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RESEARCH PAPER
Abstract
Purpose. To explore participants experiences of psychosocial adjustment within 18-months following amputation in a
manner that can inform further research and clinical practice.
Method. Transcript data from eight semi-structured interviews were analysed using Interpretative Phenomenological
Analysis.
Results. Three super-ordinate themes emerged from the analysis: (1) pre-amputation decision-making process and control,
(2) renegotiation of self-identity and the struggle to accept a new disabled identity, and (3) adjustment as a social process.
Conclusion. This research furthers understanding of pre-acute, acute and post-acute adjustment processes from the insider-
perspective of individuals who have experienced amputation. A picture emerged in which individuals adjusted to amputation
and its sequelae through a process of renegotiation of self-identity that was mediated through a wide range of decisional,
informational and social factors. Suggestions for clinical practice and further research are discussed.
Correspondence: Roger Hamill, Regional Acquired Brain Injury Unit, Belfast Health & Social Care Trust, Clinical Psychology, Musgrave Park Hospital,
Stockmans Lane, Belfast, BT9 7JB, United Kingdom. E-mail: roger.hamill@belfasttrust.hscni.net
ISSN 0963-8288 print/ISSN 1464-5165 online 2010 Informa UK Ltd.
DOI: 10.3109/09638280903295417
730 R. Hamill et al.
tending to adapt better to amputation than adoles- person relates to another on an individual friendship
cents and younger adults [13,14]. However, the basis [5]. Because of its focus on understanding
evidence for the impact on psychological adjustment participants at an individual level and placing them
of gender, ethnicity and socio-economic status is as persons-in-context [23], qualitative research can
much less persuasive [6]. promote the individuation of people living with
The adjustment role of key psychosocial factors is amputation, and thereby challenge discrimination.
more clearly supported in the literature. For in- Despite the potential benefits of using qualitative
stance, the use of an active coping style [7], down- methods to explore the adjustment experience of
ward social comparison [3], dispositional optimism individuals following amputation, the number of
and perceptions of control over disability [15], are all qualitative studies in this area remains small [2428].
significantly correlated with improved adjustment However, such studies demonstrate the unique
outcomes. Similarly, efforts to seek out positive contribution that qualitative approaches may make
meaning in the amputation experience [16], and to the understanding of adaptation. For example, in
having a strong balance confidence [17], have been his analysis of 35 semi-structured interviews with
found to be highly adaptive. Social support and individuals who successfully adapted to prosthesis
integration are also key factors in the adjustment use, Murray [26] found that the presence of PLP was
[13,18]. However, it is crucial that any help is a significant factor in promoting the embodiment of
perceived to be supportive by the individual receiving prostheses as corporeal structures. This unexpected
it [6], and that social integration emphasises the finding a clear demonstration of the elicitation role
quality of relationships over the quantity and of qualitative research suggests that the presence
structure of social networks [19]. of PLP in the early stages of rehabilitation may be
The relative strength of empirical support for the adaptive in at least one important respect, with
adjustment significance of psychosocial variables has obvious clinical implications.
led some researchers to suggest that, with the In previous qualitative studies of adjustment
exception of PLP and RLP, physical and socio- following amputation, participants were interviewed
demographic factors contribute little to explaining several years after amputation. Although the
the variance in individual responses post-amputation evidence for a significant impact on adjustment of
[2]. However, others have argued that psychosocial time-since-amputation has been described as weak
adjustment should be viewed in more holistic terms by one source [2], others have reported findings that
as the interaction of various factors, including are more consistent with the hypothesis that adapta-
physical and socio-demographic variables [7]. Either tion should generally improve with time [6,7]. Given
way, it is notable that the vast majority of research in the rehabilitative significance of the initial period
this area has been from a quantitative perspective. If after amputation, this study explored the adjustment
it is the case that the most significant variables are experiences of individuals within 18 months of
psychosocial processes relating to an individuals amputation. The aim of the study was to give voice
cognitive strategies, perceptions, attributions, mean- [29] to the participants insider perspective [30] on
ing-making, and social relationships, then qualitative adjustment in a manner that may inform future
studies, with their emphasis on understanding the research and clinical practice.
