Proctor, D - American Board of Professional Psychology



The following Practice Sample is provided as an example of one approach to demonstrating many of the expected competencies of Rehabilitation Psychology. It should not be considered the correct or preferred method. Also note that the details have been obfuscated in order to further de-identify the cases and the practitioner. Attached are the feedback responses from reviewers with strengths and suggested improvements.Practice Setting and Professional DescriptionI am a clinical Assistant Professor with dual appointment at the local University School of Medicine and the non-academic clinical university hospital group. PM&R is housed a 45-bed acute rehabilitation hospital. I serve as the attending inpatient Psychologist on the Spinal Cord Injury (SCI) Unit. I also have a thriving outpatient clinic where I deliver psychotherapy and assessment to individuals with chronic conditions including SCI, pain, and trauma to name a few. I have historically delivered all services face-to-face, but I am now one of the first providers in my department to offer telehealth services as well. In terms of teaching and service, we have a Graduate Medical Education accredited PM&R medical residency program where I work closely with the medical residents in clinical care as well as their academic requirements. Within the residency program, I serve as the coordinator for the faculty-resident mentorship program, deliver multiple lectures annually, serve as a sponsor for their journal club presentations, and mentor the design and implementation for their quality improvement and research projects. The Psychology Department has an American Psychological Association (APA) accredited doctoral program in Clinical Psychology, of which I serve as a clinical supervisor for many of the trainees as well as serving on their graduate training and dissertation committees. I am also on the Psychology Clinical Training Committee for the APA accredited Psychology clinical internship program. In addition to being an active participant in the planning of the training program, I also serve as a clinical supervisor for the predoctoral interns and teach one didactic lecture per year. In terms of service, I am on several departmental committees including a wellness committee charged with improving wellness overall for faculty, staff, residents, and patients. I have taken ownership of the faculty and staff initiative and, with an approved $10,000 annual investment from the faculty and department, I have been able to launch programs focused on decreasing burnout and improving overall wellness for our team. Nationally, I am involved in the field of Rehabilitation Psychology through memberships with APA, Division 22 Rehabilitation Psychology, the American Congress of Rehabilitation Medicine (ACRM), and American Spinal Cord Injury Professionals (ASCIP). Within these organizations, I am a member of many special interest groups, attend annual conferences, and serve as an appointed member of the SCI Medicine Consortium as their liaison with ACRM. I have also been working with a team of esteemed colleagues for more than a year to update the Clinical Practice Guidelines for the Management of Mental Health Disorders, Substance Use Disorders, and Suicide in Adults with SCI. I pursue further education and training in the field of rehabilitation psychology through annual APA Division 22 conference attendance, attending local PM&R grand rounds and resident journal club weekly, reading treatment manuals, and serving as a journal reviewer for Mental Health and Aging and PsychoOncology. Through this, I am able to obtain twenty continuing education credits annually to maintain my license and remain current in my knowledge. The issues that the field of Rehabilitation Psychology are currently grappling with, in my opinion, are related to accessibility and awareness. This includes reaching out to practitioners to increase awareness of the field through the inclusion of rehabilitation psychology curricula in training programs within Psychology, medical schools, and the allied health professions. In small part, to combat this, I serve as a lecturer in the annual Summer Health Professionals Education Program, a summer series giving graduate student experience to undergraduate students from underrepresented backgrounds interested in pursuing medical education. In this program, I give two lectures one on SCI and the other on rehabilitation psychology. I also serve as the faculty sponsor for the APA Division 22, Student Leadership Network, Rehabilitation Psychology interest group at my university where I encourage the student leadership to consider this an opportunity to include those with shared interests, but also those that may not yet know they are interested in rehabilitation psychology. I also believe that being imbedded within an interdisciplinary treatment team affords me the opportunity to train other disciplines to, within their capacity, help meet patient’s emotional needs. For underrepresented groups in particular, this has been noted as an important way to decrease barriers and increase access to mental health services (Rich, 2016). One such example, was when a new resident was providing the medical update on a non-English speaking patient, whom I knew was very anxious, during a weekly team meeting. He stated she was being transferred back to acute care for further neurologic workup. When I asked him if he had addressed this with her, he related that the neurology consult team told him they had counseled the patient. I encouraged him, as the primary provider assigned to her care, to return to the room, and with the use of an interpreter ensure she was aware of the plan and address any questions or concerns she may have. His deference to another consultation team on the care of his patient, and limited willingness to use translation services because of the inconvenience, was not acceptable practice. I am fortunate to work in an environment where I have a voice to speak up and effect change in care by shaping future independent providers to be sensitive to the rights, welfare, and dignity of others. There is also a need to improve the reach of services by those trained in the field with the incorporation of telehealth, paramental health practitioners, and other ways of ensuring patients have access to the mental health services they need. This is both an issue of social justice and access. Traumatic SCI disproportionately affects African American males at a rate of 23%, when they only make up 13% of the US population (NSCISC, 2019). The psychological wounds left by violence for the individual, their family, as well as their community often goes unrecognized and untreated in African American communities. The ongoing chronic stress of violence has also been linked to the disproportionate level of chronic disease, such as heart disease, stroke, and diabetes, in these communities (Proctor, 2019). One area that has been encouraged by social activists is to focus on training individuals of color to provide mental health services (Rich, 2016). I have made the conscious effort to train male minority students, in order to better serve the population of newly diagnosed traumatic SCI patients, typically admitted to my inpatient service. I have found the work these trainees are able to accomplish with African American male patients is very effective compared to what I have been able to do alone as a white, female mental health provider. In addition to under recognition and limited minority representation of providers, the physical limitations of SCI in getting to clinics, limited transportation options of those with limited resources, and the rural nature of my state, all create barriers to access mental health services (Proctor, 2019). In order to improve access, I became the first telehealth provider in the state to secure a Worker’s Compensation contract to provide in-home telehealth services to patients. I am also able to provide these services personally to patients with insurance benefits with in-home telehealth coverage, and via trainees for those underinsured for this benefit or uninsured overall. This took years to work through the legal and technological issues, but as with most things, this investment was well worth the benefit of improved access to care for patients with insurmountable difficulties getting to the clinic. OverVIEW OF MY APPROACH TO CLINICAL CAREWhen approaching individuals who are experiencing the effects of an illness, injury, or disability, I consider the Biopsychosocial Model as a theoretical conceptualization of the intersection between their physical health, mental health, social health, and environment as described by Rath and Elliott (2012). Given this is not a psychological model, or a model of disability per se, I also more strategically conceptualize an individual based on the guiding principles set by Dr. Beatrice Wright (1983) to ensure that I am mindful in addressing how well the rights of the individual, access to living a full life, and acceptance of self are being met. My assessment approach always includes a full psychological evaluation including collecting an educational background, social history, targeted medical history, as well as psychiatric history, functional status (including sexual function), pain, cognitive status, and history and current substance use. My approach to intervention is to use the information gleaned from the thorough initial evaluation to tailor an evidence-based treatment plan conceptualized within a cognitive behavioral framework. My most commonly used intervention approaches integrated into my work with patients are cognitive behavior therapy (CBT) for depression, anxiety, insomnia, and chronic pain. I primarily use cognitive processing therapy (Resick, 1993) and prolonged exposure therapy for post-traumatic stress disorder (PTSD) (Foa, 2007). I use exposure and response prevention for obsessive-compulsive disorder (Foa, 2012). Finally, I have also been studying and utilizing the integration