Well-Being Following Amputation: Salutary Effects of Positive Meaning, Optimism, and Control

Dana S. Dunn Moravian College, Bethlehem, PA

ABSTRACT. This study examined the salutary effects of finding positive meaning in a disabling experience, being an optimist, and perceiving control over disability on two criterion variables of psychological well-being: Depression and self-esteem. A mail-in survey on psychosocial adjustment to limb amputation was completed by 138 persons with amputations. Regression analyses revealed that finding meaning following amputation was linked to lower levels of depressive symptomatology but not to self-esteem. Both dispositional optimism and perceived control over disability were predictive of lower scores on the CES-D depression scale and higher scores on the Rosenberg Self-Esteem Scale. Theoretical and clinical implications are discussed, and it is recommended that future research consider salutary effects from a reality negotiation perspective.

Disability and rehabilitation theorists have long argued that a preponderance of psychological research on the aftermath of disabling experiences adopts negative rather than positive perspectives (e.g., Fine & Asch, 1988; Shontz, 1982; Wright, 1988, 1991). Naive professionals and lay persons, for example, often assume that people with disabilities are "victims of fate" who never physically or psychologically recover from the precipitating event. Even well-intentioned research on the experience of disability (e.g., Bulman & Wortman, 1977) has been faulted for a presumption that those affected are preoccupied with their physical states (Shontz, 1982). Fortunately, a growing number of researchers have begun to redress this negative emphasis by examining how individuals favorably deal with the experience of disability by identifying factors that promote positive adaptation to disabling circumstances (e.g., Dunn, 1994; Elliott, Witty, Herrick, & Hoffman, 1991; Fine & Asch, 1988; Heinemann, Bulka, & Smetak, 1988; Meyerson, 1988; Shontz, 1977, 1982; Silver & Wortman, 1980; Wortman & Silver, 1989; Wright, 1983). The present study is meant to further understanding of positive adaptation to disability by examining how three factorspositive meaning associated with the
REHABILITATION PSYCHOLOGY Vol. 41, No. 4, 1996
1996 by the Division of Rehabilitation Psychology of the American Psychological Association Published by Springer Publishing Company, Inc., 536 Broadway, New York, NY 10012
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disabling experience, an optimistic disposition, and perceived control over disabilityinfluence psychosocial well-being among persons who have had an amputation. Well-being was operationalized as lower levels of depressive symptoms and higher levels of self-esteem following amputation, and these two indices were chosen to reflect recent advances in the study of affective experience. Various psychological researchers have found that positive and negative affect are often uncorrelated (e.g., Diener & Emmons, 1984; Russell, 1983; Watson & Tellegen, 1985), so that the two dimensions of affective experiencehere, depression representing negative affect and self-esteem depicting positive affectshould be examined separately. Individuals who have had an amputation often face physical, emotional, social, and employment challenges that can affect psychosocial well-being. To date, however, the relevant literature has emphasized functional adaptation to amputation (e.g., learning to use a prosthesis) over psychological adjustment (Rybarczyk, Nyenhuis, Nicholas, Cash, & Kaiser, 1995; Williamson, 1995; Williamson, Schulz, Bridges, & Behan, 1994), and though a variety of studies document the incidence of depression following amputation (e.g., Frank et al., 1984; Kashani, Frank, Kashani, Wonderlich, & Reid, 1983; Rybarczyk et al., 1995), few offer ways to or identify factors that mayameliorate it. Similarly, while amputation can no doubt be psychologically threatening to self-esteem, few researchers have identified positively evaluated characteristics that are argued to promote acceptance of disability (Wright, 1983; for a related discussion involving breast cancer, see Taylor, 1983). Thus, there is a clear need for research aimed at identifying psychological factors that have salutary effects on adjustment to amputation.