subjective experience of persons-in-context, would
seem ideally placed to contribute to the research
enterprise. At the same time, if an individuals Method
adjustment response is best understood as being
determined by a complex web of multiple factors, Study design
then qualitative approaches are also well suited to an
in-depth exploration of the interconnected elements As the aim of this study was to explore the
of such processes [20]. interconnected elements of adjustment experience
The use of qualitative methodologies in this area from the perspective of individuals living with
also allows an idiographic focus. It has been argued amputation, a qualitative design was employed
that referring to individuals in terms of their [22,26]. Specifically, an Interpretative Phenomeno-
disabled group membership may encourage a logical Analysis (IPA) [30] methodology was
process of deindividuation in which they are erro- adopted because of its emphasis on understanding
neously labelled with the negative characteristics the subjective experience of persons-in-context [29],
stereotypically applied to the entire group by many and its suitability for exploring issues of great life-
non-disabled individuals [21]. This negative funda- significance that unfold over time [31]. IPA is
mental bias [22] is best challenged when the person influenced by phenomenology in its focus on
living with amputation becomes individually con- subjective experience, but also by symbolic inter-
textualised, as might happen, for example, when the actionism in its understanding that the meaning
Psychosocial adjustment following amputation 731
emergent themes and interpretations are supported am going to get it off, then the next week, No, Ill not.
by the data [35,36]. Also, the analysis process is not a Im going to keep it, keep the stiff leg. So then I just
discrete stage of the research, but rather continues weighed up everything. I put it all down on paper and
throughout, and new themes commonly emerge even weighed it all up and decided I would get it off and that
was it.
during the write-up phase [27].
The decision-making process and control [Clare] At that stage the pain was so great I wouldve
agreed to anything. I was totally out of it because the
The first question in the interview schedule Could pain was so great. I wouldnt say I was in my proper
you describe how you came to lose a limb? was senses if you know what I mean. I just didnt care what
designed to access information about the aetiology they done as long as somebody relieved this pain.
and timeline of amputation. Although this type of
data was provided by the participants, the majority of Clare felt that, despite having signed a consent
the respondents focused more on the process they form, she was not in a position to give truly informed
went through when deciding whether to opt for consent because her judgement was clouded by pain
amputation. For many, this process involved a cost and she did not remember being told of the risks
benefits analysis in which the potential losses of associated with the surgical procedure.
amputation were weighed against the risks associated
with not opting for limb removal.
[Clare] Now, I signed for the bypass, dont get me
wrong, but as I say I dont remember anybody ever
[Roy] Making the final decision was the hardest thing to saying to me that one of the complications could be that
do. You know, if I take it off now then its off, you cant you would lose your leg. So I feel that I was nearly
go back and stick it on, its gone. There was a couple of railroaded into it. Probably I took it as an escape. If I
months I didnt have much sleep. Maybe one week, I have this done then a couple of days later Ill be home.
Psychosocial adjustment following amputation 733
So I dont know if somebody had have mentioned is almost entirely passive in terms of both amputation
that to me would I have even considered it? . . . I dont cause and decision.
think so.
[Bob] Someone had removed the shower-chair out of
[Interviewer] When youre talking about things in the room and had brought it back in and never replaced
those terms, what are the feelings associated with that? the brakes on it and never put the brakes on. While
transferring over I slipped and got a tiny knick right on
[Clare] I suppose you could be very bitter about it. the scar where the leg had been re-stitched after the
amputation. District nurses were picking at it and they
[Interviewer] You could be? Are you? never let it heal properly. Then I came in here for a limb
fitting below the knee and picked up MRSA which went
[Clare] Yes . . . though I try to justify it. But is it a straight into an open wound and from there on it went
situation like a death that you go through a period of downhill. I went over to see the consultant. I cant have
mourning for your leg? Do you go through this pity me been in the room more than five minutes and I was told
and the hate stage? I dont know. I just feel that my thats coming off basically thats the way it was put to
independence and my life have more or less been taken me we have to take that off.
away from me in one sense because I cant do the things
that I normally would have done.
Unsurprisingly, Bobs reaction to the second
amputation was very different to the first: thats
In the above passage Clare appears to make an when I got depressed, really really depressed over it
attempt to rationalise her anger as a normal, and For many participants, however, decision-making
therefore transitory, stage in the grieving process. was a collaborative process in which responsibility
However, the final sentence reveals her true belief was shared with close family members or, as in Jims
that the bitterness she feels will be as permanent as case, health professionals.
the losses she has experienced. She feels that her
long-term interests have been betrayed by others in [Jim] See to keep my leg the way it was, I had a lot of
favour of a short-term goal of pain relief. Thus, the pain with that and the wound was oozing out everyday
trust relationship she previously had with clinicians is and it had to be dressed everyday and there came a bad
damaged, as demonstrated by her resistance to a smell from it. It wasnt pleasant. So it was either, wed
doctors proposal for further surgery to investigate stay with that and maybe let the infection go up the leg,
the cause of her RLP. or moving on and get the leg off. So me and the doctors
finally decided the best course of action was to get my
leg amputated.
