Monica F. Kurylo1 and Kathleen S. Brown2
1Departments of Medicine and Public Health, University of Kansas Medical Center, Kansas City, KS, USA
2Private Practice, Fort Myers, FL, USA
Our wounds are often the openings into the best and beautiful part of us.
– David Richo
Rehabilitation psychologists “enhance the lives of people with disabilities and chronic illness” (American Psychological Association Division 22 Rehabilitation Psychology and the Rehabilitation Psychology Synarchy, 2015, p. 6) as noted in the petition for recognition of rehabilitation psychology as a specialty approved by the American Psychological Association's (APA) Council of Representatives in August 2015 (e.g., Dunn & Elliott, 2008). Rehabilitation psychologists recognize the wounds and resilience of the people with whom they work. Since World War II, rehabilitation psychologists have partnered with physicians treating patients with a variety of injuries and/or chronic illness, including amputations, spinal cord injuries, and head injuries (Cox, Hess, Hibbard, Layman, & Stewart, 2010). As the field of rehabilitation psychology matured, the specialty expanded to include working with children with disabilities and their families related to the establishment of the National Society of Crippled Children and Adults, working with government vocational rehabilitation organizations funded by state‐federal partnerships, and, more recently, advocating for people with disabilities through the passage of the Americans with Disabilities Act (ADA) in 1990.
Rehabilitation psychologists may specialize in working with particular medical diagnoses, such as head injury, stroke, spinal cord injury, amputation, or other neurological illness/injury, or they may work with a more broadly varied group of patients whom they encounter in inpatient or outpatient settings, similar to health psychologists. For example, rehabilitation psychologists may work with people who have become debilitated due to treatments for metastatic cancer, patients who are being considered for or have undergone solid organ transplant, and people who have sustained burn or electrical injuries. While the focus of psychological evaluation and intervention may be similar among both rehabilitation and health psychologists, the petition for recognition of rehabilitation psychology as a specialty noted that “Rehabilitation Psychology works with individuals who have acquired a disability or chronic health condition. Clinical Health Psychology uses similar assessment and intervention techniques to identify and enact health behavior change, while Rehabilitation Psychology has a ‘specific focus on adaptation to illness or injury’ (Klonoff et al., 2011), and the interactions between the individual, family, and physical, social, and policy environments in order to enhance social role participation” (APA Division 22 Rehabilitation Psychology and the Rehabilitation Psychology Synarchy, 2015, p. 32).
In 1952, rehabilitation psychology was introduced as a new subspecialty within the APA. Rehabilitation psychologists were identified as practitioners, educators, researchers, and advocates for people with disabilities working with interdisciplinary teams. Since that time, the field of rehabilitation psychology has expanded to include expertise as policy makers, healthcare administrators, and program developers. The importance of the role of rehabilitation psychology in the team has also been recognized by regulatory agencies, such as CARF (formerly known as the Commission for Accreditation of Rehabilitation Facilities) that includes psychology in their guidelines for staff inclusion on rehabilitation teams.
The purpose of this chapter is to introduce rehabilitation psychology as a subspecialty particularly with regard to practice areas of assessment, intervention, and interdisciplinary team functioning. Although some assessment instruments and interventions are similar to clinical health psychology, readers will understand how rehabilitation psychology contrasts with health psychology in its roles and focus. The role of rehabilitation psychology in research, advocacy, and training is also explained. For further information on rehabilitation psychologists performing as program developers, policy makers, and healthcare administrators, readers are encouraged to review Cheak‐Zamora, Reid‐Arndt, Hagglund, and Frank (2012).
In rehabilitation psychology, the assessment process is used to develop a multidisciplinary or interdisciplinary treatment plan that addresses the impact of a disability or other chronic health condition. In addition, adjustment and accommodation to the disability along with the necessary social and community supports to optimize functioning are also evaluated. Reasons for referral are many: individuals may be referred for assessment of physical, cognitive, emotional, and/or social adaptation to injury, illness, and disability in the patient and family; cognitive, emotional, and behavioral dysfunction; neuropsychological evaluation to determine ability to function at home, school, and/or work with or without accommodations; evaluation of self‐care and independent living skills; evaluation of psychosexual functioning, with an emphasis on education regarding disability‐related changes and use of adaptive technology; evaluation of social and recreational participation; assessment of health self‐management and prevention of secondary complications; and assessment of caregiver status and functioning, including caregiver knowledge and skills, social support, and self‐care. Assessment of each of these domains requires knowledge of a broad range of quantitative and qualitative assessment instruments and techniques.
