November 29, 2021, by brzam5
Rehabilitation Matters: Thought and emotion in rehabilitation
Rehabilitation Matters is a series of stories and perspectives from people who care about effective clinical rehabilitation and the benefits it provides. The latest article by Dr Rob Stephens, Consultant Clinical Neuropsychologist at Nottingham University Hospitals, looks at the importance of a multidisciplinary approach to rehab and why patients’ emotional and cognitive needs are just as important as their physical needs.
There’s no question that patients admitted for clinical rehabilitation will have been through one of the most stressful or traumatic experiences of their lives.
If patients are to get the most out of rehabilitation after serious injury or illness, and regain a quality of life, then we need to work with their emotional and cognitive needs just as much as their medical and physical needs. Indeed these are essential to effective rehabilitation, and why I’m so excited by the plans for the new NHS National Rehabilitation Centre (NRC) which, as a purpose-built rehabilitation facility, is being designed to incorporate features that promote the mental and physical wellbeing of patients.
Clearly, a patient’s acute care in hospital must focus on treating their immediate health needs, which in some cases have been life threatening. While they may have received some initial input from clinical psychology during this period, I find that when they enter rehabilitation, they have the time and space to start making sense of the life-changing implications of their condition. The psychological impact of major trauma or severe illness really cannot be underestimated, and their experiences at the start of that journey will shape their adjustment for years to come.
During inpatient rehabilitation, one of our roles as clinical psychologists is to help patients navigate the complex, often difficult emotions they may experience. For example they might struggle with anger towards their situation or the cause of their injury. They might experience symptoms of post-traumatic stress. They might feel anxious about specific situations such as falling over, or more generally, anxious about their future recovery. They might feel fed-up and hopeless about their recovery, and this can have a massive impact on their engagement with rehabilitation. A further complexity is that many patients already have an underlying mental health condition, or addiction, and this new trauma presents an overwhelming challenge to them.
Delivering psychological intervention during this period is a balancing act. Some patients need to talk and make sense of their experiences, whilst for others it is too soon, and the last thing they want to do is talk about it. In either case, we want them to be able to engage fully with their rehabilitation goals, develop a positive but realistic attitude, and apply the motivation and effort that will drive them through rehabilitation. We must also ensure that during their inpatient stay, patients and their loved-ones develop mental strategies that will set them up for continued progress after they have left hospital.
As a clinical neuropsychologist I’m fascinated by the workings of the most complex thing we know of – the human brain – and helping patients who have the misfortune of injuring their brain though accident or illness. In my day-to-day work, the emotional and behavioural needs of my patients takes about half of my time, and the rest I am seeing how their injury has affected their thinking, and helping them with this. Of course, it is vital that we understand the effects of their brain injury if we are going to help them regain independence in their everyday activities (the ultimate aim of rehabilitation). This is true for quite basic activities like washing and dressing, through to the more complex demands of work or education. Neuropsychological assessment takes a detailed look at mental process related to concentration, memory and problem solving, to see which have been impaired. I do this soon after a patient arrives in rehabilitation, so that we know what to focus cognitive rehabilitation on, and which treatments are likely to be most effective. It is really important that rehabilitation is tailored to each individual, and our multidisciplinary team work together on these.
The NRC is going to make a huge difference to the way I work with patient’s cognitive and emotional needs. A simple example is having access to quiet clinical rooms in which to conduct cognitive assessment, and for these rooms to be equipped with the appropriate technology such as video and audio recording facilities. You wouldn’t believe how difficult it is currently to find a quiet room on the ward, in which to properly test a patient’s ability to concentrate.
I’ve mentioned emotional needs and cognitive needs separately, but of course these interact. For instance, an injury to the brain can directly impair someone’s awareness of their symptoms (termed ‘anosognosia’), they then become confused and frustrated when staff prevent them from doing things that are likely to cause further injury, and they refuse treatment sessions believing that they don’t need it. Neuropsychology helps us to understand the different elements here, and then finds a way to bring the patient on-side and start engaging in the rehabilitation sessions that they need.
Patients receiving rehabilitation need access to a variety of spaces. While those recovering from brain injury need a quiet and calm environment, which is not over-stimulating, the NRC will also be able to offer spaces designed for social interaction, and where patients can be supported to practise the strategies they will need for independent living. Plus, the tranquil setting of the Stanford Hall Rehabilitation Estate near Loughborough is bound to bring huge benefits in terms of emotional wellbeing.
I am also a lecturer at Nottingham University, and so I am excited about the educational and training opportunities the NRC will offer, not just for future students but also for NHS staff. An academic partnership with a consortium of universities is central to the NRC programme, and this will make it easier for NHS colleagues to benefit from high-quality professional development as well as to undertake research in their area of specialist interest. Then from the point of view of university students, the opportunity to gain practical experience of the latest rehabilitation approaches and technologies will make university courses linked to the NRC very popular.
Thinking about my profession specifically, those who have recently graduated in psychology will have a career in clinical psychology in their sights. Their next step would be to work at the NRC as an assistant psychologist. Typically these are highly motivated individuals, who deliver psychological treatments under supervision, and will help patients practice the cognitive exercises and strategies that they have been prescribed. After this, they may return to the NRC in the form of a trainee placement, and finally after qualifying in clinical psychology, they will be supported to complete their advanced training to become clinical neuropsychologists. It is a long journey, but at every step of the way the NRC will offer them an excellent learning environment and will no doubt attract the best people in the field.
In so many ways the NRC is tremendously exciting, not only because of the unique combination of physical and psychological support it will offer to NHS patients in the short term, but also because of its potential to support the development of innovative treatment approaches and technologies for the future.
If I or a loved-one had the misfortune of needing rehabilitation, I would want somewhere that had the expertise to address all of those needs; medical, cognitive, physical and psychological. And to be able to do so in a beautiful purpose-built environment would surely offer the best chance of recovery.
The NRC offers the potential to do what we do now – and know is effective – even better. That’s why it matters.
Dr Rob Stephens is a Consultant Clinical Neuropsychologist at Nottingham University Hospitals.
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