CORRELATES OF EMOTIONAL PAIN AND COPING STRATEGIES AMONG AMPUTEES AND THEIR CAREGIVERS BY ESTHER OHENEWA (10349752) THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MPHIL CLINICAL PSYCHOLOGY DEGREE JULY, 2017 Emotional Pain and Coping Strategies DECLARATION This is to certify that this thesis is the result of the research undertaken by ESTHER OHENEWA towards the award of Master of Philosophy in Clinical Psychology in the Department of Psychology, University of Ghana. ………………………….. ESTHER OHENEWA (STUDENT) ………………………….. DATE ………………………… …………………………... DR. BENJAMIN AMPONSAH DR. SAMUEL ATINDANBILA (PRINCIPAL SUPERVISOR) (CO-SUPERVISOR) …………………………… …………………………… DATE DATE i Emotional Pain and Coping Strategies ABSTRACT The study aimed at investigating the correlates of emotional pain and coping strategies among amputees and their caregivers following loss in order to get a better understanding of the concept in the Ghanaian context. A sequential mixed-method design incorporating interviews and administration of standardized measures was used to gather data. For the qualitative phase, 20 participants were purposively sampled from the group of amputees and their caregivers and interviewed using an interview guide. For the quantitative phase, standardized set of questionnaires measuring one’s psychological distress, emotional pain, personality and social support was administered to 150 participants who were conveniently sampled from the target population of amputees and their caregivers. Qualitative data was analyzed using thematic analysis. Findings revealed that caregivers and amputees experienced a built up of negative emotions following loss. Quantitative data was analyzed using Pearson Product Moment Correlation (Correlation r), Independent sample t test, Multivariate Analysis of Variance (MANOVA) and Hierarchical Multiple Regression statistical tests and findings revealed that these built up of negative emotions correlated with emotional pain and that there was significant differences in the experience of emotional pain and the coping strategies adopted by amputees and their caregivers. The benefits of the study include information for intervention formulation and guidance to clinicians for therapy. ii Emotional Pain and Coping Strategies DEDICATION This thesis is dedicated to God and my family most especially my mother, Ms. Mavis Akosua Afriyie. God richly bless you. iii Emotional Pain and Coping Strategies ACKNOWLEDGEMENT Psalm 26: 7 ‘I sing a hymn of thanksgiving and tell of all your wonderful deeds’. The Lord has been faithful to me thus, with a heartfelt gratitude I say thank you Lord for your goodness and mercies. Special thanks go to my supervisors, Dr. Benjamin Amponsah, Dr. Samuel Atindanbila and Dr. Joana Salifu Yendork, for their unflinching sense of dedication and constant supervision. I again want to thank my mother, Miss Mavis Akosua Afriyie, for believing in my capabilities. My heartfelt appreciation also goes to Dr. Wiafe Akenten-Brenya for his constant motivation, guidance and support. Special thanks go to Pastor Ebenezer Osei-Newman Sackey, for his prayers and Mr. Seth Armah for his assistance. Special thanks also go to the staff and participants from St Joseph Hospital and Nsawam Orthopedic Center for their support and participation. Finally, my heartfelt appreciation goes to all my friends, course mates, and other family members who contributed in diverse ways towards the success of this work. iv Emotional Pain and Coping Strategies TABLE OF CONTENTS DECLARATION............................................................................................................................ i ABSTRACT ................................................................................................................................... ii DEDICATION.............................................................................................................................. iii ACKNOWLEDGEMENT ........................................................................................................... iv LIST OF FIGURES ................................................................................................................... viii LIST OF TABLES ....................................................................................................................... ix LIST OF ABBREVIATIONS ..................................................................................................... xi CHAPTER ONE ........................................................................................................................... 1 INTRODUCTION......................................................................................................................... 1 Background to the Study ............................................................................................................. 1 Statement of the Problem .......................................................................................................... 11 Broad Aims/ Objectives ............................................................................................................ 12 Specific objectives: ................................................................................................................... 13 Relevance of the Study .............................................................................................................. 14 CHAPTER TWO ........................................................................................................................ 16 LITERATURE REVIEW .......................................................................................................... 16 Introduction ............................................................................................................................... 16 Theoretical Framework ............................................................................................................. 16 Review of Related Study ........................................................................................................... 22 Rationale for the Study .............................................................................................................. 47 Statement of Hypotheses ........................................................................................................... 48 Research Questions ................................................................................................................... 48 Conceptual Framework of Study............................................................................................... 49 Operational Definitions ............................................................................................................. 50 CHAPTER THREE .................................................................................................................... 51 METHODOLOGY (Study 1: Qualitative) ............................................................................... 51 Introduction ............................................................................................................................... 51 Research Design ........................................................................................................................ 51 Research Setting ........................................................................................................................ 52 Population/Sample .................................................................................................................... 52 Sampling Technique .................................................................................................................. 52 v Emotional Pain and Coping Strategies Demographic Data..................................................................................................................... 53 Inclusion Criteria ....................................................................................................................... 53 Exclusion Criteria ...................................................................................................................... 53 Interview Guide ......................................................................................................................... 53 Data Collection Procedure ........................................................................................................ 54 Ethical Consideration and Approval ......................................................................................... 55 Data Analyses Strategy ............................................................................................................. 55 Trustworthiness of the Qualitative Results ............................................................................... 57 METHODOLOGY (Study 2: Quantitative) ............................................................................. 58 Introduction ............................................................................................................................... 58 Quantitative Research Design ................................................................................................... 58 Research Setting ........................................................................................................................ 58 Population/ Sample ................................................................................................................... 58 Sampling Technique .................................................................................................................. 59 Demographic Data..................................................................................................................... 59 Inclusion Criteria ....................................................................................................................... 60 Exclusion Criteria ...................................................................................................................... 60 Research Instruments / Measures .............................................................................................. 60 Pilot Study ................................................................................................................................. 66 Data Collection Procedure ........................................................................................................ 68 Ethical Consideration and Approval ......................................................................................... 68 Data Analyses Strategy ............................................................................................................. 68 CHAPTER FOUR ....................................................................................................................... 70 RESULTS .................................................................................................................................... 70 Introduction ............................................................................................................................... 70 Thematic Analyses of Qualitative Data .................................................................................... 70 Demographic Information ................................................................................................................... 70 Emerging Themes ..................................................................................................................... 71 Antecedents of Amputation (Amputees) ................................................................................... 72 Antecedents of Emotional Pain (Caregivers) ............................................................................ 74 The Experiences of Emotional Pain .......................................................................................... 75 vi Emotional Pain and Coping Strategies Experience of Gratitude ............................................................................................................ 80 A Factor Influencing the Intensity of the Experience Emotional Pain ..................................... 81 The Experience of Emotional Pain and Wellbeing ................................................................... 83 The Experience of Emotional Pain and Coping Strategies ....................................................... 86 Summary of Qualitative Findings: ............................................................................................ 88 Statistical Analysis of Quantitative Data .................................................................................. 90 Descriptive Statistics ................................................................................................................. 90 Factor Analysis .......................................................................................................................... 91 Hypotheses Testing ................................................................................................................. 101 Summary of Quantitative Findings: ........................................................................................ 119 Observed Model ...................................................................................................................... 120 CHAPTER FIVE ...................................................................................................................... 121 DISCUSSION ............................................................................................................................ 121 Introduction ............................................................................................................................. 121 The Concept of Emotional Pain .............................................................................................. 122 The Differences and Similarities in the Experience of Emotional Pain and Psychological Distress .................................................................................................................................... 122 Precipitating/Moderating Factors that Influence the Experience of Emotional Pain .............. 128 Coping Strategies Used in the Experience of Emotional Pain ................................................ 131 Potential Impact on Wellbeing/ Psychological Wellbeing and the Need for Psychological Services ................................................................................................................................... 134 Contribution to Theory ............................................................................................................ 135 Conclusion ............................................................................................................................... 135 Limitations of the Study.......................................................................................................... 136 Recommendations/ Clinical Practice in Ghana ....................................................................... 136 REFERENCES .......................................................................................................................... 140 APPENDIX 1 ............................................................................................................................. 153 APPENDIX 2 ............................................................................................................................. 154 APPENDIX 3 ............................................................................................................................. 158 APPENDIX 4….……………...………………………………………………….…………….159 APPENDIX 5 ............................................................................................................................. 184 vii Emotional Pain and Coping Strategies LIST OF FIGURES Figure 1: A Diagrammatic Representation of the Transactional Model of Stress and Coping Figure 2: A Pictorial Representation of the Process Model of Working through Pain Figure 3: Hypothesized Model Figure 4: Observed Model viii Emotional Pain and Coping Strategies LIST OF TABLES Table 1: Demographics Data of Sample for the Quantitative Study Table 2: Interpretation of Total Scores on the Sub-Dimension of DASS Table 3: Internal Consistencies of the Scales from a Pilot Study Table 4: Demographic Data of 20 Participants for the Qualitative Study Table 5: Summary of the Means, Standard Deviations, Internal Consistencies (Cronbach’s Alpha) and Normality of the Study Variables Table 6: Factor Loadings for Exploratory Factor Analysis with Direct Oblimin Rotation of Mental Pain (Emotional Pain) Items Table 7: Factor Loadings for Exploratory Factor Analysis with Direct Oblimin Rotation of DASS Items Table 8: Factor Loadings for Exploratory Factor Analysis with Direct Oblimin Rotation of BHS Items Table 9: Factor Loadings for Exploratory Factor Analysis with Direct Oblimin Rotation of ACSI Items Table 10: Factor Loadings for Exploratory Factor Analysis with Direct Oblimin Rotation of MSPSS Items Table 11: Factor Loadings for Exploratory Factor Analysis with Direct Oblimin Rotation of BFPS Items Table 12: Correlation Matrix of Emotional Pain, Depression, Anxiety, Stress and Hopelessness ix Emotional Pain and Coping Strategies Table 13: A Summary of the Means, SD and t test of the Scores of Caregivers and Amputees on Emotional Pain Table 14: A Summary of the Means, SD and F test of the Scores of Caregivers and Amputees on Psychological Distresses Table 15: A Summary of the Means, SD and F test of the Scores of Caregivers and Amputees on their Coping Strategies Table 16: Hierarchical Multiple Regressions of the Contributions of One’s Personality (Extraversion) to the Relationship between Psychological Distresses and Emotional Pain. Table 17: Hierarchical Multiple Regressions of the Contributions of One’s Personality (Neuroticism) to the Relationship between Psychological Distresses and Emotional Pain. Table 18: Hierarchical Multiple Regressions of the Contributions of One’s Level of Social Support to the Relationship between Psychological Distresses and Emotional Pain. x Emotional Pain and Coping Strategies LIST OF ABBREVIATIONS DASS Depression Anxiety Stress Scales BFPS Big Five Personality Scale OMMP Orbach and Mikulincer Mental Pain Scale MDSPSS Multidimensional Scale of Perceived Social Support ACSI Africultural Coping Systems Inventory BLESMA British Limbless Ex-Servicemen’s Association xi Emotional Pain and Coping Strategies CHAPTER ONE INTRODUCTION Background to the Study Pain is a construct that is very difficult to describe despite its frequent usage. Every individual experiences pain in almost every sphere of life. Our ability to withstand this pain makes us who we are. According to Borsook and Becerra (2009), the International Association for the Study of Pain (IASP) has defined pain as the “unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” (pg. 154). Thus, in an attempt to describe what pain is Borsook et al. (2009) revealed that with pain, there could be actual tissue damage such as damage to one’s hands, head or potential tissue damage. Then again the researchers revealed that there could be an ‘unpleasant sensory and emotional experience’ component to the actual or potential tissue damage. It can therefore be argued that pain has an emotional component to its manifestation. Pain can be physical or psychological. Physical pain is the hurt associated with physical injuries (Macdonald & Leary, 2005). Some physical injuries that can result in physical pain include amputation. In addition, not all pain is physical as there can be social. Thus, another facet of pain is pain associated with social injuries, different terms exist for connoting such pain. For example, terms such as “emotional pain” (Bolger, 1999), “psyche-ache or psychological pain” (Shneidman, 1998, 1999) and “mental pain” (Orbach, Mikulincer, Gilboa-Schechtman, & Sirota, 2003b) have been used interchangeably. The focus of this study is on the ‘unpleasant emotional’ experiences that leads to emotional pain. In this research, emotional pain will be used to reflect all such ‘unpleasant emotional’ experiences. 1 Emotional Pain and Coping Strategies In the past, emotional pain was rarely talked about as an existing entity in and of itself and there was lack of clarity regarding the phenomenon (Bolger, 1999). Shneidman (1999) was one of the earliest scholars to discover that although physical and emotional pains could interrelate, wherein emotional pain could accompany physical pain, emotional pain could also exist without physical pain. This is to say that emotional pain, in as much as it interrelates with physical pain, can be experienced in the absence of the sensory components of pain or sensory organs that can elicit pain unlike physical pain (Borsook et al., 2009). The concept of emotional pain is now viewed as a distinct subjective state of being that is separated from other negative emotions such as depression and anxiety (Orbach et al., 2003b; Shneidman, 1999). According to Orbach et al. (2003b), in as much as some component of emotional pain constitute depression, anxiety and hopelessness, the concept of emotional pain extends to other facets of negative emotions like anger that depression, or anxiety or hopelessness does not capture. Following this distinction, researchers in the field of emotional pain have done extensive study on the concept with several definitions and means of measuring having emerged from their study. Scholars who have defined emotional pain include Bolger (1999), Orbach, Mikulincer, Sirota and Gilboa-Schechtman (2003a) and Shneidman (1999) among others. According to Orbach et al. (2003a, b), Shneidman’s (1999) work is the most extensive contribution to the field of emotional pain. Shneidman (1999) defined psych-ache as the “mental suffering”, “inner torment” or how much an individual hurts as a human being due to frustration of vital psychological needs. These vital psychological needs include the need to be loved, to have control, to protect, to avoid shame, to protect one’s image, feel secure and to understand. He further argued that when any of these needs are threatened the individual feels a sense of deep emotional pain and a resultant mixture of negative emotions such as guilt, shame, 2 Emotional Pain and Coping Strategies defeat, humiliation, disgrace, grief, hopelessness, induced sadness and rage are evoked. Following the pain, the individual could feel a sense that they cannot keep on living when these needs are not satisfied and attempts are therefore made to escape the pain through suicide at the extreme level (Olie, Guillaume, Jaussent, Courtet, & Jollant, 2010; Shneidman, 1999; 1998). Mee, Bunney, Reist, Potkin, and Bunney (2006) have highlighted two main types of emotional pain. These are emotional pain associated with major psychiatric disorders (such as depression) and emotional pain associated with internal response to unpleasant psychological stimuli, such as loss which includes the death of a loved one or broken relationship. It can be argued that this loss that Mee et al. (2006) speaks of, can encompass the loss of a body part. Amputation is a traumatic state of being that most people do not bargain for. It deprives individuals of their normal human functioning capacity and makes them dependent on other people even against their will. It is another dimension of loss (Mee et al., 2006) that stirs up unpleasant emotional experiences (Borsook et al., 2009) which consequently leads to emotional pain. Statistics on the international forum shows that 1.7 million people have some part of their body amputated in the United States (Ziegler-Graham, Mackenzie, Ephraim, Travison & Brookmeyer, 2008). In Ghana, Kyei, Dogbe, Larsen-Reindorf and Mensah (2015) estimated that there are about 245,299 amputees therein with the number rising every year due to several factors. These factors may be chronic debilitating conditions or traumatic situations that are unresponsive to medical attention (Frierson & Lippmann, 1987). Frierson et al. (1987) posits that some of the conditions that can lead to amputation include ‘…tumor of bone, soft tissue, blood vessels or nerves; infection that does not respond to conservative measures or contributes to sepsis; and peripheral vascular disease’ (pg. 183). These conditions demand a planned amputation which can be referred to as surgical amputation (Frierson et al., 1987). According to 3 Emotional Pain and Coping Strategies Frierson et al. (1987), some traumatic conditions that also necessitate an amputation include injuries like crush injuries; blast injuries; avulsion injuries; guillotine injuries and severe burns. When these injuries are not responsive to medical procedures, as Frierson et al. (1987) puts it, amputation becomes the next best option. Frierson et al. (1987) broadly categorizes this type of amputation as trauma amputation. It stands to reason that there are two categories of caregivers which are caregivers of surgical amputees and caregivers of trauma amputees. According to Margalit, Heled, Berger and Katzir (2013), waking up to the loss of a body part is traumatic for individuals. Amputation is associated with several physical and psychological consequences (Butler, Turkal, & Seidl, 1992). Some obvious physical consequences include physical disfigurement and loss of mobility which could result into a change in vocation. Some psychological consequences, on the other hand, include numbness as a way of dealing with the trauma of the loss (Muzaffar, Mansoor, Hafeez & Margoob, 2012), restless pining, preoccupation with the loss, clear visual memories of the lost object and a sense of the presence of the lost limb (phantom limb sensation) (Frierson et al., 1987). These physical and psychological consequences lead to grief (Frierson et al., 1987; Olson, 2002), difficulty in interpersonal relationship (Hanna, 1996), body image problems (Ronaldson, 1999) and phantom limb pains (Murray & Fox, 2002) in amputees. The interplay of this psychological dynamics evokes strong negative reactions from the amputees. Butler et al. (1992) and Frierson et al. (1987) reported that some of these strong negative reactions include mutism, screaming, assault on a family member, social isolation and displacement of anger and fear that their caregivers will feel they (amputees) are a burden and consequently abandon them. According to Wain, Cozza, Grammer, Oleshansky, Cotter et al. 4 Emotional Pain and Coping Strategies (2004), mutism, screaming and displaced anger among others are normal expressions of how the amputees feel and as such should be accommodated. Caregivers do not experience the physical consequences of amputation like losing a body part but their psychological processes have been totally ignored. The argument is that these psychological processes can have a great impact on their physical state. Arguing from Wain et al.’s (2004) justification of amputees’ normal expression of emotions, the ignored component is that caregivers become recipients of the amputees’ display of negative emotions which include displaced anger yet they as caregivers are expected to be empathic. This consequently implies that aside from having to deal with the traumatic ordeal that your loved one will never have his or her primary organ again to enable him or her function as a normal being, the caregiver has to deal with the temper tantrums of the patient and accommodate it as such. Butler et al. (1992) and Frierson et al. (1987) established that the amputees focus on their helpless situation that is the loss of status and their body image distortion, and tend to grow dependent on their caregivers after the realization that they are virtually handicapped. Some patients, however, deny their condition and do not seek social support at the primary stages of amputation (Frierson et al., 1987). Interestingly, the state of denial is equally experienced by the caregivers as well and they equally entertain fears of the unknown (Volker, 2015; Wain et al., 2004). Yet the pre-operative medical counseling is geared toward assisting the amputees adjust to his or her predicament to the neglect of the caregiver (Volker, 2015; Wain et al., 2004). Amputees’ reaction to the loss of a body part, as established earlier, involves a multifaceted psychological process. This rather complex psychological process is influenced by quite a number of factors. Butler et al. (1992) and Frierson et al. (1987) revealed that some of the factors that determines the patients psychological processing of his or her traumatic phenomenon 5 Emotional Pain and Coping Strategies include the patient's age, sex, type of amputation, perceived or functional value of body part, premorbid personality, past coping skills, expectations for rehabilitation, social support, family system, occupational and vocational demands. The argument is that these factors can either aggravate the patient’s emotional pain or minimize the patient’s experience of the emotional pain. The distinctions in the emotional pain amputees and their caregivers experience have been greatly overlooked. Mee et al. (2006) in their review noted that emotional pain may operate on a continuum of intensity from mild to severe or may have distinct subtypes, which are qualitatively different depending on the cause of the pain. Deducing from Mee et al.’s (2006) argument that emotional pain is qualitatively different, emotional pain found in major depression may be qualitatively different from one that is as a response to unpleasant psychological stimuli like functional loss, the loss of one’s way of life or loss of a loved one’s attention or breakup in relationship. This presupposes that the emotional pain an individual experiences is dependent on other factors like the cause of the amputation or the kind of ailment the patient is suffering from and who the recipient of care is. Thus it can be argued that, the emotional pain experienced by the amputees, who experience functional loss and loss of a body part, and their caregivers, who experience the loss of their way of life and a loved one’s attention, is qualitatively different since the cause of the emotional pain differs. For amputees, the loss of a body part leading to functional loss and in extreme cases a change in vocation, threatens their basic vital psychological need to have control, to protect, to avoid shame, and to feel secure as Shneidman (1999) explicates. The amputees’ emotional pain stems from their experience of psychological distresses like depression after coming to terms with the fact that there is loss of a body part or mobility (Cavanagh, Shin, Karamouz & Rauch, 6 Emotional Pain and Coping Strategies 2006). This is an unpleasant emotional experience which can result in emotional pain and lead to suicide eventually as explained by Shneidman (1999) that when the intensity of psych-ache is so high and when the suicidal person cannot foresee a change in the future, he/she seeks to escape the pain by committing suicide. Wain et al. (2004) discuss that amputees feel stigmatized because of their deformity. It can be argued that for the caregiver, the emotionally painful experience may be, having to reorganize one’s life to take care of a loved one who was once very able ignoring their own psychological distress at the presented situation as well as witnessing a loved one go through pain (Volker, 2015). The qualitative difference in the experience of emotional pain with regards to caregivers is one that should not be overlooked. To begin with, the caregivers basic psychological need ‘to understand’, as Shneidman (1999) posits, the dynamic psychological processes the amputees experience is taken for granted. Then again, the stigma attached to being seen publicly with an amputee and the break in relationship between the caregiver and the amputee, because the amputee is focused on himself or herself to the neglect of the society at large, is equally an emotionally painful experience. For close relatives who are caregivers, these are things they probably did not bargain for (Volker, 2015). Researchers like Monin and Schulz (2009) have disclosed that there is some physiological activation in experience of emotional pain. Monin et al. (2009) posits that caregivers do not only “…experience distress because of the supported-related demands of caregiving” (pg. 684) but also experience distress at the “exposure to a loved one’s psychological suffering” (pg. 684). This brings to fore the concept of physiological activation of empathic feeling. There is therefore the need to understand this rather unique and interesting psychological process. According to Borsook et al. (2009), empathy for pain is a common phenomenon. 