Kennedy, P. (2008). Coping Effectively With Spinal Cord ...
Description Of Work SettingCurrently, I work as a Rehabilitation Psychologist at the XXX in XXX with the Spinal Cord Injury Units and XXX Program. The XXX was founded in XXX, XXX. Over the years, it has evolved into a current XXX, where individuals with spinal cord injury, brain injury, multiple sclerosis, spine/chronic pain, and other neuromuscular conditions are treated. The average patient age-range is from XXX years old. Each patient has a lead physician and interdisciplinary team, which includes a case manager, nurses, patient care technicians, respiratory therapist, speech language pathologist, physical therapist, occupational therapist, recreational therapist, vocational therapist, chaplain, dietitian, and psychologist/counselor. Additionally, patients and families have access to support groups, peer support services, educational classes, assistive and information technology, transitional support, life skills support, and the pre-driving program. My patient population includes spinal cord injury/disorder (SCI/D) and dual diagnosis (SCI with traumatic brain injury [TBI]). I am able to follow patients and families across a continuum of care, from the Intensive Care Unit (ICU) to the outpatient setting. I typically work with three interdisciplinary inpatient teams (5 patients each) providing psychoeducation, emotional support, psychological intervention, and cognitive assessment as needed to patients and families. My responsibilities also include facilitating discussion about adjustment to injury, monitoring any possible neurocognitive/emotional functioning changes, identifying potential barriers in participation for rehabilitation, and treatment planning to address these barriers. Additionally, I lead the Patient Support Group and Family Support Group on a weekly basis. For my patients who transition to our XXX Program, I continue to work with them and their families (increasing my typical case load to 18-20 patients and families). My role as the Rehabilitation Psychologist is to support them during this often overwhelming and daunting transition towards independence and return to their home/community. I provide intervention, as needed, to facilitate their return to highest level of self-reliance and re-engagement in meaningful life activities.Professional EngagementMy position at the XXX has seamlessly aligned both with my accomplishments during clinical training and my future career goals, specifically, participating within an interdisciplinary care team and providing patient-specific treatment within a medical rehabilitation setting for patients with acquired brain injury (ABI) and/or spinal cord injury/disorder (SCI/D). My prior clinical experience during graduate school, internship, and fellowship has created a solid foundation for me to enter the next stage of my professional career. Throughout these roles, I conducted cognitive/neuropsychological assessments and provided treatment to a diverse range of individuals with various illnesses (i.e., neurodegenerative disease, movement disorders, multiple sclerosis, spinal cord injury, and acquired brain injuries) whose presentations were compounded by psychological and medical factors. During fellowship, I found my passion in the work I did as a rehabilitation psychologist which solidified my decision to specialize in this field. I enjoy being able to facilitate discussion with each patient about his/her adaption and adjustment post-injury, promote a more meaningful quality of life, and ensure functioning and self-reliance at the highest level possible. My prior experience conducting cognitive/neuropsychological evaluations has helped my understanding of how cognitive dysfunction can impact an individual’s adaption and adjustment with ABI and dual diagnosis (spinal cord injury/traumatic brain injury) populations. In addition to clinical care, I also enjoy supervising graduate students and being active with APA’s Division 22’s XXX Committees. These roles have facilitated my understanding of current issues and research within the field as well as developing essential skills of being an effective leader and mentor. Being an active member of Division 22 has provided the opportunity to connect with other rehabilitation psychologists (locally and nationally), as well as providing a professional community that I belong to. I am able to have dialogue with other psychologists about professional development, collaborate on research projects, and consult on how to better advocate for individuals with disabilities. I have enjoyed being able to step outside the “office” and address other relevant topics related to being a Clinical Psychologist within a rehabilitation setting. This past year, I attended my first Rehabilitation Psychology Division 22 Conference where I was able to network with fellow colleagues and well-known leaders/researchers/clinicians in the field. Other conferences I regularly attend and have presented at include American Psychology Association, Academy of Spinal Cord Injury Professionals, and occasionally neuropsychology-related-conferences (e.g., NAN, INS). It has helped with staying up-to-date with clinical topics, obtaining CEUs, and being exposed to new ideas/topics from esteemed speakers. Additionally, subscribing to and reading the APA Monitor, Rehabilitation Psychology, and The Journal of Spinal Cord Medicine have provided a regular influx of clinical information for my professional enhancement. Overview of My Approach to Clinical CareOne specific definition of “illness” is “a condition that causes harm and that derives from dysfunction” (Taylor & Vaidya, 2009). Dysfunction can come from a harmful environment (e.g., sexual abuse or invalidating settings), the internal disrupted mechanism of the body (e.g., brain injury or hyperthyroidism) or from a combination of both. Thus, before I even conceptualize an individual treatment plan, I collect a comprehensive history and assessment of an individual’s current and past functioning. Letting patients describe their subjective experience is key; it helps me to understand how patients view and define their own “dysfunction,” which in turn informs me of appropriate interventions. I understand that my experiences, beliefs, and values might not align with their views of themselves, others, and their world; therefore, it is very important to collect a patient’s point of view regarding his/her illness or injury, and its impact on the various facets of his/her life.Since I work with individuals with chronic illnesses or injuries that often lead to disability, I am heavily influenced by the works by Beatrice Wright. Within “Physical Disability- A Psychosocial Approach,” (1983) she explores various themes of “coping/learning, succumbing, and hoping” through the uncertainty of a disability. This social model of disability emphasizes helping to instill “an active outlook” for a person with a disability(“PWD”). Wright (1983) writes about individuals being able to feel that they can alter possible barriers, such as limited accessibility or prejudice/discrimination, and see their potential assets over their losses. I believe Beatrice Wright’s framework resonates with the widely accepted treatment in rehabilitation psychology, Cognitive Behavioral Therapy (“CBT”; Elliott & Jackson, 2005). CBT addresses the cognitive and physical changes experienced by the patient through understanding the antecedents/consequences of behaviors, and the thoughts of an individual regarding oneself/others/the world. Some of the techniques commonly used in CBT include “cognitive restructuring, increasing the person’s access and willingness to engage in rewarding activities, various forms of relaxation training, problem-solving strategies and assertiveness and coping skills training” (Metha et al., 2011). I believe these skills align well with Wright’s (1983) social model of individuals being active participants in their recovery. Therefore, I approach therapy as a collaborative endeavor using CBT techniques to challenge patients’ negative thoughts and help change distortions into more realistic perceptions of reality and instill a feeling of control of the environment. As a partner in this process, I instill “approach-focused coping” (Kennedy, 2008): having the capacity to engage in positive reappraisal. If I am able to help a patient perceive that a situation can be managed, they are more likely to adopt a problem-solving strategy, which “facilitates coping and adjustment.” My treatment objective is to help an individual “unlearn” maladaptive patterns and to bolster adaptive ones. Together, we review coping styles, automatic thoughts, or cognitive distortions to show areas of intervention and create treatment goals. I also will incorporate other approaches to enhance intervention such as using motivational interviewing techniques when patients might have difficulty engaging in the therapeutic process. Also, at times, I add components of dialectical behavioral therapy (DBT) to further augment the pattern of thought and behavior through its’ “Skills Training” of mindfulness, distress tolerance, interpersonal effectiveness, and emotional regulation (Webb, Beard, Kertz, Hsu, & Bj?rgvinsson, 2016). DBT utilizes the foundation of CBT’s problem-solving procedures through cognitive restructuring and behavioral activation to increase cognitive flexibility. However, DBT adds the layer of mindfulness- and acceptance-based strategies to decrease problematic behaviors and increase the acquisition, strengthening and generalization of more skillful behaviors (Swales, 2009). I find this component very helpful especially with aspects of disability that cannot be “changed” or avoided. I can assist a patient to work with what is in “the present” with their strengths rather their weaknesses. Additionally, throughout treatment, I monitor effectiveness through constant feedback and assessment of the existing intervention with the patient. A key feature of my focus during assessment and intervention is the importance of an individual’s personal strengths, factors that can be beneficial in adverse