Psychological Treatment Implications for Acute Inpatient Rehabilitation Hospital Settings: A Literature Review

Note: the following literature is mostly based upon research. The parts that are not based upon research, and are based on my thoughts, are the steps in treatment

I was approached by someone I know about implementing a psychological and/or counseling program in the acute inpatient rehabilitation setting at one of our local hospitals. According to this individual, there are no psychological resources in the hospital at all. No psychologists, psychiatrists, or counselors. This individual works with the patients in the acute inpatient rehabilitation within the hospital and has noticed a need for psychological interventions. I agreed to do a literature review for the person to help gather information for a potential program proposal. What follows is a literature review of the physiological and psychological issues individual’s in an acute inpatient rehabilitation setting face, the typical psychological diagnosis and issues in this setting, implications for psychological treatment, information on group therapy, and information on licensure.

                Individuals in an acute inpatient rehabilitation setting face many obstacles in a wide variety of domains. The domains can include physical therapy, occupational therapy, speech therapy, orthotics/prosthetics, and, if available, psychotherapy. According the Bria Varner (2017)

“ the inpatient rehabilitation setting is designed to provide intensive rehabilitation therapy in a resource intensive hospital environment for patients who, due to the complexity of their nursing, medical management, and rehabilitation needs, require and can reasonably be expected to benefit from an inpatient stay and an interdisciplinary approach to the delivery of rehabilitation care.”

 These individuals must meet a variety of criteria to qualify for inpatient rehabilitation including:

  • Multiple therapy disciplines (at least 2)
  • Intensive rehabilitation therapy program
  • Ability to participate in therapy program (at least 3 hours a day, 5 days a week)
  • Physician supervision
  • Interdisciplinary team approach to the delivery of care
  • Medical need for 24/7 nursing care

Typical physiological diagnosis for an acute inpatient rehabilitation setting include:

  • Stroke
  • Spinal Cord Injury
  • Amputation
  • Major Multiple Trauma
  • Femur(Hip) Fracture
  • Brain Injury
  • Neurological Disorders
  • Multiple sclerosis, Parkinson, Guillan-Barre
  • Severe arthritis involving 2 or more weight bearing joints limiting activities of daily living
  • Knee or Hip Replacement
    • both hips or knees
    • Obesity (BMI > 50) or 85 years or older
  • Other medical diagnosis’

As you can see, there are a wide range of physiological issues that can present in an inpatient rehabilitation setting. So, what are the physiological issues that can accompany these conditions? According to LaRaia (2010), amputation can result in a multiple skin issues such as sweating, heat rash, blisters, contact dermatitis, and abrasions, which can lead to infection. Lower limb amputation can also have issues such as problems with postural alignment, muscle imbalances and strains, and gait abnormalities along with leg pain, back pain, and hip pain.

                According to the American Physical Therapy Association (2013) a femur fracture can result in extreme pain, motion and strength in the area are also effected. Major multiple trauma, also known as polytrauma, is a major, and sometimes life threatening, issue that involves two or more severe injuries in at least two areas of the body (Kroupa, 1990).

Common neurological disorders include Alzheimer’s disease, epilepsy, multiple sclerosis, Parkinson’s disease, and migraines. Physiological effects of neurological disorders may include Partial or complete paralysis, muscle weakness, partial or complete loss of sensation, seizures, difficulty reading and writing, poor cognitive abilities, unexplained pain, and decreased alertness (psychguides.com, 2019).

                Spinal cord injuries effect the communication between the brain and the parts of the body below the injury, which results in difficulty carrying out daily activities (University of Pittsburgh Medical Center, 2019).

The effects of a brain injury depend upon the injury and severity. Effects of a brain injury may include loss of consciousness from several minutes to hours, persistent headache or headache that worsens, repeated vomiting or nausea, convulsions or seizures, dilation of one or both pupils of the eyes, weakness or numbness in fingers and toes, loss of coordination, profound confusion, agitation, combativeness or other unusual behavior, slurred speech, and coma and other disorders of consciousness (Mayo Clinic, 2019).

The effects of a stroke vary depending on the area of the brain effected, but physiological effects may include weakness, numbness, stiffness, fatigue, incontinence, foot drop, paralysis, and seizures (National Stroke Association, 2018).

