Satisfaction and Self-Esteem in Patients Attending a Juvenile Amputee Clinic
D. LYTTLE, MB., F.R.C.S. (ED.), F.R.C.S. (C) D. SPENCER, M.Sc. R. PERRY, PH.D.
The teams of professionals forming prosthetic clinics for juvenile amputees have as their common goal the maximum possible improvement of function of the limb-deficient child. Szasz16 has cautioned physicians against potentially detrimental psychological effects of physical treatment, and Fishman6 expressed specific concern about the behavioral and psychological reactions of juvenile amputees fitted with prosthetic devices.
Certain children reject their prostheses in spite of well-documented evidence in their cases that the use of the prostheses improved their functions in many situations of daily life. Fishman, in his study of 236 upper-limb child amputees, reported that the prostheses were rejected in 10 per cent of the cases. There is a general impression that the child's satisfaction with his prosthesis is related not only to the functional competence when wearing the prosthesis but also to the patient's self-concept and self-esteem.
The present study is concerned with the effects of various situations upon the amputee's self-esteem and satisfaction with the prosthesis. It seems probable that the day-to-day activities of an amputee produce certain situations in which self-esteem may suffer although functional competence with the prosthesis may be perfectly adequate. To identify such situations would be the first step in eliminating much of the guessing associated with the psychological aspect of a rehabilitation program. Certainly if the amputee has a self-perception of being an unattractive person or of being behaviorally less competent than his peers, he will suffer lower general self-esteem and possibly will become a candidate for rejection of the prosthesis. Lerner, Karabenick, and Stuart9 reported a significant positive relationship between satisfaction of body parts and self-concept. Gary and Guthrie7 have reported improvement in self-concept or self-esteem with the development of physical competence. We would like to see our amputee patients make a success out of life for themselves, and it has been shown by Stotland, et al.,15 that high-self-esteem subjects behaved in ways which maximized the probability of their success, while low-self-esteem subjects made it difficult for themselves to achieve success.
The psychologist in this prosthetic clinic attempted to determine some of the behavioral and situational conditions contributing to low levels of self-esteem and satisfaction in patients. Thus, the purpose of the present investigation was to detect for each subject situation-specific levels of self-esteem and satisfaction with the prosthesis. It was assumed that knowing which situations were associated with lowered self-esteem would facilitate rehabilitative efforts made by members of the prosthetic clinic team. Secondly, the present investigation enabled us to test the hypothesis that self-esteem ratings are specific for different situations. In addition, a time variable (past, present, or future) was included in that part of the experiment investigating satisfaction with the prosthesis in order to detect any change with the passage of time. It was expected that the situations which made the prosthesis salient or displayed it, and tasks which revealed any functional incompetence due to the prosthesis, would be associated with the lowest levels of satisfaction and self-esteem.
The patients were two male and four female amputee children ranging in age from 10 to 14 years. Single and multiple amputations were involved. Each of the children had been fitted with prosthetic devices. The sample represents 50 per cent of the population of children who are between the ages of 10 and 16 years, who live in Winnipeg, and who have been seen by the prosthetic clinic at the Shriner's Hospital for Crippled Children.
A modified version of Rosenberg 12 self-esteem scale was used to assess self-esteem in particular situational contexts. The major modification of the scale consisted of preceding each item with a clause describing the situation. The subjects completed the scale after each of four role-playing sessions. Each of the role-playing sessions depicted a different situational context: speaking at home, speaking at school, listening at home, and listening at school. Consequently each item was preceded by the phrase "When I speak at home ...,""When I speak at school . . . ," "When I am just listening at home. . . ," or "When I am just listening at school ...," depending on which role-playing session had just been completed.
An additional test was used to assess each subject's satisfaction with his prosthesis. Seven identical self-anchored scales 3 were completed by each subject. On each of the seven scales the subjects indicated their past, present, and future satisfaction with their prosthesis in a particular situation. After completing each self-anchored scale they were asked to put a check mark beside those things they liked and things they disliked about their prosthesis.
There were two phases of the experiment. Phase I (self-esteem) preceded Phase II (satisfaction-with-prosthesis) for the first group of three subjects, and Phase II preceded Phase I for the second group of three subjects.
Phase I consisted of four role-playing sessions. Two levels of two factors were manipulated: the setting (home or school) represented one factor, and verbal behavior (speaking or listening) represented the second. Each subject received every combination of the variables, yielding a two-by-two randomized block factorial design. The order in which the four scenes were role-played was randomly determined for each group of three subjects. The four scenes were 1) a home situation in which the subjects only listened to a conversation between their (role-playing) parents, 2) a home situation in which the subjects were required to speak (the order of speaking was determined randomly), 3) a school situation in which the subjects only listened to the teacher, and 4) a school situation in which the subjects had to speak.
