From Patient to Provider: How Personal Medical Trauma Can Inform Supervision and Clinical Practice

Abstract

Two predoctoral psychology interns share their personal reflections of neurological injuries they experienced during their adolescence and how it has informed and shaped their clinical work. Through their reflections, they provide insights and lessons learned as they have the unique first-hand experience of being a patient and now a rehabilitation psychology trainee and provider. Additionally, they describe how they have applied such knowledge during their clinical work with clients experiencing neurological and chronic health conditions. Issues involving communication with clients, families, and the treatment teams, the benefits and risks of self-disclosure, and the role of hope, meaning in life, and spirituality are discussed. The clinical practice implications of these insights are invaluable for trainees and healthcare specialists at all levels of experience, including the crucial role of supervision during the predoctoral internship year. Recommendations are made for clinical practice including providing developmentally appropriate communication and promoting an environment for growth and recovery. The authors are hopeful that the reflections provided in this article can inspire other trainees to feel comfortable in sharing their personal medical and psychological challenges as appropriate and relevant to help integrate their professional development.

Introduction

Rehabilitation psychology is a field dedicated to enhancing the lives of individuals who have experienced an illness, injury, or other condition resulting in limitations or a disability. Rehabilitation psychologists seek to apply “psychological knowledge and skills on behalf of individuals with disabilities and chronic health conditions in order to maximize health and welfare, independence and choice, functional abilities, and social role participation” (Scherer et al., 2010, p. 1). Despite this clear mission of inclusivity and advocacy, psychology trainees with history of serious injury, illness, or disability have been historically underrepresented within the field (Andrews & Lund, 2015; Lund et al., 2014, 2020).

This paper provides a unique perspective on predoctoral internship from two psychology trainees with first-hand experience of neurological injury, accompanied by individual reflections on the intersection of these personal histories with clinical experiences emerging during a psychology internship at a large urban academic medical center. These personal reflections alongside concrete examples of how a supportive training and supervision framework can facilitate trainees’ processing of complex remnants from their own medical histories, suggest implications regarding the effective support and empowerment of psychology trainees, as well as poignant insights regarding the humane and effective treatment of all patients requiring medical or rehabilitation care.

Internship

The predoctoral internship year is a capstone experience that consolidates the intern’s professional identity through developing clinical skills, gaining awareness of one’s values, trusting one’s intuition and clinical voice, and engaging in opportunities that facilitate socialization into the profession (Gordon et al., 2011). Rehabilitation psychology internships cover the lifespan with positions in pediatric and adult settings within the hospital. Interns working in this setting are often subject to intense and unexpected countertransference reactions, including helplessness, rescue fantasies, and existential anxieties involving fears of mortality, body integrity, and the random and unfair nature of traumatic events (Gans, 1983; Gordon et al., 2009; Gunther, 1987).

Communication and the patient experience

Trainees with first-hand experience of neurological injury may have unique insights with respect to the patient experience. It is common for patients in the acute medical environment to have difficult interpersonal experiences with physicians or staff, frequently referred to as difficulty with a care provider’s “bedside manner.” Trainees with first-hand experience as patients in the acute medical setting may have vivid or even unconscious recollections of what it was like to be treated in the hospital. These may include memories of care that was warm, humane, and validating; but also likely the opposite – select experiences that were invalidating, or lead to diminished sense of dignity, agency, or autonomy. The latter may include a minimal level of communication, lack of understanding what was communicated, and/or feeling uninformed regarding their injury/illness, treatment, and prognosis.

While each trainee is unique in their reservoir of experiences, a supportive, open training environment engenders the ability to process, understand, and integrate these experiences (Gordon et al., 2011), including how such experiences impact patients, as well as potential adverse reactions to the care provided by physicians and staff. While limits in power and authority are inherent to the role of a predoctoral intern, it is vital to support and empower all trainees to be able to advocate for their patients, especially in such cases where the treatment team may underestimate the impact of how information is conveyed to the patient and family.

Such instances are also critical training opportunities. Rehabilitation psychology frequently involves helping patients and families become oriented to the environment and scope of rehabilitation, but also helping to manage feelings and complicated information that may be provoked for patients and their families, especially in the acute aftermath of a life altering health condition or disability.