Arthritis is typically associated with painful and swollen knees or hands. However, there may be other issues which may include bone thinning and changes in kidney or lung function (Arthritis Foundation, 2015).

Finally, knee and hip replacements are typically associated with pain and effects in functioning.  A person who used to run may not be able to anymore. There is also a recovery time of approximately a year, in which a person may or may not return to full functioning (Harvard Medical School, 2019).

Now that we have a better understanding of the physiological issues that can result from these conditions, let’s take a look at the psychological issues. Depending on the type of injury or disease, the psychological issues can be different. Some psychological issues may be a direct result of the injury, as is the case in traumatic brain injury, which may result in agitation and increased combativeness (Mayo Clinic, 2019). Mood swings, sudden outbursts, depression, and delusions may be experienced with individuals who have a neurological disorder (PsychGuides, 2019). A common issue seen with stroke is aphasia, an inability to understand and express speech (National Stroke Association, 2018). Then there are psychological issues that are a result of going through something difficult and life changing adverse circumstances, which is often the case for patients in an acute inpatient rehabilitation hospital setting.

The psychological issues that can be implicated in experiencing a physical disability include (1, 6-7, 11, 13-17):

  • Depression
  • Anxiety
  • Adjustment disorders and growth issues
  • Employment issues
  • Social functioning
  • Identity issues
  • Grief
  • Post-Traumatic Stress Disorder (PTSD)
  • Sleep problems
  • Personality changes
  • Isolation
  • Emotional reactions– such as shock, denial, and anger
  • Substance abuse and dependency
  • Suicidal ideation
  • Shame
  • Role changes—(e.g. going from a stay at home mother to being dependent on the family)
  • Financial issues
  • Family issues
  • Coping with chronic pain

As you can see, the list of psychological issues is long and the specific issues may depend on the individual—social support, stress management skills, resiliency ability, financial situation, employment situation, and the individual’s past history of dealing with adverse circumstances. So, what are some treatment options for these issues? The treatment options, according to the literature, include (1, 6, 7, 11, 13-17):

  • Stress reduction/Management
  • Acceptance and Commitment Therapy (ACT)
  • Processing through the trauma/adverse circumstance
  • Mindfulness
  • Cognitive Behavioral Therapy (CBT)
  • Medication
  • Social skills
  • Psychoeducation
  • Case management
  • Self-awareness
  • Caregiver issues and self-care
  • Mind-body interaction
  • Spirituality
  • Communication and relationships
  • Setting goals
  • Positive Psychology (maximizing personal strengths)
  • Neuropsychology

There are several treatment options for the individuals in these specific adverse circumstances. Treatment may be different for each person, but will typically begin with some basic case management. What services does the patient require within the hospital? Outside the hospital? What and who are the person’s social/familial support? Does the person have access to transportation, medical care, medication management, and support groups? If not, how might we go about helping this person have access to the services they need?

The second step may be psychoeducation. What is the person’s disability? What does the person know about their disability? What are the effects of the disability on the person’s life—physical, mental, emotional, social, and spiritual? How might a person maximize their quality of life from here on out? How can caregiver’s help? All of these questions can be answered through psychoeducation and, in addition, normalizing the person’s struggles as struggles that majority of individuals in these circumstances experience.

The third step may be assessing the individual’s psychological and familial needs. Is the family adjusting well to this disability? If not, how can we help them? What services might the family need to help carry out their role? How can we help them have access to these services? In reference to the person’s psychological needs, what are the person’s strengths and weaknesses? Does the person have adequate stress management and coping skills? Does the person have strengths that can be maximized? If so, what are they and how can we maximize them? Does the person have growth areas, such as substance abuse, lack of awareness of self, lack of problem solving skills, low self-esteem, etc? If so, how can we go about improving these growth areas?

The fourth step may be creating a treatment plan for the individual and family unit. What goals might need to be reached in order to maximize the patient’s quality of life? Short and long term goals may be decided upon. What goals do we have for the family unit? Short and long term goals may be implemented. What modalities may we use to meet these goals? Individual counseling? Group counseling? Family counseling? A combination of two of these or all three?

The fifth step is implementing the treatment plan. Depending on the patient’s particular needs, one may begin before others, or a combination of treatment modalities may begin. Collaboration with other treatment professionals, such as physical, occupational, and speech therapists, medical doctor, social worker, and any other professionals that may be implemented in the holistic treatment of the patient.

