NeuroRehabilitation 46 (2020) 195–204 195

DOI:10.3233/NRE-192970
IOS Press

The role of rehabilitation psychology

in stroke care described through case
examples
Robert Pernaa,∗ and Lindsey Harikb
a Pate Rehabilitation, Anna, Texas, USA
b TIRR Memorial Hermann, Houston, Texas, USA

Abstract.
BACKGROUND: A stroke event, sometimes referred to as a cerebrovascular accident (CVA), is a sudden and often traumatic
life event that results in life-changing consequences with which affected people must cope. There are nearly 800,000 instances
of stroke annually in the U.S. (American Heart Association, 2018). Stroke is the leading cause of disability in adults, and
more than one-third of people who survive a stroke will have severe disability in the U.S. (Mayo, 2005). Between 35% and
75% of stroke survivors will have significant cognitive impairment (Tatemichi et al., 1994; Nys et al., 2007). An estimated
one-third of people suffer depression after stroke (Hackett et al., 2005), about one-fourth experience significant anxiety
(Barker-Collo, 2007), and about one-fifth suffer from insomnia (Leppavuoria et al., 2002). These and other stroke-related
psychological issues negatively influence rehabilitation and outcomes through a variety of mechanisms. For example, post-
stroke depression has been shown to be related to more negative functional consequences (Kneebone et al., 2000; Matsuzaki
et al., 2015). Psychological disturbances may affect rehabilitation outcomes through a reduction in adherence to home exercise
programs, reduced energy level, increased fatigue, reduced frustration tolerance, and potentially less motivation and hope
about the future.
OBJECTIVES: This manuscript aims to identify and describe the role of rehabilitation psychology in treating these common
post-stroke complaints and, ultimately, optimizing post-stroke outcomes via two case examples.
METHODOLOGY: This manuscript describes two cases of individuals in post-acute rehabilitation who had psychological
issues which were negatively affecting outcomes.
CONCLUSION: Given the abrupt and significant life-changing nature of stroke, it is often necessary to manage a diverse
array of psychological issues that often cannot be simply managed via psychotropic medications. Moreover, an understanding
of the patients’ emotional adjustment and issues can help them maximize their rehabilitation, recovery, and community
integration. For the cases discussed, psychology consultations were central in helping optimize their rehabilitation and
functional outcomes.

Keywords: Stroke/CVA, rehabilitation psychology, post-stroke depression, interdisciplinary rehabilitation

1. Introduction stroke event, stroke survivors often experience grief

and loss associated with their functional decline. The
Stroke survivors and their loved ones may expe- abrupt decrease in functioning, and the loss of physi-
rience a stroke event and resultant deficits as cal functioning and control over their situation leaves
psychological trauma. Although they have survived a many survivors and their families struggling to cope.
Stroke survivors are at an increased risk of developing
∗ Address for correspondence: Robert Perna, Pate Rehabilita- post-stroke depression, anxiety, and other psycho-
tion, 3325 Pate Way, Anna, Texas 75409, USA. E-mail: rperna@ logical challenges. Due to the intertwined etiology
paterehab.com. of psychological symptoms experienced following

ISSN 1053-8135/20/$35.00 © 2020 – IOS Press and the authors. All rights reserved
196 R. Perna and L. Harik / The role of rehabilitation psychology in stroke care

