The Role of the Psychologist in Life Care Planning

As a member of the interdisciplinary rehabilitation team, the psychologist can play numerous life care planning related roles. This post will consider the roles of inpatient and outpatient psychological services, as well as the ways a psychologist can work with individuals with disabilities, their support systems, and the rehabilitation team (also see the neuropsychologist post, which discusses the role of a related specialty). Several different topics will be considered: (1) choosing a psychologist, (2) psychological issues common to rehabilitation, (3) the psychologist’s role in assessment and diagnosis, (4) psychological testing, (5) types of psychological treatment, (6) ethical standards for the psychologist, (7) specialty guidelines for the forensic psychologist, and (8) the interface between the psychologist and life care planner.

Following is an overview of the psychological training and preparation of the licensed psychologist. Though psychologists may vary in theoretical orientation, their academic requirements are con­sistent with the requirements of the American Psychological Association. Rehabilitation profes­sionals should be well informed of the psychologist’s credentials and, in order to make the most appropriate referrals, should be aware of the psychologist’s theoretical orientation.

¦    A licensed psychologist has typically earned a doctoral degree from an accredited university program or professional school that has been approved by the American Psychological Association (or deemed equivalent, in some cases). Psychologists are required to complete a 1900-hour predoctoral internship in an approved program, followed by a minimum of a 1-year full-time equivalent postdoctoral internship supervised by a licensed psychologist.

¦    After completion of the previous requirement, the candidate petitions the state board of psychological examiners for the right to take the written examination in professional
psychology, which must be passed within state-legislated parameters. Then the candidate takes an oral examination based on legal and ethical issues for the state in which the person intends to practice. Successful passage of both examinations allows licensure within that state. It is only then that the person may use the title psychologist. Use of the title without proper licensure constitutes a violation of legal statutes and ethical principles. Please note there are some exceptions that allow the use of the term psychologist by nonlicensed employees of universities or state agencies.

¦     Psychologists practice within the scope of their training and experience, and this training may vary widely at the postdoctoral level. It will be important for those engaged in life care planning to ascertain whether a psychologist has specific personal and professional experi­ence in working with rehabilitation clients and their families. It may be helpful to choose a psychologist who has subspecialized in health, medical, or rehabilitation psychology or who has additional training as a registered nurse or rehabilitation counselor.

The following is a brief description of widely accepted theoretical orientations used by practicing psychologists (Altmaier, 1991).

¦     Psychoanalytic psychologists generally follow the theory and principles established by Sigmund Freud, including examination of early childhood and familial relationships, along with conflicts presumed to originate in early developmental stages.

¦     Psychodynamic psychologists incorporate the theories of those following Freud (Alfred Adler, Harry Stack Sullivan, Karen Horney, Erik Erikson, and others). These psychologists also focus on aspects of relationships presumed to originate in infancy and childhood.

¦     Developmental psychologists examine cognitive, social, and psychomotor development of indi­viduals relative to their age-related peers. Developmental psychologists often evaluate children, and their findings may be useful following catastrophic events occurring before adulthood.

¦     Behavioral psychologists analyze environmental and personal factors that can be identified and altered in the interest of improving the incidence and frequency of desirable behaviors and decreasing the amount of problematic behaviors in an individual.

¦     Cognitive-behavioral psychologists incorporate behavioral principles and also consider the roles of thoughts and feelings in acquiring and maintaining certain behaviors. Both behav­ioral and cognitive-behavioral psychologists can help develop systematic behavior change programs.

¦     Health psychologists tend to adhere to the systems approach: no part of a system operates exclusive of others. Therefore, they adhere to the biopsychosocial model. In the rehabilitation process health psychologists work with a multidisciplinary team of health professionals (e.g., physicians, nurses, physical therapists, occupational therapists, and case managers) to deter­mine the treatment plan and its implementation.

¦     Rehabilitation psychologists practice within the broad field of psychology. Rehabilitation psychology is the application of psychological knowledge and understanding on behalf of individuals with disabilities and society through such activities as research, clinical prac­tice, teaching, public education, development of social policy, and advocacy. Rehabilitation psychologists participate in a broad range of activities, including clinical care, program development, service provision, research, education, administration, and public policy. The American Board of Professional Psychology (ABPP) recognizes rehabilitation psychology as a specialty area of practice within psychology.

¦    Industrial psychologists analyze work environments to enhance productivity through the human element. Considerations include management style; environmental factors such as worksite layout, music, and color; employee assistance programs; policy development; atten­tion to group dynamics; and other factors.