The sixth step is continuity of care. When the individual is ready for discharge from the hospital, what goals have been met? What goals do the patient and family unit still need to meet? Adjustment of goals may be needed. What resources may the individual and family unit need to carry out these goals? Perhaps a counselor the individual and family can see on an outpatient basis. Perhaps a counselor that can come to the individual and family who may be dealing with transportation issues. Assessment of outpatient needs and resources is needed.

Now that we have an understanding of the psychological issues and treatment implications, I would like to briefly shine a light on group therapy.

Group therapy is often recognized as a treatment modality for issues such as grief, loss, depression, anxiety and other types of issues. But how does group therapy help? Well, there are several ways. Group therapy has a social support effect on individual group members. Individual group members feel support from the others, they feel that they are not the only one dealing with the struggles, they may experience new friendships, and they may increase their coping skills or understanding of their disability, and they may receive advice or input from other group members that can help the person (GoodTherapy, 2019). Group therapy also tends to be a mock of the person’s typical social situations and actions. If the patient struggles communicating with family members and friends, this will be evident during group therapy sessions. Interactions between the individual group member and other group members also shed a light on the individual’s temperament, trust issues, assertiveness, and interaction abilities. This gives the counselor a prime opportunity for insight into issues that may need to be worked on in individual counseling.

Screening for the group members may be needed. Acceptable group member qualities may include: openness, an ability to receive feedback, respectfulness, and insight. Unacceptable group member qualities may include: delusions or hallucinations, outbursts, and disruptiveness. In addition, the particular type of group therapy needs to be examined. Options can include psychoeducational groups, group therapy, and group psychotherapy. Though they sound similar, there are differences.

Group therapy focuses on growth, development, enhancement, prevention, self-awareness, and releasing blocks to growth. Group Psychotherapy focuses on both unconscious and conscious material and the present and the past. Psychoeducational groups typically focus around a certain theme, such as spinal cord injury, and focus on presentation and discussion of factual information and skill building through the use of planned skill building exercises. These groups also share common experiences, teaching people how to solve problems, teaching social skills, offering support and helping people learn to create their own social support outside of the group setting (Corey, 2015). Though group psychotherapy has important implications and can be helpful, group therapy and group psychoeducational is probably the best choice in the acute inpatient rehabilitation setting. These groups can focus on a specific topic, give and receive support, discuss experienced related to their physical issues/disabilities, improve social, emotional, and coping skills, as well as learn information related to the disability.

The last thing I would like to shed light on, that may be implicated in this particular treatment setting, is the specific professionals who can treat psychological issues in patients with physiological issues/disabilities. Typically, the professionals used in a hospital setting include psychologists, neuropsychologists, psychiatrists, and social workers. Psychologists are typically trained in doing therapy and social workers have the option of pursuing education and training in school and licensure. Neuropsychologists are trained in assessing whether issues are manifesting from a physical issue or psychological issue as well as doing therapy. Psychiatrists are used for medication management. If the person can benefit from psychological medications, a psychiatrist can evaluate the individual and treat accordingly.

Why are counselors not typically used in hospital settings? There may be a number of reasons for this. First, counselor education is usually geared towards settings such as agencies, schools, non-profit and for-profit organizations, and private practice. Second, though counselors are educated in the psychological issues that can result from these physiological issues, such as grief, substance abuse, and coping skills, they may not be educated in the vast medical issues and its implications for treatment. Third, they may not have the required licensure to work in inpatient hospital settings. Though it is unclear if hospitals require licensure, there is a specific licensure for counselors in hospital settings. The licensure implicated in rehabilitation settings is the Certified Rehabilitation Counselor licensure. This licensure is available for counselors who attended a graduate school program focusing on rehabilitation issues and treatment and/or have experience working in rehabilitation settings. In my experience, most counselors go to school for clinical counseling, human development, counseling psychology, and/or marriage and family therapy domains. The Certified Rehabilitation Counselors may be few and far between, and most likely in larger metropolitan areas (Commission on Rehabilitation Counselor Certification, 2019).