stroke (i.e., medical, medication side effects, emo- (Hackett et al., 2005; Paolucia 2008). This percent-
tional reaction/ coping, isolation), the role of mental age of post stroke depression is a remarkably high
health professionals is critical to providing compre- incidence, especially given that many if not most indi-
hensive post-stroke rehabilitation. Moreover, many viduals are put on SSRIs prophylactically since the
of the issues that warrant treatment are not simply FLAME study showed a potential benefit to motor
treated via psychotropic medications. recovery from antidepressants. When treating indi-
viduals with PSD, it is important to understand the
diverse and profound implications of this disorder
1.1. Psychological and psychosocial sequelae of fully. PSD is associated with an increased disability
stroke (Herrmann et al. 1998; Ramasubbu et al. 1998; Kotila
et al. 1999; Pohjasvaara et al. 2001), increased cog-
A stroke sometimes referred to as a cerebrovascu- nitive impairment (Kauhanen et al 1999), increased
lar accident (CVA), is a sudden and often traumatic mortality, both on short and long term (Morris et al
major life event and often results in life-changing 1993; Schulz et al 2000; House et al 2001; Williams
consequences with which affected people must cope. et al 2004), increased risk of falls (Jorgensen et al
There are nearly 800,000 instances of stroke annu- 2002) and, worse rehabilitation outcome (Sinyor et al
ally in the U.S. (American Heart Association, 2018). 1986; Paolucci et al 1999, 2001).
Stroke is the leading cause of disability in adults,
and more than one-third of people who survive a 1.2. Post stroke depression
stroke will have severe impairment in the U.S. (Mayo,
2005). Depression is the most common psychiatric syn-
An estimated one-third of people suffer depression drome following a stroke, affecting nearly one-third
after stroke (Hackett et al., 2005), about one-fourth of all stroke survivors (Hackett et al., 2005). This
suffer significant anxiety (Barker-Collo, 2007), and rate increases to approximately 50% for survivors
about one-fifth suffer from insomnia (Leppavuoria of left-sided CVA (Dubovsky & Dubovsky, 2010).
et al., 2002). Although they have survived the stroke Depression is a significant complication of stroke
event, individuals often experience grief and loss akin that may impede rehabilitation, recovery, quality of
to the death of a loved one. Stroke survivors and life, and caregiver health (Sinyor, 1986; Robinson
their loved ones must cope with an event they never et al., 1986; Anderson et al., 1995). Furthermore,
expected to happen and the need to grieve a multi- stroke-associated depression may reduce survival and
tude of never expected losses. The abrupt decline in increase the risks of recurrent vascular events (House
functioning, loss of physical functioning and control, et al., 2001; Morris et al., 1993).
decreased activity level and independence, as well Given the staggering rates of PSD and the adverse
as an unclear prognosis, leave many people unable relation of PSD and functional outcomes (Robinson
to cope with their situation. Essentially, post-stroke & Jorge, 2016), there has been considerable research
psychological issues are highly diverse and can have on the mechanism and treatment of post-stroke
a potential impact on everything from treatment par- depression (PSD). The neurological mechanism
ticipation to community integration and self-identity. of PSD is believed to be multifactorial includ-
Quality of life (Kim et al., 1996; King et al., 1996) ing lesion location, alterations in neurotransmitter
has been shown to significantly decline following a functioning, neuroinflammation, overactivation of
stroke. This decline in quality of life is thought to the hypothalamic-pituitary-adrenal (HPA) axis, and
occur because people often no longer engage in or altered brain metabolism (Villa, Ferrari, & Moretti,
will experience an altered engagement in, many of 2018). Additionally, psychological adjustment to dis-
the activities that previously brought them enjoy- ability, lack of access to normal coping skills, pain,
ment and life meaning. Moreover, many of these immobility, financial strain, and a host of never-
former activities served as a means of enjoyment or before-experienced challenges also contribute to the
emotional coping (e.g., physical exercise, meeting experience of low mood following CVA.
with friends for coffee). Regarding the treatment of PSD, pharmacologi-
Grief over losses, anxiety, and certainly depres- cal treatment includes the use of SSRIs, TCAs, and
sion. There has been considerable research on stimulants. ECT and other procedures are garnering
post-stroke depression (PSD). Several studies and support in the literature as well for treatment of
meta-analyses suggest about a 33% PSD prevalence PSD (Robinson & Spalletta, 2010). When treating
 R. Perna and L. Harik / The role of rehabilitation psychology in stroke care 197