of Acceptance and Commitment Therapy (Hayes, 2005), Mindfulness, and Self Compassion (Germer, 2009) approaches in treating these conditions as well. The use of positive psychology approaches in rehabilitation has been discussed in the literature (Ehde, 2010). The integration of these evidence based treatment protocols into the treatment plan for individuals with disabilities can sometimes be a challenge, but is one that is important to pay attention to and make accommodations for, so the patient can receive maximum benefit in their therapies. Both of the cases I chose, highlight my typical caseload in working in the inpatient and outpatient setting with patients and families adjusting to chronic conditions such as SCI. I demonstrate how I use assessment to guide treatment, with customized treatment planning based on each of the patient’s needs and preferences. Adjustment to injury is an ongoing process that requires ongoing assessment and flexibility in intervention. Although seemingly disparate approaches, the integration of CBT with “third wave” approaches have proven to me complementary to each other and the patient’s needs as well. I chose Ms. X as an example of this and one where we covered many of the “typical” psychological issues along with those specific to living with disability. I outlined the work with Ms. X across settings, as I found the environment to be a contributing factor in treatment approach. In the case of Mr. Y, his treatment plan has included work on his ongoing adjustment to chronic SCI, as well as, difficulties within his family system, which required some focused intervention with his wife. This required assessment and intervention that integrated his cultural beliefs and values with healthcare, functional status, and existential concerns. My work with him has allowed me to challenge my assumptions and learn, with a deeper understanding, how culture and beliefs can shape all aspects of our lives. It also highlights the long-term effects dealing with chronic SCI, a population I am seeing more often as individuals are living longer with SCI.Case 1: Ms XMs. X presented as a XX-year-old white female with a spinal cord injury following a motor vehicle accident (MVA) in 2005 resulting in C6 AIS C level injury (incomplete tetraplegia). She was referred to me by her SCI specialist and approved by her Worker’s Compensation case manager for treatment of “depression.” She acknowledged a history of recurrent depressive episodes spanning decades with presenting complaints of emotional numbness, anhedonia, loss of interest, worthlessness, amotivation, and passive suicidal ideation with no plan or intent. She also noted some mild anxiety specific to social situations. Through psychological diagnostic interview, I determined she was also experiencing significant PTSD symptoms including re-experiencing (nightmares, flashbacks, and physiological arousal from internal and external triggers), avoidance (dissociation, emotional numbness, anhedonia, traumatic amnesia, negative affect), and hyperarousal (hypervigilance, poor sleep, difficulty concentrating, and physiological arousal) resulting from the MVA as well as a history of domestic abuse, childhood sexual abuse, and medical trauma during very young childhood. Using single item questions, I assessed substance use through self-report. She endorsed occasional alcohol use in moderation (Smith, 2009), and denied history or current use of tobacco or illicit substances (Smith, 2010). If she had screened positive for harmful use of alcohol, illicit drugs, marijuana, or prescription medication, I would have used the CAGE-AID (Brown, 1995) to further assess for problematic use. Screening for substance use disorders is especially important in this population, because individuals with PTSD are 2-4 times more likely than those without to screen positive for substance use disorders (Kessler RC, 2005). I choose the CAGE-AID over the standard CAGE or other self-report measures such as the AUDIT, because it encompasses both alcohol and other substance use and it is brief with only four questions.The emotional responses people have to trauma exposure tend to follow one of four trajectories: resilient, recovering, chronically distressed, and delayed (Bryant, 2015; Johannesson, 2015). Approximately 25% of cases with PTSD can have late (beyond 6 months) onset (Utzon-Frank, 2014). In Ms. X’s case of trauma symptoms related to the MVA, her presentation was delayed secondary to her complete focus on physical recovery, avoiding her own emotional response for years. A recent systematic review of 17 studies concluded that multiple post-traumatic factors had clinically important relationships with increased PTSD symptoms: depression, lower levels of acceptance or adjustment, psychological distress, anxiety, and pain (Pollock, 2017). Women tended to report more severe PTSD symptomatology (Pollock, 2017). Ms. X had many of the above risk factors and although she did not come in with a presenting complaint of trauma related symptoms, this was important to assess at the onset.Approach to Assessment of Individual’s with traumatic SCI with chronic PTSD and recurrent MDD in Application in the Case of Ms. XOver the years, I have learned the importance of starting with a full psychological diagnostic interview and not taking a referral diagnosis or even presenting complaint as the basis for which to plan treatment. In the case of Ms. X, this was important, but with her, I could tell from our greeting it was going to be a delicate balance between information gathering and rapport building. She was very guarded and obviously uncomfortable, so I spent extra time with her focused on the common factors (Sage, 2015) in addition to slowly gaining a detailed clinical interview based on the DSM-5 (2013) diagnostic criteria. With this, the assessment and intervention were simultaneous from the beginning and required multiple sessions for her to become more comfortable with me and the process. In this beginning phase, she also let me know how my presence in the room made her feel. She brought in a letter stating her thoughts about me after our first session. She addressed how she was made to feel based on where I sat, how I addressed her crying, among others. I was very appreciative of this, as it allowed us to have a frank and honest conversation, and for me to be more aware of not just what questions I ask, but also how my behaviors may be perceived, which in this case was that of being non-therapeutic. Although I was appreciative, in my self-assessment and reflective practice, I was mindful to not be hypervigilant of my actions, which would keep me from being present with her during session. I was also mindful of internal feelings of intimidation due to her training as a medical provider as well as concern for being viewed as condescending if psychoeducation was banal or elementary. We also spent time in our initial visits addressing the specific issue of confidentiality related to medical records and Worker’s Compensation including: who is the client, who would have access to her records, and what would be included in her records. In my state, Worker’s Compensation (WC) law section 25-5-339 allows WC access to all progress notes following their written request. As noted in the APA Ethical Standards of Psychologists (APA, 2010), we are ethically bound to initiate therapy by covering many aspects to treatment including: 3.10 Informed Consent, 8.04 Discussing the Limits of Confidentiality, 8.05 Recording, 6.01 Documentation of Professional Work and Maintenance of Records, 6.02 Maintenance, Dissemination, and Disposal of Confidential Records or Professional Work, and 10.01 Informed Consent to Therapy.Assessment of patients with SCI in regards to sexual health and functioning is well documented as important (Richards, 2010) within the biopsychosocial model of care. Women with SCI have expressed desire to have sexuality addressed during the acute inpatient experience but noted, sexuality was not a priority to them soon after injury for a majority but assumed greater importance later (Leibowitz, 2005). As highlighted by Dr. Linda Mona (2011), in addition to considerations of the psychological (body image, redefining roles as lovers and partners, changes in sexual self-esteem, and cognitive genital dissociation) and anatomical changes following SCI (scarring, ambulation changes, devices (wheelchairs, braces, leg bags, trachs), pharmacological side effects, pain, dressing, and bowel and/or bladder issues), there are additional concerns for assessment when considering sexuality in older adults. This includes cognitive changes related to memory or expression, consent, and physiological changes with aging. Women with SCI and of older age are especially vulnerable to societal views of asexuality. It is always important to assess the patients cultural views when it comes to sex and sexuality as well. In the case of Ms. X, we discussed her percieved sense of loneliness and desire for partnership and a sexual relationship. She does have capacity to make decisions, so that was not a concern in this case. In spite of the fact she had been living with SCI for over 10 years, she had not yet explored her body to determine her errogenous zones and ability to orgasm. I shared the work of Dr. Alexander (2017) in this area and informational videos she has made on vibrator options for women living with SCI and encouraged her to explore for herself. In addition to education, the interventional work also included continued focus on improved intimacy and self-esteem, because until she could learn to become more comfortable and vulnerable with others, she would continue to be psychologically inhibited from developing fully realized relationships.Approach to Intervention of Individuals with traumatic SCI with chronic PTSD and recurrent MDD in Application to the Case of Ms. XOnce it appeared I had a good picture of the presenting issues of polytrauma-related PTSD and Major Depressive Disorder, recurrent, with severe symptoms, we began to discuss the treatment