As a Health/Rehabilitation Psychologist in a hospital setting, my role is very different from psychologists practicing in private practice or other settings. On any given day, I may provide psychological services to patients, conduct staff trainings, consult with the healthcare team and provide treatment recommendations, participate in team meetings, train students, engage in scholarly research, and a myriad of other professional activities. No two days are alike in my role, and new and exciting challenges keep me stimulated and engaged. In this blog post, I will provide a “snapshot” of what a typical day may look like in my role as a health/rehabilitation psychologist.

I work at UnityPoint Health-St. Luke’s Hospital on a CARF accredited rehabilitation unit. CARF accreditation stands for Commission on Accreditation of Rehabilitation Facilities and ensures that quality of care is being provided and internationally recognized rehabilitation standards are being met. The population on our rehabilitation unit consists of patients with neurologic disorders (e.g., traumatic brain injury, stroke), patients with amputations, traumatic burns, orthopedic injuries, physical deconditioning secondary to various medical conditions (e.g., cancer), spinal cord injury, amputation, and any other medical concern that would require acute rehabilitation. For someone to qualify for acute rehabilitation, they need to meet requirements as outlined by the Centers for Medicaid Services (CMS), and have a medical condition that requires inpatient medical rehabilitation. Patients on our unit participate in at least three hours of therapy per day, including physical therapy, occupational therapy, or speech language pathology. The “core” members of our multidisciplinary rehabilitation treatment team consist of physiatrists (i.e., rehabilitation physician), physical therapists, occupational therapists, speech language pathologists, recreational therapists, social workers, care coordinators, intake coordinators, pharmacists, registered dietitians, nurses, health/rehabilitation psychologists, and neuro-psychologists. Other specialties may be consulted including specialty physicians (e.g., neurology, nephrology, cardiology, palliative care), diabetes educators, psychiatrists, Certified Alcohol Drug Counselor (CADC), and chaplains. Each member of the multidisciplinary team addresses patients’ presenting concerns from their own unique lens. All team members are working toward the same overarching goals: increase functionality, quality of life, and assist patients with returning to the community to live independently. 

Each day starts with “morning report” at 8:00 a.m. This is a roughly 20-minute meeting where the charge nurse provides a brief report about the medical status of each patient from the night/day before. During this meeting, I often hear about patients who may be having a difficult time coping with their hospitalization, experiencing emotional lability, or other psychological factors that may be impacting their recovery. Following morning report, there are typically “team conferences,” which take place once per week based on CARF accreditation standards. During this meeting, each discipline provides a brief synopsis regarding how the patient is progressing toward their treatment goals, and barriers for discharge are identified, discussed, and addressed. This meeting illustrates the uniqueness of each discipline as we work toward common goals. There is some overlap between disciplines in terms of addressing the same medical domain area of functioning. For example, occupational therapists, speech language pathologists, neuropsychologists, and health/rehabilitation psychologists may all assess some aspects of cognition, but in different ways. Speech language pathologists may assess cognition and teach compensatory strategies, whereas neuropsychologists may conduct a more thorough and detailed assessment of the patient’s cognitive functioning and provide treatment recommendations about a patient’s ability to sign financial power of attorney paperwork or live independently.

The remainder of my day is quite variable, and I spend my time seeing patients individually or in groups, consulting with providers, attending meetings, supervising trainees, conducting scholarly research, or other professional activities. I typically see between 5-10 individual patients per day, sometimes more, sometimes less. I conduct biopsychosocial evaluations with every patient on the rehabilitation unit, and I focus clinical interventions on psychosocial factors that may enhance patient outcomes or factors presenting barriers for discharge. I typically assess for sleep concerns, appetite/diet, mental health history, acute and chronic pain, emotional functioning, cognitive functioning, substance use, psychosis (often secondary to delirium), sexual health and functioning, religious or spiritual beliefs, coping styles and strategies, knowledge of medical condition/status, expectations for recovery, social support, adherence to treatment recommendations, understanding of medical conditions and treatment course, and other factors. It is rare for me to see a patient for over 30 minutes, and most of my contacts with patients are around 20 to 25 minutes. I focus most of my attention on factors impacting patients’ ability to participate in rehabilitation activities, and then developing a treatment plan to address these factors. 