7 Emotional Pain and Coping Strategies Borsook et al. (2009) opined that “empathy” originated from the Greek word “empatheia”, meaning, empathy is “feeling or expressing emotion for another and thus the ability to understand the experience of another individual via cognitive and affective processing” (pg. 153). The researchers disclosed that when an individual observes another individual experiencing pain, the neural circuits of the individual observing another person experience the pain becomes activated. This suggests that caregivers feeling empathic for their patients, on a deeper level, activate some physiological response. The argument is that, amputees may experience emotional pain from the loss of a body part whiles caregivers may experience emotional pain from their empathic caregiving especially because according to Frierson et al. (1987), most of the amputees tend to project their feelings of inadequacy unto them (the caregivers) reinforcing the amputees’ social isolation. Orbach et al. (2003a,b) opined that social distancing is a dimension of emotional pain. The next line of argument is that psychological counseling or therapy is an important therapeutic process for both the amputees and their caregivers. According to Butler et al. (1992), caregivers have been noted to minimize their own psychological distress during the patient's recovery. Volker (2015) therefore cautions that there is the need for caregivers to take care of themselves. Wain et al. (2004) explains that it is easy to miss the psychological processes these caregivers go through because attention is focused on the amputee, but emphatically disclosed that caregivers are not usually psychologically prepared for the new life of the amputee. The concept of emotional pain is thus an important phenomenon. Emotional pain results from and into a mixture of negative emotions. Shneidman (1999) argues that a variety of negative emotions can develop into a generalized experience of unbearable emotional distress. In line with this, Mee et al. (2006) found that major depressive 8 Emotional Pain and Coping Strategies disorders, intense emotions associated with physical disease and severe social stressors such as loss, increases the tendency for psychological pain. Lindgren, Connelly and Gasper (1999) has established that caregivers of chronic illnesses experience emotional distresses as a result of negative emotions like depression, poor levels of health, decreased life satisfaction amongst others. Lindgren et al. (1999) continued that this emotional distress is experienced in reaction to the loss the caregivers feel from being incapable of helping a loved one who is dying or the loss of ones way of life because one has decided to give care to someone who needs it. Most studies have equally focused on certain psychological components like quality of life of amputees ignoring the emotional pain they go through (Pell, Donnan, Fowkes, & Ruckley, 1993; Van der Schans, Geertzen, Schoppen & Dijkstra, 2002). The review of scholarly works has shown distinct qualities of emotional pain. For example, Bolger (1999) identified four main features comprising woundedness (For instance, wound, hurt by self and others, damage, abuse and others), disconnection (For example, broken bonds, loneliness and disruptions in bonding), loss of self (For instance, loss of meaning, identity and purpose) and awareness of self (For example, new awareness, questioning, understanding and facing the self). Besides these main characteristics, emotional pain is accompanied by a set of visceral and spatial descriptions that include heaviness, hurts, emptiness and sense of darkness. Additionally, Orbach et al. (2003a,b) while validating the Orbach and Mikulincer pain Scale (OMMP) highlighted that emotional pain has 8 sub-dimensions. These dimensions include irreversibility, loss of control, narcissist wounds, emotional flooding, freezing, self- estrangement, social distancing, approach-avoidance social orientation and emptiness. Although the various characteristics of emotional pain may be distinct, each forms part of a broader 9 Emotional Pain and Coping Strategies category that surrounds perception of a negative change in the self as well as the function of the self (Orbach et al., 2003a,b). In line with the characteristics highlighted by Bolger (1999) and Orbach et al. (2003b, p. 224), emotional pain can be conceptualized as “a perception of negative changes in the self and its function that is accompanied by strong negative feelings”. Emotional pain associated with emotionally painful experiences has also been highlighted to be the core factor for explaining mental disorders (Bolger, 1999; Olie et al., 2010; Orbach, 2003; Orbach et al., 2003b). According to Shneidman (1999), unendurable psych-ache is the common stimulus for all suicide although other motives such as anger (towards others) might be present (Menninger, 1938). Orbach (2003) further affirmed Shneidman’s theory by showing that emotional pain is the core factor that predicts suicide and suicidal ideations. Relatedly, there is an inter-relationship between emotional pain, and major depressive disorder. Osmond, Mullaly and Bisbee (1984) argued that during a depressive episode, the intensity of emotional pain felt is worse than any physical pain that the individual has ever experienced. Similarly, Mee et al. (2006) opined that when emotional pain becomes chronic it can lead to depression. Moreover, it has been found that depressed suicide attempters feel emotional pain more intensely than non-attempters (Olie et al., 2010). Thus, during a major depressive episode, individuals who are predisposed to suicide feel higher emotional pain that increases their risk for suicide. Given the role that emotional pain plays in psychological disorders, there is the need for studies that seek to examine the experience of the phenomenon in the context of loss (functional loss, one’s way of life, attention of a loved one or relationship break ups) or in the context of witnessing a loved one go through pain and the role such pain plays on the mental health of amputees and their caregivers in Ghana. This is because there is an increasing number of 10 Emotional Pain and Coping Strategies amputees in Ghana (Kyei et al., 2015) and the world at large, making the role of caregivers indispensable. Unfortunately caregivers of amputees have also received little attention compared to caregivers of other chronic illnesses in relation to the emotional torment they go through having to take care of perhaps a person or loved one who was once very able. Statement of the Problem In Ghana, customs and traditions play a vital role in the expression of certain emotions. An Akan adage like “Opanin su a, osu ne tirim” (Dzokoto , Opare-Henaku, Kyei, Attah & Ahorsu (in press), pg. 17), which translates as “A senior man does not give way to grief in public” and “Barima nsu” which literally translates as “A man should not cry” entreats an individual to be emotionally strong in the face of a traumatic situation in a public gathering. The logic behind this is that an individual tends to uphold his or her social standing when he or she does not grief in public (Dzokoto et al., (in press). This hinders the expression of certain emotions and makes one feel inadequate when these emotions are expressed publicly. This makes the expression of emotional pain unique and specific to the context one finds himself or herself in. Ameka (2002) and Dzokoto (2010) revealed that Ghanaians attend more to their body or physical appearance as a way of expressing themselves than to their emotions. This can be a hindrance to the expression of emotional pain and the resolution process as a means of dealing with the emotional pain. Shneidman (1999), Orbach (2003) and Orbach et al. (2003b) have highlighted that when emotional pain is not properly dealt with, it could result into major psychological disorders and even suicide. Amputation is a delicate condition that usually requires that the patient finds an adaptable way of surviving. It also requires that the caregivers restructure their lives to make the life of the amputee comfortable, depending on the body part that has been amputated. 11 Emotional Pain and Coping Strategies Caregivers may go through emotional pain from having to care for an individual who was once able, or having to restructure their social life to accommodate a relative who is amputated. Amputees experience pain from the loss of a body part which may lead to functional loss. The dynamic psychological processes involved in the experience of these two unique experiences may be covered or showcased in order forms, considering the Ghanaian cultural norms, which may lead to other psychological problems like suicide. Troister and Holden (2010) disclose that psych-ache is the strongest predictor of suicide. According to Dzokoto (2010), Ghanaians often do not introspect the emotional suffering they experience when faced with psychological distresses and often lack the lexicon to express emotional pains. Thus, the argument is not precisely about the appropriateness of expressing one’s emotions, instead it is about how amputees and their caregivers express such emotions, that is, the distinction and similarities in the expression of emotional pain, the extent to which they acknowledge their emotional suffering and how they cope with it. According to Bakan (1968) and Orbach et al. (2003a, b), the experience of loss and also witnessing someone or a loved one go through pain is a major contributor to emotional pain. Given that amputation results in loss of body part and associated stigma, the present study therefore seeks to explore how amputees and their caregivers experience or conceptualize emotional pain, the distinction and similarities in this experience as well as the coping strategies they employ to manage potential distresses. Broad Aims/ Objectives The present study has two broad aims. The first is to explore the experiences of emotional pain following loss (i.e., the loss of one’s way of life and a loved one’s attention) or emotional pain following witnessing of a loved one go through pain in order to enhance the understanding of the 12 Emotional Pain and Coping Strategies importance of psychological services in the experience of emotional pain in the Ghanaian context and to highlight the process of working through or coping with emotional pain. The second aim is to explore the relationship between emotional pain and major psychological distresses (i.e., depression, anxiety, stress and hopelessness) among amputees and their caregivers and moderating factors in this relationship. Specific objectives: Based on the study’s broad aims and the literature reviewed in the area of the correlates of emotional pain among amputees and their caregivers, these specific objectives were examined in two different ways. Qualitative 1. To explore the experiences of emotional pain following loss and also highlight the significance of psychological services in this experience. 2. To examine the coping strategy used in the experience of emotional pain among amputees and their caregivers. Quantitative 3. To investigate the relationship between psychological distresses (depression, anxiety, stress and hopelessness) and emotional pain and the differences in this experiences among the amputees and their caregivers. 4. To investigate the differences in the coping strategies employed by the two groups that is amputees and their caregivers. 13 Emotional Pain and Coping Strategies 5. To examine the relationship between psychological distresses, personality and emotional pain. 6. To investigate the relationship between psychological distresses, perceived social support and emotional pain. Relevance of the Study The findings of this study will provide information that would inform Ghanaian clinicians on how emotional pain is experienced among amputees and their caregivers to enable them identify amputees and caregivers who are going through emotional pain to avoid wrongful diagnosis and also to refer them for appropriate psychological therapy. Additionally, information gathered will help clinicians gain insight into the mitigating effect of one’s personality and social support in the experience of emotional pain so as to assist amputees and their caregivers find a strong form of social support in the experience of emotional pain and psychological distresses. Furthermore, Moradi, Ebrahimzadeh and Soroush (2015) disclosed that the amputees’ quality of life and that of their primary caregivers are closely correlated. This presupposes that any improvement in one is likely to improve the other, thus information gathered from this study would be helpful in formulating interventions to aid amputees and their caregivers work through emotionally painful experiences like the loss of one’s life and loss of intimate relationship so as to improve the quality of life of caregivers and amputees. Finally, this is a preliminary investigation into a neglected phenomenon in the Ghanaian context that serves as a major contributor to major psychological disorders. This is to say that literature on emotional pain and literature on caregivers of amputees is very limited, thus this 14 Emotional Pain and Coping Strategies study will add to the growing knowledge of emotional pain and help Ghanaians to understand how our customs and traditions impact on the way amputees and their caregivers deal with their emotional pain. 15 Emotional Pain and Coping Strategies CHAPTER TWO LITERATURE REVIEW Introduction This chapter is divided into six (6) sections. The first section discusses theories and their relevance to this study. Two main theories are reviewed. These two theories are the transactional model of stress and coping (Lazarus & Folkman, 1984) and grounded theory of emotional pain (Bolger, 1999). These theories explain how the variables in the study relate to each other. In the next section, significant literatures discussing the relatedness of the variables in the study are reviewed. The chapter presents the rationale of the study, the statement of hypotheses and the conceptual framework. The final section of this chapter presents the research questions and operational definition of terms. Theoretical Framework The Transactional Model of Stress and Coping (Lazarus & Folkman, 1984) According to this model, stress, in itself, is a transactional phenomenon which depends on the perceiver’s interpretation of the stimulus or the meaning of the stimulus to the perceiver. The model evaluates how an individual’s cognitive appraisal of major life events and daily hassles impact on emotions and one’s ability to cope with the stress. 16 Emotional Pain and Coping Strategies INDIVIDUALS Personality/Social Support Major life Daily hassles events Ability to cope EMOTIONS Figure 1: A diagrammatic representation of the Transactional Model of Stress and Coping (Lazarus & Folkman, 1984) According to Lazarus et al. (1984) the cognitive appraisal process is a rather important process that tends to impact on the individual’s emotions greatly. The cognitive appraisal is in two folds that is the primary appraisal and secondary appraisal. The primary appraisal of the situation involves the perceiver’s assessment of how harmful the situation is or the threat that this situation poses to one’s stability. The situation refers to the life event or daily hassles. Life events 17 Emotional Pain and Coping Strategies can refer to unforeseen and unpredictable events that are beyond the individuals control like earthquakes, floods etc or events outside the individual’s control that affects just a few people in the individuals’ world like death of a loved one, divorce, automobile accidents, and disability of a loved one or life threatening illness. The daily hassles are repeated occurrences or those experiences that can lead to annoyance, irritation and distress and feeling overwhelmed by responsibilities such as being saddled with the responsibility of taking care of a relative who is an amputee. The secondary appraisal of the situation requires the individual to evaluate what he or she can do about the situation and his or her ability to manage and cope with it. The perceiver is then saddled with the responsibility of evaluating the processes of coping with the stressful events. Personality traits and social support among others are some factors which can influence one’s coping skills and abilities in relation to the outcome of one’s appraisal of the stress. Lazarus et al.’s (1984) theory of coping presents an individual orientation toward resilience and wellbeing in studies on stress which corresponds to the development of the division of positive psychology (Zaumseil & Schwarz, 2014). The concept of coping therefore used by these researchers utilizes a wider time scale than single incidents. However, Park (2010) emphasized that, in relation to this theory when it comes to coping, there is a global meaning and situational meaning of events which impacts on coping. Global meaning denotes the person’s general structure of orientation which forms fundamental schemas through which people construe their experience of the world. This according to Park (2010) comprises beliefs, global goals, and a subjective meaning of purpose. Again, situational meaning is evaluated in the framework of a precise ecological encounter. For instance, Park (2010) argued that a situational meaning could focus on whether a specific occurrence is threatening or manageable as well as 18 Emotional Pain and Coping Strategies the cause of the event and future consequences. These factors to this researcher are not actually captured by Lazarus et al. (1984). Furthermore, Park (2010) argued that, a theory of coping should consider the link between global and situational meanings since an inconsistency between appraised situational meaning and global meaning will generate distress and its effect will be an intense motivation to diminish this discrepancy through meaning making. Consequently, this process makes it probable for an individual to recover from a stressful event. To Park (2010) a theory of coping should consider meaning making as a spontaneous, unconscious process as well as active process. Such spontaneous processes include intrusive thoughts about stressful occurrences and avoidance of reminders. Theory of Emotional Pain by Bolger (1999) This theory is appropriate for this study because though the experience of emotional pain slightly differs, it portrays the in-depth process through which people work through or deal with their emotional pain so that it does not result into psychopathological behaviors. It is a grounded theory of emotional pain. According to Bolger (1999), the broken self is core of the experience of emotional pain and it is used to characterize complex sets of experiences and processes that occur at the visceral, affective and conceptual levels. Pain is experienced as a process and not a single event. Also, when experiencing emotional pain, the individual becomes aware of their own brokenness, the associated feelings of brokenness and loss of control. Bolger (1999) highlighted that the broken self is experienced as a process that starts with the sense of rupture. Rupture is then followed by surfacing/exposing, brokenness, loss of control, alarm, allowing, expressing and covering. The experience of traumatic event initiates 19 Emotional Pain and Coping Strategies emotionally painful experiences. The trauma functions to break the individual’s covers and expose aspects of the hidden self. The painful experience may not occur at the exact time of the trauma but can happen when the individual remembers, talk about the experience, hear others talk about it, or observes similar trauma of others. Emotions associated with rupture include feelings of breaking apart, having nervous breakdown or losing oneself. Bolger (1999) continued that rupture can be accompanied by surfacing/exposing which is characterized by sudden onset of tears, exploding of feelings and the exposure of the buried experience. The pain felt during rupture tends to be associated with anger, sadness, and feeling of being exposed or vulnerable. Rupture and surfacing experiences may leave the individual with a sense of brokenness. Brokenness is experienced when the individual feels as if there is something wrong with them and the feeling that a part of them is missing. In addition, brokenness is characterized by four essential properties that include woundedness, disconnection, loss of self and awareness of self as well as emotional and spatial descriptors. Woundedness is experienced as a form of physical injury such as feeling damaged or wounded. Disconnection also manifest as individuals feel a sense of broken bonds leaving individuals lonely. Individuals can also experience loss of self where the individual feels a sense of them losing aspects of themselves and relationships that was held dear. The painful experience could also lead individuals to becoming aware of themselves and the relationships that had affected them but which they were not aware of. In addition to the four main features, individuals experiencing brokenness may also experience reactions that are grounded in the body. These include feelings of pain in the internal organs, head, heaviness, emptiness or “dark hole”. According to Bolger (1999), another interesting feature of the broken self is the loss of the ability to control the pain. It is believed that at times, individuals going through emotionally 20 Emotional Pain and Coping Strategies painful experiences are unable to label the pain, think clearly or understand their experiences. Others may also experience helplessness and become hopeless about their experience. Furthermore, when individuals become aware of the loss of control and the reality of brokenness, they tend to feel alarmed about their capacity to cope with the experience. This may lead to feelings of being overwhelmed, anxious, afraid and panic attacks. Bolger (1999) further posits that when pain is allowed, a sense of relief is felt. Those who allow the pain by acknowledging and accepting the brokenness tend to use crying as a form of pain release. Pain expression could also be strengthening, constructive and provide individuals with a new dimension of understanding pain. Despite the benefits, allowing pain could also have negative influences such as causing depression, evoking fear and could leave irrevocable damage. When the impact of allowing pain becomes overwhelming, some individuals tend to find some means to disallow the pain through the use of ’covers’. Covers could be interrupting the pain either through deliberate (e.g., denial of pain, suppression of painful feelings) or unintentional means (e.g., dissociating); hiding brokenness by suppressing painful feelings; holding on to pain to prevent feeling the full impact; and rejecting/disallowing new awareness through strengthening of covers. The core issue is to investigate if amputees and their caregivers experience emotional pain and if they do, how do they deal with it? 21 Emotional Pain and Coping Strategies BROKEN SELF Expressing Allowing Surfacing Loss of Alarm Effects Covered Rupture / Brokenness of Pain Transformed Control Self Sel f Exposing Covering Figure 2: A pictorial representation of the process model of working through pain by Bolger (1999) Review of Related Study Given that this is a preliminary investigation into two main important fields, namely emotional pain and amputees and their caregivers, in Ghana, researches is quite limited thus this study will dwell on available literature on amputees, disabled patients or patients of other disorders and their caregivers in other dimensions of research and relate findings to this study. Empirical evidence is reviewed according to the objectives of this study and the methodology. These reviews are not in a chronological manner. The reviews of related studies are divided into sections as follows; Emotional Pain and Experiences of Amputees and their Caregivers; 22 Emotional Pain and Coping Strategies Emotional Pain and Psychological Distresses (Depression, Anxiety, Stress and Hopelessness); Emotional Pain and Personality; Emotional Pain and Coping Strategies and Perceived Social Support; and finally Emotional Pain and Psychotherapy. Literature revealed that while a great number of studies have focused on physical pain, emotional pain has not received much attention. Quite a minute number of the existing studies, like Muzaffar et al. (2012) and Volker (2015) have tried to interview amputees and their caregivers to gain insight into their unique experiences whiles a significant amount of literature like Lester (2000); Olie et al. (2010) and Troister et al. (2010), have shown that generally, emotional pain is associated with a variety of negative psychological states such as depression, anxiety, and could hinder hopeful and optimistic beliefs. Emotional Pain and Experiences of Amputees and their Caregivers The argument is that, when one is faced with a traumatic situation like amputation, of any kind, their unique experiences force them to sink into emotional pain. In such circumstances, the most effective remedy is a psychological intervention that targets helping such individuals work through the emotionally painful experience. When these things are left unchecked, the individual, based on his or her experience, tries to find ways and means to deal with the situation. Some of these ways and means unfortunately, are maladaptive that can lead to far worse case scenarios like suicide. Thus regardless of the cause of amputation, it may result in physical, psychological and social functional difficulties. Garafalo (2000) and Muzaffar et al. (2012) opined that a drastic change in one’s life shakes up the person’s core expectation, meaning to life and values. “Trauma alters the basic perception not only of the individual but of the whole socio cultural society and may never be the same again” (Muzaffar et al., 2012; pg.33). Thus various researches have revealed that amputees 23 Emotional Pain and Coping Strategies resort to excessive use of drugs like nicotine or alcohol as a way dealing with their predicament and uncertainties about what to expect from life and the challenges of living as an amputee (Garafalo, 2000; Kashani, Frank, Kashani, Wonderlich & Reid, 1983; Muzaffar et al., 2012). Muzaffar et al. (2012) revealed that amputees experience stigmatization because of their outward appearance. In some instances, these amputees tend to abuse drugs as a way of dealing with the emotional upheaval they are experiencing. The use of drugs becomes a resilience mechanism for some of the people in this category. It is worth noting that amputation is distinctive of other disabling conditions in that persons who experience loss of a body part also experience a loss of physical wholeness (Heafey, Golden-Baker & Mahoney, 1994). From the population they studied, Liu, Williams, Liu and Chien (2010) reported that amputees experience physical, psychological and sociocultural sufferings. Using a phenomenological research approach and a sample size of 24 with a 92% turnout they aimed at ascertaining the lived experience of the amputee population they studied. Their findings revealed several lived experiences of their participants which they thematically categorized into: lost in the dark woods; emotional collapse; difficulty in passing through the shadow and igniting a gleam of hope According to Liu et al. (2010), lost in the dark woods is a theme in which some participants (amputees) reported that while they intellectually understood the need for the amputation, they struggled to accept the decision emotionally and expressed a high degree of fear and uncertainty in relation to their future and social relations. Emotional collapse, as a theme, revealed that when amputation was offered as the only means to save their life, many defined their hopes as “shattered”. Different emotional responses, such as anger, anxiety, depression, fear, sadness and sorrow overwhelmed them (amputees) (Liu 24 Emotional Pain and Coping Strategies et al., 2010). Another rather interesting theme Liu et al. (2010) discovered was difficulty in passing through the shadow. Liu et al. (2010) revealed that the amputee felt a total change of life by the pre-prosthetic phase due to loss of independence, social isolation and coping with comorbid conditions. It was hard for them to adjust to the alterations of the body and daily life. Finally, igniting a gleam of hope is a theme Liu et al. (2010) discussed that although it was very difficult for amputees to accept the state of being an amputee, some participants after some days and months begun to re-consider the meaning and value of their life, and others are said to have even perceived benefits associated with their amputation. This the study reports happens when amputees begin rehabilitation training, practice wearing temporary prostheses and meeting other persons with amputation at prosthetic rehabilitation centers informally. The main features of the “renewed hope and future orientation (of the amputee) are made up of increased independence, positive thinking and appreciation of new peers and their own relevance in longstanding social relationships” (Liu et al., 2010, pg. 2156) which is expressed in the feelings of being needed by family members and friends. Liu et al. (2010) also discovered that there is usually a disconnection between the needs and priorities of the patient and that of the providers. While the amputee is interested in how to cope with fear and anxiety, questions about the future, the impact of amputation and what he or she should do and expect after amputation, providers are focused on the surgery, avoidance of complications and wound healing (Liu et al., 2010). This finding supports the position of Butler et al. (1992) that the family physician should be involved, especially, in the pre-surgery psychological preparation of the amputee since providers may not have the time and interest to adequately prepare the patient to cope with the mental and physical effects before and after the amputation. 25 Emotional Pain and Coping Strategies Queiroz, Morais, Silva, Guimaraes, Oliveira and Magalhães (2016) conducted an exploratory descriptive study targeted at revealing psychosocial changes and experiences of trauma amputees specifically focusing on amputation resulting from motorcycle accidents. The researchers conveniently sampled 10 victims of trauma amputation for this study. Participants’ age ranged from 18 years old to 44 years old. Three themes emerged out of the qualitative analysis of the data gathered. The themes were the daily life experiences of the trauma amputees, the psychosocial changes the trauma amputees experienced and the resilience experienced by the trauma amputees. Queiroz et al. (2016) discussed that the daily life experiences of the trauma amputees revealed that most trauma amputees wake up after surgery with no memory of the accident or/and who underwent the surgery. Furthermore, trauma victims after amputation were emotionally and physically disconnected from themselves. They (trauma amputees) lacked awareness of themselves and some were basically confused about what the future had in store for them. According to Queiroz et al. (2016), this uncertainty about life after amputation made them (trauma amputees) very depressed. Queiroz et al. (2016) continued that, trauma amputees felt a sense of fear at being discriminated against by the society. One other attribute that seemed to stand out in Queiroz et al.’s (2016) discussion of psychosocial changes the trauma amputees experienced was self- esteem. The researchers’ submission was that, trauma amputees had increased self-esteem, contrary to what one would logically think, after coming to terms with their predicament. Queiroz et al.’s (2016) discussion of the last theme revealed that the family’s unique support made the trauma amputees resilient and responsible to preserve what is left of their life. This emphasizes the important role of the family as the amputees’ social support. 26 Emotional Pain and Coping Strategies The literature revealed that most caregivers are not psychologically prepared for their role as caregivers. Volker (2015) explored the caregiver’s perspective of amputation. The researcher accomplished this by interviewing a family caregiver to find out his experiences when he realized his wife was going to be amputated. He, the participant, gave a vivid insight into the rush of emotions he felt when he was notified of the need to amputate his wife’s leg. These emotions included fear, denial and constant worrying. Yet, he felt the need to deny his own feelings and be strong for his wife. Some of the activities he had to perform as a caregiver included, giving his wife medications and keeping track of them, assisting his wife in terms of aiding her to the bathroom. He had to practically stay up all night in some instances because the side effect of some medications made his wife ill. This can be a source of stress to the caregiver. Volker (2015) explained that according to the caregiver, nothing prepared him for his role as a caregiver. Witnessing his loved one go through all this pain was emotionally exhausting for him. In the end, he had to aid his wife reintegrate into the social system. This gives an insight into the depth of the sacrifices caregivers have to make for their patient. Wain et al. (2004) puts it best when they explained that the role of caregiving is a challenging one. Drawing from literature on patients and caregivers of other disorders as explained earlier that because literature in the field of emotional pain and amputees and their caregivers is limited this study will infuse meaning from studies on patient and their caregivers in other disorders. Ae- Ngibise, Doku, Asante and Owusu-Agyei (2015) qualitatively examined the burden of care on caregivers of people living with Mental Disorders in two districts in Ghana, Kintampo North and South Districts. Seventy-five (75) caregivers of participants with mental disorders registered within the Kintampo Health and Demographic Surveillance Systems were purposively sampled for this study. The qualitative data involved in-depth interviews and focus group discussions. 