Psychosocial care should be regarded as core business for all front-line staff that are involved in SCI care, including medical and nursing staff, physiotherapists, occupational therapists and other allied health professionals, and not just the domain of those in the team with specialized training in managing psychosocial and mental health disorders. The Guide incorporates a number of models [29
] that have the capacity to improve the psychosocial rehabilitation of people with SCI. In particular, the clinical recommendations were influenced by the premises of the Biopsychosocial Model [29
], acknowledging that people with SCI, in addition to the physical challenges, have experienced psychological and social changes requiring substantial adjustment. The Guide also recognized the value of other models in shaping SCI psychosocial rehabilitation, such as the Stress Appraisal Model [36
], which suggests that adjustment and coping depend upon a person’s stress and health status, believed to be a product of how people perceive their ability to cope with life stressors, and the Transtheoretical Readiness to Change Model [37
], proposing that the ability to change depends upon the person’s psychological readiness to change.
The Guide also discussed the important contribution to psychosocial rehabilitation of several service design models. These included peer support models that encourage the use of peers as role models, mentors and for sources of support [35
]. Best evidence research into self-help and consumer initiatives consistently shows that participation by consumers is associated with reduced hospitalization, reduced use of other services, increased knowledge, information and coping skills, increased self-esteem, confidence, sense of well-being and of being in control, and stronger social networks and supports [34
]. An additional service model included the Stoke Mandeville Key-worker Goal Planning Model [33
], which places emphasis on the importance of comprehensive assessment and analysis of the SCI person’s needs, including a broad range of activities of daily living and psychosocial status, followed by specific goal planning. Breaking down goals into small practical and achievable steps with active patient involvement is central to this approach. The model contends that the role of a designated key-worker is crucial to the effectiveness of rehabilitation provision and improvement of outcomes in people with SCI.
The outlined recommendations concerning the psychosocial care of people with SCI are currently being implemented in the SCI units and outreach services in Sydney, NSW, Australia, with the goal of improving and standardizing care. Regular review of implementation is being conducted by an ongoing steering committee made up of stake holders and health professionals. There are, however, some implications and challenges that need to be considered in relation to scope of practice, selection of staff and continuing professional development for existing staff in order that staff in SCI rehabilitation services would be able to implement these recommendations. A tiered approach to provision of services is required. The demands placed upon the individual following acquisition of a SCI means that training in general self-management strategies is regarded as a core requirement for effective rehabilitation. However, it is recognized that there are also those who are clearly at risk of a poor outcome and so may need more intensive intervention, or who may be experiencing co-morbid psychological disorders that require specialist treatment.
Further investigation is required into what constitutes sensitive routine psychosocial assessment during the inpatient phase (acute and rehabilitation phases, and after discharge) that can be used to predict rehabilitation outcomes. Screening assessments must also be economical in terms of time and cost. An additional challenge involves the development of the psychosocial treatment programs recommended in the Guide with demonstration of their efficacy (in terms of improving adjustment outcomes). The intervention has been recommended to be multilayered in the sense that while all inpatients with SCI will receive a CBT program, different CBT programs will be recommended for people with SCI who present with various psychosocial risks. For instance, people with SCI who have been assessed as having a low risk of co-morbidities (such as major depressive disorder, cognitive deficits, substance dependency, and so on) will receive low intensity CBT intervention. However, inpatients with SCI assessed as at increased risk will receive specialized CBT packages designed to address the identified risk.
Finally, it is difficult enough to provide well integrated biopsychosocial care within an inpatient rehabilitation setting, but this becomes far more challenging after discharge into community. Individuals with SCI should be able to access mainstream psychosocial services, particularly where these are highly specialized (such as drug and alcohol, pain management, mental health and traumatic brain injury services). However, there are many physical and environmental barriers to the use of such services, as well as the lack of knowledge and skills of those professionals within such services in relation to SCI. This highlights that in the future for continuity of care and the ongoing provision of psychosocial support of individuals with SCI for adjustment and their families an important strategy for implementing the recommendations in the Guide will be to focus on how to support existing services in increasing access for those with SCI and staff in acquiring appropriate knowledge and skills. This will need to include providing support to individual psychosocial health professionals working in general services or in private practice in rural and remote areas to enhance access to interventions that would otherwise be inaccessible.
Dissemination of these guidelines has been achieved through publication of the recommendations and guidelines [15
] which are freely available at: http://www.aci.health.nsw.gov.au/networks/spinal-cord-injury/resources. Further dissemination is occurring through seminars, conferences and publication of papers. It is hoped that this paper will provide the basis for further discussion and be a catalyst for collaboration amongst SCI rehabilitation providers in relation to service design and delivery of psychosocial rehabilitation for people with SCI, ultimately leading to improved outcomes of care with a greater chance of individuals experiencing good quality of life after SCI. Acknowledgments
The Guide [15
] was written by Professor Ashley Craig and Associate Professor Kathryn Nicholson Perry, in association with Associate Professor James Middleton, Director of the NSW State SCI Service, and its Psychosocial Strategy Steering Committee. The contribution of the members of the Steering Committee is acknowledged: James Middleton (Chair), David Andrews, Tullio Cittarelli, Ashley Craig, Jackie Francis, Tonina Harvey, Neil MacKinnon, Frances Monypenny, Kathryn Nicholson Perry, Margaret Noonan, Helen Oosthuizen, Michelina Pelosi, Anna Satharasinghe, Catherine Shorland, Luisa Silva, Jill Stevenson, Catherine Tulinski and Kylie Wicks. Contributions to the project were also made by those attending the NSW State Spinal Cord Injury Services Psychosocial Strategy Forum on the 6th
December 2006, and by those attending related workshops at the ANZ Spinal Cord Society Conference held in Sydney in 2007. This project was supported by NSW State Spinal Cord Injury Service through the Greater Metropolitan Clinical Taskforce (GMCT) and more recently by the Agency for Clinical Innovation, which is sincerely acknowledged and appreciated. The contribution of Professor Paul Kennedy from Stoke Mandeville and Oxford University to the early development of the Guide is also acknowledged.