events (Kilic, Dorstyn, & Guiver, 2013). This is called “psychological resilience,” defined as the intra- and interpersonal resources of an individual (Warren, Agtarap, & deRoon-Cassini, 2019). I understand that the level of stress resulting in “dysfunction” is very unique from one individual to another. However, there can also be personal qualities of an individual that can enable them to persevere as described in Wright’s (1972) fourth Value-Laden Beliefs and Principles. Therefore, I assess for an individual’s coping style, faith, sense of multiculturalism or social support, and other positive resources to use as possible coping strategies and increase positive outcomes (Kortte, Gilbert, Gorman, & Wegener, 2010).Case #1: Ms. XMs. “X” is a 43-year-old right-handed, Caucasian female who presented with an acute onset of paraesthesia in her hands and feet and ascending bilateral lower and upper extremity weakness on XX/XX/2017 at her local emergency room. She was then transferred to the ICU, requiring intubation within 24 hours of admission due to respiratory failure. During her hospitalization, the neurologist confirmed the diagnosis of Guillain-Barre Syndrome (GBS) by lumbar puncture with positive findings of albuminocytologic dissociation. Ms. X underwent 5 rounds of intravenous immunoglobulin (IVIG) that led to some improvement in bilateral movement, but Ms. X’s quadriparesis and generalized pain in all extremities remained. Ms. X was appropriate for comprehensive inpatient rehabilitation and transferred to XXX on XX/XX/2017; five weeks after the initial ER visit. At the time of admission to XXX, Ms. X was no longer intubated but continued to experience autonomic dysfunction, bladder and bowel incontinence, quadriparesis, extreme fatigue, weakened voice intensity, and pain with touch. She required maximum assistance with her activities of daily living (ADLs) and instrumental activities of daily living (iADLs). Referral to Psychological Services was completed by the physiatrist for routine consultation “to assess and monitor for the risk of adjustment disorder related to injury for patient and family, and provide ongoing support as necessary.”I selected this first case because it exemplifies how a Rehabilitation Psychologist can play a role in all phases of rehabilitation (inpatient to outpatient), and on various levels of collaboration with the interdisciplinary team. The first case allows me to address multiple Functional Competencies, including Assessment (adjustment to disability (individual & family); sexuality; substance abuse; pain), Intervention (adjustment to disability/emotional adjustment; sexuality; pain; vocational/educational issues); Consultation (peer), Advocacy (client/patient; disability issues) and Consumer Protection (Federal & State Legislative Statues). Additionally, the behavior anchors of “Foundations” competencies are also bolded. It should also be noted despite Guillain-Barre Syndrome being a rarer neurological disorder, it is often a common diagnosis seen at the XXX where other rare neurological disorders such as Transverse Myelitis and West Nile Virus are treated as well. Overview of Guillain-Barre SyndromeUnlike traumatic spinal cord injuries (a direct insult to the spinal cord), GBS is an autoimmune response within the peripheral nervous system that results in similar symptoms of “muscle weakness, ataxia, autonomic dysfunction, pain, and sometimes respiratory failure” (Willison, Jacobs, & Doom, 2016). It is also known as “acute inflammatory demyelinating polyneuropathy (AIDP)”. There is limited literature regarding the psychological effects after the onset of GBS. Forsberg, Press, Einarrson, de Pedro-Cuesta, and Holmquvist (2005) demonstrated that there are significant consequences on an individual’s ADLs, work, social activities and health-related quality of life two years after GBS. Two percent of patients reported being dependent in personal activities of daily life (ADLs), 26% reported being dependent in instrumental ADL (iADLs), and 17% of individuals were unable to work. Scores on Sickness Impact Profile at the 2-year mark remained elevated in the physical dimension as well as home management, work, and recreation/pastimes. Merkies and Kieseier (2016) found that one out 15 patients with GBS had depression based on the Hospital Anxiety and Depression Scale score. Sharshar et al. (2012) revealed that a third of GBS patients have intense anxiety at the time of their admission to ICU, being related to their intubation, intensity of weakness, presence of bulbar dysfunction, and the vague prognosis of their illness. During the ICU stay, depression was noted in 67% and anxiety was observed in up to 82% of patients with GBS (Weiss, Rastan, Mullges, Wagner, & Toyka, 2002). As mentioned above, GBS can have lasting impact on an individual’s quality of life. With their common clinical features and treatments, Guillain-Barre syndrome and spinal cord injury can lead to adjustment issues with overlapping features for both the patient and family members. These factors include changes in independence, physical functioning, fatigue, impact of social function, pain, emotional adjustment, and social isolation (Parry & Steinberg, 2007). There are significant parallels with symptomology in SCI and GBS but one important factor to highlight is the difference in potential for complete or near complete recovery process between the two populations. The recovery rate in GBS varies vastly across studies; however, a large percentage of patients (ranging from 30-90%) will have complete or near complete recovery and approximately 20-25% of patients will have residual impairments (González, Sanz-Gallego, Rodriguez, & Arpa, 2013; Netto et al., 2011). Thus, the possible functional recovery towards baseline in individuals with GBS is greater than those with SCI. Factors associated with poorer prognostic outcomes include respiratory failure (with the need to intubation and ventilatory support), older age, severe deficits at onset, and injured cranial nerves (i.e., bulbar palsy). Death rates are relatively low, estimated between 1-18% (González, Sanz-Gallego, Rodriguez, & Arpa, 2013). Given Ms. X’s course of GBS (intubation and severe deficits at onset), her potential recovery could be significantly impacted by these factors. With the limited literature on Guillain- Barre Syndrome and psychological assessment and intervention, I primarily utilized and applied evidence-based treatment within the spinal cord injury population for Case #1 due to the parallels between GBS and SCI. Approach to Assessment/EvaluationI was out of the office during Ms. X’s admission. Therefore, my colleague conducted the initial intake. During my first meeting with Ms. X, I introduced myself as the Rehabilitation Psychologist for the care team and explained my role during her rehabilitation stay, including providing individual and family therapy interventions and completing any emotional/cognitive assessments to address the various areas of adjustment with her illness. I asked if Ms. X was receptive to these Psychological Services to which she expressed being open to receiving these services. This aligns with the APA Ethical Principles of Psychologists and Code of Conduct’s Informed Consent (2019) which states that when assessing or treating a patient, a psychologist must explain these services in a reasonable language that the patient is able to understand. Additionally, I explained limits of confidentiality (related to Section 4.02) where I provided details to Ms. X about the extent of the private information exchanged in our professional relationship that would remain confidential. I reviewed situations in which I would be legally required to report including suspected child/elderly abuse, possible intent to hurt oneself/others, and third-party payors requirement of certain mental health information (i.e., session notes) to which Ms. X expressed understanding verbally. Additionally, I reviewed disclosure of information to the treatment team when it was relevant to care (Sections 3.09 Cooperation with Other Professionals and 3.11 Psychological Services Delivered To or Through Organizations). I stated that in order to coordinate care, I would communicate only relevant and important information to the team. If a topic was sensitive but important to share with the team, I would always discuss with Mx. X first. These ethical codes also align with the State of XXX’s Rules and Regulations for Psychologists (Rule XXX and XXX); Consumer Protection, State Legislative Statutes. XXX is one of the states that have codified the APA’s Code of Conduct’s Informed Consent (XXX ,2017). The licensing board allows these disclosures, however, does not mandate nor provide immunity/protection for psychologist who make disclosures. Additionally, in XXX v. XXX (1982), the XXX Supreme Court ruled that a doctor at an inpatient hospital had the duty to protect identifiable third parties. XXX (2017) emphasized that this case did not “involve any legal duty to warn, but instead involved a duty to protect, which is a broader duty than the narrower duty to warn.” However, as stated in the Introduction and Applicability section of the Ethics Code, a psychologist must comply with the Ethics Code if it established a higher standard of conduct required by law. For this reason, I use APA’s Ethical Principles and Code of Conduct as my guide to practice. Additionally, if the Ethic Standard was in direct conflict with the law, I would comply to the Ethics Code and take steps to resolve the conflict in a responsible manner. Adjustment to disability- individual. Ms. X reported having a history of anxiety that began in [redacted professional] school, but was not formally addressed. Rather, she “distracted” herself with more work to manage her anxiety. During this hospitalization, Ms. X endorsed significant anxiety regarding regaining her ability to walk. She reported that she was recently promoted to a [redacted position of influence], which created concern about being able to maintain the physical demands of the job including traveling and [redacted] activities. She was also worried