Prior to each role-playing session the subjects were involved in arranging the furniture to resemble either a living room or a classroom. The subjects listened to these instructions:
Do any of you know what is meant by role-playing'? Well, for the next little while we are all going to be doing some role-playing. That is, all of us are going to pretend that we are either at school or at home. We'll he arranging the furniture to resemble either a living room or a classroom; then I will provide instructions about what we are to do. Sometimes your role-playing or acting will involve some speaking on your part, and sometimes you only have to listen to what Pat (research assistant) and I say. After each role-playing period you will be asked to answer 10 short questions. Do you have any questions'?
At this point at least one of the subjects had questions, and the relevant part of the instructions was repeated. The subjects were urged to take their task seriously, since the importance of the study depended on their being able to concentrate on how it felt to be in these settings. They were told that it was impossible to visit each of them in their homes or in their schools, and therefore the role-playing was an attempt to come as close as possible to actually being in their real homes or schools. After receiving the general instructions the subjects were presented with a more specific description of the scene which was to be role played. Following each of the sessions the subjects went to another part of the room and filled out the modified self-esteem scale.
Phase II involved the administration of a self-anchored scale to assess the subject's past, present, and future satisfaction with his prosthesis in each of seven different situations. Instructions similar to those used by Cantril3 were read to ensure that each subject was familiar with the scale and to establish individual anchor points regarding greatest and lowest satisfaction with his prosthesis. The subjects completed a separate scale for each of the situations. They were asked to:
Indicate with the letter "X" how satisfied you would be with your prosthesis if you were in this (e.g., clinic) situation today. Now, on the same ladder scale, in dicate with the letter "0" how happy you would have been with your prosthesis in this (clinic) situation six months ago or sometime before Christmas. If you think you would have felt the same amount of satisfaction, put the "0" on the same number or rung as the "X." Now, on the same ladder again, indicate with the letter "A" how satisfied you think you will be with your prosthesis next year if you are in this kind of situation. Now, on the opposite page you will see a list of things that you like about your prosthesis. Put a mark with your pencil beside each of the things you like about your prosthesis in this (clinic) situation. Now, put a mark beside each of the things that you dislike about your prosthesis in this (clinic) situation. Once this had been completed, the subjects were instructed to turn to the next page, and the same procedure was repeated for the next situation.
At the completion of both phases the experimenter spoke informally and casually with the subjects about the experiment. To establish whether there were salient expectancy effects'3, the subjects were asked what they thought they were supposed to say in response to the questions, whether they thought there was a right or wrong way to answer the questions, and what they thought the experimenter wanted to know.
To check the experimental manipulations, the subjects were asked whether they had trouble imagining what it was like in any of those situations and whether they felt their ratings were true indications of how they felt about themselves in those situations.
The response of the subjects to the post-experimental interview indicated their complete naiveté. They believed they had answered the questions truthfully, and some expressed hope that the data they provided would be of assistance in helping kids in the future.
They reported that the role-playing sessions were not really like being at home or in school. They indicated, however, that the role-playing facilitated their recall of how they actually felt in those situations.
Phase I: Changes in Self-Esteem
Table 1 presents a summary of the analysis of variance of the self-esteem scores. The diflerence between self-esteem in the home and in school was in the predicted direction.
Inspection of Table 2 reveals that self-esteem was lower in school than at home. While the A x B interaction is not significant, the discrepancy between home and school is greatest in the speak condition. This effect and the main effect itself are consistent with the prediction that self-esteem would be lower in situations characterized by a greater potential for social evaluation.
The significant effect of blocks indicates enhanced power of the test of differences between means, since the randomized block factorial design permits partitioning the total sum of squares to remove variability due to blocks (subjects in this case) from the error term, resulting in a smaller mean square residual.
Phase II: Changes in Satisfaction with Prosthesis
Table 3 presents a summary of the analysis of variance of the satisfaction-with-prosthesis scores. As in Phase I, a significant blocks effect indicated greater power of the test.
A significant difference in satisfaction occurred with the passage of time (p = 0.01). Inspection of the means presented in Table 4 indicates that satisfaction increased significantly (p = 0.01) from past to present and from present to future (Tukey's HSD 0.01, 100 = 17.2!).
