Psychological Aspects of Rehabilitation
Daniel E. Rohe
This chapter begins by reviewing the history and current status of rehabilitation psychology. This is followed by a description of the direct and indirect services typically provided by rehabilitation psychologists. Frequently encountered psychological measures are described, and their importance for rehabilitation planning is stressed. The final section examines theories of adjustment to disability.
REHABILITATION PSYCHOLOGY: HISTORY AND CURRENT STATUS
History
Rehabilitation psychology is a specialty area within psychology that focuses on the study and application of psychological knowledge and skills on behalf of individuals with disabilities and chronic health conditions in order to maximize health and welfare, independence and choice, functional abilities, and social role participation (1). The field of rehabilitation psychology received initial impetus from veterans returning from the two world wars in the first half of the last century. Physical and occupational therapy trace their roots to World War I. After World War II, the Veterans Administration focused on the psychological needs of the physically disabled, which led to acceptance of psychologists as providers of mental health services. During this same time period, Howard A. Rusk developed the first comprehensive rehabilitation center, which led, with the leadership of others, to the development of physical medicine and rehabilitation as a medical specialty. Thus, the birth and maturation of the disciplines comprising the rehabilitation team have overlapping histories (2, 3).
As the number of psychologists working in rehabilitation settings grew, the need for a professional forum arose. In 1949, a special-interest group within the American Psychological Association (APA) was created and in 1958 was granted division status. The Division of Rehabilitation Psychology of the APA provides leadership in formulating federal legislation and in various professional and lay organizations. The Rehabilitation Act of 1973 and the Education for All Handicapped Children Act of 1975 provided mandates for the participation of rehabilitation psychologists in services to the disabled (4). Rehabilitation psychologists promoted passage of the Americans with Disabilities Act of 1990 and its ongoing implementation (5). The injured veterans returning from the wars in Iraq and Afghanistan coupled with the aging population of the United States represent populations with needs that are uniquely addressed by rehabilitation psychologists.
Current Status
Rehabilitation psychologists have struggled with their identity since the field’s inception. Shontz and Wright argued for the distinctiveness of rehabilitation psychology (6). More recently, Glueckauf argued that rehabilitation psychology is subspecialty within the larger domain of health psychology. In this model, rehabilitation psychology is grouped with the subspecialties of clinical neuropsychology, geropsychology, and pediatric psychology (7). To promote this model, an Interdivisional Health Care Committee, with representatives from several divisions of the APA, was formed and continues to actively pursue a common agenda (8).
The identity problem of rehabilitation psychologists arises from the fact that they typically have doctoral degrees in clinical or counseling psychology and enter the field through internship training. A general degree program initially molds their professional identity rather than training in rehabilitation theories, principles, literature, and research; training that is available in only a select number of doctoral programs. Depending on the quality of internship and postdoctoral training, some practitioners may lack training in theoretical models of rehabilitation. There has been ongoing debate within the field of rehabilitation psychology about the “best” training model. The key area of disagreement relates to timing of specialized training (predoctoral vs. postdoctoral), with advocates for both points of view (9, 10, 11, 12, 13).
The training and practice of rehabilitation psychologists are changing for two reasons. First, the APA has developed a new model of education in which the graduate-level curriculum is generic, with specialization occurring through postdoctoral training. In 1995, the Division of Rehabilitation Psychology published guidelines for postdoctoral training in rehabilitation psychology (14). These guidelines define what constitutes comprehensive postdoctoral training of rehabilitation psychologists. A comprehensive revision of these guidelines based on the APA Board of Educational Affairs criteria is nearing completion and will be published in Rehabilitation Psychology (15, 16). These guidelines will be posted to the Division of Rehabilitation Psychology Web site (www.Div22.org) when complete.
Stiers and Stucky (17) recently surveyed clinical training programs in rehabilitation psychology. Of the 117 sites identified, 94 responded to their survey. They found that the majority of sites did not have a complete rehabilitation focus to their clinical services and did not have faculty with specialty certification in rehabilitation. They found that there
were only 11 core fellowship sites that had a primary focus on rehabilitation psychology. They concluded that many patients and rehabilitation teams receiving services from psychologists in rehabilitation settings were receiving only partial benefit. They described the unmet needs in rehabilitation psychology training and argued for the development of a “tool kit” that provides standardized curricular materials and program evaluation tools. Second, the American Board of Rehabilitation Psychology (ABRP), www.abrp.org, was established in 1995, with the first diplomate in rehabilitation psychology awarded in 1996. The ABRP provided a comprehensive rationale for specialty definition and competency-based practice standards (15, 18). Those awarded the diplomate have typically completed postdoctoral training and are required to have 3 years of experience in rehabilitation psychology, two of which must be supervised. The ABRP is part of the American Board of Professional Psychology (ABPP), an organization of psychologists that accredits subspecialties, similar to the American Board of Medical Specialties for medical specialties.