about having significant fatigue during long work days. Along with reported account of Ms. X’s symptoms, I used the BDI-II and BAI in our initial assessment (BDI-II =9, “minimal”; BAI =16, “mild”). Item 9 (suicide thoughts) was not endorsed. Ms. X reported having significant physical symptoms (e.g., heart pounding and numbness) as well as emotional distress (e.g., fear of the worst happening, pessimism, and crying). I used the BDI-II and BAI due to the brevity of these assessments. Limitations to these measures and other options are discussed in the limitations section. Currently, there is no research regarding GBS and suicide rates. Kennedy and Garmon-Jones’s (2016) systematic review revealed that 5.8-11% of deaths post-SCI were a result of suicide. Additionally, individuals with spinal cord injury (SCI) have been reported to be an increased risk of suicide compared with the general population, almost two to six times higher (Cao, et.al, 2014). During initial assessment, I assessed for suicide ideations using the “SMART” approach: Suicide state and history, Mental state (current), Assess psychological feature, Risk and protective factors, and Time-frame” (Simpson & Brenner, 2019). Ms. X did not endorse suicidal ideation upon intake. If Ms. X had endorsed suicidal or homicidal ideations, within the State of XXX’s Rules and Regulations for Psychologists, I would have the right to protect her or others (Consumer Protection; State Legislative Statutes). This would include assessing further for intent and plan, and implementing our Suicide Prevention Protocol if there was concern for self-harm. Daily safety assessments would continue until risk was diminished. Through the interview process, it was revealed that Ms. X’s social support network had recently changed. Social support has shown to be related to better psychosocial adaption in SCI patients (Livneh & Marz, 2014). Ms. X recently moved in with her mother and had one younger sister who she reported having a very close relationship. Her father passed away 19 years earlier due to lung cancer. She was recently separated from her husband of 17 years, two months prior to the onset of GBS. Her husband was not involved with her healthcare/financial decisions during her rehabilitation. Ms. X stated that her mother and sister provided significant support throughout the hospital stay. Her mother remained with Ms. X as her primary caregiver while her sister would visit every other weekend. Substance use. SCI literature has shown that premorbid history of substance abuse is an important predictor of postinjury abuse. Increased alcohol use has been correlated with longer lengths of hospital stays, decreased life satisfaction, depression, anxiety, and medical complications such as urinary tract infections and pressure sores (Tate, Forchheimer, Krause, Meade, & Bombardier, 2004). Ms. X’s history of substance use was minimal. She denied use of tobacco products, marijuana, and illicit drugs. She stated that she would socially drink alcohol one to two times a year due to “never really liking the taste.” Therefore, substance use/misuse was not seen as a risk factor for Ms. X. I did not use formal measures to assess risk during this intake.However, I could have used the Alcohol Use Disorders Identification Test (AUDIT) (Babor, de la Fuente, Saunders, & Grant, 1992), CAGE (Ewing, 1984), or WHO Alcohol, Smoking, and Substance Involvement Screening Test (WHO ASSIST) (Tate, 1993) as possible screeners. If screener yielded positive findings, I would do further assessment to help confirm or rule out a substance use disorder. Pain. Pain occurs in about two-thirds of patients with GBS due to the nerve root inflammation, which typically presents in the back and extremities (Parry and Steinberg, 2007). Poor pain management can lead to various complications including decreased participation in activities of daily living (ADLs), increased risk for depressive disorders, poor social integration, lower quality of life (Clark, Cao, & Krause, 2017), and interference with rehabilitation therapies (Dijkers & Zanca, 2013). To assess Ms. X’s experience of her pain, I used the “WILDA” approach (i.e., words to describe the pain, the intensity, location, duration, and aggravating/alleviating factors; Fink, 2000). Ms. X reported chronic pain in her lower extremities, describing it as “sharp and shooting” and variable through the day. The only alleviating factor was rest periods. Pain would become a barrier for Ms. X to fully engage in therapy; this was not related to any visible or reported anxiety with new tasks. With these findings, pain management through non-pharmaceutical interventions became a focus of our sessions. It was important to address her pain effectively by instilling adaptive coping skills. Since pain was such a significant barrier in her therapies, information was also relayed to the physician for medication management. In regards to the addition of pain medication in Ms. X’s care, it was crucial for me to understand Ms. X’s pattern of pain medication use behaviors, and the potential for misuse of medication (Clark, Cao, & Kraus, 2017) due to the ongoing “opioid crisis” in the United States. Roughly 21 to 29 percent of patients prescribed opioids for chronic pain misuse them (National Institute of Health, 2019). Ms. X denied any history of pain medication use or misuse, therefore, this was not a clinical area of concern for intervention.Fatigue. Fatigue is a common clinical feature in GBS (Parry & Steinberg, 2007; Drenthen et al., 2013). It is commonly persistent following the acute phase of recovery and is a chief complaint from patients across various aspects of his/her life (Parry & Steinber, 2007). Often individuals might want to return to work, however, continue to struggle due to fatigue. Therefore, level of fatigue was important to assess, especially given Ms. X’s strong desire to return to work. Physical functioning is one critical aspect of vocational evaluation to understand one’s stamina, and range of function (Flansburg, 2011). I did not use an established screener, but asked Ms. X if there was a change in energy level post-injury, a time of day associated with most or least energy, increased need for breaks/naps, and types of fatigue (physical/cognitive). She reported there was significant change post-injury where she was fatiguing during therapies, requiring a nap usually mid-afternoon, and feeling sluggish both physically and cognitively. With this finding, I established energy conservation as an area for intervention. Adjustment to disability - family. With Ms. X’s mother (“B”) identified as the primary caregiver and support person, I wanted to assess her own adjustment to her daughter’s disability. It was important to assess her mother’s coping to help decrease caregiver burnout which can directly impact Ms. X’s current and future prognosis (Sullivan & Miller, 2015). Positive family support is associated with improved ADL function, better treatment adherence, and lower risk of re-hospitalization (Palmer, 2017). Generally, caregivers for individuals with chronic illness often have less time dedicated to their own needs, as their loved one’s physical, emotional, and cognitive demands increase (Sullivan & Miller, 2015). Lynch and Cahalan’s (2017) literature review revealed that primary family caregivers of people with SCI have significant likelihood of “depression, anxiety, poor general health, relationship and financial pressures, stress, and lower overall satisfaction with life.” Some of the predictors of “caregiver burden” were related to the amount of ADL support, the psychological well-being of the patient, caregiver’s age, and gender (Post, Bloemen, & de Witte, 2005). Given this literature, it was important for me to assess B’s overall adjustment and stressors. B was a retired nurse who had previous experience with severe medical illnesses. Within the intake, she endorsed that she felt “very hopeful” with her daughter’s potential recovery, went on regular walks around the hospital, and continually sought out spiritual support from her Chaplain at home. I concluded that B did not require significant psychological support at the time of my assessment, however, regular check-ins were conducted to monitor any changes in distress and arising needs. Summary of Initial EvaluationIn summary, Ms. X was a 43-year-old Caucasian woman in the early stages of recovery from a severe case of GBS. She had significant family support during this hospitalization which she found very helpful with adjusting to her illness and hospitalization. There was no current concern within the areas of suicide and substance use. However, through this assessment, Ms. X and I identified that our goals included addressing her anxiety that impacted her rehabilitation, managing pain through non-pharmacological intervention, and assisting in fatigue management for optimal engagement with therapies and return to work. At conclusion of the initial assessment, Ms. X was presenting with natural emotional response to the onset of a significant medical event. She endorsed mild levels of anxiety and reported concerns about recovery and return to life activities (specifically, work). However, an Adjustment Disorder Unspecified could be a potential diagnosis if her anxiety would exacerbate and significantly impact her overall functioning. Ongoing Assessment During InterventionsSexuality. Over the first few weeks of her stay, Ms. X and I built our rapport and addressed areas of immediate clinical attention. When we were at a comfortable level in our relationship, I assessed her sexual functioning using the “Ex-PLISST Model” (Davis &Taylor, 2006). This model allows me to start with basic intervention “Permission,” and work through the other three layers (Limited Information, Specific Suggestion, and Intensive Therapy) depending on the unique needs of the patients as well as my own comfort level and expertise. This was important to address given the significant changes in impairment in sexual desire, arousal (lubrication), ability to reach orgasm, and sexual satisfaction post-injury (Sramkova, et al., 2017). I approached