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Psychology in Hospitals

Psychology is relevant to anybody who works in a clinic or medical setting. That is why students in pre-medical or nursing programs often take psychology courses as part of their studies.

In the United States, psychologists are relatively rare on the staff of small hospitals. They are more commonly employed by large university medical centers and veteran's hospitals, where they provide services such as the following:

Diagnostic testing, using standard psychological tests to assess mental disorders, level of adaptive func­tioning, brain damage, or other clinically-relevant characteristics

Patient interviews to determine the possible relevance of psychological factors or need for counseling before or after medical intervention

Staff support, talking to the physi­cians and making morning rounds with them

Counseling patients before surgery, chemotherapy, and radiation treatments on what emotional reactions to expect and how to deal with them

Therapy for specific disorders, such as pain, facial or muscle tics, and bedwetting

Rehabilitation counseling and training for amputees and for victims of stroke, burn, spinal cord injuries, and heart disease

Counseling overutilizers, patients who use medical services too often

What are services provided by psychologists at larger medical centers?

Consider the last category: counseling overutilizers. Overutilizers are people who come to a hospital more often than they should.

Emergency Rooms are expensive places to get treatment, and they are intended for genuine emergencies. Some people use them for conditions that could hardly be called an emergency.

My wife's favorite example of this, when she worked in an Emergency Room, was a patient whose complaint was "abdominal pain for 10 months." Unless the pain had suddenly gotten worse, which it had not in this case, this patient should have gone to a regular, non-emergency medical clinic.

Who are "overutilizers" and how can counseling help?

Some people come to emergency rooms because they are ignorant, or have no family doctor, and do not realize E.R.s are not for minor or long-standing problems. Two other categories of overutilizers have a more psychological twist: (1) people who request medical care but have no detectable ailment, (2) people with chronic psychiatric problems.

The former group includes those with factitious disorders, "addicted to the patient role" and skilled at simulating genuine illnesses. People with psychia­tric problems may "clear up" under medical care, then neglect to take their medicines, ending up back in a hospital or police station after acting bizarrely.

Overutilizers respond well to brief psychological consultations. They are easily detected in the triage process, used during admission to well-managed Emergency Rooms, whereby incoming patients are screened to determine who really needs emergency care.

People who do not realize emergency care is for true emergencies can be educated about more appropriate alternatives, including free public health clinics in some cases. Research shows that when people come to a clinic with imagined disorders, even a single session with a psychiatrist or a psychotherapist reduces the number of later hospital visits.

What is the distinction between rehabilitation psychology and psychological rehabilitation?

Psychologists are involved in two different types of rehabilitation at medical centers:

1. Psychologists counsel people suffering medical disorders or facing medical treatment that requires lifestyle adjustments. This is rehabilitation psychology or rehabilitation counseling. Rehabilitation psychology is aimed at helping people adjust to the aftereffects of injury or disease.

2. Psychologists aid in the adjustment of formerly-hospitalized psychiatric patients. This is called psychological (or psychiatric) rehabilitation. Psychiatric rehabil­itation is aimed at helping such people adjust to the outside world so they can live independently outside the hospital.

An example of successful rehabilitation psychology is group therapy for open-heart surgery patients. Radical changes in diet and exercise programs may help prolong the life of individuals with heart problems.

This requires a degree of behavioral change that is unlikely to take place without concentrated support. Some­times a weekly group meeting is effec­tive for promoting needed changes.

How can a weekly group meeting help heart patients?

Head injuries can produce subtle psychological problems that go over­looked by doctors. One study did a follow-up of 424 people who suffered head injuries but were discharged as "neurologically normal" from the University of Virginia medical center after two days or less of hospitalization.

Six months later, nearly 8 of 10 com­plained of headaches, 6 of 10 had mem­ory problems, and a third had not re­turned to their former jobs. Many com­plained of fatigue, difficulty concen­trating, and a shortened attention span.

Some patients with minor traumatic brain injuries (MTBI) experience depression after an accident. An experienced rehab­ilitation psychologist will look for this as a delayed aftereffect. Symptoms can occur after any injury that involves shaking the brain, including assaults, sports injuries, falls, and physical abuse.

What sorts of problems are produced by head injuries?

Dr. Thomas Boll, a neuropsychologist at the University of Alabama, found that "at least a third" of patients who had head injuries classified as minor suffered fairly severe aftereffects. Most of these people never lost consciousness after their injuries and were unaware they could experience disturbing aftereffects.

Dr. Leonard Diller of the head trauma program at New York University's Institute of Rehabilitation Medicine described symptoms of "subtle brain damage" in such cases:

...The person...sits around, loses track of things, interrupts things, has a short attention span, is unable to do his former job, has difficulty maintaining family relationships and sustaining old friendships, has trouble learning new things, develops sexual problems, or thinks of himself as worthless. (Brody, 1983)

How can counseling help people adjust to aftereffects of head injuries?

Dr. Diller added, "Fully half the families with these problems were told when the patient was discharged from the hospital that 'everything would be all right.'" Such patients and their families require a number of specialized counseling services from psychologists and related health professionals.

Patients with lingering effects from head injuries are often advised to stay away from alcohol, which typically makes their problems worse. Cognitive or peer-group therapies may help with that, or with other problem solving and planning.

What is "re-maritalization"?

Stroke presents a special problem for families and spouses of recovering victims. Some strokes have minor effects that quickly disappear, but others can change an individual's personality. That can be disturbing to family members.

A person who was formerly strong and dominant may return from the hospital weak and docile. An individual who previously would never utter a curse world may "cuss like a sailor" after a stroke.

The wife of a stroke victim spoke of the need for remaritalization. She said the marriage had to be re-invented after a stroke changed the personality of her husband.

What problems do people with lupus sometimes face?

Rehabilitation counseling helps people revise their schedules and lifestyles when required by time-consuming, repetitive treatments like hemodialysis (the blood-cleansing procedure used in cases of kidney failure). Marriage and family counseling can help when symptoms of a disease or a treatment have a negative impact on family life.

For example, patients with systemic lupus erythematosus (lupus) may suffer from mood changes, loss of energy, weakness, and hair loss. Marriages can be impacted. Such patients may benefit from counseling (including peer counseling) to help minimize negative consequences to family life.

Write to Dr. Dewey at

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