were only 11 core fellowship sites that had a primary focus on rehabilitation psychology. They concluded that many patients and rehabilitation teams receiving services from psychologists in rehabilitation settings were receiving only partial benefit. They described the unmet needs in rehabilitation psychology training and argued for the development of a “tool kit” that provides standardized curricular materials and program evaluation tools. Second, the American Board of Rehabilitation Psychology (ABRP), www.abrp.org, was established in 1995, with the first diplomate in rehabilitation psychology awarded in 1996. The ABRP provided a comprehensive rationale for specialty definition and competency-based practice standards (15, 18). Those awarded the diplomate have typically completed postdoctoral training and are required to have 3 years of experience in rehabilitation psychology, two of which must be supervised. The ABRP is part of the American Board of Professional Psychology (ABPP), an organization of psychologists that accredits subspecialties, similar to the American Board of Medical Specialties for medical specialties.
The goal of the Division of Rehabilitation Psychology is to expand knowledge and seek solutions to problems related to disability and the rehabilitation process. The mission of the organization states:
the Division of Rehabilitation Psychology will: (1) be APA’s voice for the science and practice of psychology as it relates to changes in abilities and social roles arising from illness and disability, (2) be recognized by constituents internal and external to APA for the redefinition of “rehabilitation psychology” as an expanded spectrum of community and clinical services including prevention, rehabilitation, and postacute health care within the context of quality of life across the life-span, and (3) influence the health care marketplace such that rehabilitation psychology services are widely available and accessible and that the quality of life perspective counterbalances both the economic and the medical/curative approaches (19).
The delivery of rehabilitation psychology services is adapting to the corporatization of health care and the reduction of expenditures in the Medicare and Medicaid programs (20, 21, 22, 23). The impact of the Prospective Payment System (PPS) on rehabilitation psychologists is uncertain (24). Doctoral-trained rehabilitation psychologists can bill independently under Medicare Part B and, hence, are able to generate revenue in addition to the flat fee provided by the PPS. As a result, rehabilitation psychologists may assume expanded roles in patient evaluation and treatment planning. The shift to health maintenance and preferred provider organizations presents an evolving challenge, as payers are demanding psychological services that are brief, beneficial, and cost-effective. In response, rehabilitation psychologists are shifting their venues from hospitals to less expensive settings such as subacute and outpatient rehabilitation facilities, as well as to telehealth interventions (25). Wade and Wolfe edited a special section of the journal Rehabilitation Psychology which highlighted emerging approaches by pioneers in the field of telehealth and rehabilitation (26).
The importance of aiding the process of adjustment to disability and preventing secondary conditions was acknowledged by the addition of six current procedural technology (CPT) codes by the American Medical Association and their approval for reimbursement by the Medicare program. As of 2002, the new CPT codes for health and behavior assessment and intervention services apply to behavioral, social, and psychophysiologic procedures for the prevention, treatment, or management of physical health problems. These “Health and Behavior Codes” recognize psychology’s role as a health care specialty and shift third-party reimbursement from a psychopathology model to a model focused on fostering individual adaptation and social accommodation. For example, CPT number 96152 pays for intervention services to modify the psychological, behavioral, cognitive, and social factors affecting health and well-being. For example, these services include using cognitive and behavioral interventions to initiate physician-prescribed diet and exercise programs. These codes also reimburse services such as patient adherence to medical treatment, symptom management, health-promoting behaviors, health-related risk-taking behaviors, and overall adjustment to physical illness. Federal reimbursement for these new codes will come from medical rather than from mental health funding and, hence, will not draw from limited mental health dollars. Recent passage of the Mental Health Parity Bill will enhance coverage of mental health services by eliminating the differential in co-payments between mental versus physical health services.
The paradigm shift by the World Health Organization and the National Institutes on Disability and Rehabilitation Research from a biomedical to a social model of disability bodes well for the continued relevance of rehabilitation psychology services and research (27, 28, 29, 30, 31, 32). The International Classification of Functioning, Disability and Health (ICF) has been adopted by 191 countries as the international standard for classifying health and disability. As noted by Bruyere and Peterson (33), “the ICF represents a new way for the world to talk about health… The ICF is a classification system that uses a universal, culturally sensitive, integrative, and interactive model of health and functioning that is sensitive to social and environmental aspects of health and disability and covers the entire human life span.” The authors highlight that the concepts and assumptions that comprise the ICF reflect long-standing core values of rehabilitation psychologists including inclusion of and advocacy for people with disabilities in society.
