The need for empirical research in counseling has developed rapidly in the last 15 years especially as new techniques, and client groups are being identified in relation to demand for equal economic participation by people with disabilities. As early as 1967, Paul1 suggested that counseling research should seek to identify “what treatment is most effective for this individual with that specific condition,” so empirical methods used to understand the particular needs of people with amputations help to forge better theory/practice links.
Livneh et al.2 reported that direct, active problem-focused coping strategies had beneficial effects in the psychological adaptation to acquired disability, which suggests that counseling effort should be available to facilitate the use of these strategies if necessary. They also questioned whether type, cause, or time since amputation influence people’s ability to cope or seek help. They suggested that for those patients whose initial coping strategies had not been successful, pessimism and helplessness might lead to increased emotional difficulty and poorer adaptation. These observations at least allow for individual differences in coping ability rather than the assumption of bereavement reactions as has been previously criticized by other authors.3,4
New psychological issues and coping challenges often emerge in the later stages of rehabilitation after amputation when patients attempt to adjust independently to everyday life after the initial medical and prosthetic interventions and this may be the appropriate time to target counseling to optimize coping strategies.5
Earlier studies of some of these points in more detail demonstrated that patients who had lost limbs as a result of trauma or tumor and those with upper limb amputations were the most vulnerable to emotional disruption.3,6 Additionally they indicated that the main emotional impact of amputation might emerge between 6 and 24 months after surgery as suggested by Wald and Alvaro.5 This latter aspect was the subject of a further study,6 which invited patients to attend for counseling some 6 months after amputation. However, this study produced only limited results, due partly to the small size of the sample and partly to its composition.
The present study therefore relates to patients invited for counseling between 6 and 24months after surgery, analyses the uptake of invitations and the site, cause, age, sex, and time since amputation of those who took up the invitations. It also assesses the emotional reactions evidenced by those counseled without breaching confidentiality.
SUBJECTS AND MATERIALS
An examination was made of the lists of limb-wearing patients attending a UK limb fitting Centre who had had surgery between 6 and 24 months before the study started. From that sample two categories of patients were excluded: young children and those with congenital abnormalities which did not need additional surgery.
This resulted in a sample of 121 which consisted of 14 (12%) upper limb patients (four of whom had lost only fingers) and 107 (88%) who had lost lower limbs, including four who had lost both legs.
In the summer of 2006 a letter explaining the role of counseling and a reply paid form asking whether or not the recipient wished to attend for counseling were sent to all except 16 patients in the field who had already spontaneously requested counseling.
Of the total appropriate 105 patients, replies were received from 28 (27%). Positive responses were received from 11 patients to whom may be added the 16 who had spontaneously requested counseling and had returned for further sessions after the initial one. This gave a total uptake of 27, being 22% of the sample. Seventeen patients (14%) wrote to decline the invitation and the remaining 77 (64%) made no response.
The total uptake of 22% broadly equaled the 23% in the smaller sample previously undertaken.6Table 1 shows the number of patients, according to site, cause, sex, age and time since surgery who accepted counseling, and the percentage they represented of the total number of patients in each category.
SITE OF AMPUTATION
Of the 27 patients who responded positively or who spontaneously volunteered for counseling, 5 had lost upper limbs. These represented 36% of the 14 upper limb patients in the total sample, whereas the 22 lower limb patients represented 21% their total. This gives support to the earlier finding that upper limb patients are likely to suffer the greater emotional disturbance.
CAUSE OF AMPUTATION
Those who made positive responses, either spontaneously or through invitation, included 11 who had lost their limbs on account of trauma, representing 40% of the 28 trauma patients in the whole sample. If to these are added two whose surgery derived from acute infection (i.e., those whose amputations had immediate causes) the figure rises to 13 and represents 39% of the 33 in the total sample who suffered immediate amputation. Conversely, the 10 who made positive response and who had suffered longer-term problems (i.e., diabetes, dysvascularity, congenital adjustment, and chronic infection) before amputation represented only 13% of their like (77) in the total sample. Tumor patients, of whom there were four among those counseled, accounted for 31% of the 13 in the total sample. Therefore, the premise in earlier articles that those experiencing trauma or tumor feel a greater need for counseling than do those with longer-term physical difficulties, is supported.