Many of my interventions are influenced by Motivational Interviewing (MI), Cognitive Behavioral Therapy (CBT), and Acceptance and Commitment Therapy (ACT). In the hospital environment, on the rehabilitation unit, the most common presenting concerns stem from a lack of control and autonomy, and ambiguity surrounding recovery for the future. A patient with a spinal cord injury may experience emotional distress because of uncertainty whether they will walk again, and as much as they may want to “will themselves to walk,” neurologic recovery can be a long process. Rehabilitation typically has a non-linear trajectory with some patients taking three steps forward one day and two steps back the next day. Patients have expectations to make daily progress, and when this doesn’t happen, patients may need to modify their expectations. I regularly spend time normalizing, validating, and assisting patients with navigating their rehabilitation experience including all of ups and downs associated with their journey. I spend a large amount of time providing psycho-education and helping patients understand the process of rehabilitation by letting them know they are not “crazy” and that anyone in their situation is going to experience periods of emotional distress, anxiety, self-doubt, and uncertainty for the future.

One of the activities I most enjoy about my position is helping individuals manage pain and anxiety using non-pharmacologic interventions. I use many evidence-based techniques including diaphragmatic breathing, autogenic training, mindfulness meditation, guided-imagery, and passive progressive muscle relaxation. My two “go-to” self-regulation interventions are clinical hypnosis and therapeutic Virtual Reality (VR). The most powerful tool I have to help patients manage both acute and chronic pain is clinical hypnosis. I have advanced training in the use of clinical hypnosis for pain and anxiety management, and it’s very gratifying to help patients learn a skill that allows them to take control of their own symptoms so they do not have to rely on other healthcare providers. I continue to be amazed when I help individuals with acute and chronic pain go into trance and experience a significant decrease in their experience of pain (or no pain!). Hypnosis helps patients to modulate their experience of pain, like turning down the dial on a radio or television. Patients are often pleasantly surprised how they can use their mind to change their physiological experience of pain.

More recently, I’ve started a therapeutic VR program to give patients another strategy to distract themselves from pain. VR is the “ultimate distraction” and works by creating a multi-sensory experience that blocks various pain pathways in the brain. Patients can be in their room one minute and the next minute picking from one of 70 different VR apps to create an immersive experience including, but not limited to: swimming with dolphins, sitting on the beach, hang gliding over the Hawaiian islands, going on a spacewalk at the international space station, riding rollercoasters, catching fish, or walking through an enchanted forest. Therapeutic VR has been very effective for patients who have high anxiety and need to undergo medical procedures (e.g., wound/dressing changes, staple removal, and injections) or to help people to relax and calm their sympathetic nervous system in response to stress. I recently started a VR program, and I am in the process of training all of the hospital units at St. Luke’s to use therapeutic VR for patients. Additionally, my research team is investigating the perception of nurses using VR and how to implement innovative technologies in the hospital setting.

Perhaps the most gratifying aspect of my role as a Health/Rehabilitation Psychologist is working with the multidisciplinary team. I help team members better understand how and why patients may behave or react the way they do in a hospital environment. This is accomplished through informal consultation, written treatment recommendations, and conducting formal trainings. I provide recommendations to the treatment team regarding how to address a number of behaviors and situations. For example, I provide recommendations to staff about enhancing individuals’ control or autonomy in the hospital environment by using Motivational Interviewing and taking a permissive stance (e.g., “Is it okay if I come into your room?” “Would it be okay if I asked you a few questions?”), or assisting patients who have experienced a recent trauma to feel safe and comfortable when they may feel vulnerable and hopeless. I also provide feedback to staff about why patients may respond to stimuli in certain ways (e.g., acting or lashing out, disruptive behaviors, family of origin or their cultural background), and how the language we use and the messages we convey to patients are often not in our conscious awareness and can impact the care that we provide (e.g., implicit bias). I assist staff with implementation of environmental management recommendations and plans to help curb maladaptive behaviors for individuals with newly acquired brain injuries. I work very closely with nursing staff to help with issues related to teaching a patient with a new spinal cord injury to self-catheterize or address barriers to starting a bowel/bladder program. I also provide recommendations to referring providers whether a patient’s presenting concerns (e.g., seizures) may be related to psychogenic (e.g., history of trauma) versus medical factors, and how to implement a treatment plan to address such symptoms.

