A look at the specialised field of rehabilitation psychology
Quality of life (QoL) is determined by a range of factors, from age and employment to physical and psychological health. The Better Life Index is a measure of quality of life (QoL) determined by the Organisation for Economic Co-operation and Development (OECD), and according to the OECD, Australia performs well relative to most other countries in areas such as education, health, employment, environment and disposable income. This suggests most Australians have an acceptable QoL. However, risk factors exist in Australian society that can diminish QoL, such as older age, higher socioeconomic disadvantage and obesity. Another prominent risk factor that can result in substantially reduced QoL is chronic disability arising from either physical injury or chronic disease, especially so if multimorbidity occurs. Multimorbidity is the occurrence of at least two chronic conditions. Examples could include spinal cord injury (SCI) with comorbid chronic conditions like cognitive impairment, cardiovascular disease, depression or alcohol abuse, a traumatic brain injury (TBI) with chronic pain, sleep disorder and post-traumatic stress disorder and multiple sclerosis (MS), with diabetes mellitus, fatigue and depression.
Based on a National Health Survey conducted by the Australian Institute of Health and Welfare (AIHW, 2022) the presence of multiple chronic conditions in adults was found to be associated with considerably reduced QoL, lower workforce participation and high levels of psychological distress (AIHW, 2022). The AIHW reported in 2022 that chronic conditions are an ongoing cause of considerable burden, disability and death in Australia. It estimated that in 2020–2021, 47 per cent of Australians (11.6 million people) had at least one common chronic condition such as coronary artery disease, arthritis, asthma, physical injury such as back injury, diabetes and mental disorder such as depression. Around 25 per cent (over 5 million) had at least two chronic conditions.
The burden of disease of these conditions is likely to be huge in Australia and will be associated with substantial negative impacts on QoL. ‘Burden of disease’ is defined as the impact of living with illness and injury leading to premature death (AIHW, 2022). For example, the AIHW reported in 2018 that for males, the principal causes of burden of disease were cancer, cardiovascular diseases and injuries (including suicide). For females, in 2018, principal causes of burden of disease were musculoskeletal injuries, neurological conditions (including dementia) and respiratory diseases.
Adjustment to chronic conditions
The statistics reported by the AIHW on the prevalence and impact of chronic conditions on QoL are concerning. Consequently, it is critical that Australians living with one or more chronic conditions receive help and support to adjust to their changed life circumstances, with the aim of improving or rehabilitating their QoL. ‘Adjustment’ in this context can be broadly defined as responding adaptively to chronic disability related to injury or chronic disease, by modifying behaviour, thoughts and personal circumstances, the goal being to achieve an acceptable QoL (Craig, et al., 2022). When helping someone adjust to a chronic condition(s), it is advisable that they engage in a rehabilitation process that involves attention to medical, psychological and social aspects of the condition and which is designed to assist either their recovery or adjustment process.
However, there is a large variability in adjustment to chronic conditions and a one-size approach does not fit all. Some adults with objectively more severe health conditions may have greater functional recovery than others with objectively less severe conditions. Considering this variability of recovery of function, it is important to understand people’s personal goals, processes and support needs for person-centric rehabilitative services. In their daily lives, people continue to build a sense of continuity about their lives, and indeed, some report greater development and growth living with chronic illness and disability. This variability between individuals suggests that adjustment to chronic illness and disability is both a reactive (in the sense of realignment of personal world view) and also proactive process (in the sense of learning and development through self-discovery).
Rehabilitation generally involves an ongoing process of intervention by a team of multidisciplinary health professionals, including medical specialists, physiotherapists, exercise physiologists, social workers, speech pathologists, occupational therapists, nurse practitioners, dietitians and psychologists in collaboration with the individual, and often includes their families. Rehabilitation psychologists work in a range of settings including inpatient (critical care, acute or sub-acute), outpatient services, specialised outpatient clinics, vocational/return-to-work programs and community programs depending on the duration and severity of the condition. Psychologists working in private practice settings may also provide rehabilitation services for discharged patients. Interventions are person-centered, evidence-based and involve an individualised approach to care.
Rehabilitation psychology
Rehabilitation psychology is a specialised field of psychology that primarily focuses on assisting individuals to adjust to impairment and disability following injury or chronic disease within a rehabilitation process. It involves improving the understanding of the complex factors associated with chronic conditions that have been identified through controlled research and applying this knowledge to the assessment and treatment of people who have experienced deterioration in functioning resulting from injury or disease. The ultimate goal is to help people achieve optimal physical, cognitive, psychological, social and occupational functioning given their health conditions.
