The purpose of this chapter is to (1) introduce the reader to rehabilitation psychology, (2) provide a brief history of the discipline, and (3) describe (a) medical and mental/behavioral health populations for whom rehabilitation psychology is consulted or referred, (b) the scope of work of rehabilitation psychologists, and (c) assessment and treatment modalities used by rehabilitation psychologists.

Rehabilitation psychologists serve vital functions in the management, research, and advocacy of rehabilitation patients.¹ In partnership with team members from multiple rehabilitation disciplines, rehabilitation psychologists can reduce health care costs by addressing mental health needs, adjustment to disability, cognitive and pain concerns, and noncompliance. Scherer defined rehabilitation psychology as “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 across the life span”² Along with other health care colleagues, rehabilitation psychologists navigate the changes in US health care to ensure high-quality care.^3,4 Rehabilitation psychologists serve diverse roles as clinicians, researchers, educators, advocates for people with disabilities, health care administrators, policymakers, and program developers. Additionally, they are members of professional organizations within psychology, rehabilitation psychology, and other multidisciplinary organizations. Many rehabilitation psychologists have or are pursuing board certification in recognition of their specialty training and abilities in the field.

To illustrate the treatment aspects of rehabilitation psychology, the following patient example is provided, which will be referred to throughout this chapter: TM is a 60-year-old man who sustained approximately 45% total body surface area (TBSA) chemical burns and inhalation injuries in an industrial explosion at work. He was hospitalized for 6 weeks in an intensive and acute burn care unit and for 4 weeks in the inpatient medical rehabilitation unit. A few years prior to this event and subsequent injuries, he was diagnosed with posttraumatic stress disorder (PTSD) related to his service in the Vietnam War, for which he was treated with psychotropic medication but had not participated in psychotherapy. To assist in TM’s care, a rehabilitation psychologist assessed (1) adjustment to his physical limitations and need for assistance, (2) body changes related to disfigurement, (3) emotional functioning, (4) potential cognitive disability and preserved cognitive abilities, (5) vocational capacity, (6) perceived challenges and changes in sexual functioning and intimacy, (7) substance use/abuse, and (8) social and behavioral functioning. The rehabilitation psychologist in this case provided cognitive-behavioral psychotherapeutic management, education to TM’s wife, and consultation with his physicians and other health care professionals regarding his emotional, cognitive, and vocational functioning in both inpatient and outpatient settings.

This patient represents a typical patient for rehabilitation psychologists. Rehabilitation psychologists provide a breadth and depth of care to patients and their families and significant others, from childhood through older age.

Both rehabilitation medicine, or physiatry, and rehabilitation psychology as disciplines arose from the growth of medical technologies that sustained life for people with life-altering injuries and functional changes in the 1940s.^5,6 Some of the individuals who benefited from early rehabilitation interventions included soldiers during World War II. While physiatry focused on the management of the physical injuries, rehabilitation psychology dealt with the emotional repercussions of the injuries. Both had the goal of functional restoration. The scope of injuries and illnesses that physiatrists and rehabilitation psychologists evaluate and manage has expanded over the years related in part to continued advancement of medical technologies and increasing life expectancy.

Rehabilitation psychology as a subspecialty within psychology was introduced within the American Psychological Association in 1952, although rehabilitation psychologists had been involved in health care long before that time. Early influences, such as the establishment of the National Society of Crippled Children and Adults, state-federal partnerships in vocational rehabilitation, and the establishment of the Veterans Bureau in 1921, promoted the eventual subspecialty recognition.⁵ The field has further grown since the early to mid-1900s with the creation of trauma centers for brain injury, stroke, and other neurologic injuries and with passage of the Americans with Disabilities Act (ADA) in 1990.

Today rehabilitation psychologists are members of both multidisciplinary teams within institutions and interdisciplinary organizations (e.g., American Congress of Rehabilitation Medicine [ACRM], National Rehabilitation Association, and International Association of Rehabilitation Professionals), as well as psychology groups within their home institutions. Rehabilitation psychologists assist in intensive care, acute care, and subacute care hospital settings, inpatient and outpatient rehabilitation facilities, military and Veterans Administration medical centers, nursing care facilities, and long-term care facilities. Many rehabilitation psychologists are board certified through the American Board of Professional Psychology (ABPP) within the field of rehabilitation psychology and/or neuropsychology, a national specialty recognition that is similar to board certification in physical medicine and rehabilitation. Although board certification in the specialty is not yet a requirement in all facilities, there is a growing trend toward requirement of this specialty certification, particularly within academic institutions. CARF (formerly known as the Commission for the Accreditation of Rehabilitation Facilities) recognizes rehabilitation psychologists as essential members of inpatient rehabilitation facility treatment teams.