It is important to choose a psychologist who appreciates the interdisciplinary team approach and who understands the roles of the various rehabilitation professionals. The psychologist should be properly licensed to eliminate concerns of credibility, and the psychologist’s orientation, when appropriate, should be relevant to the client’s situation from a biopsychosocial-spiritual perspec­tive, addressing the client’s needs holistically.

Following a catastrophic injury or the diagnosis of a life-threatening illness, the issue facing the client and family is that of survival. Will the person live or die? For family members, the initial reaction is usually one of panic. As this response subsides, feelings of disorientation and loss of control are common. It may be very difficult to concentrate, and family members may become confused by what they perceive to be different types of information coming from different sources. Feelings of disequilibrium continue for quite some time in many families, with members feeling in control one day and quite out of control the next. Behaviors that can signal these reactions include anger over both significant and seemingly trivial issues, concrete or very literal thinking, efforts to participate in the loved one’s care in ways that are inappropriate, and neglect of other significant areas of one’s life.

Once it seems apparent that the client will survive the initial crisis, the focus will shift toward issues of functional abilities and quality of life. Will the client be able to talk, eat, walk, and care for him or herself? Return to normal family roles and responsibilities? Return to school, or earn a living? Different levels of anxiety are associated with the different stages of stabilization and reha­bilitation. Family members need a forum for discussing some of these concerns that is private and, if appropriate, separate from the client. In addition family therapy is often very helpful. Family members may need assistance with relaxation strategies, help with prioritizing decisions, or to find as much information as necessary to make good judgments.

Denial is a defense mechanism that is initially protective, keeping families from feeling overwhelmed by the enormity of a catastrophic event. However, denial of facts often prevents the family from dealing with real issues and consequences that must eventually be addressed. The rehabilitation team treads a fine line, wanting to support optimism and hopefulness, while presenting data about deficits and limitations that may endure. The psychologist or other rehabilitation team members can encourage family members to focus on one day at a time without letting expectations for the future affect the client’s immediate needs. Gently asking family members, “How does he seem to you?” or asking them to describe how their loved one did things prior to the illness or injury may allow an assessment of the family’s degree of denial or acceptance.

Letting go of denial may lead to expressions, directly or indirectly, of anger. Anger may be expressed toward the client, individuals perceived as responsible for the injury or illness, medical care providers, the legal system, family members, or God. Dealing with anger and frustration effectively may require the assistance of a mental health professional, who will suggest appropriate problem-solving strategies and may assist with various stress management techniques.

Other psychological concerns commonly seen in family members include:

¦     Fatigue

¦     Depression

¦     Sleep disturbance

¦     Criticisms from other family members and friends regarding care provided for the client

¦     Feelings of hopelessness, helplessness, and guilt

¦     Constriction of social activities and opportunities for social support

¦     Changes in the quality of the relationship with the injured or ill person

At this point, it is important for the rehabilitation team to remember how family may be defined. Certainly where issues of consent are concerned, legal statutes apply. However, the client’s self-defined family may include those with whom no formal, legal ties exist. These relationships may, in fact, be closer than those within the biological family, including relationships with a sig­nificant other, close friends, stepfamily members, and so on. Some close relationships may have been defined within legal documents such as durable powers of attorney or living wills; the client’s wishes should be respected and followed within the scope of the law. Extended family members should be supported with mental health services as much as members of the client’s biological family.

It is important to note that psychological issues may surface and then reemerge over and over: developing a relationship with a caring provider that can endure over time, as the need arises, may be essential to a family’s adjustment.

Rehabilitation clients can face tremendous challenges: physically, cognitively, emotionally, behaviorally, financially, and socially. Following traumatic brain injury, disordered and inappropriate features may emerge as a result of altered brain functioning (DeBoskey & Morin, 1985; Ripley & Weed, 2004). For individuals with other types of injuries, it is important to remember that subtle brain injuries may have also occurred. Subtle or obvious problems may become apparent with regard to attention, concentration, memory, problem solving, insight, judgment, affective issues, pain management, and coping.

Problematic behaviors can include the following:

¦     Agitation

¦     Irritability

¦     Outbursts of anger

¦     Inappropriate statements

¦     Inappropriate sexual behavior

¦     Egocentrism

¦     Concrete thinking

¦     Impulsivity

¦     Emotional lability

¦     Denial of deficits

¦     Suspicion or paranoia

¦    Anxiety

¦     Depression

¦    Apathy

¦     Obsessiveness

¦     Social immaturity

¦     Dependency

¦     Eating disorders

¦     Sleep disorders

¦     Drug use or abuse

When a psychologist with a behavioral orientation is asked to consult regarding these problematic areas, several things will occur. The psychologist will be interested in input from all members of the rehabilitation team in order to determine when problems occur and possible patterns in the problematic behavior (Bellak et al., 1990). The client may be observed during therapies and quiet times for several days while the psychologist notes patterns of behavior. These behaviors will often be charted and used as baseline data.

