University of Southern California Mrs. T.H. Chan Division of Occupational Science and Occupational Therapy
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Emotions, Attitudes and Self-Efficacy

Do you control your emotions, or do your emotions control you? It's only natural to feel emotions; they are our reactions to the people and events all around us. But sometimes emotions feel so strong that they can change our outlook or make us behave in a way we wouldn't normally, for better or worse. For example, we're all familiar with reports on television and in newspapers about athletes who lose their temper and throw something at noisy fans, or about drivers who pull out a gun or chase another car when under the influence of "road rage." On the more positive side, someone who is full of joy might start a conversation with a total stranger on the street or in a store, or go out with friends and buy a round of drinks for everyone in the room.

Emotions also tie in to a person's overall attitude, and an attitude can affect emotions. As an example, a sunny person who is optimistic, that is, who tends to believe that things will turn out all right, will be more likely to feel happy, hopeful or determined to get something done. Another example would be a person who has an attitude or belief that they have been the victim of bad luck throughout their life; they would probably be likely to feel angry, bitter, helpless, sad or even depressed. A person's emotions or attitudes can even influence their health, as studies have found that having an optimistic outlook and a "can-do" attitude - what psychologists and others who deal with the science of human behavior call "the hardy personality" - can lead to better health, better on-the-job performance and a higher ability to handle stress and find a positive way to react when something unexpected happens 1 2. Since we all have emotions, the challenge for us is to find a way to make the best of our emotions, to inspire a positive attitude, and maybe learn a few tips from the people who have had some success because they have the "hardy personality."

Many of our study participants had very definite attitudes about life, and those attitudes often influenced the emotions they had, and influenced the actions they took. One attitude that might affect someone's health is denial, that is, believing that either nothing is wrong or that things are not as serious as they really are. Denial is different from optimism. Optimists are hopeful, but they accept the reality of what is happening; an optimistic way to look at a problem is to see that there is trouble, but to be confident and look for possible solutions to the problem.

A person in denial does not admit there is a problem at all. As an example, Rachel, who took part in our study, proudly stated that "I don't have transverse myelitis [the disease that caused her paralysis]. I don't claim it. I just do not. I don't claim it. I feel in my heart that I am going to get up, so I don't claim it." Because Rachel carried this attitude that her condition was temporary, she refused to learn how to take care of herself, instead relying on her mother to feed her (even though she had function at C-5 and C-6, enough to feed herself if she wanted to). She also turned down the opportunity to adapt her truck so that she could have driven it herself. Unfortunately, Rachel's attitude of denial applied to pressure ulcers (which means the same thing as "pressure sores" or "bedsores") as well. When she got blisters on the balls of her feet, she didn't think they were important. She washed them with a bleach-based solution, which might have been too strong for skin that was already in trouble. By time she saw a doctor, they had become Stage 4 ulcers. This is not uncommon; studies show that denial often causes people to neglect taking care of themselves, resulting in their health getting worse or even developing a new illness 3.

Some who have had a serious illness or injury might have an attitude of feeling sorry for themselves. For example, Billy held onto the viewpoint that his entire life was stolen from him when a bullet caused a spinal cord injury before he could start on a promising future as a college athlete. With this attitude of regret, Billy felt depressed, fearful and angry. His actions often matched these negative feelings; for example, he passed up the chance to get involved in coaching or in wheelchair sports because he felt it would remind him of what he lost, and he usually ignored his pressure ulcers in the early stages (when they were more curable and less damaging 4) because he was afraid to admit that he even had them. This is not at all unusual; in fact, studies have found that getting a spinal cord injury can often cause a person to feel hopeless or depressed, and that becoming dependent on others for help or moving back in with parents (and Billy does live at his mother's house, although his family does not give him a lot of support in other ways) can reduce a person's sense of self-efficacy, that is, their belief that they are able to accomplish their goals 5. And researchers have also discovered that people who feel depressed or angry, who have a lowered feeling of self-esteem, or who have lost their sense of self-efficacy are more likely to ignore their self-care, which can in turn increase the chances that they will develop a pressure ulcer 6.