A main effect was also obtained for the situation factor ( Table 3 ). Comparison of the means ( Table 4 ) indicates that satisfaction was lowest in those situations which may be characterized as having a high probability of evaluation and public scrutiny. No differences were obtained between the dinner, passive-school, and same-sex-meeting situations; but satisfaction with prosthesis was significantly greater (Tukey's HSD .0!, 100 = 20.6) in these situations than in the shopping, clinic, school-drama, and opposite-sex-meeting situations.
To obtain an indication of the rank-order correlation between satisfaction with prosthesis and self-esteem, the subjects were ranked on the basis of their self-esteem scores and their satisfaction scores averaged across all situations. The rank-order correlation between self-esteem and satisfaction with prosthesis was 0.60.
The subjects reported, by means of a check list, those things they liked or disliked about their prosthesis in each of the situations. The number of items related to cosmesis and the number related to function of the prosthesis were identical. Table 5 presents the like-minus-dislike scores for each situation. All scores are positive since the number of dislikes was less than the number of likes in each situation. In every situation the subjects reported greater liking for the functional properties of the prosthesis than for the cosmetic properties. The rank-order correlation between situations (in terms of satisfaction scores averaged across three time periods) and the number of liked characteristics (including both cosmesis and function) was 0.72. Thus, those situations characterized by a high degree of satisfaction with prosthesis tend also to be situations in which the subjects report a relatively greater number of favorable characteristics of their prosthesis.
The data confirmed the experimental hypotheses. Self-esteem differed depending on the situation. These results are consistent with an interactionist position 1,2,4,5 since they confirm that the personality variable, self-esteem, as measured by a modified version of Rosenberg's 12 scale, is not global but rather is partially dependent on the situation.
Self-esteem was significantly lower in the school situation than in the home situation. The school setting is one in which a limb deficiency would be relatively salient in terms of physical appearance and associated incompetence. Since both appearance 9,11 and behavioral competence 7,10 are positively correlated with self-esteem, lower self-esteem in school than at home was expected.
The speaking-listening factor did not produce a significant difference in self-esteem. This was contrary to expectation, since speaking was expected to be associated with an increased probability of social evaluation. One explanation of this result is that speaking represents a skill that is relatively unaffected by the subject's limb deficiency and hence is a subregion of self-concept that he perceives to be within the normal range expected of both himself and his peers. Support for this explanation is provided by Ziller 17 , who suggests that a history of reinforcement will be associated with higher self-esteem. If these subjects have experienced a history of reinforcement for their verbal skills, they would be less likely to experience low self-esteem in a situation characterized by speaking and no other physical activity. This explanation is plausible since all but one of the subjects rated themselves as average or above-average students, a rating that probably reflects competency regarding verbal skills.
The correlation of 0.60 obtained between satisfaction with prosthesis (averaged across seven situations) and self-esteem is approximately twice those reported by Lerner, et al. 9 , between self-evaluation and satisfaction with body appearance. While differences in the samples tested and the methods of assessment prevent any valid comparison between the two studies, the results suggest that satisfaction with body parts and prosthesis accounts for more of the variance in the self-esteem of amputees than in nonamputees.
The satisfaction data indicated clearly that there are some situations, particularly those characterized by potential for social evaluation of physical appearance and behavioral competence, in which amputees were significantly more dissatisfied with their prosthesis. The clinic, school-drama, and opposite-sex situations were associated with lower satisfaction scores. The reasons for dissatisfaction varied. However, when the reasons were divided into cosmetic and functional likes and dislikes, it appeared that the appearance and concomitant attention it drew contributed most heavily to the dissatisfaction with the prosthesis in each of the situations.
Inclusion of the time factor revealed that while satisfaction ratings increased over time for the group as a whole, there were specific individuals who did not expect to experience greater satisfaction in the future; there were also specific situations associated with an expectation of a decrease in satisfaction over time for some individuals. From a diagnostic and rehabilitative point of view this type of information may be useful in detecting those people with a higher probability of prosthesis rejection.
Previous studies 8,14,15 have shown that low self-esteem is associated with a greater probability of maladaptive or less successful behavior. The present results indicate that self-esteem and satisfaction with prosthesis are situation specific. While the direction of causality is not clear, it does seem reasonable, in view of previous results, to concentrate rehabilitative effort on behavior which occurs in those situations that are associated with low self-esteem and satisfaction.
It is interesting to note (Table 4 ) that the lowest satisfaction rating was obtained in the clinic situation. This confirms the observation by Szasz 16 that medical practitioners might profitably he more concerned about the psychological outcomes of treatment programs. The clinic situation is the environment with the greatest potential for making the patient feel good and confident about his appearance and abilities.
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