The direct and indirect services described in the following section reflect services typically found within an inpatient medical rehabilitation setting. Similar services are provided in a suitably adapted manner on an outpatient basis. As service delivery shifts to outpatient and community settings, adaptations in these services continue to evolve. Despite the consolidation of health care payer and delivery systems, consumers continue to demand quality and value (34). The value of rehabilitation psychology services is acknowledged by the Commission on the Accreditation of Rehabilitation Facilities through their mandated availability of the rehabilitation psychologist as part of the
rehabilitation team in both acute and subacute rehabilitation facilities. Rehabilitation psychology’s focus on enhancing the quality of life for those with chronic illness and disability remains the central goal despite changes in health care delivery paradigms. Expected changes in the health care delivery system will include universal coverage for all citizens with a focus on prevention, multidisciplinary health care team communication, and measuring outcomes (35, 36). Rehabilitation psychology has a long-standing focus on recognizing and maximizing an individual’s strengths and helping them to create a meaningful life despite being confronted with the challenges of living with a disability. Interestingly, a contemporary focus in the field of psychology is on “Positive Psychology.” Positive psychology explores factors that make life worth living, enable people to successfully confront challenges, and facilitate extracting meaning from daily life (37, 38, 39). Dunn and Dougherty (40) argue for actively connecting rehabilitation psychology’s foundations and existing strengths to the emerging field of positive psychology, thus enriching both fields of inquiry.
rehabilitation team in both acute and subacute rehabilitation facilities. Rehabilitation psychology’s focus on enhancing the quality of life for those with chronic illness and disability remains the central goal despite changes in health care delivery paradigms. Expected changes in the health care delivery system will include universal coverage for all citizens with a focus on prevention, multidisciplinary health care team communication, and measuring outcomes (35, 36). Rehabilitation psychology has a long-standing focus on recognizing and maximizing an individual’s strengths and helping them to create a meaningful life despite being confronted with the challenges of living with a disability. Interestingly, a contemporary focus in the field of psychology is on “Positive Psychology.” Positive psychology explores factors that make life worth living, enable people to successfully confront challenges, and facilitate extracting meaning from daily life (37, 38, 39). Dunn and Dougherty (40) argue for actively connecting rehabilitation psychology’s foundations and existing strengths to the emerging field of positive psychology, thus enriching both fields of inquiry.
DIRECT SERVICES
The Clinical Interview
The psychologist’s first contact with a patient is pivotal in the development of a therapeutic relationship and may occur before transfer to a rehabilitation unit. The psychologist may visit the patient before the initial interview to explain his or her role. The patient’s expectations of meeting with the psychologist are determined by previous exposure to mental health professionals, communications from other team members, including the physician, and preliminary explanations from the psychologist. The patient’s willingness to interact meaningfully with the psychologist can be strongly influenced by the physician. At the introduction, the psychologist will explain that comprehensive rehabilitation includes help with problematic thoughts and feelings associated with chronic illness or the onset of disability. Frequently, patients are relieved to discover that contact with the psychologist is a routine part of comprehensive rehabilitation.
The initial interview may last an hour or more. Patients with cognitive impairment may be seen only long enough for a general determination of their information-processing capacity and emotional state. Further assessment will await improvement in their cognitive status or contact with an informed family member. The length of the initial interview with noncognitively impaired patients depends on the complexity of the medical or social issues. There are two major goals for the initial interview. First, a comprehensive history of the patient’s social background is obtained. Table 14-1 lists frequently asked biographical questions. These data provide insight into previous learning experiences that may affect rehabilitation-related attitudes and behaviors. Second, the psychologist attempts to understand the disability as the patient sees it, with the most critical question being, what is the meaning of the disability for the patient and his or her life? The foundation for a meaningful therapeutic relationship is laid, in part, by taking sufficient time to elicit the patient’s perspective. The patient often faces a medical situation that he or she does not fully comprehend. Anxiety and fear often block the reception and communication of information between the patient and rehabilitation team members, especially physicians. The opportunity to have one’s perspective, including cognitive and emotional aspects, aired in a supportive and clarifying manner is often therapeutic in
itself. As the U.S. population becomes older and more diverse, understanding the meaning of disability through the unique cultural background of the patient is imperative (41, 42).
itself. As the U.S. population becomes older and more diverse, understanding the meaning of disability through the unique cultural background of the patient is imperative (41, 42).