[Clare] She [the doctor] thought maybe there was a
nerve that had recoiled back so they were about
exploring it. But I dont want any more surgery unless For Sue, retaining control over the timing of
its an absolute necessity. Ive had a bad experience decision-making was important even when it in-
where you walk in and come out like this. curred a considerable health cost. When asked why
she had delayed seeking medical help for a chronic
Thus, in a reverse of her previous position, Clare foot infection, even though it resulted in her needing
chooses to live with significant pain rather than opt a higher level amputation than might otherwise have
for the risk of further limb loss that she now been the case, she replied,
associates with surgery.
The significance of perceived control over the [Sue] I think in all honesty, although it had drastic
decision-making process was not unique to Clare, effects, I still think I did the best for me personally
but rather emerged as a strong theme across various because I needed to come to the point that I had no
participants accounts. This is clearly illustrated by choice, I had to go to hospital. I think if people had have
comparing Bobs reaction to two different amputa- pushed me and pulled me down to the hospital
tion procedures. For the first amputation (a below screaming and shouting, I think it maybe would have
knee removal), Bob acknowledged personal respon- been a worse experience for me for I would have been
sibility by noting the role that smoking had played in blaming everybody else then you see. But by the time I
did it I knew I had to do it, Id left it that I could not go
precipitating the need to amputate. He then de-
on any longer. So I think for me I did it at the right time.
scribed the process of opting for surgery almost
exclusively in terms of active I decided statements
(in stark contrast to Clares almost exclusive use of Control over timing was also significant for Pam,
they statements). Finally, Bob was able to conclude but in her case she used an assertive strategy to
of his decision, It was hard, but it felt the right thing ensure that surgery occurred as soon as possible after
to do. However, for the subsequent (above knee) what she felt was an unacceptable delay following her
re-amputation, Bob provides an account in which he decision to opt for amputation.
734 R. Hamill et al.
[Pam] I suppose looking back on it and knowing the thinking that I was making the right choice. I asked him
[UK National Health Service] systems I should have what he was fit to do after the amputation and what he
been a lot more patient. But it was some girls here [in wasnt. So I knew. Yes, I was going to lose my leg, there
the rehabilitation hospital] actually got it in the ear one was things I wouldnt be fit to do. But I knew it wasnt
Friday and then I went on to the Complaints Officer going to be the end of my life. I knew Id get my limb on
[. . .] and then, it was funny, I got an appointment the and Id still be fit to do most things.
next Wednesday [laughs].
Once an appropriate source was located, that [Jim] From when I had the accident I didnt like people
person was in a position to both inform and validate fussing around me. It made me feel as if I was disabled. I
the decision made by the participants, thereby dont like classing myself, putting the label on me as
instilling hope for the future following amputation. disabled, but people fussing around me, trying to do
things for me, trying to encourage me to do things made
me feel more as if I was disabled.
[Jim] I had a cousin that lost his leg about three years
before I had my accident. So talking to people [without
Dave had a very similar experience with his family,
amputation] about it, they didnt really understand what
and it was only by taking direct action that he was
you were going through because they couldnt. So I went
round and I talked to my cousin about it and he showed finally able to communicate his need to reassert his
me his leg and told me what all he went through, and I independence as much as possible.
asked his advice. And he advised me, If I had to do it all
again I wouldnt have to think twice. So talking it over [Dave] Sometimes its a bit annoying cause theyre
with him, it helped because it confirmed what I was always wanting to do things for me. But I have to get at it
Psychosocial adjustment following amputation 735
and do it myself. Like buttering bread or toast in the attempts to reassert independence in their lives
mornings. You know, I can do it now myself. Before subsequent to amputation.
they wouldve wanted to do it for me and I wanted to do
it but they wouldnt let me. You know, Sit you down, [Sue] I had great big long lists when I got out of hospital
relax and things like that. So I just told them to leave it of things I could not do and I got great joy ticking them
alone and Id do it myself. At one stage, when they were all off as they became doable. The list is very very short
finished I went up and I made my own so that sort of now, very short.
killed that then. So I do everything now myself.