plan. We initiated the treatment course with psychoeducation, as Ms. X had not considered her symptoms could be related to PTSD. As highlighted in the Health Belief Model (Henshaw & Freedman-Doan, 2009), once a diagnosis is made and treatment course is being set, it is important to assess the patients understanding and belief about their diagnosis and treatment options and use that to determine the treatment plan. Because she was a cognitively intact, psychologically-minded individual, I proposed we utilize CPT to treat PTSD. CPT is based on a social cognitive theory of PTSD that focuses on how the traumatic event is construed and coped with by a person who is trying to regain a sense of mastery and control in his or her life. The other major theory explaining PTSD is Lang’s information processing theory (Lang, 1977), which was extended to PTSD by Foa, Steketee, and Rothbaum (1989) in their emotional processing theory of PTSD. In this theory, PTSD is believed to emerge due to the development of a fear network in memory that elicits escape and avoidance behavior. Attempts to avoid intrusive symptoms activation result in the avoidance symptoms of PTSD. According to emotional processing theory, repetitive exposure to the traumatic memory in a safe environment will result in habituation of the fear and subsequent change in the fear structure (Monson, 2006; Resick, 2002; Resick, 1992; Resick, 1993).With the recovery of traumatic memories and increased awareness of the trauma experiences she had throughout her life, Ms. X began experiencing nightmares that were very disruptive to her sleep and emotionally distressing. As many with PTSD do, she was avoiding sleep in order to avoid the memories and therefore experiencing worsening mood in relation to insomnia. As someone with neurogenic bowel related to her SCI, she requires following a bowel program. She was delaying her nightly bowel program as a way to avoid sleep. We discussed this underlying avoidance and she was able to acknowledge this and recognize her underlying fears. We worked to improve consistency in her nightly schedule and relaxation at bedtime to decrease any lingering arousal from the day. One potential limitation for individuals with SCI utilizing guided imagery as a relaxation tool is that most scripts utilize “walking” to help guide the patient through the environment. For individuals with limited acceptance of their inability to walk, this can be emotionally disturbing. Therefore, I always have a discussion with the patient prior to choosing their imagery to ensure we chose options that will be relaxing for them and also avoid language that may trigger their insecurities. The development of SCI specific guided imagery would be an asset for rehabilitation clinicians. Three case studies demonstrating individualized relaxation interventions with patients with varying physical abilities following SCI have been reported in the literature (Hough & Kleinginna, 2002), but there is much more to be done in the standardization of these interventions. In the case of Ms. X, she did not want to use session time to practice this skill because she felt efficacious in her ability to engage in the task on her own. In most cases, when patients are learning this skill for the first time, I use the Imagery Vividness Scale as a training tool (Lazarus, 1977). Using this scale, I guide the patients in ways to increase the vividness of the images they choose.In order to ensure Ms. X was allowing adequate time to work through her tasks related to psychological recovery we discussed adding structured time during the day (not too close to bedtime) to do the work with additional time set aside for pleasant activities. We discussed grounding techniques and other behavioral strategies to help manage symptoms when they do occur. Finally, we discussed the efficacy of prazosin for decreasing nightmares (Arnsten, 2015). She was given an article to review and we worked in consultation with her primary medical provider to find an adequate dose.? Quality of sleep has been noted as an important indicator for maintenance of psychological well-being following treatment for PTSD and is therefore an important aspect for treatment goals in trauma-focused therapy (Belleville, 2011). These are all empirically based treatments to limit arousal and facilitate sleep at bedtime. As we worked through the PTSD protocol and Ms. X began to gain a good grasp on how to restructure her thoughts, limit avoidance, and habituate to traumatic memories, we then moved on to assess for lingering depressive symptoms, disruptions in coping due to pain, and acceptance of her disability. Prevalence rates of chronic pain following SCI are high with estimates of 60–80%, with at least 1/3 of the patients reporting severe pain (Masri & Keller, 2012). Overall, she continued to be depressed with chronic passive suicidal ideations, anhedonia, sadness, and feelings of worthlessness. Suicidal ideation is common after SCI. Over 13% of an SCI cohort reported recent suicidal ideation and 7.4% reported a lifetime suicide attempt (Mccullumsmith, 2015). Because CPT is based within the CBT framework, we were able to transition her skills in identifying antecendent, beliefs, and consequences to track these ideations.The root of so much of her suffering was related to limited acceptance of herself as a survivor of trauma and her disability, as well as, self-judgement and blame. With that, we added in two workbooks based within the ACT and self-compassion framework. We utilized Get out of your Mind and Into Your Life workbook (Hayes, 2005) and The Mindful Self Compassion Workbook (Neff, 2018). ACT has been demonstrated to be an effective strategy to help individuals achieve a value-meaning life after trauma (McLean, 2016). Based on the entrenched maladaptive thinking patterns she exhibited, we added additional focus on mindfulness and self-soothing from the self-compassion approach outlined by Dr. Neff (2018). In order to track effectiveness of treatment, I follow the guidelines set by the Veteran’s Administration and The Joint Commission in using principles of measurement-based care (MBC) to improve treatment effectiveness. These principles include: (a) measuring response to treatment at regular time intervals with valid symptom measures that are sensitive to change; (b) using specific criteria to define response, remission, and worsening; (c) systematically adjusting treatment (e.g., stepped care) in response to outcome data, and (d) treating to targeted outcome (Guo, 2015; Landes, 2015; Fortney, 2017; Pollock, Dorstyn, Butt, & Prentice, 2017). In the case of Ms. X, I utilized the Patient Health Questionnaire 9 question version (PHQ-9) (Kroenke, 2010), the PTSD Check List 5 (PCL-5) (Weathers, Litz, Keane, Palmieri, Marx, & Schnurr, 2013), the Numerical Rating Pain Scale (Farrar JT, 2001), and Subjective Units of Distress (SUDS) (Tanner, 2012) throughout the treatment course.Overall, Ms. X exemplified treatment adherence. She would buy a book and have it read prior to initiating each new approach at the following session. She wanted to understand the science and did her own systematic review prior to moving forward with each new goal of treatment. In order to stay abreast of her knowledge, I too would read the books she read, watch the TED talks she watched, and listen to the podcasts she recommended. This sharing of knowledge became an integral part of the therapy and our therapeutic alliance, but also my continuing education as I learned about new therapy approaches we would put into practice together. Using the patient portal inhibited the timeliness of our knowledge transfer and so for the first time with a patient, I shared my direct work email address with her to facilitate timelier communication between sessions. As an ethical dilemma, I was concerned for crossing boundaries in this instance, but it proved to be very helpful in this case. However, I was sure to let her know that although secure, sharing in this capacity was not as secure as the electronic medical record, and she gave consent to communicate in this way. Once we began to move through the value portion of ACT, she expressed desire to increase the meaning and purpose in her life by returning to school. The importance of assessment and rehabilitation related to vocation following SCI has been well documented (Fraser, 2010) and even described as the “brass ring”of rehabilitation (Vestling, Tufvesson, Iwarsson,?2003). Vocation rehabiliation is the, “provision of a particular set of services aimed at enhancing the employability of people whose lives have been impacted by a disabling physical or psychological condition” (Blessing, Golden, Pi, Bruyere, & Looy, 2012). I requested she take the Personal Values Assessment (Barrett Values Centre, 2019) in order to guide value-based discussions exploring her interests and vocational goals. As a former educator, she noted inability to return to work teaching nurses, which led to a discussion of her rights through the federal Americans with Disabilities Act Amendments Act of 2008 (ADAA), which prohibits employers from discriminating against qualified individuals with disabilities who are able to perform the essential functions of the job with or without accommodation. Rohe and Krause (1998) demonstrated that SCI does not change a person’s interests. Prior to the MVA, Ms. X was enrolled in a doctoral program. She noted renewed interest in pursuing a PhD, so we the steps necessary. In preparing for the GRE we discussed the accommodations required based on her physical disabilities. I provided documentation to ensure she could receive the necessary accommodations while taking the examination as well as connected her with colleagues to discuss various specializations and requirements for achieving an advanced degree.Ms. X completed inpatient rehabilitation at my facility directly following her initial injury and recalled her experience well. She related positive aspects of the intensive rehabilitation environment, as well as areas that were insufficient or not