What indicates the need for psychotherapy after a spinal cord injury?

When I’m working with people who have spinal cord injuries, there might be a couple of things that come up that tell me they benefit from having therapy. One of those things might be depression. The way depression is commonly seen is what’s called “anhedonia,” a decreased interest in things that are important to you. If I find that a person isn’t as interested in things they would typically care about and that they're withdrawing; that to me is a pretty good indication that it’s time to meet with them and talk about what’s going on. That’s something again that’s very normal in different phases of spinal cord injury and that is not indicative of diagnosis, it is a point for discussion to see how they’re doing. Anxiety is also something that may be common, and if I see anxiety, it might be in the rehab therapies. What I’ll do is ask if the patient wants to discuss what’s going on in rehab that is challenging, ask if it’s okay if we can bring in a couple of their other providers so we can troubleshoot what’s going on in rehab. Often times it’s that fear of movement, sometimes people feel very fragile after a spinal cord injury or surgery—this may be fear of falling or hurting themselves. It could be something as basic as providing education, or there might be some very visual reminders of the injury in therapy that can be anxiety provoking, and so addressing that from more of an existential approach or meaning—what this means for my full life and who I am.

Either when somebody has symptoms of suffering that they want to be helped with,  or when people are not functioning well—if they’re not getting along with their family, if they’re not getting back into life whether it’s work, or school, or volunteering, or parenting or some kind of useful purpose. When people are having a hard time getting along with staff, not collaborating with their treatment team, those are all indications that psychotherapy might be helpful. Also, people that are having a lot of difficulty with pain and other physical adaptations with sexuality, psychotherapy can be very helpful.

Well there are some factors—if you’re suicidal, if you feel that you can’t get out of bed, if you feel you’re just going to give up, that would be a time to speak with someone. Now there are different types of psychotherapy, and sometimes I want to make sure that I have the right approach. And I don’t think you, in my opinion, feel you should have a canned approach to fit everyone, there’s too much diversity out there. So when you feel depressed, there are some people who say, “I feel depressed," and then I’m like, “Yeah, I understand that.” It doesn’t necessarily mean you need psychotherapy; that’s getting in touch with the reality of the situation. I would worry about a person who had a spinal cord injury and said, “This is something that I look forward to, I’m doing ok.” Now I have met one or two people who’ve said something like that and we talk about it. One person said, “This is not the worst thing that happened to me.” I think people get that and that you have to keep that in mind. Horrible things sometimes people have come through, and so you can’t look at someone and project your feelings onto the situation.

When the sadness continues beyond the first few weeks of rehab, maybe even after the first few days of rehab, we do psychotherapy throughout the inpatient rehabilitation stay. And if the depression, and anxiety and anger continue to persist as they get ready leave the community, then we try to get them to do psychotherapy out in the community. But we also always keep the door open to let them know that if they run into any of these challenges, whether it be anger, depression, anxiety, fears after they’re in the community, they can always feel comfortable coming back to see a psychologist, a therapist and sort of work on those issues.

If you feel stuck, if things aren’t working. If you feel like you just need it to be about you for awhile, and you need to think through and process, and get your handle on what’s going on, and wrap our brain around, “What is going on now and how do I move forward?” psychotherapy can provide an opportunity to do that. It doesn’t have to be about a major depression, it doesn’t have to be about drinking yourself into a coma. What it is about is the opportunity to say “How do I make adjustments?” And, “How can someone else looking from the outside help me fine-tune or recognize the strength I have to move forward.”

Certainly if we are finding factors related to depression or high anxiety. Those factors are interfering with the individual’s ability to go forward whether it’s to participate in rehab or to participate in life. If the individual is more isolated, not involved in life activities, not getting out and doing things, then we may want to talk about that. It’s best to do it sooner, a person shouldn’t have to be desperate before they get some help. It’s okay to ask for it any time if nothing else to confirm or affirm what they’re thinking of. So I would certainly want them to reach out and have it if they just have some questions or want some affirmation, but also if they’re finding whatever they’re struggling with is interfering with their ability to participate in life activities. A lot of folks haven’t had a lot of contact with a psychologist and they’re a little anxious about what that means. So getting past that barrier and understanding what it may offer to the individual, and realizing that it’s a relationship, a place where you can talk about a lot of things, can be very helpful.

Some of the risk factors for me for true psychotherapy would be substance abuse, risk factors in terms of noncompliance, not doing weight shifts in ways that keep people safe. So risky behaviors, getting skin sores, and smoking which cuts down vascular supply and oxygenation, which render people not healing. Those things are warning signs for me.

Everybody’s who’s got a spinal cord injury is seen by a psychologist. Not because they’re depressed, or they’re anxious or they’re crazy. As I tell my patients often times when I first come to see them, “I’m not here because someone thought you were crazy, I’m here because dealing with something like a spinal cord injury is a physical, emotional, spiritual and psychological journey, and I’m here to help you figure out how we’re going to manage the shoulders-up piece of this.” I follow people throughout their inpatient stay, and we make a decision together by the time they're getting close to discharge about whether ongoing counseling is going to be needed. Or whether we’re going to play it by ear and they’re going to get in touch as they need it, or as they feel things come up that they’d like to talk about.