TABLE 14.1 Psychosocial Information Sought During Initial Interview | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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The psychologist occupies an unusually difficult position. Although a team member, the psychologist has the professional responsibility of maintaining the confidentiality of the therapeutic relationship. The patient may confide information that is personally sensitive and inappropriate to share with other team members. If directly asked by other team members about such information, the psychologist may have to explain that the information is confidential. Usually the patient is told that any information considered sensitive by the psychologist or so indicated by the patient will not be communicated to others. General information of a less sensitive nature is provided in the form of an initial interview note. Subsequent therapeutic contacts are recorded in the hospital chart or summarized periodically. The frequency of these contacts depends on the goals established during the initial interview, the current degree of psychological distress, the potential for behavioral decompensation, concerns expressed by other team members, and staffing levels.
Standardized Assessment
Given the time-consuming and subjective nature of clinical interviews, rehabilitation psychologists use standardized tests to speed assessment and enhance interventions (43, 44). This section describes several frequently used instruments. Standardized measures of personality, mood, intellectual ability, and academic achievement are briefly discussed. The domains of neuropsychological and chemical use assessments are covered in more detail.
Personality
A personality test conventionally refers to a measure of personal characteristics such as emotional status, interpersonal relations, motivation, interests, and attitudes. Personality inventory development has generally relied on one or more methods including content validation, empirical criterion keying, factor analysis, and personality theory. Personality measurement has generated controversy over two issues. The first concerns the stability of personality traits across situations as opposed to the situational specificity of behavior (45). The second issue involves the degree to which a given personality characteristic reflects a merely transitory state rather than a stable underlying trait. Anastasi and Urbina (46) provided a thorough overview of these issues and of other psychological measurement concepts including norms, item analysis, reliability, and validity. Elliott and Umlauf (47) caution that the insensitive use of personality measures with individuals who have medical symptoms or limited physical abilities can produce misleading results. Johnson-Greene and Touradji (48) provide a contemporary review of the role of personality in rehabilitation outcomes and adjustment to disability. The most frequently used personality inventory designed to measure psychopathology is the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) that is now available in a new form entitled the Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF). Two personality measures of nonpathologic or “normal” personality relevant to rehabilitation are the Revised NEO Personality Inventory (NEO-PI-R) and the Strong Interest Inventory (SII).
Minnesota Multiphasic Personality Inventory-2
The MMPI-2 is the revised version of the MMPI, the most widely used and thoroughly researched objective measure of personality (49, 50, 51, 52, 53). The MMPI-2 is composed of statements describing thoughts, feelings, ideas, attitudes, physical and emotional symptoms, and previous life experiences. In general, the material included on the MMPI-2 is usually covered in a clinical interview. However, factors of privacy, time-savings, and the clinical relevance of the items have ensured its acceptance in health-care settings.
The MMPI-2 was originally designed to yield information about personality factors related to the major psychiatric syndromes. The 567 true-false questions are grouped into ten clinical scales (Table 14-2) that continue to reflect important aspects of personality despite their obsolete psychiatric titles. The items composing each scale were determined statistically. An item was included only if a carefully diagnosed group of patients (e.g., those hospitalized for depression) answered that question in a manner statistically different from that of other carefully diagnosed groups of patients (e.g., schizophrenics) and from the normal standardization sample. The MMPI-2 standardization sample consisted of 2,600 persons from several states chosen to reflect several national census parameters, including minority group status. This system of item selection (i.e., empirical criterion keying) fostered the inclusion of subtle items, items that make the MMPI-2 less easily faked when compared with other personality measures.
The ten clinical scales are interpreted with the aid of four validity scales (see Table 14-2). These scales provide information on the client’s response style such as literacy, cooperation, malingering, comprehension, and defensiveness. The empirical nature of the inventory has permitted construction of special scales. For example, there are scales to help predict rehabilitation motivation, headache proneness, and tendencies toward the development of alcoholism. Additionally, there are extensive MMPI norms on persons with specific diagnoses such as multiple sclerosis and spinal cord injury (SCI) (54). Norms are reported as standard scores with a mean of 50 and a standard deviation of 10. A score of 65 or greater is the point at which the normal and the pathologic groups are most reliably discriminated. However, depending on the scores obtained on the validity scales, this “cut-score” may be adjusted by the trained interpreter.