MEANING, OPTIMISM, AND CONTROL Negative events elicit a search for meaning, or the ways in which people make sense of their social experience (Wong & Weiner, 1981). The view that meaning is somehow linked to people's abilities to cope with undesirable life events is prominent in clinical (e.g., Frankl, 1963), sociological (e.g., Antonovsky, 1987), and psychological (e.g., Janoff-Bulman, 1992; Taylor, 1983) theories. Empirical evidence supports theory by demonstrating that positive adaptation to physical and/ or emotional trauma is enhanced when people find meaning afterwards (e.g., Schulz & Decker, 1985; Taylor, Lichtman, & Wood, 1984; Thompson, 1985; Thompson & Janigian, 1988). The process of finding meaning involves a search for a "silver lining" amidst adversity so that the affected individual actively tries to make sense out of the experience by identifying something positive about it (Thompson, 1985). Why is this process beneficial? Searching for a positive side to a trauma allows a person to retain a degree of cognitive coherence about the world because events are construed as happening for a reason (e.g., Janoff-Bulman, 1992) and to have significance for the self (Taylor, 1983). Finding meaning where one has little controlessentially gaining control by accommodating to existing circumstances through focus on the

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self (i.e., secondary control; see Heckhausen & Schulz, 1995; Rothbaum, Weisz, & Snyder, 1982)can promote acceptance of the situation (Thompson, 1993; see also, Wright, 1983). Finally, the positive meaning derived from the experience not only enables people to psychologically deal with accompanying emotional or physical life changes, but may in fact be indicative of recovery (Collins, Taylor, & Skokan, 1990; Tait & Silver, 1989). People have been shown to find positive meaning following adversity using a variety of attributional strategies. Individuals who have experienced negative life events often make favorable social comparisons (e.g., Taylor & Lobel, 1989), reevaluate the event as positive, find side benefits (e.g., social support), imagine worse situations, or forget negative aspects of their situation (Taylor, 1983; Thompson, 1985). No particular attribution has been linked with better adjustment, implying that causal meaning itself is the goal of the search (Taylor, 1983) and that such ascription should simply satisfy the affected individual (Bulman & Wortman, 1977). Amputations are not mere medical events, and they initiate a search for meaning because they represent irrevocable, physical losses that are imbued with social and psychological overtones (e.g., Parkes, 1975). Amputations can challenge people's assumptions about an orderly, controllable world and their role in it. Though the literal cause of an amputation may be apparentbe it acute (traumatic injury) or chronic (disease, a congenital condition)such knowledge will presumably not prevent the individuals affected from seeking to place this life-changing event into a broader context in order to make sense of it: Why did this amputation happen to me? How will it affect my life now and in the future? Following this reasoning, those individuals who seek a positive side to their amputation may be anticipated to demonstrate better psychological adjustment than those who focus more on the negative aspects of the situation. To find meaning in their experience, persons with an amputation might be expected to use any one or even several of the aforementioned strategies; the main point is construing positive meaning, however, and not the specific form it takes. Beyond the meaning individuals impute to disabling circumstances, it is also important to examine how they are dispositionally disposed to cope with them. Recent efforts center on the benefits of possessing an optimistic as opposed to a pessimistic personality, where dispositional optimism is defined as a generalized expectation that future outcomes will be positive ones (Scheier& Carver, 1985). In reaction to health threats (Scheier et al., 1989) and important life transitions (Aspinwall & Taylor, 1992), for example, optimists demonstrate better adjustment than do pessimists. Mounting evidence suggests that in contrast to pessimists, optimists manage stressful events by using problem-focused coping strategies; when such strategies are not applicable, optimists invoke more emotion-focused approaches, including acceptance, humor, and positive reframing of the situation (e.g., Scheier, Carver, & Bridges, 1994). By this analysis, persons with an amputation who are by nature optimistic would be expected to view their future life with a disability in more favorable terms than theirmore pessimistic counterparts. Examining such expectations in light of current