individuals with PSD, it is important to understand 1.4. Common cognitive sequelae related to stroke
the diverse and profound implications of this disor-
der fully. PSD not only negatively affects treatment Besides a diverse range of psychological issues,
but has the potential to affect essentially all aspects most stroke patients will experience cognitive impair-
of one’s life negatively. PSD is associated with an ments. A study found that approximately 83% of
increased disability (Herrmann et al., 1998; Rama- people had cognitive impairments in one domain and
subbu, et al. 1998; Kotila et al, 1999; Pohjasvaara 50% had cognitive impairments in multiple domains
et al, 2001), increased cognitive impairment (Kauha- of cognitive functioning at three months post stroke
nen et al 1999), increased mortality, both on short (Jokinen et al., 2015). Though various rehabilitation
and long term (Morris et al 1993; Schulz et al 2000; disciplines may work on these issues, rehabilitation
House et al 2001; Williams et al 2004), increased psychology is often centrally involved in helping
risk of falls (Jorgensen et al 2002) and, worse reha- these people gain awareness of these issues, develop
bilitation outcome (Sinyor et al, 1986; Paolucci et al, insight, and follow through on appropriate exercise
2001). Due to the well-established negative relation to improve these impairments. Several organizations
of post-stroke depression and functional outcomes, have suggested that the inclusion of these disci-
rehabilitation neuropsychologists play an essential plines in stroke care should be the standard. The
role in identifying and assessing symptoms related evidence-based National Institute for Health and Care
to PSD to assist in treatment planning in the near and Excellence (NICE) quality standards exist for stroke
long-term. (NIH, 2010) and suggest the psychology is a core
component of appropriate stroke care.
1.3. Post-stroke anxiety (PSA) Between 35% and 75% of stroke survivors will
have significant cognitive impairment (Tatemichi
In contrast to PSD that has been well-studied, et al., 1994; Nys et al., 2007). Approximately 65 per-
post-stroke anxiety (PSA) is less well understood. cent of stroke survivors present with residual cogni-
Available research suggests between 20–25% of tive deficits that can include difficulty with attention,
stroke survivors experience PSA. PSD does not sequencing, memory, problem-solving (Hoffmann,
better explain those symptoms. PSA can manifest Bennett, Koh, & McKenna, 2010), and hemi-
many ways including: fear of putting weight on inattention. It is widely acknowledged that cognitive
the affected extremity (affecting physical therapy), problems caused by stroke are strongly associated
fear (and muscle tensing and avoidance) of the with later daily life disability such as limitations to
pain caused by passive stretching of affected upper community and social participation (Brown et al.,
extremity (affecting occupation therapy outcomes), 2013; Wagle et al., 2011). Even mild or minor strokes
worry about persistent hemiparesis, worry about how are associated with disabling memory, spatial, and
one will be perceived by friends and extended family, mood disorders that, due to their “invisible” nature,
and being self-conscious about adaptive devices. The may be overlooked or minimized (Blum et al., 2012).
mechanism of PSA is less clearly explained in the Moderate to severe strokes have been shown to cause
available literature, but there is evidence to suggest not only the cognitive impairments but also executive
that pre-stroke anxiety may predict PSA at higher system dysfunction in approximately 40% of individ-
rates than in the case of pre-stroke depression and uals (Soros et al., 2010; Blum et al., 2012). These
PSD where the relationship is less clear (Schottke deficits are associated with increased functional dis-
& Giabbiconi, 2015). Other identified predictors of ability, such as limitations in community and social
PSA include age under 65, female gender, inability participation (Brown et al., 2013; Wagle et al., 2011).
to work, depression treatment, smoking, and stroke There is evidence to suggest that the incidence of
severity up to ten years post-stroke. In keeping with dementia and cognitive decline in stroke survivors
the research around PSD and outcomes, PSA at three is generally underestimated (Pendlebury et al.,
months has been shown to predict the quality of life 2010; Bour et al., 2010). Interestingly, in different
at ten-year follow-up (Ayerbe, Ayis, Crichton, Wolfe, studies, the dementia ratio within three months
& Rudd, 2014). In a recent German sample, PSD and after stroke varies from 6% to 27% (Zhou, 2004;
PSA were significantly positively correlated, suggest- Madureira et al. 2001). Contrasting findings are
ing that there is still research needed to disentangle likely secondary to both sample-specific findings
these disorders as well as further clarification of the and differential application of diagnostic criteria for
mechanism for PSA (Schottke & Giabbiconi, 2015). dementia. Moreover, another complicating factor is
198 R. Perna and L. Harik / The role of rehabilitation psychology in stroke care

