426 Spinal Cord Injury
level of injury or completeness of lesion (Richards, Brown,
Hagglund, Bua, & Reeder, 1988).
Some persons have complicated histories of alcohol and
substance abuse that may likely have contributed to the SCI
and in”uence their later adjustment. These persons are at risk
for developing secondary complications (e.g., urinary tract
infections, pressure sores) that might be prevented in part
by behavioral self-care regimens (Elliott, Kurylo, Chen, &
Hicken, in press; Hawkins & Heinemann, 1998). Alcohol
abuse has also been associated with higher levels of depres-
sion and life stress, and ratings of poor health among persons
with SCI (Tate, 1993; Young, Rintala, Rossi, Hart, & Fuhrer,
1995). Persons who have previous histories of abusive alco-
hol ingestion often revert to their preinjury levels of intake
soon after their return to the community (Heinemann, Keen,
Donohue, & Schnoll, 1988); others may be susceptible to
pressure sore development even if they abstain from alcohol
(Heinemann & Hawkins, 1995). Individuals who consider
alcohol and other substances as a means for coping with prob-
lems tend to report more problems with depression and anxi-
ety a year following SCI than persons who do not report such
ideation (Kennedy et al., 2000). Individuals with signi“cant
alcohol histories also appear to be at a higher rate for suicide
among persons with SCI (Charlifue & Gerhart, 1991).
Persons with substance abuse histories prior to SCI may
have a decreased investment in their health or a preoccupa-
tion with activities that might compromise their personal
health. Persons with signi“cant alcohol histories have been
found to spend less time in rehabilitation therapies (Heine-
mann, Goranson, Ginsberg, & Schnoll, 1989), and they
evidence impaired self-care behaviors up to 18 months fol-
lowing SCI onset (Bombardier & Rimmel, 1998). Evidence
of inadequate coping in the Kennedy et al. study (2000) may
indicate de“cits in ef fective coping resources requisite for
successful adjustment following SCI.
Preinjury Psychopathology
Early research using clinical personality measures found that
persons with SCI report more impulsive characteristics than
those with other chronic health conditions (Bourestrom &
Howard, 1965); similar differences were found between per-
sons incurring SCI in high-impact incidents and those who
incurred SCI via other means (Fordyce, 1964). For many
years, there has been some concern that persons who adven-
titiously acquire SCI may have more sensation-seeking
tendencies than people in general (Kunce & Worley, 1966;
Rohe & Krause, 1999), and these behaviors may be related to
pressure sore development (Richards, 1981). Although eleva-
tions in excitement-seeking and impulsivity may re”ect
characteristics of young men generally (who traditionally are
at greatest risk for SCI; Trieschmann, 1980), research using a
matched control design has found a greater degree of sensa-
tion seeking and criminality among persons with SCI than
among others with similar demographics and from the same
locale (Mawson et al., 1996).
Other work has examined the rate of individuals who meet
operational criteria for personality disorder characteristics
(Temple & Elliott, 2000). Although a high rate was found
among persons with recent-onset SCI and among those re-
ceiving surgical repair for severe pressure sores, the instru-
ment used was known to be reactive to existing mood states.
Higher elevations on summary scales were predictive of
lower acceptance of disability after controlling for depressive
behavior reported at admission.Personality CharacteristicsMany psychological constructs have been related to adjust-
ment following disability. For example, persons who have an
internal locus of control often report less distress than those
with more external expectancies (Frank, Umlauf, et al.,
1987). Persons with a disability who have effective social
problem-solving skills and who have positive orientations to-
ward solving problems, as compared with their counterparts
who lack these skills, are more assertive, psychosocially mo-
bile, accepting of their disability, and less depressed (Elliott,
1999; Elliott, Godshall, Herrick, Witty, & Spruell, 1991).
There is also evidence that people with SCI who develop
pressure sores may lack effective problem-solving skills
(Herrick, Elliott, & Crow, 1994).
Persons who are hopeful and optimistic may selectively
attend to certain aspects of their situation following the onset
of SCI (Elliott, Witty, Herrick, & Hoffman, 1991). Higher
levels of hope and goal-directed energy are associated with
less distress, greater use of more con“dent and sociable cop-
ing styles, and higher self-reported functional abilities
(Elliott, Witty, et al., 1991). People who have greater tenden-
cies to use denial and who have greater psychological
defensiveness are less distressed, less angry, and have fewer
handicaps throughout the “rst year of acquired disability
(Elliott & Richards, 1999). These differences are also ob-
served among those who have been injured for longer periods
of time (Rosenbaum & Raz, 1977).
Early anecdotal models of adjustment following SCI
borrowed liberally from Freudian notions of acceptance and
loss (Grzesiak & Hicock, 1994). Empirical research has
not been kind to the basic tenets of these models, due in
part to the poor operationalization and ambiguous de“nitions
of key constructs. Current research suggests that Kohutian