Self-disclosure

Psychology trainees may encounter a unique set of challenges associated with self-disclosure regarding history of illness, injury, and their experiences as a patient in rehabilitation. Encounters that may provoke different considerations regarding self-disclosure include working with patients, supervisors, colleagues, peers, or fellow interns.

From the perspective of psychotherapy, purposeful self-disclosure involves the therapist intentionally sharing information with the patient about their thoughts, feelings, or personal history to facilitate the therapeutic exchange. Disclosures might include information about age, education, theoretical orientation, relationship status, as well as visible and/or hidden disability status (Gordon et al., 1998). Special therapeutic considerations involved in whether or not to engage in self-disclosure include prioritizing the patient’s freedom to share their thoughts and feelings about the therapist, not wanting to burden the patient with intrusive information about the therapist’s problems or needs, and remaining alert to deflecting attention away from the client’s concerns and goals (Aron, 1996). Conversely, theory and research suggest that artful self-disclosure can help facilitate the patient’s care in important and crucial ways. Given the nuances of self-disclosure, it is often considered an advanced therapeutic technique and may be new for trainees entering predoctoral internship. Thus, it is crucial for internship training programs to provide support and supervision to help guide the proper use of this important clinical tool. As the narratives below attest, trainees with a personal history of illness or disability may utilize supervision to process how this history intersects with clinical and professional encounters.

Supporting trainees with a history of neurological injury

Predoctoral internship training in acute or outpatient neuro rehabilitation setting may yield intense and challenging experiences with medical care, patient impairment or pain, and family distress. Supervision plays a key role in supporting psychology trainees in navigating this process and the difficult feelings that may come along with these experiences.

This is especially the case for trainees with first-hand experience of neurological injury, who may be in the medical environment as professionals for the first time, but have extensive historical experience as a patient. A healthy supervision dialogue provides room for the trainee to process feelings and memories that may be provoked by returning to an environment they once had treatment. For some trainees, as is outlined below, they may be returning as colleagues to a relationship that was once hierarchical with a physician or other rehabilitation clinicians. Unique care is required in these circumstances to support and foster the intern’s sense of professional identity, agency, and empowerment, especially if the trainee’s personal experiences with injury or illness led to feelings of disempowerment or shame. Additionally, supervision is a venue for trainees to process internal reactions to their clinical encounters (e.g., countertransference) and the context of the medical environment, in the case of a rehabilitation psychology internship. Supervision relationships can offer trainees a space to examine what clinical challenges may be hearkening back to their similar life experiences.

This supervisory function is exemplified in the narratives below, in which two rehabilitation psychology trainees share their internal experiences of returning to the medical setting as clinicians and utilizing supervision to help process their experience and inform clinical care. The personal vignettes offer valuable reflections on both the patient and clinical experience and provide a unique perspective to inform clinical practice for healthcare clinicians at all levels of experience.

Clinical vignettes

Clinical trainee 1

Injury narrative 1

My experience as a pediatric clinician is constantly informed by my unique understanding of being a Pediatric Intensive Care Unit (PICU) patient. Walking home from school near Union Square in Manhattan when I was 15 years old, a giant wooden divider leaning against a truck was taken by the wind, flew up into the air, and crashed down, hitting me in the head. I lost consciousness and sustained a severe Traumatic Brain Injury (TBI) with right side hemiplegia, causing nerve damage in my neck and significant numbness in my right side, specifically my arm. I went from daydreaming about my Sweet 16 to living in the PICU.

Due to my injuries and the uncertain prognosis, I vividly remember not being removed from the EMS board for what felt like forever. I recall waking up in the ambulance with a very patient first responder trying to calm my father down on the telephone and give him directions to the hospital.

Life in the PICU was surreal; my bed faced the giant nursing station, it was hard to distinguish daytime and night. Children from all over the city made up the unit. When I was able to navigate walking, I would often sit with a boy in a coma and his mother. We would talk to him because his mother read that maybe he could hear us. I remember her constant presence by his side, always in different Disney sweatshirts; she loved how much I loved Elvis Presley, and I would make her laugh. I remember the night nurses who snuck me ice cream after hours.