Along with instruments for mood, pain, coping, adjustment to disability, and cognitive and physical functioning in health populations, assessment instruments have also been created to be used with diverse rehabilitation populations to address capacity for self‐care, work, and independent living. Instruments specific to rehabilitation populations, for example, may include instruments that assess the psychological assimilation of traumatic events, monitor progress throughout inpatient rehabilitation, and assess how people with disabilities function as active members of their communities (Heinemann & Mallison, 2010). Given the high prevalence of brain injury in traumatic physical injuries, cognitive screening measures are vital to determine the presence and extent of potential cognitive processing issues that can negatively impact treatment and recovery (Novack, Sherer, & Penna, 2010). Assessments of specific environmental or behavioral features relevant to intervention, such as stimulus control or contingency management, often focus on factors to aid integrative assessment for the development of a rationale for a particular intervention, to develop a working relationship with the patient and/or significant others, to address emotional reactions, and to develop expectations and attributions that support the intervention.
The importance of assessing and providing psychological services that best meet the individual and diverse needs of people with disabilities while maximizing their health and welfare, independence and choice, functional abilities, and social participation was highlighted in the Guidelines for Assessment of and Intervention with Persons with Disabilities (APA, 2012). Multiple issues relevant to diversity must be considered (e.g., age, gender, sexual orientation, socioeconomic status, religion, race, ethnicity) along with disability identity. An individual's military or veteran status may be an important part of their identity and may differentially affect their adaptation to disability or approach to assessment. Individuals with disabilities need to be included in all aspects of decision making to the best extent possible to ensure that their preferences and values are integrated into the conceptualization of assessment results.
As part of the comprehensive evaluative process, a rehabilitation psychologist may consult with other professionals, such as attorneys, government agencies, educational institutions, the Department of Vocational Rehabilitation, insurance companies, and case managers to optimize an individual's community functioning. Such consultations may include evaluation of acquired cognitive deficits with educational or vocational implications, development of reasonable accommodations for return to school or work, quantification of accident‐related “loss” for forensic purposes, recommendations related to hospital discharge plans, or recommendations concerning resumption of premorbid activities such as driving.
Psychotherapeutic interventions are an important part of the rehabilitation plan for individuals with disabilities to improve emotional distress often produced by changes in physical, task, and social functioning; to address the disruption of prior personal, family, and community roles; and to aid motivation, adherence, or participation in rehabilitation efforts. Interventions in rehabilitation psychology focus on applying the findings of assessment and diagnosis to facilitate functional task performance and social role participation in order to maximize the productive engagement of the individual in all environments. As disability is seen as a problem of exclusion from ordinary life through a “person‐first” perspective (Wright, 1983), interventions are aimed at facilitating adaptation and accommodation to illness or injury while seeking to minimize the attendant limitations. Evidence‐based interventions are modified to address the specific challenges an individual, couple, or family face that limit activities and restrict social role participation. Therapeutic interventions can involve emotional, cognitive, and/or behavioral domains. They can help shift the focus of the individual with a disability from premorbid sources of self‐esteem, such as physical prowess, to less impaired areas, such as cognitive and personality strengths (Keany & Glueckauf, 1993). At the family and community level, such emotional, cognitive, and behavioral shifts in emphasis can also significantly reduce disability by helping develop accommodations in the physical and social environments.
Hart and Ehde (2015) developed a theory‐driven framework for specifying rehabilitation interventions according to its targets, its active ingredients, and the mechanisms of action that connect them. They suggest that rather than describing rehabilitation treatments by the discipline(s) providing them (e.g., physical therapy, vocational retraining program), or by the problems they are intended to solve (e.g., attention training), treatments must specify the desired changes to narrow choices about specifically what one can do to effect change. Hart and Ehde call for a common system of nomenclature for characterizing and quantifying the treatment targets and ingredients used in clinical interventions and research to advance theory development and improve the quality of intervention research.
In rehabilitation, the team includes not only direct service providers but also the patient, family and significant others, and available community, school, and work relationships. Family members who provide care for persons with disability are themselves at risk for associated physical, mental, emotional, social, and financial problems and therefore may benefit from caregiver‐oriented interventions (Chwalisz & Dollinger, 2010). Caring for the caregiver improves and sustains the care provided to the person experiencing chronic illness or disability resulting in improvements in outcomes. Rehabilitation psychologists not only help caregivers understand their loved ones' difficulties but also help to manage problem behaviors, obtain and utilize social supports, and provide interventions to maintain caregiver health and well‐being. In caring for others, caregivers must take care of themselves in order to avoid burnout and the disintegration of a previously workable care plan.
