After a month-long hospitalization from COVID-19, a once-independent older adult struggles to complete daily tasks. They can't make breakfast without getting fatigued or focus on reading the paper. They've been in physical therapy for months and are not making the progress they think they should be making. Depression is starting to set in. Family members wonder if they should consider a care home.

On a wet morning, an avid mountain biker loses control and is knocked out. They're hospitalized and initially make great strides in recovery. Months later, however, physical therapy hasn't fully resolved their feeling of being off-balance. They've been avoiding biking, and even walking or running, because they're terrified of falling again.

Physical rehabilitation alone isn't working for these patients, and it's beginning to feel like recovery either won't come or won't end. These are circumstances in which a rehabilitation psychologist may be useful to guide them through the process of rehab and recovery, says Brigid Waldron-Perrine, Ph.D., a rehabilitation psychologist at Michigan Medicine.

"You don't get a manual that comes with your injury that tells you how to navigate returning to your usual pattern of functioning," said Waldron-Perrine, who is also an associate professor of physical medicine and rehabilitation at U-M Medical School. "In many cases, there are cognitive, behavioral or emotional barriers to progress that patients may not understand or know how to manage. As experts in human functioning, that's where we can be useful guides."

What is rehabilitation psychology?

Around 25% of Americans – more than 60 million people – have some type of disability. And millions of people are evaluated each year for traumatic brain injury, stroke, heart attacks and other conditions that can affect a person's mobility, cognition or other forms of functioning.

Many conditions don't have one straightforward treatment or "answer" that will result in certain success. There may not be a surgery to receive or pill to take that returns someone to optimal functioning. This uncertainty, Waldron-Perrine says, makes many patients very uncomfortable.

"There is this sort of internalized belief in society that medicine is certain, but when you actually find yourself in the health care system, you realize very quickly that there is a great deal more uncertainty in medicine that anyone would have ever guessed," she said. "Physicians often do not have the skill set or tools to respond to your discomfort with uncertainty."

Rehabilitation psychology addresses that uncertainty directly and encourages maximizing meaningful engagement in individually relevant ways. The field developed after World War II as soldiers were treated and was further advanced by Beatrice Wright in the 1970s and beyond. Wright notably expresses that coping with or adjusting to disability cannot be fully understood without examining social and environmental factors that contribute to success in living or, alternately, distress.

Rehabilitation psychologists assess and treat cognitive, emotional and functional difficulties. Often working in multidisciplinary treatment teams, they help people to identify and overcome barriers to participation in life activities. If a patient who had a stroke because of high blood pressure or diabetes is not effectively managing their condition and continually ends up back in the hospital because they don't understand the physician's instructions or can't follow them, a rehab psychologist could be consulted.

"We encourage the patient to understand their own needs and to assert those needs within the system, while assisting the system in meeting the care needs of the patient," Waldron-Perrine said. "Oftentimes, addressing issues of communication or identifying problems to be addressed proactively can cut downstream costs of rehospitalization or redundant treatment because of lack of an integrated treatment plan."

Rehabilitation psychologists are integral members of the rehabilitation team at U-M Health, says Ted Claflin, M.D., associate director of the Michigan Medicine Inpatient Rehabilitation Facility.

"Their understanding of human behavior allows them to better understand and treat psychological issues that confront our patients after a significant medical issue has happened," Claflin said. "They can help people adjust to a new diagnosis, stay motivated during their recovery or deal with the emotional aftermath of hospitalization and/or treatment."

Where is the field of rehabilitation psychology heading?

During the COVID-19 pandemic, several studies have shown increasing demand for therapy after people experience long hospitalizations. While it may seem to be solely a growing demand for rehabilitation and psychologists dedicated to it, Waldron-Perrine says, it's just a need that has consistently not been met.

"The need is being met in some places where the system recognizes the impact we can have not just at the patient level but at the clinician, therapy team and system level," she said. "But the traditional medical model does not necessarily include rehabilitation psychology as a universally available resource, which means our services and reach are often limited."

Over several decades, as rehab psychologists have seen a need for more of their services, reimbursement margins for the care provided have dipped. The costs of tests and technology used to assist patients continue to rise, while services for patients are met with less coverage by insurance providers. Additionally, categorization by insurance panels can provide an additional barrier to accessing care, with separate coverage and authorizations often the only option for patients seeking what is considered "mental health" treatment, no matter the medical context. 

In a recent "state of the field" study, Waldron-Perrine and several experts concluded that rehab psychologists need to be more active in promoting their unique contributions to health care, with the ultimate goal of being seen as "go-to" experts for the many roles they serve. The results are published in Rehabilitation Psychology.

In addition to cost savings from decreased hospitalization and redundant care, researchers say rehab psychologists can demonstrate their ability to assess the likelihood of successful outcomes for surgical intervention, such as bariatric surgery for obesity and spinal cord stimulator placement for back pain.

Ultimately, Waldron-Perrine says, there are simply not enough people in the field to optimize the care of the many and diverse patients seen in rehabilitation settings. The researchers noted that professional recruitment outreach needs to happen "broadly and simultaneously" at the high school, college and graduate school levels.

"A rehabilitation psychologist recognizes that individuals have unique needs, and function within a complex system," Waldron-Perrine said. "The goal is to maximize function and adaptation of every person in every aspect of life. With increased public awareness of this profession and increased recruitment from a relatively early level of education, we will hopefully see payoff in future research and public policy advocacy that contributes to meeting the needs of all patients and, ultimately, a more equitable world."

Like Podcasts? Add the Michigan Medicine News Break on iTunes, Google Podcasts or anywhere you listen to podcasts.

Additional authors include: Laurie N. Baker, Ph.D., Mark Barisa, Ph.D., Mark Sweatman, Ph.D., all of the Shepherd Center, and Robert L. Karol, Karol Neuro+Rehab Consulting, Greg A. Stern, PsyD, Courage Kenny Rehabilitation Institute

Paper cited: "Rehabilitation Psychology: 2020 State of the Field Survey," Rehabilitation Psychology. DOI: 10.1037/rep0000433

Like Podcasts? Add the Michigan Medicine News Break on iTunes, Google Podcasts or anywhere you listen to podcasts