Every day, physicians would evaluate me, updating my parents, sometimes in front of my bed, but never explaining to me what was happening. I was given significant amounts of medications, primarily steroids around the clock to strengthen my neck, but no information on the potential side effects. I went through constant cognitive evaluative measures to decide whether there were lasting effects to my TBI. I could feel my body changing in ways that I did not understand. During that time, I experienced how incredibly valuable multidisciplinary care was. One day, I was lying in a hallway waiting to be wheeled in for yet another MRI when the person who transported me, moved me abruptly and left me there, without explanation. Restrained to the bed because my stability was poor, I could feel tears running down the sides of my face, pooling into my ears. I laid there afraid and made a pact with myself: one day, I will work with children and I will never let them feel this way. They would not feel this alone.

Over time, I was introduced to the hospital psychology team. This integrated team made up of psychologists, social workers, child life specialists, and others made it clear they were there for me. It was not until I began working with this team that I felt hope. They talked with me about my fears and frustrations, explained what they knew about my prognosis; (this was the first time recovery was ever brought up), they listened to my questions. For weeks I had been convinced that I could die at any minute because a medical resident had informed me that I was “this close” to dying (pinching his thumb and pointer finger to indicate an inch) or becoming paraplegic given my injuries – he was genuinely very fascinated by my “luck” and decided to tell me all about it, terrifying me. I truly did not know if the worst was over. When the rehabilitation team would come in to get me, I was petrified to go, thinking one wrong move and I could die. I was fearful when the rehabilitation team noted any of my progress; I was fearful of getting better because I was afraid to leave the hospital.

Instead, because of the psychology team, I was afforded the ability to hope again. I felt important and cared for after feeling helpless, vulnerable, and numb. They helped me gradually process and begin to heal; they reminded me that I was still 15, my birthday was coming up, and that I would one day leave the hospital strong and healed. While other teenagers my age may meet a psychologist at the behest of a teacher or through family therapy, my first introduction to psychology was via the acute medical setting.

When I was finally discharged on a rigorous 6-day a week physical and occupational therapy program, I never forgot the psychology team and how they gave me back the ability to hope. I made it my goal to become the kind of doctor that helped me.

I have chosen to carry my traumatic experience with me into every clinical situation as a reminder to instill hope. Buechler (2004) believed that hope is expressed through one’s whole relationship to life; Frankl’s (2019) call to action, “What does life expect from us?” resonates greatly with me. Having survived a traumatic event, it would not have been questioned had I wanted to run away from hospitals completely. Instead, I felt a calling to work with children and adolescents, especially in an acute setting; to nurture the resiliency I know is there; to notice the subtle nuances expressed by a child patient who is exhibiting anger or avoidance when it could actually be fear and frustration; to listen and to make sure they do not feel alone because someone is in their corner.

Predoctoral internship 1

With the help of my pediatric team, I was able to regain full mobility in my right side, finished high school and college, and turn my sights to graduate school. Over time, I slowly began to disconnect with what happened, and focused more on learning to help others who had been through similar difficulties. While I had worked on inpatient units before, it was not until my predoctoral internship year that I came face to face with patients in a rehabilitation setting. I had specifically hoped to match at my internship because one of the providers from my medical team all those years ago was on staff; I had great expectations of being able to work alongside her, and treat a population of individuals who had similar experiences to my own. While that expectation has been fulfilled with many fascinating cases, I did not realize the impact a rehabilitation internship would have on my own case – the file I never got to read. I found myself in seminars and didactics where physicians were outlining the medical and psychological treatment for patients who have suffered a TBI, long-term effects, and how providers work with adolescent patients with neurological concerns. All of a sudden, I was remembering rehabilitation techniques I had forgotten, recognizing the enormity of what had happened; I was finally seeing the sobering information my parents must have been presented, that was shielded from me. I thought of how I could at least look at this information with medical and psychological training, wondering how helpless my parents must have felt with no hospital experience to guide them. Here I was, at the culmination of my doctoral career, and my 15-year old patient self and my adult clinician self were meeting for the first time.

In one particular seminar, a physician presenting on TBI residual effects noted that most patients show signs of aggression or even regressive behaviors following their injury. I immediately asked if they could explain “most” and the physician paused, redacted the statement and noted that in their particular practice, they had seen some of these side effects, but that numbers do vary. I wondered if something was triggering about that statement, as I had not had those side effects. I did not want to feel lumped into a statistic. Thanks to my supervisors, training director, and my fellow interns, I found it a safe place to disclose what had happened to me during group supervision and how I had always carried the experience, but had never looked at my own case study through the lens of a provider. I knew my experience was a catalyst to enter the profession, but I had not realized just how much that experience had informed my approach to my clinical worldview.