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indicators of well-being should reveal that optimists with an amputation should demonstrate fewer depressive symptoms and possess more positive self-images than pessimists (e.g., Schulz, 1992). In turn, both optimism (favorable expectations for future life with an amputation) and the search for positive meaning (interpretation of the amputation) implicate a motivation to perceive control over disability. Perceived control refers to the belief that one can influence potentially positive or negative outcomes, as well as a general motivation to obtain the former while avoiding the latter (e.g., Brehm, 1993). Numerous studies demonstrate that having a sense of personal control leads people to feel better about themselves and to cope better with adversity (for a review, see Thompson & Spacapan, 1991; see also, Weary, Gleicher, & Marsh, 1993, for a broader discussion of control), and it can promote physical as well as psychological well-being (Thompson, 1993). In the relevant literature on life stressors, a sense of personal control is linked with lower levels of depression and higher levels of selfesteem. Among persons with an amputation, therefore, heightened perceptions of control over disability should also result in such psychological well-being. Beyond assessing optimism and meaning, then, it is also important to ask persons with an amputation to reflect on how much control they perceive they have over their physical condition. The present study examined the salutary effects of finding positive meaning in a disabling experienceamputationand possessing an optimistic personality on the two criterion variables of psychological well-being. It was expected that finding meaning and being an optimist would be significantly predictive of lower levels of depressive symptomatology and higher levels of self-esteem. Participants were also asked to rate how much control they perceived they had over their disability, and it was hypothesized that higher perceptions of control would be linked to psychological well-being. Because age and time since amputation have been found to be predictive of well-being in some studies (e.g., Heinemann et al., 1988) but not others (e.g., Frank et al., 1984; Rybarczyk et al., 1992), these two factors were also treated as predictors. Given that relevant research demonstrates a lack of association between measures of adjustment and additional demographic factors (e.g., Kashani et al., 1983; Rybarczyk et al., 1992), the latter were not anticipated to be linked to psychological well-being.

METHOD Participants and Sample Characteristics The 138 participants, all golfers and members of the Eastern Amputee Golf Association (EAGA), were 123 male and 15 female persons with amputations (38% below knee, 27% above knee, 4% below elbow, 10% above elbow, 11% multiple sites/other, 10% unspecified) who ranged in age from 19 to 78.6 years (M = 52.39 years; SD = 15.0). Their amputations resulted from trauma (67.4%), disease

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(25.4%), a combination of trauma and disease (4.4%), birth defects (2.2%), or were unspecified (< 1 %). The average length of time since amputation was 20.36 years (SD = 15.9; range .3 to 73 years). Ninety-nine percent of the participants were White and most (76%) were married (11% were single, 10% were divorced/separated, and 3% were widowed). In terms of education, the majority had either some postsecondary experience (29%), a college degree (26%), or postgraduate training/degree (21%); the remainder completed high school (17%) or had less than a high school education (7%). Most participants were either currently employed (54%) or retired (29%), though some were on disability (10%) or unemployed (4%). Their average yearly incomes fell into the $35,000 - $45,000 range. The sample's religious affiliations were Roman Catholic (39%), Protestant (37%), "Christian" (5.1%), Jewish (5.1%), or none indicated (13.8%).

Questionnaire
A 10-page self-report questionnaire consisting of open-ended questions, selfreport rating scales, and validated psychosocial instruments was developed. Only those measures that related to the effects of positive meaning, optimism, and perceived control on depression and self-esteem are described below. Predictor Variables

Age and Time Since Amputation. Participants provided their age (birth date) and estimated the length of time (in years and months) since the amputation was performed. Positive Meaning. Participants were told that "Some people say that every dark cloud has a silver lining. Has anything positive or good happened to you as a result of your amputation?" Participants could select a "yes" or "no" response. If they responded affirmatively, they were then asked to describe the positive meaning resulting from the amputation. Dispositional Optimism. Dispositional optimism was measured using the Life Orientation Test (LOT; Scheier & Carver, 1985), an 8-item scale comprised of favorable ("In uncertain times I usually expect the best") and unfavorable ("If something can go wrong for me, it will") statements. Respondents rate their agreement with each item on a 5-point scale (1 = strongly disagree to 5 = strongly agree). The LOT has been shown to have reasonable psychometric properties, as well as adequate predictive and discriminant validity (Scheier & Carver, 1985; Scheier, Carver, & Bridges, 1994). In the present sample, Cronbach's alpha for internal reliability was .79. Perceived Control Over Disability. Using a 5-point rating scale (1 = no control to 5 = total control), participants were asked "how much control do you have over your disability?"