Dave used an implied meat metaphor to represent night and she just didnt work. So that sort of clicked
a process of disembodiment at the point of losing his that Id need to catch myself on. You start to think of the
lower arm in a work accident. However, in his case ones youre going to leave behind. Like my daughter,
the representative process was highly adaptive. she wasnt too old then, around ten I think.
[Dave] The other boy, I told him to go and get something A double meaning of the words clicked and
to tie my arm off. He came back with a bit of dirty rope. So catch is evident in Roys narrative. According to
I chased him away with that, I said, Go and get me this interpretation, it was the click of the trigger
something finer and cleaner. So I tied it off and waited failing to fire the gun that prompted him to rethink
until the blood stopped, and then after, I went down to the his suicidal intent, and it was an awareness of the
hospital. I had a clear head. I used to work in a meat factory
impact of such behaviour on significant others that
so I was used to the blood and stuff.
acted as a safety catch against his attempting suicide
again in the future.
Thus, by severing his arm psychologically as it was During the initial rehabilitation phase, many
severed physically, he was able to retain an objectivity participants derived comfort and motivation from
(notably lacking in his work colleague) that ulti- comparing themselves to other individuals with
mately ensured the survival of the rest of his person. amputation. This occurred in a number of different
ways. For example, Sue was encouraged by the
Adjustment as a social process example of other people in the physiotherapy gym
who were ahead of her in the rehabilitation process.
The role of social factors as mediators of adjustment
was another key theme to emerge from the partici- [Sue] Everybody wasnt on my Day-One. So I went in
pants accounts. For instance, the negative impact of there as a Day-One person and there was somebody was
being socially isolated immediately after surgery was in there a week, a fortnight, six weeks, whatever. And
expressed by Bob. you could instantly see people ahead of you what they
were doing. And people that were older than you doing
[Bob] Having no one to talk to, being down at the very things and Im saying, Well, hes seventy-eight years of
end of the ward. All youd hear was the doors opening age and if he can do that, I can do that! You know, what
and people going into the next ward. And thats all. You excuse could I possibly think of not being able to do it?
never heard anybody talking.
Another very common form of comparison with
[Interviewer] And how did that affect you?
others involved comparing the impact of disability so
[Bob] Suicidal. Really suicidal . . . I had my insulin pens that the participants own problems were reappraised
in the room. Id maybe three insulin pens. Feeling as if as less serious. Sue described this process when she
you could load them pens up and just jack yourself and talked of a 16-year-old boy who was undertaking
nobody would have knew. And nobody would have physiotherapy at the same time as her.
come near you.
[Sue] I felt so sorry for him then Id not time to feel
Bob was well aware of the irony in responding to sorry for myself. At least Im past working age, Ive done
this social isolation by increasing the very behaviour, things, you know. Im not missing out whereas hes
smoking, that had precipitated his amputation. missing out on nearly everything because hed a full
amputation and something with the other leg. So that
kind of took any self-pity I might have been going to
[Bob] I got up every morning about half six and went
achieve right out of the picture.
down to the smoke room and sat there till about quarter
to eight just to get company. And by doing that you were
smoking your brains out the whole day. Instead of A more abstract process of comparison also
maybe smoking maybe eight cigarettes a day you were occurred in which some participants compared their
smoking thirty which wasnt doing you any good. But current situation favourably to the circumstances of
just for company. Just to have someone to talk to. individuals who had experienced amputation in years
past.
For Roy, it was the implications of being socially
integrated that persuaded him to get rid of his [Roy] I dont know how they done years ago when they
firearms after making an attempt to take his own life had nothing, had to make their own pegs.
during a depressive episode soon after amputation.
For many participants, social support was more
[Roy] I got that bad I had to get rid of my guns out of significant than practical support, as demonstrated
the house, I got them away. I tried to use the gun one by Clares account of her telephone conversation
Psychosocial adjustment following amputation 737
with a social worker soon after returning home from [Roy] I imagine everybody is staring at me, thinking that
the hospital. youre a freak or something, or that youre not walking
right. I expected people to be worse, to maybe say things
[Clare] The social worker rang me and asked me did I or something like that, but it hasnt been. It was all just a
need her and I said I would need help around the house. bit up in my head. Whether I felt that way when I had
Oh, your husband works, youll have to pay and thatll two limbs that I probably looked at people in the same
be 7 an hour. I said, Right. And she said, Is there way, and that has been in my head too.
anything else? And I said, I cant think of anything.
