Feature

Long before “cross-collaboration” and “integrated health care” became buzzwords, rehabilitation psychologists were working right alongside physicians, nurses and physical therapists. According to its mission statement, Div. 22 (Rehabilitation), established in 1958, seeks to integrate psychological science into physical, emotional and behavioral rehabilitation — a mission that seems prescient today.

The field’s future is less certain. The emergence of neuropsychology as a field exploring similar questions — and the fact that grant-giving agencies tend to favor randomized controlled trials — have muddled rehabilitation psychologists’ role, said Tim Elliot, PhD, a professor of educational psychology at Texas A&M University in College Station. In response, Div. 22 is campaigning to rehabilitate the field’s image by encouraging psychologists to be explicit about the value they contribute.

“People’s cognitive, mood and behavioral aspects are strong predictors of medical outcomes — even more so than co-morbidities and initial prognosis,” said Brent Van Dorsten, an associate professor at the University of Colorado Health Sciences Center. “And people don’t realize that.”

Those themes threaded throughout the presentations at Div. 22’s 12th Annual Rehabilitation Psychology Conference in Tucson, Ariz., Feb. 25–28. Psychologists shared new research and their own experiences with piloting Web-based rehab programs for people with brain injuries, caring for “difficult” patients and clients, and helping people with injuries develop a positive self-image.

In a series of pre-conference talks, psychologists discussed the importance of rehabilitation psychology at large and to public health.

One problem they mentioned is that its interventions are often adopted and implemented by physicians and nurses, and people don’t realize rehabilitation psychologists researched and designed them in the first place, Elliot said.

It’s a branding issue, he said. When the field doesn’t receive the credit it deserves, it means its members are also less likely to receive funding to continue creating and refining treatments. Also, because policymakers look to randomized controlled trials as the “highest grade” of evidence, rehabilitation psychologists have a hard time impressing them because they often work with very specific types of brain injury or small sample sizes.

“It’s impossible to provide a control group for many of the issues we deal with,” Elliot said.

Barry Nierenberg, PhD, an associate professor for psychological services at Nova Southeastern University in Fort Lauderdale, Fla., emphasized that rehabilitation psychologists have a role to play in the big public health issues, too.

“All of the top five things that kill Americans have a behavioral and/or attitude component,” he said.

Heart disease, cancer, accidents, stroke and diabetes all can be prevented or have their risks reduced, he said, which is encouraging. Rehabilitation psychologists who work in medical teams can recognize some of these risks when they encounter patients with early warning signs and push the importance of preventative measures.

“If someone develops preventable diabetes, or has diabetes and it progresses, and that person loses a foot, insurance companies will pay $10,000 for a surgeon to remove that foot,” Nierenberg said. “But they’ll pay people nothing to prevent that from happening in the first place.”

The good news, he said, is that continuing to pay for after-the-fact surgeries and operations to the exclusion of preventative measures is an unsustainable model: Sooner or later, insurance companies will have to adjust their payment models because there’s just not enough money to support their current approach. At that point, they’ll be forced to adopt a prevention-centered model because it’s less expensive in the long run, Nierenberg said.

One way to help rein in health-care costs is by experimenting with new approaches to delivering care. One such experimenter is Thomas Bergquist, PhD, a neuropsychologist at the Mayo Clinic in Rochester, Minn., who is pioneering an Internet-based cognitive rehabilitation program for people with acquired brain injuries.

Bergquist noticed that the highest death rates from traumatic brain injury occurred in states with large rural populations: Alabama, Arkansas, Idaho, Louisiana, Mississippi, Montana, Nevada, Oklahoma and Wyoming. People from these states may not have convenient access to care, perhaps resulting in unusually high death rates.

Bergquist said the need reminded him of an earlier era, when caregivers made house calls. With today’s technology, they can do so virtually.

“In a way, we’re kind of revisiting an old concept,” he said.

Along with his colleague Carissa Gehl, PhD, Bergquist set up online chat rooms in which clients with brain injuries could talk with therapists many miles away. In their pilot study, the researchers sought to deliver a “memory notebook” intervention, through which researchers help people with brain injuries learn to use a calendar or notebook to compensate for impaired memory. On scheduled days, the clients logged onto the chat software and had a 30-minute online session with a therapist. A control group did the same and was instructed to keep a diary, but wasn’t specifically instructed to use it to compensate for memory.

After 30 sessions, Bergquist and Gehl faced both a disappointment and a success: Clients’ use of the memory notebook didn’t produce any better results than using the diary, but family members of those in each group rated the clients’ memory and mood as significantly better. That could be a side effect of having to remember the chat sessions in the first place and of having a listening, attentive person to talk to regularly, Bergquist noted, but still, it suggests that Internet-based therapies can improve the lives of people with brain injuries.

But even when traumatic brain injury patients receive the best care available, many will not get back to where they were, both in mind and body, before their injuries. That’s an important and often ill-considered aspect of rehabilitation psychology, said Robert Karol, PhD, director of psychology and neuropsychology at Bethesda Hospital in St. Paul, Minn.

He recommends that psychologists — as well as society as a whole — learn to emphasize the person before his or her limitations. “This isn’t a person,” said Karol, pointing to an image of a neuron. “And people aren’t their disabilities.”

We shouldn’t discount the importance of terminology either, he added. He points to a term frequently used in the past to refer to people with brain injuries, “brain damaged.” Not only is that offensive and demeaning, Karol said, but it implies hopelessness: The brain is damaged and defunct. (Karol uses the term “person with a brain injury.”)

Karol also emphasized that people with brain injuries fear losing their independence and becoming a burden to loved ones. Karol suggests that psychologists stress that nobody is truly independent. Few of us grow our own food, make our own clothes, refine our fuel, concoct our own pesticides, and so on.

A rehabilitation psychologist’s job is, therefore, not just to help people with injuries acknowledge the reality of their situations, but also to put those situations in context.

“We need to let our clients know that it’s OK to not be independent — none of us are,” Karol said.