this area by asking and normalizing sexuality with Ms. X. With the significant functional gains for both motor and sensation in her lower extremities, Ms. X stated that intimacy post-injury was not an area of significant concern for her. Adjustment to disability (individual). I continued to use the BDI-II and BAI across care for on-going evaluation of her emotional adjustment and monitoring for the risk of adjustment disorder. By routinely assessing her emotional adjustment through these instruments, I was monitoring her mood in a quantifiable manner to accompany her subjective report throughout her recovery. Additionally, I continued to assess fatigue, especially given its impact on engagement in the rehabilitation process and Ms. X’s concerns about return to work.Approach to InterventionAdjustment to disability (individual). Torch and Radnitz (2000) discussed how SCI can create irrational thoughts within individuals concerning their “future, their environment, and themselves.” Six categories of cognitive distortions were suggested following SCI such as “an overly negative view of self and others” and “the expectation about consistent failure.” These distortions were consistent with Ms. X’s worries which included “being a bother to her mother,” “not progressing with her therapies,” and “always needing a wheelchair,” despite evidence of significant physical improvement in lower extremity functioning for gait training. I utilized the CBT interventions of identifying and modifying cognitive distortions due to CBT’s effectiveness in addressing depression, anxiety, adjustment, and coping symptoms after SCI (Metha et al., 2011). Through antecedent, behaviors, and consequence (“ABC”) charts to address Ms. X’s anxiety, we were able to reframe these thoughts and instill a balanced perspective of her reality through identifying cognitive distortions and challenging/reframing those thoughts (see Appendix A: list of therapy goals). I suggested this list when she felt anxious about not progressing “far enough” when transitioning to our intensive outpatient program. Before this transition, I typically work with each individual to identify goals for this next phase of rehabilitation. For Ms. X, I was able to apply this list in two ways: 1) providing a reframe of her current physical status and 2) helping her establish short-term goals to focus on during the outpatient program. Through this list, she was able to alter her thoughts by viewing how drastically she had changed in the last few months. For example, Ms. X was initially intubated but now she had a goal of walking in heels. Additionally, Ms. X felt more comfortable with conveying her outpatient therapy goals with her new team. As we further discussed and processed Ms. X’s anxiety, we recognized that her anxiety had impacted her ability to be assertive in many aspects of her life. This was evidenced by 1) not asserting herself when in the community as a person with disability (e.g., others pushing her or skipping her in a line), (2) interpersonally (e.g., her husband visiting her at the hospital unexpectedly while intoxicated several times as well as previously being in a “controlling” relationship with him), and, (3) professionally (e.g., unable to establish boundaries with staff members). With Ms. X’s interpersonal skills impacting her ability to fully engage in adjustment post-GBS and return to community, I incorporated a DBT section of Interpersonal Effectiveness skills to promote and practice assertiveness for oneself (Linehan, 2014). We were able to identify certain tools that Ms. X was able to utilize and practice advocating for herself including “FAST,” and “DEAR MAN.” Ms. X was encouraged to apply these skills that we developed over time in real scenarios. Therefore, these DBT skills were also shared with the team to help cue Ms. X during treatment if a situation in which assertiveness was warranted (e.g., a trip to a store and people getting too close to her wheelchair). I also engaged in a co-treatment session with Occupational Therapy and Recreational Therapy on Ms. X’s first community outing to address anxiety management and promote effective problem-solving in a novel situation, such as opening a door while in a manual chair. I coached her through diaphragmatic breathing (Chen, et al., 2017) and mindfulness (Hofmann, Sawyer, & Oh, 2010) to address her anxiety and help her slow down to think through about how to approach a new problem. Second, I asked the core team-members to “overstay their welcome” in some sessions to help Ms. X practice her assertiveness. Ms. X was receptive to the possibility of practicing her skills within the hospital environment by having certain members put her in safe but uncomfortable situations. Initially, she had difficulty asserting herself, but with practice and cueing, she was able to politely ask staff members to leave or listen to her requests by using DBT skills. With Ms. X’s reported feelings of isolation resulting from her diagnosis and prognosis compared to the other patients with primarily traumatic spinal cord injuries on the unit, and her endorsement of worry regarding independence and return to work, I thought it would be beneficial to connect her with other patients diagnosed with GBS. Peer mentees within SCI populations have reported greater life satisfaction, more involvement in occupational/recreational activities, improvements in self-efficacy over time, and fewer days of rehospitalization within 180 days of post-discharge (Sherman, DeVinney, & Sperling, 2004; Gassaway, Jones, Sweatman, Hong, Anziano, & DeVault, 2017). I facilitated Ms. X to meet with other current patients with GBS as well as peer mentors through our Peer Mentorship Services to provide normalization of some of her worries. Through these interactions, Ms. X stated that she felt “less lonely” and began meeting with other patients on a regular basis.Ethical dilemma. In regard to her husband, Ms. X disclosed the reason for their separation was a long-standing history of alcohol abuse that led to a recent hostile interaction. She reported that she was “afraid for her life” when he pointed a gun at her, after which she moved out and filed for separation. She did not want the team to know about the circumstances of their relationship, however, she disclosed to me that he had attempted to visit her during this hospitalization. I assessed safety by reviewing history of previous physical violence, sexual assault and/or legal problems related to alcohol use or violence. All of these were denied by Ms. X. However, she stated that often he was jealous and controlling during their relationship. The firearm was removed after she reported to her friend/neighbor who was a Police Officer. Ms. X stated that she felt “very safe” after she moved in with her mother. Ms. X reported that her husband was not hostile in their interactions after this incident; however, she continued to have trouble with asserting herself especially when he attempted to communicate or visit her while intoxicated. B, her mother, often had to intervene in these situations. With the guiding principles of beneficence and nonmaleficence, and fidelity and responsibility (APA General Principles), I wanted to assure Ms. X’s welfare and safety during this hospitalization, but not break her trust while doing so. Therefore, with her permission, I gave her husband’s name to the security desk (without disclosing the reason) and advised that she did not want him to visit or be able to access any of her information (APA Code 4.04 Minimizing Intrusions on Privacy). Additionally, her mother was the point of contact if anything further was needed. Sexuality. Ms. X attended the Female Sexuality class, where she received information about sexual arousal, orgasms, fertility, and romantic relationships after neurological injury. Upon follow up, Ms. X said she felt comfortable with the information given and had no further questions. However, I provided her with online resources (i.e., Model System Factsheets, and ) for future reference. Pain. Using Ms. X’s new coping skill of mindfulness, I applied this skillset for pain management in regards to her neuropathic pain (Kim & Kim, 2018; Dunford & Miles, 2010). The bio-psycho-social model of pain was reviewed with Ms. X to show how multiple factors impact one’s experience of pain and response to treatment (Benrud-Larson & Wegener, 2000). Once we identified that mindfulness was beneficial and helpful for Ms. X, I coordinated with Physical Therapy to involve her in the weekly Yoga Group for SCI patients as way to practice the components of breathing and mindfulness (Green et al., 2019). Fatigue. As Ms. X progressed in her rehabilitation, we began addressing her endurance, especially given her significant fatigue stemming from GBS. I provided psychoeducation about energy conservation, pacing/scheduling, prioritizing tasks (Kos et al., 2015), and the importance of exercise (Parry, 2007). Research has shown that exercise can reduce fatigue in GBS since avoidance of exercise leads to deconditioning and thus more fatigue. Additionally, Ms. X and I discussed using her previously mentioned assertiveness skills to request breaks through the day as needed when she transitioned back to work. Vocational issues. Individuals with disabilities often experience barriers to re-enter work and rehabilitation psychologists can assist with addressing various aspects such as physical changes and mood management through individual intervention (Turner & Bombardier, 2019). With direct access to Vocational Rehabilitation Counselors, I sought consultation to provide comprehensive and effective care for Ms. X (Rath & Langer, 2019). Vocational Services was able to provide a comprehensive vocational assessment and create an individualized plan for Ms. X to return to the workforce (Gobelet, Al-Khodairy, & Chamberlain, 2007). It was also helpful to coordinate with the Vocational Counselor and use some of their worksheets in my sessions with Ms. X. We were able to use the previously mentioned skills of fatigue management to help coordinate rest breaks and yoga practice when she returned back to