razor blades, pinpricking, or cigarette burning, should be immediately reported to a doctor and referral made to a psychiatrist.
Box 26.2 Common Defense Mechanisms
Instead of expressing feelings verbally, the patient uses actions to release stress. For example, a patient is angry with the insurance company for not funding an athletic wheelchair, so refuses to use the standard wheelchair. Acting out occurs because certain feelings such as anger and hurt are too difficult to express verbally. Unexpressed feelings build anxiety until they are released through action.
The therapist should identify the feeling behind the acting out behavior by asking the patient why he or she behaved in that way. For instance, the therapist would ask the patient above about using the wheelchair. The patient's responses will eventually trace back to the original unexpressed feeling. Through questioning, the therapist brings to the patient's awareness the link between the feeling and the action. The patient can now verbalize and discuss the feeling. In the case above, the patient may be more willing to use the wheelchair. A patient who does not have difficulty verbalizing feelings tends not to act out.
The patient becomes dedicated to helping others in order to manage his or her own stress. An altruistic patient may stop treatment to help everyone else in the treatment room, including the therapist. Such a patient receives gratification through these actions, and hence decreases his or her stress.
The patient engages in excessive daydreaming instead of pursuing human relationships in order to decrease stress. The patient may have difficulty following directions, may appear to be in another world, but happily so, and may become emotional and tense when returned to reality. If asked what he or she is thinking about, the patient may describe his or her fantasies, which can be a rich source of wishes and desires that can be used by the therapist to motivate the patient to work on short-term goals. For instance, a male patient relates a fantasy of dating his favorite teen idol. However, in order to engage in dating, he must first develop interpersonal skills and practice them in simulated and real-life settings.
Denial protects the ego from being overwhelmed by pain through an unrelenting process of disbelief. In the case of disability, denial may be used to protect the patient from reminders of an altered external reality and the resultant sense of loss. Therefore, the patient may refuse to acknowledge an emotionally painful condition or situation that is apparent to others. The patient often denies the severity of a new disability, believing he or she can return to previous jobs or roles, despite reality testing from the therapist. The patient may refuse rehabilitation, claiming that he or she just wants to leave the hospital in order to care for his or her children.
It is important to help the patient work through denial slowly in order to avoid depression, which may occur if the patient becomes aware of his or her reality before psychologically ready to accept it. If the patient's denial is so great that treatment cannot proceed, he or she should be referred to a psychologist to explore what disability means to his or her future life.
The patient is overly critical of others and of himself or herself and may insult therapists and other personnel. The therapist should not take such insults personally, but should offer empathy and kindness, which usually decrease devaluation and build rapport. Once a patient trusts the therapist, he or she may discuss insecurities and fears instead of defending against them through criticism. If the therapist becomes angry with the patient, the insults usually become worse and a power struggle may ensue.
The patient transfers a response to, or feeling about, one object onto a less threatening object to minimize stress. For example, a patient may be angry with a spouse for driving the car recklessly and having an accident but takes the anger out on the physical therapist. In this situation, it may not be safe or helpful for the patient to express anger directly to the spouse, who may be the patient's only emotional support.
The therapist should help the patient transfer the misplaced feeling back to the object for which it was originally intended. The therapist might accomplish this by asking the patient a series of questions concerning the origin of the anger.
The patient deals with stress through a breakdown in memory, perception, consciousness, or sensorimotor behavior. The patient becomes detached from what is happening in the moment because it is too painful. The patient may stop speaking or participating in therapy and stare blankly into space for up to several minutes without responding to the environment. Afterward, the patient may not be aware of his or her dissociated state, or if he or she is, the patient may state that he or she "just spaced out." The patient who uses dissociation usually relies on it often; a physical therapist may note its occurrence several times during a session. It is important to notice what happened just before the dissociation to identify the painful thoughts, feelings, or actions that upset the patient.
The patient deals with the stress of having covert hostile feelings toward caregivers by frequently asking for help and then rejecting every suggestion. Working with a patient who uses help-rejecting as a defense mechanism can be very frustrating. Such patients seem to sincerely seek help but reject all advice as ineffectual. In these cases, it may be helpful to point out to the patient that efforts to help have been thwarted. The patient is usually not aware that he or she has rejected all solutions and may then come up with a solution or be more open to one that has already been proposed.
Humor can be used to minimize stress by highlighting the ironic or amusing aspects of a stressful situation. For instance, a patient states that he is going to open up a hardware store since he has so much hardware (meaning surgically placed pins and plates) in his leg. A patient who uses humor as a defense mechanism usually feels better if the physical therapist laughs at his or her jokes and participates in joking behavior. It is a safe way for the patient to recognize the difficulty of his or her situation.
A patient endows another individual with overly positive attributes to enhance an otherwise negative situation. This other individual may be the therapist, in which case the therapeutic relationship is often strengthened. Or it could be a spouse, in which case problems could arise if he or she is not such a positive support to the patient. It is important to uncover the reality of the situation so necessary treatment and discharge plans can be made.