that someone may meet MNCD diagnostic criteria and calendar/planner use), practice writing checks,
early post-stroke and subsequently recover to the or typing an email may be ways to work on sustained
point of no longer meeting criteria. and visual attention and following directions.
Awareness is defined as the “ability to recognize
1.5. Treatment of cognitive sequelae and the problems caused by impaired brain function”
awareness/insight (Dirette, 2002, p. 861). Awareness and insight into
one’s capabilities and deficits play a critical role in
There is substantial evidence to support inter- learning to compensate for deficits in complex cog-
ventions for various cognitive domains (attention, nitive processes such as planning, problem-solving,
memory, social communication skills, executive and cognitive flexibility, which are required in many
function), and for comprehensive-holistic neuropsy- daily occupations and functional tasks (Mateer &
chologic rehabilitation after TBI. Evidence supports Sira, 2006). Some research suggests a significant
visuospatial rehabilitation after right hemisphere relationship between limited self-awareness and
stroke, and interventions for aphasia and apraxia after negative outcomes regarding community integration
left hemisphere stroke (Cicerone et al., 2011). Given and return to work (Sherer et al., 1998; Sherer et al.,
the high prevalence of cognitive impairments after 2003). In order to understand the complexity of
stroke it is essential for rehabilitation psychologists self-awareness, Crosson et al. (1989) developed a
to understand these issues and have ideas about how model to explain it by separating awareness into three
to help promote awareness and insight into them. It is parts: intellectual awareness is the understanding
common for stroke survivors to experience cognitive that there is an impairment, emergent awareness
and/or perceptual deficits that negatively impact their is the ability to recognize difficulty at the moment
participation in meaningful tasks and occupations it is occurring, and anticipatory awareness is the
(Bowen, Knapp, Gillespie, Nicolson, & Vail, 2011). skill of expecting a difficulty before it happens. All
However, often the most salient symptoms to stroke three types of awareness can be compromised after
survivors in early phases of recovery are physical a CVA (Bruce & Borg, 2002). Limited knowledge of
impairments such as paresis and ataxia. These deficits, especially cognitive and perceptual deficits,
deficits often become a preoccupation, especially is a common impairment after CVA (Ekstam et al.,
in the context of hemiplegia and hemiparesis. As 2007), and it can affect the work of each discipline
a result, it can sometimes be difficult to get these and rehabilitation outcomes. How limited awareness
patients to focus on cognitive impairments, which is managed needs to be individualized based on an
they may perceive as inconsequential compared to understanding of the patient’s psychology. Clinician
their physical issues. Empirical research consistently feedback, daily self-ratings, peer ratings, and other
shows the frequency of unawareness for motor and forms of feedback can all contribute to improved
sensory deficits is low as compared to an unaware- awareness. Gentle constructive feedback coupled
ness of cognitive deficits (Maeir et al., 2002). In this with the recognition of progress or reasonable effort
context, it can be challenging to cultivate full patient may help cultivate insight and motivation. However,
buy-in for this potentially frustrating work. Because feedback regarding impairments should be in small
these individuals may be receiving assistance with doses and always with an understanding of the
diverse cognitive tasks and have not yet resumed person’s current level of awareness.
work or driving where cognitive deficits are revealed
(coupled with frank anosagnosia), the cognitive 1.6. Interventions for short-term memory
issues are sometimes difficult or impossible to appre-
ciate. Moreover, once the clinician begins working Short-term memory is commonly affected after
on these issues, the cognitive exercises used often do stroke, particularly after left middle cerebral artery
not appear related to real-life tasks. For this reason, strokes. As a result, post-acute treatment of strokes
it is often necessary, and perhaps represents best often involves working on memory restoration and
practices, to do some initial and ongoing education compensatory skills. Consistent and efficient use of
about cognitive rehabilitation and make sure part of compensatory strategies usually requires several clin-
each session either involves talking about real-life icians all cueing the patient and reinforcing the use
functional tasks or involves working on aspects of of these strategies.
these tasks. For example, having someone practice Though the empirical research on memory reha-
using their Smartphone (for calls, texts, alarm setting, bilitation is mixed and suggests that people with
 R. Perna and L. Harik / The role of rehabilitation psychology in stroke care 199

