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Physical Rehabilitation: The Role of the Psychologist

Steve M. Shindell, Ph.D.

Steve M. Shindell, Ph.D. is in private practice at 1938 Peachtree Road NW, Suite 708, atlanta, GA 30309

As traditional psychotherapy modalities come under siege from insurance carriers, many psychologists are rediscovering practice areas that have long been the purview of psychology. One of these areas is rehabilitation psychology. It has been said that most disabilities are psychosocial problems with medical complications because of the severe changes that occur to a person's life post-disability. This article will discuss the various ways in which psychologists have been active in care of individuals with physical disabilities.

As a graduate student I tended to gravitate toward what I considered "emergency room" psychology rather than traditional mental health treatment. The patients I saw had tangible stresses and a relatively wary eye toward mental health practitioners. I found this work refreshing. The patients, by and large, rapidly became better psychologically. They were very apt to try new things, read books and, for the most part, eschew the victim role. In many ways, working within this field has made me more optimistic about people's coping skills. Also, working within a rehabilitation treatment team with physicians, nurses and rehabilitation therapists is wonderful for a psychologist. The psychologist tends to be the sole mental health practitioner. There are no ridiculous battles between psychiatry and psychology. Medical professionals see you as being solely responsible for your area, and for communicating this knowledge to the team.

Psychologists have been involved in physical rehabilitation for over 50 years for many reasons. Not the least of these reasons is that morbidity studies have shown that the best predictors of longevity following certain disabilities are psychological status, vocational attitudes and activity level. Interestingly, medical status was not a good predictor of longevity (Krause and Crewe, 1987). Thus, psychological interventions were not only important in producing quality of life changes they actually were the most important factors in improving length of life in persons with disabilities such as spinal cord injury.

This finding is not surprising in light of the fact that most disability care during the lifespan is focused on prevention of problems and remediation of behavioral problems such as depression , substance abuse, pain or cognitive deficits that could impair one's ability to adequately care for him/herself. Also, many social situations change after disability and learning appropriate responses to these situations is vital for their functioning. For example, learning how to deal with a bowel accident in public or how to ward off unsolicited help often is crucial in a person's successful rehabilitation.

Ironically, as payors have curtailed rehabilitation treatment by demanding shorter stays or less comprehensive treatment the role of the psychologist has grown. Many "difficult" patients who would be easily handled by a strong rehabilitation team are now discharged before the problem behavior is resolved. As a result, outpatient psychology treatment and rapid consultation services are needed. The psychologist who is in a position to offer such services can find a strong demand for his/her services.

Behavioral problems faced by individuals with disabilities fall into several categories.

  1. "problem patient" behaviors which are generally identified as upsetting to the operation of a rehabilitation treatment team, such as substance abuse, pre-existing psychopathology or personality disorders;
  2. "normal patient" behaviors which though not in and of themselves upsetting to a treatment team are seen as the psychologist's responsibility, such as adjustment problems, pain, depression, anxiety, sexuality and social skill training;
  3. "good patient" behaviors not upsetting to the team but disruptive to the patient's ability to progress in rehabilitation treatment, such as passivity and dependency.

The psychologist's goal in inpatient rehabilitation is to rapidly assess the patient and offer brief action-oriented treatment to patients in order to aid the physical medicine team in best serving the patient. Patients with unrealistic goals, affective disorders, or secondary gains can delay or reduce their chances for successful completion of the rehab program. Therefore, it is crucial that there is an optimal match between the patient and treatment so that the patient does not become "stuck" in a portion of their program, or miss an integral part of their rehabilitation training before discharge.

In addition to my direct work with patients, I try to train the rehab team in basic psychological principles that they can apply to their work with patients. Many times these rehabilitation therapists (physical, occupational or speech therapists, or nurses) have little training in the emotional aspects of their work. By training them, I am providing valuable consultation to the team, and helping the team members to know when a referral for psychological treatment is most appropriate.

The following are some simple explanations of psychological principles that rehabilitation staff can use on a day to day basis.

1. Recognize that all behavior is purposeful. There is a reason why people act and react the way they do. Simply "wishing it was different" only tends to cause frustration and anger. The first step in any problem solving should include asking yourself, "What would make this person behave this way?" This questions leads to answers concerning irrational beliefs, inadequate coping styles, or a disparity in goals.

2. See disability as a social disease. Having a disability affects the way people interact with you, how their accomplishments or capacity for accomplishments are viewed. For better or worse the majority of people will be ignorant of their needs. After a disability a person is responsible for becoming a better communicator, to listen for unasked questions, and to take appropriate action. The individual with a disability becomes a member of a minority group, and every underprivileged group has to undergo prejudice, ignorance and injustices with either a smile, a sermon or a baseball bat. The person has the responsibility for deciding how to handle these injustices. Keep from seeing patients as people with disabilities but rather as unique people dealing with a process that is special and potentially frightening to them. Try to approach each visit as if it was a first time contact for you (as it is for them).

3. Recognize that disabilities are shared. People with disabilities may view family members differently. Their lives change; roles, attitudes and priorities change. Often the patient may not be the main problem, or the best solution may not always involve intervention with the patient. Family members may have unrealistic or conflicting expectations. Other economic or vocational pressures may be present. For example, patients with marginal disabilities such as partial vision loss or benign multiple sclerosis have the highest rates of seeking psychological help. One reason for this finding is that it is harder for these patients to find a place to belong or to find others who can identify with their disability. As a result, they may inappropriately deny their disability or accentuate the problems to "fit in better" with others who are more disabled.