The MMPI-2 requires an eighth-grade reading level and is intended for adults 18 years of age and older. A version of the MMPI entitled the MMPI-A is intended for use with adolescents (55). The MMPI-2 requires about 90 minutes to complete. Although many computerized scoring services are available, this does not obviate the need for interpretation by an experienced psychologist. A variety of factors—including
race, socioeconomic status, unique family circumstances, ethnic background, and physical disability—may distort the MMPI-2 profile (56).
race, socioeconomic status, unique family circumstances, ethnic background, and physical disability—may distort the MMPI-2 profile (56).
TABLE 14.2 Brief Description of the Minnesota Multiple Personality Inventory-2: Validity and Clinical Scales | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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An important goal in the development of the MMPI-2 was to preserve sufficient item continuity with the original MMPI to allow for the generalizability of the voluminous MMPI research literature to the MMPI-2. Unfortunately, Humphrey and Dahlstrom reported that profiles generated by the MMPI and the MMPI-2 on the same subjects are too frequently at variance to be able to consider the two instruments interchangeable (57). Hence, it would be an error to assume that the MMPI clinical research literature can be uncritically generalized to the MMPI-2 for all patients. Moreover, many of the original criticisms of the MMPI remain problematic for the MMPI-2 (58). In particular, the MMPI was originally written to aid physicians in the medical management of patients who were believed to have psychological factors intertwined with their presenting complaints. MMPI and MMPI-2 normative studies on medical patients (59) consistently reveal elevations of three to six points on clinical scales 1, 2, and 3 when compared to the MMPI normative samples. Appropriate interpretation of the MMPI-2 with medical and rehabilitation patients requires knowledge of these normative biases (60).
Minnesota Multiphasic Personality Inventory-2 Restructured Form
The MMPI-2-RF represents the continuing evolution of the MMPI (61). The original ten MMPI clinical scales were problematic because of their intercorrelations, item overlap, and heterogeneous item content. To address these problems, a set of nine Restructured Clinical Scales (RCS) was derived (Table 14-3) by identifying the major distinctive “core” components of each clinical scale. Tellegen et al. (62) provided
data documenting the improved psychometric properties of the RCS that included improved reliability, reduced scale intercorrelations, and improved convergent and discriminant validity. Once the RCS were devised, 23 additional specific problem scales were constructed that reflected distinctive components of the old clinical scales that were not captured in the new scales with titles such as malaise, suicidal/death ideation, anger proneness, substance abuse, shyness, and ideas of persecution. In addition, the MMPI-2-RF has a total of eight validity scales and three higher order scales, entitled emotional/internalizing dysfunction, thought dysfunction, and behavioral/externalizing dysfunction. The MMPI-2-RF has a total of 338 items and 50 empirically revised scales. The MMPI-2-RF requires 35 to 50 minutes to complete and is written at a sixth-grade reading level.
data documenting the improved psychometric properties of the RCS that included improved reliability, reduced scale intercorrelations, and improved convergent and discriminant validity. Once the RCS were devised, 23 additional specific problem scales were constructed that reflected distinctive components of the old clinical scales that were not captured in the new scales with titles such as malaise, suicidal/death ideation, anger proneness, substance abuse, shyness, and ideas of persecution. In addition, the MMPI-2-RF has a total of eight validity scales and three higher order scales, entitled emotional/internalizing dysfunction, thought dysfunction, and behavioral/externalizing dysfunction. The MMPI-2-RF has a total of 338 items and 50 empirically revised scales. The MMPI-2-RF requires 35 to 50 minutes to complete and is written at a sixth-grade reading level.
TABLE 14.3 Brief Description of the Minnesota Multiple Personality Inventory-2: Restructured Clinical Scales | ||||||||||||||||||||||||||||||||||||||||||
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NEO Personality Inventory Revised
The NEO Personality Inventory Revised (NEO-PI-R) reflects the culmination of decades of personality research that concludes that personality traits can be summarized in terms of the so-called five-factor model (63, 64). The NEO-PI-R was designed to measure the five major dimensions or domains thought to be central to normal adult personality. These dimensions are entitled Neuroticism (N), Extraversion (E), Openness (O), Agreeableness (A), and Conscientiousness (C). Each domain scale has six facet scales resulting in a total of 35 scales on the inventory. Neuroticism refers to a general tendency to experience negative affect, self-consciousness, poor coping, irrational ideas, feelings of vulnerability, and difficulties controlling cravings and urges. Extroversion relates to interpersonal warmth, gregariousness, assertiveness, activity, excitement seeking, and the tendency to experience positive emotions. Openness pertains to depth of imagination, aesthetic sensitivity, intensity of feelings, preference for variety, intellectual curiosity, and independence of judgment. Agreeableness includes the characteristics of trust, straightforwardness, altruism, methods of handling interpersonal conflict, humbleness, and sympathy for others. Finally, conscientiousness encompasses the characteristics of competence, organization, reliability, achievement striving, self-discipline, and deliberation before acting.
