Rehabilitation Psychology

Due to the increased awareness of the important influences of emotional and behavioral factors on health and illness, the last two decades have seen a substantial increase in the number of psychologists working in medical settings. Although most are employed in departments of psychiatry, psychologists have also become valuable members of other medical specialties including pediatrics, geriatrics, primary care, family medicine, anesthesiology/pain, and rehabilitation. In fact, over the last decade, the field of rehabilitation has been hailed as perhaps the greatest opportunity for psychologists to make unique contributions in the lives of health care patients (Frank, Gluck, & Buckelew, 1990). Rehabilitation psychology is a specialized discipline within the broad domain of clinical health psychology, and focuses on researching and providing clinical services to a broad group of health care patients to facilitate their adjustment to, coping with, and recovering from illness or injury. The American Medical Association (2002) generally defines impairment as the loss of, or loss of use of, a body part or system due to an injury or illness. Whereas impairment is solely a medical description of loss, disability is defined as a limitation or loss of one’s ability to meet personal, social, or occupational demands due to one’s illness or injury. Thus, disability is defined in terms of the functional impact of one’s impairment, and a person may have a physical impairment, but no corresponding functional disability. Finally, the AMA defines an individual as having a handicap if their impairment substantially limits their involvement with work, social, or leisure activities. As such, a handicap is generally interpreted as a barrier or obstacle to certain functional activities. The goal of rehabilitation psychology is to assist individuals in increasing their ability to function independently and to minimize any disability or handicap associated with a medical impairment. Rehabilitation psychology services may address issues in any or all of the physical, cognitive/affective, and social domains to improve quality of life.

Training

Rehabilitation psychologists typically complete doctoral-level training in clinical psychology programs that offer specialized coursework, practica, and predoctoral internships in health care facilities. After graduation, postdoctoral fellowship programs can provide additional specialized training, often directly in a rehabilitation environment. For practicing professionals, a variety of professional organizations, conferences, journals, books, and websites offer access to rehabilitation information and continuing educational training. The American Board of Professional Psychology (ABPP) recognizes rehabilitation psychology as a specialized area of psychological practice for certification. The American Psychological Association (APA) contains a specialized division for rehabilitation psychology, and this division’s website provides an important resource for information sharing and professional interaction among rehabilitation psychologists.

Scope Of Practice

Rehabilitation psychologists are employed in a variety of work settings including university medical schools, public and private hospitals, community-based rehabilitation centers that specialize in treatment for a specific rehabilitation population (e.g., brain injury or spinal cord injury), nursing homes, assisted-living facilities, and specialized private practices. Fewer than 5% of psychologists working in U.S. medical schools are specifically employed in rehabilitation medicine departments (APA, 1998), but instead provide services in the variety of work settings listed.

The process of rehabilitation is widely referred to as multidisciplinary in nature, and interventions are most often team based rather than being provided by a single person. Persons served are empowered to actively contribute to treatment goal setting and ongoing care decisions with their health care providers, and many professional specialties contribute their expertise toward achieving these goals. Rehabilitation psychologists are members of treatment teams that include physicians, nurses, physical and occupational therapists, speech language pathologists, and recreational therapists. Additionally, other mental health professionals including psychiatrists, social workers, neuropsychologists, specialized clinical health psychologists (i.e., pain management, biofeedback), and school psychologists may also contribute to the assessments, goal setting, and treatments of rehabilitation patients. Outside of the immediate medical environment, rehabilitation psychologist’s work may have far-reaching impact as they interact with schools, employers, state/federal agencies, correctional facilities, or courts regarding the various aspects of physical and emotional rehabilitation.

Surveys of practicing rehabilitation psychologists suggest that they spend the majority of their professional time providing clinical care or conducting research on health, cognitive, or emotion issues. Other duties include consulting with health or community services, teaching psychologists and physicians in training, contributing to program development, or consulting on the development of public policies addressing rehabilitation and public reintegration of people with certain disabilities or handicaps.