As mentioned above, important principles in rehabilitation psychology include providing person-centred health care, working within or in association with an interdisciplinary health professional team, and dealing not only with the injured or chronically ill person, but also their family, friends and support networks. Applying all elements of the widely accepted biopsychosocial model in a timely manner to assist the person with a chronic health condition.
Rehabilitation psychologists can be involved in research and/or treatment of a wide range of traumatic and non-traumatic injuries as well as a variety of chronic diseases. As examples, they can be involved in the following areas in the adult population:
- Severe injuries like SCI. SCI occurs when the spinal cord is damaged, resulting in permanent motor and sensory loss. It can be a result of a traumatic injury or a non-traumatic disease process. SCI is associated with a range of secondary conditions or comorbidities, such as grief, psychological disorders, fatigue, chronic pain, chronic infections, cardiovascular disease, TBI, cognitive impairment, social isolation due to restricted social access, poor return to work, and relationship and sexual problems (Craig et al., 2022). While SCI and its impact seems overwhelming, rehabilitation psychologists have an important role in helping individuals with SCI adjust and develop resilience to the multiple challenges associated with the injury by using psychological therapies tailored to the injury.
- Severe brain injury. Damage to the brain is called acquired brain injury (ABI) and can be caused by a traumatic accident, a stroke, a brain infection, alcohol/drug abuse, hypoxic injury or dementia. TBI is a type of ABI and is caused by a violent blow to the head or penetration injury into the brain. Impacts are life-changing and can include grief and loss, cognitive impairment, headaches, personality change, behavioural difficulties, psychological disorder, sleep problems, fatigue, problems returning to work and relationship problems. Rehabilitation psychologists use a range of techniques such as cognitive behaviour therapy for treating the behavioural and emotional disturbances associated with a TBI, cognitive rehabilitation to address cognitive impairment and positive behavioural support to address challenging behaviours (Ponsford et al., 2022). These therapies can be used to improve the function of people with TBI and in partnership with other rehabilitation professionals, rehabilitation psychologists play an integral role in improving functional, psychosocial and health outcomes in chronic illness and disability.
- Musculoskeletal injuries. Injuries such as as whiplash injuries, mild TBI, fractures and upper or lower back injuries may be classified as mild to moderate injuries when assessed for compensation purposes. However, comorbidities can be extensive and include chronic pain, sleep problems, challenges returning to work, and a range of psychological disorders like depression, post-traumatic stress disorder (PTSD) and panic disorder. Rehabilitation psychologists will mostly be involved with these types of injuries in outpatient services or in private practice after discharge from the emergency department, or even later, following referral from their general practitioner, should they find difficulties coping with everyday life.
- Chronic diseases and illnesses include multiple sclerosis, diabetes, asthma, chronic obstructive pulmonary disease, heart disease, arthritis, neuromuscular disorders, myalgic encephalomyelitis/chronic fatigue syndrome, long COVID and back pain. There is a high risk of people with these chronic conditions to become depressed, anxious and socially isolated; experience financial stress, have difficulties sleeping, and develop secondary health conditions. Rehabilitation psychologists address the implications of the chronic health condition as the person’s requirements change over time, assess psychosocial status and treat cognitive, emotional and functional conditions associated with the chronic disease. They will also assist clients to overcome barriers to social participation in daily activities and can become involved in advocacy, with the broad goal of fostering independence and resilience.
Rehabilitation psychology and compensation schemes
Clients with a physical injury and/or a chronic disease who also present with a primary or comorbid mental health disorder are eligible to be treated under Medicare’s Better Access to Mental Health Care program. In private practice, clients are seen at the practice rooms, via telehealth or on home visits. However, many people with a physical injury arising in the workplace or following a transport crash who have a comorbid mental health condition may also have access to compensation schemes in each Australian state and territory. Examples include the Lifetime Care and Support Scheme in NSW and ACT, Lifetime Support Authority in South Australia and the WorkSafe and Transport Accident Commission (TAC) schemes in Victoria. In most workers’ compensation schemes, psychological injuries are accepted if employment is the main cause or a contributing factor. A summary of the inclusions and exclusions for the 11 workers’ compensation systems that exist across Australia is published by Safe Work Australia annually (Safe Work Australia, 2019). The relationship between psychological injury and traffic accidents as a causal factor is often more clearly defined due to the traumatic nature of the accident.