Rehabilitation psychologists also intervene to assist with reducing the morbidity and cost of work injuries. Delivering health and rehabilitation services to injured workers in the work environment, instead of in community care settings, has been demonstrated to significantly reduce days away from work and worker's compensation costs (Wegener & Stiers, 2010). Negative experiences, including stereotyping and marginalization, discrimination, and disempowerment in the workplace, may also need to be addressed for individuals with disabilities, as with any individuals of minority status.
Rehabilitation includes many disciplines working collectively to serve patients with a wide variety of disabilities and chronic conditions. Rehabilitation psychologists contribute across the full spectrum of care from prevention, diagnosis, consultation, treatment, rehabilitation, and/or end‐of‐life and palliative care. As rehabilitation psychologists practice in these diverse healthcare delivery systems, they have a long tradition of working within multidisciplinary and interdisciplinary teams (Butt & Caplan, 2010). Interdisciplinary typically implies a team that is not only composed of different disciplines working toward a shared set of treatment goals but also have some fluidity of professional boundaries as team members collaborate to best assist the patient to achieve their goals. Functioning within teams requires expertise in communication, behavioral issues and management, patient decision making, and human interaction in systems with attention to the environment, culture, and context in which care is delivered. Rehabilitation psychologists must understand the roles, skills, and contributions of each discipline involved on the team as they educate other disciplines about the potential contributions of psychologists to the team. Awareness of areas of overlap in team member's contributions is aided by clear communication and respect for each team member's identified role that can change across patients or an individual's rehabilitation program. Barriers to effective team functioning can include hierarchical attitudes, unhealthy stress reactions, the lack of understanding of the advantages of coordinated team care, fear of change, risk aversion, and the challenge of developing an entrepreneurial spirit. Rehabilitation psychologists operate within rehabilitation teams, systems, and programs and provide expertise in the measurement and understanding of rehabilitation team functioning, rehabilitation outcomes, and facilitation of interdisciplinary rehabilitation team functioning (Butt & Caplan, 2010). Participation in interdisciplinary team meetings, case consultations, and rounds allow for the psychologist to aid the integration of problem definition, goals, observations, and services of different providers. As disability results from person–task–environment interactions, a focus on effective and efficient team functioning is necessary to optimize outcomes.
Health and rehabilitation psychology research has grown significantly in the past several decades. Although pioneers in the field of rehabilitation psychology provided an early framework for conceptualizing the work of rehabilitation psychology (i.e., Meyerson, 1948; Wright, 1983), rehabilitation psychology has generally been more focused on empirical evidence and clinical application than theory development (Dunn & Elliott, 2008). This is due in part to the challenge of applying psychological theories in multidisciplinary settings as well as the focus of rehabilitation on the individual and family, whose circumstances are unique and limit generalization as demanded in science. As scientist‐practitioners, practitioners often rely on single‐subject designs to apply the rigorous methods of science to their daily practice in an effort to determine whether interventions work and to improve patient outcomes. For general and geriatric rehabilitation populations, common areas of rehabilitation research typically focus on the natural history of disability, functional assessment and performance evaluations, intervention issues and outcomes, and rehabilitation service delivery systems.
Rehabilitation has been called a black box as its precise ingredients, their mechanisms of action, and their efficacy and effectiveness remain largely unknown. This lack of a systematic way to characterize interventions in rehabilitation has prevented advances in the field of rehabilitation in several ways (Dijkers, Hart, Tsaousides, Whyte, & Zanca, 2014). Rehabilitation research has been disadvantaged by interventions that cannot be readily replicated, tested against one another, or analyzed to try to match specific components to different kinds of patients. Lack of clear evidence about effective treatments and the lack of guidance by which to choose specific therapies for individual patients have hampered progress in clinical applications in rehabilitation. Communication and collaboration across the rehabilitation team, as well as communication with patients and third‐party payers, has been impeded by the lack of a common system for naming and describing treatments. Rehabilitation research needs to apply a systematic approach to treatment definition. When we can clearly define the active ingredients and targets of a treatment, then we can reliably study its effects; assess the fidelity of its implementation; replicate it in the correct doses in further studies, both experimental and observational; specify the changes and refinements that might be made to improve it; and disseminate it to the clinic setting (Hart & Ehde, 2015).