work. We also discussed receiving reasonable accommodations in accordance with the American Disability Act’s Title I (1990). Possible accommodations include physical changes, accessible/assistive technology, accessible communications, and policy enhancements. I re-iterated some of the modifications that were suggested by the team for Ms. X such as handrails in the bathroom. Ms. X found these documents very helpful and wanted to share them with her workplace. Advocacy-client/patient. I sought out supervision when I saw Ms. X screaming at a nurse which was an atypical behavior for her. When I approached her, she reported that the nurse repeatedly made derogatory comments about individuals with GBS. Ms. X was visibly upset by his statements and did not want to address this with him further. She requested that I address her feelings with him, but I did not know how to proceed. Therefore, I immediately went to my supervisor for consultation. It was revealed that this nurse had previous history of poor patient interaction, as well as disciplinary action, and I was strongly encouraged to consult with the Charge Nurse to involve management with the issue. I also requested to meet with the nurse individually to discuss and advocate for Ms. X. As stated by Gans (1987), resolving major staff and patient conflict in the rehabilitation setting is often facilitated by staff and by providing education to enhance “psychological sophistication.” During our conversation, I was able to provide psychoeducation about GBS and provide a different perspective on how Ms. X felt to the Nurse in a respectful manner. This also aligned with Beatrice Wright’s (1972) first Value Laden Beliefs and Principles: every individual needs respect and encouragement in the presence of a disability. I also understood that he and I would continue working within various care-teams, and I had to be mindful in how I approached this situation. After his meeting with the Charge Nurse, the nurse was removed from her care-team, and received further training in patient interactions.Summary of Interventions and Final Disposition of Case #1I saw Ms. X for a total of 26 individual sessions through her inpatient rehabilitation and the intensive SCI outpatient program. With this case, there were multiple layers in our interventions regarding her anxiety. Through understanding and processing her anxiety that began in [redacted professional] school, and how it was exacerbated with the onset of GBS, I was able to use CBT to help her understand and manage her anxiety during her rehabilitation. As we continued to work on mood management, it evolved to include other areas that have been impacted by her anxiety. I was able to start delving into how it impacted Ms. X as a person with a disability, her relationship with her husband, and her career. Ms. X’s anxiety impacted her assertiveness and limited her ability to communicate her needs and wants. This allowed me to start adding layers of DBT to help promote advocacy skills including direct communication. This progression of treatment gave a path for team involvement: Ms. X being able to practice realistic scenarios with team members and I participating within co-treatments. I also enjoyed being able to work with Ms. X to create a weekly schedule to ensure a seamless transition back to work that addressed her current physical and emotional needs such as having time to go to yoga class and ending certain work days early. At the end of treatment, she reported that her anxiety and pain were well-managed, but fatigue continued to be a barrier. But Ms. X stated that she felt that she had the tools to manage fatigue more effectively, and would continue to work on this. Upon discharge and termination, we identified possible providers within her community if she or her mother noticed a need for ongoing psychological support. Limitations of Case #1Though I was actively engaged in individual treatment, I provided limited assessment and intervention with her mother, B, the primary caregiver. If B was having difficulty with her own adjustment, I would have worked with her to identify ways to implement self-care, provide support for being the primary caregiver, and establish a better understanding of roles/boundaries between herself and her daughter. If B had reported emotional distress, it might be beneficial to do individual sessions with her regularly, and schedule family sessions to help clarify Ms. X’s and B’s expectations of one another during treatment and transition to home. Additionally, as I further reflect and review this case, there are weaknesses of using the BAI and BDI-II given the overlap of the symptoms in GBS, and the symptoms of depression/anxiety. Thus, these results were skewed. In order to draw a better clinical conclusion during initial intake and following sessions, I would go through each item and see if this symptom was related more to GBS (“wobbliness in legs”) or to Ms. X’s anxiety. With those identified items related to anxiety, I would monitor the severity endorsed each time Ms. X completed the screener. The PHQ-9, HADS, or GAD-7 would have been other options for measures of depressive and anxiety symptoms, due to their psychometric properties within the SCI/D population (Partiz et al., 2018; Bombardier et al., 2012).Case #2: Mr. BMr. “B” is a 35-year-old right-handed, African American male with a history of uncontrolled hypertension who presented with an acute onset of right-sided paraesthesia, weakness, and slurred speech on XX/XX/2019 at his local emergency room. Head CT revealed an occlusion of the left middle cerebral artery (MCA) and MRI indicated MCA infarct involving the left temporal lobe and insular cortex. Tissue plasminogen activator (TPA) was administered within two hours of the onset of these symptoms. However, post-TPA, Mr. B had a grand mal seizure and Ativan was started. Following his acute medical stabilization, Mr. B was deemed appropriate for comprehensive inpatient rehabilitation, and transferred to the XXX on XX/XX/2019 (three weeks post-stroke). At the time of admission to rehabilitation, Mr. B’s difficulties included aphasia, right-sided hemiplegia, and right-sided paresthesia. He required moderate assistance with his activities of daily living (ADLs) and instrumental activities of daily living (iADLs). Additionally, Ativan was switched to Keppra (500 mg twice a day) upon transfer. Referral to Psychological Services was completed by the physiatrist for routine consultation “to assess and monitor for the risk of adjustment disorder related to injury for patient and family and provide ongoing support as necessary.” It should be noted due to limited beds on ABI Unit, Mr. B was placed within the SCI/D unit.I selected this second case because it exemplifies how a Rehabilitation Psychologist works within ecological systems to address intra- to inter-personal interactions and support ongoing adaptation and advocacy. The second case allows me to address multiple Functional Competencies, including Assessment/Evaluation (cognitive function; adjustment to disability (individual and family); sexuality; substance abuse; pain; vocational/educational issues); Intervention (adjustment to disability (individual and family); sexuality; vocational/educational issues); Consultation (community and organizational), and Consumer Protection (Federal & State Legislative Statues; Community Health/Safety Resource). Additionally, the behavior anchors of “Foundational” competencies are also bolded. Approach to AssessmentAs discussed to in my approach to Case #1, upon meeting Mr. B, I explained my role during his rehabilitation stay in reasonable language and reviewed limits of confidentiality and disclosure of information to the treatment team when it was relevant to care. General principles. When working with individuals after a stroke, I do a thorough medical record review to differentiate the type and location of stroke, to begin conceptualization of the possible areas of impairment and prognosis in rehabilitation. Additionally, epidemiology and risk-factors are assessed to help with management of post-stroke symptoms and promote prevention of future strokes, since 3% to 4% of patients are at risk for another stroke (Centers for Disease Control and Prevention, 2017). As an African American, Mr. B was at twice the risk of a stroke compared to Caucasians. Stroke also has the highest rate of death within this population. It is estimated that two out of five African American men have uncontrolled high blood pressure increasing their risk for stroke (Centers for Disease Control and Prevention, 2017). Given this literature, I assessed Mr. B’s past medical history and health habits. With Mr. B’s history of uncontrolled hypertension and body mass index within the obese category, these were significant risk factors for another stroke. He also endorsed a sedentary lifestyle; often being in the office at a desk and not engaging in regular exercise. Additional risk factors of hyperlipidemia, smoking, and diabetes were not a risk factor for Mr. B. These factors were important to identify to address in our individual sessions and in consultation with other disciples, such as the Nurse Educator and Clinical Dietician. This was especially important since the literature has shown that there are deficits in stroke knowledge and prevention for the African American population (Sharrief, Johnson, Abada, & Urrutia, 2016). Mr. B had an ischemic stroke, which is one of the three different categories of stroke (ischemic, hemorrhagic, and transient ischemic attack) and has a lower mortality and better recovery compared with hemorrhagic strokes (Mozaffarian, et al., 2016). With the middle cerebral artery being the largest cerebral artery, supplying two-thirds of the hemisphere and temporal regions, it is the most common cerebrovascular accident (CVA; Teasell, Hussein, Viana, Donaldson, & Madady, 2016). The clinical features associated with a left MCA stroke include: contralateral hemiparesis, contralateral sensory loss, and aphasia. Given this literature, these key symptoms were important to assess during my intake. Contralateral changes in