In general, behavioral interventions will be specifically described and the team will be asked to chart information about client responses. It is common for behavioral problems to increase for a short period of time when the behavioral program is instituted. The psychologist will look for decreases in the frequency, intensity, and duration of problem behaviors over time. Do not become concerned if the behavioral program does not instantly solve behavioral issues: modifications are commonly required, and consistency in application is essential.

The following describes how a behavioral psychologist might work to assist the client in resolving problems.

¦    The psychologist may be able to identify patterns of events that precede the problem behavior. For example, a client may become agitated when a specific family member visits. Perhaps that family member is doing something that contributes to the problem. In other cases, clients become agitated when the stimulation level in the environment becomes excessive, or when they are fatigued or uncomfortable.

¦    The psychologist will also try to identify the impact or effect of the client’s behavior. For example, if an inappropriate behavior is followed by an event that the client perceives as rein­forcing (e.g., allowed to discontinue an unpleasant physical therapy activity, or being given a milkshake as a distraction), the probability is that the inappropriate behavior will continue or even worsen with time. The psychologist will recommend different ways of responding to inappropriate behaviors that will lessen the likelihood of recurrence. It is important for the entire team to follow the behavioral plan consistently.

¦     Rehabilitation team members are in a unique position of being able to model ways of interacting with clients. Family members may be at a loss about how to respond to angry
outbursts or episodes of poor social judgment. The team can show family members how to simplify language when speaking to someone who cannot think abstractly, how to distract a client who is focusing inappropriately, and how to ignore certain behaviors in order to eliminate the reinforcing power of attention.

¦     As a client’s level of awareness and insight improves, it will be important to involve the client in the setting of behavioral goals. Explaining treatment rationales and getting the client to take responsibility for his or her own behavioral problem will increase the client’s investment in the process and, ultimately, in the success of the program. Clients can keep track of prog­ress on charts, in memory logs, or by other creative ways that measure successes over time.

As insight improves, adjustment concerns become central. Individuals follow very similar patterns of adjustment to disability. Cohn (1961) has described a five-stage process of adjustment. The first stage is shock, wherein denial or minimization is common. In the second stage, expectancy for recov­ery, the client may admit to current deficits but continues to expect a quick and complete recovery. As the extent of the disability becomes apparent, mourning occurs. Depression, suicidal ideation, suicidal attempts, and disengagement from or active resistance to the therapy process are common during this stage and should be identified. During the fourth stage, defense, the adjustment process begins. The person reaches a critical point where either denial, or movement toward independence, tends to occur. The final stage, adjustment, occurs when the client has a realistic appraisal of his or her strengths and/or weaknesses, and begins to focus on moving forward with life.

When traumatic injuries have occurred, posttraumatic stress disorder (PTSD) can result (van der Kolk, Roth, Pelcovitz, Sunday, & Spinazzola, 2005). According to the American Psychological Association (1994) in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV, TR, 2000), criteria, PTSD follows from exposure to “an extreme traumatic stressor … that involves actual or threatened death or serious injury” to the self or someone else, or finding out about such an event experienced by a loved one (p. 424). The person’s response must involve “intense fear, helplessness, or horror; a persistent avoidance of stimuli associated with the trauma; a numbing of general responsiveness; and persistent symptoms of increased arousal” (p. 424). The symptoms must be present for over 1 month and cause clinically significant distress or impairment in daily functioning (DSM-IV, TR, 1994). The epidemiology of posttraumatic stress disorder varies, with 50% to 80% of those experiencing a devastating disaster going on to develop symptoms of the disorder (Kaplan & Sadock, 1991; van der Kolk, Roth, Pelcovitz, Sunday, & Spinazzola, 2005). The likelihood of developing PTSD correlates positively with the severity of the stressor.

Early intervention programs are being used to encourage clients to talk about their traumatic experiences in a supportive context. Behavior therapy, cognitive therapy, hypnosis, and some experimental approaches have been used (Hammond, 1990). Group therapy can be particularly effective when members of the group have shared similar precipitating events. Family therapy is often useful because of the high incidence of marital disruption caused by PTSD symptoms.

Medication therapy may be indicated in clients who are seriously affected and are not responding optimally to other therapeutic interventions. Hospitalization may be required during periods of severe symptoms or when there is a risk of suicidal or violent behavior.