Recently, while working with the integrated behavioral team, a physician asked if I would be available to speak with a 15-year-old, nephrology patient, “Sarah.” According to the physician, she was “all of a sudden” refusing to follow her medication regimen, medication that was vital to her continued care and candidacy for any future transplant needs. The physician was extremely concerned, had tried to impress upon Sarah just how dangerous not taking her medication was and that she could die. While reading her chart, it was clear that this teenager had spent many years with kidney disease as well as a variety of gastrointestinal concerns, familial history of kidney disease, among other things.

When I walked into the room, I made sure to introduce myself and raised my ID badge (given our COVID-19 protocols to remain masked) so she could see what my face actually looks like. I began by asking her how she was feeling and to tell me about herself in her own words (remembering the medical resident who was too fascinated about my case, I choose not to disclose just how much her chart I already knew).

Within minutes, she broke down in tears, explaining how angry she was at her diagnoses, and how she just wanted to be 15. She explained that 15-year-olds should be healthy. She wanted to go shopping and eat out with friends. I deeply understood that feeling. She explained that oftentimes her medication made her nauseous and frightened, and she had difficulty swallowing pills. She was also angry that no one was answering her questions. She was sad she could not eat her favorite foods. She was aware she needed her medication, yet she was afraid and felt alone. Together, we worked through how to solve the situation by coming up with plans of action, one by one.

In this case, Sarah was a patient who appeared to be refusing medication. She appeared angry and indifferent. However, when given the opportunity to have the space to speak, she was very aware that she needed her medication; she was also very anxious, angry, afraid, and alone. I worked to reevaluate the situation to best understand where this patient was coming from. Together, we strategized that she would discuss with her physician how to adhere to her medication regimen while avoiding the nausea, perhaps see if the dosage could change or if any pills came in liquid form. Additionally, I made sure she understood who on the team would be the best person to explain what foods she enjoys and to fit them within the nutritional requirements, as well as who else was part of her team; I reminded her that she too was a member of the team. We talked about things she was excited for as a 15-year-old, including upcoming family trips, music she liked, Tik Toks, and being in the school band.

When I returned to the physician to explain how our session went, he was surprised to hear the patient had cried, noting she “seemed just fine” when he was in there. While I am sure that the physician did all he could during his meeting with Sarah to understand what she was feeling, I hope that my personal experience, now more present than ever, my focus on instilling agency, hope, and awareness gave me a unique perspective to connect with children and adolescents in a medical rehabilitation medical setting. While I did not disclose my own experience being angry and scared and just wanting to be 15, I use that perspective to inform what I say, and how I say it to patients like Sarah.

As stated before, you do not have to have lived trauma experience to work with the pediatric population, but simple rules and guidelines to meet them where they at. I utilize an acronym I made up, Set the space, set the PACE – Set the space means to ensure the patient feels safe to speak, to build rapport and trust. PACE stands for: Patience, Awareness, and Care & Engagement.

With any adolescent, patience can be difficult, but lead with patience. Any child or adolescent living with a medical condition or diagnosis may be frightened, scared, or angry; be patient to their emotional output; be aware of their background, ethnicity, culture, who they live with, and who they are as a person – have icebreaker questions that are not medically related. Tend to these patients with care; if you only have a few minutes to speak, let them know, explain who they will be seeing next. Engage them: take the time to ask questions, explain if they will see you again, and remind them that they are an active and important participant in their own care. While her physician had significant concerns regarding her medication compliance and rightfully so, in that moment, Sarah needed to discuss being angry, scared, and 15 first so she was in the safe space to discuss her ongoing treatment. “Chelsea” is an 18-year old female who was referred to me from the gastroenterology team. Chelsea was a candidate for bariatric sleeve surgery due to chronic, morbid obesity. The team physician referred her with concerns of “being unmotivated” and they were unsure whether she was prepared “or interested” in her surgery. One of my responsibilities is to complete a pre-bariatric psychological evaluation, which consists of a variety of self-evaluative measures given to both parent and child as well as an extensive intake interview that is turned into a report clearing the patient for surgery or raising concerns.