27 Emotional Pain and Coping Strategies This data was gathered between January and June 2010. Data collected was centered on the experiences of caregivers regarding the provision of care for their relations with mental disorders. According to Ae-Ngibise et al. (2015) caregivers reported various degrees of burden, which included financial burden, lack of social support, social exclusion, emotional distress, stigma and depression. According to Shneidman (1999) and Orbach et al. (2003a, b), social exclusion, emotional distress and depression can lead to emotional pain and vice versa. This presupposes that caregivers do experience emotional pain. May, Cummings, Myall, Harvey and Pope (2016) in their research, conducted a meta- review and synthesis of published qualitative studies on factors that shape the experiences (expectations, choices and emotional states) of the patients and caregivers of chronic heart failure (CHF), chronic obstructive pulmonary disease (COPD) and chronic kidney disease (CKD). The review showed that the behavior of patients and caregivers are shaped by (i) structural factors like socioeconomic status (income, age, gender and ethnicity), spatial location (access to services and transport, and pollution density) and health service quality (professional support and material assistance, continuity of care, coordination of services and intra- professional communications, professional expertise in multi-morbidities, and slow professional responses to anxieties and emergencies); (ii) Interactional factors which include cognitive advantage (the availability of educational resources and information, and proper understanding of symptoms); (iii) Affective state (changes in self-identity, along with reduced self-esteem and self-worth, loss of social functioning, increased fear, anxiety, isolation and discomfort), and interaction quality (Good professional–patient relations); (iv) Patients and caregivers resilience abilities in relation to their adaptation to adversity (the normalisation of experienced symptoms and physical limitations, normalization of self-management strategies, capacity to manage 28 Emotional Pain and Coping Strategies uncertainty, tolerance of disruption of everyday activities and competing clinical priorities, perceived burdens and workload that interfere with normal life (May et al., 2016). In other words, structural, spatial and systemic disadvantages are significant factors that may hinder or facilitate active engagement with formal healthcare and self-management. Patients and caregivers experience multiple affective, cognitive and interactional disadvantages as they seek to participate in encounters with clinicians and decisions about their self-management processes. Patients and caregivers value resilience, functional performance and social support that make a practical contribution to their current state and self-management. Negative impressions of these generate negative emotions (May et al., 2016). The review concludes that patients and caregivers’ expectations, choices and emotional states are not accidental or illogical but are the outcome of an experiential process (May et al., 2016). The review can be commended for the point that interventions that seek to empower individual patients may have limited effectiveness for those who are negatively affected by the joint weight of structural, interactional and resilience factors identified in the synthesis. Although the patients of chronic heart failure (CHF), chronic obstructive pulmonary disease (COPD) and chronic kidney disease (CKD) and their caregivers were the focus of the review, the factors which determine their expectations, choices and emotional states may also be true for the amputees and their caregivers. The review with its emphasis on structural determinant factors makes it more relevant to this study which has the Ghanaian healthcare system and healthcare service provision which has a number of limitations as the study context (May et al., 2016). In a case study on four amputees, Rybarczyk, Edwards and Behel (2004) in order to better appreciate the psychological factors which shape the psychological adjustment of an amputee to amputation, revealed that several factors confirmed by previous studies (Gallagher & 29 Emotional Pain and Coping Strategies Maclahlan, 2000; Katz 1992; Williamson, Schulz, Bridges, & Behan, 1994) influence the psychological adaptation of amputees. For the purposes of this study, only factors relevant to this study will be mentioned. These include phantom limb pain, residual limb pain, activity restriction, perceived vulnerability, perceived social support and positive coping (finding positive meaning, optimism) among others. Nonetheless, they assert that the psychosocial, developmental and environmental contexts of disability are more important in the adjustment process than the physical disability. Rybarczyk et al. (2004) just like Butler et al. (1992) and Liu et al. (2010) did not consider the caregivers who also play an inevitable role in the adaptation process of the amputee, a gap this study will fill. Emotional Pain and Psychological Distresses (Depression, Anxiety, Stress and Hopelessness) Emotional pain, as Orbach (2003) portrays, is the amassing of multiple intense negative emotions of which anxiety, depression among other negative emotions is a factor. According to Orbach (2003), the basic constituent of emotional pain also includes the loss of self, surfeit of the negative, incompleteness and emptiness. These emotions may have a qualitative feature of psychological distresses like depression, anxiety and hopelessness. Despite this overlap, Woo, Wang and Tran, (2017) brings out a unique difference between emotional pain and psychological distresses by defining psychological distress as the unpleasant feelings or emotions resulting in negative perception of the environment or society, others and oneself that interferes with a person’s level of functioning and activities of daily living. Orbach (2003) and Bolger (1999) explains that being in this state for a prolong duration comes along with the feeling of brokenness which depicts the experience of emotional pain. 30 Emotional Pain and Coping Strategies Erinfolami, Olagunju, Oshodi, Akinbode, Fadipe and Adeyemo (2016) further cemented the unique differences between psychological distress and emotional pain by investigating the prevalence of psychological distresses and emotional pain among adult attendees of a Nigerian dental clinic using a case control mode of evaluation. Erinfolami et al. (2016) identified the unique content of psychological distresses as being dental fear or depression. Erinfolami et al. (2016) further brings to fore that emotional pain can co-occur with psychological distress. The review showed that there are interconnections among emotional pain and other negative emotional states (e.g. depression, anxiety, anger, hopelessness). Lester (2000) explored correlates of psychache or emotional pain using Shneidman's psychache questionnaire along with a measure of manic-depressive tendencies. The correlates of two dimensions of the psychache namely current psychache and worst ever psychache were examined. Lester (2000) explored the correlates of psychache using 12 male and 39 female students enrolled in two social science courses. Findings of the study indicated that current psychache was weakly associated only with depression scores however worst ever psychache was associated with depression scores. Additionally, Orbach et al. (2003a) investigated the relationship between mental pain/emotional pain and depression in the normal population using 255 Israeli University students. The total sample consisted of 194 women and 61 men ranging from the ages of 18 to 47 years old. Results indicated that certain factors on the scale that was used to measure mental pain/ emotional pain that is, the Orbach, Mikulincer Mental Pain scale (OMMP), moderately correlated with depression but the OMMP had a unique variance beyond its association with depression. Emotional pain was found to strongly correlate with anxiety (Olie et al., 2010; Orbach et al., 2003b). Orbach et al. (2003a) noted that some defined aspect of mental pain/emotional pain 31 Emotional Pain and Coping Strategies can overlap with anxiety but mental pain and anxiety are two distinguished emotions in and of itself. Orbach et al. (2003) also noted that changes in the self and its function share common features with anger and anxiety. This result indicates that emotional pain may overlap with other emotional states of being like depression but it is a completely distinguishable emotion from these other negative emotions. Thus it is worth noting that emotional pain is distinguishable from psychological distresses. It is therefore important to acknowledge that researchers like Orbach (2003); Woo et al. (2017); Erinfolami et al. (2016) and Lester (2000) have explained that though there may be correlation between psychological distresses like depression, anxiety among others and emotional pain, these two emotional states remain distinct. Psychological distresses like depression and hopelessness when left unattended to could lead to suicide (Shneidman, 1985, 1999). To investigate how intense psychache during major depressive episode would be a factor of vulnerability to suicide behavior, Olie et al. (2010) conducted a field experiment using 210 participants with ages ranging from 18 to 70 years. Results indicated that psych-ache is associated with the intensity and frequency of suicidal ideation. Similarly, Troister et al. (2010) also examined the contribution of psych-ache, depression and hopelessness to the prediction of various suicide related criteria. Among the hypotheses tested in the study included “In the statistical prediction of suicidality, controlling for psychache (emotional pain) would reduce the unique contributions of depression and hopelessness to non-significant levels” (pg. 690). Through a cross-sectional survey, they studied 1474 undergraduates, who were aged between 16 to 45 years. Results indicated that statistically controlling for psych-ache as the strongest predictor of all suicidal criteria reduced the contributions of depression and hopelessness to non-significant levels. 32 Emotional Pain and Coping Strategies In a two phase study, Orbach et al. (2003b) explored the relationship between mental pain and suicide in a sample of suicidal and non-suicidal individuals. In the first study, they explored the relationship between mental pain (emotional pain) and emotional expressivity in 32 suicidal inpatients. Results indicated that mental pain was inversely associated with emotional expressivity (expressive confidence, positive expressiveness, negative expressiveness, inputs intensity and masking). In the second study, the researchers explored the relationship between loss (as defined by commitment to goals) and mental pain (emotional pain). It was found that optimism and “life guard” were inversely related to mental pain. These findings suggest that when experiencing emotional pain, one could have difficulties expressing emotions and could reduce the individual’s sense of hope and optimism. Moreover, Pompili, Lester, Leenaars, Tatarelli and Paolo (2008) have established that hopelessness scores were significantly associated with rating of worst-ever psych-ache. These findings suggest that emotional pain could be the common factor that explains depression, hopelessness and even suicide thus there is the need to allocate much attention to the experiential process of emotional pain. Amputation is a process that psychologically stresses patients and their caregivers. According to researchers like Ide (2011) and Queiroz et al. (2016) amputees evidently experience depressive disorders, with feelings of sadness, discouragement, apathy, guilt and disappointment with self. Ide (2011) evaluated and examined the relationship between pain and depressive mood amongst persons with limb amputations, and the relationship between the etiology of trauma and depressive mood respectively. Ide (2011) sought to investigate this by conducting a mail survey. Sixty-nine (69) limb amputees living in the community responded to the mailed questionnaires. Results indicated that out of the 69 limb amputees who responded to the mailed questionnaires, 33 Emotional Pain and Coping Strategies eighteen (18) participants representing 26.1% of the total participants had mild depression, sixteen (16) participants representing 23.2% of the total participants had moderate depression, and seven (7) participants representing 10.1% of the total participants had severe depressive mood. A substantial fraction of respondents with moderate or severe depression were amputees with work-related etiology for their loss of limbs. Queiroz et al. (2016) opined that trauma amputees’ focus on a positive outcome despite their present situation makes them optimistic and confident which tends to increase their self- esteem. This gives them a sense of hope and personal control over their present predicament. This finding tends to support the finding of Livneh, Antonak and Gerhardt (2000) that amputees are optimistic/positivistic. Muzaffar et al. (2012) investigated the psychiatric comorbidity in amputees in a conflict zone of South Asia with average socio-demographic status. The researchers achieved this aim by conducting interviews using a semi- structured interview guide. After interviewing 100 cohorts of amputees who were diagnosed and identified as per DSM-IV, (Diagnostic and statistical manual of mental disorders. 4thEd. APA,1994), lead criteria for psychiatric comorbidity, they drew their conclusions by obtaining simple percentages from the responses given. The data obtained disclosed that quite a significant amount of amputees had various forms of psychiatric comorbidity, 58% to be precise. Sequentially, 63% of patients had Major Depressive Disorder (MDD); 20% of patients had Post Traumatic Stress Disorder (PTSD); 19% of the patients had Impulse Control Disorder; 14% of the patients had phantom limb sensation; 10 % of the patients had Generalized Anxiety Disorder; 6% of the patient had panic disorder and finally, 4% of the patients had Sub-syndromal Post Traumatic Stress Disorder. This depicts that, amputees given 34 Emotional Pain and Coping Strategies their state experience psychological distress. Just about 16% of the patients had no psychiatric comorbidity. Similarly, Singh, Hunter and Philip (2007) primarily sought to examine the relative progression of depressive and anxiety symptoms shortly after amputation and again after a period of inpatient rehabilitation. The researchers investigated this phenomenon by using a unit of 105 amputees at a rehabilitation ward. These amputees were initially screened for the presence of symptoms of anxiety and depression. It was realized that at admission, 28 amputees representing 26.7% of the participants had symptoms of depression and 26 amputees representing 24.8% patients had symptoms of anxiety. The number of patients who had depression and anxiety at the time of discharge dropped to 4 patients representing 3.8% of participants and 5 patients representing 4.8% of the participants. After a couple of days, the level of depression and anxiety among the patients dropped to a mean of 54.3. These progressive reductions were statistically significant, as was the association between patients having symptoms of both depression and anxiety. This finding revealed that depression and anxiety are commonly reported after lower limb amputation and previously thought to remain high for up to 10 years however it was realized that levels of both depression and anxiety resolve rapidly. This is in sharp contrast with the findings of Horgan and Maclachlan (2004) that depression and anxiety of an amputee lasts for two years based on the literature on the subject they reviewed. What accounted for this rapid resolution of depression and anxiety, according to Singh et al. (2007), are among other factors, the presence of a specialist at the rehabilitation center, the learning of new motor skills and improving mobility in the weeks after amputation, and the positive attitudes of staff . These help the amputee to have a new outlook different from 35 Emotional Pain and Coping Strategies the entirely bleak fate and equally help the amputees to reason that a new life is still possible despite the loss of a limb. Drawing from patients and caregivers of other ailments, Price, Butow, Costa, King, Aldridge et al. (2010) investigated the prevalence and predictors of depression and anxiety in patients (women with ovarian cancer) and their caregivers. The study was part of a nationwide Australian Ovarian Cancer project (2002 – 2006) which recruited 798 women with invasive ovarian cancer and 373 caregivers. They discovered that, generally, the rates of anxiety and depression among the patients were significantly lower than previous studies have reported. Caregivers reported higher levels of depression but there was no difference, comparatively, in the patients’ and caregivers’ depression levels. Further, caregivers reported higher anxiety than patients. The study also revealed that symptom burden, lower optimism and mental health treatment are predictors of both depression and anxiety in a patient, while lower social support is a forecaster of patient’s anxiety. On the other hand, lower social support and lower optimism are predictors of depression and anxiety in caregivers, and a patient being treated for mental health is also a significant predictor of depression in the caregiver. Price et al. (2010) therefore concluded that, although, depression is prevalent in women with ovarian cancer than in a general population, “caregivers of such patients have higher levels of both subclinical and clinical depression and anxiety” (Price et al., 2010; pg. 52). If such is the case between women with ovarian cancer and their caregivers, then it is possible a similar situation may exist between amputees and their caregivers. Emotional Pain and Personality Individuals’ personality type has also been highlighted as influencing the experience of emotional pain. The five-factor model of personality proposes that there are five major 36 Emotional Pain and Coping Strategies personality attributes namely, Neuroticism, Extraversion, Openness, Agreeableness, and Conscientiousness which are believed to offer the most comprehensive description of personality structure (Chioqueta & Stiles, 2005; Costa & McCrae, 1992). Leenaars and Lester (2005) found that psych-ache was negatively associated with extraversion but positively related to neuroticism and introversion. This suggests that individuals who are high on neuroticism and introversion are likely to have high levels of psych-ache whereas those who are high on extraversion are likely to be low on psych-ache. Lester (2000) also found out that psychache, current and worst, was not associated with extraversion, sensing, thinking, or judging. Similarly, in a study, Chioqueta et al. (2005) examined the relationship between personality traits and depression, hopelessness, and suicide ideation with 219 participants. Among the instruments used were NEO Personality Inventory Revised (NEO-PI-R), the Beck Hopelessness Scale (BHS), and the Hopkins Symptom Checklist-25. After running a multiple regression analyses they found that neuroticism is a significant predictor of depression, hopelessness, and suicide ideation. The positive association between neuroticism and depressive symptoms confirms the findings of previous studies (Enns & Cox, 1997; Hirschfeld, Klerman, Lavori, Keller, Griffith, & Coryell, 1989) According to Chioqueta et al. (2005) extraversion, on the other hand, a personality trait which is described by sociability, liveliness and cheerfulness was negatively associated with depression and hopelessness. Openness to experience is a significant predictor of depression. This supports the view that open individuals experience both positive and negative emotions more intensely than those who are not open (Costa & McCrea, 1992). Furthermore, hopelessness is found to be significantly associated with neuroticism and negatively associated with 37 Emotional Pain and Coping Strategies extraversion as asserted by Dyck (1991). Among the five personality traits only neuroticism was positively associated with suicide ideation in the study (Chioqueta et al., 2005). Resilience has been noted to be a trait that aids people to deal with their traumatic situation (Zeb, Naqvi & Zonash, 2013). According to the researchers, basically resilience is one's ability to view misfortune in a positive lens. Zeb et al. (2013) investigated the liaison between one’s personality and ego-resilience in amputee soldiers with emphasis on the established big five dimensions of personality namely; openness to experience, conscientious, extraversion, agreeableness and neuroticism (OCEAN). Zeb et al. (2013) purposively and conveniently sampled 92 soldiers (men only) with ages ranging from 20 years old to 50 years old who had been amputated. Findings revealed that one’s level of ego- resilience was negatively related to neuroticism but positively related with extraversion, openness, agreeableness, and conscientiousness. Extraversion, as a personality trait positively predicted the ego-resilience. This suggests that when one is faced with a traumatic situation and as such is in pain, the individual’s ability to bounce back to life or view his predicament in a positive light depends on the person’s personality trait being extraversion, agreeableness, conscientiousness or open to experience. This will invariably reduce the individual’s experience of emotional pain felt at his or her predicament. Whereas if an individual is a neurotic, when faced with a traumatic situation, he/she will not be able to view the positive dimension of what has befallen him or her and as such will have an increased emotional pain. Soldiers face death at every battle ground. They usually end up seriously wounded which may lead to amputation. It is thus interesting to realize that their ability to cope with their traumatic experiences and not wallow in emotional pain depends on their personality trait. 38 Emotional Pain and Coping Strategies A number of researchers have maintained that some phantom limb pain can be attributed to the personality makeup of the amputee. For example, Parkes (1984) in a study found that persistent phantom pain of amputees are significantly associated with compulsive self-reliance and rigidity because people with rigid personalities have an aversion and resist change. Therefore, they experience persistent phantom pain because they found it difficult to deal with the changes that are an inevitable consequence of amputation. This can be a source of emotional pain. Further, Parkes (1984) found that those who are compulsively self-reliant are also likely to experience persistent pain because of the helplessness that often accompanies amputation. If such individuals are to depend on others for things they previously did themselves, they become distressed and this leads to pain (Parkes, 1984). In a study, Melo, Maroco and Mendonc (2010) using a cross sectional design with 105 participants of consecutive patients with dementia and their family caregivers, living at home, and attending a Dementia Clinic hypothesized that “personality influences the caregiver’s depression, burden and distress associated with the behavioral and psychological symptoms of a patient with dementia [BPSD]” (p.1276). The study revealed that neuroticism increased the caregiver’s depression and burden, whereas extraversion decreased, both caregiver’s depression and burden. Agreeableness was also found to decrease the burden. These personality traits were found to have an indirect influence on the caregiver’s distress in relation to BPSD. However, as noted by George (1994), considerable amounts of variance in caregiver and personality outcomes remain unexplained. 39 Emotional Pain and Coping Strategies Emotional Pain and Coping Strategies and Perceived Social Support According to Singh et al. (2007) the psychological adjustment required to cope with amputation can be compared to that required to cope with bereavement. Thus it is essential to investigate the coping strategies of amputees and their caregivers. A relationship has also been found between emotional pain and coping strategies. Coping is the cognitions and behaviours that are designed to channel resources to solve stress-creating problems (problem-focused coping) or to ease tension-aroused threats by intra-psychic activities (emotion-focused coping) (Orbach et al., 2003b). According to Orbach et al. (2003b) as coping intensifies or mitigates psychological stress and negative affect, coping could also affect emotional pain in a similar way. In line with this, Orbach et al. (2003) probed to find out the relationship between mental pain/ emotional pain and coping using a 100 Israeli University students comprising of 66 women and 34 men with ages ranging from 20 to 48 years. Findings indicated associations between emotional pain and four categories of coping. Problem-focused coping was inversely related to all factors on the Orbach and Mikulincer Mental Pain Scale (OMMP). Emotion-focused coping was positively related to most of the OMMP factors (with the exception of narcissist wounds and social distancing), support seeking was inversely associated with social distancing on the OMMP, and distancing coping was positively associated with emptiness on OMMP. These findings suggest that coping, particularly problem-focused coping and emotion-focused coping, could have mitigating effects on psychological pain, despite previous studies highlighting the potential harmful effects of emotion-focused coping on mental health (Marsac, Donlon, Hildenbrand, Winston, & Kassam- Adams, 2014; Morris & Rao, 2013). 40 Emotional Pain and Coping Strategies Muzaffar et al.’s (2012) report on the use of theologic and family support system as a coping mechanism for amputees. Muzaffar et al. (2012) revealed that amputees who did not report psychiatric conditions made use of spiritual means of coping and family support. The patients became more religious after the traumatic phenomenon and also resorted to visiting shrines with the sole aim of achieving inner peace of mind and salvation. Such patients were close to their family members, friends and close relatives and tend to engage in a vocation that kept them occupied enough not to think about their predicament. Valizadeh, Dadkhah, Mohammadi and Hassankhani (2014) sought to aid in the understanding of trauma patients and their experience of support sources in the process of adapting to a lower limb amputation by conducting a qualitative research using 20 patients with lower limb amputation. Patients were purposively sampled and interviewed until saturation was met. After a qualitative content analysis, results indicated that amputees’ strong hold of support that helped improved their quality of life and the adaptation process was from a supportive family, gaining friends’ support, gaining morale from peers and assurance and satisfaction with the workplace. Thus strengthening these sources of support would go a long way to improve the quality of life of the amputee. Livneh, Antonak and Gerhardt (2000) investigated the dimensional structure of coping with disability-related stress among 61 adults with amputations. They conducted a mail survey to achieve this purpose. The researchers mailed 200 packets of questionnaires however only 64 questionnaires were returned representing 32% return rate and of these, only 61 questionnaires were properly filled and statistically analyzed. The statistical analysis used were multidimensional scaling (MDS) analysis and cluster analytic (CA) which allows for a qualitative categorical structure. Two of their findings are very relevant to the concept of coping 41 Emotional Pain and Coping Strategies strategies employed by amputees. They found out that amputees use more of active/confrontive or adaptive, abstract and social affective coping strategies in dealing with the daily stressors. The active/ confrontive coping strategy refers to the ‘traditionally regarded adaptive coping efforts’ (pg. 238) juxtaposed the maladaptive coping skills like excessive alcohol consumption. The use of abstract coping skills is the individual’s reliance on religion or religious activities as a coping mechanism. The social affective coping strategy refers to the social support available for emotional reasons. However, with regards to the latter (social affective coping strategy), the researchers (Livneh et al., 2000) found moderate differentiation between social affective coping and cognitive coping strategy. Ae-Ngibise et al. (2015) concluded, after investigating the coping strategies used by caregivers of people with mental disorders and the available support for them, that caregivers make use of religious prayers and the anticipation of cure as a coping strategy. Then again, according to Ae-Ngibise et al. (2015) there was no social support for caregivers of people with mental disorders. The only mentioned support was for the patients with mental disorders but not their caregivers. According to Iseselo, Kajula and Yahya-Malima (2016) there is a relationship between caregivers’ social support and the stigma associated with being a relative of a mental patient. They used a qualitative approach involving four focus group discussions and two in-depth interviews of fourteen (14) family members who were caring for patients with mental illness. These four groups of participants were purposively selected. The study reported that the participants (caregivers) coped with the social stigma and the psychological burden that comes with it through acceptance and faith. Caregivers learn to accept and reconcile with the state of their mentally ill relative in order to prevent the dissatisfaction and disappointment of the bizarre 42 Emotional Pain and Coping Strategies behavior and condition of the patient. In the view of Iseselo et al. (2016), some family caregivers took positive steps by employing problem solving strategies to address their relatives’ psychological, emotional and practical needs by taking the patients to the hospital after visiting traditional healers. In relation to faith, family caregivers sought religious support and prayed as the only means of hope and encouragement. Emotional Pain and Psychotherapy Psychological therapy is an important intervention in the experience of negative emotions. Thus for this research, the important role of psychotherapy will be teased out of the literatures reviewed. Again, due to lack of literature in this dimension, a lot will be deduced from literature in other fields. Preoperative psychological preparation is an important aspect that aids with dealing with a traumatic event. The need for amputation is usually not anticipated and the preoperative period can be used as an opportunity for the psychological preparation of the patient and the family. Butler et al. (1992) in their article which focused on pre-surgical psychological preparatory interventions asserted that psychological intervention during the preoperative period by a family physician leads to a less complicated postoperative adjustment and grieving experience. The family physician relies on the experience of the patient and the family to promote the patient’s adjustment by providing accurate information, eliciting unspoken fears, encouraging the involvement of the patient's family, emphasizing the patient's enduring characteristics and his or her past coping ability to make him or her ready for the amputation, the aim is to lessen the psychological distress of amputation and facilitate adaptation (Butler et al., 1992) The use of an effective intervention plan has been noted to reduce psychological distress like depression to its barest minimum in amputees. Ide (2011) after finding out from his study 43 Emotional Pain and Coping Strategies that a great number of amputees suffered depression realized how essential psychological counseling is for amputees. According to Ide (2011), psychological counseling can go a long way to improve upon the mental health of individuals with limb amputations. On the contrary, Knowlton, Gosney, Chackungal, Altschuler, Black et al. (2012) laid emphasis on the need for a psychiatrist in the health team that attends to an amputee. The researchers further emphasis on the need for a multi-disciplinary care team and as such did not explicitly de-emphasis the need for psychological therapy. Knowlton et al. (2012) identified specific areas of concern for amputation care and these include, the “team member composition, medical record keeping including consents and post-operative care, anesthesia and pain management, surgical technique and operative considerations, spectrum of rehabilitation services, patient follow-up and community reintegration, data tracking/ surgical outcomes reporting” (pg. 440-441). According to Knowlton et al. (2012), there is the need for psychiatrist to give psychiatric counseling to patients to help diminish feeling of stigmatization with regards to the patient’s mental health. According to the Blesma (British Limbless Ex-Servicemen’s Association) organization, members of the multidisciplinary team that attends to an amputee may include: a surgeon, a nurse, a psychologist, a social worker, a pharmacist, a prosthetics, a dietitian, a physiotherapist, an occupational therapist and a Blesma. The unique role of the psychologist is to provide psychological assessment to determine how well the patient will cope with the psychological and emotional impact of amputation, and whether they will require additional support. Knowlton et al. (2012) and the Blesma organization tend to immerse the unique activities of the psychiatrist and psychologist with the former requesting the need of a psychiatrist on the medical team that attends to an amputee in the absence of a psychologist and the latter requesting the aid of a psychologist on the medical team that attends to an amputee in the absence of the psychiatrist. 44 Emotional Pain and Coping Strategies Ide (2011) however lays particular emphasis on the indispensable role of the psychologist by focusing on the need for psychological counseling for amputees. Rybarczyk et al. (2004) explained that although psychologists played a limited role in the adjustment inventions of amputees, however, their role and that of other mental professionals cannot be underestimated. According to the researchers, psychologists’ roles included identification of amputees who were at risk for maladjustment, identification of factors influencing the adjustment, provision of acute or long-term service to facilitate adjustment, liaising with individual amputees and other rehabilitation or hospital staffs. Gaps in Literature A critical examination of the studies revealed a significant gap that this current study intends to fill. This gap is discussed with focus on the methodology used, the sample size used, analytical tool used and the focus of the research. A critical review of the studies above revealed that most of the studies used a single method of investigation that is qualitative or quantitative, which affects the richness of the information received. For instance, several studies, (eg., Ae-Ngibise et al., 2015; Liu et al., 2010; May et al., 2016; Muzaffar et al., 2012; Queiroz et al., 2016 & Volker, 2015), used a purely qualitative method of investigation whiles other studies (eg., Ide, 2011; Singh et al., 2007) focused on a strictly quantitative method of investigation. Furthermore, a review of the literature revealed that the small sample size used for investigation will limit the extent to which findings from these studies can be generalized. Studies like Volker (2015) and Rybarczyk et al. (2004) interviewed just one (1) caregiver and four (4) amputees respectively. 