I’m very fortunate to work with a wonderful team. More recently, since the onset of the pandemic, I’ve facilitated debriefing sessions to enhance resiliency and self-compassion, teach self-care strategies (e.g., mindfulness exercises), and address issues surrounding compassion fatigue. After debriefing sessions, I typically meet with the leadership team to provide recommendations about how to better care for and support frontline staff and other team members. The pandemic has taken a significant toll on frontline healthcare providers, and taking care of the team is essential to providing the best care possible to our patients.

I’m fortunate to use my scientist-practitioner training in number of professional roles to keep me energized and stimulated. Along with my responsibilities on the inpatient rehabilitation unit, I also co-lead our outpatient Pain Empowerment Program (PEP), where we provide a number of groups (CBT, ACT, and hypnosis) to patients with chronic pain concerns. I also have an active research program that focuses on investigating the implementation of using non-pharmacologic treatments in hospital settings. Lastly, I lead our undergraduate internship and post-doctoral fellowship programs by serving as the Psychology Program Training Director. I’m passionate about training the future of our psychology workforce.

No two days are alike working as a Health/Rehabilitation Psychologist in a hospital setting. My day can change very quickly, and everything I had planned may have to take a back seat to emergent patient or staff needs. I’ve learned that flexibility is a critical aspect of my role and self-care is important in a fast-paced, highly demanding position. I love what I do, and I hope more psychologists consider the possibility of working in a hospital setting. 

If you are interested in learning more about becoming a Health/Rehabilitation Psychologist, please contact Benge Tallman at Benjamin.tallman@gmail.com.

I was fortunate to acquire an academic job directly out of my pre-doctoral internship. However, the downside of this was that opportunities to apply my clinical skills were largely nonexistent, and acquiring the required 1500 hours of postdoctoral licensure hours was a daunting task while embarking on the tenure track. While I had always found academia fulfilling, after two years focusing solely on teaching and research, a level of monotony began to appear, and the lack of opportunities to work with clients began to frustrate me. Not to mention, I dreaded the prospect of having to repeat the same stories from my past clinical work to my students for the next 50 years if something did not change. Accordingly, despite the challenge and risk of adding a new responsibility to an already full workload, I decided to take on a part-time clinical position to complete my licensure hours. Looking back, this was one of the best decisions I have ever made, and the following case exemplifies why I will always have one foot in the clinic.

One of the aspects of clinical practice that I always admired is the variety of challenges, twists, and turns it brings. Even the most seemingly “simple” cases always seem to offer a wealth of complexity, opportunities for creativity and problem solving, as well as the ability to put science to practice. Needless to say, “monotonous” is never a descriptor I would use for clinical practice. This brings me to the case of “Jerry.”

Due to my behavior therapy training and experience, I received a referral to treat Jerry, a college student who was seeking treatment for an unspecified phobia. The referring psychologist contacted me and informed me that Jerry would benefit from exposure and response prevention (ERP) therapy, but cautioned me that his phobia was “unique” and that he was very reluctant and embarrassed to discuss it. Given my experience, I had my initial assumptions of what this phobia could possibly be. Never in a million years would I have guessed that his phobia involved an intense fear of makeup and cosmetics. More specifically, Jerry had an intense fear response to the sight of makeup. Even the discussion of makeup, or seeing someone casually apply makeup, caused him to feel uncomfortable, nauseous, and panicked. Worse yet, “unnatural,” unexpected, or heavy applications of makeup made him faint—often in social situations. Jerry did not know how or why he had these fears, but his difficulties existed as he could remember.