Healthcare in the United States suffers from high and rising costs and poor and uneven quality and safety, factors that increase the vulnerability of individuals with disabilities. The increasing prevalence of disability and chronic health conditions across the general population is largely driven by behavioral and lifestyle factors that are the primary contributors to premature morbidity and mortality and the foundation of the work of rehabilitation psychologists. Theories of health behavior change applied to people with chronic illness and disability help to explain the cognitive mechanisms of behavior change and adherence to treatment in the rehabilitation setting.
Research in positive psychology and posttraumatic growth, which focuses on resilience and promotes the concept that individuals can grow positively in response to challenge, stress, and trauma, has been applied to a variety of medical populations. The integration of positive psychology and rehabilitation psychology research has only more recently been applied to rehabilitation populations. Peter, Geyh, Ehde, Müller, and Jensen (2015) identified three commonalities between the two areas of study: positive principles, focus on individual strengths and resources, and well‐being, social participation, and growth as key outcomes.
Within a population health context, MacLachlan and Mannan (2014) identified areas of potential research that rehabilitation psychology could contribute to in an effort to address many of the challenges identified in the World Report on Disability. Specific targeted contributions include addressing the human resources needed for health crises in rehabilitation, developing prosocial and community‐based interventions and programs, helping to identify and overcome difficulties to accessing healthcare, refining the measurement and classification of disability, and strengthening research, policy, and advocacy for and with people with disabilities.
Research in interdisciplinary team science has also grown significantly within the past decade. Interdisciplinary research in rehabilitation is performed by individuals or teams that integrate information, data, technique, tools, perspectives, concepts, and/or theories from two or more disciplines or bodies of specialized knowledge to advance fundamental understanding or to solve problems whose solutions are beyond the scope of a single discipline or field of research (Committee on Science, Engineering and Public Policy [COSEPUP], 2004). Elements necessary to facilitate interdisciplinary team science include mutual respect among scientists; regular interactions focused on science; common language, constructs, and cultural norms; and institutional leadership and funding that supports transdisciplinary research. For rehabilitation psychologists practicing in the field, interdisciplinary science must address pragmatic concerns that impact how the psychologists can be an effective partner on the team. Concerns may include how the team's mission is determined; how the team and its mission is tied to the larger organization and the climate for the team's functioning; how leadership is determined, if it is shared, and whether and how it may change over time; what are the team's communication patterns; and how does the team make decisions and review and evaluate its progress and decisions. Each of these aspects of effective interdisciplinary team functioning is crucial to understand within our changing healthcare environment and shift toward integrated care in order to optimize patient outcomes within person–task–environment models of care.
The essence of advocacy in rehabilitation psychology is captured in Guideline 21 of the Guidelines for Assessment of and Intervention With Persons With Disabilities (APA, 2012), which states that “When working with systems that support, treat, or educate people with disabilities, psychologists strive to keep the clients' perspectives paramount and advocate for client self‐determination, integration, choice, and least restrictive alternatives” (p. 26). Rehabilitation psychologists advocate on treatment teams, within their family structure and social network, and in the community for their patients with regard to their physical and emotional needs. They advocate for needed environmental changes, such as accessibility to/from health provider offices (e.g., ramps, curb cuts), for additional time to complete tasks or other accommodations (e.g., at work or at school), or for therapeutic assistance (e.g., obtaining a therapy dog to assist with physical or sensory needs).
Rehabilitation psychologists also advocate at local, state, and national levels for legislation to assist people with disabilities, including ensuring access to affordable healthcare, social service, and rehabilitative therapy resources, and inclusion in social roles through the ADA (1990) (Cheak‐Zamora et al., 2012). They do this because they are “mindful of the fact that limitations of functioning may not only be inherent in the disability itself, but are often attributable, in whole or part, to environmental and institutional barriers, and to negative social attitudes” (APA Division 22 Rehabilitation Psychology and the Rehabilitation Psychology Synarchy, 2015, p. 6).
Graduate students in clinical and counseling psychology programs may first be introduced to physical rehabilitation in practicum experiences in inpatient and/or outpatient medical rehabilitation settings tied to clinical health psychology programs. For example, at the University of Kansas and the University of Kansas Medical Center, where the first author is located, graduate students in clinical psychology (health track) participate in required health practicum medical center experiences, including a neurorehabilitation psychology rotation (the first author is the supervisor) that allows them to participate in interviews, evaluations, and treatment of patients with new onset or chronic physical and medical issues. Externs also have the opportunity to participate in interdisciplinary team meetings, patient/family education, support/education groups, and community outings. The foundation of clinical psychology, learned within the first 2 years of their graduate program, provides a basis from which the students apply their skills in the new setting of inpatient or outpatient physical rehabilitation. Training may also occur during predoctoral internship or in postdoctoral experiences.