45 Emotional Pain and Coping Strategies Additionally, some studies like Muzaffar et al. (2012) analyzed their qualitative data using simple percentages. Moreover, a significant amount of research focused on abled population or the general population (Erinfolami et al., 2016; Lester, 2000; Orbach et al., 2003a), suicidal patients (Olie et al., 2010; Orbach et al., 2003b) and patients and caregivers of other conditions (Ae-Ngibise et al., 2015; Chioqueta et al., 2005; May et al., 2016; Price et al., 2010). These reviews provide us with a bedrock understanding of how emotional pain is experienced in the abled population and its psychological consequences. None of the studies focused on experiences following loss, which includes functional loss, loss of a relationship or loss of one’s way of life, although these experiences are considered emotionally traumatic. Among other critiques such as the heterogeneous set of reports from different studies with different aims, perspectives and methods put together one cannot overlook the inability of the reviewers to make a clear distinction between the responses of the patients and their caregivers to the factors mentioned above, where they converge and where they diverge due to teasing out difficulties, May et al. (2016) is a typical example. Focusing on the amputees and their caregivers, unlike other studies, this study will bring out the distinctions in the responses to the determining factors of expectations, choices and emotional states of the amputees and their caregivers. The literature reviewed also revealed that, to date, majority of the studies on emotional pain have been done in countries outside Africa and none could be traced in the Ghanaian context. Given the differences in cultures of the West and Ghana, it can be argued that how emotional pain is experienced and dealt with may vary. Finally, experiences of amputees and their caregivers may differ greatly depending on what caused the amputation and the condition 46 Emotional Pain and Coping Strategies the patient receiving the care is suffering from and just how greatly one’s life as a functional individual could be affected by it. As a result, there is the need for studies in the Ghanaian context. Rationale for the Study Review of the literature on emotional pain revealed that the concept plays an immense role in the understanding of psychopathology. However, Orbach et al. (2003b) confirms that globally, the phenomenon is under-investigated. The review also shows that no study, on the emotional pain experienced by amputees and caregivers nor the differences in the psychological experiences of amputees and their caregivers, to date could be traced in the Ghanaian context even though literature reveals that caregivers suffer physical distress, social distress, emotional distress and spiritual pain and as such face a lot of psychological consequences (Brodaty, Green, & Koschera, 2003; Delgado-Guay, Parsons, Hui, De La Cruz, Thorney & Bruera, 2012). Given the significant role of emotional pain in the understanding of the psychological states and the indispensable role of cultural norms in an individual’s life, there is therefore the need for scholarly works that seeks to explore the basic constituent of emotional pain in the Ghanaian context and the individuals’ use of psychological services in the experience of emotional pain in the Ghanaian context. Therefore, this study seeks to enhance the understanding of the phenomenon of emotional pain by bringing to the fore the unique experiences of amputees and their caregivers in the Ghanaian context and to tease out the importance of psychological services in this experience. The study will also tease out the amputees’ and their caregivers’ level of acceptance or avoidance of emotional pain, how they process emotionally painful experiences and the coping strategies they use in dealing with the emotional pain. 47 Emotional Pain and Coping Strategies Statement of Hypotheses 1. Psychological distresses (i.e., depression, anxiety, stress and hopelessness) will be significantly related to emotional pain. 2. There will be a significant difference in the emotional pain experience of amputees and their caregivers. 3. Psychological distresses of amputees will be significantly different from that of their caregivers 4. There will be a significant difference in the coping strategies employed by amputees and their caregivers. 5. Personality will moderate the relationship between psychological distresses and emotional pain 6. Perceived social support will moderate the relationship between psychological distresses and emotional pain. Research Questions 1. What are the experiences of emotional pain? 2. What are the factors that affect the experience of emotional pain? 3. What is the potential impact of the traumatic situation on one’s wellbeing? 4. What are the coping strategies employed in dealing with emotional pain? 48 Emotional Pain and Coping Strategies Conceptual Framework of Study Personality (Openness, Conscientiousness, Extraversion, Agreeableness, Neuroticism) Social Support Psychological Distress Emotional Pain (Depression, Anxiety, (Caregivers and Stress and Amputees) Hopelessness) Figure 3: Hypothesized Model The above model suggests that there will be a relationship between psychological distresses (depression, anxiety, stress and hopelessness) and emotional pain in amputees and their caregivers. Additionally, Personality and Perceived social support will moderate the relationship between psychological distresses and emotional pain. 49 Emotional Pain and Coping Strategies Operational Definitions Trauma refers to any experience that individuals recognize as painful. Examples include loss of way of life, witnessing others experience pain, loss of intimate relationship and functional loss. Psychological distresses refer to one’s level of depression, anxiety, stress and hopelessness as a result of unpleasant feelings or emotions that impacts one’s level of functioning. Emotional pain is conceptualized as a perception of negative changes in the self and its function or a sense of brokenness due to frustration of vital psychological need that is accompanied by strong negative feelings like guilt, shame, defeat, humiliation, disgrace, grief, hopelessness, induced sadness and rage among others. 50 Emotional Pain and Coping Strategies CHAPTER THREE METHODOLOGY (Study 1: Qualitative) Introduction This chapter discusses the method employed in this research. This chapter is broadly divided into two, the methodology for the qualitative study and the methodology for the quantitative study. The first part, which is the methodology for the qualitative study, was discussed under thirteen (13) sections. The first section discusses the research design used for this study. The subsequent sections discusses the research setting, population/sample, sampling technique, inclusion criteria, exclusion criteria, research instruments/measures, demographic data, pilot study, data collection procedure, ethical consideration and approval, data analyses strategy and trustworthiness of the qualitative results. These subsections are discussed into detail to acknowledge their unique contribution towards the development of this study. Research Design A sequential mixed method design was employed for this study. The qualitative phase utilized an exploratory research design. In-depth interviews were conducted using a semi-structured interview. The semi-structured interview targeted at capturing the unique experience of emotional pain and inferring the importance of psychological services. The researcher sought to accurately describe the phenomenon under study while refraining from any pre-given frameworks (Groenewald, 2004). This was to enable an enhanced understanding of the dynamics which exist within the individual’s social world (Giorgi & Giorgi, 2003). The semi-structured interview guide was used as the primary form of data gathering. Interviews were audio taped and in certain circumstances where participants felt uncomfortable with being recorded, content of 51 Emotional Pain and Coping Strategies the interviews were written verbatim. Given that this study is a preliminary investigation into individuals’ (amputees and their caregivers) emotionally painful experiences in the Ghanaian context, the use of standardized measures only would not have captured the unique experiences of emotional pain hence the interviews. Research Setting The study was conducted at Nsawam Orthopedic Center and St Joseph hospital. Both hospitals are located in the Eastern region of Ghana. Nsawam Orthopedic Center is a rehabilitation center for orthopedic cases located at Nsawam. St Joseph hospital is a catholic hospital that serves as a referral point for people with orthopedic conditions and other conditions as well. It accepts individuals from diverse religious background. Twenty (20) participants were interviewed from these hospitals. Population/Sample The populations for this study were amputees and their caregivers who were seeking medical attention from Nsawam Orthopedic Center and St Joseph hospital. Meanwhile, the target population were amputees and their caregivers who were 18 years and above. Morse (1994) suggests at least five (5) participants, as the minimum sample size for a qualitative research. Thus, ten (10) participants were sampled from each group (amputees and their caregivers) for the qualitative phase for interviews. Sampling Technique To facilitate the selection of participants who fitted the criteria, purposive sampling technique was used to select amputees and their caregivers. This implies that participants who met the required attribute under investigation were selected for the interview. This sampling method was 52 Emotional Pain and Coping Strategies chosen given that the nature of the sample is determined by the phenomenon under study (Hycner, 1999). Demographic Data For the qualitative phase, twenty (20) participants comprising of ten (10) amputees and ten (10) caregivers were interviewed. Inclusion Criteria 1. Participants were eighteen (18) years old and above. 2. Participants were either in-patients or out-patients 3. Participants were amputees who have been amputees for not more than six (6) months or caregivers of amputees for not more than six (6) months. Exclusion Criteria 1. Participants below eighteen (18) years of age 2. Participants who had been an amputee or caregiver of an amputee for more than six (6) months. Interview Guide A semi-structured interview guide comprising of eight (8) questions was used to facilitate discussion into participants’ emotionally painful experiences and how these experiences were dealt with. Questions on the interview guide included; 1. What does emotional pain mean to you? 2. What was your initial feeling when you were faced with this situation? 3. Do you feel your present situation causes you emotional pain? 53 Emotional Pain and Coping Strategies 4. What were your thoughts at the time you heard of/experienced the situation? 5. Did your emotional pain become unbearable? 6. How do you deal with the emotional pain? 7. Do you feel your situation will get better? 8. Explain your daily experiences in detail. Data Collection Procedure The researcher obtained ethical clearance from Ethics Committee for Humanities (ECH) after which an introductory letter was acquired from the Psychology Department. After this process, the actual study proceeded. The introductory letter obtained from Psychology Department was submitted to the various institutions (37 Military Hospital, St Joseph Hospital, Nsawam Orthopedic Center) selected for the study, however an institutional approval was obtained from St Joseph Hospital and Nsawam Orthopedic Center thus the study took place in these institutions. These two hospitals are in the Eastern region of Ghana and serve as a referral point and rehabilitation center for amputees. Informed consent was sought from participants. The researcher was introduced to the prospective respondents by the public relations officers of the two hospitals. Respondents were then approached individually to seek their consent for their voluntary participation in the study. Respondents’ experiences and views about their emotionally painful experiences and their coping strategies were explored through an interview using a semi- structured interview guide. The interviews were conducted by the researcher to minimize inter- interviewer discrepancies. The researcher is an MPhil female candidate of the Akan background. Twenty-nine (29) respondents comprising thirteen (13) amputees and sixteen (16) caregivers were approached. However, only twenty (20) interviews were included in the analyses because seven (7) respondents could not complete the interviews and two (2) respondents felt 54 Emotional Pain and Coping Strategies uncomfortable about their responses being included in the analyses though they gave their consent to part take in the study. Thus, their data were withdrawn. Six (6) amputees were in- patients, their caregivers lodged in a facility close by and reported in at appropriate times to feed and attend to their patients. Four (4) amputees were out-patients who were reporting for review with their caregivers. However, the amputees were not matched to their caregivers due to availability of the individual and the concept of voluntary participation. The first set of interviews (7) was conducted at St Joseph hospital and the second set of interviews (13) was conducted at Nsawam Orthopedic Center. One interview was conducted in the local dialect (Akan) and the rest were conducted in the English language. Each interview lasted for about thirty (30) minutes to an hour. Interviews progressed until saturation was achieved. Ethical Consideration and Approval Ethical clearance was sought from the University of Ghana Ethics Committee for Humanities (ECH). Institutional approval was sought from the authorities in Nsawam Orthopedic Center and St Joseph hospital. Informed consent was sought from participants. Respondents were assured of the confidentiality, privacy and anonymity of their responses and identity. Respondents were also informed that their participation is voluntary and that they could withdraw from the study at any point in time without any consequences to them. Some participants experienced slight psychological discomfort from the recall of traumatic situation and as such were given psychological counseling. The benefits of the study include information for intervention formulation and guidance to clinicians for therapy. Data Analyses Strategy Data was transcribed and analyzed by four people comprising of three research assistants and the main researcher. Out of the three female research assistants, one was a first degree graduate and 55 Emotional Pain and Coping Strategies the others were MPhil candidates. The research assistants were natives of the Akan dialect (a tribe in Ghana) and were trained in the processes of transcription and qualitative data analyses. Data was transcribed individually by the research assistants and discrepancies were resolved at the group analyses level. The interview conducted in Akan was transcribed by two out of the three research assistants, one being a first degree graduate and the other being an MPhil candidate, to ensure consistency. Disagreements in the verbatim transcription by the research assistants were resolved in consultation with the researcher’s supervisor. Data was analyzed at an individual and group level comprising of the three research assistants and the researcher, thus the researcher’s personal biases were curbed from the analyses process. Discrepancies in generated codes and themes were resolved in consultation with a third supervisor who is a known qualitative researcher. All interviews were transcribed and analyzed using Braun and Clarke’s (2006) six phases for thematic analyses (Boyatzis, 1998). The steps included; 1) Familiarization with data; This involved the researcher getting familiar with the data through reading and re-reading to understand the data at hand. Therefore, after the interviews were transcribed, the researcher and the research assistants listened to the audios over again and re- read through the transcribed interviewed to add something they missed or re-write information that was not transcribed verbatim. Transcribed interviews were passed around for other research assistants to validate it authenticity. 2) Generating initial codes; Codes refers to phrases that captures both a semantic and conceptual meaning of the data of quotes from participants. Initial codes from the transcribed data were generated separately and agreed upon at the group level. Generated codes were further scrutinized by the researcher’s supervisor. 56 Emotional Pain and Coping Strategies 3) Searching for themes among codes; The codes were then clustered together to identify similar patterns (themes) at the group level. 4) Reviewing themes; The themes were reviewed for similarity. Similar themes were clustered to avoid redundancy. The generated themes were further scrutinized and agreed upon by the researcher’s supervisor. 5) Defining and naming themes; This involves finding the essence of each theme and writing out a detailed analysis of each theme. Thus the defined meaning of each theme was further analyzed. 6) Producing final report; It involved giving analytic narratives and putting narratives into perspective by supporting it with existing literature. Narratives were sought to support the analyzed themes. Then, existing literature was reviewed to support these narratives. Trustworthiness of the Qualitative Results According to Maxwell (1996), to ensure the validity of qualitative data, three steps needs to be followed. These steps were followed to the latter. These three steps included providing accurate and complete representation of respondents’ accounts. Also, making interpretations on the basis of participants’ perspectives that emerged from the data and finally, providing alternative perspectives on experiences that emerged from the data. Consequently, at the data collection stage, respondents’ responses were written verbatim. At the data analysis stage, these responses were analyzed from respondents’ perspectives and in-depth meaning derived. According to Green and Thorogood (2009), to warrant reliability of data obtained, there is the need for the use of quality tape recorder and detailed transcription of interviewed data. Thus a quality tape recorder was obtained and used for data collection. A detailed transcription of audios was done. 57 Emotional Pain and Coping Strategies METHODOLOGY (Study 2: Quantitative) Introduction Study 2 discusses the methodology for the quantitative study under thirteen (13) sections. These sections include the research design used for this study, the research setting, population/sample, sampling technique, inclusion criteria, exclusion criteria, research instruments/measures, demographic data, pilot study, data collection procedure, ethical consideration and approval, data entry and cleaning and data analyses strategy. Quantitative Research Design In the quantitative phase, a cross-sectional design was adopted. This method was suitable given that the present study aimed to investigate the relationship between emotional pain and psychological distresses and coping strategies in a subgroup of amputees and their caregivers within a population of disabled people and their caregivers. Data was collected using standardized questionnaires. Research Setting This is the same as that of the research setting for Study 1. Population/ Sample This is the same as that of the population/ sample for Study 1. For the quantitative phase, 150 participants were recruited. The required sample size was calculated using Cohen’s (1992) calculation for suitable sample size. According to Cohen, with regression statistical analyses, for a medium effect size, when power= .80, with alpha at .05, the required sample size for four (4) predictors is 84 participants. However, according to Opoku (2005), in order to ensure that the sample statistic will be representative of its corresponding population parameter, there is a need 58 Emotional Pain and Coping Strategies to increase the estimated sample size thus the estimated sample size was increased to 200 participants however only 150 completed questionnaires were further analyzed. Sampling Technique The convenient sampling technique was used to select participants for the quantitative phase. This technique was appropriate because the researcher did not have the full list of the population. Following this method, participants were selected based on availability of participants and participant’s willingness to participate. Demographic Data A hundred and fifty (150) participants responded to a set of questionnaires. A demographic questionnaire was used to find out the participants’ age, gender, religious affiliation, level of education, one’s status as a caregiver or an amputee, the caregiver’s relationship to the patient, the category of amputee and the category of the caregiver. Table 1: Demographic data of sample for the quantitative study Variables Frequency Percentage Participants Trauma amputees 48 32.0 Surgical amputees 27 18.0 Caregiver of trauma amputees 39 26.0 Caregiver of surgical amputees 36 24.0 Gender Male 76 50.7 Female 74 49.3 Age 18-23 40 26.7 24-29 59 39.3 30-35 33 22.0 36 and above 18 12.0 Educational Level Primary 20 13.3 JHS 35 23.3 SHS 58 38.7 Tertiary 37 24.7 Religious Background Christian 119 79.3 Muslim 31 20.7 Caregiver’s Relationship Parent 12 8.0 59 Emotional Pain and Coping Strategies to Amputee Spouse 18 12.0 Ward 28 18.7 Sibling 17 11.3 Inclusion Criteria This is the same as that of the inclusion criteria for Study 1. Exclusion Criteria This is the same as that of the exclusion criteria for Study 1. Research Instruments / Measures Materials for the quantitative phase included questionnaires. The questionnaires were used to gather information on one’s level of emotional pain, including one’s level of psychological distress (depression, anxiety, stress and hopelessness, perceived social support, individual’s personality and coping strategies. The instruments used for collection included; Depression Anxiety Stress Scales; DASS (Henry & Crawford, 2005; Mahmoud, Hall & Staten, 2010) DASS 21 is a 21-item self-report measure of depression, anxiety and stress used for measuring distress levels in the general population in diverse settings. Items that measures depression are 3, 5, 10, 13, 16, 17 and 21. Sample items on this subscale include “I couldn't seem to experience any positive feeling at all”. Items that measures anxiety are 2, 4, 7, 9, 15, 19 and 20. Sample items on this subscale include “I was aware of dryness of my mouth” Items that measures stress are 1, 6, 8, 11, 12, 14 and 18. Sample items on this subscale include “I tended to over-react to 60 Emotional Pain and Coping Strategies situations”. Responses on the scale range from 0 (did not apply to me at all) to 3 (applied to me very much). Higher scores on a sub dimension denote higher distress level of that sub dimension. It consists of three 7- item self-report scales assessing depression, anxiety and stress. The intensity of any of the three conditions is determined by the sum scores of responses on the subscales multiplied by 2. Table 2: Interpretation of Total Scores on the Sub-Dimensions Is Displayed Below; Depression Anxiety Stress Normal 0-9 0-7 0-14 Mild 10-13 8-9 15-18 Moderate 14-20 10-14 19-25 Severe 21-27 15-19 26-33 Extremely 28+ 20+ 34+ Diagram by Lovibond and Lovibond (1995) High psychometric properties have been established for DASS. This includes alpha reliability coefficients of .88 for depression, .82 for anxiety and .90 for stress and .93 for the whole scale and it has a good convergent and discriminant validity (Henry et al., 2005; Mahmoud et al., 2010). Beck’s Hopelessness Scale: BHS (Beck, Weissman, Lester & Trexler, 1974) The BHS was used to measure hopelessness. It contains 20 items which are used to measure three major dimensions of hopelessness: feelings about the future, loss of motivation, and expectations. The BHS is a true/false response type and was designed for adults aged 17-80 years. Respondents are asked to decide about how each sentence describes his/her attitude for the 61 Emotional Pain and Coping Strategies last week including that day. Seven items are reversed scored: 1, 5, 6, 8, 13, 15 and 19. Total scores ranging from 4 to 8 indicate mild hopelessness, 9-14 moderate and 15-20 severe hopelessness. Sample of items on the scale include “I look forward to the future with hope and enthusiasm” and “I might as well give up because there’s nothing I can do about making things better for myself”. The Cronbach alpha coefficients range from .82 to .93 in seven norm groups, however the test-retest reliability coefficients are modest ranging from .69 after one week to .66 after six weeks (Aiken, 2002). The Big Five Personality Scale: BFPS (John & Srivastava, 1999). BFPS is a 44-item inventory that measures five broad dimensions of individual’s personality (Goldberg, 1993). The personality facets are openness (10 items; 5, 10, 15, 20, 25, 30, 35, 40, 41 and 44), conscientiousness (9 items; 3, 8, 13, 18, 23, 28, 33, 38 and 43), extraversion (8 items; 1, 6, 11, 16, 21, 26, 31, and 36), agreeableness (9 items; 2, 7, 12, 17, 22, 27, 32, 37 and 42) and neuroticism (8 items; 4, 9, 14, 19, 24, 29, 34 and 39). Item 2, 6, 8, 9, 12, 18, 21, 23, 24, 27, 31, 34, 35, 37, 41, and 43 are revered before scoring. Sample items on the openness sub-dimension include “I see myself as someone who is original, comes up with new ideas”. Sample items on the conscientiousness sub-dimension include “I see myself as someone who does a thorough job”. Sample items on the extraversion sub-dimension include “I see myself as someone who is talkative”. Sample items on the agreeableness sub-dimension include “I see myself as someone who tends to find fault with others”. Sample items on the neuroticism sub-dimension include “I see myself as someone who is depressed, unhappy”. Reponses range from 1 (disagree strongly) to 5 (agree strongly) and domain scores are calculated by summing up scores on the items designated for each domain. Higher scores for a particular domain or subscale represent a higher representation of that personality trait. The test-retest reliability of the items under the five facets 62 Emotional Pain and Coping Strategies are .82 for extraversion, .76 for agreeableness and conscientiousness, .83 for neurotism and .80 for openness (Gosling, Rentfrow & Swann, 2003) as well as high convergent validity (John et al., 1999; Goldberg, 1993). For the purposes of this study, scores on only extraversion and neuroticism will be used for data analysis. The Orbach and Mikulincer Mental Pain Scale: OMMP (Orbach et al., 2003a) The OMMP is a 44-item scale that assesses individual’s experience of mental pain along nine dimensions. Items explored different aspects of a person’s perception that their life and self have changed for the worse as well as the negative feelings that accompany the change. The dimensions are irreversibility of pain, loss of control, narcissist wounds, emotional flooding, freezing, self-estrangement, social distancing, confusion, loss of control and emptiness. The irreversibility of pain has nine (9) items, which are 10, 22, 26, 29, 30, 32, 34, 43, 44, with an alpha of .95 (Orbach et al., 2003a). A sample item of this dimension is “I have lost something that I will never find again”. The next dimension which is loss of control has ten (10) items which are 2, 5, 6, 9, 13, 21, 28, 31, 33 and 36. Loss of control has a Cronbach alpha of .95 (Orbach et al., 2003a), with sample items as “I am afraid of the future”. Five (5) items measures the dimension of narcissist wounds. These items are item 1, 7, 12, 16 and 18. The narcissist dimension has a reliability coefficient of .93 (Orbach et al., 2003a), with sample items as “Nobody is interested in me”. The emotional flooding dimension of the scale is measured with four (4) items which are item 3, 8, 14, and 35. It has a reliability coefficient of .93 (Orbach et al., 2003a), with sample items as “I feel an emotional turmoil inside me”. Three (3) items on the scale measures the freezing dimension of emotional pain. These items are 4, 11 and 19. The freezing dimension has a reliability coefficient of .85 (Orbach et al., 2003a). Sample items include “I cannot do anything at all”. Item 15, 17 and 23 measures self-estrangement. The self- 63 Emotional Pain and Coping Strategies estrangement dimension has a reliability coefficient of .79 (Orbach et al., 2003a), with sample items as “I am a stranger to myself”. The confusion dimension of the scale is measured with three (3) items and these are item 20, 24 and 27. It has a reliability coefficient of .80 (Orbach et al., 2003a), with sample items as “I cannot concentrate”. Social distancing is another dimension of the scale which is assessed with four (4) items on the scale. These items are item 25, 37, 40 and 42. Items 25 and 42 are scored in reverse. The social distancing dimension has reliability coefficient of .80 (Orbach et al., 2003a), with sample items as “I need the support of other people”. Emptiness is the last sub-dimension of the scale and it is assessed with three (3) items. These items are item 38, 39 and 41. The emptiness dimension has a reliability coefficient of .75 (Orbach et al., 2003a). Sample of items on the scale include “I have no future goals”. Items on the emotional pain scale are scored on 5-point Likert scale with responses ranging from 1 (strongly disagree) to 5 (strongly agree). Total scores are obtained through summation of scores on all items with higher scores suggesting higher emotional pain. Other researchers like Levi, Horesh, Fischel, Treves, Or and Apter (2008) and Meerwijk (2013) reported that the psychometric properties of the scale, specifically the Cronbach alpha ranges from .72 to .89 for the sub-dimensions. OMMP also has good test-retest reliability coefficient ranging from .79 to .94 (Orbach et al., 2003a). The Multidimensional Scale of Perceived Social Support [MDSPSS] (Zimet, Dahlem, Zimet, & Farley, 1988) The scale measures perceived adequacy of support from three different sources: family, friends, and significant other. By description, the MDSPSS consists of 12 items with 7-point Likert-type scales ranging from “very strongly disagree” to “very strongly agree”. Four items are dedicated to measure perceived social support from one particular source. The MSPSS measures the 64 Emotional Pain and Coping Strategies adequacy of support from three sources: family (items 3, 4, 8, 11) with an item like “My family really tries to help me”, friends (items 6, 7, 9, 12), sample item include “My friends really try to help me” and significant other (item 1, 2, 5, 10), sample item include “There is a special person who is around when I am in need”. A score of 69 to 84 is indicative of high social support, 49 to 68 indicate moderate social support and 12 to 48 indicates low social support. Reliability Coefficient alphas for the subscales and scale as a whole ranged from .85 to .91 with 275 undergraduates (Wang & Gan, 2011). The Africultural Coping Systems Inventory: ACSI (Utsey, Adams & Bolden, 2000). This scale was used to assess participants’ means of coping with stressful situations. The ASCI is well grounded in an African-centered conceptual framework. It is a 30-item self-report measure of unique coping behaviours. It assesses four dimensions of coping, including the cognitive/emotional debriefing (CED; 11 items; 5, 8, 12, 14, 15, 17, 18, 19, 20, 21 and 29, e.g “Sought out people I thought would make me laugh”), spiritual centered coping (SC; 8 items; 1, 6, 10, 13, 16, 22, 28 and 30, e.g “Read passage from a daily meditation book”), collective coping (CC; 8 items; 2, 3, 4, 7, 9, 11, 23 and 25, e.g “Got a group of family and friends together to help with the problem”), and ritual-centered coping (RC; 3 items; 24, 26 and 27, e.g “Burned incense for strength or guidance in dealing with the problem”). This measure is scored on a 4-point Likert scale with scores ranging from 0 (did not use) to 3 (used a great deal). Sample items on the scale include ‘prayed that things would work themselves out’ and ‘got a group of family or friends together to help with the problem’. The Cronbach’s alpha coefficients for the four dimensions were .79 for CED, .82 for SC, .78 for CC, and .76 for RC. A high score on a particular sub dimension indicate the frequent use of that coping strategy. 65 Emotional Pain and Coping Strategies Pilot Study The instruments used for data collection for both the qualitative and quantitative phase were adapted and translated using the Brislin Translation Model. Using this model, instruments were translated into a local dialect (Twi) and back-translated to the English version. The realized English version was then compared to the original English version of the scales for similarities and authentication of the Twi version of the instrument. The aim was to cater for participants who may not be fluent in the English Language. According to Burns and Grove (2001), before a data collection it is essential to ensure that questionnaires that will be used for data collection are reliable and as such will produce valid responses before it use. Thus the measures used for data collection was first piloted after transcription into the local dialect (Twi) to ascertain it reliability in the Ghanaians context specifically in the context of amputees and their caregivers. The measures were administered to ten (Ten) outpatient amputees and their caregivers who were conveniently sampled at St Joseph hospital in Koforidua and Legon main hospital in Accra and addressed before the main data collection. Informed consent was sought before the administration of questionnaires. Some items on the DASS scale and BFP scale were modified because they were found to be non- applicable in the Ghanaian context based on the views of the respondents. The items modified on DASS scale were “I found it hard to wind down”, “I felt down-hearted and blue” to “I found it hard to calm down” and “I felt down-hearted and unhappy” respectively. The item modified on the BFP scale was “Is depressed, blue” to “Is depressed, unhappy”. These scales were re-administered to different set of amputees and their caregivers to obtain it reliability in the Ghanaian context. The Cronbach alpha (Internal Consistency) for each subscale was analyzed. 66 Emotional Pain and Coping Strategies Table 3: Internal Consistencies of the Scales from a Pilot study of 10 Participants Scale M SD α Emotional Pain (OMMP) Mental Pain Scale 112.20 23.66 .87 Psychological Distress (DASS & BHS) Depression 14.30 4.24 .75 Anxiety 14.20 4.73 .78 Stress 15.20 4.08 .64 Hopelessness 35.20 4.61 .63 Coping Skills (ACSI) Cognitive/emotional debriefing 24.00 5.81 .69 Spiritual centered coping 15.60 5.03 .81 Collective coping 16.60 5.27 .79 Ritual-centered coping 7.90 2.96 .77 Social Support (MDSPSS) Perceived social support 56.80 14.78 .94 Personality (BFP) Extraversion 27.00 6.96 .81 Conscientiousness 28.60 7.09 .77 Neuroticism 22.70 6.15 .65 Openness 34.60 7.92 .82 Agreeableness 29.60 5.77 .63 67 Emotional Pain and Coping Strategies Data Collection Procedure This is the same as that of the data collection procedure for Study 1 with a few additions and subtractions. The measures used were first transcribed and piloted to find its reliability in the Ghanaian context. Data was then analyzed for the reliability coefficient of the measures. After this process, the measures were administered to find out the correlates of emotional pain among amputees and their caregivers in the Ghanaian context. Two hundred (200) participants were approached to part take in the study. Thirty (30) participants declined and twenty (20) uncompleted questionnaires were identified and withdrawn from the analysis. The questionnaires were administered by the researcher and the research assistants. Participants completed the questionnaires by themselves. Ethical Consideration and Approval This is the same as that of the ethical consideration and approval for Study 1 Data Analyses Strategy Data was analyzed using SPSS version 20.0 for windows. Descriptive statistics was computed for normality of data which included skewness and kurtosis, central tendency (means) and dispersion of scores (standard deviations). All inferential statistical analyses was computed at two-tailed and the level of significance was set at 95% (ρ<0.05). The inferential statistics was computed using the following statistical tools;  The Cronbach Alpha was computed to test the reliability of measures  Pearson Product Moment Correlation (Pearson r) was used to analyze the relationship between variables 68 Emotional Pain and Coping Strategies  The independent t test was used to analyze the differences between independent means of emotional pain among the amputees and their caregivers.  