both motor and sensory functioning on his right side were endorsed. Aphasia is addressed below.Cognitive function. After a left MCA stroke, it is estimated that 42% of patients have impairments in verbal expression, auditory comprehension, reading, and/or writing (Rohde, et al., 2018). It should be noted that although the majority of individuals are left hemisphere dominant for language, there are some who have reversed dominance or bilateral presentation of language (Knecht, 2000). To assess for aphasia, my first assessment when meeting Mr. B was the Mississippi Aphasia Screening Test (MAST), one of the possible screening tests to detect aphasia (Hachioul et al., 2017). I started with the MAST to understand if Mr. B was able to comprehend and express himself for the formal intake. It would not be beneficial nor patient-centered if he were unable understand questions and/or be unable to express his thoughts and feelings in a clear manner during the intake and following sessions. Additionally, it was crucial to understand Mr. B’s language abilities and difficulties to make appropriate treatment recommendations (Rohde et al., 2018). In Rohde et al.’s (2018) systematic review of language tests, the MAST was identified as a brief screening measure that could be used by multiple professions and administered within a short time frame. There are other comprehensive language batteries such as the Western Aphasia Battery (“WAB”) and Boston Diagnostic Aphasia Examination (“BDAE”) however they require significant time (more than 90 minutes to administer; Nakase-Thompson et al., 2005). Additionally, these batteries, when used with patients with severe aphasia, might not reflect gradual (but small) improvements and can be frustrating to the patient to complete. Other language tests such as the Boston Naming Test, Token Test, or Controlled Oral Word Association are brief, but do not evaluate for all the components of language. Therefore, it would require combing multiple tests to accurately understand an individual’s language abilities. Also, these tests may do not allow for repeat admission, whereas the MAST was designed for serial assessment to track changes over time. I like to use the MAST since it allows for a quick and relatively “whole” understanding of a patient’s language abilities during intake. I also try to re-administer this prior to a patient’s discharge to measure any changes. If there were positive findings of language deficits, I would consult with the speech language pathologist (SLP) to further assess and address any language impairments (see Appendix B, note regarding the results of MAST). Mr. B’s Total Score on the MAST was 54/100. His Expressive Subscale was 16/50. Difficulties noted included naming, writing, verbal fluency, and repetition of complex phrases. His performance was within normal limits for automatic speech and repetition of 1- or 2-word phrases. Mr. B’s Receptive Subscale Score was 28/50. He had variable abilities with yes/no questions, and as questions became more complex, his performance declined. Reading instructions (8 out 10) was relatively intact. However, following instructions and object recognition was poor. In addition to the testing results, I observed that Mr. B had both semantic (“ear” or “foot” for “nose”) and phonemic (“pedicine” instead of “medicine”) paraphasic errors. He demonstrated no awareness of these errors when communicating.?From this brief screen, I found that Mr. B’s relative strengths included reading simple phrases and answering simple yes/no questions and commands. As phrases became complex, he demonstrated significant difficulty for both expressive and receptive abilities. Poor naming, semantic, and phonemic paraphasias were also noted. I relayed my findings to the speech-language pathologist (SLP) since she is the primary provider for cognitive rehabilitation within the team. The SLP had similar findings for Mr. B, including moderate linguistic/aphasia severity and mild issues with new learning. Based on the SLP’s findings, his language difficulties also included naming (significant improvement with phonemic cueing) and comprehension. With the findings of the MAST, I was able to modify both my initial interview and subsequent sessions to accommodate Mr. B’s current language abilities by using simple questions and providing additional time when he demonstrated word finding difficulties. I also recommended to the team that when providing steps in therapy, it might beneficial to visually demonstrate a task, keep explanations short, and ask Mr. B to summarize what he was told to ensure his understanding.Cognitive changes can also impact a patient’s capacity to process their experiences and hinder positive behaviors that help with adjustment (Taylor, Todman, & Broomfield, 2011). It was important for me to assess Mr. B’s other cognitive domains. I grossly assessed his attention, memory, visual-spatial/constructional, and executive dysfunction through behavioral observation and clinical interview. Mr. B was orientated to person, date, place, and situation (Orientation-Log “O-Log” Score= 30/30). At intake, O-Log was used to due to its convenience of administration and availability of cueing compared to the Galveston Orientation and Amnesia Test (GOAT; Novack, Dowler, Bush, Glen, & Schneider, 2000; Frey, Rojas, Anderson & Arciniegas, 2007). Mr. B had fair insight that he had impairments with his language, memory, and multi-tasking. However, he was not always aware of his language errors in the moment. Given that Mr. B was 3 weeks post-injury, he was demonstrating relatively good carry over from session to session. I made the clinical decision not to complete formal cognitive testing for these areas since his cognitive issues posed no significant barrier to his progress in rehabilitation. I would continue to monitor his cognitive functioning and its impact on his engagement in the rehabilitation process. If there was indication of cognitive barriers, I would have conducted a more thorough assessment to help with recommendations. Given the location of Mr. B’s stroke, the cognitive evaluation would have further assessed his attention, memory, visual perceptual, and coordination skills (motor apraxia); Sila and Schoenberg, 2011. Additionally, I started considering the need for conducting more assessment prior to his discharge for transition planning, whether completed by me or via neuropsychology consultation. I also met with his wife, Mrs. B or “C”, independently, to corroborate Mr. B’s reports. She also endorsed her husband having attention, memory, language, and executive functioning difficulties. Adjustment to disability (individual). Depression, also known as post-stroke depression (PSD), is the most common mood disorder within the stroke population (Taylor, Todman, & Broomfield, 2011). It has been linked to causing or worsening cognitive deficits (Taylor, Todman, & Broomfield, 2011), limiting functional outcomes, hindering use of rehabilitation services (Hadidi, Treat-Jacobson, & Lindquist, 2009), and poor quality of life (Tang, Lau, Mok, Ungvari, & Wong, 2013). The area of Mr. B’s stroke has been associated with mood changes, usually depressive symptoms, in about 33% of patients (Wei et al., 2015). Anxiety prevalence rates are estimated to be around 20-30% within the stroke population (Campbell Burton et al., 2013). Given these statistics, it was important to assess Mr. B’s current mood to ensure optimal coping and adaptation post-injury. Mr. B was tearful during our intake, stating that he was worried about the impact of the stroke on his family and his career. He stated that in the months prior, a significant promotion was offered if he was able to continue at his current work performance. He did not want to jeopardize his chances of the promotion, and was worried about his ability to support his family financially if unable to return to work. He also endorsed sadness regarding his independence, self-identify, and self-esteem. When I explored his feelings with Mr. B, he reported feeling “stupid” due to his aphasia and feeling like a “baby” instead of a husband with his wife. Another critical area to assess with Mr. B was suicidal ideation (“SI”). One out of 8 stroke survivors endorse SI (Centers for Disease Control and Prevention, 2017). I used the “SMART” approach: Suicide state and history, Mental state (current), Assess psychological feature, Risk and protective factors, and Time-frame” to further assess suicidal ideation (Simpson & Brenner, 2019). Mr. B denied both past and current suicidal and homicidal ideations. Substance abuse. With the immense research indicating the prevalence of alcohol and substance use following disability, and their impact on rehabilitation such as medical compliance and re-integration into the community (Turner & Bombardier, 2019; Cardoso, Chan, Pruett, & Tansey, 2006), it was important to assess Mr. B’s substance use history. Mr. B endorsed “rare” use of alcohol, and denied past or current use of tobacco products, marijuana, and other illicit drugs. There were no reports of others voicing concern about Mr. B’s alcohol or drug use, nor had Mr. B sought out formal treatment. Mrs. B corroborated these statements. I concluded that this was not an area of treatment concern.Pain. There is a high prevalence of pain after a stroke (50%-70% of patients experience daily pain), which is related to greater cognitive and functional decline, lower quality of life, fatigue, and depression (Field, 2015). Additionally, pain is a predictor of suicidality after stroke. Given the literature, pain was an important factor to assess with Mr. B, and I used the “WILDA” to gather information (Fink, 2000). Mr. B reported having sporadic pain in his lower back, but that it did not interfere with therapy, and resting provided alleviation. At most, moderate pain was completely resolved with Tylenol #3. I concluded that this was not an area for current intervention, but would continue to assess throughout his rehabilitation. Vocational/Educational issues. Upon his intake, Mr. B reported significant concerns about returning to work and driving. A recent systematic