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Depression. Depressive symptomatology was assessed using the Center for Epidemiological Studies Depression Scale (CES-D; Radloff, 1977), a general measure of depressed affect or mood designed for use with cross-sectional samples in survey research. The CES-D's 20 items are scored on a 4-point scale (0 to 3) that measures the frequency of a symptom's occurrence during the previous week (e.g., "My sleep was restless"). Scores can range from 0 to 60 (present sample range was 0 to 41), and higher scores reflect a greater prevalence of depressive symptoms. A score of 16 or higher is indicative of being "at risk" for a depressive episode (Myers &Weissman, 1980); 18.2% of the present sample scored a 16 or higher. Mean scores in the general population range between 8.6 and 10.0, and the scale's psychometric properties are adequate (Radloff, 1977). The CES-D is not a measure of clinical depression, but it has been used successfully in previous studies with persons with amputations (e.g., Rybarczyk et al., 1995; Williamson et al., 1994). In this study, Cronbach's alpha for internal reliability was .88. Self-Esteem. Self-esteem was measured using the Rosenberg (1965) SelfEsteem Scale (RSE), a measure of global feelings of self-worth and self-acceptance. The RSE includes 10 items (e.g., "I feel that I have a number of good qualities") that participants were asked to rate on a 4-point scale (1 = strongly disagree to 4 = strongly agree). Scores could range from 10 to 40 (present sample range was 18 to 40), and higher scores reflect higher levels of self-esteem. The RSE has been found to have good reliability and validity (Blascovich & Tomaka, 1991; Rosenberg, 1965), and in this sample Cronbach's alpha was .87. Procedure The officers of the EAGA agreed to make one set of mailing labels available to the author if it was used only for this study and if confidentiality was ensured. Representing 21 states, the District of Columbia, and 2 foreign countries, 275 EAGA members were mailed a questionnaire and return envelope. A cover letter guaranteeing anonymity requested participation in a study on the experiences of persons with amputations. Informed consent was obtained through an individual's decision to participate by returning a completed questionnaire. Fifty percent of the questionnaires were returned completed (an additional five questionnaires were returned unopened or blank because the addressees were deceased or had changed their mailing address).

RESULTS The results begin by addressing the question of whether participants found something positive regarding their amputations. The first analysis relates the presence or absence of positive meaning, optimism, and perceived control over disability to depression. The second analysis relates these same factors to self-esteem.

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Positive Meaning Seventy-seven percent of the respondents said something positive happened as a result of their amputation, conceptually replicating prior research suggesting that people frequently search for a silver lining in adversity (Schulz & Decker, 1985; Taylor et al., 1984; Thompson, 1985). Participants' open-ended attributions were categorized by a research assistant who used categories based on related research (e.g., Taylor et al., 1984; Thompson, 1985). The responses fell into the following categories of meaning: Found side benefits (60%), made social comparisons (3%), imagined a worse situation (< 1%), forgot negative aspects of the event (2%), and redefined the event/reappraised life (35%). Sample attributions of positive meaning by these categories are shown in Table 1. It is important to note that these attributions demonstrate the viability of the "yes" responses participants gave when they were asked if anything positive or good resulted from their amputations; that is, their affirmations were supported by specific beliefs. As noted in the introduction, however, particular sorts of attributions do not predict better adjustmentit is whether one finds meaning per se in the critical life event that is linked with well-being (e.g., Taylor, 1983). For purposes of analysis, then, the key is simply whether participants say they did or did not find positive meaning following their amputations.

TABLE 1. Sample Attributions of Positive Meaning by Meaning Category Found side benefits "I changed to a different occupation [where] I became very successful" "I was ( very much a 'wallflower' and since I can no longer blend in, I've become more outgoing." Made social comparisons "I have one leg. What about the person who has no legs." "[I| have come to realize that there are many people who have more and bigger problems than I and I am lucky to have what I have." Imagined worse situations "I survived. I have a second chance at life. I love it." Forgot negative aspects "I found that I can still do about everything I did before-only it takes longer to do it." "|I have] been able to compete in most ways [with] my peers in the business and social climate." Redefined event/reappraised life "All good has come out of it. I found God through it. It has given me purpose. It makes me special." "I think I've become a much better person-more humble, more considerate and less selfish. I now know that I am not perfect."