A patient uses intellectual reasoning rather than expressing emotions in order to avoid painful feelings. For example, the patient describes neurotransmitters and synapses when asked about a head injury. Therapists can relate to such patients by intellectualizing with them. For example, the therapist may speak about the patient's head injury in terms of science and facts instead of emotions.
Isolation of Affect
A patient separates feelings from ideas when thinking about and discussing an upsetting event to minimize negative feelings associated with it. He or she speaks of the details regarding the recent accident that caused a disability without mentioning any feelings associated with the event to avoid reexperiencing them. Therapists should help the patient integrate feelings about an event into his or her memory of it. This can be achieved by asking the patient how he or she feels about certain aspects of the event while talking about it.
A patient feels or acts as if he or she is better than others to guard against feelings of inadequacy. For instance, a patient looks down on other patients with disabilities because he does not want to see himself as disabled. A therapist might observe criticism and devaluation of external objects, bragging about accomplishments or skills, conceit, and grandiosity. The therapist could use this defense mechanism to motivate the patient to get better in order to avoid feeling inferior.
A patient transfers his or her own unacceptable feelings, thoughts, and beliefs onto another person and becomes certain that the other person really feels, thinks, and believes that way. A patient cannot tolerate the idea of having unacceptable feelings such as anger, but expresses them by projecting them onto another person, remaining relatively guilt free. For example, a patient says that his therapist is annoyed with him when in fact the patient is annoyed with his therapist.
A patient uses elaborate explanations to reassure him or her that personal actions are driven by sound motives, when he or she may truly be unsure. A family member caring for a relative with congestive heart failure asks for a do not resuscitate (DNR) status, citing extensive research studies. The family member states that the relative will die soon anyway, thereby concealing the real and less acceptable reason for seeking the DNR status—to relieve himself or herself from caregiving responsibilities.
A patient unconsciously erases negative experiences, wishes, or thoughts from consciousness in order to decrease stress. For example, a patient finds an endearing letter to a spouse from a student and forgets to mention it because the possibility of the spouse having an affair is painful. Repressed material can be dangerous because it remains in the unconscious. Encouraging the patient to express his or her feelings, both good and bad, helps free him or her of these feelings and any possible negative urges to act on them.
A patient views a person or event through a positive or negative lens at any given point in time. Later, the patient may flip his or her feelings to the opposite end of the spectrum regarding the same person or situation, acting in this manner because he or she has difficulty integrating ambivalent feelings. Some patients will often attempt to split staff, identifying one staff member with unrealistic positive attributes, while identifying another staff member with unrealistic negative qualities. The staff member who has been identified as negative has usually denied some desire the patient requested. The patient may approach the positively identified therapist and complain that the first therapist is insensitive and does not understand his or her needs. The patient may express that only the positively identified therapist understands his or her problems. However, when the positively identified therapist also denies the patient's request, the patient then vilifies that therapist as well. The therapist may help the patient to integrate the opposite poles of his or her emotions by bringing both positive and negative emotions into consciousness. The patient then may be able to see the reality of his or her situation.
Sublimation occurs when patients transform unacceptable emotions or desires into socially acceptable actions. For example, a patient who is angry about a recent divorce may be unable to consciously express those feelings for fear of losing the affection of his or her children. Instead of expressing the anger he or she may sublimate those emotions into a more socially acceptable action, such as working out in the gym and eventually training for marathons. By participating in an activity that is valued and admired in the society, he or she gains the positive support of others.
A patient intentionally avoids thoughts of disturbing feelings, situations, experiences, or problems in order to reduce stress. When refusing to talk to his or her therapist about the accident that brought him or her to rehabilitation, the patient suppresses disturbing thoughts. Therapists can refer patients to creative arts therapists (e.g., dance, music, art, drama, or poetry therapists) to facilitate the expression of disturbing thoughts, because such emotions accrue over time if not expressed.
A patient uses behavior or words to negate unacceptable actions, thoughts, or feelings. For example, one who is frequently bullied by another patient during rehabilitation feels rage against the aggressor, but invites him or her to lunch.
Note: In both undoing and suppression, disturbing feelings are intentionally avoided. In suppression, the feelings are avoided and nothing else happens. Feelings are avoided and concealed through opposing words or actions. Both undoing and suppression differ from repression in that repression is an unconscious act.
Patients with histrionic personality disorder seek attention via excessive emotionality. Since these patients respond well to audiences, therapists should provide situations in which patients can gain positive attention from doing well in rehabilitation. Physical therapists should set boundaries to help patients achieve a balance between their need to express themselves and their need to focus on therapeutic interventions. A calm and logical approach to rehabilitation helps settle intense emotions. Patients who have difficulty verbalizing their feelings can be referred to a creative arts therapist to facilitate expression through nonverbal means—such as music, dance or art.
Patients with narcissistic personality disorder are condescending and have a need for admiration and feelings of superiority. If an illness causes a reduction in this image, they will require help from their physical therapists to identify strengths and feel acceptable.
Patients with schizoid personality disorder have a flat affect, or limited range of emotional expression, and are detached from social interactions. The therapist should attend to the patient's rehabilitation without trying to engage him or her in a great deal of social interaction. If the disorder has been long-standing, the patient will likely feel uncomfortable socializing.