And she said, Oh, well then theres no need for me to
come out. But if shed even have come out and sat and Discussion and conclusions
talked to me as a one-to-one. I think this [research
interview] is really the first time Ive had a conversation This study contributes to the process of redressing
with anyone to actually talk about the leg on a one-to- the balance between quantitative and qualitative
one basis. research in the area of adjustment to amputation
[24]. Unlike previous qualitative research in the area,
The terms on which social contact was provided this study focuses on adjustment experiences of
were crucial. As Clare describes, in many family and individuals in the initial period following amputa-
social situations she felt under pressure to minimise tion. Perhaps because of the relatively short time gap
or deny her adjustment problems in order to avoid between amputation and research interview, the key
evoking negative feelings in others and potentially theme to emerge in the analysis related to the
jeopardising the prospect of future social contact. adjustment significance of perceptions of control in
the pre-amputation decision-making process. This
[Clare] I felt that once you came out of hospital you theme was not anticipated by the research team, and
were on your own. There was nobody to talk to, and emerged despite there being no direct prompt in the
when you did go out you tried to talk about everything interview schedule. However, in retrospect, it is
other because you feel youre being a whinge. People hardly surprising that a majority of the participants
dont want to listen to you whinge, Ive no leg, Ive no should attach such significance to this issue. It has
this, Ive no the other. I wouldnt want to listen to been noted that for most individuals the process of
anybody like that. So therefore you try to be, Im great, adjustment begins long before surgery, as soon as the
Ive only got one leg, it doesnt bother me. possibility of amputation is first considered [4].
Given the predominant vascular-related aetiology of
Although the majority of participants reported that amputation in the developed world, most individuals
the response they received from others following here have a considerable period of time in which to
their amputation was overwhelmingly positive, the weigh up the pros and cons of amputation. As
following extract from Bobs account clearly illus- demonstrated in this study, where two of three
trates the serious emotional and behavioural con- individuals with traumatic aetiology had a gap of
sequences that one negative social interaction can years between trauma and amputation, even a
have. Bob, who has a visible congenital bilateral arm significant proportion of people who lose limbs as a
disability, reported the comment of an acquaintance result of trauma have an opportunity to go through a
upon meeting him for the first time since his decision-making process before the limb is finally
amputation. removed.
Despite the clear importance of this issue for the
[Bob] I got a comment made to me on Boxing Day that, current participants, it is notable that previous
I was a real spastic bastard now, which didnt go down research on decision-making and amputation focuses
too well. I let that get to me, and at one stage I primarily on the decision-making of health profes-
completely thought about not coming back here [to the sionals rather than patients [3840]. Given that the
rehabilitation centre] cause I was going like, Whats the association between higher levels of perceived con-
use, you know, if people are going to treat you like that? trol and improved adjustment is widely acknowl-
edged in health psychology [41], this represents a
For others, concerns about what non-disabled significant gap in the literature. In this study, the
people were thinking were sufficient to prompt accounts provided by Clare and Bob suggest how
them to avoid social interaction. In the following negatively adaptation can be impacted when an
extract, note how Roy acknowledges that, though his individual perceives a lack of decisional control prior
initial fears of being treated as abnormal by others to amputation. Perceptions of informational control
were not realised, his own remembrance of how he [40] were also identified as important, although there
previously viewed individuals with amputation was was a clear hierarchy of credibility in terms of who
enough to cause him to stigmatise himself now as a provided the information. The most privileged
freak. sources were other individuals with amputation
738 R. Hamill et al.
who were afforded insider status [5] by dint of their isolation rather than risk social isolation from her
personal experience of limb loss. However, health family and friends. As a result, even though she felt
professionals could also be awarded a form of insider that her familys constant physical presence was
status that derived as much from their manner of suffocating, she felt unable to connect with others to
relating to participants as from their credentials and help her cope with the emotional sequelae of her loss.
technical expertise. Clares account is a clear demonstration of the
According to Terror Management Theory [42], finding that it is the quality of relationships, rather
adjustment is a process in which an individual than the extent or structure of social networks that
attempts to protect their self-esteem by asserting ultimately mediates psychosocial adjustment [19].