reinforced enough to improve her self-efficacy when she discharged home to the community. The care of those with SCI across the care continuum became an area of concern for me as an advocate realizing equity in care for those with SCI was not the same for all. The hospital service individuals with SCI are admitted to, and the care team they have any given day, determined how well the issues specific to SCI are managed. Also, the hospital-wide initiatives focused on decreasing secondary hospital-acquired conditions for all patients were not being uniformly applied to those with SCI. I learned that most acute care teams at my institution were not knowledgeable or equipped to address the specific care needs for those with SCI, including how to provide diagnosis, decrease their risk for pressure ulcers, bladder and bowel protocols, and education for the patients and families. Interventions, especially at an organizational level, rely on behavioral principles and techniques to facilitate planned change (Robertson, 1990). I took an active leadership role in creating a hospital wide initiative to standardize and improve the acute care for those with SCI. I utilized my training in research methods and design to ensure we had quality data at the end of the process to demonstrate efficacy of the intervention. I utilized my understanding of human behavior and training in systems theory (Coffey, 2010), as well as the documented literature on team based healthcare models (APA, 2008; Frank, McDaniel, Bray, & Heldring, 2004) to ensure we created a product that had buy-in from all involved, and that all were dedicated to the overall process and motivated to see it through the multi-year plan. We accomplished this strategic organizational consultation, by using the Model for Improvement (MFI) (IHI, 2019) (Appendix A). This model starts with a guiding framework focused on developing the Aim, Measurement, and Change, which is constantly evaluated with a feedback loop. Creating the framework allowed us to create the guide to Plan, Do, Study, and Act in order to test our ideas. With our defined aim to standardize and improve quality of care for individuals with SCI in acute care, we measured the secondary complications that individuals with SCI are most at risk to develop and created a plan to measure incidence rates in our institution. Our plan was to change the way in which patients were treated in acute care in order to limit secondary physical complications such as pressure ulcers, constipation, and urinary tract infections as well as improve access to information, community resources, funding, and education of patients and families earlier in their medical course. We created a plan to pilot the project in one area of acute care with ongoing feedback to help us refine our project before launching it hospital-wide. Feedback from healthcare providers highlighted their desire to provide quality of care for patients with SCI, but lack of training and knowledge on best practices for how to do so. With this, we developed a multifactor intervention and moved to the doing phase of MFI. We created a “powerplan” in the electronic medical record that covered all of these aspects of care for individuals with SCI. The primary team launches it once a patient is admitted to the hospital with suspected SCI and it is carried out for the duration of the patient’s admission. In order to ensure success, we also created online education of the aspects of this plan, and SCI in general, in order to ensure the orders can be carried out effectively. This education is required for all acute nursing and therapy staff. Overall, this was all done in collaboration with acute care teams in order to ensure their buy-in as well as feasibility based on their workflow. Overall, they were appreciative for this initiative and this project has been a rewarding illustration of patient advocacy at my local level.Ms. X returned to my facility for inpatient rehabilitation following rotator cuff repair of her primary functioning arm. I envisioned the sense of setback she was due to experience secondary to loss of function and confinement within the rehabilitation unit; however, no preparatory work was able to provide her with what she needed emotionally to anticipate and prepare for the emotional disturbance ahead. The experience proved difficult but fortunately, I was able to be right alongside her. Having her at my home institution made it easy for me to assist in her care, but I believe it also made it easier for her to feel connected to someone nearby. I am consulted to complete a neurobehavioral examination for all patients admitted to the inpatient SCI rehabilitation service. As part of this examination, I complete an in-depth chart review in order to obtain pertinent medical history from the electronic medical record. Following, I complete the in-person interview with the patient, and family if available, at bedside. The referral question, or purpose of the evaluation, is to assess cognitive, emotional, and behavioral status, which may prove to be barriers to participation in therapies or barriers to successful discharge. Therefore, the components of the examination include collecting information related to the patient’s social, education, work, substance use, and psychiatric histories. This is important in creating a conceptual picture of how the patient was prior to their injury. Research has demonstrated, that all of these personal historical aspects have strong indications in an individual’s ability to adjust and cope with the stress of functional change and disability. In addition to history, I assess their current functioning. This includes cognitive abilities using behavioral observation and bedside screening tools, Orientation Log (OLog) and Cognition Log (CogLog) (Novack, 2000; Novack, 2004). There are many brief cognitive screening tools that evaluate similar cognitive domains as the OLog and CogLog, including the MoCA, SLUMS, and MMSE. All of these tools, with the exception of the MMSE, are non-proprietary, which is why I do not typically use the MMSE. The benefit to the CogLog in an acute care setting compared to the other open-source measures, is it can be given across multiple days because there are multiple recall options for testing memory. However, one limitation with serial testing overall that should be considered is the opportunity for practice effects (Goldberg, Harvey, Wesnes, Snyder, & Schneider, 2015). In the case of the CogLog this is a limitation for the domains related to attention, working memory, and impulsivity. Once the cognitive screening is complete, feedback is always given to the patient. The focus is on any strengths and weaknesses that may affect participation in therapy, nursing care, or learning. If further assessment during acute care is warranted that is also addressed. As the patient approaches hospital discharge, I work to set up outpatient neuropsychological testing with one of my Neuropsychology colleagues when indicated. Following cognitive screening, I have the patient provide their current emotional status. For this, I use the Patient Health Questionnaire 2 (PHQ-2) question version to determine how well they have been doing emotionally in the previous two weeks. There are many other options for depression screening, but I use the PHQ-2 because it has been demonstrated to be a sensitive measure for depressive symptoms and has the benefit that is very brief (Kroenke,?Spitzer,?& Williams, 2003). However, in its brevity, it lacks a specific question related suicide. Therefore, I also ask each patient if they are experiencing any suicidal ideation, as well as, homicidal ideation. If they indicate recent thoughts of harming themselves or others, I delve further to determine if they have a plan, intent, means, in addition to risk and protective factors. In terms of other functioning that can be a symptom of mood disturbance or adversely affect mood if disrupted, I assess sleep, appetite, social support quality and quantity, and pain level and location. Finally, I assess substance use history, including tobacco, alcohol, illicit drug use or abuse of prescription medication. When patients present to the emergency room with traumatic injury, there is always a toxicology screen completed, so I am sure to look up those results before assessing the patient. There have been many instances whereby patients have told me that I was the first person to address these lab results with them. As noted above, I use the CAGE-AID (Brown, 1995) if the patient endorses alcohol, illicit drug use or abuse of prescription medication. We have access to a smoking cessation and addiction medicine programs in the hospital, so I also assess their interest in speaking to someone about treatment options and their overall motivation to make changes in their substance use at the time of evaluation. This is an ongoing evaluation and discussion with the patient throughout their hospital admission. Overall, I use the information obtained from the neurobehavioral examination to determine their risk level for difficulty adjusting to the rehabilitation environment and treatment planning for psychological services indicated during their admission as well as connection with other supports as indicated. Such referrals include Vocational Rehabilitation, smoking cessation, Addiction Medicine, Social Work, and Psychiatry. I also make recommendations to our team based on the findings. For instance, if a patient is having difficulties with attention or working memory, I will make a general recommendation to nursing, therapists, and physicians, to keep instructions simple and limited to one or two steps in order to ensure the patient can hold the instructions and carry out their requests. I have found this type of practical guidance to be much more beneficial to the team than just describing their strengths and weakness in a more general way using language they are not necessarily familiar with or able to generalize to their interventions with patients on their own. I completed an abbreviated