This literature review discussed the physiological and psychological issues implicated in an acute inpatient rehabilitation setting as well as discussed the potential focus of treatment for psychological issues, treatment modalities, and professionals implicated in treatment. Acute inpatient Rehabilitation settings may benefit from including a counselor, psychologist, or social worker licensed in therapy to provide individual, group, and family counseling for patients to accent the physical, occupational, and speech therapy services the patients may be receiving.

Resources

  1. N., & Tawadrous, N. (2018).  Psychological Evaluation & Intervention in Acute Rehabilitation. Retrieved February 12, 2019, from https://accessmedicine.mhmedical.com/content.aspx?bookid=1180§ionid=70382832
  2. About CRC Certification. (2019). Retrieved February 12, 2019, from https://www.crccertification.com/about-crc-certification
  3. American Physical Therapy Association. (2014, May 09). Physical Therapists Guide to Femur Fracture. Retrieved February 12, 2019, from https://www.moveforwardpt.com/SymptomsConditionsDetail.aspx?cid=f85bbe8f-685c-43bf-bb51-9bc43dd8fb01
  4. Varner, B. (2017) Inpatient Rehab 101. Powerpoint.
  5. Corey, G. (2016). Theory & practice of group counseling (9th ed.). Boston, MA, USA: Cengage Learning.
  6. Dunkin, M. A. (2019). More Than Just Joints: How Rheumatoid Arthritis Affects the Rest of Your Body. Retrieved February 12, 2019, from https://www.arthritis.org/about-arthritis/types/rheumatoid-arthritis/articles/rhemuatoid-arthritis-affects-body.php
  7. Fann, J. R., Crane, D. A., Graves, D. E., Kalpakjian, C. Z., Tate, D. G., & Bombardier, C. H. (2013, December). Depression treatment preferences after acute traumatic spinal cord injury. Retrieved February 12, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/23872078
  8. GoodTherapy.org. (2018). Coping with Health Issues. Retrieved February 12, 2019, from https://www.goodtherapy.org/learn-about-therapy/issues/health-illness-medical-issues/coping
  9. Harvard Health Publishing. (2019). Harvard expert: What you can expect from knee and hip surgery. Retrieved February 12, 2019, from https://www.health.harvard.edu/healthbeat/harvard-expert-what-you-can-expect-from-knee-and-hip-surgery
  10. Kroupa, J. (1990, July). [Definition of “polytrauma” and “polytraumatism”]. Retrieved February 12, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/2239047
  11. LaRaia, N. (2010, December). What Are Some of the Long-Term Physical Effects of Using or Not Using a Prosthesis? Retrieved February 12, 2019, from https://www.amputee-coalition.org/resources/long-term-physical-effects/
  12. Mayo Clinic. (2019). Traumatic Brain Injury: Symptoms and causes. Retrieved February 12, 2019, from https://www.mayoclinic.org/diseases-conditions/traumatic-brain-injury/symptoms-causes/syc-20378557?p=1
  13. National Stroke Association. (2018). Physical Effects of Stroke. Retrieved February 12, 2019, from https://www.stroke.org/we-can-help/survivors/stroke-recovery/post-stroke-conditions/physical/
  14. PsychGuides.com. (2019). Neurological Problem Symptoms, Causes and Effects. Retrieved February 12, 2019, from https://www.psychguides.com/guides/neurological-problem-symptoms-causes-and-effects/
  15. Psychosocial Issues of Spinal Cord Injury. (2019). Retrieved February 12, 2019, from https://www.upmc.com/services/rehab/rehab-institute/conditions/spinal-cord-injury/education-spinal-injury/psychological-issues
  16. Ramanathan-Elion, D., McWhorter, J., Wegener, S., & Bechtold, K. (2016, August). The role of psychological facilitators and barriers to therapeutic engagement in acute, inpatient rehabilitation. Retrieved February 12, 2019, from https://psycnet.apa.org/doiLanding?doi=10.1037/rep0000095
  17. Tirr Memorial Hermann. (2017, December 13). Behavioral Health Counseling. Retrieved February 12, 2019, from http://tirr.memorialhermann.org/programs-specialties/behavioral-health-counseling/
  18. Wu, D. Y., Guo, M., Gao, Y. S., Kang, Y. H., Guo, J. C., Jiang, X. L., . . . Liu, T. (2012, November). Clinical effects of comprehensive therapy of early psychological intervention and rehabilitation training on neurological rehabilitation of patients with acute stroke. Retrieved February 12, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/23146809

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