their value as a person in a meaningful context. For The primary aim of this study was to give voice to
many of the participants in the current study, this the experiences of eight individuals who are in the
process was manifested in a resistance to accept a early stages of adjusting to life with amputation. The
new disabled identity, and a struggle to adapt to a picture that emerged from their accounts was one in
loss of independence and functioning with regards to which attempts to assert control over decision-
activities of daily living (ADL). The specific markers making and protect self-esteem occurred in a social
of this disabled status were highly idiosyncratic. context that, at different times, both promoted and
Thus, for example, Sue could perceive her wheel- hindered adjustment. A secondary aim widely
chair as disabling while Jim perceived his as enabling. endorsed by the participants themselves relates to
Many of the participants successfully adopted a the role this study may play in informing future
self-instigated strategy of goal-setting as a means to research and clinical practice.
gradually reassert their sense of self-efficacy. A In terms of future research, the findings of this
process of reality negotiation [43] was also com- study suggest that more qualitative and quantitative
monly employed to transform contingencies of research is required to investigate the process of
self-worth [44] in a manner that was protective of patients pre-amputation decision-making, and the
self-esteem. However, all of the participants ac- impact that perceptions of decisional and informa-
knowledged that their attempts to adapt to the tional control may have on their subsequent adjust-
sequelae of amputation were significantly mediated ment. With regards to implications for clinical
by factors in their social context. practice, the difficulties some participants reported
One positive consequence of experiencing adjust- in officially accessing individuals who had previous
ment in a social context was that it allowed participants experience of amputation suggests that a database
the opportunity to compare their situation with other should be established of people currently utilising
individuals with amputation in a way that either rehabilitation and prosthetic services who would be
motivated them in their rehabilitation efforts (upward willing to discuss their experiences with others in the
social comparison) or helped them to reappraise the future. Finally, the important adjustment role played
severity of their own situation in a way that enhanced by key members of participants social networks
their self-esteem (downward and temporal social suggests that the family members of individuals with
comparison) [45]. Less adaptive was a recurring social amputation should be provided with more education
process in which participants were de-individuated regarding various relevant topics such as the differ-
[21] and stigmatised by other, non-disabled indivi- ence between support behaviours (perceived as
duals. Sometimes this was a conscious process, as in helpful by the person providing the support) and
the malicious comment from Bobs acquaintance in support appraisals (perceived as helpful by the
the street. More often, though, it was a non-conscious person receiving the support) [6].
process in which the well-intentioned efforts of others To conclude, this study aimed to give voice to the
had the effect of classifying the individual with experiences of adjustment of eight participants who
amputation solely in terms of their disability as had experienced amputation within the previous 18
dependent, incompetent and vulnerable. In effect, months. Key themes to emerge from the research
the person got lost behind the label. related to, (1) the pre-amputation decision-making
Rybarczyk et al. [3] argue that, in a process of self- process and control, (2) renegotiation of self-identity
stigmatization, individuals with amputation often and the struggle to accept a new disabled identity and
internalise aspects of social stigma relating to feelings (3) adjustment as a social process. It is acknowledged
of shame and embarrassment about their perceived that the validity of this study may be limited by the fact
abnormality. Such a process was clearly evidenced that only three of the eight participants were involved
in many of the current participants accounts. in the analysis triangulation process at the write-up
Ironically, for Roy this process was driven more by stage. However, this research furthers understanding
a projection of his pre-amputation self than by of the pre-acute, acute and post-acute adjustment
stigmatisation from a non-disabled other. For Clare, process from the insider-perspective of individuals
self-stigmatisation led her to choose emotional who have experienced amputation in a manner that
Psychosocial adjustment following amputation 739
provides specific suggestions for further research and 18. Hanley MA, Jensen MP, Ehde DM, Hoffman AJ, Patterson
clinical practice. DR, Robinson LR. Psychosocial predictors of long-term
adjustment to lower-limb amputation and phantom limb
pain. Disabil Rehabil 2004;26:882893.
19. Williams RM, Ehde DM, Smith DG, Czerniecki JM,
Acknowledgements Hoffman AJ, Robinson LR. A two-year longitudinal study of
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The authors wish to thank Mr. Roger Parke, Dr.
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Colin Wilson, Dr. Martin Dempster and Dr. Jennifer Health 2000;15:215228.
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research process. ment individuation. In: Snyder CR, Forsyth DR, editors.
Handbook of social and clinical psychology: the health
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