Rehabilitation psychology: Meeting the needs of individuals with acquired disabilities in Ireland

Purpose. The current articles reviews the epidemiology of disability in Ireland, discusses the political and social factors which have increased focus on disability issues and offers training guidelines for rehabilitation psychology based on those of the APA's Rehabilitation Psychology Division.

Rationale. With the growing number of individuals with acquired (vs developmental) disabilities in Ireland, there is increased recognition of the need to train psychologists to assist persons with acquired disabilities (e.g. spinal cord injury, acquired brain injury, stroke, etc.) in adjusting to their impairments, reintegrating back into their communities and reducing the long-term financial costs associated with disability.

Conclusion. Social and political factors suggest that the time is right to develop rehabilitation psychology as a specialty in Ireland given the increased focus on disability in Ireland, including recently passed disability legislation (i.e. 2005 Disability Bill), international events (e.g. 2003 Dublin World Special Olympics) and increases in rehabilitation training programmes (i.e. medicine; physio, occupational and speech therapy).     

Religion and disability: clinical, research and training considerations for rehabilitation professionals

Purpose. This article (i) reviews existing research on the relationships that exist among spirituality, religion, and health for persons with disabilities; and (ii) compares different theoretical coping models (i.e., spiritual vs. psychoneuroimmunological).

Background. Over the past decade interest has increased in relationships among spirituality, religion, and health in both the mainstream media (e.g., Newsweek) and scientific literature (e.g., Koenig). In general, research has concluded that religion and spirituality are linked to positive physical and mental health outcomes. Most religion and health research has focused on populations with life-threatening diseases (e.g., cancer, cardiovascular disorders, AIDS) with minimal attention to persons with chronic, life-long disabling conditions such as brain injury, spinal cord injury, and stroke. However, religion is used by many individuals with disabilities to help them adjust to their impairments and to give new meaning to their lives.

Conclusions. Religion and spirituality are important coping strategies for persons with disabilities. Practical suggestions for rehabilitation professionals are provided regarding: (a) strategies to enhance religious coping; (b) methods to train rehabilitation professionals about religious issues; and (c) issues to consider regarding future research on rehabilitation and religion.     

Rehabilitation students' attitudes toward persons with disabilities in high- and low-stakes social contexts: A conjoint analysis

Purpose. The primary objective of this research is to examine factors influencing rehabilitation services students' attitudes toward people with disabilities in two social contexts using a conjoint analysis design.

Method. Ninety-nine students in rehabilitation counselling participated in a conjoint measurement study featuring 55 stimulus cards representing varying disability types, genders, races or ethnicities, grade point averages, internship evaluations, and employment statuses for both high-stakes scenarios and low-stakes scenarios. The participants were instructed to order the stimulus cards to indicate their preferences for associating with different people with disabilities in two social contexts: A high-stakes context as a rehabilitation administrator hiring a counsellor and a low-stakes context as a mentor/companion.

Results. The results showed that age and disability type were most involved in the decision-making process in the low-stakes group, and performance-related variables were most important in the high-stakes context. Attitude was significantly affected by client characteristics unrelated to disability including age and race or ethnicity, and factors influencing attitude formation differed across the two social contexts.

Conclusion. Conjoint analysis can contribute to our understanding of the formation of attitudes or preferences in multiple social contexts. Using these results, it may be possible to develop effective attitude change strategies.     

Understanding the complex interplay between tourism, disability and environmental contexts

Purpose. To explore and describe the complex issues and factors related to participation in tourism as perceived by people with disabilities in Hong Kong.

Method. Naturalistic inquiry using key informant interviews and focus groups with 86 people with disabilities. Interviews were transcribed, translated and coded to develop themes and relationships. Triangulation of three investigators from different backgrounds occurred.

Results. The Process of Becoming Travel Active emerged as a six-stage process, intricately related to the personal/disability context and the environmental/travel context. Personal and environmental factors contribute to the six-stage model explaining the complex interplay between tourism, disability and environmental context.

Conclusion. Understanding the complexity provides insight into ways to increase active participation in tourism. Health, tourism and disability sectors have a role to play in the development of accessible tourism.     