It is important to note that clients adjust to disability in highly individual ways. The stages of adjustment within the individual can vary as well. Often, personal stressors will arise that can lead to a revisiting of adjustment issues (e.g., changes in a personal relationship may lead to further examination of the impact of the disability). It may be quite helpful for the client to have a relationship with a psychologist who can be available, repeatedly if needed, for periods of brief therapy.

Psychologists are asked frequently to contribute to the initial assessment of a rehabilitation client. Generally, psychologists enter the picture in the rehabilitation facility, rather than during the acute hospitalization. In complex cases, however, it may be helpful to have psychological input during the transitional phase between acute hospitalization and rehabilitation placement.

The psychologist may address the following factors:

¦     Medical diagnosis

¦     Preexisting conditions (medical conditions, mental health issues)

¦     Premorbid health beliefs and behaviors (religious beliefs about health care, degree of compli­ance with medical treatment in the past, health-related practices, quality of prior relation­ships with health care providers, use of alternative medicine, degree of faith in medical treatment, etc.)

¦     Educational background

¦     Employment history (job titles and stability of employment)

¦     Medications, including side effects and interactions

¦     Functional limitations

¦     Physical rehabilitation potential, from a team perspective

¦     Premorbid personality characteristics

¦     Marital status and stability of primary relationship

¦     Role within family prior to injury or illness (e.g., wage earner status, parenting responsi­bilities, household management tasks, financial obligations, and relationship with extended family)

¦     Financial resources

¦     Extent of social support network

¦     Substance use and abuse history

¦    Abuse history (physical, emotional, and/or sexual)

¦     Legal history

¦     Coping resources and compensatory strategies

¦     Community resources

¦    Adjustment, including stage of adaptation to disability

¦    Affective status (depression, anxiety, anger, etc.)

¦     Suicidal potential and lethality

¦     Insight

¦    Judgment

¦     Potential for posttraumatic stress disorder

¦     Compliance with treatment

¦     Initiative and motivation

¦     Passivity vs. proactivity

¦     Beliefs about outcomes

¦     Role of spirituality, past and present

Following a psychological evaluation, the team should have a better understanding of who the client was prior to the injury or onset of illness, how the event has impacted the client and his or her support system, and what changes can be anticipated in the future.

A number of psychological instruments can provide valuable information when planning care for a rehabilitation client. This section will identify some psychological tests that may be given, along with descriptions of the types of data they will generate.

This 390-item questionnaire investigates issues related to the management of chronic pain (Lewandowski & Tearnan, 1993). Answers reveal the client’s perception of pain and its severity, health care use patterns, degree of physical activity and activity avoidance behaviors, spousal influ­ences on pain and wellness, physician influences on pain and wellness, perceived quality of the physician-patient relationship, nonproductive pain beliefs, coping strategies used, mood, and use of medications. Treatment recommendations are generated for managing the physician—patient relationship, reducing pain behaviors, examining pain beliefs, and addressing use of drugs and other substances. A posttreatment questionnaire is available for outcome evaluation. For more information, see www.painassessmentresources .com/prods/bapwin.html.

Twenty-one physical and emotional symptoms are listed in this questionnaire. The client rates whether symptoms experienced within the past week are absent or are mild, moderate, or severe in intensity. Scores indicate whether symptoms of anxiety are within normal range or range from mild to severe. The physical symptoms within the inventory must be evaluated with medical diagnoses in mind: many may be manifestations of disease processes rather than symptoms of anxiety, though the severity of symptoms may be affected by anxiety as well. For more information, see http://harcourtassessment .com/HAIWEB/Cultures/en-us/Productdetail.htm?Pid=015-8018- 400&Mode=summary.

The inventory contains 21 sets of statements related to depressing thoughts, feelings, and behaviors. The client circles the statement that most accurately describes symptoms during the past week. Scores indicate whether symptoms of depression are within normal range or range from mild to severe. Suicidal ideation, intent, and plan are assessed by one set of statements within the
inventory. For more information, see http://harcourtassessment .com/HAIWEB/Cultures/en-us/ Productdetail.htm?Pid=015-8018-370&Mode=summary.

CRIS measures perceived coping resourcefulness based on transactional models of stress (Curlette et al., 1992). According to these models, stress is the outcome of a perceived imbalance between demands and coping resources. CRIS scales measure self-disclosure, self-directedness, confidence, acceptance, social support, financial freedom, physical health, physical fitness, stress monitoring, tension control, structuring abilities, problem solving, cognitive restructuring, functional beliefs, and social ease. An overall Coping Resources Effectiveness Score is computed, along with primary and composite scales, wellness-inhibiting items, and validity keys.

This scale asks 30 yes/no questions about thoughts, feelings, and activities related to depression in older adults. Scores range from normal to severe. For more information, see www.stanford. edu/~yesavage/GDS.html.