review for return to work (RTW) post-stroke indicated a large range of individuals (19% to 69%) want to return to work (Harris, 2019). Fatigue, psychiatric morbidity, aphasia, and impaired activities of daily living have been related to lower RTW rate. The rate of individuals who are deemed fit to return to driving varies from 30-66% post stroke due to impairments in motor, visual-perceptual, and cognitive skills required for driving (Aufman, Marghuretta, Barco, Carr, & Lang, 2017). Therefore, it was important to assess Mr. B’s typical work schedule, and his understanding of what responsibilities might be impacted by his stroke. Mr. B reported that he drove to work daily, and had a sedentary job including phone calls and computer work. He understood that at this time, he was unable to return to work primarily due to aphasia. But Mr. B stated that he was hopeful to return to work part-time, once he was discharged from rehabilitation. Mr. B also believed that since he was quickly regaining physical abilities, he would return to driving. He lacked insight into the impact of the recent onset of seizures and aphasia for return to driving. This became a crucial area to address and provide intervention due to the increased risk of potential (and significant) harm to himself and possibly others if he returned to driving prematurely. Adjustment to disability - family. Caregivers of patients with stroke have been identified as a high-risk group for poor psychological outcomes, due in part to the sudden onset of stroke and the potential level of care necessary post-stroke (Young, Lutz, Creasy, Cox, & Martz, 2014). Bakas et al. (2002) found that within the first six months post-discharge, caregivers had various needs and concerns related to information for stroke recovery. Additionally, without support, caregivers might develop their own solutions and strategies to meet the needs of the patients after discharge. This often results in safety issues or care-related injury, and poor health for the caregivers. Lutz et al. (2017) demonstrated that caregivers are more likely to have depressive symptoms, report fair to poor physical health, and less likely to engage in health promotion activities than non-caregivers. Given these common themes within the literature, I needed to assess Mrs. B’s understanding and expectations for of her husband’s recovery, her concerns, her capacity and commitment for Mr. B’s care, and to identify protective and risk factors for her new caregiver role. It should be noted that within the limited research investigating race and caregivers of stroke survivors, African American caregivers show higher quality of life and resilience post-injury (Clay, Grant, Wadley, Perkins, Haley, & Roth, 2013); a protective factor for Mrs. B. I used the Veteran Affair/Department of Defense’s Clinical Practice Guidelines for Management of Stroke Rehabilitation (2010) to guide my assessment. I find the Clinical Practice Guidelines to be useful because they provide an outline of a psychosocial assessment for caregivers, to asses for pre-stroke functioning for both patient and primary caregiver; capabilities and caregiver experiences; understanding of patient’s needs; family dynamics, availability of other family members; resources such as financial and social; spiritual activities; leisure activities; and expectation of recovery. Mrs. B stated that her relationship with Mr. B was “stable and strong.” She had prior caregiving experience providing care for her now deceased parents, and demonstrated good insight into the difficulty that can come with trying to anticipate the needs for her husband. There was limited family and social support nearby. Mrs. B worked full time and recognized that she needed to find moments for self-care, as well as, to be comfortable with attendants providing oversight when she was unavailable. I concluded that at this time, Mrs. B needed ongoing individual support throughout the inpatient stay to address these concerns to ensure optimal outcomes for both herself and husband when adjusting and adapting to his stroke.Summary of Initial EvaluationMr. B was a 35-year-old African American gentleman who was three weeks post-left MCA stroke with ongoing deficits of aphasia, right-sided hemiplegia, and right-sided paresthesia. He had a strong and supportive relationship with his wife, Mrs. B. Mr. and Mrs. B both reported having difficulty navigating coping after his injury. With the assessment results, we identified that our goals for our sessions included: addressing change in Mr. B’s self-esteem and role changes between himself and wife; providing psychoeducation about RTW and RTD; and adjusting to his communication impairments. At conclusion of the initial assessment, Mr. B was presenting with expected emotional symptoms in response to a stroke, including worrying and endorsing sadness related to impact of stroke on his family and himself. However, Adjustment Disorder Unspecified could be a potential diagnosis if his anxiety exacerbated and significantly impacted his overall functioning. Ongoing Assessment During InterventionsSexuality. Professionally, I do not assess for sexuality/intimacy after injury during the first intake due to limited rapport. However, as I begin to work alongside patients and their partners, I then begin to assess for patient’s possible concerns and dysfunction after a stroke. Regardless of the patient population, I use the “Ex-PLISST Model” (Davis &Taylor, 2006) which allows me to start with basic intervention “Permission,” and work through the other three layers depending on the unique needs of the patients, my own comfort level, and expertise. More than half of patients and spouses reported diminished libido, arousal, and sexual satisfaction post-stroke (Korpelainen, Nieminen, & Mylyla, 1999). Some of the factors related to decreased sexual activity included decreased general attitude towards sexuality, fear of impotence, and functional disability. The functional disabilities could be physical changes such as changes in sensorimotor impairment, cognitive impairments, and psychological coping (Rosenbaum, T., Vadas, D, & Kalichman, L, 2014). Therefore, over the course of treatment, I assessed for Mr. and Mrs. B’s concerns regarding intimacy after injury as well as their understanding of how to return to this aspect of their relationship. Both of them, individually and collectively, stated that this was not a primary concern for them, but both requested further information regarding this topic. Therefore, psychoeducation about intimacy after injury became one of the treatment goals.Approach to Intervention Adjustment to disability (individual). Within the inpatient rehabilitation setting, my intervention includes assisting patients to understand their impairments post-stroke, processing how it impacts their functioning, and helping to implement possible strategies and coping skills. Based upon the findings from his assessment, I utilized CBT with Mr. B due to the significant negative thoughts about himself, his surrounding world, and future (Barton, 2012). Broomfield et al.’s (2001) review demonstrated CBT being effective with patients who are post-stroke in addressing their lower self-esteem and feelings of hopeless about their future. CBT can also be modified with “cognitive deficits adaption,” or changing the way information is presented to a patient and accommodating their cognitive impairments from the stroke. When creating “ABC” or cognitive restructuring charts, I utilized simple language due to Mr. B’s personal strength of reading. I challenged his negative thinking and worked with him to shift his thoughts for a more balanced and positive perspective. Through our sessions, he was able to recognize his worth and understand that there was potential for positive changes within his recovery. To address his concerns about the role-changes between himself and his wife, I worked with Mr. B to identify various ways of providing for his wife and their three sons (all under the age of 8 years old). Despite not being able to provide for his family financially at this time, he was able to see that physically (e.g., setting the table for dinner) and emotionally (e.g., being on the sidelines at his son’s soccer game to cheer), he supported them. We also recognized that when his anxiety level increased, his aphasia worsened when trying to communicate with me or others. Mr. B and I started working on relaxation techniques such as diaphragmatic breathing and visualization to address his emotional distress and aphasia (Chen et al., 2017). His wife was taught these skills to prompt Mr. B when he became worried or his language was more impaired. Within these sessions, I think the most significant impact as an intervention was through normalization of Mr. B’s embarrassment stemming from his aphasia. With Mr. B being placed on the SCI Unit due to limited bed space on the ABI Unit, Mr. B often felt like an outlier being one of the higher functioning patients on the unit given his physical abilities and communication difficulty. His aphasia was the most distressing for him, because he often felt like a “dummy” around SCI/D patients and his family and friends. To address these feelings, I utilized the National Aphasia Association’s website to read other individual’s personal experience with aphasia. Through the website, we came across a sign stating “I have a loss of language, not a loss of intelligence” which resonated strongly with him. Mr. B asked for a sign to put on his wall to help reinforce that other patients have felt the same way he did and had similar concerns. Mr. B felt validated that his worries were important and real despite never meeting a person who had language impairments. Once the team established his discharge plans to an intensive outpatient program for acquired brain injury, I encouraged him to connect with other patients who might have aphasia in that program to further normalize his feelings post-injury. Adjustment to disability - family. Some overarching themes in research about caregivers within the stroke population include that caregivers lack knowledge about addressing