neurobehavioral exam for Ms. X (Appendix B) because she and I had already been working together for two years. I knew her history well and was able to fill in this information in my report to the team from my knowledge of her. Through clinical interview I was able to determine she was oriented and remained cognitively intact without the need for OLog and CogLog assessment. My treatment plan for her inpatient stay included frequent check-ins to her hospital room, which were initially daily and became less frequent as the weeks progressed and her comfort level improved. We then moved sessions to my office to improve privacy and her willingness to engage in frank open conversations, without the concern for staff members walking in. Just as I do for all patients, I helped bridge communication between the care team, patient, and (in this case) Workers Compensation (WC). As indicated by Hamm et al (2007), mental health care is often denied by employer insurance. I have learned from my previous experiences with patients seeking treatment via WC, it is crucial that I clearly document the link between the psychological effects of the physical injury incurred by the work related injury to ensure patients receive the psychological treatment they need. As a mental health professional, it is imperative we recognize our competency and not let WC determine the treatment modality or length of treatment required. Finding my voice was a challenge for me as I was starting my career, but once I conceptualized this as an advocacy opportunity, I was empowered to speak up for my perceived need of each patient. They, nor the patient are the experts in mental health care, we are, and is crucial that we advocate for what the patient needs, no matter the barriers WC creates for us in terms of documentation and treatment request protocols. The time and effort is always well spent when the patient’s best interest and needs are at stake. Our interventions in the inpatient acute rehabilitation setting focused on coping with acute pain as well as how to employ previously effective coping techniques in the current environment with her functional change. As described by Levite and Johnston (2011), effective post-operative pain management is crucial in the overall recovery, but can be very challenging to accomplish, often requiring multidisciplinary care plans to execute. Ms. X has always worked to limit reliance on prescription pain medication due the cognitive and bowel slowing side effects she experiences. However, she was not getting good sleep and unable to fully participate in therapies as a secondary effect of the acute post-operative pain. Therefore, I created a behavioral health management plan that included her entire rehabilitation team focused on improving her pain control. I encouraged nursing staff to get her up earlier in the morning every day to give time for her joints and muscles to loosen after overnight stiffening. I discussed the timing and dosing of her pain medications with her prescribing physician and they made adjustments according to her presenting difficulties. Finally, Ms. X and I explored her cognitions (fear of opiate dependence and side effects) that were ultimately limiting her willingness to ask for her prescribed medications. I took the lead on routine follow-up and ongoing communication to ensure this behavior management plan was carried out by all involved. Overall, as tracked by the medical record when she would take her prescription pain medication as we planned, she reported improved sleep quality and quantity. Her therapists reported improved participation in therapies because she was up and ready when they arrived each morning. And her self-reported experience of her stay improved as she related ability to maximize her inpatient rehabilitation experience. In order to help her accommodate her previous coping strategies to her current functional abilities, I printed affirmational quotes and placed in view for her room, we addressed “writing” with alternative methods, stretching and yoga poses in the hospital bed, and the increased time in meditation with relevant mantras to the experience. We worked to improve her willingness to express her care needs to both her rehabilitation care team and her family members. She created meaning by using this experience to provide feedback for changes that would improve care in the design of our new inpatient building that was in the planning and design phase during her admission. Now that I have worked at my institution for three years, I am now seeing readmissions for patients I have treated in the past and inpatient admissions for outpatients I have treated, which is truly is a unique opportunity to use the history and connection we have as a cornerstone to help with the unique changes related to the patient’s current environment. In summary, overall, none of the treatment manuals have been validated in SCI populations. In fact, there is a derth of evidenced based practice options for treating mood disorders in patients with SCI. However, research has demonstrated that trajectories of psychological recovery and disturbance following SCI are similar to those seen in other populations. Therefore, without other knowledge I use what has been demonstrated effective in other populations with adaption for the specific needs and issues related to SCI.Although this case covers many competencies regarding assessment and treatment of trauma-related mood disturbance, adjustment to disability, and pain, it does not include cultural differences that arise working with patients and family issues related to disability or family issues related to adjustment to injury. These issues are covered in the case of Mr. Y. I also did not complete formal neuropsychological screening as part of the standard neurobehavioral protocol because of my long-standing relationship with her and clinical judgement that her cognitive status had not changed following surgery. Nor did I use the Chronic Pain Acceptance Questonaire (McCracken, Vowles, & Eccleston, 2005) or Pain Catrasthrophisizing Scale (Sullivan, Bishop, & Pivik, 1995), which are two self-report instruments I typically use to assess patient’s psychological expereince of their pain. Finally, beyond initial assessment of tobacco, alcohol, illict substance use, and abuse of presciption medication, there were no indications for intervention in this domain. Case 2: Mr. YMr. Y presented for his first outpatient psychotherapy session with me in June 2017 (Appendix C). At that time, he was a XX-year-old Black male who sustained a C4 ASI A spinal cord injury secondary to a motor vehicle accident in 1987. Other pertinent medical history included diabetes, hypertension, risk for autonomic dysreflexia (due to his level of injury), neurogenic bowel and bladder, and erectile dysfunction. He ambulated with head controlled electric wheelchair, and received assistance for all activities of daily living and instrumental activities of daily living from his wife and paid care attendant. They had a wheelchair accessible van and neither he nor his wife work. He was followed by the same rehabilitation psychologist from his acute rehabilitation at the local hospital through to outpatient services provided on an as needed basis. His provider retired, so he was scheduled with me when he called requesting an appointment for “depression and anxiety.” Based on medical record review, other than intermittent psychotherapy, he had been prescribed the selective serotonin reuptake inhibitor (SSRI) sertraline 100 MG daily since 2016. In general, SSRIs and SNRIs are likely the best tolerated antidepressant classes (Fann, Bombardier, Richards, et al., 2015) for individuals with SCI and depression. From studies in non-SCI populations, the efficacy of different SSRIs and SNRIs are similar, with the exception of fluoxetine which has a longer half-life and not typically indicated in the SCI population (Craske, 2017), thus, medication choice is based on anticipated side-effects, interactions with other medications, and patient treatment history or preferences.Approach to Assessment of Individual’s with Y and Application in the Case of Mr. YMr. Y had been living with SCI for 30 years, and as a new provider, he had been living with SCI longer than anyone I had treated. For individuals with high tetraplegia injured at the age of 40, his life expectancy beyond injury is 21 years (NSCISC, 2019). At 30 years post-injury, 40% of individuals living with SCI are married, 24% are divorced, and 30% are single (NSCISC, 2019). He was still married to the same woman he was married to prior to his injury. Despite the fact that SCI has been associated with both reduced quality of life and elevations in depression and anxiety, studies have shown that many SCI survivors nonetheless exhibit healthy long-term adjustment (Craig, 1994; Whiteneck, 1992; Quale, 2010). Longitudinal data following patients for two years after injury, demonstrated that approximately 75% of individuals recover psychologically (Bonanno, 2012) and that changes in psychological adjustment among SCI survivors are pronounced during the course of the first year after the injury, but then change little from that period on (Craig, 1994; Pollard, 2007). Factors associated with resilience are optimism, positive affect, social support, and controlled pain (Quale, 2010). In looking back, because he was married, decades post-injury, without indication of substance abuse, and male, I let the data and medical record guide my assumptions in my conceptualization of his case in a way that was not accurate. I explain these assumptions and effects on his care in more detail below. The International Classification of Functioning, Disability, and Health (ICF) is a comprehensive and widely accepted framework to classify and describe aspects of functioning, disability, and health in people with a broad spectrum of diseases and conditions, including SCI (Post, Kirchberger, Scheuringer, Wollaars, & Geyh , 2010). It is a helpful framework to use in the initial assessment when working with