Clinical Challenges

As the field of rehabilitation medicine provides treatment to people with specialized injuries or illnesses, rehabilitation psychologists provide clinical services to individuals coping with limb loss, brain injury, spinal cord injury, burn injuries, neurological diseases (e.g., multiple sclerosis), sports medicine or athletic injuries, persistent pain problems, and mobility challenges (e.g., those using wheel chairs, walkers, or artificial limbs for movement). Rehabilitation psychologists serve people of all ages, ethnicities, and cultures, and interventions commonly involve both the patient and family members. In certain instances, members of the treatment team may be trained in specific behavioral or psychosocial interventions to promote improved patient functioning, and specific family members may receive training to provide care at home. The wide-ranging clinical assessment and treatment challenges addressed by rehabilitation psychologists are well described in several recently published books (Cushman & Scherer, 1995; Frank & Elliott, 2000; Radnitz, 2000).

Desirable Skills For Rehabilitation Psychologists

Whereas rehabilitation psychologists need to be competent in the professional skills of most practicing psychologists (i.e., psychological interviewing, testing, and psychotherapy), it is the specialized application of these skills to the unique rehabilitation populations that demands enhanced skill training for these practitioners. Rehabilitation psychologists rarely work in isolation from other multidisciplinary team members, and must be skilled in medical team consultation regarding cognitive or emotional issues, and capable of coordinating psychosocial assessment and treatment schemes within the context of a broad-based rehabilitative plan.

Rehabilitation psychologists employ psychological testing in several areas to assess patient’s cognitive functioning (e.g., mental status, intelligence, memory, learning, problem solving), emotional functioning (e.g., depression, anxiety, anger, personality issues, readiness for change, locus of control, self-efficacy, motivation, health-related beliefs and attitudes), and ability to cope with illness or injury (e.g., cognitive coping skills, active or passive coping, perceived control, confidence in one’s coping ability, social support). The typical goal of psychological testing in rehabilitation is to determine the extent to which emotional, behavioral, cognitive, or attitudinal factors may influence or interfere with an individual’s recovery from illness or injury. For example, results of cognitive testing (typically conducted by a neuropsychologist) can be used to estimate or predict a person’s ability to independently and safely perform activities in his or her home environment including self-care, child care, driving, managing money, self-administering medications, performing wound care, or understanding and consistently following health recommendations.

Rehabilitation psychology therapy is intended to enhance a person’s understanding of his or her illness or injury, and to determine the individual and family’s readiness to begin making adjustments to any physical, cognitive, behavioral, or emotional changes they have encountered. Rehabilitation therapy must be individualized in all cases because people adjust to, cope with, and accept change in many different ways and at different paces. For some, psychological adjustment may be rapid and there may be few struggles after weeks. However for others, it may take months or years of psychological assistance to gain even partial acceptance of changes brought about by illness or injury. Instructing patients and family members in any of several behavioral or cognitive coping skills, and allowing them to gain confidence in their ability to perform these skills, can facilitate personal adjustment. Specific skills taught in rehabilitative therapy might include ways to manage emotional extremes (e.g., depression, anxiety, or anger) or other important psychosocial issues such as self-esteem, body image, grief and loss, or pain and stress management exercises. Furthermore, assisting individuals and families in making cognitive changes, forming realistic expectations for recovery, or challenging unhealthy beliefs and attitudes about the patient after injury may aid recovery.

Rehabilitation psychologists are often involved in preparing people to undergo invasive medical tests or procedures (e.g., magnetic resonance imaging, injections, surgeries) by providing information and instructing in relaxation, imagery, and cognitive distraction skills (Deardorff & Reeves, 1997). Rehabilitation psychologists encourage patients to adopt healthy lifestyle practices including following healthy diets, increasing exercise, improving sleep patterns, consistently following treatment recommendations, and decreasing tobacco, alcohol, or drug use. The ultimate evaluation of the benefit of rehabilitation psychology therapies may include improved emotional functioning and either independent or modified reintegration of the person into his or her pre-injury or illness family roles and work, school, and leisure activities. All efforts in rehabilitation are aimed at improved quality of life for the person with illness or injury-related impairment. The value of providing psychological support to patients with physical and emotional disorders has been well established from both treatment efficacy and cost-saving perspectives (Friedman et al., 1995).

In summary, the impact of emotional, cognitive, and behavioral influences on recovery from illness or injury is being increasingly recognized in medical care. Rehabilitation psychologists play an important role in assisting persons with illness or injury to successfully return to their home, work, family, and leisure environments. The activities of rehabilitation psychologists encompass many settings, populations, and multidisciplinary treatment partners, and may have far-reaching effects in clinical, teaching, research, and program and public policy development areas.

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