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Preliminary Analyses One participant was dropped for failing to complete a majority of the measures and two others were not included in all the analyses due to missing values. Preliminary analyses determined that gender, amputation location, marital status, race, income level, education level, employment status, and religious affiliation were not related to any of the predictor or criterion variables, and thus will not be discussed further. Means and standard deviations for four of the predictors (positive meaning, which is dichotomous, was excluded) and the two criterion variables may be found in Table 2. It should be noted that the mean CES-D score of 8.92 is within the range found for the general population. Correlations among the continuous predictors and the criterion variables are shown in Table 3. Multiple Regression Analyses Multiple regression was used to predict depression and self-esteem. All the predictor variablespositive meaning (dummy-coded as 0 for "yes" responses to the positive meaning question, 1 for "no" responses), optimism, control over disability, age, and time since amputationwere entered as a block in a single step. Four of the predictors made significant individual contributions to depression: As measured by the CES-D, higher levels of depressive symptomatology were found among those persons who did not find meaning (P = . 17, t[ 131 ] = 2.39, p < .05), were less optimistic (p - -.52, f[131] = -7.38,/>< .001), perceived less control Table 2. Means and Standard Deviations for Continuous Predictor and Criterion Variables M SD 5.04 29.93 Optimism (LOT) .77 4.18 Control 15.00 52.39 Age 15.90 20.36 Time Since Amputation 8.92 8.11 Depression (CES-D) 4.89 35.08 Self-Esteem (RSE) Table 3. Correlations Among and Continuous - Predictor _ Criterion _ Variables _

1. Optimism (LOT) 2. Control .27* 3. Age .03 .02 4. TSA .13 .12 .43** 5. Depression (CES-D) -.60** -.31** -.13 -.10 6. Self-Esteem (RSE) .66** .32** .05 .08 Note. TSA = Time since amputation (in years). */7<.01. **/?<.001.

-.71**

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over their disability (p = -.14, r[131] = -1.99, p < .05), and were younger (Beta = .18, r[131] = -2.32, p < .05). The model was statistically significant, with adjusted R2 =.40, p < .001 (see Table 4). A parallel simultaneous analysis was performed on self-esteem, as measured by the RSE (see Table 4). This analysis was also statistically significant, with adjusted R2 = .44, p < .001 (see Table 4). Two of the predictors were influential: Higher levels of self-esteem were found among those persons who were more optimistic (p = .60, t[ 131] = 8.73, p< .001]) and who perceived more control over their disability (P =. 14, t[ 131 ] = 1.99, p < .05). However, positive meaning had no influence on selfesteem (p = -.10, r[131] = -1.40, p< .20), nor did age (p = .07, f[131] < 1.0).

DISCUSSION Descriptively, meaning appears to be related to psychological well-being following amputation. When asked if anything positive resulted from their amputations, the majority of participants responded affirmatively and proceeded to provide descriptive answers that fit categories of meaning derived from previous research (e.g., Taylor et al., 1984; Thompson, 1985). Similar to participants in Schulz and Decker's (1985; see also Bulman & Wortman, 1977) research on adjustment to physical disability, members of the present sample not only attached meaning to the loss of a limb, they frequently attributed positive aspects to the amputation (see Table 1). Indeed, the two most frequently ascribed categories of meaning were finding side benefits to the amputation and redefining the amputation in one's life. That other construal categories were reported less frequently should not be surprising, as the study was cross-sectional rather than longitudinal, and the participants varied in how recently their amputations had taken place. Other cross-sectional studies on coping with illness or injury, for example, suggest that downward social compariTable 4. Simultaneous Multiple Regression Analyses for Depression and Self-Esteem Standardized Regression Coefficients Predictor Depression Self-Esteem .17* Positive Meaning -.10 Optimism (LOT) -.52** .60** -.14* .14* Control .07 Age -.18* .04 TSA -.03 .40 .44 Adjusted /? F 22.36 19.31 df 5,131 5,131 .001 .001 P Note. TSA = Time since amputation (in years). *p<.05. **/><.001.