individuals with disability. I used the ICF, and what is known about adjustment to SCI and resilience, to assess his symptoms of mood disturbance, social support, pain, as well as substance use, and overall function during my initial evaluation with him. He endorsed symptoms of depression and anxiety, but progress was slow initially, in part based on my assumptions that his symptoms must be related to other issues, not his SCI, and in part due to his reluctance in discussing his difficulties with me. Once I realized I was off on my assumptions and he was experiencing a setback in his ongoing adjustment to SCI, I was able to determine the precipitating factors for the mood disturbance. For one, his social supports were failing because his wife and home health aide were aging and becoming less able to meet the physical demands his care required. Second, he had limited access to the environment, which was limiting his independence and increased reliance on his support network. All of which were inhibited with preexisting personality characteristics that made it difficult for him to problem solve through these life changes. With a more open mind, I was better able to conceptualize the etiology of his depression and anxiety as well as attributes that have allowed him to persevere for decades with SCI. Part of the assessment also required understanding his willingness for change. The Transtheorectical Model (Prochaska, 2005) outlines six stages of change that evolves from a complex, often cyclical progression. Even when a patient calls requesting treatment, and consents to engage in therapy, it does not necessarily mean they are ready to put a plan in to action. In the case of Mr. Y, he was in the contemplation stage with a desire to change, but lack of clarity for how to go about it. He was also hampered by an external locus of control (Lefcourt, 2014), which limited his self-efficacy in making change in his own life. When working with contemplators, it is important to assess how long they have been thinking about change. Mr. Y was a “chronic contemplator” which is when someone contemplates change often, to the point of rumination, but they never move beyond this stage (DiClemente, 1998). Some studies have found a relationship between contemplation and higher levels of depression (Velasquez, 1999). Overcoming the ambivalence and shifting the decisional balance was going to take time.Approach to Intervention of Individuals with Depression and Anxiety and Application in the Case of Mr. YIn developing a care plan focused on increasing his motivation to change and decreasing his perceived barriers to make such change, I had to learn more about Mr. Y’s and his wife’s values, cultural beliefs, and personal characteristics. Effective mental health treatment depends upon good communication and productive interactions between patients and mental health providers (Wills, 2006). Tailoring mental health services to address the needs and preferences of a diverse clientele is a central tenant of patient-centered care and has been shown to be associated with increased engagement in care (Ryan, 2002), increased adherence (Thompson, 1991), and improved outcomes of care (Lin, 2005). A nationally representative study of 2,107 Blacks in the US, found that this group used informal care from ministers more often than formal mental health care provided by psychologists and others within the specialty mental health sector (Neighbors, 1985). A qualitative study found that Black Americans being treated for depression, have a preference for their providers to spend the initial work getting to the know the patient on his or her own terms, demonstrating value of their expertise on themselves, and then adjusting treatment to their level and needs (Mulvaney-Day, 2011). Mr. Y and I have many cultural differences. He is a Black, male, disabled, older adult with strong value placed in his Jehovah’s Witness faith. I am a White, female, able-bodied, adult with limited experience with the Jehovah’s Witness faith, and without personal practice of seeking advice from religious leaders. This required I spend time listening to him, and his wife, to really understand what their worldview is and how it affects them in their daily life. Although religiousness has been shown to be a protective factor against depression, pain, cognitive decline, and associated with greater quality of life in older adults in outpatient rehabilitation settings (Lucchetti, Lucchetti, Baden-Neto, et al., 2011), this was not necessarily the case for Mr. Y. I came to understand religious beliefs were a strong factor in his (and his wife’s) personal identity and, at times, the source of his internal, as well as, their interpersonal struggles. Consistent with the research, he had a tendency to seek counsel from church leaders when he experienced personal conflicts. This was particularly relevant when it came to sexuality. He described himself as a “eunuch” when relating his lack of ability to have sexual relations with his wife. We discussed options in terms of sexual intimacy, and he was provided online resources trough reputable groups such as United Spinal and Facing Disability to investigate positioning and interventions for erectile dysfunction. I also connected with him with a male peer mentor with tetraplegia, so he would have someone to connect with and ask questions. I consulted with his physiatrist and referred him to do the same, in becoming educated on assistive device options most appropriate for him and his specific needs. However, his struggle continued, and I came to learn he was grappling with a conflict of faith as well as lack of information. He reached out to the elders of his church for guidance in the spiritual implications of oral sex and the use of devices. Their response was basically, “Your bedroom, your business,” but this was not satisfactory in helping Mr. Y overcome his existential dilemma. His wife participated in these conversations and reinforced her personal faith beliefs that echoed that of their church leadership. This was a bridge for us to move discussions toward developing his internal locus control and taking ownership for his daily meal preferences, access to his environment, and ultimately eternal fate. From my assessment, I determined Mr. Y demonstrated significant Obsessive-Compulsive Personality Disorder (OCPD) personality traits that were limiting his social and behavioral functioning including his ability to complete tasks and make simple day-to-day decisions. As per DSM 5 (2013) criteria, he exhibited four of the eight criteria for OCPD including: perfectionism that interferes with task completion; overly conscientious, scrupulous, and inflexible about matters of morality, ethics, and values; unable to discard worn-out objects; shows rigidity and stubbornness. Per his previous mental health provider, “He appears to enjoy debate.” However, I quickly learned that engaging in this behavior with him perpetuated, and likely validated his inactivity and desire for achieving the “correct” answer instead of acquisition of a reasonable understanding allowing him to move forward. Even simple decisions in daily life, such as how he wanted his potato prepared took him much internal discernment with ultimate response to his wife being, “It doesn’t matter.” The problem was, it did matter to him, but he could not identify a strategy to determine what he wanted. Instead of debate, I utilized motivational interviewing skills to help move him through the stages of change and break the cyclical pattern that had been keeping him stagnant in life. Individuals can spend years in the contemplation phase. That is until an event tips the balance in their risk-reward scale (DiClemente, 2002). This required learning the values held by Mr. Y and how they were factoring in to his daily decisional balance. Then, in rolling with a bit of resistance, and coming alongside him, we were able to illuminate that even though he had a strong desire for independence, he was giving away his control on a daily basis when not speaking for himself, and slowly building resentment toward others in the process. In order to maintain his autonomy, I would always ask in each session if he wanted his wife present. His response would vary, but I would honor his request regardless. I learned how to operate his wheelchair, always asking permission before taking over drive control when his eye tracking device was malfunctioning. There were times it was very helpful to me when she was present because she would provide a more well-rounded view to his struggles and his voiced concerns. For example, he expressed reluctance in continuing to work with me at home because of my race and gender, and it was his wife that brought this to light in session. He agreed he had concerns, and by me knowing, we were able to discuss it further and come to resolution. I also came to learn his preferences in medical care providers. When I would offer him referrals, he expressed concern for seeing female providers of color. Along with culture, trust is another individual factor that is important in treatment outcomes. Mr. Y’s pre-existing beliefs related to this subgroup of physicians’ ability to provide quality care came from one negative experience with a provider in his past, but continued to shape his perception of healthcare delivery for an attire group years later. From a clinical perspective, patients trust in providers is associated with more beneficial health behaviors, less symptoms, greater quality of life, and more satisfaction with treatment (Birkh?uer, 2017). Therefore, understanding and making referrals in line with his preferences allowed him increased likelihood from benefit in the healthcare he was being set up to receive.The experience of the caregiver is an important aspect of consideration as their adjustment to the patient disability can play a significant role in the experiences of all involved (Rivera, 2012). The stress of long-term care provisions can also lead to adverse health outcomes for the caregivers (Son, 2007; Teel, 