Spinal injury – finding strength for an unplanned future

Three months ago, my patient tripped, fell down the stairs and woke up unable to move their own body from the neck down. They cannot get themselves out of bed, feed themselves, or dress. Their only agency now is through using a wheelchair. My patient tells me they feel down, hopeless, that they have no reason to live, that they are not the parent they were before and that it's all too difficult. How do you formulate a therapeutic plan for someone who has undergone such life-changing events?

This is the kind of scenario I often see as an Assistant Psychologist at the Yorkshire Regional Spinal Injuries Centre at Pinderfields Hospital in Wakefield (Mid Yorkshire Hospitals NHS Trust). Working in health psychology has allowed me to grow not only as a practitioner and a psychologist, but also as a person.

My career started in inpatient mental health hospitals. Working with adolescents and women from the forensic system, I worked in a high risk environment with patients in crisis. I learnt core therapeutic skills, as well as resilience and teamworking. From there, I worked in NHS community Child and Adolescent Mental Health Services. My appreciation grew for systemic ways of working and I broadened my understanding of therapeutic models and formulations. The opportunity to work in physical healthcare arrived. The prospect excited me – it was so different from my previous experiences.

Car accidents and rugby

At the service, I work with adults of different economic classes, heritages, occupations, social backgrounds, faiths and more. Spinal Cord Injuries (or SCIs) can occur through trauma such as a car accident, rugby gone wrong, or a fall from a ladder; or they can occur physiologically, either suddenly (such as a spinal stroke or abscess) or gradually (such as spinal stenosis, where the gaps between the vertebrae narrow). Some patients on the SCI ward have a psychiatric history and diagnoses of mental health disorders prior to their injuries, and may have engaged with community mental health services in the past. Others may not consider themselves to have ever had mental health issues.

Within our psychology team in Spinal Cord Injuries, we meet every patient admitted to the centre, whether they have a history of mental health difficulties or not. We offer a screening session, which the majority of patients are keen to accept. This involves a clinical interview to learn more about the individual's background, the nature of their injury, and their goals and expectations for rehabilitation. We often complete psychometric measures, which can be helpful to understand the patient's current mental state and management of their injury. We then encourage patients to make a plan with us around what support would be helpful.

Therapeutic work with patients usually focuses around acceptance and adjustment. We therefore draw from Acceptance and Commitment Therapy and Compassion Focused Therapy models most frequently. We work with patients to develop strategies to make room for their emotions and to validate their feelings in the context of their recent life change. We often use the Kubler-Ross grief cycle to demonstrate how loss of bodily function and the loss of a loved one can elicit similar feelings of denial and bargaining before reaching acceptance. Relatedly, we work with the multi-disciplinary team (MDT) to share our understanding of where the patient is at mentally and psychologically with rehabilitation, alongside their understanding of their physical progress and our psychological plan for care. This can be particularly helpful for patients with psychiatric histories to help the MDT better understand their needs.

Prolonged fight or flight

I recently worked with a client who has a long and complex history with mental health services and has experienced a lot of life trauma. As a priority, I worked with the patient to firstly, manage the re-traumatisation that was occurring as a result of their spinal injury and hospital admission. We achieved this through gentle and gradual anxiety management and grounding. Secondly, with the patient's consent, I shared the necessary parts of their story with the MDT – so that they could understand how, why and when rehabilitation was so challenging for this patient.

As part of their coming to terms with their spinal cord injury, some patients can have unrealistic goals (which may be to walk again), whereas others can struggle to find the motivation to achieve anything (when they are capable of doing so). We work with patients in aligning their goals and expectations with the professional advice of physiotherapists, occupational therapists and medical consultants.

As well as low mood and motivation, another common emotional response to a spinal cord injury is anxiety. Our patients can experience a prolonged fight or flight mode, due to the stress of surgery, the medical environment and ongoing challenges as they learn basic skills all over again. Some patients also feel fragile and concerned that further injury may occur. This can extend to the degree of post-traumatic stress symptoms, particularly when the spinal injury has occurred through a traumatic incident, or if they found the surgical procedure incredibly stressful.

Some people with a spinal cord injury experience neuropathic or musculoskeletal pain. The pain can heighten emotions and increase stress, and in turn, elevated emotional distress can increase pain. Pain can then become a barrier to their engagement in their physical rehab (physiotherapy and occupational therapy). We work alongside the medics to provide a psychological perspective on pain management, helping patients to understand how they can take control of their pain and what parts of their daily living can impact pain.

Relationships and sex

Patients often also think about how their bodies have changed (often including the use of a wheelchair or aid) and this can involve relationships and sex or sexual dysfunction. We work on self-esteem and body image, sometimes with the involvement of their partners. We work with patients to help them understand what the body may, in time, be capable of and direct them to strategies and equipment available to support sexual intercourse.

An observational reflection of mine has been how much of my therapeutic work at the ward is to provide a safe space where patients can express their thoughts and feelings. Being a physical healthcare service, many of my clients have never encountered the psychologist-client dynamic and this can bring anxiety and/or uncertainty. Psychology in a health world can come with stigma; patients have queried if I have been sent to see them because they have been perceived as not coping, or 'losing the plot'. I dedicate time to ensuring the patient understands how sessions are a safe space and the purpose of our role. We bring lots of normalising into our sessions – not just that what they are feeling is normal following such a physical change, but also, in most people's lives at some point.

I have noticed that the group which needs the most time and reassurance is working age or older adults, who identify as male. My time in the spinal injuries centre has highlighted how so many men go through life feeling as though they should not share their feelings, express their emotions, cry, struggle… because of the expectations set and reinforced for their gender.

Impact of Covid-19

Coronavirus has been another challenge for the unit's patients. Over the last 18 months, almost all patients went through their rehabilitation unable to see their loved-ones. Our Trust had to make the difficult decision to cease visiting to keep patients and staff safe from Covid-19. So patients went through significant life changes, large surgical procedures and length periods of recovery without the level of support we would have hoped. Some more technologically accustomed patients were able to regularly access their support networks via telephone or video calls. However, many others did not have the skills or means for this contact. The Psychology service took on a family liaison-like role; this involved facilitating video calls to spouses and children, as well as regular supportive and informative phone calls to family members. The vulnerability of spinal cord injured people to severe Coronavirus symptoms, the impact of Covid on our wonderful staff, the barriers to accessing further services and the removal of peer support workers should also be acknowledged in this context.

My role at the SCIs unit has contributed to my development on a personal level. I work with people from all walks of life who, in the face of fear, change and uncertainty, are able to find the most amazing strength to achieve varied levels of independence again and adapt to a future they had not planned. My patients have experienced loss, anger, injustice, panic and embarrassment. They have fantastic senses of humour and are kind, caring and generous towards each other. I am inspired every day within my work and the patients motivate me to be the best practitioner I can be. One thing I find patients saying most often is 'I didn't think something like this would happen to me'. It has emphasised to me just how much we take for granted in our daily lives. It's also reinforced within me the power that the mind has to drive us through the most difficult times – if we have the right tools to do so.

- Melissa Potter is an Assistant Psychologist at the Yorkshire Regional Spinal Injuries Centre at Pinderfields Hospital, Wakefield (part of the Mid Yorkshire Hospitals NHS Trust)