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sonsself-enhancing comparisons made with those perceived as worse off than oneselfare a short- rather than long-term coping response in that they do not provide information about successful adjustment (Schulz & Decker, 1985; Taylor, Aspinwall, Giuliano, Dakof, & Reardon, 1993). Rather, such comparisons only improve mood and bolster self-evaluations when the adversity is close in time. In contrast, side benefits and reappraisals of life represent ongoing, broader instances of how disability has been advantageously assimilated into the participants' lives. An ability to identify such "silver linings" in disability no doubt serves to affirm the self and may be indicative of disability acceptance (Dunn, 1994). Ideally, future research should examine the origins of positive meaning following a disabling event and follow its course across time, highlighting initial construal strategies and their development into more coherent beliefs about the self (see Dunn, 1994, and Keany & Glueckauf, 1993, on values and value change following disability). With respect to the depression results, it is important to note that the CES-D emphasizes the affective component (i.e., mood symptoms) of depression (Radloff, 1977). The mood symptoms (e.g., sadness, fear, loss of appetite, restless sleep) are among those upon which a diagnosis of clinical depression can be made. The inferential results of this study suggest that finding positive meaning following amputation, dispositional optimism, and perceived control have some salutary effects for individuals who have had an amputation: Multiple regression analyses revealed that these three factors were linked with lower levels of depressed mood among a sample of persons who experienced amputation. The fact that finding positive meaning or a "silver lining" in one's amputation was linked with lower scores on the CES-D is noteworthy, as this variable is usually examined in the context of self-attributions regarding disability (e.g., Schulz & Decker, 1985) rather than as a buffer for depressive symptoms potentially related to disability. Beneficial psychological effects have been attributed to dispositional optimism by various studies (for a review, see Scheier & Carver, 1992), and the present one is no exception: Having a favorable outlook toward the futurein contrast to a pessimistic onecorresponded to lower scores on the CES-D. Beyond such general expectancies for the future, perceiving greater control over disability as a current and ongoing event was also predictive of less depressed affect. Interestingly, higher levels of depressive symptoms were noted among the younger members of the sample, replicating prior research which found that older individuals who experienced an amputation tended to experience less depressive symptomatology (Frank et al., 1984; Williamson et al., 1994). The cross-sectional nature of the present data precludes specifying the causal factors involved, but some speculation regarding the relation between age and depression among individuals with amputations is warranted. Activity restriction is one compelling factor that may explain the link between age and depression. Williamson and Schulz (1995) argue that the restriction of routine activities due to illness and pain is relatively more distressing to younger rather than older persons. In a study of adult cancer patients, when they were compared to younger individuals, older persons were less troubled by restrictions in their activities because they generally possessed lower expectations concerning

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their functional status and they also had more prior experience with illness and disability (Williamson & Schulz, 1995). In the present investigation, it is plausible that the older persons with amputations had fewer depressive symptoms because they habituated to lower activity levels and perhaps viewed them as a normal aspect of aging. It follows that adjustment would be more difficult forand depressive symptoms more frequent amongthe younger members of the sample because they are not an age where functional limitations are deemed normal or expected. Thus, older persons can be characterized as possibly exhibiting better coping with amputation due to normative age-related developmental changes. Beyond activity restriction, however, concerns about body image may also be important in understanding the link between age and depression. General concern about body image declines with age, and so should concomitant concerns about physique following amputation (Frank et al., 1984). In contrast to older persons, however, younger individuals may still be experiencing anxiety about body image, social stigma, and related adjustment issues. Recent research by Rybarczyk and his colleagues (Rybarczyk et al., 1995) persuasively argues that body image concerns and perceived social stigma are significant, independent predictors of depression following amputation. According to these researchers, perceived social stigma, in particular, has been overlooked in the study of psychological adjustment to amputation. Rybarczyk et al. did not, however, find a link between age and depression, nor did the present researchgiven its salutary emphasisinclude measures pertaining to body image or stigma. Future research should consider stigma and body image measures from a salutary vantage point in order to determine whether their effects are moderated by age and, in turn, under what conditions they predict depressive symptomatology. As predicted, higher levels of optimism and perceived control had a salutary relation to self-esteem. The optimistic individuals who had an amputation had higher self-esteem relative to the pessimists in the sample. It is important to note that as a personality variable, optimism is conceptually linked to but argued to be distinct from self-esteem (Scheier, Carver, & Bridges, 1994). To a degree, both constructs do emphasize positive over negative outcomes; however, optimism focuses on expectations for the future, whereas self-esteem carries one's sense of self-worth and acceptance by others. Heightened perception of control over one's amputation as a disabling event, too, was linked with higher levels of self-esteem. Individuals who possessed higher selfesteem presumably viewed themselves as more causally influential where their disability was concerned than did those who had lower self-esteem. This result is consistent with the extensive psychological literature demonstrating that perceived control promotes a sense of mastery or competence over adverse life events and their aftermath. Even when personal control perceptions are nonveridical, they can nonetheless provide practical and desirable consequences, including promoting goal-oriented behaviors and persistence (Alloy, Clements, & Koenig, 1993). Coupled with perceptions of control, self-esteem no doubt enhances living with a disability.