This 150-item true/false questionnaire is designed to assess psychological characteristics of patients receiving general medical care or evaluation. It contains 20 scales that provide data regarding coping factors related to the physical health care of adult medical patients. It can help identify possible psychological or psychosomatic complications, and may help predict responses to illness or medical treatment. The inventory takes about 20 minutes to complete and assumes an eighth- grade reading level. The MBHI report generates hypotheses that must be used as one facet of a total patient evaluation. For more information, see www.millon .net/instruments/MBHI.htm.

This self-report instrument contains 175 true/false items designed to assess personality disorders and clinical syndromes described in the Diagnostic and Statistical Manual (DSM-IV, TR). It can assist the clinician in developing individualized treatment plans and help identify potential bar­riers or obstacles to treatment. The MCMI-III assumes an eighth-grade reading level. For more information, see www.pearsonassessments .com/tests/mcmi_3.htm.

This inventory is an empirically based test of psychopathology, derived specifically for adolescents (Archer, 1992). It is used primarily to aid in problem identification, diagnosis, and treatment planning in a variety of settings, including hospitals, clinics, school counseling programs, private practice, and correctional facilities. There are 478 true/false items. Administration time takes up to an hour and assumes a sixth-grade reading level. Family problems, eating disorders, and chemi­cal dependency issues are addressed. For more information, see www.pearsonassessments .com/ tests/mmpia.htm.

This inventory is the restandardized version of the original MMPI, an empirically based test of adult psychopathology. It is used to measure objectively psychopathology across a broad range of client settings where social or personal adjustment problems are acknowledged or suspected. The MMPI-2 can aid in identifying appropriate treatment strategies and potential difficulties with treatment. The inventory contains 567 true/false test items and assumes a reading level of sixth grade (Greene, 1991).

The MMPI-2 is an extremely sophisticated psychological assessment instrument, and it is beyond the scope of this post to present the test in detail. However, the test yields several validity indexes that measure a client’s degree of psychological functioning, as well as attempts to fake “good” psychological health or to present a more deviant picture. Ten basic clinical scales measure symptomatic and characterological symptoms, and numerous subscales assess subtle and obvious aspects of psychological functioning. The consistency of responses and attentiveness while taking the test are also assessed. For more information, see www.pearsonassessments .com/tests/mmpi_2.htm.

The PAI is a 344-item inventory that provides a broad-based assessment of mental disorders. The PAI includes 4 validity scales, 11 clinical scales, 5 treatment scales, and 2 interpersonal scales. Clinical scales are clustered in neurotic, psychotic, personality disorders, and behavioral disorders. For more information, see www3.parinc.com/products/product.aspx?Productid=PAI.

This inventory was developed to measure the anxiety level of individuals. It consists of two 20-item self-report scales designed to assess anxiety proneness and the current level of anxiety. The test is appropriate for those with a seventh-grade education or higher and requires approximately 15 minutes to administer.

This test is based upon a definition of intelligence as “the aggregate or global capacity of the individual to act purposefully, to think rationally, and to deal effectively with his environment” (Wechsler, 1944). The subtests evaluate verbal intelligence and performance intelligence. The test is of value for determining intellectual functioning for occupational, educational, and neuropsy­chological purposes. For more information, see http://harcourtassessment .com/haiweb/cultures/ en-us/productdetail.htm?pid= 015-8980-727.

Wechsler (1944) applied the same definition of intelligence as noted under WAIS-III to the development of a measure of intellectual functioning in children ages 6 years 0 months to 16 years 11 months. Twelve subtests classify verbal intelligence and performance intelligence. The WISC-IV is often administered as part of a neuropsychological test battery. For more information, see http://harcourtassessment .com/ HAIWEB/Cultures/en-us/Productdetail.htm?Pid=015-8979-044&Mode=summary.

This is a norm-referenced test designed to measure current arithmetic, word recognition, and spelling skills. Results provide grade equivalents, standard scores, and percentile rankings for an individual. The spelling and arithmetic subtests can be administered individually or in groups. The reading subtest is individually administered. Jastak and Wilkinson (1984) report greater test— retest reliability on the reading and spelling subtests than on the arithmetic subtest. For more information, see www.minddisorders .com/Py-Z/Wide-Range-Achievement-Test.html.

The Woodcock—Johnson Test (2001) is widely used by educators and psychologists. It is individually administered and measures achievement in the areas of reading, mathematics, written language, knowledge, and cognitive abilities in the areas of cognitive factors, oral language, and differential aptitudes. The test is divided into two major parts: achievement and cognitive abilities.