dependency and feelings of helplessness for their loved ones (Thompson & Ryan, 2009). With Mrs. B’s prior experience as her parents’ caregivers, she understood some aspects of caregiving, but she endorsed having a hard time “backing off” with her husband throughout the day. She reported that she was the one who called EMS for her husband and since then, she felt her husband needed constant supervision even for basic tasks, such as brushing his teeth while in his manual chair, “just in case.” I validated her feelings and emphasized that Mr. B needed the opportunity to practice his skills and demonstrate his strengths and self-reliance. I consulted with the interdisciplinary team to generate a list of tasks that Mr. B could not do at this time (e.g., driving), tasks that they can do together (e.g., transferring or showering), and tasks Mr. B could manage on his own (e.g., sitting in his manual chair and watching television). It was helpful for Mrs. B to see that there were many tasks that Mr. B was able to do based on the team’s professional feedback. This list also helped set the expectation of one another in his care. Another area of intervention was working alongside the B family to discuss and process the shift of Mr. B being at home and Mrs. B being the primary bread-winner for the household. We explored what it meant to be a father and husband according to Mr. and Mrs. B. Many of the roles Mr. B played as a father and husband did not stem from financially supporting them. Rather, he began to see other ways that he could support his family. Additionally, since the B family was placed on the SCI Unit due to limited beds on ABI Unit, I referred Mrs. B to attend the ABI Family Lecture Series to receive additional information about stroke rehabilitation, services, and to interact with other ABI family members. Sexuality. Through discussion using the ex-PLISSIT model, Mr. and Mrs. B expressed that intimacy after injury was not a primary concern at this time. Both, however, wanted information for the future. This aligns with the “Limited Information” stage within the Ex-PLISST model (Davis &Taylor, 2006). I reviewed a variety of topics including the sexual response pathway and erectile dysfunction. Additionally, I reviewed the sex response cycle (desire, excitement, and orgasm), and how the limbic system with thoughts, emotions, and memories can help with arousal (Kaplan, 1995). I emphasized how psychological, physiological, and medical factors can impact sexual functioning (Miljkovic & Tita, 2018). One area I highlighted was that aphasia can impact intimacy (Calabro, Gervasi, & Bramanti, 2011) due to limited ability to express one’s feelings or engage in conversation, especially since adequate communication skills are necessary for forming and maintaining social and sexual relationships. I recommended that non-verbal communications might be helpful, such as holding hands, when starting to re-engage with each other intimately. Vocational issues. With the stroke population, I often will spend significant time in session discussing their worries about return to work, given evidence that 77% of patients report that their work is of great value, and they hope to resume work post-injury (Baldwin & Brusco, 2011). With Mr. B’s strong desire to return to work and driving, many of my sessions focused on processing his feelings of not feeling “independent.” Additionally, I provided psychoeducation about the various aspects that needed to be taken into consideration for a safe return back to work and driving. I consulted with Vocational Services for their expertise in providing individual assessment of the patient’s skills and the development of a graded return-to-work program (Baldwin & Brusco, 2011). The Rehabilitation Services Administration under the Office of Special Education and Rehabilitative Services (OSERS) was another resource provided to Mr. B. I spoke about the Rehabilitation Act of 1973 which allows for federal funds to assist individuals with disabilities in preparing for and engaging in gainful employment. It is estimated between 21% to 73% of individuals return to work post-stroke (Wozniak, Kittner, Price, Hebel, Sloan & Gardener, 1999). Even though, Mr. B was not appropriate for return to work at this time, given his significant aphasia, and the majority of his work responsibilities requiring communication skills, I assessed that it was important for him to receive information about what was available for a successful transition when he was further along in his rehabilitation. Some studies have found that cognitive and behavioral impairments were more important than physical deficits for vocational prognosis (Treger, Shames, Giaquinto, & Ring, 2007). I recommended a comprehensive neuropsychological evaluation 6 -12 months post-injury to assess for Mr. B’s current strengths and weaknesses, provide recommendations for accommodations/modifications, and to clarify if Mr. B was ready to return back to work (Cullum, Rossetti, Batjer, Festa, Haaland, & Lacritz, 2018). This neuropsychological evalution would also be beneficial to address and predict driving safety (Haddad, Uswatte, Mark, & Bechtold, 2019). Many states have regulations for return to driving post-stroke given the physical and cognitive impairments (Mardh, Mardh, & Anund, 2017), and require an interdisciplinary approach to assess fitness for return to driving (Burns, et.al, 2018). The gold standard is a road test, so I provided Mr. B with information for local Driving Rehabilitation Programs, driving services for individuals with disabilities, for assessment in the future. Given his diagnosis of seizures post-injury, I reviewed his local XXX Driving Licensing Law related to clearance to drive after a seizure (XXX Neurological Guidelines for Applicants with Seizures) and the impact of his current cognitive and physical symtoms on driving. I emphasized that I had the responsibility of protecting him and others around him. However, I assured him that he would have the opportunity to return to driving once he was seizure-free for a period of time and assessed by appropriate providers. Mrs. B was also informed of these recommendations to help her husband follow-up with them.Consultation (community and organizational). Before any of patients discharge, I will begin the process of discussing the importance of ongoing emotional support once home due to trying to re-establish within their community with post-injury limitations (Caplan, 2019). Often, I will try to introduce resources that could be beneficial for ongoing integration and support for both patient and family. Both reported being receptive for ongoing services after their discharge from inpatient rehabilitation. The B family was directly transferring to an intensive outpatient ABI program where Psychological Services were provided within the interdisciplinary team. Additionally, I have found the American Stroke Association and National Aphasia Association as useful websites to help find support groups for patients/caregivers and be an ideal resource for any questions that arise in the future. I met with Mr. and Mrs. B to identify possible groups for each of them to attend within 10 miles of their home zip code. Consumer protection (community health and safety resources). Assistive technology has allowed for increased safety and self-reliance within the stroke population (Haddad, Uswatte, Mark, & Bechtold, 2019). I thought it might be beneficial for Mr. B to be able to use external devices to ensure his safety and well-being, so I consulted with Assistive Technology regarding “smart” devices. We were able identify important numbers such as Emergency Services and neighbors in Mr. B’s phone which could be linked with a “smart home” device (Thordardottir, Fange, Lethin, Rodriguez, & Chiatti, 2019). This would enable Mr. B to readily call the appropriate individual if a fall or other adverse event occurred. Additionally, we were able to set reminders for medication administration through this device. Summary of Interventions and Final Disposition of Case #2I chose Case #2 because it demonstrated a balance of intervention between the patient (Mr. B) and family (Mrs. B). I utilized CBT as my main intervention and helped instill hope for Mr. B. Despite his current changes, he was able to perceive other ways to support his family and feel valued as a father and husband. My sessions with Mrs. B provided ways to help promote Mr. B’s independence, ensure his safety and well-being, and decrease caregiver burnout. Additionally, I worked with both of them to discuss what their roles would be at home and address intimacy after injury. With the clinical features of aphasia and seizures, psychoeducation and interventions related to return to work and driving were provided extensively. I was able to review Federal and State laws regarding return to work/driving as well as consult with Vocational Rehabilitation and Driving Rehabilitation. At the end of our sessions, Mr. B continued to struggle with the role changes and impact of his aphasia on his functioning. Ongoing psychological support was strongly recommended with an outpatient ABI program. Limitations of Case #2After reviewing Case #2, I think a significant weakness was I never advocated for Mr. B to possibly transfer to the ABI Unit, especially given how distressing his aphasia was when he compared himself to the SCI patients. It might have benefited him to be in an environment where this social comparison was diminished by being surrounded with others having the same or similar cognitive difficulties. Additionally, I could have reached out to the ABI Peer Support to set up individual sessions to let Mr. B further discuss and process his experience with other individuals post-injury. I also never had the opportunity to meet his three young sons to provide intervention, as they were living at home and being taken care of by Mr. B’s mother. This could have been another area of assessment, intervention, and education if the children expressed distress related to their father’s stroke and changes within their home. 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