Psychological factors as facilitators versus barriers to therapeutic engagement in acute inpatient rehabilitation


Ramanathan-Elion, D. M., McWhorter, J. W., Wegener, S. T., & Bechtold, K. T. (2016). The role of psychological facilitators and barriers to therapeutic engagement in acute, inpatient rehabilitation. Rehabilitation Psychology, 6(3), 277-287


In today’s climate of increasingly short acute inpatient rehabilitation stays, there is a need to identify factors that can be prioritized to improve the effectiveness of rehabilitation efforts. For rehabilitation psychology services, in particular, there are often many factors that must be addressed. One of the challenges can be in recognizing how to prioritize these factors in the inpatient setting, in order to impact the degree to which patients are invested in the goals of treatment and engaged in the rehabilitation process. To this end, a recent study by Ramanathan-Elion, McWhorter, Wegener, and Bechtold (2016) built on a model of engagement in rehabilitation, examining personal variables that have been previously linked to rehabilitation outcomes and identifying those factors that may be most implicated in engagement.  The authors recruited participants from three acute inpatient facilities within the East Coast. Inclusionary criteria included (1) receiving higher than a 21 on the MMSE, and (2) undergoing a first rehabilitation admission. A total of 206 individuals participated - drawn from common rehabilitation diagnoses (105 persons with spinal cord dysfunction, 37 individuals with stroke, 39 individuals with orthopedic problems, and 25 individuals with lower limb amputations). Hope, benefit finding, and positive affect were the personal factors hypothesized to facilitate engagement; and depression, denial of illness, and negative affect were proposed as barriers. Demographic variables including FIM scores at admission and length of stay were also examined for their impact on engagement.  The proposed factors were measured at admission and analyzed for mediating effects on rehabilitation engagement at discharge (as measured by The Hopkins Rehabilitation Engagement Rating Scale, HRERS, a 5 item behavioral and observation scale rated by physical and occupational therapists and assessing level of attendance in therapy, need for prompts, patient’s acknowledgment of the need for treatment, and the level of active participation). The primary study analyses consisted of Pearson correlations demonstrating that the hypothesized facilitators (greater benefit finding, hope, and positive affect) were related to greater engagement in rehabilitation, and the proposed barriers (greater reported negative affect, denial of illness, and depression) were related to poorer engagement in rehabilitation. Further examination using a hierarchical multiple regression model demonstrated that the proposed facilitators and barriers together accounted for 15% of the total variance in engagement, over and above demographic variables. Of all of the proposed barriers and facilitators, however, only denial of illness and positive affect were individually identified as contributing significantly to levels of engagement. The authors eloquently identified limitations of their research including that this study examined patients during acute inpatient rehabilitation only, and that the factors related to engagement may change over the course of rehabilitation treatment. Notably, the outcome measure of engagement utilized was dependent on the observations of OT and PT, and may be biased by the focus of those professions. As the authors note, future research should examine how individuals from other modalities in rehabilitation may perceive engagement during rehabilitation.  

We chose this article because of its applicability to conducting therapeutic work with a broad range of patient populations in an inpatient rehabilitation setting. This research provides an empirical effort to guide the clinician in identifying and prioritizing factors that have the best chance of impacting engagement in rehabilitation. These are factors that rehabilitation psychologists are uniquely prepared to target in patient care, and that can contribute to the efficiency and effectiveness of the rehab program - two very important components in the evaluation of acute inpatient rehabilitation programs overall.

THIS MONTH’S REHABILITATION SCIENCE SPOTLIGHT was provided by Casey Dawson, PhD, a rehabilitation psychologist at Memorial Rehabilitation Institute at Memorial Regional Hospital South in Hollywood, Florida; and Laura Tabio, MS, a doctoral student at Nova Southeastern University completing a practicum at Memorial Rehabilitation Institute at Memorial Regional Hospital South in Hollywood, Florida, members of the Division 22 Science Committee.