Multivariate analysis of variance (MANOVA) was used to analyze the differences in psychological distresses and coping strategies among amputees and their caregivers  Hierarchical multiple regressions was used to test the moderating role of personality and social support on psychological distresses and emotional pain. 69 Emotional Pain and Coping Strategies CHAPTER FOUR RESULTS Introduction This chapter reports findings from analyzed qualitative and quantitative data. This chapter is divided into four (4) sections. The first subsection discusses thematic analyses of qualitative data, descriptive statistics, hypotheses testing and summary of findings. Findings of the qualitative data are presented in themes. Findings of quantitative data are presented in tables and their interpretations provided. Data for the quantitative phase was analyzed using version 20.0 of the Statistical Package for Social Science (SPSS). The statistical tests used for analyzes were Pearson moment correlation coefficient (Pearson r), Independent t test (Independent t), Multiple analysis of variance (MANOVA) and Hierarchical regression analysis. Significant findings are summarized and the observed model presented. Thematic Analyses of Qualitative Data Emerging themes from the thematic analysis are discussed. Demographic Information Twenty participants were interviewed. Out of the twenty participants interviewed, ten (10) participants were amputees and ten (10) participants were caregivers of amputees. Majority of the amputees were males, specifically six (6) males and four (4) females whiles majority of the caregivers were females specifically eight (8) females and two (2) males. For both amputees and their caregivers, the age range for those interviewed was between eighteen (18) years old to fifty- eight (58) years old. The categories of amputation were lower leg, arm or foot. Caregivers were 70 Emotional Pain and Coping Strategies either parents, spouses, wards, siblings or other form of relatives. Amputees and their caregivers had variant forms of professions. A detailed description is given on table 4 below; Table 4: Demographic data of 20 participants (amputees and their caregivers) for the qualitative study Amputees Percentages Caregivers Percentages Gender Gender Males 60 Males 20 Females 40 Females 80 Age Age 18-23 10 18-23 10 24-28 20 24-28 30 29-33 10 29-33 30 34-38 30 38-43 20 39-43 10 53-58 10 44-48 10 49-53 10 Type of Amputation Relationship to Amputee Lower leg 70 Parent 10 Arm 10 Spouse 10 Foot 20 Ward 10 Sibling 30 Relative 40 Profession Profession Unemployed 30 Unemployed 20 Student 20 Student 30 Mechanic 30 Petty trader 30 Waitress 10 Health worker 20 Health worker 10 Field data, 2017 Emerging Themes Respondents were asked to respond to questions that related to emotional pain. Amputees’ opinion on how their current situation or loss causes them emotional pain and how they dealt 71 Emotional Pain and Coping Strategies with it was juxtaposed the caregivers’ perception of that phenomenon as well. Four overriding themes were identified. These umbrella themes are the antecedents of amputation and emotional pain; the experiences of emotional pain; A factor influencing the intensity of the experience of emotional pain; the experience of emotional pain and wellbeing and finally, the experience of emotional pain and coping strategies. Under the overriding themes, excerpts were grouped under major themes and sub-themes where applicable. Attempts were made to contrast the views of amputees versus that of the caregivers where possible and applicable. Antecedents of Amputation (Amputees) This described how participant’s amputation came about and how this related to their feelings of emotional pain. Butler et al. (1992), Cavanagh et al. (2006), Frierson et al. (1987) and Wain et al. (2004) discusses that amputation results into distinct negative emotions like anger, sadness, depression among others. Orbach et al. (2003b) opine that these negative emotions are the basic constituent of emotional pain. Therefore it can be argued that the antecedents of emotional pain were rooted in the amputation and its accompanying reactions which resulted into physical and emotional pain and breakup in relationships. Majority of the amputees aligned with either having their body part amputated due to a traumatic accident (n=6) or purely medical reasons (n=4). Their antecedent for emotional pain resulted from an unexpected traumatic occupational accident or as a possible anticipated method of managing a disease. It was noted that occupational accidents was a core factor for amputation. Most of the amputees (n=6) where either employees of major companies or managed a self-owned job. They never anticipated that working on a particular day like any other day would result into an accident that would lead to them being amputated. 72 Emotional Pain and Coping Strategies Some amputees (n=2) described their cause of amputation detached from the entire episode and the emotional experience therein. Bolger (1999) explains that these are covers the individuals uses so as not to experience the brokenness which is a core factor of the experience of emotional pain. According to an amputee: ‘… I was asked to go and do some repairs… at … Tarkwa, close to the mines. So … when we got there, I was working under the truck … when the axle fell on my leg... mistakenly,…when I came to this place, they tried their best to see whether they can do it without cutting the leg... and they couldn’t get it, so …they asked me … what do we do next..? … do I agree that …they should… cut the leg? And I said … they should go ahead’ (Amputee, Male, 42 years old, Mechanic) Other amputees (n=4), on the other hand, described vividly their experience and were emotional at the recall of this traumatic experience. Bolger (1999) explains that this is the experience of brokenness indicating the gravity of the emotional pain the individual is experiencing. An amputee explains that: ‘... it was at Roman hills, on top of the hill, the truck reversed from that hill. It was a container truck loaded fully with company goods which passed over my leg..instantly my leg detached from my body.’ (Amputee, Female, 30 years old, Waitress) Some patients (n=4) described what led to their amputation as disease-related. This made them feel bad about themselves and their ordeal because of their lack of control over the issue. Though these patients foresaw that amputation was the best method to deal with their predicament it did not make the acceptance phase an easy one. They struggled with the idea of being amputated (Frierson et al., 1987). An amputee disclosed that: 73 Emotional Pain and Coping Strategies ‘…I had pain in my left toe. I went to the hospital, the first time they gave me…pain killer…but it was getting worse … it was soo severe that my sister came and… took me to her home. We went to the hospital to see the doctor… At first they amputated the toe, just…the left toe..but the wound…didn’t heal…because I am a diabetic…my foot was getting black…they decided to amputate [the foot]…the blood flow to my left foot wasn’t adequate…I felt bad but there was no other solution…’ (Amputee, Female, 49 years old, Nurse) Antecedents of Emotional Pain (Caregivers) This theme described what preceded caregiver’s feelings of emotional pain. Caregivers’ antecedents of emotional pain were broadly captured under patients’ disability (n=4) and patients’ attitude towards them (n=6). Caregivers’ source of pain was that their child or colleague had become disabled. This sparked up strong emotions within the caregivers. The caregivers explain that these are incidents they did not bargain for. A caregiver described her experience below: ‘…his uncle is in Accra…He went there to learn a vocation… one Friday one of my children called me and informed me that my child has had an accident. At the hospital, they told me my child will become disabled. I became speechless all of a sudden.’ (Caregiver, Female, 56 years old, Mother, Petty trader) Another source of caregivers’ experience of strong emotions was the patient’s attitude towards them. Wain et al. (2004) explains that these are normal emotions and reactions on the part of the amputees and should be accommodated as such but these reactions and emotions have strong negative impact on the caregivers resulting in them feeling sad and sadness is a component of emotional pain (Bolger, 1999; Shneidman, 1998, 1999; Orbach et al., 2003b). A caregiver experience was that: 74 Emotional Pain and Coping Strategies ‘…I was not around when the incident occurred. I was at Obusai when my mother asked my siblings and [I] to come home because there was a problem. When we got there she was rolling on the ground, when you touch her she would shout [at you to] leave her. … it was very sad...In the beginning she was always angry when we go around her and would send us away.’ (Caregiver, Female, 24 years old, Sister, Student) The Experiences of Emotional Pain The emotions expressed in relation to loss are an interesting phenomenon. Bolger (1999), Shneidman (1999), Orbach et al. (2003a, b) and Wain et al. (2004) identified a wide range of negative emotions which spells out the emotional pain the individual is experiencing. It was realized from the data analyses that emotional pain displayed before amputation was a bit distinct from emotions expressed after amputation. Interestingly, in some instances, amputees and their caregivers expressed similar emotions whiles in other instances distinct emotions was identified. These emotions pertaining to amputees and their caregivers are contrasted under specific themes for a better appreciation of similar and unique feelings towards a single defined phenomenon. Affect before Amputation This theme probed into the emotions experienced before amputation. Thematic findings revealed that common emotions expressed before amputation were negative emotions which connotes emotional pain. Experiences of amputees will be contrasted with that of their caregivers. Some of the most common emotions that surfaced, in relation to amputees were broadly categorized into two which were anger and emotional pain leading to a behavioral display of noncompliance or refusal to let go off the primary organ. Caregivers aligned themselves to either feelings of sadness or empathic pain. 75 Emotional Pain and Coping Strategies Amputees affect before amputation. Amputees (n=7) revealed that letting go off their primary organ sparked up strong emotions like anger. This confirms Frierson et al.’s (1987) argument that amputees do struggle with the idea of being amputated. Wain et al. (2004) explains that the feeling of anger is the normal expression of the emotional torment the amputee is experiencing. Thus it does not deviate from the norm of emotions one is expected to display following loss. This emotion is an expression of the emotional pain they were feeling. Amputee explains that: ‘My heart started to burn up.. because when I asked the doctor the extent to which he was going to cut, he said he didn’t know unless he gets there first…So my parents said if that is the case then they won’t do it’ (Amputee, Female, 26 years old, Unemployed nurse) Other amputees (n=3) revealed that the pain of letting go off their primary organ made them defensive and to refuse amputation as the outstanding solution to their problem. However, a careful evaluation of the possible harm the damaged organ could cause made them agree to get rid of the damaged organ. An amputee captured this by saying: ‘I was really hurt. Initially, I didn’t even want to agree for them to cut my leg…’ (Amputee, Male, 35 years old, Unemployed) Caregivers affect before amputation. For some caregivers (n=6), on the other hand, they felt a deep sense of sadness at the disability of their relatives. The idea of the person being disabled was accompanied with an automatic evaluation of the person’s significance in their lives and the limit to the person’s capabilities now that he or she has become incapacitated. This is depicted in the quote below: ‘…indeed I was very sad when they told me my son will become disabled… When we got there he was on a bed, fuming with anger and holding a sharp object claiming he would hurt anyone who comes close to his bed though he was about 76 Emotional Pain and Coping Strategies to be taken to the theater. Indeed I was sad and worried.’ (Caregiver, Female, 56 years old, Mother, Petty trader) In addition to sadness, empathic pain (Borsook et al., 2009; Monin et al., 2009) was also another angle of emotional pain that emerged strongly (n=4). Caregivers explained that they shed tears within yet displayed a happy face outward just to give the patient hope for the future. It stands to reason that the caregivers denied their own emotional pain to cater for the pain of the amputee. According to a caregiver: ‘Yes we [herself and her family] went through pain…but we didn’t make it obvious to those around us...For me that was not the time to get hurt…I would be with her cracking jokes, we would be playing…yet I cried within…everybody did, even my daddy’ (Caregiver, Female, 24 years old, Sister, Student) Affect Following Loss This theme probed into the emotions experienced after amputation. When participants, amputees and their caregivers, were asked to describe their emotional pain after they had been amputated due to medical reasons or accidents, some participants pointed out that they were sad at the turn of events. Other participants expressed feelings of shock at their loss, hopelessness and loneliness, these emotions are constituents of emotional pain as captured by Bolger (1999) and Orbach (2003a, b). Interestingly, gratitude, which is not a feature of emotional pain, was a common emotion expressed by amputees and their caregivers. This emotion, gratitude, will be discussed under a different subtheme. 77 Emotional Pain and Coping Strategies Amputees affect following loss. Participants (n=8) were quick to describe how lonely they felt after amputation. This loneliness was alleviated when a third person lend a listening ear to their plight bringing to fore the importance of psychotherapy and caregivers in the experience of loss. An amputee explained that: ‘..sometimes I feel very lonely..and I have a lot of things running through my mind when am seated. So when I have someone to talk to, then I become a little bit relieved’ (Amputee, Male, 35 years old, Unemployed) Sadness is a common experience following loss. This emotion is captured as one’s feeling of brokenness in the experience of emotional pain. It was interesting to notice that whiles caregiver’s felt sad before amputation, amputees (n=10) on the other hand felt sad after amputation. The discrepancy between this could be that amputees before amputation try to find out meaning to their situation, thus they are at the denial stage and as such experience a deep surge of anger whiles caregivers identify what has happened and feel sad this should happen to someone they know. After the loss of a primary organ however, caregivers move from the face of sadness to identifying how they can help the amputee. Amputees on the other hand now come into the full blown realization that this (amputation) has indeed occurred. This is life itself. An amputee described that: ‘…when I was discharged, even descending the stairs and…seeing the sun, my eyes ached..you can’t imagine the tears..my eyes were piercing and I was really sad… I was filled with sorrow on my way home … It really hurt me. It’s really difficult when this thing happens to you…’ (Amputee, Female, 30 years old, Waitress) It was noted that some amputees (n=6) found it difficult to describe the emotional pain they felt. Participants used terms as ‘hurt’ to attempt to describe the emotions that surfaced following the loss of a primary body part. For instance, a participant disclosed that: 78 Emotional Pain and Coping Strategies ‘… when I think about it, what I realise is that, it hurts me…’ (Amputee, Male, 42 years old, Mechanic) Shock was a common emotion expressed by amputees (n=6) and their caregivers (n=5). For the amputees, the gravity of the shock resulted into tears (n=4) and others mutism (n=2). The behavioral display of tears reflects the grieving process. It connotes amputees coming to terms with their ordeal. For instance, a participant disclosed that: ‘…when I gained consciousness, I realized my leg was itching so I started scratching it…after scratching it I moved to scratch the left leg and my hand landed on the bed and I shouted ‘Jesus’!. Suddenly the doctors came around … I was even crying at that moment’ (Amputee, Female, 30 years old, Waitress) Another amputee explained that: ‘…I was hit by a car in reverse…when I tried getting up, I noticed my foot was detached from my leg…instantly, I couldn’t speak. I just starred at the detached foot. I couldn’t cry either. People kept asking me questions all I did was to stare at them…but in my mind I kept saying ‘Oh my God, what will I do now’ (Amputee, Female, 46 years old, petty trader) Hopelessness is a feature of emotional pain that is experienced when an individual cannot foresee any positive change in the negative experience or negative change in the self. This was a common emotion among amputees (n=8). ‘I was a student and…something pricked me just like when a needle pricks someone…I called my mum and she came…she sent me to a prayer camp… the case started getting worse. It got to a point I couldn’t go anywhere…one day my brother …sent me to the hospital to see the doctor… the doctor checked, he said with the rate of the infection, there was no option than to amputate...at that moment when he said it, I was really shocked. That day, I really prayed and then my brother encouraged me and told me that in any thing, he will support me…I was very sad. I was hit by the situation. I won’t be able to do anything. I mean I was very confused and couldn’t even eat anything I was given’ (Amputee, Female, 24 years old, School drop-out) 79 Emotional Pain and Coping Strategies Caregivers affect following loss. Similarly, some caregivers (n=6) also found it difficult to define the emotional pain they were experiencing. Thus, just as the amputees, they used terms as ‘hurt’ to define the emotional pain they felt. Caregivers felt they could not dwell on their own hurtful feelings because they needed to be strong for the amputee. For example, a caregiver disclosed that: ‘… I should say I was really hurt though. But it has happened … Even if it hurts you, you cannot say you will abandon her. You just have to be strong’ (Caregiver, Female, 39 years old, Aunt, Petty Trader) Caregivers’ feeling of shock (n=5), on other hand, resulted into numbness in some part of the body. The caregivers’ vivid description of the emotions they felt after amputation displayed how they were affected by the amputation though they are not the direct recipient of the action or sufferers. For example, a caregiver explained that: ‘…when I saw it... at once my entire heart ached…I didn’t even know where I was. Both of my hands stopped working…it became stiff… I didn’t notice I had hands that I could use to hold something, so little by little they massaged it with iced block for while…’ (Caregiver, Female, 24 years old, Wife, Petty Trader) Caregivers (n=6), after assessing the gravity of the implication of the amputation also lost hope. Compounded with the responsibility of taking care of an amputee did not make matters any easier. According to a caregiver, for instance: ‘...it got to a point that I really lost hope in everything’ (Caregiver, Female, 39 years old, Aunt, Petty Trader) Experience of Gratitude Gratitude was a common emotion expressed by both amputees (n=3) and their caregivers (n=7). This was an interesting twist to events. The concept of emotional pain is that people experience a build-up of negative emotions following a traumatic event or loss. The finding revealed that, 80 Emotional Pain and Coping Strategies people are sometimes grateful even following loss when the magnitude of the loss is compared to the worth of life in relation to death. Amputees still found reasons to express positive emotions despite their predicament. It was found that their positive emotion was as a result of their religious beliefs. Religious teachings gave them faith that the body was but a perishable being that would not embark on the eternity journey with them. For example an amputee explained his experience as: ‘…some were crying…and I told them that… we won’t take this body anywhere… and I asked them ‘when someone dies, where is the body placed?’ they said in the ground.. then why are they crying? If the thing had fallen on my head or even my chest, I won’t have been able to talk’ (Amputee, Male, 42 years old, Mechanic) Caregivers’ positive emotion was embedded in their spiritual and religious beliefs as well. The idea of showing appreciation to an external being for the gift of life connotes the caregivers believe in a greater being who is the controller of events in our lives. This tends to cement the idea that Ghanaians are religious (Pobee, 1992). Religion shapes the lived experiences of people. For instance, a caregiver explained that: ‘… for my sister … to say the truth, she sometimes got angry but I tell her it is just a matter of patience, because it is not everyone who is able to survive such a situation. Some even die out of it… so we ought to thank God that, although she is this way, God has been able to save her and she is still alive and with us here. We only give thanks to God.’ (Caregiver, Female, 39 years old, Aunt, Petty Trader) A Factor Influencing the Intensity of the Experience Emotional Pain This theme probed into factors that intensified participants’ feelings of emotional pain. Literature has established that several factors can affect one’s experience of emotional pain. Butler et al. (1992) and Frierson et al. (1987) explain that factors that determine how the amputee will 81 Emotional Pain and Coping Strategies psychologically process the traumatic phenomenon include patients’ age, sex, type of amputation, premorbid personality among others. A totally unique concept surfaced. It was noted from the findings that the method of breaking the news, as to the necessity for amputation for the individual, before or after amputation was an important factor that either elevated or alleviated the gravity of emotional pain for both caregivers and amputees. News Breaking Method Some amputees (n=4) exclaimed their displeasure about not being informed of the need for amputation prior to the operation. For these participants, they felt psychologically unprepared for the procedure. It seemed that the amputees felt exempted from major decision making pertaining to their bodies and lives. These feelings led to refusal of the procedure. For instance an amputee explained that: ‘…they didn’t tell me that..for instance maybe on this day I will be operated on out of the blue I heard I am to be operated on … They didn’t tell me anything.. so just then I told them that for this one I wasn’t going to do because if you are going to do such a thing I have to be psychologically educated about it before. … And where were they going to cut to? They just said they would have to get there first.. So my parents said if that is the case then they won’t do it so they brought me home’ (Amputee, Female, 26 years old, Unemployed nurse) Similar experience was shared by caregivers. Caregivers (n=6) explained that doctors not preparing them for the amputation process made them angry to the extent that they refused to give their consent for the amputation to be carried out. For instance a caregiver disclosed that: ‘…As the days pass his leg began to rot. The doctor came in one day and told us point blank that he was going to cut off his leg. I was very angry and could not allow them to do that to my child…’ (Caregiver, Female, 56 years old, Mother, Petty trader) 82 Emotional Pain and Coping Strategies However, active deception can cause hope in some amputees. An amputee disclosed that though she was deceived after the amputation that was what gave her hope. Thus though concealing the truth from a patient and deliberately giving misleading information may be viewed in the negative light culturally and religiously, it however, made the amputees hopeful. The amputee explained that: ‘…I had collapsed so when I gained consciousness, I realized my leg was itching so I started scratching it… after scratching it I moved to scratch the left leg and my hand landed on the bed and I shouted ‘Jesus’!. Suddenly the doctors came around and asked, ‘Connie why?’ and then I asked, ‘what has happened to me? Where is one of my legs’? … they explained to me that I was knocked by a car and one of my legs detached from my body but they’ve placed the leg in a fridge. In fact, if it was not for the faith I had at the moment… I would have died on that day…’ (Amputee, Female, 30 years old, Waitress) The Experience of Emotional Pain and Wellbeing This theme explored how emotional pain impacted on one’s wellbeing. Thematic analyses revealed that the impact of the loss on patient’s wellbeing resulted in emotional pain as participants’ recounted the implication of the unexpected event on their lives. This experience was evaluated for both amputees and their caregivers. Some of the potential impact on psychological wellbeing included a change in vocation and phantom limb sensation for amputees, stress for both amputees and their caregivers and fear and economic hardship with its gravity being felt by the caregivers mainly. Amputees’ Experience of Emotional Pain and Wellbeing Amputees (n=6) recounted that the implication of the traumatic event was for them to change their vocation. This resulted into a state of confusion as to where to start life for them. Changing a vocation with complete unpreparedness could result into serious psychological distress. As 83 Emotional Pain and Coping Strategies explained above, this resulted into a state of confusion for some amputees. Others (n=2) disclosed that for them death would have been a better option as captured below. ‘I was thinking that, now I won’t be able to come and work like I used to do..and also I have a wife and kids...so I was really confused in my mind and I thought that if that would be the case, then they better leave my leg the way it is because when I even die it would be better’ (Amputee, Male, 35 years old, Unemployed) The concept of phantom limb sensation is the feeling of the presence of the primary organ in the absence of the primary organ. Murrray et al. (2002) reported that some amputees experience phantom limb sensation after amputation. A constant feeling that one’s primary organ is still present when evidently the primary organ is no more, is psychologically traumatizing. It can disrupt one’s daily function because then the individual in question will always have to remind himself or herself that his or her primary organ is no more. Some amputees (n=5) reported this experience in their narratives. ‘… Sometimes my leg can itch for a while but when I try to scratch it, I realize that my leg is no longer there’ (Amputee, Female, 26 years old, Unemployed nurse) It was identified that both amputees (n=8) and their caregivers (n=9) feel stressed out when they recounted their daily experiences. The daily experience of amputees revealed that wearing artificial body part had limitations on one’s choice of outfit and comfort was compromised as well. This is an adjustment and adaptation phase that can be stressful for the individual without the right kind of support. For instance an amputee disclosed that; ‘Sometimes when I wake up, I just assume that I could just get up from bed and start moving but I need to take my leg [prosthetic leg] and wear it. After wearing it, I feel pains on taking the first few steps…every morning when I get up and wear it, I feel pain upon using it to take steps before it becomes normal. Sometimes too, it feels as though it wants to fall off… when you wear skirt like this… it can remove … you don’t feel [comfortable]… even when you are going to 84 Emotional Pain and Coping Strategies bath you have to take it along to the bathroom and when you are bathing you need remove it’ (Amputee, Female, 26 years old, Unemployed nurse) Caregivers’ Experience of Emotional Pain and Wellbeing Likewise, caregivers also described the stress they go through with some having to abandon their work to stay beside the amputee within the interim. Staying with the amputee was accompanied with responsibilities aside from one having to abandon his or her job to stay with the amputee. This is a shift from one’s way of life to make life comfortable for another individual. The adjustment process can be equally stressful for the caregiver as well. For example a caregiver explained that; ‘… I stayed with him here because there was no one who could come and stay here…I had to gather courage to come and stay here. I sleep here…I get up early to clean him up and cook for him…I stay by his side so I help him with things he needs until it is time for us to leave them…I have not been to work ever since he came here…’ (Caregiver, Female, 24 years old, Wife, Petty Trader) Thematic analyses revealed that amputation led to economic hardship which greatly impacted the lives of the caregivers of the amputees (n=7). The amputee was shielded from feeling the full impact of the economic hardship because the caregivers viewed the amputee, at that point in time, as vulnerable and in need of proper care or food in order to recover from his or her ordeal. This is the denial of the self in order to please the other. For instance a caregiver’s narration revealed that: ‘…things really got difficult…there were days we chewed just roasted corn and groundnuts and we gave her [amputee] proper food to eat… there were days we chewed in front of her’ (Caregiver, Female, 39 years old, Aunt, Petty Trader) 85 Emotional Pain and Coping Strategies Caregivers (n=4) revealed that they could not comprehend why this (a close relative being amputated) should happen to them. This opened a new window for fear. Fear of the unknown. For example, according to a caregiver: ‘…I am scared…because I have never seen something like this and it has happened to me so sometimes I get scared…’ (Caregiver, Female, 24 years old, Wife, Petty Trader) The Experience of Emotional Pain and Coping Strategies The coping mechanisms adopted in the experience of emotional pain was explored. Thematic analyses revealed that amputees used social distancing, social reference and social support as a means of coping with their emotional pain whilst caregivers just encouraged themselves as a means of dealing with their ordeal. However, a common means of dealing with the emotional pain and their predicament was religious coping that is the belief in the power of an extraordinary being and prayers. This was to be expected because Pobee (1992) has disclosed that Ghanaians are highly religious and this study was conducted in the Ghanaian context. Amputees’ Experience of Emotional Pain and Coping Strategies Amputees (n=6) felt the need to create a gap between themselves and the society. According to Orbach et al. (2003b), social distancing is an exhibition of emotional pain. Amputees disclosed that though creating a gap between themselves and society made them unhappy, they still felt the need to do it. They just did not want to go anywhere. This was a different way of life compared to their premorbid way of life. It was quite unfulfilling for the amputees. For instance an amputee explained that: ‘… when I was at home… I could go out… but since I went back, I am unable to at all..for you to see me outside even is difficult.. I don’t want to go anywhere ...so 86 Emotional Pain and Coping Strategies personally I wasn’t really that happy’ (Amputee, Male, 35 years old, Unemployed) Amputees (n=3) reported that comparing their situation to others assuaged the gravity of their ordeal hence lessening their experience of their emotional pain. The comparison was not done in a way to make the other person feel bad but to make the amputee grateful that his or her predicament was not worse off. For example, a rather positive amputee explained that: ‘…when I see other people, some with both legs cut off, some have theirs cut at other places, then my own … becomes small’ (Amputee, Male, 42 years old, Mechanic) Amputees (n=10) reported relying on families and significant others for strength to deal with their emotional pain. Thus, though the amputees acknowledged their limitations now that they are handicapped, the love and support of significant others in their lives encouraged them to give their best to life regardless of their situation. ‘… if you are going through such a situation and you don’t get the love of your family or something like that, it may cause you to think about it a lot and you may also end up dying... I sometimes cry over the fact that now that I had completed school, that I’m supposed to be working and this has happened to me.. but I get advice from my parents and my church members also come around to advise me. That is what has encouraged me to continue [living]’ (Amputee, Female, 26 years old, Unemployed nurse) Amputees (n=5) reported the use of prayers and belief in God as a coping strategy they employed to deal with their emotional pain. In some cases, it was people in the larger community who encouraged the amputees to rely on God. This depicts that, at that moment, the amputees were still in their dark shells trying to find meaning to their situation. Individual’s assist in this process by redirecting their attention to a supreme being they believe in. For example, an amputee revealed that: 87 Emotional Pain and Coping Strategies ‘They told me to leave everything to God and that its more important to have life and strength..so I should leave all to God and just pray that things will get better so I listened’ (Amputee, Female, 30 years old, Waitress) Caregivers’ Experience of Emotional Pain and Coping Strategies Equally, caregivers (n=8) depended on God as well. The interesting twist was that whiles amputees depended on God because people in the community told them to, caregivers naturally, turned to God for provision of their vital needs and aid. For example a caregiver unveiled that: ‘God says in every situation we should call on him and He will answer. It gets to a point that I tell God we have nothing to even eat, or to even give to the sick person, but before the next day God is able to provide...’ (Caregiver, Female, 39 years, Aunt, Petty Trader) The reliance on a supreme being also made some caregivers hopeful. ‘[when I think of it] the only thing I say is God is alive once he did not die and I am also not dead God will bless us in the future. Maybe, help will come from somewhere so that is what I use to encourage myself …that God will lift his hands in my life’ (Caregiver, Female, 24 years old, Wife, Petty Trader) Caregivers (n=10) reported that aside the belief in God as a means of coping with their emotional pain, they had to encourage themselves as well. Caregivers felt the need to draw closer to the amputees and be strong as well, shielding their (caregivers) emotional pain in the process. For instance a caregiver explained that: ‘…when it happens that way… you just have to encourage yourself…and focus on helping the person who needs help the most’ (Caregiver, Female, 39 years old, Aunt, Petty Trader) Summary of Qualitative Findings: The thematic analysis revealed that while the emotional pain of amputees was rooted in their amputation, that of their caregivers was rooted in the patient’s disability and attitude. The 88 Emotional Pain and Coping Strategies experiences of emotional pain before amputation for amputees included anger and pain whiles that of their caregivers included sadness and empathic pain that led to denial of self. The experiences of emotional pain following loss for amputees included loneliness and sadness whiles amputees and their caregivers alike experienced hurt, shock, hopelessness and gratitude. Analysis revealed that an outstanding factor that influenced the experience of emotional pain for amputees and their caregivers was the news breaking method that is how health professionals broke the news about the necessity for amputation to amputees and their caregivers. Thematic analysis further revealed that the potential impact of the traumatic situation on one’s wellbeing included a change in vocation and constant phantom limb sensation for amputees, stress for amputees and their caregivers, economic hardship and fear for caregivers only. Finally, analysis revealed that coping strategies adopted by amputees in the experience of emotional pain included social withdrawal/distancing, social reference and social support whiles their caregivers made use of self-encouragement. Amputees and their caregivers both employed religious coping in the experience of emotional pain. 89 Emotional Pain and Coping Strategies Statistical Analysis of Quantitative Data Descriptive Statistics Preliminary analysis of data was done before hypothesis testing. The summary of the means and standard deviations of the measures used for data collection was analyzed. The reliability of measures and the normality of data were also checked. This is presented in Table 5 below; Table 5: Summary of the means, standard deviations, internal consistencies (Cronbach’s Alpha) and Normality of the study variables Variable Mean SD α Skewness Kurtosis Emotional Pain (OMMP) 131.74 22.91 .88 -.02 -.05 Psychological Distress Depression 17.10 4.54 .71 .04 -.78 Anxiety 16.96 4.50 .70 .00 -.69 Stress 16.28 3.81 .73 -.08 .00 Hopelessness 31.04 3.35 .71 -.17 -.20 Coping Skills (ACSI) Cognitive/emotional 32.04 5.39 .70 -.54 -.21 Debriefing (CED) Spiritual centered 20.94 3.96 .72 .14 .30 Coping (SC) Collective coping 24.46 3.75 .66 -.05 -.77 (CC) Ritual-centered 7.42 2.45 .76 .01 -.92 Coping (RC) Social Support (MDSPSS) 41.76 11.49 .79 .52 .50 Personality (BFP) Extraversion 24.79 6.75 .72 .04 -.46 Conscientiousness 28.82 6.24 .76 -.03 .11 Neuroticism 23.70 6.10 .75 -.18 -.98 Openness 30.16 6.14 .70 -.31 .25 Agreeableness 27.85 6.45 .73 .41 -.45 90 Emotional Pain and Coping Strategies According to Doane and Seward (2011) scores are normally distributed when they fall within the acceptable range of +/- 1. Table 5 above shows that the skewness and kurtosis of scores fall within +/- 1, indicating that the scores are normally distributed and as such can be used for analysis. Factor Analysis The various scales used in measuring the variables were validated to ensure that they indeed measure what they purport to measure in the Ghanaian context. An exploratory factor analysis was used to test how modified and unmodified items on the various scales will measure what they are supposed to measure in the Ghanaian context. The results for the various scales are presented below. Emotional Pain/ Mental Pain Scale (MPS) A Principal Component Analysis (PCA) was conducted on 44-items of the Emotional Pain Scale. The 44 items on the scale were correlated and a minimum of .30 correlations was observed. The Kaiser-Meyer-Oklin measure of sampling adequacy was .605, which is acceptable according to Field (2009). Bartlett’s test of sphericity was statistically significant (P=.000). An initial analysis was run to obtain eigen values for each component of the data. The initial eigenvalues which are for a principal component analysis had communalities of 1 and accounted for a total of 76.11% variance. The Principal Component Analysis (PCA) showed that 13 components explained 17.9%, 8.3%, 7.3%, 7.0%, 6.5%, 4.8%, 4.6%, 3.9%, 3.5%, 3.3%, 3.1%, 2.8% and 2.5% respectively. Results are presented on Table 6 below. 91 Emotional Pain and Coping Strategies Table 6: Factor Loadings for Exploratory Factor Analysis with Direct Oblimin Rotation of Mental Pain (Emotional Pain) items Component 1 2 3 4 5 6 7 MPS1 .566 MPS2 -.419 MPS3 .457 MPS4 .507 MPS5 .482 MPS6 .427 MPS7 .580 MPS8 .388 MPS9 .415 MPS10 .411 MPS11 .527 MPS12 .496 MPS13 .415 MPS14 .473 MPS15 .408 MPS16 .482 MPS17 .370 MPS18 .492 MPS19 .471 MPS20 .520 MPS21 .427 MPS22 .389 MPS23 .454 MPS24 .479 MPS25 .456 MPS26 .524 MPS27 .491 MPS28 -.516 MPS29 .466 MPS30 -.569 MPS31 .460 MPS32 .471 MPS33 -.489 MPS34 .458 MPS35 .516 MPS36 .528 MPS37 .581 MPS38 .603 MPS39 .495 MPS40 -.376 MPS41 .358 MPS42 .519 MPS43 .578 MPS44 .541 Extraction Method: Principal Component Analysis. Rotation Method: Oblimin with Kaiser Normalization. 92 Emotional Pain and Coping Strategies Depression Anxiety Stress Scale (DASS) A Principal Component Analysis (PCA) was conducted on 21-items of the DASS scale. The 21items on the scale were correlated and a minimum of .30 correlations was observed. The Kaiser-Meyer-Oklin measure of sampling adequacy was .625, which is acceptable according to Field (2009). Bartlett’s test of sphericity was statistically significant (P=.000). An initial analysis was run to obtain eigen values for each component of the data. The initial eigenvalues which are for a principal component analysis had communalities of 1 and accounted for a total of 61.85% variance. The Principal Component Analysis (PCA) showed that 7 components explained 20.38%, 8.9%, 7.7%, 7.3%, 6.7%, 5.7% and 4.8% respectively. Results are presented on Table 7 below. 93 Emotional Pain and Coping Strategies Table 7: Factor Loadings for Exploratory Factor Analysis with Direct Oblimin Rotation of DASS items Component 1 2 3 4 5 6 DASS1 .628 DASS2 .606 DASS3 .416 DASS4 .593 DASS5 .672 DASS6 .623 DASS7 .443 DASS8 .483 DASS9 .506 DASS10 .491 DASS11 .530 DASS12 .477 DASS13 .527 DASS14 .481 DASS15 .438 DASS16 .508 DASS17 .389 DASS18 .558 DASS19 .613 DASS20 .477 DASS21 .327 Extraction Method: Principal Component Analysis. Rotation Method: Oblimin with Kaiser Normalization. Beck’s Hopelessness Scale (BHS) A Principal Component Analysis (PCA) was conducted on 20-items of the Beck’s Hopelessness Scale. The 20 items on the scale were correlated and a minimum of .40 correlations was observed. The Kaiser-Meyer-Oklin measure of sampling adequacy was .736, which is acceptable according to Field (2009). Bartlett’s test of sphericity was statistically significant (p=.000). An initial analysis was run to obtain eigen values for each component of the data. The initial 94 Emotional Pain and Coping Strategies eigenvalues which are for a principal component analysis had communalities of 1 and accounted for a total of 66.51% variance. The Principal Component Analysis (PCA) showed that 6 components explained 29.2%, 11.0%, 8.0%, 6.4%, 6.1% and 5.5% respectively. Results are presented on Table 8 below. Table 8: Factor Loadings for Exploratory Factor Analysis with Direct Oblimin Rotation of BHS items Component 1 2 3 4 5 6 BHS1 -.463 BHS2 .764 BHS3 .576 BHS4 -.749 BHS5 .407 BHS6 .760 BHS7 .720 BHS8 .639 BHS9 .454 BHS10 -.873 BHS11 .694 BHS12 .708 BHS13 .447 BHS14 .526 BHS15 .725 BHS16 .601 BHS17 .501 BHS18 .644 BHS19 .488 BHS20 .420 Extraction Method: Principal Component Analysis. Rotation Method: Oblimin with Kaiser Normalization. 95 Emotional Pain and Coping Strategies Africultural Coping Systems Inventory (ACSI) A Principal Component Analysis (PCA) was conducted on 30-items of the Africultural Coping Systems Inventory. The 30 items on the scale were correlated and a minimum of .30 correlations was observed. The Kaiser-Meyer-Oklin measure of sampling adequacy was .664, which is acceptable according to Field (2009). Bartlett’s test of sphericity was statistically significant (p=.000). An initial analysis was run to obtain eigen values for each component of the data. The initial eigenvalues which are for a principal component analysis had communalities of 1 and accounted for a total of 63.93% variance. The Principal Component Analysis (PCA) showed that 10 components explained 17.1%, 8.1%, 6.5%, 5.5%, 5.3%, 4.9%, 4.6%, 4.2%, 3.9% and 3.4% respectively. Results are presented on Table 9 below. 96 Emotional Pain and Coping Strategies Table 9: Factor Loadings for Exploratory Factor Analysis with Direct Oblimin Rotation of ACSI items Component 1 2 3 4 5 6 7 ACSI 1 .412 ACSI 2 .605 ACSI 3 .426 ACSI 4 .453 ACSI 5 .455 ACSI 6 .372 ACSI 7 .375 ACSI 8 .505 ACSI 9 .634 ACSI 10 .412 ACSI 11 .468 ACSI 12 .465 ACSI 13 .428 ACSI 14 .512 ACSI 15 .651 ACSI 16 .534 ACSI 17 .615 ACSI 18 .531 ACSI 19 .482 ACSI 20 .663 ACSI 21 .612 ACSI 22 .579 ACSI 23 -.427 ACSI 24 .550 ACSI 25 .350 ACSI 26 .362 ACSI 27 .515 ACSI 28 .484 ACSI 29 .537 ACSI30 -.572 Extraction Method: Principal Component Analysis. Rotation Method: Oblimin with Kaiser Normalization. 97 Emotional Pain and Coping Strategies Multidimensional Scale of Perceived Social Support (MDSPSS) A Principal Component Analysis (PCA) was conducted on 12-items of the Multidimensional Scale of Perceived Social Support. The 12 items on the scale were correlated and a minimum of .40 correlations was observed. The Kaiser-Meyer-Oklin measure of sampling adequacy was .676, which is acceptable according to Field (2009). Bartlett’s test of sphericity was statistically significant (p=.000). An initial analysis was run to obtain eigen values for each component of the data. The initial eigenvalues which are for a principal component analysis had communalities of 1 and accounted for a total of 73.71% variance. The Principal Component Analysis (PCA) showed that 4 components explained 32.3%, 19.9%, 12.4% and 9.0% respectively. Results are presented on Table 10 below. Table 10: Factor Loadings for Exploratory Factor Analysis with Direct Oblimin Rotation of MSPSS items Component 1 2 3 MSPSS1 .727 MSPSS2 .836 MSPSS3 .571 MSPSS4 .801 MSPSS5 .805 MSPSS6 .708 MSPSS7 .643 MSPSS8 .594 MSPSS9 .586 MSPSS10 .654 MSPSS11 .712 MSPSS12 .470 Extraction Method: Principal Component Analysis. Rotation Method: Oblimin with Kaiser Normalization. 98 Emotional Pain and Coping Strategies The Big Five Personality Scale (BFPS) A Principal Component Analysis (PCA) was conducted on 12-items of the Big Five Personality Scale. The 44 items on the scale were correlated and a minimum of .30 correlations was observed. The Kaiser-Meyer-Oklin measure of sampling adequacy was .678, which is acceptable according to Field (2009). Bartlett’s test of sphericity was statistically significant (p=.000). An initial analysis was run to obtain eigen values for each component of the data. The initial eigenvalues which are for a principal component analysis had communalities of 1 and accounted for a total of 70.9% variance. The Principal Component Analysis (PCA) showed that 13 components explained 14.9%, 14.7%, 7.2%, 5.1%, 4.3%, 3.9%, 3.6%, 3.3%, 3.2%, 2.8%, 2.6%, 2.5% and 2.3% respectively. Results are presented on Table 11 below. 99 Emotional Pain and Coping Strategies Table 11: Factor Loadings for Exploratory Factor Analysis with Direct Oblimin Rotation of BFPS items Component 1 2 3 4 5 6 7 BFPS 1 .394 BFPS 2 -.495 BFPS 3 .616 BFPS 4 -.371 BFPS 5 .649 BFPS 6 .392 BFPS 7 .494 BFPS 8 -.531 BFPS 9 .488 BFPS 10 .704 BFPS 11 .494 BFPS 12 .405 BFPS 13 .665 BFPS 14 .595 BFPS 15 .756 BFPS 16 .747 BFPS 17 .634 BFPS 18 .498 BFPS 19 .407 BFPS 20 .689 BFPS 21 .408 BFPS 22 .581 BFPS 23 .654 BFPS 24 -.459 BFPS 25 .660 BFPS 26 .487 BFPS 27 .439 BFPS 28 .437 BFPS 29 .393 BFPS 30 .509 BFPS 31 .527 BFPS 32 .529 BFPS 33 .437 BFPS 34 .422 BFPS 35 .482 BFPS 36 .610 BFPS 37 .612 BFPS 38 .490 BFPS 39 -.607 BFPS 40 .457 BFPS 41 .406 BFPS 42 .390 BFPS 43 .452 BFPS 44 .480 Extraction Method: Principal Component Analysis. Rotation Method: Oblimin with Kaiser Normalization. 100 Emotional Pain and Coping Strategies Hypotheses Testing Six hypotheses were tested using the Pearson Product Moment Correlation Coefficient (Pearson r), Independent t test (Independent t), Multivariate Analysis of Variance (Manova) and Hierachical Multiple Regression. Results are presented below. Hypothesis 1 Psychological distresses (i.e., depression, anxiety, stress and hopelessness) will be significantly related to emotional pain. This hypothesis seeks to investigate if indeed there is any form of relationship between the experience of these negative emotional states (depression, anxiety, stress and hopelessness) and emotional pain. The Pearson Product-Moment Correlation Coefficient was used. This is because the hypothesis seeks to determine the relationship between psychological distresses (as measured by the DASS scale and Beck’s Hopelessness scale) and emotional pain (as measured by the OMMP Scale). The results are demonstrated in Table 12 below; 101 Emotional Pain and Coping Strategies Table 12: Correlation Matrix of Emotional Pain, Depression, Anxiety, Stress and Hopelessness. VAR 1 2 3 4 5 1. EP - 2. DEP .16* - 3. ANX .20* .58 ** - 4. STR .17* .57 ** .47 ** - 5. HOP -.08 .18 * .12 .07 - **Correlation is significant at .01 alpha level, *Correlation is significant at .05 alpha level. 1. EP= Emotional Pain, 2. DEP= Depression, 3. ANX=Anxiety, 4. STR=Stress, 5. HOP=Hopelessness. Preliminary analyses were performed to ensure no violation of the assumptions of normality, linearity and homoscedasticity. Analysis revealed that there was a significant positive relationship between the depression dimension of psychological distress and emotional pain [r = .16, n = 150, ρ = .045], with high levels of depression associated with higher levels of emotional pain. Furthermore, it was observed that there was a significant positive relationship between anxiety and emotional pain [r = .20, n = 150, ρ = .014], with high levels of anxiety associated with higher levels of emotional pain. It was again observed that there was a significant positive relationship between stress and emotional pain [r = .17, n = 150, ρ = .042], with high levels of stress associated with higher levels of emotional pain. Finally, there was a negative correlation between the two variables (hopelessness and emotional pain) though this correlation was not significant, [r = –.08, n = 150, p = .324], with 102 Emotional Pain and Coping Strategies high levels of hopelessness associated with low levels of emotional pain. Therefore, ‘psychological distresses (i.e., depression, anxiety, stress and hopelessness) will be significantly related to emotional pain’ was partially supported. Hypothesis 2 There will be a significant difference in the experience of emotional pain of amputees and their caregivers. This hypothesis seeks to examine if amputees and their caregivers differ in their experience of emotional pain. An independent-samples t-test was conducted. This is because the hypothesis sought to compare the emotional pain scores for caregivers and amputees. The results are demonstrated in Table 13 below: Table 13: A summary of the Means, SD and t test of the scores of caregivers and amputees on emotional pain Participants N Mean SD df t p Effect Size Caregivers 75 127.72 20.24 148 -2.18 .031* .049 Amputees 75 135.76 24.79 *Significant at .05 alpha level 103 Emotional Pain and Coping Strategies There was a significant difference in scores for caregivers (M = 127.72, SD = 20.24) and amputees [M = 135.76, SD = 24.79; t (148) = -2.18, p = .031]. The magnitude of the difference in the means was small (eta squared = .049). This hypothesis was supported. Hypothesis 3 Psychological distresses of amputees will be significantly different from that of their caregivers. This hypothesis sought to examine if any difference existed between amputees’ experience of psychological distresses and their caregivers’ experience of psychological distresses. A Multivariate analysis of variance (MANOVA) was used to test this hypothesis with psychological distresses being the dependent variable and caregivers and amputees being the independent variable. The results are summarized in Table 14 below: Table 14: A summary of the Means, SD and F test of the scores of caregivers and amputees on psychological distresses Mean Scores Caregivers Amputees df F p Depression 32.88 33.36 148 .16 .688 Anxiety 33.95 32.19 148 1.89 .171 Stress 32.75 32.40 148 .08 .782 Hopelessness 29.19 29.08 148 .13 .717 *Significant at .05 alpha level 104 Emotional Pain and Coping Strategies A one-way between-groups multivariate analysis of variance was performed to investigate groups’ (amputees and their caregivers) differences in psychological distresses. Four dependent variables were used: depression, anxiety, stress and hopelessness. The independent variable was the group. The assumptions were tested for normality, linearity, univariate and multivariate outliers, homogeneity of variance-covariance matrices, and multicollinearity, with no serious violations noted. There was no statistically significant difference between amputees and their caregivers on the combined dependent variables [F(4,145) = 1.09, p = .375; Wilks’ Lambda = .97; partial eta squared = .03]. When the results for the dependent variables were considered separately, the difference between the groups (amputees and their caregivers) on the psychological distresses did not reach statistical significance, depression at the significant level of .05, showed an [F(1,148) = .16, p = .688, partial eta squared = .001]. An inspection of the mean scores indicated that there was no difference in the levels of depression between amputees (M = 33.36, SD = 7.73) and their caregivers (M = 32.88, SD = 6.88). Furthermore, anxiety at the significant level of .05, showed an [F(1,148) = 1.89, p = .171, partial eta squared = .013]. An inspection of the mean scores indicated that there was no difference in the levels of anxiety between amputees (M = 32.19, SD = 7.54) and their caregivers (M = 33.95, SD = 8.12). Stress at the significant level of .05, showed an [F(1,148) = .08, p = .782, partial eta squared = .001]. An inspection of the mean scores indicated that there was no difference in the levels of stress between amputees (M = 32.40, SD = 7.29) and their caregivers (M = 32.75, SD = 8.00). 105 Emotional Pain and Coping Strategies Hopelessness at the significant level of .05, showed an [F (1,148) = .13, p = .717, partial eta squared = .001]. An inspection of the mean scores indicated that there was no difference in the levels of hopelessness between amputees (M = 29.08, SD = 1.77) and their caregivers (M = 29.19, SD = 1.83). Thus this hypothesis was not supported. Bonferroni adjustment was not done because the p values for the variables were not significant. Hypothesis 4 There will be a significant difference in the Africultural coping strategies employed by the two groups (amputees and their caregivers). Given the cultural context of Ghana, this hypothesis sought to examine if differences may exist in the coping strategies adopted by amputees and their caregivers in the experience of emotional pain. This hypothesis was analyzed using the MANOVA with Africultural coping strategies being the dependent variable and amputees and their caregivers being the independent variable. The results are summarized in the table below: 106 Emotional Pain and Coping Strategies Table 15: A Summary of the Means, SD and F test of the scores of caregivers and amputees on their coping strategies Mean Scores Caregivers Amputees df F p * CED 31.08 33.01 148 4.94 .028 SC 20.64 21.25 148 .90 .345 * CC 23.83 25.11 148 4.46 .036 RC 6.93 6.89 148 0.01 .913 *Significant at .05 alpha level. 1. CED = Cognitive/Emotional Debriefing, 2. SC = Spiritual-Centered Coping, 3. CC = Collective Coping, 4. RC = Ritual-Centered Coping. A one-way between-groups multivariate analysis of variance was performed to investigate group (amputees and their caregivers) differences in coping strategies. Four dependent variables were used: cognitive/emotional debriefing, spiritual-centered coping, collective coping and ritual- centered coping. The independent variable was the groups. Preliminary assumption testing was conducted to check for normality, linearity, univariate and multivariate outliers, homogeneity of variance-covariance matrices and multicollinearity, with no serious violations noted. There was no statistically significant difference between groups (amputees and their caregivers) on the combined dependent variables [F(4, 145) = 1.40, p = .237; Wilks’ Lambda = .96, partial eta squared = .037] using a Bonferroni adjustment of .0125 (.05÷4) that is four variables divided by the significance level of .05. This new significance level was used to test the significance of the dependent variables separately. 107 Emotional Pain and Coping Strategies When the results for the dependent variables were considered separately, the difference between the groups (amputees and their caregivers) on the coping strategies did not reach statistical significance with cognitive/emotive debriefing at the significant level of .0125, showed an [ F(1, 148)= 4.94, p = .028, partial eta squared = .032]. An inspection of the mean scores indicated that there was no difference in the use of cognitive/emotive debriefing between amputees (M = 33.01, SD = 5.19) and their caregivers (M = 31.08, SD = 5.47). Spiritual- centered coping at the significant level of .0125 showed an [F(1,148) = .90, p = .345, partial eta squared = .006]. An inspection of the mean scores indicated that there was no difference in the use of collective coping between amputees (M = 21.25, SD = 4.10) and their caregivers (M = 20.64, SD = 3.82). Collective coping at the significant level of .0125 showed an [F(1,148) = 4.46, p = .036, partial eta squared = .029]. An inspection of the mean scores indicated that there was no difference in the use of collective coping between amputees (M = 25.11, SD = 3.49) and their caregivers (M = 23.83, SD = 3.92). Ritual- centered coping at the significant level of .0125 showed an [F(1,148) = 0.01, p = .913, partial eta squared = .000]. An inspection of the mean scores indicated that there was no difference in the use of collective coping between amputees (M = 6.89, SD = 2.15) and their caregivers (M = 6.93, SD = 2.32). Thus this hypothesis was not supported. 108 Emotional Pain and Coping Strategies Hypothesis 5 Personality will moderate the relationship between psychological distresses and emotional pain. This hypothesis sought to find out if one’s personality (Extraversion, Neuroticism, Openness, Conscientiousness, and Agreeableness) could play a major factor in the experience of psychological distress and emotional pain by changing the relationship between psychological distress and emotional pain. This hypothesis was analyzed using hierarchical multiple regression because the hypothesis sought to test a moderation effect. Before the analysis was done, the relationship between demographic characteristics and emotional pain was analyzed to investigate if one’s demographic features affect one’s experience of emotional pain. It was realized that one’s group (participant) as a caregiver or an amputee had a statistically significantly positive relationship with one’s experience of emotional pain. Thus participants were dummy coded and its effect was controlled for in the main analysis. Preliminary analyses were conducted to ensure no violation of the assumptions of normality, linearity, multicollinearity and homoscedasticity. The independent variable (psychological distress) and moderator variables (Personality: Extraversion, Neuroticism, Openness, Conscientiousness) were centered by subtracting their individual means from their individual scores respectively. The interaction between the centered independent variable and the centered moderator was computed to produce a product variable (Baron & Kenny, 1986). This was followed with the main moderation analysis. Results showed that the various personality types did not significantly moderate psychological distress and emotional pain. 109 Emotional Pain and Coping Strategies For instance, the ANOVA table, (attached to Appendix), showed that the entire model was not significant with openness as a moderator, openness = [F(10, 139) = 1.793, p = .067] and openness did not make a significant contribution to the model, [ F change(4, 139) = .628, p = .643]. The ANOVA table, (attached to Appendix), showed that the model as a whole was significant with conscientiousness as a moderator, conscientiousness = [F(10, 139) = 2.412, p = 011]. However, conscientiousness did not make a significant unique contribution to the model, [F change(4,139) = .942, p =.442]. Also, the ANOVA table, (attached to Appendix), showed that the model as a whole was not significant with agreeableness as a moderator, agreeableness = [F(10,139) = 1.134, p = .343] and agreeableness did not make a significant contribution to the model, [F change(4, 139) = .321, p = .864]. Therefore only results on extraversion and neuroticism were presented. This is consistent with the work of Chioqueta et al. (2005), Enns et al. (1997) and Leenars et al. (2005) who have also demonstrated a relationship between the variables (extraversion and neuroticism) and emotional pain and psychological distresses. The results are presented in Table 16 and 17 below: 110 Emotional Pain and Coping Strategies Table 16: Hierarchical Multiple Regressions of the contributions of one’s personality (extraversion) to the relationship between psychological distresses and emotional pain. Predictors B SEB β t p Model 1 Constant 119.680 5.843 20.482 .000 Participants 8.040 3.696 .176 2.176 .031 Model 2 Constant 130.012 30.897 4.208 .000 Participants 8.965 3.668 .196 2.444 .016 Depression .017 .339 .005 .050 .960 Anxiety .561 .294 .193 1.912 .058 Stress .253 .297 .084 .851 .396 Hopelessness -1.341 1.028 -.105 -1.305 .194 Model 3 Constant 130.428 31.683 4.117 .000 Participants 8.968 3.681 .196 2.436 .016 Depression .020 .344 .006 .059 .953 Anxiety .562 .295 .193 1.906 .059 Stress .249 .303 .083 .824 .411 Hopelessness -1.334 1.037 -.104 -1.287 .200 Extraversion -.025 .391 -.005 -.064 .949 Model 4 Constant 125.228 31.816 3.936 .000 Participants 10.089 3.799 .221 2.656 .009 Depression .033 .346 .011 .097 .923 Anxiety .560 .299 .192 1.872 .063 Stress .243 .307 .081 .791 .430 Hopelessness -1.161 1.045 -.091 -1.111 .269 Extraversion -.103 .399 -.021 -.257 .797 Depression*Extraversion .090 .070 .136 1.298 .197 Anxiety*Extraversion -.044 .065 -.075 -.678 .499 Stress*Extraversion -.084 .070 -.130 -1.199 .233 Hopelessness*Extraversion -.233 .246 -.077 -.949 .344 Dependent Variable: Emotional Pain. R2=.031, .097, .097, .126 and ΔR2=.031, .066, .000, .029 for steps 1, 2, 3 & 4 respectively. 111 Emotional Pain and Coping Strategies Hierarchical multiple regression was computed to investigate the extent to which the relationship between the independent (psychological distress) and dependent variable (emotional pain) changes as a result of the role of a third variable (extraversion personality) called the moderator variable. The influence of one’s group as an amputee or a caregiver was controlled for and preliminary analyses conducted to ensure no violation of the assumptions of normality, linearity, multicollinearity and homoscedasticity. After the variables in Block 1 (participants) have been entered, the overall model explains 3.1% of the variance (.031 × 100), [F(1, 148 )= 4.733, p = .031]. This was statistically significant. After Block 2 variables, psychological distress (depression, anxiety, stress and hopelessness) have also been included, the model as a whole explains 9.7% (.097 × 100), [F(5, 144) = 3.078, p = .011]. This was statistically significant. The four independent variables, psychological distress (depression, anxiety, stress and hopelessness) explained an additional 6.6% of the variance in emotional pain, after controlling for participants, R squared change = .066, [F change(4, 144) = 2.612, p = .038]. This was significant contribution. After Block 3 variable, extraversion personality have also been included, the model as a whole explained 9.7% (.097 × 100), [F(6, 143) = 2.548, p = .023]. The ANOVA reported that this was statistically significant. However, the moderator variable (extraversion personality) did not explain an additional variance in emotional pain, R squared change = .000, [F change(1, 143) = .004, p = .949]. This was not a statistically significant contribution. Finally, after Block 4 variables, interaction between independent variables and centered moderator variables (psychological distress and extraversion) were also been included, the model as a whole explained 12.6% (.126 × 100), [F(10, 139) = 1.995, p = .038]. The ANOVA table showed that this was statistically significant. The interaction between the independent variables 112 Emotional Pain and Coping Strategies and moderator variable explained an additional 2.9% of the variance in emotional pain, R squared change = .029, [F change(4,139) = 1.150, p = .336]. This was not a statistically significant contribution thus the hypothesis that ‘Extraversion will moderate the relationship between psychological distresses and emotional pain’ was not supported. 113 Emotional Pain and Coping Strategies Table 17: Hierarchical Multiple Regressions of the contributions of one’s personality (neuroticism) to the relationship between psychological distresses and emotional pain. Predictors B SEB ß t p Model 1 Constant 119.680 5.843 20.482 .000 Participants 8.040 3.696 .176 2.176 .031 Model 2 Constant 130.012 30.897 4.208 .000 Participants 8.965 3.668 .196 2.444 .016 Depression .017 .339 .005 .050 .960 Anxiety .561 .294 .193 1.912 .058 Stress .253 .297 .084 .851 .396 Hopelessness -1.341 1.028 -.105 -1.305 .194 Model 3 Constant 126.796 31.516 4.023 .000 Participants 8.925 3.677 .195 2.427 .016 Depression .011 .340 .003 .032 .975 Anxiety .579 .296 .198 1.955 .053 Stress .268 .299 .089 .898 .371 Hopelessness -1.440 1.046 -.113 -1.377 .171 Neuroticism .214 .388 .045 .552 .582 Model 4 Constant 123.979 32.720 3.789 .000 Participants 8.770 3.730 .192 2.351 .020 Depression -.055 .342 -.018 -.161 .872 Anxiety .530 .303 .182 1.750 .082 Stress .310 .306 .103 1.015 .312 Hopelessness -1.293 1.083 -.101 -1.193 .235 Neuroticism .274 .404 .058 .677 .499 Depression*Neuroticism .122 .072 .207 1.683 .095 Anxiety*Neuroticism -.042 .064 -.083 -.660 .510 Stress*Neuroticism .014 .085 .020 .164 .870 Hopelessness*Neuroticism -.107 .247 -.036 -.432 .667 Dependent Variable: Emotional Pain. R2=.031, .097, .098, .129 and ΔR2=.031, .066, .002, .030 for steps 1, 2, 3 & 4 respectively. 114 Emotional Pain and Coping Strategies Hierarchical multiple regression analysis was equally used to evaluate the hypothesized influence of one factor of personality (neuroticism) on the relationship between psychological distresses and emotional pain. Equally, the independent variables (psychological distresses; Depression, Anxiety, Stress, Hopelessness) and the moderator variable (neuroticism) were centered and a product term was created for the centered variables (Baron & Kenny, 1986). Preliminary analyses were conducted to ensure no violation of the assumptions of normality, linearity, multicollinearity and homoscedasticity. From Table 17, depression did not predict emotional pain independently, (β = .005, t(150) = .050, р = .960). Anxiety predicted emotional pain independently, (β = .193, t(150 )= 1.912, р = .058). Stress did not predict emotional pain independently, (β = .084, t(150) = .851, р = .396). Hopelessness did not predict emotional pain independently, (β = -.105, t(150) = -1.305, р = .194). The four independent variables, psychological distress (depression, anxiety, stress and hopelessness) explained an additional 6.6% of the variance in emotional pain, after controlling for participants, R squared change = .066, [F change(4, 144) = 2.612, p = .038]. This was significant contribution. Neuroticism independently predicted emotional pain, (β = .045, t(150) = -.552, p = .582). Neuroticism explained .2% of the variation in emotional pain after being introduced as a moderator. The interaction between depression and emotional pain was not moderated by neuroticism (β = .207, t(150) = 1.683, p = .095). The interaction between anxiety and emotional pain was moderated by neuroticism (β = -.083, t(150) = -.660, p = .510). The interaction between stress and emotional pain was not moderated by neuroticism (β = .020, t(150) = .164, p = .870). The interaction between hopelessness and emotional pain was not moderated by neuroticism (β = -.036, t(150) = -.432, p = .667). The interaction between the independent variables and moderator variable explained an additional 3.0% of the variance in emotional pain, R squared change = .030, [F change(4,139) = 1.209, p = 310]. This was not a statistically significant contribution thus the hypothesis that 115 Emotional Pain and Coping Strategies ‘Personality (Neuroticism) will moderate the relationship between psychological distresses and emotional pain’ was not supported. Hypothesis 6 Perceived social support will moderate the relationship between psychological distresses and emotional pain. Given that the individuals in the Ghanaian cultural context make use of social support, this hypothesis sought to examine if one’s level of perceived social support could affect the relationship between one’s experience of psychological distresses and emotional pain. Hierarchical multiple regression was used to assess this relationship because the hypothesis sought to examine the moderating role of perceived social support on psychological distress and emotional pain. The influence of one’s group as an amputee or a caregiver was controlled for and preliminary analyses conducted to ensure no violation of the assumptions of normality, linearity, multicollinearity and homoscedasticity. Results are presented in Table 18 below: 116 Emotional Pain and Coping Strategies Table 18: Hierarchical Multiple Regressions of the contributions of one’s level of social support to the relationship between psychological distresses and emotional pain. Model B SEB ß t p Model 1 Constant 119.680 5.843 20.482 .000 Participants 8.040 3.696 .176 2.176 .031 Model 2 Constant 130.012 30.897 4.208 .000 Participants 8.965 3.668 .196 2.444 .016 Depression .017 .339 .005 .050 .960 Anxiety .561 .294 .193 1.912 .058 Stress .253 .297 .084 .851 .396 Hopelessness -1.341 1.028 -.105 -1.305 .194 Model 3 Constant 130.334 30.957 4.210 .000 Participants 8.852 3.678 .194 2.407 .0117 Depression .055 .344 .018 .159 .874 Anxiety .530 .297 .182 1.781 .077 Stress .231 .299 .077 .772 .441 Hopelessness -1.493 1.053 -.117 -1.418 .158 Social Support .114 .165 .057 .692 .490 Model 4 Constant 155.446 31.213 4.980 .000 Participants 5.634 3.650 .123 1.544 .125 Depression -.089 .339 -.082 -.261 .794 Anxiety .661 .293 .227 2.253 .026 Stress .217 .290 .072 .748 .456 Hopelessness -2.390 1.074 -.187 -2.226 .028 Social Support .287 .166 .144 1.725 .087 Depression* Social Support -.045 .027 -.169 -1.657 .100 Anxiety* Social Support .071 .026 .293 2.723 .007 Stress* Social Support -.079 .029 -.269 -2.735 .007 Hopelessness*Social -.168 .092 -.150 -1.817 .071 Support Dependent Variable: Emotional Pain. R2=.031, .097, .098, .129 and ΔR2=.031, .066, .002, .030 for steps 1, 2, 3 & 4 respectively. 