Thankfully, there is an intervention that can be applied to an infinite number of situations—behavior therapy. I love behavior therapy for its simplicity. Clinical “wisdom” or “insight” is not necessary. In my experience, the most simple and straightforward approaches are often the most successful. We can address the problem as well as make immediate progress without necessarily knowing its origins. Further, behavior therapy is a treatment that is idiographic, and can be uniquely applied to the client’s specific concerns. Moreover, behavior therapy, particularly ERP, is an active treatment that allows one to step outside the walls of the clinic and engage in creative interventions in nearly any environment. I particularly appreciate ERP’s logical and straightforward rationale: exposing one to feared stimuli and situations allows one to habituate to them and unlearn the threatening associations. Best of all, behavior therapy allows a client to take their life back, and ERP is one of the few treatments I feel confident informing the client that, if they complete it, they will get better.

While initially nervous about the intervention, Jerry recognized the opportunity to overcome his phobia and bought in. Our work began in a straightforward manner (e.g., thoroughly discussing his phobia, tracking behavior, creating a fear hierarchy). I was excited to have an opportunity to identify creative exposure exercises to target each level of the hierarchy. However, just as treatment was about to commence, the COVID-19 pandemic escalated, forcing us to move to telehealth. It was back to the drawing board. While I had my initial doubts regarding how we would successfully continue treatment via telehealth, I was motivated by the challenge and it was another opportunity to creatively address my client’s concerns.

Thankfully, Zoom actually happened to be an incredible asset for our work together. Having been previously forced on to Zoom to teach my classes, I was familiar with its capabilities and saw its potential as a stimulus delivery mechanism. Borrowing again from my teaching experience, I put together PowerPoint slide shows of images involving makeup, each photo increasing in intensity. It was successful. At the start, even the most seemingly benign images of makeup elicited a strong fear response from Jerry. However, he was determined, and pushed on. Our work expanded into slideshows targeting specific aspects of his phobia (e.g., makeup application around eyes, extreme unnatural-looking makeup, mortuary makeup). This then advanced to using Zoom to show YouTube makeup application videos, and then eventually, live demonstrations of me applying makeup to my face (which led to many humorous, frantic attempts to remove it before the start of my next class).

Jerry continued to make progress, habituating to more and more intense stimuli. Before long, he had reached the point where he had the courage to go to the store and purchase makeup items himself. Over several sessions, Jerry slowly gained comfort applying makeup to himself—first a dot of eyeliner on his hand, slowly working up to him applying makeup to his face, and eventually, around his eyes. Perhaps the most significant moment was when we began exposures involving nail polish. Mirroring our previous work, we worked up to where he was able to apply the polish to his fingernails, and sit with the anxiety. Beaming with pride and confidence that he overcame an obstacle that he once thought was insurmountable, Jerry went from being incapable of having and seeing the polish on his fingernails, to tolerating it, to eventually embracing it.

To Jerry, being able to wear the nail polish became a symbol of overcoming, a recognition that, if he could triumph over this lifelong fear that negatively affected nearly every domain of his life, he could take on anything. Jerry now confidently wears nail polish on at least one of his fingernails every day. When people ask him about it, Jerry proudly shares his success story of overcoming his fears. He is no longer ashamed and embarrassed about his struggles. Rather, he more confident in social settings and now shares his story to inspire others.  

When our clinic reopened, we continued our exposure work together in-person. Jerry has continued to make strides. While there is much more work to go, the impairment Jerry experiences from his phobia has decreased significantly. He no longer avoids social situations where makeup might be present, nor does he fear having panic attacks or fainting.

Cases like Jerry’s highlight what I admire about clinical practice, and what I missed most when I was away from it. It is a privilege to work with Jerry and several other incredible clients, and I am grateful to have a career where I have opportunities to teach, research, and now, practice.

The Clinician Corner is a new monthly feature of the Iowa Psychological Association Blog where we highlight a therapeutic tool, intervention, or style of therapy that has been useful in the therapy room. Please consider contributing so that we all might continue to learn from one another. If you are interested in contributing, contact the blog editor here.