The importance of cultural factors in the planning of rehabilitation services in a remote area of Papua New Guinea

Purpose: The aim of this study in the Middle Ramu, Papua New Guinea, was to gain a better understanding of how cultural factors work to influence the lives of persons with disability in a remote area. The study also explores how this information can be used for the planning of rehabilitation services.

Method: Two phase screening identified persons with disability in the study area and questionnaires were completed for all those identified. Information documented included the nature of the disability, a biomedical cause (where appropriate), the perceived cause of the disability, as well as some indication as to where help had been sought for the disability. In depth interviews were later done with disabled individuals and their families, to determine how they explained their disability.

Results: Thirty-two per cent of persons with disability and their families attributed disability to sorcery or other supernatural causes, a greater proportion than for any other category of perceived aetiology. There was widespread acceptance of Western medicine, although help was more likely to be sought from sources in the community for disabilities believed to have a supernatural origin.

Conclusions: This study demonstrates that an understanding of cultural factors is fundamental to implementing rehabilitation services that are culturally appropriate and address the social dimension of disability.     

Unique aspects of women's emotional responses to disability

Purpose. To improve rehabilitation clinicians' awareness of gender differences in emotional responses to disability as a means of enhancing accuracy and sensitivity in diagnosis and treatment of persons in their care.

Method. A prospective survey study using a new grief measure, the Loss Inventory (LI), with a diverse convenience sample of persons undergoing inpatient rehabilitation in the USA. Focused review of the bereavement, depression, and disability literatures related to observed gender differences.

Results. Study participants reported grief symptoms in varying intensities. Consistent with all literature reviewed, significant gender differences were found in kind and intensity of grief and depression symptoms reported. Ethnicity also significantly affected responses to disability by LI study participant responses.

Conclusions. While persons with disabilities as a whole may not necessarily develop depression, gender is a risk factor for onset of mood problems after illness or injury-related losses. As compared with study sample disabled men, disabled women reported more intense and different symptoms of grief and depression. Women with disabilities in the LI sample were twice as likely as disabled men to be depressed. Rehabilitation clinicians may wish to incorporate consideration of these differences in their mental health assessments, diagnoses, and treatment plans.     

To regain participation in occupations through human encounters--narratives from women with spinal cord injury

Purpose. To gain an understanding of how women with spinal cord injury (SCI) experienced human encounters in occupations and how these influenced their participation.

Method. The data were collected through two or three in-depth interviews with 13 women (age 25 - 61 years) with SCI. Data analysis was carried out by using a paradigmatic analysis of narrative data, followed by an interpretation based on a narrative theory.

Results. The results showed a complexity where the women's experiences and acting in human encounters changed over time. In these human encounters the women struggled with conflicts, supported other persons that were insecure and revaluated their apprehension about persons in their social network. These multidimensional human encounters thereby enabled them to regain participation in occupations.

Conclusions. This shows that human encounters are important for persons with disabilities so they can restructure their occupational identity and their needs for participation in occupations. The study also showed that the use of narratives as a tool within rehabilitation could lead to an increased understanding of the subjective changes that occur over time for a person with a disability.     

Depression in adults with disabilities, in primary care

Purpose: This research was designed to answer the question: Does the prevalence of depression differ between adults with and without disability, in the same family medicine practice?

Method: A retrospective cohort design was used, to study depression among adults, with and without primary disabling conditions, receiving primary care in either a university based urban or rural family practice setting.

Results: When we compared individuals with disability to those without disability, and controlled for individual characteristics, the relative risk for depression was significantly lower for individuals with autism (Relative Risk (RR) 0.20: 95% Confidence Interval (CI) 0.05 - 0.55), cerebral palsy with mental retardation (RR 0.40: 95% CI: 0.24 - 0.65), and MR (RR 0.56: 95% CI: 0.39 - 0.77). The risk for depression was significantly higher for those with cerebral vascular accidents/stroke (RR 2.18: 95% CI: 1.72 - 3.76) and traumatic brain injury (RR 2.55: 95% CI: 1.72 - 2.77). The earliest onset of depression was among individuals with traumatic disabilities and mild mental retardation. Our estimate of depression prevalence for the non-disabled and disabled primary care patients was 22.8% and 24.9% respectively, when patients with disabilities were grouped together (p = 0.008).

