15 | Psychological Issues And SCI

Assignment and Intervention

In Ingrid's Rehab-Cycle®, a psychologist was assigned to address her emotional and psychological needs, focusing primarily on Ingrid's cycle goal 4 ‘psychosocial well-being’.

One important component of the psychologist’s interventions at the beginning of the Rehab-Cycle® was cognitive behavioural therapy (CBT). The psychologist met with Ingrid two to three times a week in CBT sessions. CBT was performed to help Ingrid increase her emotional stability, promote the development of relationships with others, support her ability to carry out a daily routine, and optimise Ingrid's handling of stress.

Box 3 | Cognitive Behavioural Therapy

Considered "a talking therapy"{cs15-fn22} cognitive behavioural therapy (CBT), a structured approach that incorporates various techniques focussed on education, problem-solving, and emotional and behavioural change on the part of the person, has shown to be helpful in reducing depression in persons living with spinal cord injury (SCI) and in fostering their short- and long-term adjustment to SCI. In SCI, CBT is designed to help persons with SCI develop coping strategies to deal with the challenges they face. 4 5 6 18

In CBT, the patient/client together with the therapist seeks to pinpoint and understand the patient/client's problems in terms of the dynamic interaction between thoughts, feelings and behaviour. CBT can include, among other things, strategies to reduce irrational or negative perceptions, reduce "all or nothing" thinking, and address issues of assertiveness. It ranges from structured individual psychotherapy to self-help material. It also calls for providing instruction on various topics, such as on relaxation or social skills, and facilitates a person's participation in rewarding activities. 4 5 6 18{cs15-fn22}

A number of factors can impact the effective delivery of CBT:{cs15-fn22}

  • A safe and trusting therapeutic relationship
  • A collaborative partnership in which both the patient/client and the therapist each have a contribution to make
  • The presentation of problems and situations that draws information from assessments, theory as well as evidence-based practice
  • A style of questioning that gently explores how and what the person thinks, while also fostering the person's own discovery of alternative ideas or way of thinking
  • Having the opportunity to try out and practice the lessons learned during CBT

CBT in a group can be a practical and cost-effective way to practice social skills, be exposed to other viewpoints and offer peer support. 4 6 18

Research has indicated that interventions such as CBT can improve a patient/client’s mood, lower alcohol and drug use, reduce medical complications related to SCI, and maintain these improvements for at least 2 years. Furthermore, CBT has shown to shorten hospital stay as well as reduce the frequency of clinical re-admissions. 6{cs15-fn18192012

In addition to providing CBT, the psychologist also conducted Feldenkrais therapy sessions with Ingrid once a week. Feldenkrais therapy{cs15-fn23} was intended to help improve Ingrid's energy and drive functions as well as how she perceives her own body. The psychologist also took the lead in the efforts toward improving Ingrid’s acceptance of her SCI and new life situation. Part of these efforts included increasing Ingrid's knowledge about SCI, for which every member of the rehabilitation team shared the responsibility. Each member of the team also contributed to assisting Ingrid develop effective coping strategies.

Beyond the interventions to address Ingrid's emotional and psychological needs i.e. cycle goal 4 intervention targets, the physical therapist (PT) and the occupational therapist (OT) provided interventions aimed at cycle goals 1 ‘improved mobility’ and 2 ‘improved use of fingers, hands and arms’. For example, the PT conducted prop-up training as well as movement reaction training to help Ingrid improve the ability to maintain a sitting position. The OT provided passive movements of selected joints to improve fine hand use and therapeutic games to improve hand and arm use. To improve overall mobility, muscle relaxation therapy was conducted to help reduce Ingrid's neck pain. Water therapy in the pool not only addressed the cycle goal 1 intervention target of muscle tone functions, it was also provided to help Ingrid become more aware of her altered body (as a result of her SCI).

While the majority of the intervention targets was addressed by one member of the rehabilitation team, the responsibility for selected intervention targets was shared by several members of the team. For example, the nurse, the PT and OT each provided interventions to help Ingrid improve her ability to change body positions. The nurse and OT also shared the responsibility for helping Ingrid improve her transferring skills as well as look after her health better, one of several intervention targets associated with cycle goal 3 ‘increased independence in self-care’. The other intervention targets related to self-care were primarily the responsibility of the nurse.

Along with the standard members of the rehabilitation team i.e. physician, nurse, PT, OT and psychologist, a nutritionist and vocational counsellor were also part of Ingrid's rehabilitation team. To assist Ingrid with weight maintenance the nutritionist advised Ingrid on the ideal dietary plan given her activity level, and helped Ingrid monitor her weight throughout the Rehab-Cycle®. To support Ingrid in clarifying her vocational options, a vocational counsellor was in contact with Ingrid’s former employer.

In addition to the clarification of Ingrid's future employment prospects, other issues related to community reintegration were also addressed during the Rehab-Cycle®. For example, both the social worker and the OT collaborated on exploring the possibilities of a wheelchair-accessible place to live after Ingrid's discharge from the rehabilitation centre.

The interventions and the corresponding intervention targets, as well as the rehabilitation team members who were responsible for implementing the interventions were documented on the ICF Intervention Table. See table 3.

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Table 3: ICF Intervention Table; Doc = Physician; PT = Physical Therapist; OT = Occupational Therapist; Psych = Psychologist; SW = Social Worker. The first value refers to the rating at the initial assessment, the goal value refers to the rating that should be achieved after the intervention, and the final value refers to the actual rating at the second assessment or evaluation. ICF qualifiers were used to determine these ratings (0 = no problem to 4 = complete problem) in the intervention targets. For the intervention targets representing the environmental and personal factors, the plus sign next to the value indicates a facilitator.

The interventions were conducted over a three-month period. About halfway through this time period, a major event took place that posed a significant set-back to Ingrid's rehabilitation  – Ingrid's boyfriend, a close and key person in her life, broke up with her. This life event negatively affected both her physical functioning and psychological well-being. As a result of the break-up, Ingrid's mood swings were exacerbated with longer depressive episodes, and getting through the day became more physically and emotionally challenging. Furthermore, she became increasingly frustrated and stressed out after realising that many of the goals set would most likely not be achieved within the Rehab-Cycle®.

"...a major event took place that posed a significant set-back to Ingrid's rehabilitation  – Ingrid's boyfriend, a close and key person in her life broke up with her."

Ingrid regularly felt overextended, repeatedly missing therapy sessions and other activities. In response, the team psychologist intensified CBT, counselling on coping strategies, and Feldenkrais therapy. Not only did the frequency of these therapies increase, more effort was made at funnelling Ingrid's personal resources. Moreover, the other members of the rehabilitation team reduced the number of their therapy sessions.

At the end of the three-month intervention phase, Ingrid's functioning was re-evaluated.

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