the greatest need for memory rehabilitation (those post-stroke paralysis and improved motor recovery.
with severe memory impairments and those who Vallar et al. (1997) had two patients with left-sided
have comorbid executive impairments along with the weakness and spatial neglect after right brain stroke
memory impairments) may get the least benefit from view dots moving 45 degrees/second leftward. These
most strategies, nevertheless, everyone needs some optokinetic stimuli induce an illusory sensation of
way to keep track of things in their life. There is body movement, previously demonstrated to reduce
some evidence supporting aspects of cognitive reha- left spatial neglect, via asymmetric vestibular-spatial
bilitation for short-term memory though outcomes stimulation. The investigators showed that during the
don’t always match between objective and subjective period the patients with left neglect viewed optoki-
measures (Das Nair et al., 2016) and it is not clear netic stimuli, grip strength in the left, paretic hand
which strategies will be most efficient for the patient. improved; there was no change in left grip strength
Rehabilitation psychologists, along with their speech with a control stimulus.
and occupational therapy colleagues, often use vari-
ous internal memory strategies including chunking,
semantic elaboration, rhymes, acronyms, imagery, 1.8. Role of rehabilitation psychology and
and method of loci (Pino et al., 2015). neuropsychology in stroke rehabilitation

Stroke rehabilitation is best performed through

1.7. Interventions to compensate for visual field Transdisciplinary/Interdisciplinary treatment. Psy-
loss and inefficient visual scanning chologists work collaboratively alongside therapy,
nursing, medical, and other staff members as a part
Visuoperceptual impairments such as hemispatial of a specialized treatment team. Some clinical mod-
inattention/neglect not only have significant func- els prescribe rehabilitation neuro/psychologists as
tional implications but also negatively affect physical consultants/liaisons as needed to address specific
recovery and rehabilitation. Inattention to the affected questions (e.g., competency for decision-making,
side and limbs can reduce the recovery potential of neurobehavioral challenges), but a more ideal role
those limbs (Barrett et al., 2014). As such, interven- is to have these professionals integrated into the team
tions that include scanning and attending to stimuli on with other disciplines to help ensure holistic case con-
the neglected side are doubly important. Not uncom- ceptualization and care, to help provide brain injury
monly these exercises can also be used to promote education to the patient and family, to help cultivate
insight (e.g., when a patient or client is shown their the team messages regarding prognosis and recovery,
previous clock drawing and can appreciate omissions and also to help monitor mood, insight, and patient
or distortions on the affected side of the earlier picture motivation.
for which they were previously unaware). Additionally, each rehabilitation neuro/psycholo-
Some cognitive impairment, such as hemineglect gist may have their niche in which they may
beyond the acute stage of recovery, is associated with provide a specialized skill such as pain man-
poor outcome in terms of independence (Denes et al., agement, cognitive rehabilitation, treatment for
1982; Stone, 1992). Some research also suggests insomnia, and trauma-based therapies. As described
that hemispatial neglect may suppress motor recov- earlier, many post-stroke symptoms have multi-
ery and reduce motor learning, even when patients factorial explanations and etiologies. Rehabilitation
receive appropriate rehabilitation to build strength, neuro/psychologists are well-poised to assess post-
dexterity, and endurance (Barrett et al., 2014). Spatial stroke emotional, behavioral, and cognitive sequelae
neglect rehabilitation acts to promote motor as well in the context of premorbid factors, demographic
as visual-perceptual recovery (Barrett et al., 2014). information, interpersonal and social factors, injury
Given that there is ample evidence to demonstrate the information, and finally post-injury comportment.
effectiveness of unilateral spatial neglect (Robertson Unfortunately. not all stroke survivors who need
1999); it makes sense that multiple clinicians, includ- psychological services receive them. Psychological
ing rehabilitation psychologists, should be involved care for these individuals is as essential as physical
in helping treat this issue. rehabilitation, particularly as people with stroke and
Vallar et al. (1997) and Paolucci et al. (2001) their families endeavor to manage the impact of
reported that interventions to improve visual per- stroke on their lives in the longer term (Gillham
ceptual orienting in spatial neglect also reduced et al., 2011).
200 R. Perna and L. Harik / The role of rehabilitation psychology in stroke care