117 Emotional Pain and Coping Strategies After the variables in Block 1 (participants) have been entered, the overall model explains 3.1% of the variance (.031 × 100), [F(1, 148) = 4.733, p = .031]. This was statistically significant. After Block 2 variables, psychological distress (depression, anxiety, stress and hopelessness) have also been included, the model as a whole explains 9.7% (.097 × 100), [F(5, 144) = 3.078, p = .011]. This was statistically significant. The four independent variables, psychological distress (depression, anxiety, stress and hopelessness) explained an additional 6.6% of the variance in emotional pain, after controlling for participants, R squared change = .066, [F change (4, 144) = 2.612, p = .038]. This was significant contribution. After Block 3 variable, social support have also been included, the model as a whole explained 10.0% (.100 × 100), [F(6, 143) = 2.635, p = .019]. The ANOVA showed that this was statistically significant. The moderator variable social support explained an additional variance 0.3% in emotional pain, R squared change = .003, [F change (1, 143) = .480, p = .490]. This was not a statistically significant contribution. Finally, after Block 4 variables, interaction between independent variables and centered moderator variables (psychological distress and social support) were also included, the model as a whole explained 18.9% (.189 × 100), [F(10, 139) = 3.238, p = .001]. The ANOVA table showed that this was statistically significant. The interaction between the independent variables and moderator variable explained an additional 8.9% of the variance in emotional pain, R squared change = .089, [F change(4,139) = 1.150, p = .006]. This is a statistically significant contribution thus the hypothesis that ‘Social support will moderate the relationship between psychological distresses and emotional pain’ was supported. In the final model, only the two control measures, interaction between anxiety and social support and interaction between stress and social support, were statistically significant, with the 118 Emotional Pain and Coping Strategies interaction between anxiety and social support recording a higher beta value (ß = .29, t(150)= 2.723, p = .007) than the interaction between stress and social support (ß = –.27, t(150)= -2.735, p = .007). Summary of Quantitative Findings: The study tested six (6) hypotheses to assess the correlates of emotional pain and coping strategies among amputees and their caregivers. The summary of findings is presented below: 1. Psychological distresses (i.e., depression, anxiety and hopelessness) will be significantly related to emotional pain. This hypothesis was partially supported. 2. There was a significant difference in the experience of emotional pain between amputees and their caregivers. 3. Psychological distresses of amputees were not significantly different from that of their caregivers. 4. There will be a significant difference in the Africultural coping (coping strategies) employed by amputees and their caregivers. This hypothesis was not supported. Amputees and their caregivers did not significantly differ on the use of cognitive/emotional debriefing, spiritual-centered coping, collective coping and ritualistic-centered coping. 5. Personality did not moderate the relationship between psychological distresses and emotional pain. 6. Perceived social support moderated the relationship between psychological distresses and emotional pain. 119 Emotional Pain and Coping Strategies Observed Model Social Support Personality (Extraversion, Neuroticism) Depression ß= -.269* ß=.293* Emotional Anxiety Pain ß=.193* Stress Hopelessness Figure 4: Observed Conceptual Model From figure 4, it was observed that only one dimension of psychological distresses (anxiety) significantly predicted emotional pain. Depression, stress and hopelessness did not predict emotional pain. Personality did not moderate the relationship between psychological distresses and emotional pain. However, social support moderated the relationship between two dimensions of psychological distresses (anxiety and stress) and emotional pain. 120 Emotional Pain and Coping Strategies CHAPTER FIVE DISCUSSION Introduction The objective of this study was to explore the experiences of emotional pain following loss (i.e., functional loss, the loss of one’s way of life and a loved one’s attention) in order to tease out the importance of psychological services in the experience of emotional pain in the Ghanaian context, and to highlight coping mechanisms used in dealing with emotional pain in the Ghanaian context. The second aim was to explore the relationship between emotional pain and major psychological distresses (i.e., depression, anxiety, stress and hopelessness) among amputees and their caregivers and the moderating role of personality and perceived social support in this relationship. These aims/objectives were achieved using a mixed method design. This chapter discusses aims and objectives in relation to the findings that were obtained from the data analyses pertaining to whether the hypotheses that were tested were supported or rejected. The findings are discussed with reference to past studies and theories reviewed in the study. Findings were expounded to put the results into proper perspective taking into consideration culture, personality differences and other relevant factors that may be contributing to the different results. The implications of the findings and recommendations for subsequent related studies, clinical practitioners and the health sector were stated. The limitations, contribution to theory and conclusions of the study are also presented taking into consideration the findings and implications of the study. 121 Emotional Pain and Coping Strategies The Concept of Emotional Pain Emotional pain is a feeling common to every human being at one point in time due to the harsh and tender strokes of reality or life though the cause of emotional pain may differ significantly from person to person. The definition of the basic concept of emotional pain has assumed variant forms with one form being emotions following self-disappointment (Bakan, 1968; Baumeister, 1990; Frankl, 1963) and the other form being a negative change instigated by trauma and loss (Bulman, 1992; Freud, 1959; Herman, 1992). The basic underlying notion is that emotional pain is an unpleasant feeling an individual harbors following several negative factors of which self-disappointment, trauma and loss are sub-components. Given that the experience of emotional pain differs, it was necessary to investigate how amputees and their caregivers experience this phenomenon considering the fact that emotional pain “…as a distinctive psychological state can be useful in the study of many aspects of behavior and subjective experiences such as pathology, suicide, maladjustment, meaning in life, aversive life events and therapeutic changes, as well as a wide range of personality functioning” (Orbach et al., 2003b; pg. 220). The Differences and Similarities in the Experience of Emotional Pain and Psychological Distress The first segment of the qualitative objective was to explore the experiences of emotional pain following loss or following witnessing a loved one go through pain. This was investigated using research questions such as “what are the experiences of emotional pain?” to attempt to find the distinct emotions experienced by amputees who experience loss of a body part and their caregivers who experience emotional pain from witnessing a loved one go through pain or from adjusting one’s way of life to accommodate an amputee. Thematic analysis revealed that the 122 Emotional Pain and Coping Strategies antecedents of emotional pain for amputees was rooted in letting go of their primary organ whilst that of the caregivers was rooted in the reaction of some of the amputees and also from the realization that someone who was once able has become disabled. This, in relation to amputees and their caregivers, spurt up emotions some of which are common to both amputees and their caregivers. Emotions unique to amputees before and after amputations included anger, pain of letting go off the primary organ leading to refusal to amputate the damaged organ and loneliness. This finding is consistent with Liu et al.’s (2010) finding that amputees struggle to deal with the fact that amputation is the solution to their predicament and this spurts up negative emotions of which anger is part. Emotions unique to caregivers before and after amputation included, empathic pain that is the pain one feels by observing a once abled person become disabled or go through pain, thus leading to denial of one’s painful emotions to assist the patient deal with his or hers. This finding is consistent with Borsook et al.’s (2009) assertion that empathic pain is a common phenomenon and also consistent with Monin et al. (2009) and Volker’s (2015) findings that though caregivers experience a lot of negative emotions at the thought of seeing a loved one handicapped and are usually not prepared for it they still see the need to deny their emotions and to concentrate on the patient. Common emotions to amputees and their caregivers following loss was shock and hopelessness. In some instances amputees and their caregivers could not find the appropriate word to define their emotions thus they simply tagged it as ‘hurt’. Another common emotion to amputees and their caregivers was the feeling of sadness. The interesting twist however was that, whiles amputees’ experienced this negative emotion (sadness) after loss, caregivers experienced this before loss. These negative emotions confirms Bolger’s (1999) theory of emotional pain that whiles experiencing emotional pain individuals who allow this 123 Emotional Pain and Coping Strategies feeling of emotional pain to take its natural course, experience a sense of brokenness and this is exhibited through feelings of sadness, hopelessness, hurtful feelings among others. Orbach et al.’s (2003a, b) findings support this assertion that the constituent of emotional pain is a buildup of negative emotions. A rather unique finding was caregivers and amputees’ experience of feeling of gratitude. They (amputees and caregivers) were grateful for the life that was not taken away by their object of worship. This brings into fore the role of culture in the experience of emotional pain. Literature, (e.g., Pobee, 1992), has established that Ghanaians are highly religious. It can therefore be argued that, Ghanaians are likely to offer thanks to their object of worship when they consider that they have been exempted from worse case scenarios. Therefore, it was not surprising that caregivers and amputees alike also shared the same opinion. The assumption is that once there is life, there is hope for the future and also one will not miss the presence of a loved one because the person is alive though he or she may be handicapped. Cavanagh et al. (2006) and Wain et al. (2004) assert that amputation stirs up unpleasant emotional experiences. This study has revealed that, these unpleasant emotional experiences are common to both amputees (Liu et al., 2015; Queiroz et al., 2016) and their caregivers (Ae- Ngibise et al., 2015; Volker, 2015) with a feeling of gratitude at the gift of life. Lester (2000), Olie et al. (2010) and Troister et al. (2010) discuss that there is an association between these unpleasant negative psychological states and emotional pain thus another objective of this study was to quantitatively investigate the relationship between emotional pain and psychological distresses and the differences in these experience between amputees and their caregivers. It was observed that psychological distresses (i.e., depression, anxiety, stress) was positively and significantly related to emotional pain with the exception of hopelessness which was not 124 Emotional Pain and Coping Strategies significantly related to emotional pain. This confirms the findings of Erinfolami et al. (2016), Lester (2000), Liu et al. (2010), Olie et al. (2010), Orbach, (2003) and Troister et al. (2010) that there is a link between emotional pain and other negative state of emotions like depression and anxiety. Orbach (2003) explains that emotional pain is the perfect combination of multiple intense negative emotions. According to Liu et al. (2010), amputees experience various emotional reactions such as anger, anxiety, depression, fear, sadness and sorrow as established by the qualitative aspect of this study as well. Lester (2000), Olie et al. (2010) and Troister et al. (2010) have shown that generally, emotional pain is associated with a variety of negative psychological states such as depression, anxiety, and could hinder hopeful and optimistic beliefs. For both amputees and their caregivers, and in line with the outcomes of previous studies (Lester, 2000; Orbach et al., 2003a; Erinfolami et al.,2016) this current study found that high levels of depression is associated with higher levels of emotional pain. Furthermore, anxiety and stress were also associated with emotional pain. Hopelessness, however, had no significant association with emotion pain in the amputees and their caregivers. This could be as a result of the feeling of gratitude that was found in the qualitative analysis, which is a cultural element. If one is grateful for the gift of life, then it stands to reason that one is hopeful as well. Thus aside the relationship literature (e.g., Erinfolami et al., 2016; Lester, 2000; Olie et al., 2010; Orbach, 2003; Troister et al., 2010) has established between negative psychological distresses like depression, anxiety, hopelessness and emotional pain, this study went a step further to investigate the relationship between another psychological distress which is stress and emotional pain and the relationship was a significant positive relationship. Indicating that in the Ghanaian context one’s level of stress could increase one’s feelings of emotional pain. 125 Emotional Pain and Coping Strategies After identifying that amputees and their caregivers experience psychological distresses or negative emotions following loss and confirming that there was a significant positive relationship between these psychological distresses and emotional pain, the study sought to quantitatively investigate the differences in these experiences (psychological distresses and emotional pain) among amputees and their caregivers. Thus it was hypothesized that “There will be a significant difference in the experience of emotional pain between amputees and their caregivers”. This hypothesis was supported per the data analysis. It was noted that the level of emotional pain of the amputees was slightly higher than the level of emotional pain of their caregivers. Pain is experienced as a process and when one is experiencing emotional pain due the sense of loss the individual experiences brokenness and a loss of control on events in his or her life according to Bolger’s (1999) theory of emotional pain and Volker (2015). The argument has always been that when one experiences amputation of any kind he or she sinks into emotional pain and the caregivers also experience emotional pain from being exposed to a loved one’s suffering and also the patients attitude towards the caregiver after amputation of which according to Wain et al. (2004) is the normal expression of how the amputee is feeling and should be accommodated as such. The finding of this study revealed that, amputees become the immediate recipient of loss and as such may feel a deep sense of emotional pain than their primary caregivers who are not the immediate recipients of the loss. The caregivers may experience empathic pain as established by the qualitative finding of this study and supported by Borsook et al. (2009). Then again, researchers like Garafalo (2000) and Muzaffar et al. (2012) have explained that when there is a drastic change in an individual’s life, the person’s core expectations, meaning to life and values changes as well, this may account for amputees experiencing a greater 126 Emotional Pain and Coping Strategies percentage of emotional pain compared to their caregivers because they have to find adaptable and adjustable ways of living while caregivers find only adjustable ways of living. Adapting to a new self-image, new occupation and perhaps a new way of life in just a matter of minutes, when one had not anticipated for, may cause one a great deal of emotional pain whiles adjusting to a new circumstances, though not planned for, may equally cause one emotional pain but may be on a lighter note. Orbach et al. (2003a) and Shneidman (1999) also asserted that people experience emotional pain following loss of control over one’s predicaments, event or life. Liu et al. (2010) in their study concluded that patients of amputation undergo emotional collapse. The current study confirms these conclusions and goes a step further to reveal that the experience of emotional collapse is not the preserve of the patients of other clinical conditions, in that amputees and their caregivers also experience emotional collapse. Thus, though the level of emotional pain of the amputees was slightly higher than the level of emotional pain of their caregivers, as explained earlier, this may be attributed to the fear and anxiety of the amputee, his or her questions about the future, the loss of independence and what he or she should do and expect in life, as found in previous research (Butler et al., 1991; Liu et al., 2010; Queiroz et al., 2016). This does not dispute the fact that caregivers also experience emotional pain because of fear of the unknown of what the future holds for them as established by Volker (2015) and the qualitative finding of this study. It was again hypothesized that “Psychological distresses of amputees will be significantly different from that of their caregivers”. This hypothesis was not supported. Psychological distress in this study, as explained previously, relates to the person’s level of depression, anxiety, stress and hopelessness. On these four distinct but similar levels there was no significant 127 Emotional Pain and Coping Strategies difference between amputees and their caregivers despite previous findings by Ae-Ngibise et al. (2015), Queiroz et al. (2016) and Volker (2015) establishing that amputees and their caregivers do experience various distinct degrees of psychological distress. It can be argued that though no distinct difference was found between amputees and their caregivers, literature (eg. Ae-Ngibise et al., 2015; Queiroz et al., 2016; Volker, 2015) has established that amputation psychologically stresses amputees and their caregivers. Which means the level of psychological distress experienced by these two groups is not different. Amputees and their caregivers experiences depressive disorders, emotional distress, sadness, discouragement, apathy, guilt and disappointment with self (Ae-Ngibise et al. 2015; Ide, 2011; Queiroz et al., 2016). Price et al. (2010) in a study revealed that there is no difference, comparatively, in patients’ and caregivers’ depression levels. In support of this, the findings of this study also found no significant difference in the levels of depression among amputees and their caregivers. On the other hand, Price et al. (2010) reported that caregivers experienced higher anxiety than the patients. Contrary to this, there was no significant difference in the anxiety levels reported by the amputees and their caregivers in the current study. What may account for the difference among other things is the difference in patients involved in both studies (women with ovarian cancer and amputees respectively) who make different demands of their caregivers, clinically and personally. Precipitating/Moderating Factors that Influence the Experience of Emotional Pain The qualitative bit of this study sought to explore the factor(s) that influence the participants’ (amputees and their caregivers) experience of emotional pain. The basic research question that this aspect sought to answer was “What are the factors that affect the experience of emotional pain”. Thematic analysis revealed that the outstanding factor that influenced the experience of 128 Emotional Pain and Coping Strategies emotional pain for amputees and their caregivers was the news breaking method. Participants explained that health professionals just disclosed sensitive information without consideration to how the patient or the caregiver may feel. The amputees’ bitterness was from the fact that health professionals took for granted that they (amputees) will not object to doing what they considered will aid their (amputees) health and as such did not take initiatives to counsel them before announcing to them that their primary body part needs to be amputated. Caregivers on the other hand were not given primary attention either. The caregivers’ complaint was that health professionals felt they (caregivers) will not mind giving their consent for an appropriate measure to be taken with regards to the patients’ health. Defying all the laws of reasoning, these two categories of people, that is, amputees and their caregivers, were alarmed when health professionals announced their intention to amputate the patient’s primary organ without prior counseling. Thus in some instances, both amputees and their caregivers refused amputation until issues got out of hand and there was no other solution in the broader picture. It was therefore noted qualitatively that the manner and mode of breaking the news of the necessity to amputate the patients’ primary organ to the patients and their caregivers either elevated or alleviate the intensity and feeling of emotional pain. This tends to support Monden, Gentry and Cox’s (2016) assertion that the method in which bad news is broken can lead to negative consequences, of which emotional pain is not excluded. The researchers explain that, unfortunately, physicians are not properly trained for this role. Accordingly, the quantitative aspect of the study investigated how factors like one’s personality and perceived social support will influence the relationship between psychological distresses and emotional pain. It was hypothesized that “Personality will moderate the relationship between psychological distresses and emotional pain”. This hypothesis was not 129 Emotional Pain and Coping Strategies supported. This finding contradicts Lazarus et al.’s (1984) transactional model of stress and coping which explains that in the experiences of psychological distress factors like one’s personality could aid one to deal with the stressful event. In fact, individuals’ personality type is noted to influence the experience of pain and one’s ability to withstand traumatic events in life (Chioqueta et al., 2005; Lazarus et al., 1984; Lester 2005; Zeb et al., 2013). Melo et al. (2010) established in a study that neuroticism increased the caregiver’s depression and burden, whiles extraversion decreased caregiver’s depression and burden. Leenaars et al. (2005) found a positive relationship between emotional pain and neuroticism and introversion. In relation to amputees and their caregivers, this study investigated the moderating effects of personally traits between psychological stresses and emotional pain and found that extraversion and neuroticism did not moderate the relationship between psychological distress (depression, anxiety, stress and hopelessness) and the emotional pain of amputees and their caregivers. This contradicted the findings of Chioqueta et al. (2005), Leenaars et al. (2005) and Melo et al. (2010). The factors which accounted for this association were not identified. As noted by George (1994), a considerable amount of variance in caregivers and patients, and personality outcomes remain unexplained. It could, however, be argued that the intensity of emotional pain felt by these two groups was intense to the extent that personality factor could not aid in moderating this experience. Thus irrespective of the individuals’ personality, the stage of complete brokenness as explained by Bolger’s (1999) theory of emotional pain, could not be aided by an individual factor or attribute. It was again hypothesized that “Perceived social support will moderate the relationship between psychological distresses and emotional pain”. This hypothesis was supported. According to Iseselo et al. (2016) there is a relationship between the social support available to 130 Emotional Pain and Coping Strategies patients and caregivers and their psychological wellbeing. Muzaffar et al. (2012) reported that in the amputee population they studied those who did not report psychiatric conditions had a good family support and strong spiritual devotion. Patients who were close to their family members, friends and close relatives and engaged in a vocation worried less about their predicament also recorded lower levels of emotional pain. In examining the moderating effects of social supports between psychological distress (depression, anxiety, stress and hopelessness) and the emotional pains of amputees and caregivers, it was realized that social support moderates the relationship between psychological distresses and emotional pain. This tends to support the findings of Iseselo et al. (2016), Muzaffar et al. (2012) and the transactional theory of stress and coping by Lazarus et al. (1984) that social support is an important factor that serves as a buffer in the experience of psychological distress and by inference emotional pain as well. Coping Strategies Used in the Experience of Emotional Pain Coping strategies was explored qualitatively and quantitatively. Qualitative analysis revealed that coping strategies adopted by amputees in the experience of emotional pain included social withdrawal/distancing, social reference and social support. These findings are at variance with the findings of Garafalo (2000) and Kashani et al. (1983) that amputees make use of excessive alcohol consumption and drug as a means of dealing with their dilemma. Regarding social withdrawal or distancing, it was realized that some amputees avoided the larger community after amputation. They no longer mingled with friends and even relatives. Charlton and Thompson (1996) explain that when an event is carefully placed in the past, distancing is more easily adopted. Thus this finding supports the assertion of Charlton et al. (1996). In social referencing it was noted that some amputees compared their situation to other people whose conditions are worse off than theirs and that made them feel calm about their 131 Emotional Pain and Coping Strategies condition. Amputees relied greatly on the love and care of relatives, loved ones and friends for support in dealing with their ordeal. This finding was in line with Livneh et al.’s (2000) finding that amputees made use of social support as a way of dealing with their ordeal. Interestingly, caregivers on the other hand relied on no one but themselves (Self Support) for strength. They encouraged themselves to deal with their predicament. This tends to support Ae-Ngibise et al.’s (2015) finding that caregivers indeed have no form of social support. Despite the emotional stressors they have to deal with, their only form of support was religious support and prayers (Iseselo et al., 2016). Amputees and their caregivers both employed religious coping in the experience of emotional pain. They relied on God for a better future, prayed about their situation intermittently and believed God to be in control of their situation. This finding is in line with that of Ae-Ngibise et al. (2015) and Livneh et al.’s (2000) finding that amputees and caregivers made use of religion and religious prayers respectively as a means of coping with their ordeal. This also reinforces the cultural element of religion in the experience of a traumatic situation since Pobee (1992) has already noted that Ghanaians are religious. Following the findings of the qualitative analyses, the study sought to quantitatively investigate the differences in the coping strategies employed by the two groups, that is, amputees and their caregivers using an African centered coping mechanism. It was hypothesized that “There will be a significant difference in the coping strategies employed by the two groups (amputees and their caregivers)”. This hypothesis was not supported. The dimensions of coping strategies that was quantitatively investigated included; cognitive/emotive debriefing; spiritual coping; collective coping and ritualistic coping. Utsey et al.’s (2000) asserts that Africans make use of cognitive/emotional debriefing and collective coping aside them (Africans) using the other dimensions of coping which are spiritual and ritualistic coping. This assertion was debunked by 132 Emotional Pain and Coping Strategies the findings of this study. Utsey et al. (2000) explains that with the cognitive/emotional debriefing, the individual tends to entertain hope. Hope to face uncertainties. Though the qualitative finding of this study revealed that amputees entertained greater hope compared to their caregivers despite their (amputees and their caregivers) feelings of hopelessness as established by the qualitative finding of this study, the quantitative did not reveal that amputees and their caregivers differed on use of cognitive/emotional debriefing. Utsey et al. (2000) again explains that the use of collective coping means the individual relies more on in-groups to manage their distressing events. They solicit for comfort from members of their in-group. This reinforces the idea that Africans are collective in nature. The use of collective coping thus refers to drawing support from other significant figures in the individual’s life. Despite the qualitative finding of this study establishing that amputees’ use social support, which is a form of collective coping, than their caregivers, the quantitative findings revealed no differences in this dimension. Livneh et al. (2000) however asserts that amputees lean in to social support in dealing with their predicament. Caregivers do not make use of collective coping perhaps because they feel that cannot rely on anyone but themselves and be strong for the amputee as the qualitative find of this study has established. The quantitative finding revealed that amputees and their caregivers did not differ on the use of spiritual and ritualistic coping method in dealing with their traumatic situation or emotional pain as measured by the Africultural coping systems inventory by Utsey et al. (2000). The qualitative finding of this study however revealed that amputees and their caregivers make use of religious coping mechanism. Religious coping has a dimension of spiritual coping which includes praying to one’s object of worship. 133 Emotional Pain and Coping Strategies Potential Impact on Wellbeing/ Psychological Wellbeing and the Need for Psychological Services Psychological services are needed when individuals and families face traumatic situations. Literature has established that in the case of amputation, attention is concentrated on the amputees (Butler et al., 1992; Volker, 2015; Ide, 2011) to the neglect of caregivers who also suffer some form of emotional pain as established by the qualitative finding of this study. Thus one important research question was to investigate the potential impact of the traumatic situation on one’s wellbeing so as to establish the indispensable role of psychological services in the Ghanaian context when one is faced with such traumatic situation. This was with particular concentration on amputees and their caregivers. Thematic analysis revealed that the potential impact of the traumatic situation on one’s wellbeing included a change in vocation and constant phantom limb sensation for amputees, stress for amputees and their caregivers, economic hardship and fear for caregivers only. Caregivers experience of stress, economic hardship and fear supports the findings of Ae-Ngibise et al. (2015) and Volker (2015). The experience of fear for the caregivers was as a result of the fear of the unknown. Since, they never anticipated a close relative or acquaintances experiencing this traumatic ordeal, they fear this ordeal is not far-fetched from them. The new realization creates fear and panic depicting anxiety. This however juxtaposes the finding of Queiroz et al. (2016) that amputees rather experience a sense of fear of being discriminated against by the society. The findings of this study revealed that though previous literature has established that amputees did experience a sense of fear, their fear was concentrated on what life held for them after amputation and caregivers’ sense of fear was rooted in the possibility of this trauma occurring again. In order for these two groups of people, amputees and their caregivers, to have a functional life, there is the 134 Emotional Pain and Coping Strategies need for psychological therapy. Rybarczyk, et al. (2004) acknowledges the necessity for psychological assessment and entreats that this be part of daily routine care for amputees irrespective of the time lapse in amputation. Contribution to Theory The findings of this study confirmed Orbach et al.’s (2003a,b) that emotional pain involves a mix of negative complex set of emotions. The qualitative findings did confirm some dimensions of Bolger’s (1999) theory of emotional pain that individuals experiencing emotional pain following loss feel sad amidst other emotions and this depicts a complete state of brokenness. However, this study has proven that Bolger’s (1999) theory is not context specific because in the Ghanaian setting, amidst the feelings of emotional pain following loss, people find reasons to be grateful for the gift of life and this was depicted by amputees and their caregivers alike. They were grateful to their object of worship and Pobee (1992) has confirmed that Ghanaians are highly religious. Also, according to Frais, Watkins, Webber and Froh (2011), sometimes in the phase of a traumatic event, the individual’s reflections on death causes him or her to appreciate life as a limited resource. Lazarus et al. (1984) explained that when individuals are searching for various was to cope with a distressing situation, their personality trait and the social support available to them aid them in dealing with the stressful situation. This study however revealed that when the state of emotional pain is intense, personality may not be a factor that will aid in dealing with it but one’s social support may be an indistinguishable factor. Conclusion Putting everything into perspective, emotional pain is a phenomenon common in the Ghanaian context as well. This study was a preliminary investigation into this phenomenon. 