Making a compensation claim, receiving medical treatment and financial compensation for loss of wages and permanent injury can be a daunting and confusing experience for the injured person. In addition to dealing with their physical and psychological injuries, injured people report difficult interactions with insurers, including experiencing disbelief, stigma, slow approvals for medical treatment, poor communication and lack of knowledge, and poor provision of information regarding their rights and responsibilities (Victorian Ombudsman, 2019). Particularly for longer term claimants, these difficulties can impact recovery, delay return to work and extend claim duration (Kilgour and Kosny, 2018).
Some compensation schemes have recently made changes to improve claims management for psychological injury by offering provisional liability, whereby payment of benefits and medical treatment is provided before the decision regarding claim liability is made (Safe Work Australia, 2018). Rehabilitation psychologists aim to intervene earlier rather than later to encourage improved outcomes and recovery.
Rehabilitation psychologists can play an important and influential part in the treatment and recovery of injured persons engaged in compensation. In addition to providing psychological therapy for conditions that injured persons may experience such as depression, anxiety, pain, PTSD and adjustment to injury concerns, rehabilitation psychologists can also incorporate best practice approaches that include liaising with other treating professionals and employers, and focusing treatment on clear rehabilitation and vocational goals. The Clinical Framework for the Delivery of Health Services (Health Services Group, 2012) is accepted by both workers’ compensation and transport accident compensation organisations in all states of Australia and provides clear principles to improve recovery outcomes. By having a thorough knowledge of compensation systems, rehabilitation psychologists can further empower and support injured people by facilitating a better understanding of their rights and responsibilities within the relevant compensation system (Safe Work
Australia, 2021).
Paediatric rehabilitation psychology
We have previously focused on the adult population, however, rehabilitation psychologists very much work across the lifespan. Paediatric rehabilitation psychology is a specalised area, that necessarily considers the ongoing developmental process of the child or young person over the course of their health condition or disability. Embedded into the paediatric rehabilitation framework is a family-sensitive approach to ensure parents and siblings are considered in interventions and support services. The rehabilitation psychologist helps to promote the social participation of the child or young person, including home, school, sport, friends and peers and their community. Transition to adult services is thought about at an early stage of adolescence and promoting self-management, where the child assumes more responsibility as they age, is the aim where appropriate (Agency for Clinical Innovation and Trapeze, 2014).
Injury, chronic illness and Pain Interest Group
The Rehabilitation Psychology Interest Group within the Australian Psychological Society was formed in 2007, with the purpose of developing a network of psychologists throughout Australia with an interest in professional practice, research, teaching and learning in the specialised field of Rehabilitation Psychology. About 12 months ago, the name was changed to the Rehabilitation Psychology of Injury, Chronic Illness and Pain Interest Group (RPICIPIG), to broaden the areas of relevance to the interest group and promote the role of psychologists in supporting clients with chronic illness and pain conditions. The RPICIPIG is focused on bringing together psychologists with an interest in the principles, processes and practice of rehabilitation psychology in the context of injury, chronic illness and pain. Psychologists who are members of this group are involved in the rehabilitation field and work in private practice, research or in public rehabilitation facilities as part of a multi-, inter- or transdisciplinary team, helping individuals affected by a chronic, traumatic or congenital illness or injury.
In conclusion, it is optimal if psychologists working in rehabilitation psychology have a working knowledge of the client’s condition including the physical/medical nature of the condition, symptomatology, psychosocial and systemic factors, so they can assist in maximising independence and wellbeing. Psychologists in this area gain enormous satisfaction as they assist people with chronic conditions to adjust and become more resilient. We hope this short article stimulates the interest of psychologists in the Australian Psychological Society to consider widening their skill set so they can professionally help people with chronic conditions. With this in mind, we welcome APS members interested in developing and broadening their skillset to join the RPICIPIG where ongoing professional development and support is available.
Contact the author
1John Walsh Centre for Rehabilitation Research, Kolling Institute, Royal North Shore Hospital, The Faculty of Medicine and Health, The University of Sydney
2Healthy Working Lives Research Group, School of Public Health and Preventive Medicine, Monash University
3People Change Consulting PO Box 633, Buninyong, Victoria
4Comfort Psychology, comfortpsychology.com
5School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria
6College of Health and Public Service, University of North Texas, TX, USA; School of Health Sciences, The University of Sydney, Australia
7 Kids Rehab, The Children’s Hospital at Westmead, Sydney, New South Wales
8Brain Injury Rehabilitation Research Group, Ingham Institute for Applied Medical Research, & School of Psychology, University of Wollongong