The numbers of men who desired counseling represented 21% of the total number of men in the sample, lower than the 25% of the women.
Two patients (29% of a small sample) under 30 years accepted counseling. Compared with the total sample, the percentage figures were 36% for those aged between 30 and 60 years and 13% for those more than 60, thus confirming earlier findings that the younger age groups are the more emotionally vulnerable.
TIME SINCE AMPUTATION
The incidence of patients requesting counseling according to time since amputation was 26%, 24%, and 17% through the three consecutive 6-month periods.
The numbers of counseled patients who raised the most usual emotional issues are given in Table 2, compared with the results of two earlier studies.3,6
As in the previous studies,3,6 by far the most common emotional problem was depression and its associated symptoms—in the present case by a much larger margin than before. The most notable feature, however, was the high percentage of patients who expressed anger and resentment—emotions less common in the earlier studies but which were raised comparatively often by those affected. These emotions were experienced by 30% of those in the current exercise. A greater percentage of patients in this latest study recalled problems in their past, giving this aspect a higher place in Table 2 than body image, which had held second place in the two earlier studies.
This study has supported the results of earlier work in that it again demonstrated that patients who lose limbs through trauma or other immediate causes suffer greater emotional distress than do those whose amputations result from longer-term causes. It has also confirmed that upper limb amputees are more vulnerable to emotional distress than those who lose lower limbs and that emotional disturbance is less prevalent in those over 60 years of age. This last finding may possibly be because of the adaptation to the ageing process which the more elderly have already experienced.7
As in previous studies, slightly more women than men accepted counseling, but this does not lead to a significant conclusion.
Depression and similar problems are again shown to be the most pressing among those patients who opt for counseling. There was a greater emphasis in this study on feelings of anger and resentment, possibly enhanced by the comparatively high proportion of trauma patients in the present study, two of whom had been injured in the bombing on the London underground on July 7, 2005 and one victim of the tsunami in the Far East at the end of that year.
The primary purpose of this latest study was to check the validity of earlier findings that the period between 6 and 24months after amputation is the most fertile for the emergence of emotional distress. The results showed an uptake of counseling within this period of 22% of all patients in the field, virtually equal to the 23% indicated by the previous, less comprehensive, exercise.6
The methodology of the current study is similar to that of a previous investigation8 in which consecutive general referrals to the limb fitting clinic were subsequently contacted by letter to ask about their emotional concerns. In the previous study, only 15% (of an initial sample of 122 patients) were found to have participated in counseling. The 22% in the latest study compares favorably with the 15% figure and endorses the significance of the 6–24-month period after amputation as the crucial time for emotional problems to emerge. This is consistent with Wald and Alvaro’s assertion that emotional issues may emerge later in rehabilitation.5
Table 1 shows a reduction in the uptake of counselling in the 19–24-month period after amputation, so it may be that the 6–18-month period is the most important. In earlier studies, 37 (28%) of 133 patients returned for further sessions who had had initial counseling3 and 24 (34%) of 70 returned who had participated in counseling.6 However, these figures were drawn from fields of patients who had already opted for counseling, generally shown to be a minority of the total and are therefore not comparable to the present findings. All these figures, however, are consistent with other studies that indicate 23% to 35% of postamputation patients will experience emotional distress.9,10 Although this represents a significant number of actual people who evidently require a holistic approach to their rehabilitation, it also demonstrates that emotional distress is not an essential and universal reaction to limb loss.
This study endorses the validity of the 6–24-month period after amputation as the crucial time-span for emotional problems to emerge, the earlier two-thirds of this period probably being more significant than the final 6 months. Thus, when counseling facilities are limited this period represents a suitable area to which the available resources may best be directed especially to patients with amputations resulting from trauma or tumor and those affecting the upper limb.
The authors thank the clinic administration staff who provided them with the relevant patient sample and Beth Brennan, Counselor for offering the service to those patients who replied positively to the invitation to attend.
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