Rehabilitation psychologists assess and treat individuals with a wide variety of injuries and illnesses across the lifespan. The more common injuries/illnesses that rehabilitation psychologists assess and treat include traumatic brain injury (TBI), cerebrovascular accident (CVA or stroke), spinal cord injury, traumatic or nontraumatic limb amputation, burn injuries, orthopedic injuries (singular and multitrauma), and neurologic illnesses, including dementia, multiple sclerosis, Gullian-Barré syndrome (GBS), and Parkinson’s disease. Rehabilitation psychologists also work with oncologic rehabilitation patients with brain tumor, debility from prolonged cancer treatments, and palliative care. Patients with developmental sensory, motor, and physical disabilities receive care from rehabilitation psychologists. Essentially any patient with need for inpatient or outpatient rehabilitative treatment care is likely to encounter rehabilitation psychologists who are treatment team partners in most settings.

Rehabilitation psychology focuses on the holistic assessment and treatment of issues related to disability, including the social, physical, and policy environments that affect how limitations and restrictions are expressed in functioning. These services are provided in the context of a team approach and with a perspective of individual-environment interactions. The health care needs associated with disability make it important to maximize disease self-management abilities, to prevent secondary complications, to prevent and treat psychological comorbidities, and to promote community reintegration. The goal of appropriate assessment and intervention is for minimization of the restrictions and limitations of the individual with a disability and optimization of function as such individuals return to daily activities.

Rehabilitation psychology integrates multiple aspects of the patient, including disability, impairments or limitations, individual and family strengths, and the current social situation. Disparities in access to rehabilitation services in general are compounded when individuals with disabilities also are members of other underrepresented social groups, e.g., low socioeconomic status (SES), visible racial or ethnic groups, linguistically diverse individuals, older adults.⁷ Awareness of available community programs is important to maximize an individual’s productive involvement in daily living and community participation. The ultimate goal is to enhance their quality of life. Functional models of disability, such as the World Health Organization’s International Classification of Functioning, Disability, and Health (WHO-ICF), emphasize a biopsychosocial understanding of impairment and disability. Such models underscore the importance of understanding the social and cultural aspects of disability.

While our focus in this chapter will be on assessment and intervention, rehabilitation psychologists are also involved in research, administration, advocacy, public policy, and program development and management. More information on these areas of work can be found in other readings.^8–10

TM’s initial care consisted of assessment and brief interventions with education to the patient, family, and staff. Outpatient care expanded to more specific interventions aimed at long-term adjustment and education related to TM’s burn injuries, his recurring reactions to the work explosion that prompted his hospitalization, his responses to the hospitalization and care required to treat his life-altering and catastrophic injuries, and reemerging psychological reactions to the prior events in Vietnam. The following sections describe how rehabilitation psychologists are involved in assessment of and intervention with patients like TM.

Rehabilitation psychologists perform assessments by interviewing patients and their loved ones, using assessment instruments, observing the patient, and receiving feedback from other health professionals engaged in treatment of the individual. Evaluation of family, social, cultural, diversity, and environmental issues related to disability is important for treatment planning and optimizing community functioning. The Guidelines for Assessment of and Intervention with Persons with Disabilities highlight the importance of assessing and providing psychological services that best meet the individual and diverse needs of people with disabilities while maximizing their health and welfare, independence, choice, functional abilities, and social participation.¹¹ Multiple issues relevant to diversity need to be considered (e.g., age, gender, sexual orientation, SES, religion, race, and ethnicity) in addition to their disability identity. An individual’s military or veteran status may be an important part of their identity and may differentially affect their adaptation to disability or approach to assessment. Individuals with disabilities need to be included in decision making to the best extent possible and to have their preferences and values integrated into the conceptualization of assessment results. Treatment options should be developed which reflect their values without imposing one’s own biases. The assessment process is used to develop a multidisciplinary treatment plan that accounts for the impact of and accommodation to the disability.