1999; Schulz, 1999). The physical and psychological demands from the care recipient, the limitations in time, the economic costs, the legal concerns, and the role conflicts experienced by the caregiver, have all been determined to be contributing factors to caregiver burden (Poulshock & Deimling, 1984). This is why the assessment of caregiver’s adjustment to the patient’s disability is critical. In the case of Mr. Y, the care recipient - caregiving role had clearly worn down their marital relationship and chronic stress was adversely affecting his wife’s health. We were making good progress, but then months went by where I did not hear from them. When they returned, I learned his wife had been diagnosed with breast cancer and undergone treatment. Navaie-Waliser and colleagues (2002) found that more than one-third of caregivers continue to provide intense care to others while suffering from poor health themselves.As with major life events, this led her to reflect on what was important to her and when they did return, she was clearly detached and in a new place in their relationship, which she defined as only his caregiver. A study determined that couples married at the time of an SCI were about 1.5-2.5 times more likely to get divorced than the general population during the initial three years post-injury. After that time, the divorce rate slowly lowered to the national average of about 40%. Protective factors for remaining married were being White, college educated, employed, and in good health (Karana-Zebari, 2011). Level of injury did not predict marriage outcomes post-injury. Mr. Y has many risk factors for poor marital outcomes being a man of color, unemployed, and now with increasing chronic conditions leading to hospitalizations. This study followed participants for 15 years, but this case begs the question, “What happens when individuals with SCI start aging and their caregivers for that matter, and experience health decline?” In the case of Mr. Y that was the factor that led to his wife making the final draw in their marital relations. They did not get a divorce, but she no longer considers herself his spouse, only his caregiver. In terms of aging, with all of the changes occurring in their lives, I directed them toward discussion of advance care planning. They both expressed desire for an advance directive in order to have documentation for his wishes at the end of life. Our hospital recently instituted an initiative to help patients in this process, so I sought consultation from the outpatient medical social worker in my department and he provided me with the procedures and I was able to help Mr. Y achieve assistance from pastoral care in completing this documentation, which afforded them both peace of mind. With these turn of events, he was ready to make some changes to improve personal safety and independence. I gave Mr. Y a referral to a technology education specialist with request to aid his capability to call for assistance from anywhere in the house and be able to obtain emergency medical assistance if he needed it. In the interim, I researched options for patients without hand function to call for emergency help, because this was an issue I lacked previous knowledge about and required education. I encouraged him to acquire a smart phone and set up a contact name that would call for emergency help because calling 911 is not a capability voice controlled assistance is capable of doing. With this technology assistance access to his environment improved with ability to turn on electronic devices, adjust lights, and room temperatures with voice command. Secondary to his OCPD symptoms, he was reluctant to give up the equipment he had invested in over the years, in spite of the fact it was outdated and non-functional, so we worked toward letting go, so he could make space for the updates required for him to achieve his goals. Following, he started putting to use the communication strategies we discussed all along: assertive, value-based decision making, and slowly began shifting his focus on his power and control in his immediate environment and life. The work continues, but he has moved to the action phase. In the case of Mr. Y, I completed all of my assessments verbally through questioning with him and his wife and through behavioral observations. Therefore, a significant limitation to this case is that it does not include any formal assessment measures. I could have utilized the MMPI-2-RF for formal personality assessment using the computerized voice reading system and his wife recording his responses. However, I felt the balance between asking her to engage in one more activity when she was already experiencing burnout, did not outweigh the benefit of information it would have provided. I also did not give a formal assessment of his wife’s level of caregiver burden and her adjustment to his disability. The Family Caregiver Alliance in collaboration with the Benjamin Rose Institute on Aging (2012), created a comprehensive guide of assessment measures for caregivers, which has many tools that would have given excellent insights. Tracking this would not only provide quantification of her level of caregiver burden, but also could have been an asset as an intervention tool to motivate both of them for change. As quoted by Feinberg & Hauser (2012), “Caregiver assessment is a systematic process of gathering information about a caregiving situation to identify the specific problems, needs, strengths, and resources of the family caregiver, as well as the ability of the caregiver to contribute to the needs of the care recipient.” Mr. Y had no complaints of pain, cognition, or substance use present during the treatment period. Instead, this case focused on the long-term effect SCI has on the patient and their support systems within a cultural context. This is an area requiring more research as individuals are now achieving longer life expectancy with SCI.In summary, these two cases highlight the different approaches to care I provide based on setting, presenting complaint, and disability- all with the primary conceptualization to improve their access to the environment and live a life of personal meaning with respect and dignity. These cases also highlight lessons I have learned along the way as I have been able to see the guiding principles of Beatrice Wright come to life in my patient’s personal experiences and what it truly means to live life with disability. I feel I have learned so much more from sharing in their lives than I can ever give them and continue to be grateful for the privilege of working as a Rehabilitation Psychologist. ReferencesAlexander, M. M. (2017). Sexuality after Spinal Cord Injury. Retrieved online May 5, 2019 from: Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (DSM 5) (5th ed.). Arlington, VA: American Psychiatric Association.American Psychological Association (2010). Ethical Principles of Psychologists and Code of Conduct. Retrieved online April 10, 2019 from: Psychological Association Presidential Task Force on Integrative Health Care for an Aging Population. (2008). Blueprint for change: Achieving integrated health care for an aging population. Retrieved from pi/aging/blueprint.html ADDIN EN.REFLIST Arnsten, A., Raskind, M. A., Taylor, F.B., & Connor, D.F. (2015). The effects of stress exposure on prefrontal cortex: Translating basic research into successful treatments for post-traumatic stress disorder. Neurobiology of Stress, 1, 89-99. DOI: 10.1016/j.ynstr.2014.10.002Barrett Values Centre (2019). Personal Values Assessment. Retrieved online March 7, 2018 from: tools-assessments/pva/Blessing, C., Golden, T. P., Pi, S., Bruyere, S. M., & Looy, S. V. (2012). Vocational Rehabilitation, Inclusion, and Social Integration. In P. Kennedy (Ed.), The Oxford Handbook of Rehabilitation Psychology (pp. 453). 2012: Oxford University Press.Bonanno, G. A, Kennedy, P., Galatzer-Levy, I., Lude, P. (2012). Trajectories of Resilience, Depression, and Anxiety Following Spinal Cord Injury Rehabilitation Psychology 57(3):236-47. DOI: 10.1037/a0029256Bryant, R. A., Nickerson, A., Creamer, M., O'Donnell, M., Forbes, D., Galatzer-Levy, I., . . . Silove, D. (2015). Trajectory of post-traumatic stress following traumatic injury: 6-year follow-up. Br J Psychiatry, 206(5), 417-423. DOI:10.1192/bjp.bp.114.145516Family Caregiver Alliance & Benjamn Rose Institute on Aging (2012). Selected Caregiver Assessment Measures: A Resource Inventory for Practitioners (2nd Ed.). Retrieved online on September 28, 2019 from: , J. R., Bombardier, C. H., Richards J.S, Wilson, C.S., Heinemann, A.W., Warren, A.M., Brooks, L., McCullumsmith, C. B., Temkin, N. R., Warms, C., Tate, D. G., PRISMS Investigators (2012). Venlafaxine Extended-Release for Depression Following Spinal Cord Injury:?A Randomized Clinical Trial.?JAMA Psychiatry.?72(3), 247–258. DOI:10.1001/jamapsychiatry.2014.2482Farrar, J. T., Young, J. P., LaMoreaux L., Werth J. L., & Poole R. M. (2001). Clinical importance of changes in chronic pain intensity measured on an 11‐point numerical pain rating scale. Pain, 94, 149-158. Feinberg, L. & Houser, A. (2012). Assessing family caregiver needs: Policy and practice considerations.AARP Public Policy Institute, Washington, DC.Foa, E. B., Steketee, G. S., & Rothbaum, B. O. (1989). Behavioral/cognitive conceptualizations of posttraumatic stress disorder. Behavior Therapy, 20, 155–176. Foa, E. B., Yadin, E., & Lichner, T. K. (2012). Exposure and Response (Ritual) Prevention for Obsessive-Compulsive Disorder (2nd ed.). New York, NY: Oxford University Press.Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007).?Treatments that work. Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences: Therapist guide.?New York, NY, US: Oxford University Press. DOI: 9780195308501.001.0001Fortney, J. C., Unutzer, J., Wrenn, G., Pyne, J.M., Smith, G.R., Schoenbaum, M., Harbin, H.T. (2017). A tipping point for measurement-based care. Psychiatry Serv, 68, 179-188. Frank, R. G., McDaniel, S. H., Bray, J. H., & Heldring, M. (Eds.). (2004). Primary care psychology (pp. 3-21). Washington, DC: American Psychological Association.Fraser, R. T. J., K. (2010). Vocational Rehabilitation. In R. G. R. Frank, M.; Caplan, B. (Ed.), Handbook of Rehabilitation Psychology (2 ed.). Washington, DC: American Psychological Association.Germer, C. K. (2009). The Mindful Path to Self-Compassion. Freeing Yourself from Destructive Thoughts and Emotions. New York, NY: Guilford Press.Goldberg, T. E., Harvey, P. D., Wesnes, K. A., Snyder, P. J., & Schneider, L. S. (2015). Practice effects due to serial cognitive assessment: Implications for preclinical Alzheimer's disease randomized controlled trials. Alzheimer's & dementia (Amsterdam, Netherlands), 1(1), 103–111. DOI:10.1016/j.dadm.2014.11.003Guo, T., Xiang, Y.T., Xiao, L., Hu, C.Q., Chiu, H.F., Ungvari, G.S., Correll, C.U., Lai, K.Y., Feng, L., Geng, Y., Feng, Y., Wang, G. (2015). Measurement-based care versus standard care for major depression: A randomized controlled trial with blind raters. American Journal of Psychiatry, 172, 1004-1013. Hamm, R. M., Reiss, D. M., Paul, R. K., & Bursztajn, H. J. (2007). Knocking at the wrong door: Insured workers’ inadequate psychiatric care and workers’ compensation claims. International Journal of Law and Psychiatry, 30, 416-426.Hayes, S., C.; Smith, Spencer. (2005). Get out of Your Mind and Into You Life. The New Acceptance and Commitment Therapy. Oakland, CA: New Harbinger Publishers.Henshaw, E. J., & Freedman-Doan, C. R. (2009). Conceptualizing Mental Health Care Utilization Using the Health Belief Model. Clinical Psychology: Science and Practice banner, 16(4), 420-439. DOI:10.1111/j.1468-2850.2009.01181.xHough, S. & Kleinginna, C. (2002). Individualizing relaxation training in spinal cord injury: Importance of injury level and person factors. Rehabilitation Psychology 47(4), 415-425.Institute for Healthcare Improvement (2019). Model for Improvement. Retrieved online September 19, 2019 from: , K. B., Arinell, H., & Arnberg, F. K. (2015). Six years after the wave. Trajectories of posttraumatic stress following a natural disaster. Journal of anxiety disorders, 36, 15-24. doi:10.1016/j.janxdis.2015.07.007Kroenke, K.,?Spitzer, R.L.,?Williams, J.B. (2003). The Patient Health Questionnaire-2: validity of a two-item depression screener. Medical Care, 41(11):1284-92. DOI: 10.1097/01.MLR.0000093487.78664.3CKroenke, K., Spitzer, R.L., Williams, J.B., Lowe, B. (2010). The patient health questionnaire somatic, anxiety, and depressive symptom scales: A systematic review. General Hospital Psychiatry, 32, 345-359. Landes, S. J., Carlson, E.B., Ruzek, J.I., Wang, D., Hugo, E., Degaetano, N., Chambers, J.G., Lindley, S.E. . (2015). Provider-driven development of a measurement feedback system to enhance measurement-based care in VA mental health. Cognitive and Behavioral Practice, 22, 87-100. Lang, P. J. (1977). Imagery in therapy: An information processing analysis of fear. Behavior Therapy, 8, 862–886. Lazarus,?A.??(1977).?In the mind's eye: The power of imagery for personal enrichment.?New York:?Guilford Press.?Lefcourt, H. M. (2014). Locus of control: Understanding the concept. In Lefcourt, H. M. (Ed.), Locus of control. Current trends in theory and research (2nd ed.). New York, NY: Psychology Press.Leibowitz, R. Q. (2005). Sexual Rehabilitation Services after Spinal Cord Injury: What Do Women Want? . Sexuality and Disability, 23(2). DOI:10.1007/s11195-005-4671-6.Levitt, F. C., & Johnston, E. V. (2011). A+post-op pain management. Nursing Made Incredibly Easy!,?9(5), 49-52. DOI: 10.1097/01.NME.0000398469.01393.c8Lucchetti, G., Lucchetto, A. G., Baden-Neto, A. M., Peres, P. T., Peres, M. F., Moreiva-Almeida, A., Gomes, C., Koenig, H. G. (2011). Religiousness affects mental health, pain, and quality of life in older people in an outpatient rehabilitation setting. Journal of Rehabilitative Medicine, 43(4). DOI: 10.2340/16501977-0784 Masri, R., & Keller, A. (2012). Chronic pain following spinal cord injury.?Advances in experimental medicine and biology,?760, 74–88. DOI:10.1007/978-1-4614-4090-1_5McCracken, L. M., Vowles, K. E., & Eccleston, C. (2005). Acceptance-based treatment for persons with complex, long standing chronic pain: a preliminary analysis of treatment outcome in comparison to a waiting phase. Behavior Research and Therapy, 43, 1335-1346.Mccullumsmith, C. B., Kalpakjian, C.Z., Richards, J.S., Forchheimer, M., Heinemann, A.W., Richardson, E.J., Wilson, C.S., Barber, J., Temkin, N., Bombardier, C.H., Fann, J.R., Investigators, P. (2015). Novel risk factors associated with current suicidal ideation and lifetime suicide attempts in individuals with spinal cord injury. Archives of Physical Medicine Rehabilitation, 96, 799-808. McLean, C., & Follette, V. (2016). Acceptance and Commitment Therapy as a Nonpathologizing Intervention Approach for Survivors of Trauma. Journal of Trauma and Dissociation, 17(2), 138-150. Mona, L. R. (2011). Sexuality, Intimacy, and Disability. PVA Summit, Orlando, FL 2011.Monson, C. M., Schnurr, P. P., Resick, P. A., Friedman, M. J., Young-Xu, Y., & Stevens, S. P. (2006). Cognitive processing therapy for Veterans with military-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 74, 898–907. National Spinal Cord Injury Statistical Center (2019). Facts and Figures at a Glance. Birmingham, AL: University of Alabama at Birmingham. Retrieved online September 12, 2019 from: nscisc.uab.edu/Public/Facts%20and%20Figures%202019%20-%20Final.pdfNeff, K. D. G., C. (2018). The Mindful Self-Compassion Workbook. A Proven Way to Acept Yourself, Build Inner STrength, and Thrive. New York, NY: The Guilford Press.Novack, T. (2000). The Orientation Log.?The Center for Outcome Measurement in Brain Injury.?Retrieved online September 2, 2019 from: , T. (2004). The Cognitive Log.?The Center for Outcome Measurement in Brain Injury.?Retrieved online September 2, 2019 from: bi/coglogPollock, K., Dorstyn, D., Butt, L., & Prentice, S. (2017). Posttraumatic stress following spinal cord injury: a systematic review of risk and vulnerability factors. Spinal Cord, 55(9), 800-811. DOI:10.1038/sc.2017.45Post M. W., Kirchberger I., Scheuringer M., Wollaars M. M., Geyh S.?(2010). Outcome parameters in spinal cord injury research: a systematic review using the International Classification of Functioning, Disability and Health (ICF) as a reference.?Spinal Cord?48(7), 522–528.Poulshock, S. M., & Deimling, G. T. (1984). Families caring for elders in residence: Issues in the measurement of burden. Journal of Gerontology, 39, 230-239. Proctor, D. (2019). Where Mental Health and Social Justice Meet. Culture of Health Blog. Robert Wood Johnson Foundation. Retrieved online September 12, 2019 from: , J., & Elliott, T. (2012). Psychological Models in Rehabilitaion Psychology. In P. Kennedy (Ed.), The Oxford Handbook of Rehabilitation Psychology. Oxford University Press.New York, NY. 32-46Resick, P. A., & Schnicke, M. K. (1992). Cognitive processing therapy for sexual assault victims. Journal of Consulting and Clinical Psychology, 60(5), 748–756. Resick, P. A., & Schnicke, M. K. (1993). Cognitive processing therapy for rape victims: A treatment manual. Newbury Park, CA: Sage Publications.Resick, P. A., Nishith, P., Weaver, T. L., Astin, M. C., & Feuer, C. A. (2002). A comparison of cognitive processing therapy, prolonged exposure and a waiting condition for the treatment of posttraumatic stress disorder in female rape victims. Journal of Consulting and Clinical Psychology, 70, 867–879. Rich, J. (2016). Moving Toward Healing: Trauma and Violence and Boys and Young Men of Color. Issue Brief. Robert Wood Johnson Foundation. Retrieved online September 12, 2019 from: , J. S., Kewman., D.G., Ricahrdson, E., & Kennedy, P. (2010). Spinal Cord Injury. In M. C. Frank. R.G; Rosenthal, B. (Ed.), Handbook of Rehabilitaion Psychology (2nd ed.). Washington D.C.: American Psychological Association.Rivera, P.A. (2012). Families in Rehabilitation. In P. Kennedy (Ed.), The Oxford Handbook of Rehabilitation Psychology. Oxford University Press.New York, NY. 160-163.Rohe, D. E., & Krause, J. S. (1998). Stability of interests after severe physical disability: An 11-year longitudinal study. Journal of Vocational Behavior, 52,45-58.Rothbaum, B. O., & Davis, M. (2003). Applying learning principles to the treatment of post-trauma reactions. Ann N Y Acad Sci, 1008, 112-121. Sullivan, M. J. L., Bishop, S. R., & Pivik, J. (1995). The Pain Catastrophizing Scale: Development and validation. Psychological Assessment, 7(4), 524-532. DOI: 10.1037/1040-3590.7.4.524The SAGE Encyclopedia of Theory in Counseling and Psychotherapy. (2015). In. Thousand Oaks, CA: SAGE Publications, Inc.Tanner, B. (2012). Validity of Global and Physical and Emotional SUDs. Applied Psychophysiological Biofeedback, 31-34. Utzon-Frank, N., Breinegaard, N., Bertelsen, M., Borritz, M., Eller, N. H., Nordentoft, M., . . . Bonde, J. P. (2014). Occurrence of delayed-onset post-traumatic stress disorder: a systematic review and meta-analysis of prospective studies. Scand J Work Environ Health, 40(3), 215-229. DOI:10.5271/sjweh.3420Weathers, F.W., Litz, B.T., Keane, T.M., Palmieri, P.A., Marx, B.P., & Schnurr, P.P. (2013). The PTSD Checklist for DSM-5 (PCL-5). Wright, B. A. (1983). Physical disability: A psychosocial approach (2nd ed.). New York, NY: Harper & Row Publishers.Vestling, M., Tufvesson, B., & Iwarsson, S. (2003). Indicators for return to work after stroke and the importance of work for subjective well-being and life satisfaction. Journal of Rehabilitation Medicine. DOI:10.1080/16501970310010475AppendicesAppendix A: IHI Model for Improvement Summary Sheet Appendix B: Ms. X de-identified neurobehavioral examination consult note printed from the hospital electronic medical recordAppendix C: Mr. Y de-identified initial psychotherapy note printed from the hospital electronic medical record.Appendix A: IHI Model for Improvement Summary Sheet Appendix B: Ms. X Neurobehavioral Examination Inpatient Consult NoteSupporting materials removed from this practice sample. ................
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