Conclusion: It is important for physicians to recognize the higher prevalence of depression among patients with adult onset disabilities (e.g. stroke, traumatic brain injury). In addition, they should be aware of lower prevalence of depression among many individuals with lifelong disabilities, such as mental retardation, cerebral palsy, and autism.     

Potential contributions to disability theorizing and research from positive pyschology

Purpose. Within the context of taking the perspectives of disabled individuals themselves more seriously, it is imperative that researchers and practitioners accord due primacy to the experiential worlds and everyday lived experiences of individuals with disabilities. Based on the premise that theoretical groundedness (along with methodological rigour) is integral to sound research, it is argued that the existing body of knowledge regarding the lived experiences of individuals with disabilities may be complemented by a conceptual placing of understandings of disability in relation to a prominent theoretical pathway at the moment, namely, the interdisciplinary emphasis on human strengths and wellness.

Method. A critical engagement with key conceptualizations of disability entailed a focus on the development, strengths, and challenges of medical, social and psychologically based conceptualizations of disability.

Results and conclusion. The existing body of knowledge around disability may be extended and complemented by key concepts regarding human health/wellness from the field of Positive Psychology. Positive Psychology's keynote contribution to the study of disability and rehabilitation entails directing researchers and practitioners to the aim of building, reinforcing and extending disabled individuals' strengths and capacities in order to optimize their functioning in all areas of life, and thereby promote wellness.     

Trends in disability-free life expectancy

Purpose: To assess trends in Disability-Free Life Expectancy, in life expectancy with disabilities according to levels of severity and in Disability-Adjusted Life Expectancy in the Netherlands between 1989 and 2000.

Method: The disability-free life expectancy, a composite population health status measure, was calculated with data on long-term disability. Weights reflecting the impact of disability on personal functioning were assigned to different levels of severity of disability, in order to calculate a Disability-Adjusted Life Expectancy and to define cut-off points, in order to distinguish between levels of severity.

Results: At an aggregated level, for both males and females at the ages of 16 and of 65 years, an increase in years with disabilities and a decline in disability-free life expectancy were observed. These trends were mainly caused by a rise in the number of years with mild disabilities, with the number of years with moderate and severe disabilities decreasing. The combined changes have resulted in an increase in the Disability-Adjusted Life Expectancy.

Conclusion: Trends in disability-free life expectancy and in years with disabilities provide support for a scenario of dynamic equilibrium. The number of years with moderate and severe disabilities has reduced, resulting in an increase in the number of years with minor disabilities. Further research should focus on the underlying causes of the increase of years with minor disabilities.     

The potential for utilizing inter-limb coupling in the rehabilitation of upper limb motor disability due to unilateral brain injury

Purpose. Symmetry tendencies in human movement have generally been regarded as a constraint to upper limb motor performance. However, several recent studies have suggested that this phenomenon might be utilized in the rehabilitation of individuals with motor disability due to unilateral brain injury. In this paper the efficacy of such a rehabilitative approach is explored by reviewing: (i) examples of symmetry tendencies in healthy individuals, (ii) the potential neurophysiological mechanisms responsible for inter-limb coupling, and (iii) recent studies which have directly assessed the effects of inter-limb coupling on individuals with unilateral brain injury.

Method. A thorough review of current published evidence was conducted utilizing various electronic search engines (Medline, PreMedline, Embase and Cinahl). Studies included those that focused on symmetry tendencies and/or inter-limb coupling in the upper limbs with a particular emphasis placed on studies of individuals with unilateral brain injury.

Results. Based on the current literature it seems that motor function of the affected upper limb in individuals with unilateral brain injury can be improved through a rehabilitation approach that incorporates inter-limb coupling.

Conclusion. This approach should be considered as an adjunct to more common rehabilitation strategies with future research aimed at determining the most effective means of employing this paradigm.     

Theoretical aspects of goal-setting and motivation in rehabilitation

Purpose: The purpose of this article is to provide rehabilitation theorists and researchers with an introduction to some key theories of goals and motivation from the field of social cognition and to argue for increased dialogue between the two disciplines.

Method: The use of goals and goal-setting in rehabilitation is briefly surveyed and the somewhat ambivalent attitude toward the concept of motivation in the rehabilitation literature is highlighted. Three major contributors to the study of goals and motivation from the field of social cognition are introduced and their work summarized. They include: (i) Deci and Ryan's Self-Determination Model; (ii) Emmons' work on goals and personal strivings, and (iii) Karniol and Ross' discussion of temporal influences on goal-setting.