Academic achievement is measured in the following areas: mathematics, written language, knowledge, skills, and reading.

Cognitive factors measured include comprehension—knowledge, long-term retrieval, visual- spatial thinking, auditory processing, fluid reasoning, processing speed, and short-term memory. For additional information, see www.riverpub .com/products/wjIIIComplete/index.html.

Different psychotherapeutic approaches have been used with success with those who have had a catastrophic injury or illness. Often an appropriate mixture of therapeutic approaches is needed to provide the client with the maximum benefit. When completing a life care plan, it will be important to include therapeutic modalities that will address the patient’s changing needs over time, and to allow some flexibility so that the patient may enter and exit therapy as life experiences occur.

¦   Individual therapy allows the person to explore issues of a personal nature in a protected and private manner. The individual will need time and privacy to explore the feelings of loss related to the disability or illness. Having a confidential relationship with one therapist over time will facilitate disclosure and allow the therapist and client to develop individualized approaches to treatment issues. The therapist can help the client deal with personal feel­ings about relationships, manage the fluctuating emotions that emerge, develop plans for behavioral change, troubleshoot potential problem areas, and work on reintegration goals. In many instances, individual therapy can offer the client the opportunity to practice new skills and to bounce ideas off of a caring, neutral party in ways that are potentially less threatening than doing so with a relative or friend.

Individual therapy typically should be requested approximately three times per week during the rehabilitation facility phase. Once the individual is stabilized and participating in outpatient therapies, weekly therapy visits for the first 3 to 6 months are appropriate. Check with the psychologist regarding issues specific to the individual that may require more inten­sive monitoring (e.g., suicidal ideation).

¦     Biofeedback (Basmajian, 1989) is a helpful modality for many clients as well, particularly those dealing with psychophysiological problems such as hypertension, muscle tension dis­orders, pain problems, and stress disorders. Biofeedback techniques help the client learn more about his or her individual responses to stressors and ways that he or she can learn to intervene directly, often without using medications or other medical interventions. Physical and occupational therapists have found biofeedback to be a helpful adjunct in neuromuscu­lar reeducation programs.

When adding biofeedback therapy to the life care plan, request approximately 12 hour- long weekly sessions initially, in order to learn and apply the technique. Follow-up visits can be scheduled every 2 weeks for 2 months, then once a month for 2 months. Check with your biofeedback referral source for recommendations.

¦     Hypnotherapy is a somewhat controversial therapeutic technique that can be helpful for some clients. When practiced by a competent therapist, hypnotic techniques can help a client change behaviors he or she is already willing to change (Hammond, 1990). For example, a person who wishes to quit smoking may find hypnotic suggestions regarding smoking cessation to be very powerful in encouraging abstinence. Hypnosis may also be a helpful stress management technique for some.

¦     Family therapy is an extremely important therapeutic modality. A catastrophic injury or illness has profound effects on family functioning, and these effects need to be dealt with by involving the entire family. Changes in role behavior, role expectations, marital relation­ships, communication pathways, financial status, and family goals will require sensitive sup­port and negotiation (Lezak, 1988). When completing a life care plan, family therapy should be considered when major life transitions are encountered (e.g., a child leaving home, a death in the family, or a major illness diagnosed) by any family member. Family therapy sessions can provide an effective forum for discussing quality-of-life issues, developing living wills and advanced directives, and renegotiating family rules.

¦     Group therapy is helpful for many rehabilitation clients. Group therapy designed specifically for individuals with similar injuries (e.g., spinal cord injuries only) may be beneficial. An important consideration when selecting a group will be the members’ functional communication level rather than functional physical level. Having a mixture of participants who are operating at different stages of adaptation to their disabilities can be helpful in providing newer members with hope and inspiration. A skilled group leader will acknowledge the various stages of adaptation while sensitively encouraging the group to progress to a focus on abilities rather than disabilities, to hope rather than despair.

When completing a life care plan, psychologists will generally include a group therapy modality on a regular basis (some groups meet weekly, others less often) for the first 6 months at least, if the client shows willingness to participate.

¦     Pain management is an important subspecialty area that requires mention. Following catastrophic injury, pain problems are often related to the tissue damage that has occurred. Pain management strategies usually include the use of medications and, hopefully, relaxation techniques (Hanson & Gerber, 1990). As time passes, however, the client will need to reduce his or her reliance on potentially addictive pain medications and to increase independence in managing pain. A pain management specialist can help the client learn

relaxation techniques, cognitive strategies, reactivation steps, and ways of dealing with the psychological components of pain.

If pain continues to be a focus of treatment after physical stabilization has occurred, consider a referral to a pain specialist. Pain is no longer merely a symptom: it has become a problem and needs to be addressed in an intensive manner.