According to postdoctoral training guidelines first published in 1995 by Patterson and Hanson, training at the postdoctoral level is expected to occur for a minimum of 1 year with a minimum of two supervisors and include supervised practice, seminars, and coursework, a minimum of 2 hr of weekly didactics, a minimum of 2 hr of weekly supervision, and the patient populations and didactics are to be related to disabilities and chronic health conditions (Patterson & Hanson, 1995). In addition, trainees should be funded, written objectives for the training program are to be provided, formal trainee evaluations are to occur at least twice a year, and program evaluations are to occur annually.
The petition for rehabilitation psychology as a specialty notes that “Training in Rehabilitation Psychology is based upon a disability‐specific body of theory and research (Cox, Cox, & Caplan, 2013; Dunn & Elliott, 2005) which focuses on the physical, psychological, social, environmental, and policy aspects of disability and rehabilitation, and includes individual, psychosocial, and cultural aspects of disability. Knowledge acquisition concentrates on the application of psychology principles to understanding the needs of diverse people with disabilities in rehabilitation settings and their families. Content focuses on understanding the impact of physical, cognitive, and/or mental health disabilities on diverse individuals and their relevance in providing rehabilitation services such as assessment, intervention, vocational rehabilitation, case management, and advocacy. Such training can occur in formal experiences, such as didactics, seminars, and journal clubs, in interdisciplinary forums, such as interdisciplinary team‐patient care meetings, case conferences and grand rounds, and in supervision, both individual and group” (APA Division 22 Rehabilitation Psychology and the Rehabilitation Psychology Synarchy, 2015, p. 21).
The American Board of Rehabilitation Psychology has also determined specialty competencies for practice in rehabilitation psychology that guide training in progress toward an individual's attainment of board certification in the specialty (Cox et al., 2013). Such competencies include, but are not limited to, the ability to provide assessment and treatment related to adjustment to disability, cognitive functioning, family/couples functioning, pain, substance abuse, and educational, vocational, and recreational functioning; the ability to participate in interprofessional collaboration and consultation; knowledge of ethical, legal, and professional issues including laws related to persons with disability; knowledge of research and treatment and program evaluation methods as well as the ability to apply research findings to patients; and knowledge of and attention to diversity and cultural issues (Stiers & Nicholson Perry, 2012).
In this chapter, we have introduced rehabilitation psychology as a specialty within psychology, simultaneously recognizing its similarities with and differences from clinical health psychology. We have discussed practice aspects including assessment, intervention, and interdisciplinary team functioning that together allow rehabilitation psychologists to assist the team in treating the whole person. Research in rehabilitation psychology was reviewed, and the need for more theory‐driven research was described. Advocacy and training in rehabilitation psychology, both vital engagement areas, were also described. While rehabilitation psychologists are involved to varying degrees in research, practice, advocacy, and training, the Division of Rehabilitation Psychology within the American Psychological Association provides a home for those interested in this discipline of psychology. The approval of rehabilitation psychology by the APA Council of Representatives in August 2015 as a recognized specialty within psychology demonstrates the importance of this distinct field, thereby recognizing the ability of rehabilitation psychology to treat the wounds that expose the “best and beautiful” aspects of our patients.
Monica F. Kurylo, PhD, ABPP(Rp), is an associate professor and director of neurorehabilitation psychology in the Departments of Psychiatry and Rehabilitation Medicine at the Kansas University Medical Center. She received her doctorate in clinical psychology (health/rehabilitation emphases) and has internship and postdoctoral experience in rehabilitation psychology and neuropsychology. She is active in practice, training, advocacy, and research and has served on several local, state, and national professional psychology, rehabilitation psychology, and interdisciplinary groups (http://www.kumc.edu/school‐of‐medicine/psychiatry‐and‐behavioral‐sciences/faculty/clinical‐psychologists/monica‐kurylo‐phd‐abpp.html).
Kathleen S. Brown, PhD, is a rehabilitation psychologist involved in consulting, leadership training, and supervision in her independent practice in Fort Myers, Florida. Dr. Brown's clinical and research interests include pain management, interdisciplinary team development, leadership training in healthcare, and adjustment/coping responses to medical illness.