NEO-PI-R item construction was based on rational-theoretical methods. Item selection was determined by internal consistency and factor analytic data. The scale’s 240 items are rated on a five-point continuum from “strongly disagree” to “strongly agree.” The inventory is designed for adults, 17 years of age and older. The inventory requires a sixth-grade reading level and about 45 minutes for completion. There are separate adolescent norms for those less than 21 years old. The NEO-PI-R has a self-report (Form S) and an observer rating form (Form R). This dual-form feature is unique among personality measures and is especially relevant to rehabilitation research. Also noteworthy, the NEO-PI-R items do not contain references to physical abilities or sensations that might distort a physically disabled subject’s responses.
The NEO-PI-R is a reliable and valid measure. Validity has been established through numerous studies that correlate the NEO-PI-R with other measures of personality. All these correlations have been in accord with theory and expectation (65). There are two limitations to the NEO-PI-R. The NEO-PI-R assumes an honest respondent; no subtle items or validity scales are provided. In addition, it remains unclear to what degree the subject’s current mood (state) may impact the response to test items that describe long-standing personality characteristics (trait).
The NEO-PI-R has been used in a number of rehabilitation studies. Rohe and Krause administered the initial version of the NEO-PI-R to males with traumatic SCI 16 years after injury (66). The subjects scored lower on the scales of conscientiousness, assertiveness, and activity; they scored higher on the scales of excitement seeking and fantasy when compared with the adult male normative sample. Scales reflective of negative affect were not elevated. The subjects’ reduced conscientiousness and non-elevated neuroticism scale scores have negative implications for adherence to rehabilitation regimens but positive implications for long-term coping abilities. A subsequent study on the same sample correlated personality and self-reported life adjustment. Rohe and Krause discovered that elevated scores on the depression scale were associated with poorer outcomes, whereas elevated scores on the scales dealing with warmth, positive emotions, actions, and values were associated with superior outcomes. The authors suggested that personality assessment may be an invaluable aid in predicting long-term outcomes and can help delineate those individuals most vulnerable to negative outcomes, perhaps indicating a need for more careful follow-up and supportive services for this subgroup (67). In a seminal study using the NEO-PI-R, the authors assessed whether SCI is associated with personality change by comparing the personality test scores of identical twins, one of whom sustained an SCI. The authors found no significant differences between the NEO-PI-R scores of the twins with SCI and their non-SCI twins (68).
The Strong Interest Inventory
The SII is traditionally considered a measure of vocational interests; however, research has supported its use as a valid non-pathology-oriented measure of personality (69). First published in 1927, the SII is one of the most thoroughly researched, highly respected, and frequently used psychological tests. The SII was revised in 2004. Improvements include more focus on business and technology occupations, number of items reduced from 317 to 291, representative sampling of ethnic, racial, and demographic workforce diversity, and an expanded number of scales. The SII asks the respondent to indicate their level of interest on a five-point Likert scale ranging from strongly like to strongly dislike for occupations, subject areas, activities, leisure activities, and people. The last section asks the respondent to rate their possession of nine personal characteristics. The test requires 35 to 40 minutes to complete and is written at an eighth- to ninth-grade reading level (70).
The General Occupational Themes, one of the four types of scales on the SII, are based on trait theory as derived by Holland (71). Holland drew on factor-analytic studies of personality and interests to produce a typology of six basic personality types. These types are titled realistic, investigative, artistic, social, enterprising, and conventional. Rohe and Athelstan administered the SII to a national sample of persons with SCI (72). Contrary to previous research, they found unique personality characteristics associated with persons having SCI of traumatic onset. These characteristics included an interest in activities requiring physical interaction with things, such as machinery, and a disinterest in activities that require intense or complex interaction with either data or people. Malec used the Eysenck Personality Inventory with people having SCI of traumatic onset and discovered a pattern of personality characteristics congruent with that found in Rohe and Athelstan’s study (73).
