How ICRP began...

Rehabilitation is a team effort, much like psychiatric treatment. Originally, I was trained as a clinical psychologist and worked inpatient residential and intensive outpatient care in addition to weekly psychotherapy. Inpatient psychiatric teams rely on frequent and focused communication to routinely and emergently adjust treatment goals to maximize skills and identity development while managing the intense emotional laden relationships between staff and patients and how that manifests in the relationships between staff. In my clinical training there was no discussion or training on managing brain injury and rehabilitation.

Learning about rehabilitation from wise and caring rehabilitation therapists while developing a knowledge base to adapt and expand my clinical skills was an extraordinary gift. The children with brain injury and their families taught me about the value of love, hope, and faith through the process of dealing with tragedy and trauma. Dr. Linda Laatsch was so very kind and generous in teaching me the developmental metacognitive approach that she developed.

Rehabilitation teams rely on focused communication to routinely and emergently adjust treatment goals to maximize skills and identify development. The main difference between psychiatric and rehabilitation inpatient care is the active involvement in therapy of the family in rehabilitation. From my perspective, I was surprised by the intensity of emotion that was part of the process of rehabilitation and the limited processing by the team on how they and the family were managing the trauma. Finding ways to manage the emotional process within the team was something I was familiar with. Applying those lessons to inpatient rehabilitation required a multilevel approach that met with mixed success.

Transitioning teenagers from inpatient to outpatient rehabilitation brought on the challenge of re-integration into the community. Typically, teenagers in rehabilitation, as well as inpatient psychiatric care, have been removed from any pre-injury drug or alcohol use while inpatient. Re-entry into the community brings on a new set of challenges. Inpatient psychiatric care focuses on the development of coping skills that are relevant to avoiding substance use post discharge and appropriately flows to outpatient work. For teenagers who use substances rehabilitation becomes more complicated and the outcome can be potentially damaging and fatal.

The focus in inpatient rehabilitation is on recovery of physical and cognitive skills while treating any acute or chronic medical issues. Treatment of addiction varies depending on the substance used. It is difficult to fully address substance use issues in the busy and emotionally charged process of rehabilitation but some basic skills and psychoeducation can be addressed. The adolescent and their family are primarily focused on the labor in and emotionally intensive experience of recovery of the physical and cognitive skills, including the all-important return to age appropriate autonomy. The psychologist’s clinical training on skills to assess and treat mood and substance use complement the rehabilitation goals. Rehabilitation training provides skills to integrate the mood and substance use issues with the physical, cognitive, emotional, and social skills.

In my experience substance use created a quandary post discharge from acute care and into outpatient treatment. Seeking traditional care for substance use seemed appropriate for the team but the reality was traditional care did not accommodate for cognitive issues. Over time the use of traditional psychotherapy for the emotional issues related to recovery proved difficult due to the lack of accommodations and adaptation to the cognitive and physical issues. Limitations of availability of services for co-occurring issues required innovation in accommodating treatment. Providing several types of therapy simultaneously made sense. Developing ways to integrate care of cognitive, psychosocial, and substance use issues allowed for continuity of care while maintaining a therapeutic alliance over the long-term.

Teaching professionals the range of interventions that can be applied across different domains of care provides support to integrate various domains of care into a holistic model without confusing the person living with brain injury, interrupting treatment over time, or overwhelming them through the time demands of going to several therapists in one week, and most likely the lack of integration of skills taught across domains. In addition, training helps professionals learn to be comfortable with providing three types of therapy simultaneously while tracking and modifying goals and objectives over stages of recovery.

Mark Pedrotty, PhD