There are a number of reasons why a rehabilitation patient may be referred to a rehabilitation psychologist for an evaluation, including an assessment of (1) physical, cognitive, emotional, and social adaptation to injury, illness, and disability in the patient and family, (2) cognitive, emotional, and behavioral dysfunction, (3) neuropsychological evaluation to determine ability to function at home, school, and/or work with or without accommodations, (4) evaluation of self-care and independent living skills, (5) evaluation of psychosexual functioning, with an emphasis on education regarding disability-related changes and use of adaptive technology, (6) evaluation of social and recreational participation, (7) assessment of health self-management and prevention of secondary complications, and (8) assessment of caregiver status and functioning, including caregiver knowledge and skills, social support, and self-care (e.g., instruments; see Table 54–1).

Standard instruments of mood assessment are used that are also employed in general clinical psychological settings. Depressed mood is assessed with use of the Geriatric Depression Scale¹² and its shorter forms (15- and 5-item versions,^13,14 Patient Health Questionnaire–9,¹⁵ and the Beck Depression Inventory¹⁶; anxious mood with instruments such as the Beck Anxiety Inventory (BAI)¹⁷ or Generalized Anxiety Disorder seven-item scale (GAD-7)¹⁸; and acute stress or posttraumatic stress via the Impact of Events Scale¹⁹ or Abbreviated PCL-C, a shortened version of the PTSD Checklist–Civilian Version.²⁰ All these instruments can delineate symptoms and guide treatment. In TM’s case, depression, anxiety, and PTSD screening instruments were administered during his hospitalization and after to monitor his symptomatology and assist in determining treatment focus.

Instruments that measure coping and adjustment to disability include the Acceptance of Disability Scale,²¹ Ways of Coping Questionnaire,²² and Katz Adjustment Scale and Activity Pattern Indicators.²³ Each measure typically represents a specific theoretical approach and often addresses a specific behavioral, motivational, or belief domain. Assessments of specific environmental or behavioral features relevant to intervention, such as stimulus control or contingency management, often focus on factors to aid integrative assessment for the development of a rationale for a particular intervention, to develop a working relationship with the patient and/or significant others, to address emotional reactions, and to develop expectations and attributions that support the intervention (Table 54–2).

Assessment of pain is also important and can be done using a multitude of instruments, including the Wong-Baker FACES Pain Rating Scale,²⁴ the Brief Pain Inventory,²⁵ or numerical and visual analogue pain rating scales²⁶ (Fig. 54–1). Inadequate pain management can contribute to mood issues, and chronic pain is frequently an issue for rehabilitation patients, particularly in the inpatient setting.

Cognitive screening measures are vital to determine the extent to which patients can benefit from psychological treatment. Such screening instruments include the St. Louis University Mental Status Examination (SLUMS),²⁷ the Montreal Cognitive Assessment (MoCA),²⁸ and the Repeatable Battery for the Assessment of Neuropsychological Status.²⁹

Both pain and cognitive instruments were administered serially with TM to monitor his pain control and improve cognition over time. This allowed for progressively more involved psychological intervention and eventual shift of responsibility for initiating recommended relaxation techniques from his family and hospital staff to the patient himself.

Assessment instruments have been created to be used with diverse rehabilitation populations to address capacity for self-care, work, and independent living. Within an inpatient medical rehabilitation setting, measures are typically used to quantify the extent of physical disability and capacity for self-care, such as the Barthel Index (BI).³⁰ and the Functional Independence Measure (FIM).³¹ The Functional Assessment Inventory (FAI),³² Matching Person and Technology (MPT) Model,³³ and Craig Handicap Assessment and Reporting Technique (CHART)³⁴ are used primarily for psychosocial and vocational dimensions of function within outpatient settings or vocational rehabilitation agencies.

As part of the evaluative process, a rehabilitation psychologist may consult with other professionals, such as attorneys, government agencies, educational institutions, the Department of Vocational Rehabilitation, insurance companies, and case managers to optimize an individual’s community functioning. Such consultations may include evaluation of acquired cognitive deficits with educational or vocational implications and development of reasonable accommodations for return to school or work. Other objectives may include quantification of accident-related “loss” for forensic purposes and recommendations related to hospital discharge plans, in addition to possible recommendations concerning resumption of premorbid activities such as driving.