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Unexpectedly, finding positive meaning in one's amputation did not predict higher self-esteem. There are at least two possible explanations for the absence of a link between positive meaning and self-esteem. First, consider the nature of selfesteem as a psychological construct. As an indicator of self-worth or self-acceptance, global self-esteem is often construed as being trait-like and thus relatively stable in adults (Blascovich & Tomaka, 1991; see also, Brown, 1993). In retrospect, the ability to find positive meaning in a disabling experience may not have been predictive of self-esteem in this study because the RSE is a measure of global selfesteemit does not measure what has been called attribute-specific self-esteem (Brown, 1993). If an attribute-specific measure of self-esteem tailored to disability had been included in the study, then the presence or absence of positive meaning regarding amputation might have been predictive of self-esteem linked to the life domain of disability. Future research relating meaning to self-esteem should consider this possibility. Alternatively, Wright (1983) calls attention to a reason that the self-esteem construct can be somewhat problematic in research with persons with disabilities. Feelings of inferiority (i.e., low self-esteem) and the objective reality of a disability (here, amputation) do not and should not necessarily covary with one another. Numerous studies demonstrate that persons with disabilities and the nondisabled are frequently not discernable from one another on this dimension (Wright, 1983). That is, one's feelings of adequacy and self-acceptance may be related to but are not predicated upon disability, just as nondisabled persons do not draw a sense of wellbeing from the absence of disability. While it is important to include measures of self-esteem in research on disability and well-being, it is just as important to realize that disability is often perceived very differently by those who actually experience it (so-called "insiders") and those who only observe but nonetheless draw conclusions about it (so-called "outsiders"; Dembo, 1964; Wright, 1983). As has long been acknowledged, these often divergent perspectives must be considered when interpreting psychosocial adjustment among persons with disabilities (e.g., Fine & Asch, 1988; Shontz, 1982). Finally, though some prior research suggests that time since the amputation is associated with fewer depressive symptoms (e.g., Heinemann et al., 1988), in the present sample, neither this facet of psychological well-being nor self-esteem was predicted by greater distance from the event. The lack of predictability of this variable has been previously noted by others (e.g., Frank et al., 1984; Rybarczyk et al., 1992). The lack of consistent effects for time since the event suggests that, depending upon a given study's focus, it may be confounded with other variables (e.g., value change). Future work should explore this possibility. Possible limitations in the generalizability of these results to the general population of persons with amputations must be acknowledged. As a whole, the study's participants can be described as rather advantaged and affluentparticularly in terms of education and incomewhen compared to the average individual with an amputation in the United States. Indeed, the presence of these two factors may explain why the participants had no more depressive symptoms on average than the general population. The relatively high levels of well-being exhibited by