1.9. Barriers and proposed solutions to receipt of of variables and treatment situations has resulted in
psychological services in stroke rehabilitation somewhat limited and mixed data supporting psy-
chosocial interventions. Because psychological care
There are a number of barriers to receiving psy- is less about ‘fixing’ and more about understanding
chological services following stroke, whether in and offering timely support and understanding the
inpatient, outpatient, or community settings. While effects are sometimes hard to quantify.
the physical deficits associated with stroke are Current research reveals that in spite of some of the
widely recognized by experts and lay people alike potential challenges, individuals with stroke are able
(e.g., hemiparesis, aphasia), the cognitive, emotional, to participate and benefit in a wide array of interven-
and behavioral sequelae are less well-recognized. tion modalities including those formats with some
Moreover, the symptoms may be less apparent or of the strongest empirical support including cogni-
subclinical or not things that are readily observable tive behavioral therapy (Lincoln et al., 1997; Rasquin
to therapists. For example, approximately, 40% of et al., 2009). Another potential barrier to receipt of
stroke survivors at any given time may have one or psychological intervention following stroke is the
more of the following difficult for therapist to notice stigma around mental health and need for treatment.
symptoms (identity change, isolation, sexual issues, Barriers:
anxiety, depression (Mckevitt et al., 2010). Some
1) psychology not always embedded in treatment
enormously important issues may go unnoticed such
team
as decreased self-esteem and identity disturbance
2) cognitive impairment interfering with tradi-
may go completely unnoticed (Vickery et al., 2008,
tional mental health treatment
Pallesen, 2014). As a result, treatment of these deficits
3) stigma around mental health post-stroke, it’s not
is often delayed or unfortunately never provided,
just motor
despite the significant prevalence of psychological
4) Transportation and mobility limitations
dysfunction following stroke). This highlights the
need for mental health professionals with training in 1) rehabilitation team members should empower
brain-behavior relationships embedded in treatment patients and families to request referral to men-
teams focused on rehabilitation from stroke. How- tal health; education to rehab staff re: role of
ever, many programs do not have full time psycho- psychology so they know when to refer;
logical support, identifying one barrier to accessing 2) Empirically supported treatments for mood and
psychological treatment in the rehabilitation process. anxiety disorders in low functioning individu-
One proposed solution to this barrier is ongoing and als or individuals with ABI (e.g., Reminiscence
continued education about the neurobehavioral and Therapy)
psychological sequelae of stroke to physicians, thera- 3) local and federal resources for transportation,
pists, nurses so that appropriate referrals can be made telehealth options
for consulting or community psychologists when 4) education for staff, family, emergency physi-
needed. Additionally, education should be provided cians, PMR physicians, PCPs, etc so that they
to patients and their family caregivers to advocate can normalize the experience, set expectations
for mental health services, as many health systems for improvement, and be able to identify post-
do offer these services in a consult/liaison capacity stroke psychological adjustment and quality of
if full time psychological support is not available. life issues (Poritz et al., 2018).
Patients and caregivers should be empowered to ask
questions of their treatment teams about the short-
and long-term expectations for mental health as they 2. Methods
recover. The second barrier that many clinicians may
face, is that cognitive impairment as a result of stroke, To demonstrate some of the plethora of psycholog-
especially aphasia, may interfere with the typical for- ical issues that affect stroke rehabilitation, two cases
mat of psychotherapy. That is, if one experiences are described below, which describe clinical prob-
diminished ability participate in a back-and-forth lems and how they were managed. These patients
conversation, understand what is being said to them, were both involved in comprehensive post-acute
recall what was previously discussed, reflect on one’s brain injury rehabilitation. They had no pre-existing
emotions and behavior, etc, can they benefit from psy- psychological history, but both benefited from coun-
chotherapy? The combined effects of the vast array seling during treatment.
 R. Perna and L. Harik / The role of rehabilitation psychology in stroke care 201