Most life care planners are familiar with the role of the psychologist. The interface between the life care planner and the psychologist can be productive as the life care planner requests long-term care recommendations. However, there are a number of areas that the psychologist and the life care planner should be aware of to reduce the possibility of miscommunication.

Initially, the life care planner should determine if the psychologist involved is a treating psy­chologist or has been retained by one of the attorneys to provide expert testimony or provide an independent medical evaluation. In nearly all cases, the psychologist will be either a treating psy­chologist or a retained expert.

Psychologists often treat individuals with catastrophic injuries, and those clients may become involved in litigation. Therefore, the psychologist may be familiar with the litigation process and should be familiar with requests for records, discovery depositions, and occasionally testifying as a treating psychologist. The psychologist’s office can be expected to have policies and procedures describing how to respond to requests for records and related activities concerning the litigation process.

However, the treating psychologist may not be familiar with the role of life care planners, and an explanation of the life care planning process, along with specific questions, will be helpful. The psychologist may be concerned about your role and why all of these questions are being asked. Perhaps reference to this post would be helpful.

Psychologists are generally oriented toward patient care, and the type of information life care planners solicit is familiar to the psychologist. For example:

¦     What is the client’s diagnosis?

¦     What is the client’s current treatment program?

¦     What is the client’s projected course of treatment?

¦     What is the client’s projected prognosis?

Typically psychologists are comfortable projecting the number of sessions per week or per year and treatment time frame. In addition, they can provide information on charges for psychological services as a part of the life care planning process.

The life care planner communicating with the treating psychologist or retained expert psy­chologist should inquire regarding specific services. The following is an outline that can aid communication between the life care planner and the psychologist:

Projected evaluations (include duration and frequency; consider the effects of aging).Psychotherapy/counseling (consider group, family, and individual sessions). Remember that counseling and psychotherapy are similar and somewhat dependent on the setting. Options may include:

¦     Biofeedback

¦     Counseling regarding sexual dysfunction (e.g., associated with spinal cord or brain injury)

¦     Individual counseling regarding behavioral management

¦     Family counseling for family members’ adjustment

¦     Group counseling

¦     Family consultation (disability education, behavior management)

Psychologist/neuropsychological testing, to include intellectual assessment, academic assessment, interest assessment, personality assessment, and neuropsychological function­ing. Provide approximate ages at which the assessments should occur.Psychological services related to pain management.Personal care attendant for issues related to mental capacity/incapacity.Recommendations related to restrictive/least restrictive environment.Computer hardware/software related to socialization/independence.Case management related to psychological care.Psychiatric hospitalization—inpatient or partial hospitalization.Chemical dependency treatment. Opinions and recommendations relating to vocational outlook (personality, trauma, intel­ligence, etc.).Opinions regarding the person’s pre- vs. postinjury functioning.Referral to other professionals such as psychiatrist for medication.

Psychologists can provide valuable information to the life care planner as the life care report is being developed. However, both life care planner and psychologist should clearly be aware of their roles, boundaries, and limitations.

Once the psychologist has provided the list of recommendations, it is suggested the life care planner type up the recommendations and return them to the psychologist for review and signature. This provides the psychologist the opportunity to review for any areas of miscommunication or omission. The written document also provides documentation of the participation of the professionals involved in the planning process.

In addition, the life care planner may request the psychologist to sign the document listing the recommendations. Having a signed form in the file reduces the potential for a challenge of the life care planner’s testimony being based on hearsay since the recommendations were only provided orally and not in a written form. The courts typically allow life care planners significant leeway regarding hearsay. Life care planners solicit oral recommendations from health care members in the normal course of their business. However, due to the potential for an error in communication, and the extent to which that error may affect the admissibility of testimony in forensic cases (and the rare occasion where the psychologist may change his or her opinion), the life care planner is well advised to at least request the psychologist to review and sign the list of recommendations.

The primary national association for psychologists is the American Psychological Association (APA) (www.apa .org). Based in Washington, DC, the APA is a scientific and professional orga­nization that represents psychology in the United States. With more than 155,000 members, the APA is the largest association of psychologists worldwide. The 2002 APA Ethics Code was published in the December 2002 issue of the American Psychologist. Electronic copies of the ethics code are available at www.apa .org/ethics/.

