At the start of this Rehab Cycle, a psychologist was assigned to address Ingrid’s emotional and psychological needs, focusing primarily on One important component of the psychologist’s interventions at the beginning of this Rehab Cycle was the initiation of cognitive behavioural therapy (CBT) that took place two to three times weekly. CBT attempted to address a number of issues over the course of the Cycle, including improving emotional and personality functions, promoting relationships, carrying out a daily routine and handling stress.

Box 3 | Cognitive behavioural Therapy 1819

Cognitive behavioural therapy (CBT) is a major form of psychotherapy that includes a range of therapies intended to treat emotional disorders. The use CBT originates in human psychological models of behaviour and “is based on the clinical application of extensively researched theories of behaviour”. It is cognitive in that it deals with how individuals process and instill meaning in events and situations. CBT is behavioural in that it deals with a person’s responses to stress. CBT aims to “target distressing symptoms, reduce stress, reevaluate thinking and promote helpful behavioural responses by offering problem-focused, skills-based treatment interventions”. Patients and therapists together seek “to identify and understand problems in terms of the relationship between thoughts, feelings and behaviour”.

A number of factors can impact the effectiveness of CBT:

  • A safe, trusting therapeutic relationship
  • The degree and quality of the collaboration, both on the patient’s and the therapist’s part
  • How the therapy is formulated i.e. how are hypotheses relating to a patient’s problems and situation integrated?
  • “Socratic dialogue”, a line of inquiry that explores meaning and encourages alternative thinking
  • Assigned homework where the patient attempts to practice what is learned in the CBT sessions

Research has demonstrated that behaviour therapy initiated early in the rehabilitative process can be beneficial to those with SCI, both in short- and long-term rehabilitation. Such an intervention can improve a patient’s moods, relationships, self-care and independence, as well as lower the length of hospital stays, the frequency of clinical readmissions and the risks of subsequent substance abuse. 192012

The psychologist would also undertake Feldenkrais therapy (see Case Study 9 for further information) once a week to help increase energy and drive functions and improve Ingrid’s relationship to her body.

Together with the other health professionals the psychologist would take the lead in improving Ingrid’s acceptance of her disease. Additionally an educational component was established: every member of the team would share some responsibility in increasing Ingrid’s knowledge of her SCI. Each member of the team would also help contribute to establishing coping strategies.

Ingrid’s physical and occupational therapists would undertake many of the interventions aimed at Cycle Goals 1 (mobility) and 2 (handling objects). Muscle relaxation therapy would help reduce the neck pain, while active power training (e.g. utilizing exercise machines) would improve Ingrid’s abilities in mobility and handling objects. Movement reaction training would help her maintain a sitting position. Water therapy would contribute to her overall muscle tone and body awareness. Both therapists and nurses would train Ingrid in transferring and changing body positions.

Ingrid’s nurse was largely responsible for interventions related to self-care (CG 3). Instruction and support were given for self-washing, dressing, eating, looking after her health and caring for different body parts. Additional support was offered for regulating urination and defecation, as well as for performing skin care and wound dressing to address her pressure sores.

Other team members contributed to other areas of need for Ingrid. A nutritionist would monitor and advise her as to the best diet for weight maintenance given her activity level. Ensuring remunerative employment would be supported by her social worker and a vocational trainer who would address the issue with Ingrid’s former employer. Additionally, affairs with Ingrid’s health insurance would be mediated by the social worker to ensure that financial aspects of her rehabilitation were cared for. The social worker and occupational therapist would also work on exploring possibilities for a place to live.

These interventions among others were planned for a three-month period, at the end of which Ingrid’s functional status would be reevaluated.

A major setback took place midway through the cycle that negatively impacted all of her rehabilitative efforts. Ingrid’s boyfriend – a close and key individual in her network of support – made a difficult decision to break up with her. This one event sent her into a depressive mood and affected both her physical functioning and emotional well-being.

Ingrid’s boyfriend – a close and key individual in her network of support – made a difficult decision to break up with her.

Throughout the Rehab Cycle, and particularly as a result of the break-up, her mood swings continued with long episodes of depressive moods and getting through each day was both a physical and an emotional challenge. Frustrations also mounted
along with her levels of stress as she realized that the established goals couldn’t be achieved. Carrying out a daily routine proved ever more challenging and Ingrid felt herself continually overextended, repeatedly missing therapy sessions and other activities.

Ingrid’s health care team responded to her emotional decline by attempting to minimize her stress. Reductions among the rehabilitative interventions helped to lower her physical stress. Additionally, those interventions focusing on
emotional well-being were intensified: behaviour therapy, coping counseling and Feldenkrais therapy took place more often and greater efforts were made at marshalling her resources.

Figure 3: ICF Intervention Table

Figure 3: ICF Intervention Table Phys: Physician, PT: Physiotherapist, Psych: Psychologist, SW: Social worker