4. Communicate that adaptation is forever. People do not finish adjusting to disability any more than they finish adjusting to growing up. Adaptation is a continuous process but it is also important to realize that the disability may not always be the main stress in a person's life. Professionals and family members tend to overestimate the severity and duration of depression secondary to a disability because of their own discomfort and wish to help.

5. See psychological rehabilitation as everyone's responsibility. All team members should teach the person how to interact effectively the with world as a part of physical rehabilitation treatment. Psychological issues should not be viewed as an obstacle to rehab treatment such as physical therapy exercises, but rather as part of the treatment itself.

6. Recognize adaptation as a unique, dynamic and complex process. There are many varieties of adaptation, but successful adaptation always involves four parts:A focus on abilities, not disabilities; realistic expectations of strengths and weaknesses; expression of a wide range of acceptable emotions; Integration of the disability in self-concept.

7. Act as an expert consultant. This role keeps you from assuming responsibility for your patient's successes and failures (a paternalistic attitude that keeps both sides unsatisfied). This allows you to continue to provide care within your expertise, and to debunk myths that your staff or patient has about his/her condition. It keeps the responsibility of change with the patient.

8. Reinforce positive behavior in your patients. Remember, you are part of your patients' world. Their behavior with you can be a microcosm of their behavior at home. Patients that are assertive with you probably will be assertive in everyday life, while passive patients take what you have to offer may not have the social skills necessary to get their needs met outside of the your office.

9. Don't impose your own values. Rather than looking at what a patient should be doing, look at what their goals are and how they might attained. Just because one coping style (for example, religion or Western medicine) works for you for other patients does not make it the only means of adaptation.

10. Don't assume that psychological defense mechanisms are always bad and best confronted directly. For example, people use denial to remain safe and to maintain their emotional homeostasis. Denial is a way of shutting off frightening information. Direct confrontation of a patient's denial without looking at the reasons behind it will simply not work. Making the information less frightening while still presenting the facts in a clear manner will decrease denial. If the professional avoids the belief that change has to be instantaneous, that things needs only to be said once or that the timing of intervention is not important, then he/she will probably help patients make more lasting changes.

12. Stick with behavioral problems. An identified problem can be assessed by asking the following questions:

How does the patient describe the problem? Use your own feelings as a guide to what the patient might be experiencing. Ask yourself if these feelings are going to lead to a positive behavioral change. What might be happening in the patient's life to make his/her behavior seem like the best choice to him/her?
What would happen if I describe the difficulty in honest terms at the beginning of a session, before the problem surfaces?
What is possible for me to do now? How can I tell if I am successful?

Once you clarify the behavioral problem, make sure your recommendations and treatment are understood. Good clinicians spend a great deal of time having themselves and their patients paraphrasing each others comments, thus continually evaluating whether information is flowing in both directions.

13. Look at your own behavior. Recognize misbeliefs that you may have that are thwarting your efforts with respect to disabilities as well as with respect to professional practice.

Table 1. Misbeliefs concerning disability
  1.   I must have a disability to really understand it.
  2.   I should feel guilty and defensive about #1.
  3.   Adaptation to disability is a positive, linear process with a clear end point.
  4.   People with disabilities are all alike.
  5.   People with disabilities need to be depressed sometimes.
  6.   Denial is always bad and if I says things loud enough the person will stop denying.
  7.   There is a single, correct way to adapt to disability.
  8.   The less disabled someone is, the less difficult it is for him/her to adapt.
  9.   The social skills necessary after a disability are obvious to everyone, and professionals don't have to   assume this responsibility.
  10.   The disability is always the most important stress in the person's life and the cause of any problem.
  11.   Disability is a legitimate reason for making mistakes or avoiding responsibility.
  12.   People with disabilities are either gifted or defective.
  13.   People with disabilities are fragile.
  14.   The disability is more important in defining personality than any other environmental or personal characteristic.

I find that the items listed in Table 1 generate a lot of discussion. The discussion can then be applied to specific patients on the unit. Making the staff more psychologically minded makes the psychologist an integral part of the team process and, thereby, able to intervene more effectively with patients and staff. Such training also dramatically increases the amount of "mental health" staff that will be interacting with the patient throughout the day, thereby increasing treatment effectiveness.

Rehabilitation is an exciting psychological specialty. Although like most areas of practice, it is changing rapidly, there continue to be many new opportunities. For a psychologist, it offers a unique look at a varied group of people who are adapting to what is often the biggest stress of their lives. The psychologist must use all of his/her diagnostic and clinical skills while observing a rare view of real world human complexities.

References and Suggested Readings

    DeLoach, C. and Greer, BG (1981). Adjustment to severe physical disability: A metamorphosis. New York: McGraw-Hill

    Goffman, E. (1963). Stigma: Notes on management of spoiled identity. Englewood Cliffs, NJ: Prentice Hall.

    Krause, JS and Crewe, NM (1987). Prediction of long-term survival of persons with spinal cord injury: an 11 year prospective study. Rehabilitation Psychology, 32, 205-13.

    Scotch, K. (1984). From good will to civil rights: Transforming federal disability policy. Philadelphia, PA: Temple University Press.

Jeff McKee
Saturday, April 25, 1998