Did the psychologist provide a diagnosis?Does the report contain information about the person’s ability to function in everyday life (e.g., in a job, in his or her own behalf, under stress, etc.)?Is the client competent, or should he or she have a guardian for contracts, finances, and judgment? Or a personal care attendant?• What is the difference in the person’s functioning ability pre- vs. postincident (if an injury)?• Should the client be referred to another professional for treatment or evaluation (e.g., psychiatrist for medication, biofeedback for pain, etc.)?• What effects does the person’s psychological functioning have on his or her vocational potential?• What is the specific treatment plan? (Include frequency, duration, and expected costs. For example, individual treatment for 1 time/week for 6 months at $100/week and then group treatment for 36 months, 48 weeks/year at $40/session.)• Are there recommendations that are family related (such as therapy, consultation, or education for parents and siblings)?Did the psychologist offer an opinion with regard to global assessment of functioning (GAF)?

For various reasons, some licensed psychologists have chosen to not join the APA. However, most state licensing laws for psychologists incorporate the APA Ethics Code into the licensing law. Therefore, even though a psychologist may not be a member of the APA, he or she is very likely held to the ethical code of the APA based on the specific stature of the state in which the psycholo­gist is licensed.

Psychologists are licensed to practice at the state level, not the national level. Each state has a unique license law that describes the practice of psychology in that particular state.

The “Specialty Guidelines for Forensic Psychologists” (1991) represent a joint statement of the American Psychology—Law Society and Division 41 of the APA. In addition, the guidelines have been endorsed by a majority vote of the American Academy of Forensic Psychology. The guidelines do not represent an official statement of the APA. They provide assistance to psychologists and others who are interested in the process psychologists will follow when they are involved in a litigation event or retained as an expert witness.

A copy of the “Specialty Guidelines for Forensic Psychologists” may be obtained from www. ap-ls.org/links/currentforensicguidelines.pdf.

Since 1975, the federal government has played an important role in ensuring that children with disabilities receive the best possible education through the Individuals with Disabilities Education

Act (IDEA). Reforms in the No Child Left Behind Act made fundamental improvements in elementary and secondary education to enhance the education of children with disabilities by sup­porting accountability for results, expanded parental choice, a focus on what works, and increased local flexibility.

The life care planner who is developing a pediatric plan should endeavor to contact the school psychologist as a part of the information-gathering process. In many injury cases, school testing may also provide the foundation for preinjury functioning.

The patient is a 28-year-old female that is 30 months postinjury. She had significant physical inju­ries, including injury to her brain, in a motor vehicle accident. She has deficits in organizational skills. She tires easily. Neuropsychological testing reveals significant impairment in the ability to maintain attention and concentration. Problem-solving ability is impaired. She is clinically depressed. Memory impairments are present. Short-term and long-term memories are impaired. Auditory and visual memories are also impaired. In addition, she has impaired receptive language and chronic pain.

The life care planner completed a phone conference with the patient’s treating psychologist, Dr. Mary Smith. Following the phone conference, Dr. Smith’s recommendations were typed and sent to her for review and signature. A sample summary with request for confirmation is in the following.

Recommendations/information from Dr. Mary Smith, psychologist, on April 23, 2008, regarding Ms. Susan Jones:

Diagnosis

Acquired brain injury, PTSD, impaired mobility, impaired memory, and chronic pain.

Psychological Evaluation

Annual psychological evaluations for 4 years, then PRN.

Neuropsychological exam, one per year for next 3 years, then PRN.

Counseling and Psychological Services

Counseling two times a week for 1 hour each session for next 3 years, then one session per week for 4 years. She should continue to receive counseling and psychological services because of her ongoing medical and psychological problems. She will need counseling regarding her self-concept and relationship issues.

She will need pain management services and cognitive retraining services. If pain continues, additional psychological services of 20 sessions (1 hour per session) per year are recom­mended until pain levels abate.

Counseling for Family

Support services and counseling for family for next 2 years. Approximately 50 counseling hours per year.

Implications for Current and Future Adjustment to Disability

She will need assistance with day-to-day problem solving and planning. I am unable to pro­vide a specific number of hours per day for attendant care, but she may need an attendant 24 hours per day due to cognitive deficits, safety issues, and poor judgment.

Case Management Services

She will need a case manager 4 hours per month to coordinate services.

Specialized Services

She will need a vocational assessment to determine if she can return to work (which is unlikely) and to assist with avocational activities.

This post has reviewed the ways in which a trained, experienced rehabilitation psychologist can participate as a member of the rehabilitation team. In rehabilitation, much attention is given to the preservation and restoration of functioning. Psychological issues can color the work of reha­bilitation in subtle and obvious ways and should be carefully considered when planning for the client’s care.

It is also important to remember that the relationship a psychologist establishes with a client can continue for many years following the catastrophic injury or diagnosis of illness. As a life care planning professional, you can ensure that your client receives the emotional and behavioral sup­port needed to achieve goals of functional independence.

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