Rohe’s review of the literature suggested that when a disability is of traumatic onset and secondary to the individual’s behavior, statements in the literature about the lack of a relationship between disability and personality characteristics appear to be inaccurate (74). He noted that the previous literature either used pathology-oriented measures (e.g., MMPI) or studied individuals whose disability was not the result of trauma associated with their behavior. An additional study sought to determine if those personality characteristics associated with people having SCI would change after years of living with the disability. The data indicated that personality characteristics remained constant over an average of ten years (75). Rohe and Krause conducted a follow-up study to the aforementioned personality stability study. They found that males with traumatic SCI displayed marked consistency in personality characteristics over an 11-year follow-up period (76).
The MMPI-2, MMPI-2-RF, NEO-PI-R, and SII represent four measures of personality relevant to clinical rehabilitation settings. These measures can help answer diagnostic and management questions. For example, a patient’s unwillingness to comply with requested medical interventions or the structure imposed by the hospital environment may be discerned with the use of personality measures. Knowledge of such personality characteristics can help prevent ill-advised interventions and can create a treatment environment designed to maximize patient compliance. While clinical experience attests to the usefulness of such assessment, systematic empirical research on this topic is a pressing need.
Mood
Problematic mood, especially depression, in patients is one of the most common concerns among rehabilitation team members and a frequent reason for psychological assessment. Depression is an imprecise term used to describe an affective state that ranges from “being down” to major depressive disorder (MDD). The incidence and prevalence of MDD in rehabilitation populations has been the focus of significant research and debate. Assessing depression immediately after disability onset is complicated by such medical and environmental factors as sleep disruption, pain, and decreased appetite. Two brief, psychometrically robust and helpful instruments are the Patient Health Questionnaire-9 (PHQ-9) (77) and the Beck Depression Inventory-Fast Screen (BDI-FS).
TABLE 14.4 PHQ-9 Items | |||||
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Patient Health Questionnaire-9
The PHQ-9 is a brief, nine-item measure whose item content parallels the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (78) criteria for major depression (Table 14-4). The PHQ-9 was developed for medical patients with high rates of nonspecific physical symptoms. Although the PHQ-9 contains somatic items that might confound accurate diagnosis, the clinician reviews the responses to ensure that any positive somatic responses are not due to medically based symptoms or normal bereavement. Bombardier et al. (79) studied the PHQ-9 with an SCI sample 1 year post injury. The average score was 5.48, with 11.4% of the sample meeting the criteria for probable MDD with a mean score of 18.1. The PHQ-9 appears to be a promising instrument for detecting MDD in rehabilitation populations.
Beck Depression Inventory-Fast Screen for Medical Patients
The BDI-FS for medical patients (80) is a self-report inventory that screens for depression in adults and adolescents. The items were extracted from the original 21-item Beck Depression Inventory-II (81) and focus on the cognitive and affective components of depression, systematically excluding the somatically focused items. The BDI-FS consists of seven groups of four statements. The item groupings focus on sadness, pessimism, past failure, loss of pleasure, self-dislike, self-criticalness, and suicidal thoughts. A score of 4 falls in the mildly depressed range while a score of 8 is average for persons with MDD. The inventory requires 5 minutes to complete and has acceptable reliability and validity data. The correlation between the 7-item and the 21-item inventories is 0.91. A recent study using the BDI-FS with persons with multiple sclerosis supported its concurrent and discriminative validity (82).
Intellectual Ability
Intellectual ability tests provide a summary score that serves as a global index of a person’s general problem-solving ability, frequently referred to as an IQ or intellectual quotient score. This summary score is validated against a broad criterion such as scholastic achievement or occupational success. Although such tests are constructed of a number of subtests that sample facets of intellectual functioning, they are usually weighted toward tasks requiring verbal ability. The most frequently encountered measure of intellectual ability is the Wechsler Adult Intelligence Scale, III (WAIS-III) (83).
Wechsler Adult Intelligence Scale, III
The WAIS-III is the second revision of the WAIS originally published in 1955. The WAIS-III was standardized on a normative sample of 2,450 “normal adults” from ages 16 to 89, divided into 13 age groups. They were chosen to be representative of the US population as determined by the 1995 census update. The sample was stratified by gender, educational level, ethnicity, and region of the country. On the WAIS-III, items from earlier versions of the test that had become obsolete because of societal changes or bias against ethnic groups were altered or eliminated and the artwork was updated. Other improvements include extending the range of possible scores both downward and upward (full-scale IQ range = 45 to 155), decreased reliance on timed tests, and addition of a new subtest that requires conceptual reasoning using abstract symbols (matrix reasoning). The WAIS-III must be administered by a trained examiner and requires 75 to 90 minutes for completion.