Patients with schizotypal personality disorder have eccentric behavior, perceptual or cognitive distortions, and marked distress in social relationships. The social intimacy and physical restriction of a rehabilitation environment may cause anxiety. Slow, unforced integration into the therapeutic setting may be required. Asking patients whether their views of reality are accurate may help them remain focused on achieving rehabilitation goals.
Patients with avoidant personality disorder suffer from social inhibition, feelings of inadequacy, and hypersensitivity to criticism. Physical therapists should reassure these patients that they are doing well and emphasize their strengths.
Patients with dependent personality disorder exhibit clinging behavior, need others to care for them, and are submissive. They may fail to function independently in their life roles even after physical functioning has returned, continuing the pattern of dependency. They fear abandonment and require constant reassurances that staff members understand their condition and care about them. Some respond to clear explanations and feedback about their progress and treatment plans. The therapist should reinforce independent behavior through attention and positive feedback while extinguishing dependent behavior by ignoring or redirecting it.
Patients with obsessive-compulsive personality disorder have a long-standing preoccupation with control and order and are often perfectionists. Their self-esteem may suffer if they perceive a loss of control, and they may react by becoming more obstinate, demanding, and inflexible. Those who publicly express their anger may become ashamed. These patients require greater predictability in treatment than usual, dislike change, and do well when given an established routine to follow. The therapist should provide rehabilitative activities that promote a sense of control and predictability, and consider allowing patients to set treatment goals, and then monitor their daily progress.
Coping styles are ways that people deal with stress and include behavioral, emotional, and cognitive efforts to cope with internal and external challenges that strain ordinary resources.46 Theories of coping suggest that it is not what happens to people that is important, but rather how they react.47 Various coping strategies have been identified in the literature and summarized by Livneh and Antonak.22 They include planning, problem solving, wishful thinking, avoiding, minimizing, seeking social support, searching for meaning, emoting feelings, blaming, accepting, negotiating, disengaging, and turning to religion. These and others can be categorized into three different types of coping: (1) seeking versus avoiding control and information; (2) expressing versus repressing emotional reactions; and (3) seeking versus withdrawing from social interactions and networks.
Coping strategies have been found to be of great importance in rehabilitation. Patients with higher-level coping skills can more easily identify and report symptoms, make treatment decisions, comply with intervention, and accept support. Patients with good problem solving skills and positive attitudes have been found to make more positive adjustments to their disabilities than patients with low self-esteem and poor self-concept.48 Coping styles often determine whether or not patients seek medical help and follow advice.46
Social influences, psychological characteristics, and health beliefs have been shown to modify the impact of disability and disease on an individual. Social activism, positive self-acceptance, and information seeking have predicted better ability to cope with a disability.49 Krause and Rohe50 studied the relationship between adjustment and personality following SCI and found that positive values, emotions, actions, and warmth correlated with superior outcomes. Adaptive coping styles that result in positive outcomes for people with disabilities utilize positive, direct, and active problem solving, social support seeking, and information seeking. Maladaptive coping styles that lead to unfavorable adaptation outcomes include self-blame; non-direct, passive, and escape/avoidance modes of coping; and substance abuse.
Locus of control is a belief about one's ability to control life conditions and events.51 Patients with an external locus of control believe that other people or outside factors determine outcomes. Patients with an internal locus of control take responsibility for change because they believe they can affect their own circumstances. The latter leads to goal-directed activity and active coping.
The ability to intentionally change the relative importance of events that occur in one's life requires constant practice.52 It has been shown that patients with external loci of control experience stress and anxiety in rehabilitation, whereas patients with internal loci of control have quicker recoveries, better motivation, more hope, and more energy.
Coping styles can be examined through interviews, observations, self-report surveys, checklists, and information from the family. Treatment considerations based on these findings should include emphasis on previous ways of successfully coping and expanding the range of coping strategies, such as maintaining a journal to increase self-expression. Taking care of a pet or using animal assistance can lend help, comfort, and companionship, as well as increase motivation. Group treatment can also be used to increase social networks.53,54
Many people with disabilities who have risk factors for emotional problems, such as lower education, less income, and social isolation, still do well in life because of a certain resilience defined as successful adaptation to stressful situations or events.55 Researchers of resilience identify protective factors that safeguard people from adverse consequences. Protective factors can arise from the individual, family, and society and are concerned with how these strengths and supports provide security, safety, and positive opportunities.
Turning points are important experiences and realizations that enable people to find new direction, purpose, or meaning in life. King et al56 reported four protective factors: determination, perseverance, spiritual beliefs, and social support. Seven protective processes were also identified: transcending, self-understanding, accommodating, receiving a diagnosis that helps explain a patient's experiences, believing in oneself, using anger as motivation, and setting goals. These protective factors and processes help people with disabilities during turning points in their lives. Analysis of turning points revealed three major ways that patients maintained meaning in their lives: through doing, belonging, and understanding themselves in relationship to the world. Doing involves participating in activities that are fulfilling and facilitate competency. Belonging involves perceived acceptance by others or membership in a valued group. Understanding oneself in relationship to the larger world provides a sense of identity and sometimes purpose.