Hypothesis 7

As hypothesised, problem-focused coping was positively related to time since injury, suggesting that as time elapsed, participants used more problem-focused coping efforts. There was a slight increase in this style of coping until about 20 years after injury following which there was a slight decrease.

These findings are inconsistent with those of a study of TBI caregivers between 6 months and 15 years post injury, which found no relationship between problem-focused coping and years since injury (Hanks et al., 2007). Sander et al. (1997) also found no relationship and suggested that the caregivers’ approach to coping with the effects of

114 TBI remained relatively stable over the years and was related to premorbid personality and coping behaviours. However, that explanation would not be consistent with the stress, appraisal, and coping model that states coping is a process that changes over time and situation, rather than being a trait, in which case it would be consistent (Lazarus, 1993). However, when coping strategies are effective, they are used consistently in similar situations (Lazarus & Folkman, 1984). As the use of problem-focused coping in the current study remained at similar levels in the first six to seven years and increased after that, suggests that this style of coping was indeed effective in reducing stress related to TBI caregiving.

Contrary to the current findings, other researchers discovered a drop off over time. In a sample of caregivers of people over 65, which were interviewed twice one year apart, overall use of all coping strategies reduced in that time. Chronister (2006) found that the use of problem-focused coping decreased with time in a sample of TBI caregivers using a situational version of the COPE. The authors suggested that caregivers might have felt they had control over the situation in the earlier stages and therefore used problem-focused coping more frequently than later, which would be in line with the stress, appraisal, and coping theory. Even though each stressful situation, including TBI caregiving, contains controllable and uncontrollable events, the early years following injury would have many more uncontrollable situations related to the survival of the patient and the care by health professionals, questioning Chronister’s appraisal of controllability.

More likely is the explanation evident in the current results, that in the early years, the stressful situations were appraised as uncontrollable and unchangeable, resulting in the lower use of problem-focused coping. Over time, the caregivers adapted to the impact and the changes caused by the injury, learned the skills necessary to care for their loved one, and basically got on with life. This would lead to an appraisal of the situations being changeable, leading to increased use of problem-focused coping, which is in line with the theoretical premise that problem-focused forms of coping increases in situations that are appraised as changeable, thereby holding the potential for control (Folkman, 1984).

The slight drop in the use of this style of coping after about 20 years has to be interpreted with caution, as only six participants had been caregivers for longer than 20 years. It is possible that as the caregivers get older stress increases again, due to concerns associated with aging in general. These could include worries about

115 retirement, changes in income, or concerns about health, being a burden to others, and concerns about the ability to continue caring for their family member. This could have led to a change in appraisal to uncontrollable as getting older is something that cannot be controlled. This could then result in the use of less problem-focused coping and an increase in emotion-focused coping, which was also evident in the current sample.

A second finding was that planful problem solving was positively related to time since injury. The use of this style of coping dropped sharply from its initial level over the first six to seven years, after which there was a steady increase again. This is a novel finding and no previous research was found investigating this style of coping in relation to changes over time. Salisbury et al. (2007) examined coping in parents during their child’s spinal surgery and suggested that an increased use of planful problem solving might have been due to them feeling they had to be advocates for their child and felt responsible for their needs. This could suggest that caregivers in the current research initially acted as advocates and actively planned the care for their family members. It is unclear why the use of this strategy decreased sharply over the first few years. It might have been due to healthcare professionals such as the rehabilitation team being in charge of the treatment plan during the early years. The caregivers might have appraised the stressful situations as uncontrollable but learned to cope over the years, increasing their sense of control. In addition, there is a decreased likelihood of major change with time once a routine is established, which does not require much modification. With relative stability there is less stress and less need for planning. Further investigation is required to examine this finding. Possible hypotheses include getting more detailed information on what sort of problems the caregivers were planning to solve over time. This could clarify whether the difference in problems over the years determined the amount of times this style of coping was being used or whether there were fewer problems to deal with.

In summary, problem-focused coping was used more in later years following injury, while emotion-focused coping was used more in the earlier years. As evident in the visual examination of the data, as one coping strategy increased, the other decreased giving support to the theory’s premise that appraisal determines the coping style used. Due to the uncontrollability of stressful situations early after injury such as survival of the patient, the use of emotion-focused coping would have been elicited with an increased use of problem-focused coping (and decreased use of emotion-focused

116 coping) over the years as the stressful situations were appraised as more controllable. This was also reflected in the use of accepting responsibility and planful problem solving. Sampling differences, such as population, range of time since injury, cross- sectional versus longitudinal studies, as well as differences in measurement of caregiver coping might explain different results across the limited studies that existed.