The WAIS-III consists of 14 subtests, one of which is optional. Table 14-5 lists in their order of administration these subtests and what they measure. On the WAIS-III, six subtests are used in the computation of the verbal IQ, and five subtests determine the performance IQ. In general, the WAIS-III has deemphasized speed of responding by reducing the number of items with time bonus points, eliminating the picture arrangement subtest, and replacing the timed object-assembly subtest with the nontimed matrix reasoning subtest. Object assembly remains available when time and motoric response capabilities are not an issue. All WAIS-III subtest scores are corrected for age and standardized with a mean of 10 and a standard deviation of 3. The full-scale IQ is calculated by averaging scores obtained from the verbal and performance IQs.
The WAIS-III incorporates earlier research of Cohen, who discovered that three underlying factors accounted for most of the WAIS-R test variance (84). The Cohen factors are now codified as three of the four WAIS-III “index scores.” The names of the index scores and the subtests used to compute them are verbal comprehension (vocabulary, similarities, information), perceptual organization (picture completion, block design, matrix reasoning), working memory (arithmetic, digit span, letter-number sequencing), and processing speed (digit symbol-coding, symbol search). As with the traditional IQ
scores, index scores have a mean of 100 and a standard deviation of 15. They are sometimes reported in lieu of the traditional IQ scores. The subtests of digit symbol coding and symbol search were added to the WAIS-III to measure the proposed fourth factor, speed of information processing, as suggested by Malec et al. (85). The test exceeds all standards of reliability and validity. Reviewers have been uniformly impressed with the quality of the resulting instrument (86, 87). The WAIS-IV was published in late 2008 (88). This new version has reduced emphasis on motor demands and timed performance, enlarged visual stimuli, reduced testing time, updated norms, and improved psychometric properties. Many of these improvements reflect specific requests by rehabilitation psychologists working with populations who have compromised sensory and motor functions.
scores, index scores have a mean of 100 and a standard deviation of 15. They are sometimes reported in lieu of the traditional IQ scores. The subtests of digit symbol coding and symbol search were added to the WAIS-III to measure the proposed fourth factor, speed of information processing, as suggested by Malec et al. (85). The test exceeds all standards of reliability and validity. Reviewers have been uniformly impressed with the quality of the resulting instrument (86, 87). The WAIS-IV was published in late 2008 (88). This new version has reduced emphasis on motor demands and timed performance, enlarged visual stimuli, reduced testing time, updated norms, and improved psychometric properties. Many of these improvements reflect specific requests by rehabilitation psychologists working with populations who have compromised sensory and motor functions.
TABLE 14.5 The 14 Subtests of the Wechsler Adult Intelligence Scale-III | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Given the emotional significance of IQ scores, psychologists usually convert both IQ scores and discussions about them into either percentiles or classifications (Table 14-6). When the physician is confronted with questions about test results from patients, the use of either percentiles or classifications
is recommended. Measures of intellectual ability help the physiatrist set appropriate expectations about the rate and complexity of learning legitimately expected from the patient. They also serve as the cornerstone for determining the presence of organic brain dysfunction and provide guidance for post-dismissal vocational planning.
is recommended. Measures of intellectual ability help the physiatrist set appropriate expectations about the rate and complexity of learning legitimately expected from the patient. They also serve as the cornerstone for determining the presence of organic brain dysfunction and provide guidance for post-dismissal vocational planning.
TABLE 14.6 IQ Scores, Percentile Ranges, and Classifications for the Wechsler Adult Intelligence Scale-III | ||||||||||||||||||||||||
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Academic Achievement
A frequently overlooked but nonetheless important factor within rehabilitation settings is academic achievement. Reading and mathematics achievement are of particular concern not only during inpatient rehabilitation but also for longer-range educational and vocational planning. The patient’s reading level is a potential limiting factor in tasks ranging from filling out hospital menus to incorporating ideas presented in patient education materials. The average reading level in the United States is at the sixth grade, the level required to read a newspaper. Patient education materials, however, often reflect the reading levels of the professionals who devise them. As the patients’ reading level falls below the national average, progressively greater reliance on oral instruction and audiovisual materials becomes necessary. Patients are often expected to use mathematics when recording fluid intake and taking correct dosages of medications. Two frequently used measures of reading and mathematical achievement are the Wide Range Achievement Test-4 (WRAT-4) and the Woodcock-Johnson Psycho-Educational Battery-III.
Wide Range Achievement Test-4
The WRAT-4 is the current edition of the WRAT (89
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