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Psychological Issues in the Rehabilitation of Persons with Spinal Cord Injury
Robert A. Moverman, Ph.D., Division of Neuro-Behavioral Medicine
(The following is based on the chapter “Psychological Factors in Spinal Cord Injury” from the text Spinal Cord Medicine: Principles and Practice (Demos Publications), the second edition of which has an expected release date of Spring 2010.)
Spinal cord injury (SCI) occurs primarily among young adults, with more than 80% being male. Most cases of SCI are due to the effects of motor vehicle accidents. Many persons who sustain SCI may have impulsive and sensation-seeking personality traits and a focus on physical abilities as a central basis of their self esteem. It is thus not surprising that many persons with SCI have considerable adjustment problems—SCI can severely impact one’s physical capacity and functional independence.
Emotional Response to Spinal Cord Injury (SCI)
One of the more common defense mechanisms found among newly injured SCI patients is denial. Patients may insist that they will “walk out of” the hospital despite being told that this is not at all likely. Although this may not be a rational perspective, it does have the benefit of reducing depression, anxiety, and other mood disturbance. As the person progresses through a course of inpatient rehabilitation, denial generally gives way to other coping patterns. Anger is not at all uncommon, and a well-trained staff, including a rehabilitation psychologist, can help manage these issues. Although some patients may go through “stages” of adjustment, there is no established or common pattern—all patients find their way and adjust to their circumstances with their own style.
The greatest amount of emotional distress usually occurs two to three weeks post-injury and may involve more of a feeling of sadness than true depression. Factors such as pain, fatigue, and decreased sleep can increase the likelihood of emotional unrest. Interestingly, one study found that one of the most distressing issues for patients with SCI was the perception that the rehab staff expected them to be distressed. It is thus important for treating professionals to be aware of such bias and focus on realistic hope and optimism for the SCI patient.
In addition to psychological difficulties, neuropsychological deficits have been found in a sizeable number of persons with SCI. This may be related to mild traumatic brain injury or concussion occurring at the time of injury. It is important to screen for such deficits, particularly given that a person with SCI needs to absorb, learn, and remember a good deal of information related to the management of their condition.
Physical Adjustment
Once out of rehab, the person with SCI enters a new stage of adjustment—dealing with the “real world.” Among the challenges are those associated with architectural barriers, social stigma of being disabled and in a wheelchair, and decreased support and attention from others as life goes on. Being assertive—in terms of requesting help, expression of feelings, and standing up for one’s rights—can be most important in determining the level of psychological adjustment. Here is an actual example of the challenges such a person can face:
A man with paraplegia was able to drive his car to a ballfield to watch his son play in a Little League game. The only handicap parking spot was directly behind the backstop and was occupied by a non-disabled woman in a big Cadillac. The man beeped his horn and tried to get her attention, but his efforts were fruitless. He thus had to park behind her vehicle for the duration of the game. When it ended, he did not back up but instead stayed parked in his spot, much to the consternation of the other driver. She finally got out of her car, approached the man and complained about his blocking her car, as she wanted to leave now. He politely explained that he did not move because he wanted to tell her how upsetting it was to have a non-disabled person occupy the handicap parking spot, thus resulting in his having an obstructed view of the game. She angrily replied, “Well, I suggest you learn to walk!”
Other challenges to the person with SCI include realignment of family roles and responsibilities, sexual challenges, work and leisure issues, and the effects of aging (e.g., decreased ability to be mobile at a wheelchair level).
Quality of Life
A particular concern from a wellness and lifestyle perspective involves the issue of return to unhealthy behaviors such as smoking, drinking,
and/or drug misuse. This is most likely to occur three to six months post-discharge from the hospital. This can have serious ramifications such as further decrease in one’s alertness and attention to bodily needs such as regular pressure relief, and increased susceptibility to respiratory, balance, and bladder problems.
Another post-rehab matter of concern involves depression. The majority of persons with depression do not get diagnosed or treated, and the incidence of depression among persons with SCI is particularly high. Furthermore, suicide or unplanned self-harm is the primary cause of death in SCI for up to six months post-injury.
Quality of life for persons with SCI may seem to be a major concern, but the loss of ambulatory ability is not reported to be the most frustrating issue. Rather, the loss of bowel and bladder function is at least as distressing. Nonetheless, the ability to rise to the challenge and overcome adversity may include a person’s developing enhanced stress management skill, increased patience, and an increased sense of interconnection to significant others. One person with paraplegia who spoke to an audience at our rehab hospital, proclaimed that the good things that arose in her life from her SCI and eventual success in wheelchair marathons were so enriching that she was actually glad to have acquired this disability! This is not dissimilar to Dr. Bernie Siegel’s half-joking response to the question, “What do you give to the person who has everything?—Cancer!”
The Rehab Team
The role of the rehab psychologist is very important to the overall success of persons in SCI rehab. Helping patients develop strategies to manage anxiety, depression, pain, insomnia, and other problems ensures an optimal outcome. Additionally, some patients can display behaviors (anger, treatment resistance, withdrawal, etc.) that can be rather challenging to rehab team members. Bringing the team together to consult and brainstorm (we call it “Behavior Rounds”) can help ameliorate or better control these issues.
In summary, SCI can present a myriad of challenges not only to the patient but to the treating professionals as well. Personal and interpersonal conflicts can be due to a combination of individual personality factors and the more universal struggles that occur with SCI. The rehabilitation psychologist can be a key member of the treatment team for the purpose of consulting with patient, family, and other treatment team members.
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