Even people who have made the adjustment to living with a spinal cord injury can have problems later if something else comes up that might cause them to lose their commitment to take care of themselves. For example, after 6 years without any pressure ulcers because he was taking good care of his body, our study participant Frank ran into a difficult time in his life. Feeling stressed out and depressed by a number of issues that were happening in his family, Frank stopped doing his daily skin checks and the result was that he got a pressure ulcer that needed surgery. As Frank himself described it, "I got a little careless at the end, I guess....I had a lot of problems at the time. I remember I had the attitude I didn't care at the time. I stop even treating myself a little bit and I paid for it."

But even if someone loses their sense of self-efficacy, whatever the reason, they can get that belief in themselves back, either on their own or with help from supportive people in their lives. An example of this can be found in Ken, another of our study participants. While in the hospital recuperating from a gunshot wound, which caused a spinal cord injury at C-4, Ken experienced anger, loneliness and hopelessness, and eventually lost his desire to live. He said he felt no purpose in life, which can commonly lead people to stop following their doctors' orders and to stop taking care of themselves 3. Fortunately for Ken, he slowly became inspired by the kindness he was shown by his mother, friends, youth pastors, and a young doctor who gave him a cross and prayed with him. Ken renewed his hope, and decided to become a Christian; with his sense of self-efficacy restored, he got a job counseling students at a private school run by his church. Another study participant who gained strength from social support was Dave, whose relationship with his girlfriend gave him hope about the future and helped him rediscover his sense of self-efficacy.

Some of our study participants found their own ways to maintain positive attitudes and positive emotions. Brenda, for example, went through a range of emotions in the years after the car accident that caused her incomplete spinal cord injury at C-7. She had difficulty making the transition from being an active person to being dependent on a care attendant for many of her needs; as stated earlier in this article, it's common to feel depressed or lose self-efficacy when a person becomes dependent 5. But Brenda worked out for herself that she still had control of her decisions, and so she still had control over much of her life. This is what Brenda said about maintaining control:

It is two different shades of control. To be an upright-walking person compared to somebody in a wheelchair, it is two different kinds of control. Yeah, it is totally different. [I have control over] my decisions, things that have to be done. No one is going to do that. No one is going to control me to making up my mind. I am totally in control of things there.

Realizing that she could improve how she accomplished her health care goals, Brenda learned the rules of the hospital, such as finding out the staff's schedule and making her requests at times when there were extra nurses on duty. When minor things went wrong, Brenda let it go, so that when there was a serious problem, like the time she remained on a metal exam table for hours waiting for an MRI (which caused a pressure ulcer to form), Brenda's complaints carried more weight and got more satisfying results. In this way, Brenda created her own self-efficacy.

While Brenda came up with ways to be more effective, some of our study participants seemed just naturally to have a sense of self-efficacy. For example, Chris chose not to worry or feel afraid about what could happen, but to be flexible and deal with events as they came. Both Alley and Judy were self-reliant and energetic, getting involved in a number of work and personal activities. When Odel found an interest in art, he took courses in computer programming, then learned to use an art software program, and eventually learned to paint with a mouthstick because he found actually painting to be the most fun of the three activities. Just see how optimistic Odel was about the challenge of learning to paint with a mouthstick: "I'm going to conquer it, you know. This day, I'm going to do it, no matter how long it takes or how upset I get trying to get it. I'm going to get it right, you know. And I won't be satisfied until it's done right. Yep!" In the meantime, he was glad he studied computer because it could be a valuable job skill. These people already had the "hardy personality" that Brenda created for herself.