2.1. Case example: Psychological issues right dominant hand hemiparesis. Since the stroke,
affecting treatment she has struggled with being dependent on others
for hygiene, dressing, and transportation. She started
2.1.1. Case one: Talking about hemiplegia post-acute rehabilitation about one month ago and
Mr. Z is a 40-year-old bartender who suffered a appeared to have some symptoms of a major depres-
hemorrhagic stroke four months ago and is now in his sive disorder though has been on 20 mg fluoxetine
third month of post-acute transdisciplinary rehabilita- since her inpatient care. She was very motivated with
tion. He has dense hemiparesis and has nonfunctional her psychologist but had several psychological symp-
grasping movement of his left nondominant hand. toms that other disciplines felt were problematic. For
His occupational therapist is doing weight-bearing example, her occupational therapist has asked for co-
and neuromuscular electrical stimulation, and pas- treatments because when they work on her shoulder,
sive range of motivation exercises with him. She Ms. Z tenses up, holds her breath, and tries to avoid
has told him that it is unlikely he will regain any her exercises. During the co-treatments, the psychol-
functional use of his affected hand. This is now ogist helped her do deep diaphragmatic breathing and
the second time he has been told this. He exhib- use positive affirmations and coping self-statements.
ited anger during his neuropsychology session and A component of her resistance to treatment was the
vented his feelings and became very tearful. Mr. Z acute shoulder pain that was being exacerbated by
was not ready to hear that message, and his readi- the stretching exercises. She and the therapist had an
ness to accept that message should have been assessed ongoing dialogue about this “therapy pain.” Her tol-
beforehand. Clinicians can either think about Kubler- erance for the exercises improved significantly. Her
Ross stages of grieving or the Transtheoretical Model physical therapist complained about limited stamina
(Stages of Change) of Prochaska-Diclemente, & Nor- and thought it might be low motivation. This was
cross (1992) when trying to figure out with what a brought up to the psychologist who discussed it with
patient may be ready to cope. Some clinicians sug- Ms. Z, and it turns out that she was having poor
gest that these issues should be considered when sleep since the stroke and often felt afternoon fatigue
thinking about and crafting the appropriate message and had developed the habit of late afternoon long
about a potential loss such as this. Ms. Z appeared naps. The psychologist helped her with several sleep
somewhat traumatized by the message, and he pro- hygiene issues, including sleep restriction (Lu et al.,
cessed his feelings of loss with his psychologist and 2016), which involved significantly limiting the nap
also talked about how there is no definitive way for time and having a fixed nightly sleep time. By her
anyone to predict at this time just how much recov- third month of rehabilitation, sleep had improved
ery he will achieve and they also talked about the as did her stamina. At this point in rehabilitation,
normal variability in clinician opinions. Since his she was working on mobility, and some more co-
occupational and physical therapists were starting to treatments were needed for fear of falling. Ms. Z
discuss discharge with him, his neuropsychologist just needed some cueing for her breathing and self-
suggested that Mr. Z contact some other local Occu- talk. For her final month of treatment, Ms. Z and her
pational therapists and both that he called believed therapist worked on grieving her losses and her self-
that there was still ample time to improve his active concept. During her last few weeks, she began to dress
hand movement. The ideal situation is that a treatment more like she did before the stroke and started to
team collectively discusses prognostic issues early attend more social events than she had been since the
in treatment and based on the psychologist assess- stroke. Outpatient counseling was continued for one
ment of the persons insight, a cohesive message is additional month and appeared to help her be more
created and given by the whole team and modified as at ease with her post-stroke limitations.
needed based on progress and clinical needs. Hear-
ing a consistent message from different disciplines
at the very least gives face validity to the message 3. Conclusions
and often helps preserve clinician-patient working
rapport. Even in the context of no pre-existing psycholog-
ical issues, a stroke can cause a variety of reasons
2.1.2. Case two: Managing fear of pain why someone might benefit from seeing a psycholo-
Ms. Z is 47 years old and is three months post- gist during either acute or post-acute treatment. Some
ischemic left MCA stroke and continues to have of the more common symptoms treated in this context
202 R. Perna and L. Harik / The role of rehabilitation psychology in stroke care

include awareness/insight into impairments, depres- independence in adults who have had a stroke. Occup Ther
sion and other emotional distress, insomnia, use of Int, 20, 11–22.
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(2011). Non-pharmacological
tive rehabilitation, pain management, follow through Bruce, M. A. G., & Borg, B. (2002). Psychosocial frames of ref-
with home exercise programs, life planning, and erence: Core for occupation-based practice. Thorofare, NJ:
return to work planning and job simulations. The SLACK.
ideal situation is that the psychologist also does some Bour, A., Rasquin, S., & Boreas, A., et al. (2010). How predictive
brain injury education with the patient and the fam- is the MMSE for cognitive performance after stroke? Journal
of Neurology, 257, 630-7.
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Bergquist, T., Azulay, J., Cantor, J., & Ashman, T. (2011).
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issues such as Power of Attorney or guardianship, Crosson, B., Barco, P. P., Velozo, C. A., Bolesta, M. M., & Cooper,
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