135 Emotional Pain and Coping Strategies Amputees and their caregivers experience various degrees of emotional pain. Therefore, these categories of people should receive the needed attention to alleviate the development of any psychological disorder in the experience of a traumatic phenomenon. Limitations of the Study Though the study was successful, it was not without limitations. For instance, the use of correlational analysis means causality cannot be inferred. Thus findings only determined relationship between the variables. Furthermore, a notable limitation was the use of a moderate sample size. The sample size for the study was not large enough due to the fact that amputees represent a special population and they are not readily available, it was therefore difficult to recruit a larger sample size for the study. Finally, the time frame for data collection was rather short. A longitudinal study would have provided a longer time frame for data collection which would have permitted the researcher to gather enough data from a larger sample size. Despite these limitations, the findings of this study remain substantial and beneficial for the understanding of a concept that serves as a factor for most of the psychopathological situations of which suicide is part. Recommendations/ Clinical Practice in Ghana Based on the findings of this study, a few recommendations were made in the area of future studies, health sector and clinical practice. 136 Emotional Pain and Coping Strategies To start with, findings of this study revealed that amputees and their caregivers experience emotional pain and various forms of psychological distresses thus clinicians should screen amputees and their caregivers for emotional pain and psychological distress before and after amputation so appropriate measures can be taken to prevent unforeseen circumstances like suicide in the event that the emotional pain and psychological distresses are not properly managed by the patients and their caregivers. The fact that amputees and their caregivers both experience emotional pain and there are no significant differences in their (amputees and their caregivers) psychological distresses implies that an individualized therapy may not be beneficial for individuals with disability like amputation. Thus clinical psychologists should consider structuring intervention in such a way that the amputees and their caregivers are involved in the psychotherapeutic sessions. Then again, psychotherapy should be held intermittently until the psychotherapist deems both the amputee and his or her caregiver as psychologically fit and prepared for the life ahead of them. Findings again revealed that health professionals have a poor means of breaking news to amputees and their caregivers on the need for amputation and this aggravated their feeling of emotional pain. Thus health professionals should be educated on how to disclose sensitive information to individuals who need medical attention and their caregivers. An important recommendation for the health sector is that health professionals who attend to people with disability or people who have had traumatic experiences should always have a clinical psychologist on board. The role of the clinical psychologist is an indispensable one. The findings of this study revealed that the clinical psychologists need to provide psychotherapy for these individuals with traumatic experiences before and after they have been attended to by health officials. They provide individuals with psychological stability. 137 Emotional Pain and Coping Strategies Findings further revealed that amputees had various forms of coping with their ordeal (social withdrawal, social referencing, social support and religious coping) whiles their caregivers’ only form of coping was through self-encouragement and religious coping. However, for both amputees and their caregivers, social support moderated the relationship between psychological distresses and emotional pain. Therefore, psychotherapy should concentrate on strengthening the positive means of coping with their ordeal that is religious coping and social support so as to improve their (amputees and their caregivers) quality of life. In relation to research, future studies should consider using a larger sample size. Though the sample size in this study was adequate, it was not large enough to make concrete conclusions. One way to increase the sample size is for the researcher(s) to collect data over a long period of time. Also, future studies should consider investigating the phenomenon (emotional pain) among various categories of participants in multiple settings. Emotional pain has not been investigated in the Ghanaian context though literature has established that is a major cause for suicide. Therefore it will be important for future studies to investigate the phenomenon among people of diverse background like healthy population, students, adolescents or people with chronic illness for an in-depth understanding of the experience of the phenomenon in the Ghanaian context. An understanding of this phenomenon in the Ghanaian context will help curtail the incidence of suicide in the country because the experience of emotional pain has been positively linked to suicide by previous literature. Finally, it will be important to investigate the impact of the demographics like one’s gender or socioeconomic status on the experience of emotional pain. Factors which accounted 138 Emotional Pain and Coping Strategies for personality not being able to moderate the relationship between emotional pain and psychological distresses in the Ghanaian context should also be investigated. 139 Emotional Pain and Coping Strategies References Ae-Ngibise, A. K., Doku, K. C. V., Asante, P. 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Journal of Personality Assessment, 52 (1), 30–41. 152 Emotional Pain and Coping Strategies Appendix 1 153 Emotional Pain and Coping Strategies Appendix 2 UNIVERSITY OF GHANA Official Use only Protocol number Ethics Committee for Humanities (ECH) PROTOCOL CONSENT FORM Section A- BACKGROUND INFORMATION Title of Study:C Correlates of Emotional Pain and Coping Strategies among Amputees and their Caregivers Principal Ms. Esther Ohenewa Investigator: Certified Protocol Number Section B– CONSENT TO PARTICIPATE IN RESEARCH General Information about Research  The primary objective of this research is to examine the correlates of emotional pain among amputees and their caregivers who have to restructure their lives to take care of an amputee, that is, the factors that predict emotional pain, and the coping strategies amputees and their caregivers use to deal with their emotional pain. 154 Emotional Pain and Coping Strategies  The expected duration for participants in the qualitative phase will be thirty (30) to forty-five (45) minutes at most and forty-five(45) minutes to an hour (1hr) at most for the quantitative phase.  Some participants will be interviewed individually to gain an in-depth understanding of the emotional pain they experience using an interview guide. Other participants will be required to fill out a set of questionnaires to examine the correlates of emotional pain using standardized measures. Benefits/Risks of the study  Some benefits include; an in-depth understanding of how emotional pain is experienced among amputees and their caregivers so as to be able to identify amputees and their caregivers who are going through emotional pain. The findings of this study will aid clinicians develop better interventions to assist amputees and their caregivers work through emotionally painful experiences like the loss of one’s life and loss of intimate relationship. Finally, literature on emotional pain and literature on caregivers of amputees is very limited, thus this study will add to the growing knowledge of emotional pain.  There are no possible risk to be incurred by participants should they decide to part take in the study. However, participants may experience psychological distress at the recall of the traumatic event. In such situations, participant may be referred to a clinical psychologist. Confidentiality  The data to be collected will be aggregated and used for academic purposes only. The data will not be linked to any particular individual.  Supervisors, Dr. Benjamin Amponsah and Dr. Samuel Atindanbila, may sometimes look at my research records thus by signing or thumb-printing a written consent form, the participant or their representative is authorizing such access. Compensation  There will be no compensation for participants. Withdrawal from Study  Participation is voluntary and participants may withdraw at any time without penalty. 155 Emotional Pain and Coping Strategies  More specifically, participant will not be adversely affected if he/she declines to participate or later stops participating.  The participant or the participant's legal representative will be informed in a timely manner if information becomes available that may be relevant to the participant's willingness to continue participation or withdraw.  There are no circumstances and/or reasons under which the participant’s participation may be terminated.  Contact for Additional Information  Ms. Esther Ohenewa, University of Ghana, Psychology Department, P. O. Box LG 86, Legon. 0209045047/ 0263583473; ohenewaa.estherbg@gmail.com.  If you have any questions about your rights as a research participant in this study you may contact the Administrator of the Ethics Committee for Humanities, ISSER, University of Ghana at ech@isser.edu.gh / ech@ug.edu.gh or 00233- 303-933-866. Section C- PARTICIPANTS AGREEMENT "I have read or have had someone read all of the above, asked questions, received answers regarding participation in this study, and am willing to give consent for me, my child/ward to participate in this study. I will not have waived any of my rights by signing this consent form. Upon signing this consent form, I will receive a copy for my personal records." ………………………………………………………………… Name of Participants …………………………………………………. …………………….. Signature or mark of participants Date 156 Emotional Pain and Coping Strategies If participants cannot read and or understand the form themselves, a witness must sign here: I was present while the benefits, risks and procedures were read to the volunteer. All questions were answered and the volunteer has agreed to take part in the research. ………………………………………………………………… Name of witness ……………………………………………….. ………………………….. Signature of witness /Mark Date I certify that the nature and purpose, the potential benefits, and possible risks associated with participating in this research have been explained to the above individual. ……………………………………………………………….. Name of Person who Obtained Consent …………………………………………….. ……………………….. Signature of Person Who Obtained Consent Date 157 Emotional Pain and Coping Strategies Appendix 3 INTERVIEW GUIDE 1. What does emotional pain mean to you? 2. What was your initial feeling when you were faced with this situation? 3. Do you feel your present situation causes you emotional pain? 4. What were your thoughts at the time you heard of/experienced the situation? 5. Did your emotional pain become unbearable? 6. How do you deal with the emotional pain? 7. Do you feel your situation will get better? 8. Explain your daily experiences in detail. 158 Emotional Pain and Coping Strategies Appendix 4 UNIVERSITY OF GHANA RESEARCH QUESTIONNAIRE MODEL This questionnaire is part of a study that seeks to capture the emotional pain amputees and their caregivers go through. As one of the respondents, your contribution will be very significant in drawing conclusions for this study. It is however assured that, information collected will be handled with utmost confidentiality. Please be as candid in your opinion as much as possible. Please answer the following questions by placing a check mark against options that most applies to you. Demographics Please provide some information about yourself. Please pick appropriately. 1. Gender: Male__ Female__ 2. Age: 18-23years__ 24-29years__ 30-35years__ 36years and above___ 3. Educational Level: Primary ( ) JHS ( ) SHS ( ) Tertiary ( ) 4. Religious Affiliation: Christian ( ) Muslim ( ) Traditionalist ( ) None ( ) Other Specify: 5. (i) Caregiver( ) (ii) Patient( ) 6. Relationship to Patient (Applicable to 5(i) only): (i) Parent ( ) (ii) Spouse ( ) (iii) Ward ( ) (iv) Friend ( ) (v) Other ( ) 7. Type of amputation: Accident ( ) Other Specify:……………………………………. 8. Body Part Amputated: 159 Emotional Pain and Coping Strategies Depression, Anxiety and Stress Scale Please read each statement and circle a number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement. The rating scale is as follows: 0 Did not apply to me at all 1 Applied to me to some degree, or some of the time 2 Applied to me to a considerable degree, or a good part of time 3 Applied to me very much, or most of the time 1 I found it hard to calm down 0 1 2 3 2 I was aware of dryness of my mouth 0 1 2 3 3 I couldn't seem to experience any positive feeling at all 0 1 2 3 4 I experienced breathing difficulty (eg, excessively rapid breathing, 0 1 2 3 breathlessness in the absence of physical exertion) 5 I found it difficult to work up the initiative to do things 0 1 2 3 6 I tended to over-react to situations 0 1 2 3 7 I experienced trembling (eg, in the hands) 0 1 2 3 8 I felt that I was using a lot of nervous energy 0 1 2 3 9 I was worried about situations in which I might panic and make 0 1 2 3 a fool of myself 10 I felt that I had nothing to look forward to 0 1 2 3 11 I found myself getting agitated 0 1 2 3 12 I found it difficult to relax 0 1 2 3 13 I felt down-hearted and unhappy 0 1 2 3 14 I was intolerant of anything that kept me from getting on with 0 1 2 3 what I was doing 15 I felt I was close to panic 0 1 2 3 16 I was unable to become enthusiastic about anything 0 1 2 3 17 I felt I wasn't worth much as a person 0 1 2 3 18 I felt that I was rather touchy 0 1 2 3 160 Emotional Pain and Coping Strategies 19 I was aware of the action of my heart in the absence of physical 0 1 2 3 exertion (eg, sense of heart rate increase, heart missing a beat) 20 I felt scared without any good reason 0 1 2 3 21 I felt that life was meaningless 0 1 2 3 161 Emotional Pain and Coping Strategies Beck’s Hopelessness Scale Please read each statement and underline either True or False which indicates how much the statement apply to you. There is no right or wrong answer. 1. I look forward to the future with hope and enthusiasm. True/False 2. I might as well give up because there’s nothing I can do about making things better for myself. True/False 3. When things are going badly, I am helped by knowing they cannot stay that way forever. True/False 4. I can’t imagine what my life would be like in ten years. True/False 5. I have enough time to accomplish the things I want to do. True/False 6. In the future, I expect to succeed in what concerns me the most. True/False 7. My future seems dark to me. True/False 8. I happen to be particularly lucky, and I expect to get more of the good things in life than the average person. True/False 9. I just can’t get the breaks, and there’s no reason I will in the future. True/False 10. My past experiences have prepared me well for the future. True/False 11. All I can see ahead of me is unpleasantness rather than pleasantness. True/False 12. I don’t expect to get what I really want. True/False 13. When I look ahead to the future, I expect that I will be happier than I am now. True/False 14. Things just don’t work out the way I want them to. True/False 15. I have great faith in the future. True/False 16. I never get what I want, so it’s foolish to want anything. True/False 17. It’s very unlikely that I will get any real satisfaction in the future. True/False 18. The future seems vague and uncertain to me. True/False 19. I can look forward to more good times than bad times. True/False 20. There’s no use in really trying to get anything I want because I probably won’t get it. True/False 162 Emotional Pain and Coping Strategies The Big Five Inventory (BFI) Here are a number of characteristics that may or may not apply to you. For example, do you agree that you are someone who likes to spend time with others? Please tick for each statement to indicate the extent to which you agree or disagree with that statement. I see Myself as Someone Who... Disagree Disagree Neither Agree Agree Strongly a Little Agree Nor a Strongly (1) (2) Disagree(3) Little (5) (4) 1. Is talkative 2. Tends to find fault with others 3. Does a thorough job 4. Is depressed, unhappy 5. Is original, comes up with new ideas 6. Is reserved 7. Is helpful and unselfish with others 8. Can be somewhat careless 9. Is relaxed, handles stress well 10. Is curious about many different things 11. Is full of energy 12. Starts quarrels with others 13. Is a reliable worker 14. Can be tense 15. Is ingenious, a deep thinker 16. Generates a lot of enthusiasm 17. Has a forgiving nature 18. Tends to be disorganized 19. Worries a lot 20. Has an active imagination 21. Tends to be quiet 22. Is generally trusting 23. Tends to be lazy 24. Is emotionally stable, not easily upset 25. Is inventive 26. Has an assertive personality 27. Can be cold and reserved 28. Perseveres until the task is finished 29. Can be moody 30. Values artistic, aesthetic experiences 31. Is sometimes shy, inhibited 32. Is considerate and kind to almost everyone 33. Does things efficiently 163 Emotional Pain and Coping Strategies 34. Remains calm in tense situations 35. Prefers work that is routine 36. Is outgoing, sociable 37. Is sometimes rude to others 38. Makes plans and follows through with them 39. Gets nervous easily 40. Likes to reflect, play with ideas 41. Has few artistic interests 42. Likes to cooperate with others 43. Is easily distracted 44. Is sophisticated in art, music, or literature 164 Emotional Pain and Coping Strategies The Mental Pain Scale Please tick for each statement to indicate the extent to which that statement applies to you Strongly Disagree Agree to Agree Strongly Disagree (2) Some Extent (4) Agree (1) (3) (5) 1.Nobody is interested in me 2.I am completely helpless 3.I feel an emotional turmoil inside me 4.I cannot do anything at all 5.I will fall apart 6.I am afraid of the future 7.I am rejected by everybody 8.I am flooded by many feelings 9.I am completely defeated 10.I have lost something that I will never find again 11.I feel numb and not alive 12.I feel abandoned and lonely 13.I have no control over my life 14.My feelings change all the time 15.I am a stranger to myself 16. Others hate me 17.I feel that I am not my old self anymore 18.I am worthless 19.I feel paralyzed 20.I cannot concentrate 21.I cannot trust myself 22.The difficult situation will never change 23.I feel as if I am not real 24.I have difficulties in thinking 25.I need the support of other people 26.The world has changed forever 27.I feel confused 28.I have no control over what is happening inside me 29.I will never be able to reduce my pain 30.My life has stopped 31.I have no idea what to expect of the future 32.Something in my life was damaged forever 33.There is uncertainty about my life and 165 Emotional Pain and Coping Strategies myself 34.I will never be the same person 35.There are strong ups and downs in my feelings 36.I have no control over the situation 37.I want to be left alone 38.I have no future goals 39.I have no desires 40.I don’t feel like talking to other people 41.I can’t find meaning in my life 42.I can’t stay alone 43.I can’t change what is happening to me 44.The pain will never go away 166 Emotional Pain and Coping Strategies Multidimensional Scale of Perceived Social Support We are interested in how you feel about the following statements. Read each statement carefully. Indicate how much you agree or disagree to each statement. Use the following answers: 1= Very strongly Disagree; 2= Strongly Disagree; 3= Mildly Disagree; 4= Neutral; 5= Mildly Agree; 6= Strongly Agree; 7= Very strongly Agree 1 There is a special person who is around when I am in 1 2 3 4 5 6 7 need 2 There is a special person with whom I can share my joys and sorrows 3 My family really tries to help me 4 I get the emotional help and support I need from my family 5 I have a special person who is a real source of comfort to me 6 My friends really try to help me 7 I can count on my friends when things go wrong 8 I can talk about my problems with my family 9 I have friends with whom I can share my joys and sorrow 10 There is a special person in my life who cares 11 My family is willing to help me make decisions 12 I can talk about my problem with friends 167 Emotional Pain and Coping Strategies The Africultural Coping Systems Inventory Please tick for each statement to indicate the extent to which that statement applies to you Did not Used a Used a lot Used a great use little (2) deal (0) (1) (3) 1. Prayed that things would work themselves out 2. Got a group of family or friends together to help with the problem 3. Shared my feelings with a friend or family member 4. Remembered what a parent (or other relative) once said about dealing with these kinds of situations 5. Tried to forget about the situation 6. Went to church (or other religious meeting) to get help from the group 7. Thought of all the struggles Black people have had to endure and this gave me strength to deal with the situation 8. To keep from thinking about the situation I found other things to keep me busy 9. Sought advice about how to handle the situation from an older person in my family or community 10. Read a scripture from the Bible (or similar book) for comfort and/or guidance 11. Asked for suggestions on how to deal with the situation during a meeting of my organization or club 12. Tried to convince myself that it wasn’t that bad 13. Asked someone to pray for me 14. Spent more time than usual doing group activities 15. Hoped that things would get better with time 16. Read passage from a daily meditation book 17. Spent more time than usual doing things with friends and family 18. Tried to remove myself from the situation 19. Sought out people I thought would make me laugh 20. Got dressed up in my best clothing 168 Emotional Pain and Coping Strategies 21. Attended a social event (dance, party, movie) to reduce stress caused by the situation 22. Asked for blessings from a spiritual or religious person 23. Helped others with their problems 24. Lit a candle for strength or guidance in dealing with the problem 25. Sought emotional support from family and friends 26. Burned incense for strength or guidance in dealing with the problem 27. Used a cross or other object for its special powers in dealing with the problem 28. Sung a song to myself to help reduce the stress 29. Found myself watching more comedy shows on TV 30. Left matters in God’s hands 169 Emotional Pain and Coping Strategies TWI VERSION OF THE SCALE Depression, Anxiety and Stress Scale Mepa wo kyew, kenkan xkasamu ahodox yi firi (0, 1, 2 anaa 3) a sadeq xkasamu yi fa wo ho wx nnawxtwe a qtwaa mu yi. Nsqe berq kqse wx qbiara ho. qnni wati anaa watwa biara. Deq wobqfa so ahyehyq na qdidisox yi: 0 qmfa me ho koraa 1 qfa me ho kakraa bi anaa berq bi. 2 qfa me ho berq tenten kakra 3 qfa me ho paara anaa berq nyinaa 1 0 1 2 3 qyq me den sq mqgyae mu 2 M’anom to wxho 0 1 2 3 3 Mennya atenka papa biara wx ho 0 1 2 3 4 Menya xhome me haw (sq mehome ntqntqm anaa mentumi nhome.) 0 1 2 3 5 qyq me den mpo sq mqtumi ayx ade foforx 0 1 2 3 6 qma me yq nneqma mmorosox wx deq qsisi makwan mu 0 1 2 3 7 qma me ho woso nkanka me nsa 0 1 2 3 8 qma me tenka sq mede ahoxden kqse yq 0 1 2 3 9 qtumi ha me ma me ho so na awieq no medane xkwasea 0 1 2 3 10 Mete nka sq anidasox nyinaa asa. 0 1 2 3 11 Me ho yq me basabasa 0 1 2 3 12 qyq me den sq mqtena ase ahome 0 1 2 3 13 M’akoma tu 0 1 2 3 14 qmma nnya aboterq mma deq qtwee me firi deq na mereyq ho. 0 1 2 3 170 Emotional Pain and Coping Strategies 15 qba sq aka kakra na me ho awoso 0 1 2 3 16 qmma me nya anigyeq biribi foforx biara 0 1 2 3 17 Mete nka sq me ho nhia sq nnipa 0 1 2 3 18 Mete nka sq aka me papa. 0 1 2 3 19 Na me ti nka sq biribiri kx su makoma mu qbere a biribia nyq me (Ti sq, makoma 0 1 2 3 qbx ntemtem) 20 qhu bx me a mennim deq nti a. 0 1 2 3 21 qma mete nka sq abrabx ho nhia. 0 1 2 3 171 Emotional Pain and Coping Strategies Beck’s Hopelessness Scale Mepa wok yew xkasamu yinon kyerq sqdeq qbiara si fa wo ho. Sensan sq qyq nokorq anaa qnyq nokorq.Wati anaa watwa biara nni mu 1. Mehwq daakye wx anidasox pa mu. (qyq nokorq /qnyq nokorq) 2. qma megyae mu qfiri sq biribiara nni hx mqtumi ayq.(qyq nokorq /qnyq nokorq) 3. qma mehunu sq nneqma rekx so bxne wx abrabx mu a qhyq me nkuran sq qnka hx daa. (qyq nokorq /qnyq nokorq) 4. Mentumi nkyerq sqdeq m’abrabx bqyq wx mfie du a qdi manim yi. (qyq nokorq /qnyq nokorq) 5. Me wx berq tenten a mede bqyq neqma qda manim yi. (qyq nokorq /qnyq nokorq) 6. Menim sq daakye mqdi nkunim wx neqma qhia me paara mu. (qyq nokorq /qnyq nokorq) 7. Menni anidasox wx daakye. (qyq nokorq /qnyq nokorq) 8. Ama me tiri ayq yie. Na merehwq kwan sq mqnnya nnepa wx abrabx mu asen nnipa pii. (qyq nokorq /qnyq nokorq) 9. Mesuahunu dada no asiesie me ama daakye. (qyq nokorq /qnyq nokorq) 10. Deq mehunu wx manim biara nyq deq qhyq nkuran nkanapq sq nkuranhyq. (qyq nokorq /qnyq nokorq) 11. Menhwehwq kwan sq mqnya deq mehia nyinaa. (qyq nokorq /qnyq nokorq) 12. Sq mehwq daakye mqnya deq m’akoma hwehwq. (qyq nokorq /qnyq nokorq) 13. Sq mehwq daakye mehunu sq mqnya anigyeq akyqn nnq.(qyq nokorq /qnyq nokorq) 14. Neqma nkx yie sqdeq mehwehwq.(qyq nokorq /qnyq nokorq) 172 Emotional Pain and Coping Strategies 15. Mewx awerqhyq mu kqse ma daakye. (qyq nokorq /qnyq nokorq) 16. Mentumi nya biribiara a me hwehwq, qyq nkwaseasqm sq mehwehwq biribiara. (qyq nokorq /qnyq nokorq) 17. qntumi nyq hx sq mqnya deq qsx m’ani daakye. (qyq nokorq /qnyq nokorq) 18. Anidasox biara nni hx mma me daakye. (qyq nokorq /qnyq nokorq) 19. Matumi ahwq berq papa anim akyqn berq bxne. (qyq nokorq /qnyq nokorq) 20. Mfasox biara nni so sq mqnya biribiara qfirisq mentumi nya. (qyq nokorq /qnyq nokorq) 173 Emotional Pain and Coping Strategies The Big Five Inventory (BFI) Yqwx su ahodox bi a qbqtumi ayq wo su anaa qnyq wo deq. Nhwqsox ne sq woyq obi a wo ne afoforx bom kx sqe berq. Me pa wokyqw sensan xkasamu a qkyerq wogye tom anaa wonye tum. Me hhu me ho sq me yq: Mennye Mennye Menhunu sq Menyetu Menyetu ntom ntom Meyetum m kakra m papaa Koraa kakra anaa sq (4) (5) (1) (2) Mennye ntom (3) 1. Meyq kasatenten 2. Me hunu afoforx mfomsox 3. Yq adwuma qho teq 4. Me honhom boto 5. qfiri me ara, metumi de adwen foforx ba 6. Meyq koom 7. Meyq boafox na menyq pq sq menkomenya 8. Tumi toto nneqma basabasa 9. To mebo ase yi amanneq firi hx 10. Tumi yq nhwehwq mu wx nneqma ahodox mu. 11. Wx ahoxden sq 12. Hyq aseq ne afoforx kasakasa 13. Yq adwumayqni yqde yqn ho to no so. 14. Tumi de xhaw ba. 15. Sesa nneqmu qfiri sq me sesa nneqma 174 Emotional Pain and Coping Strategies 16. Ma ahuoden pii 17. Me wx fakyq honhom 18. Ntumi ntotox nneqma ne kwan so 19. Nneqma ha me dodo 20. Nsusuiq kx yie 21. Tumi yq din 22. Gye biribiara di 23. Yq kwadwofox 24. Gyina xhaw ano, na mma biribiara mmu maba mu. 25. Tumi hyehye nneqma foforx 26. Me wx su bi a ama metumi kyerq madwen 27. Metumi yq din na matwe mehu qfiri nipa hu 28. De nsiyq wie dwumadie biara 29. Tumi yq bxtee 30. Nani gyi nneqma a qyq fq hu na xtumi yq su 31. Metumi fqre adeq berq anon a mede me ho hyq mu. 32. qrekame ayq sq meyq ayamyq ma obiara 33. Meyq biribiara yie 175 Emotional Pain and Coping Strategies 34. Yq din wx xhaw berq mu 35. Pq daadaa dwumadie 36. Ne afoforx kabom 37. Nbu afoforx 38. Yq nhyehyq na xkx so de nhyehyq no kx awieq. 39. Kakra bi a na ahopopox aka no. 40. Mepq sq wxhu me de adwenkyerq di dwuma. 41. Wx adwennieq ho nimdeq kakrabi 42. Tumi ne afoforx bxm yq ade korx 43. Biribi tumi twe madwen ntqm 44. Madesua kx nkan wx adeyq, nnwum ena nkrata kyqrq hu 176 Emotional Pain and Coping Strategies The Mental Pain Scale Me pa wo kyqw yi xkasamu yi baako sese sqkeq qsi fa wo ho. Mennye Mennye Megye tom Megye Megye tom ntom ntom kwan bi so tom Kqse kqse Koraa (5) (2) (3) (4) (1) 1. Obiara ani nnye me ho 2. Menhumu me ho ano koraa 3. Mete atenka bxne bi wx me mu. 4. Mentumi nyq biribiara koraa. 5. Me mu batete 6. Me suro me daakye 7. Nnipa nyinaa apo me 8. Dodox no atenka atwa me ho ahyia. 9. Madi nkogyo pii. 10. Mayera biribi a mentumi nhunu bio. 11. Me tinka sq nkwa ni me mu. 12. Me hunu sq meyq ankonam a w’apo me. 13. Mentum nhyq mabrabx so. 14. Matenka sesa berq biara. 15. Madane me ho hxhox. 16. Afoforx tane me. 17. Mehunu sq menni me tebea dada mu bio. 177 Emotional Pain and Coping Strategies 18. Mensom bo. 19. Mete mmubuo nka wx me mu. 20. M’adwene nsisi so 21. Mentumi nnye me ho nni. 22. Berq qmu yq den no nsesa. 23. Mete nka te sq mensq hwee. 24. Me wx nsusuiq ho haw. 25. Me hia afoforx mmoa. 26. Wiase no asesa koraa. 27. Mehunu deq menyq me ho. 28. Mentumi nni nea aha me wx me mu no so. 29. Mentumi nte me yaw so 30. M’abrabx asi 31. Menni adwene biara mede bqhwq daakyi anim. 32. Biribi a qwx mabrabx mu asqe koraa. 178 Emotional Pain and Coping Strategies 33. Me ne m’abrabx nni nsusuiq biara. 34. Mentumi nnyina me ho so. 35. M’atenka a qkx soro ba fam no ano yq den. 36. Mentumi nni nnxxma a qsisie no so. 37. Mepq sq meyq ankonam. 38. Me nni daakye botaeq biara 39. Menni atenka afoforx 40. Menni atenka sq me ni afoforx nkasa 41. Mentumi nkyerqkyerq mabrabx mu. 42. Mentumi ntena sq ankonam. 43. Mentumi nsesa nneqma asisi makwan mu. 44. Me yaw ntumi mfiri me so. 179 Emotional Pain and Coping Strategies Multidimensional Scale of Perceived Social Support Sx nea saa nsxmfua yi ka watinka na ehia yxn. Kenkan nsxmfua yi mu biara yiye. Na kyirx sx nea wogye tom anaa wonye tum. Fa saa nyiano yi. 1= Me ni no nyx adwin kora koraa. 2= Me ni no nyx adwin koraa. 3= Me ni no nyx adwin. 4= Meda mfinfin. 5= Me ni no yx adwin kakra. 6= Me ni no yx adwin paa. 7= Me ni no yx adwin paa yie. 1 Onipa suronko bi bxn me bire a me wq ahohia mu. 1 2 3 4 5 6 7 2 Onipa suronko bi wq hq a me tumi ni no kyx mxnigye ne mawerxhoq. 3 Mxbusua bq mqdin sx wqbxboa me. 4 Me nya atinka mu nkuranhyx a mehia fi mxbusua hq. 5 Me wq onipa suronko bi a qyx mawerxkyikyi farebai. 6 Me ndamfonum bq mqdin paa sx wq bxboa me. 7 Metumi di m’ani to me nnamfofoq so bere a nneama nko yiye. 8 Metumi ni mxbusua adi me haw ho nkqmq. 9 Me wq nnanfoa me tumi ni wqn kyx mxnigye ne mawerxhoq. 10 Onipa suronko bi wq m’abrabq mua odwin me ho. 11 Mxbusua wq qpx sx wq bx boa me ma mesi agyinai. 12 Metumi ni me nnamfo adi me haw ho nkqmq. 180 Emotional Pain and Coping Strategies The Africultural Coping Systems Inventory Mepa wokyew boa xkasamu a qne wow o su kx pq. Yemfa nyq De yq biribi De yq De yq biribi kqse hwee kakra adwuma kqse kqse (0) (1) (3) (2) 1. Bx mpaeq sq nneqma bqkx so yie. 2. Boa kuo, abusua ne nnamfox ano ma wxboa sx xhaw ano 3. Ne abusua anaa nnamfox kyq m’atenka. 4. Me kae deq abusua anaa mawofox ka fa sqdeq yqsi yq xhaw ho adwuma. 5. Me bx mmxden ma me werq firi xhaw berq. 6. Me kxx asxre anaa Kristosom kuo ahodox mu hwehwq mmoa firi wxn hx. 7. Dwene sqdeq abibifox pere yq na ahyq me den ama matumi adi xhaw so. 8. Mema ade foforx fa madwene sqdeq qbqyq mennwene xhaw ho pii 9. Gye afutuo firi mpanyifox qwx mabusua mu ne me mpxtam, sqdeq a metumi ase xhaw ano. 10. Kenkan twerq Kronkron mu nsqm anaa nwoma foforx bi na ahyq me nkuran na abx me ho ban 181 Emotional Pain and Coping Strategies 11. Gye adwenekyerq firi me kuo mma wx me haw ho. 12. Bx mmxden hyq me ho nkuran sq tebea no nsae saa. 13. Ma obi bx mpaeq ma me. 14. Sqe berq pii kyqn berq biara yq akuoakuo dwumadie. 15. Wx anidasox sq aberq rekx anim no nneama bqyq yie. 16. Kenkan kasapan wx me daadaa mpaeabx nwoma mu. 17. Sqe bera pii kyqn bera biara ne mamfox ne abusua di nkutaho. 18. Bx mmxden twe me ho firi me haw mu. 19. Hwehwq nnipa me dwene sq wxbama me asere. 20. Me sxre hyq me ntaade papa. 21. Sq me haw so bate nti me sxre kx baabi adxfox ahyia tesq apontox ase, asabea anaa sini dan mu. 22. Gye nhyira firi honhom mu nnipa anaa Nyame nnipa bi hx 23. Boa afoforx wx amanneq mu. 182 Emotional Pain and Coping Strategies 24. Sx kyanerq ano de hwehwq ahoxden ne mmoa mede basi annanneq ano. 25. Hwehwq akyitaeq firi abusua ne nnamfox nkyan. 26. Hye duhwam de hwehwq ahoxden ne mmoa mede basi amanneq ano 27. Fa asennua anaa nneqma afoforx bi de hwehwq tumi soronko me de bqsi amanneq ano. 28. To dwom ma me ho de te ne haw so. 29. Hunu me ho sq merehwq agodie ahodox bi wx kasa mfonin so 30. Gyae amannea nyinaa hyq Onyankopxn nsa. THANK YOU FOR YOUR COOPERATION 183 Emotional Pain and Coping Strategies Appendix 5 ANOVA Table for Openness Model Sum of Df Mean Square F Sig. Squares b Regression 2424.060 1 2424.060 4.733 .031 1 Residual 75796.800 148 512.141 Total 78220.860 149 c Regression 7552.147 5 1510.429 3.078 .011 2 Residual 70668.713 144 490.755 Total 78220.860 149 d Regression 7686.600 6 1281.100 2.597 .020 3 Residual 70534.260 143 493.247 Total 78220.860 149 e Regression 8938.794 10 893.879 1.793 .067 4 Residual 69282.066 139 498.432 Total 78220.860 149 184 Emotional Pain and Coping Strategies ANOVA Table for Conscientiousness Model Sum of Df Mean Square F Sig. Squares b Regression 2424.060 1 2424.060 4.733 .031 1 Residual 75796.800 148 512.141 Total 78220.860 149 c Regression 7552.147 5 1510.429 3.078 .011 2 Residual 70668.713 144 490.755 Total 78220.860 149 d Regression 9758.663 6 1626.444 3.397 .004 3 Residual 68462.197 143 478.757 Total 78220.860 149 e Regression 11565.949 10 1156.595 2.412 .011 4 Residual 66654.911 139 479.532 Total 78220.860 149 185 Emotional Pain and Coping Strategies ANOVA Table for Agreeableness Model Sum of Df Mean Square F Sig. Squares b Regression 2424.060 1 2424.060 4.733 .031 1 Residual 75796.800 148 512.141 Total 78220.860 149 c Regression 7552.147 5 1510.429 3.078 .011 2 Residual 70668.713 144 490.755 Total 78220.860 149 d Regression 7552.936 6 1258.823 2.547 .023 3 Residual 70667.924 143 494.181 Total 78220.860 149 e Regression 8413.914 10 841.391 1.675 .092 4 Residual 69806.946 139 502.208 Total 78220.860 149 186