As defined by experts on coping styles, the "hardy personality" or "hardiness" is "a set of attitudes or beliefs about yourself in interaction with the world around you that provides the courage and motivation to do the hard work of turning stressful changes from potential disasters into opportunities instead...." 2 This set of beliefs can be described with "3 Cs": commitment, control and challenge. In the case of the "hardy personality," commitment is shown by getting involved with people and activities that you find interesting and meaningful; control is shown by your desire to influence your own world through your choice of words and actions, even if that seems difficult; and challenge is shown by your enjoyment of finding new experiences and learning from everything that happens in your life, whether the events are positive or negative 1. How would a hardy person use these "3 Cs" in everyday life? Well, when something stressful happens, or when something unexpected happens, the hardy person sees the stressful events not as terrible setbacks, but instead as the kind of changes that are natural in everyone's life (in other words, they accept that nothing stays the same forever), and they grow from what they've learned - this is challenge. The hardy person sees stressful events as something they can find a way to deal with, rather than thinking it is so overwhelming that they may never recover (in other words, they have a strong sense of self-efficacy) - this is control. And the hardy person believes that it's better to deal with stressful events by taking action than it would be to avoid the subject or stay in denial - this is commitment 2.

The good news about having a "hardy personality" is that it increases your chances of having good health (because hardy people tend to take better care of themselves, since they believe that they have control and they are committed), and helps you cope better with the stressful events (for the same reasons). People with a "hardy personality" also tend to do better at their jobs, because they welcome all new experiences as opportunities to learn (challenge), they take action to deal with problems (commitment) and they have a good sense of self-efficacy (control) 1 2. A good example of this attitude comes from our study participant Alma, who said, "There's a lot of neat things out in the world to offer, and it's neat to try and do different things and to experiment. And if it works out and you like it, great. If it doesn't, you tried it, then you move on. But try to have fun and make the best of what you have." And research has shown that having that kind of positive attitude and belief in your own abilities helps give you the confidence to form the habits you need to avoid pressure ulcers 3 7.

There's even more good news about the "hardy personality": their tricks for dealing with stress can be learned, even for people who don't see themselves as hardy. Remember how Brenda learned how to deal with the hospital and regain her sense of self-efficacy? She had taught herself to be hardy (even if that's not the exact word she might have used).

So what are the secrets of hardiness that you can use? When something disturbing happens, like unexpected changes that throw off your routine or uncomfortable conflicts that are stressing you out, remind yourself that changes are unavoidable in life, and that even bad experiences can be a chance to learn something new (challenge). Believe that you can make a difference in the situation to help yourself, even if you can't "fix" everything about it (control). Encourage and empower yourself to take action instead of pretending the situation will just go away on its own (commitment) 2. (Of course, there are rare situations where the best choice is to do nothing - for instance, in a situation where saying or doing something will make someone even madder than they are now, or where someone would be offended if you said something. In these unusual cases, the "action" that you are taking is your choice not to do the wrong thing!)

People with the "hardy personality" have two more secrets to coping. When things are getting tough, hardy people look around for social support. They ask friends, family members, co-workers or professionals from the community (like health care providers, clergy members, case workers, government officials, lawyers and so on) to assist them or at least provide emotional support and encouragement. As Alma put it, "When you're out having a good time, you don't feel pain. I think that being around good people who are fun and happy makes you happy." Very importantly, hardy people use self-care practices to help reduce their stress and make them more able to deal with problems; some of these healthy habits include relaxing activities (like meditation, doing a hobby, listening to music, and getting plenty of sleep), good nutrition (including not eating junk food when they feel nervous), exercise, and avoiding harmful habits like smoking or using recreational drugs or alcohol. If hardy people have prescription medications, they take the right dose, along with any vitamins, minerals or herbs their health care provider might have suggested. For a hardy person with a spinal cord injury, add to this list that they use prevention practices to avoid getting a pressure ulcer.