Results: It is argued that there is a need for a greater emphasis upon theory development in rehabilitation research and that closer collaboration between researchers in rehabilitation and social psychology offers considerable promise. Instances where the three theories from social cognition might have relevance to clinical rehabilitation settings are described. Some possible directions for research are also briefly sketched.

Conclusion: Both rehabilitation and social cognition have much to gain from increased dialogue.     

Variables related to job satisfaction among professional care providers working in brain injury rehabilitation

Purpose : To examine variables that contribute to work satisfaction among rehabilitation professionals involved in brain injury rehabilitation.

Method : One hundred and thirty-three respondents completed a job satisfaction questionnaire and qualitative questions regarding sources of stress and satisfaction in working with individuals with acquired brain injury (ABI).

Results : Factor analysis yielded four factors relating to intrinsic satisfaction, perceived importance to the organization, organizational support and training support. Although intrinsic satisfaction was significantly related to the three other factors, it was best predicted by training support, particularly training that addressed the management of intrusive and/or aggressive behaviours. Qualitative correlates of both work stress and satisfaction were also identified with respect to personal issues, client-related issues, and organizationally-related issues.

Conclusions : Satisfaction with work in ABI rehabilitation is derived from multiple sources, but it appears to be largely dependent on feeling important to, and valued by, the organization and on the level of support and training provided in the workplace.     

The adoption of tobacco dependence treatment by rehabilitation clinicians

Purpose: Individuals with disabilities tend to smoke at rates that surpass those of the general population. The Public Health Service Guideline on the treatment of tobacco dependence suggests that all smokers be screened at every health care visit and counselled regarding how best to quit smoking. We review the literature on the adoption of tobacco dependence treatment by rehabilitation clinicians working with disabled individuals. Despite the deleterious health effects of smoking on individuals with disabilities, the limited data suggests that rehabilitation clinicians rarely encourage their clients who smoke to quit.

Method: Studies were collected using various computerized databases from 1980 to the present. Because of the paucity of literature on tobacco dependence treatment utilization among rehabilitation clinicians, we also examine research on the use of tobacco dependence treatment by health care providers in the general population and in substance abuse treatment settings.

Results: Despite the efficacy of tobacco dependence treatment in smokers with disabilities, tobacco dependence treatment appears to be underutilized by rehabilitation clinicians.

Conclusions: Interventions that have successfully increased adoption by the two other clinician groups should be utilized to increase tobacco dependence treatment provision by rehabilitation clinicians. Additional research is warranted to determine how to overcome obstacles to adoption.     

Developing world rehabilitation strategy II: Flex the muscles, train the brain, and adapt to the impairment

Purpose. To understand some reasons behind the lack of medical rehabilitation resources in developing regions and to propose some actions that can change this problem.

Methods. Focused Medline literature review on AIDS disability in Africa. Editorial observation.

Results. Disability, rather than death or cost of treatment, is likely the greatest burden from AIDS. However only 0.05% of published research on AIDS in Africa relates to disability, so we cannot know this with certainty. This is a direct result of funding priorities, and a consequence of both traditional epidemiological methods and old-line 'cure or die' medical education. The disproportionate lack of medical rehabilitation specialists and facilities is a consequence of the same forces. Similar patterns are seen in rural and developing regions around the world.

Conclusions. Rehabilitation professionals must change healthcare service by using rehabilitation techniques: flexing muscle by insisting that governments, agencies, and philanthropists look at the cost of disability, not just disease; training the brains of young professionals who will practice, research and advocate locally; adapting intervention strategies to the impairments imposed by poverty and distance.     

Physiotherapy in Afghanistan: an analysis of current challenges

Introduction. Afghanistan has high levels of disability due to prolonged conflict. An important part of the reconstruction process in Afghanistan is strengthening health service capacity and, within this, rehabilitation services.

Aims: To identify training needs of, and key issues affecting, Afghan physiotherapists.

Methods. 20 interviews and clinical accompaniment of 15 physiotherapists/physiotherapy assistants (APA) carried out in the second quarter of 2003. Analysis was using a grounded theory approach.