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the present sample are noteworthy and possibly even unique; in contrast, the majority of persons with amputations have comorbidities that can adversely affect their physical as well as mental health. Finally, a higher percentage of the individuals in this sample had amputations resulting from trauma than is true for the general population of persons with amputations, most of whom have lost limbs as a result of chronic illnesses. Nonetheless, the participants in the study's sample should be of interest to disability research precisely because they could be described as successful rehabilitation clients. Most sustained an amputation following some sudden, traumatic event, and yet many subsequently adopted a salutary perspective on their experiences and elected to participate in an athletic group activity. While the present results cannot necessarily be extended to the majority of individuals with amputations, the findings are suggestive and, beyond issues of theory regarding well-being, they also have implications for rehabilitation. Implications for Rehabilitation In the study of salutary effects following disability, finding positive meaning in the disability is representative of the "phenomenology of coping" (Schulz & Decker, 1985, p. 1171), an apt phrase for the present circumstance where meaning was both ascribed and linked with fewer depressive symptoms. It is clearly premature to suggest that persons with amputations should be compelled to identify specific "silver linings" to their situation during the course of their rehabilitation. Nonetheless, the present research suggests that finding something favorable associated with one's amputation can be an indicator of psychological well-beingand it is not the particular attribution that matters; rather, it is the mere act of ascription. In the course of discussing adjustment to amputation with their clients, rehabilitation professionals should take note of whether any beneficial aspects are described and, if so, to consider discussing their import with the clients. Dispositional optimism proved to be a particularly strong predictor of both measures of psychological well-being. This result is consistent with numerous studies that now substantiate a link between optimism and various subjective as well as objective indicators of health and well-being (for a comprehensive review, see Scheier & Carver, 1992). Although they live with an amputation, the optimists in the present sample tended to maintain positive expectancies for their futures. In comparison, the pessimists held more negative expectations for their futures. These opposing expectations are presumably prominent in the affective experiences of individuals who have had an amputation, and no doubt have an influence on their motivation and goal setting during rehabilitation. Mental health professionals and members of rehabilitation teams should consider what role, if any, optimistic and pessimistic personalities play during adjustment to amputation. Finally, there are clear advantages associated with the development and maintenance of perceptions of control over disability. Heightened perceptions of control serve to enhance people's beliefs in personal autonomy and mastery over their physical condition, and no doubt influence their activities during rehabilitation and

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beyond. Rehabilitation specialists should consider ways to promote a primary sense of perceived control by pointing to aspects of a client's behavior (e.g., adherence to therapy regimen) and environment (e.g., obtaining helpful devices, remodeling the home) that can be modified or changed (see also, Schulz, Heckhausen, & O'Brien, 1994). In addition to such direct intervention, however, ways of promoting intrapsychic changesecondary controlshould not be ignored. The present research demonstrates that deriving positive meaning is but one strategy related to secondary control. Other means to exert secondary control, such as self-selecting appropriate rehabilitation goals or thinking about the self in new ways, should also be encouraged by professionals. Future Directions: A Theoretical Framework for Salutary Effects Reliance on a framework for the study of salutary effects regarding disability generally, and amputation specifically, is desirable, particularly since research in both areas often emphasizes physical over psychosocial adjustment. Several authors have recently advanced the idea that people's reactions to threatening events, including disability, can be interpreted as a process of reality negotiation (Dunn, 1994; Elliott et al., 1991; Snyder, 1989). Reality negotiation involves relying on cognitive strategies that promote positive beliefs about the self under conditions that are threatening to the self (Elliott et al., 1991; Snyder, 1989). The benefits associated with negotiating reality in routine and traumatic situations include higher levels of self-esteem, happiness, optimism, empathy, and greater capacities for creative and productive work (Taylor, 1983; Taylor & Brown, 1988, 1994). Snyder (1989) argues that effective reality negotiation involves two factors: Protective and self-enhancing behaviors. Protective behaviors (e.g., making excuses) lead the self away from activities that jeopardize self-image, while enhancing behaviors (e.g., being hopeful) direct the self toward positive events. The present study focused on three self-enhancing social-cognitive strategiesderiving positive meaning, being optimistic, and perceiving controlthat were linked to wellbeing in a group of persons with amputations. The study of these and other strategies that promote coping with both major and minor vagaries of life, sustain positive selfimage, and foster efficacy expectations should prove to be fruitful for rehabilitation researchers and practitioners. Future efforts should consider the salutary implications of reality negotiation in research and counseling with persons with disabilities.

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