Your attitude tells a lot about who you are as a person, and it is also something that you can change if you want to. Having an attitude of self-efficacy, of believing in yourself and your ability to make changes in your life, can help you not only to get things done, but even to stay healthier. Take a tip from what has been learned from people with a "hardy personality:" keep a commitment to activities that are interesting and meaningful to you; believe that you have at least some control over your life, and, as Brenda learned, you especially have control over your own decisions; and accept the challenge created by changes or new experiences, because life is always changing and you can learn even from unpleasant experiences. Empower yourself with encouragement from yourself and others, and take care of yourself with healthy habits. You can do it!

There are many sites on the Internet where people write about the value of a good, positive attitude. One example is this page about Motivation on Rex Donald's website, called "The Healthy Gimp". Rex is a person with paraplegia and a former competitor in the Paralympics who is married and the father of four children. He runs his own marketing company and works as a motivational speaker, so keeping up his spirits and believing in himself is obviously a very important part of Rex's life! And You Are How You Feel, on the website of Craig Hospital in Denver, Colorado, explains how having a good attitude can lead to making good decisions.

Two online articles from New Mobility magazine are about people who had both positive and negative feelings, and how natural it is to feel a variety of different emotions. What's in Your Head? Who Put It There? is an interview with three counselors who are disabled to ask them how they help themselves and their clients with sad subjects, like discrimination and depressed thoughts of worthlessness or suicide, and with happier subjects, like learning to deal with problems in new and better ways. The other article, Tending Emotions Cultivating Humor, Owning Grief and Anger, lists the comments, in their own words, of a number of people with disabilities about how they deal with grief and anger, and how they encourage humor and laughter in their lives.

If you or someone you know have recently had a spinal cord injury and you are interested in knowing what kind of emotions to expect, or if you want to compare your own experiences with other people's, Age, Aging and Disability, on the website of the LIFE Center at the Rehabilitation Institute of Chicago, might be a very good resource. It is a list of sample questions that people might ask if they are feeling worried or pessimistic about how to deal with a spinal cord injury as they go through life, with excellent and rational - that is, using calm and clear thinking instead of emotions - answers by Eric B. Larson, Kenneth A. LeFebvre and Dr. Richard Trezona, staff members at the LIFE Center. In Living With a Chronic Illness, Dr. Robert Simmonds, a licensed psychologist in La Jolla, CA, talks about "stages" of feelings and attitudes that many people experience from the time they are seriously injured to when they have rehabilitation to when they accept what has happened and see their injury as just one part of life.

And if you are interested in learning about a system to help yourself adjust your attitude to one of acceptance and even optimism, check Adjustment to Spinal Cord Injury, on the website of the Spinal Cord Injury Information Network, maintained by the University of Alabama at Birmingham. It tells about "REBT," or "rational emotive behavioral therapy," a formal way of saying "looking at fearful, emotional thoughts, and changing them into realistic, calm thoughts." However you choose to do it, know that you have the power, literally, to "change your mind!"

1 Harris, S. M. (2004). The effect of health value and ethnicity on the relationship between hardiness and health behaviors. Journal of Personality, 72, (2), 379-412.

2 Maddi, S. R. (2004). Hardiness: An operationalization of existential courage. Journal of Humanistic Psychology, 44, (3), 279-298.

3 Wichowski, H. C., & Kubsch, S. M. (1997). The relationship of self-perception of illness and compliance with health care regimens. Journal of Advanced Nursing, 25, 548-553.

4 Dharmarajan, T. S., & Ahmed, S. (2003). The growing problem of pressure ulcers: Evaluation and management for an aging population. Postgraduate Medicine, 113, (5), 77-90.

5 Gill, M. (1999). Psychosocial implications of spinal cord injury. Critical Care Nursing Quarterly, 22, (2), 1-7.

6 Consortium for Spinal Cord Medicine. (2000). Pressure ulcer prevention and treatment following spinal cord injury: A clinical practice guideline for health-care professionals. Washington, DC: Paralyzed Veterans of America.

7 Tenn, L., & Dewis, M. E. (1996). An evaluation of a Canadian peer-driving injury prevention programme for high-risk adolescents. Journal of Advanced Nursing, 23, (2), 329-337.