Results. Five themes emerged: (1) Low professional profile of physiotherapy; (2) Difficult working conditions; (3) Difficulty identifying personal training needs; (4) Difficulty with clinical reasoning at undergraduate level; (5) Variable levels of clinical competence.

Discussion. Many of the challenges facing Afghan physiotherapists are not unique to Afghanistan but are exacerbated by a lack of government recognition of the profession. War has isolated Afghan physiotherapists from completed professional links and consequently the undergraduate curriculum had not matched developments in other comparable countries. This has contributed to the difficulties therapists' experience with current clinical reasoning and accessing new practice developments. Culture also influences attitudes towards training and has restricted female travel and access to education.

Conclusions. Core training needs include disability sensitization, reflective practice and clinical reasoning. The physiotherapy curriculum needs updating and links with ongoing research need to be established to keep abreast of new developments.     

The relationship between catastrophizing and disability in amputees experiencing phantom pain

Purpose: In recent years, researchers have noted that catastrophizing predicts both self-reported and objective measures of disability in a variety of chronic pain conditions. The present study sought to examine this in a working-age amputee population experiencing phantom pain.

Method: Participants completed a postal questionnaire incorporating measures of pain, disability and coping. A response rate of 62% resulted in 315 completed data sets being incorporated into the study.

Results: Utilizing the three subscales of the Sickness Impact Profile, catastrophizing uniquely predicted 11% of the variance in overall level of disability, 6% in physical disability and 13% in psychosocial disability after accounting for demographic, amputation and pain-related variables.

Conclusion: The findings suggest that catastrophizing is a significant predictor of self-reported disability in an amputee population. This population have lifetime rehabilitation needs in that prostheses have to be remade on a regular basis. The service provided tends to focus on physical rehabilitation with the goal of providing amputees with limbs that most closely resemble the appearance and function of the intact limb. This study provides tentative support for development of an intervention that specifically targets catastrophizing.     

An introduction to the Korean Employment Promotion Agency for the Disabled

Purpose. The main aim of this article is to provide an introduction to the Korean Employment Promotion Agency for the Disabled (KEPAD), and to provide comparative thought regarding government-based vocational rehabilitation service delivery between South Korea and the USA.

Method. Relevant literature is considered, and current issues and comparative discussion in practice are highlighted.

Results. Introductory information in terms of organization, eligibility, services and programmes are presented. In addition, practical problems associated with the KEPAD system and a cross-cultural analysis is elaborated, comparing the USA and South Korean vocational rehabilitation systems.

Conclusion. KEPAD has successfully derived public support and acknowledgement of its national responsibility in ensuring vocational rehabilitation services for persons with disabilities. The KEPAD system demonstrates a unique approach in implementing vocational rehabilitation services by providing various benefits for both employers and persons with disabilities. However, considerable cautiousness in terms of cross-cultural analyses is required for international application. Furthermore, successive research of rehabilitation infrastructure is warranted.     

Disability prevention and communication among workers, physicians, employers, and insurers--current models and opportunities for improvement

Purpose: To review prevailing models of disability management and prevention with respect to communication, and to suggest alternative approaches.

Method: Review of selected articles.

Results: Effective disability management and return to work strategies have been the focus of an increasing number of intervention programmes and associated research studies, spanning a variety of worker populations and provider and business perspectives. Although primary and secondary disability prevention approaches have addressed theoretical basis, methods and costs, few identify communication as a key factor influencing disability outcomes. Four prevailing models of disability management and prevention (medical model, physical rehabilitation model, job-match model, and managed care model) are identified. The medical model emphasizes the physician's role to define functional limitations and job restrictions. In the physical rehabilitation model, rehabilitation professionals communicate the importance of exercise and muscle reconditioning for resuming normal work activities. The job-match model relies on the ability of employers to accurately communicate physical job requirements. The managed care model focuses on dissemination of acceptable standards for medical treatment and duration of work absence, and interventions by case managers when these standards are exceeded. Despite contrary evidence for many health impairments, these models share a common assumption that medical disability outcomes are highly predictable and unaffected by either individual or contextual factors. As a result, communication is often authoritative and unidirectional, with workers and employers in a passive role.

Conclusion: Improvements in communication may be responsible for successes across a variety of new interventions. Communication-based interventions may further improve disability outcomes, reduce adversarial relationships, and prove cost-effective; however, controlled trials are needed.