When I first met Chelsea, she was quiet, reserved, and brief in her responses. Some of the questions I asked about related to her eating habits, weight loss history, and physical activities. When I asked any question about preparing for her surgery, surgery itself, or post-surgical plans, she barely expressed a word or an opinion either way. I inquired about her motivation for surgery and she responded that the physician had informed her mother that it was a good idea, to which I asked, “What is your opinion?” I could see her eyebrow raise, she paused, and explained she did not have one. I asked her to explain what she knew about the surgery and she admitted she had no idea what was going to happen. I realized that the “unmotivated” teen was a woefully uneducated teen about the entire surgical process.

I conferred with my supervisor who agreed further psychoeducation was needed for Chelsea and her mother and that the treatment team need to be made aware this patient had valid questions and concerns that had never been addressed because she had never been asked. Together with Chelsea, we wrote up a list of questions she wanted to ask ranging from asking what she should expect to happen, how long the hospital stay would be, if there were YouTube videos she could watch, if her mother could stay overnight, and whether she needed to take out her belly button ring. I could see that Chelsea was proud of her efforts and that finding these words to express her concerns and anxieties was difficult. Sharing these questions with her physician, we could tell their surprise that the “unmotivated teen” was actually a teen who had been left out of the conversation.

My trauma is part of who I am, but not my whole identity. It is an invisible scar that I wear forever. Gordon and McGiffin (2021) describe resiliency and flexibility as facilitated by several constructs, such as hope, optimism, perseverance, and mindfulness. I find my trauma has informed these constructs and the flexibility to utilize my experience to help others. Given the population I work with, I do not self-disclose my health history with my patients. However, my work and decision-making is constantly informed by my experience, in how I work with patients, their families, and is a constant reminder of the promise I made to my younger self. With Sarah, I deeply felt her sentiment that 15-year olds should just be healthy and that informed my approach to how I could support her. With Chelsea, I saw an adolescent being completely left out of the conversation of her own care, as I had been, and it informed the direction I needed to take to support her.

I am thankful to my training director, supervisors and fellow interns who have allowed me to retrace my steps within my own story. I have certainly spent this year through my clinical work and creation of this article recognizing the impact of my experience, how it has shaped me, and how it informs my work with the various treatment teams and patients as a clinical provider, TBI survivor, and PICU alumni.

Sarah and Chelsea are both pseudonyms.

Clinical practice implications.

• It is important to note the first-hand experience like mine is not a prerequisite for working effectively with children and adolescents in a medical setting. It does not take much to help a pediatric patient feel recognized, valued, and hopeful. However, it does take time and commitment. Express a desire to get to know and work with the patient and how they view their strengths, goals, and aspirations.

• Each patient may have unique wants and needs as far as knowing medical prognosis and treatment; however, they may not feel comfortable expressing them or even know what to ask. Thus, ask the patient what they need or want and listen to their answers.

• Discuss what the patient is looking forward to in the future in order to foster hope and resiliency throughout the recovery process. Remind the patient that they are an active and valued member of their own team.

• Communicate regularly with the multidisciplinary team to ensure that each member is providing a consistent message.

Psychology trainee 2

Injury narrative 2

It was a beautiful, sunny, and hot Friday afternoon. The usual 90-degree weather you would expect to have in Puerto Rico in August, the type that felt like 100 degrees. I was working out when I suddenly began to feel a sharp and pounding pain in my head as if someone was hammering my head. It was the type of headache that would not allow you to move or think of anything else. I remember telling my fitness instructor that I needed to rest for five minutes before doing the next set. Those five minutes turned into ten, and being my stubborn self, when I decided to power through the pain and went to stand up, I was unable to. My body did not let me. Little did I know that I was heading to one of the most life-altering events of my life.

A few minutes later, my mom arrived. Looking at my state, she decided to call my dad who is a radiologist. My dad told her to take me to his office, where he decided to do a CT scan. He found that I just had a subarachnoid hemorrhage. I remember looking at my mom’s face. I could see that she was worried with tears streaming down her face. Yet, I could not focus, I just kept asking, “What is happening?” “Why do I feel like someone is hammering my head?” I then got in the ambulance and vividly recall these words: “Natalia . . . stay with us, try to stay awake, okay? Do your best to stay awake.”

The pain level was so high; I could not think or process any information. I was certainly not aware of the gravity of the situation. I did not have time to get worried, nervous, or anxious about my brain being cut open and the possibility of dying. Sixty percent chance . . . that is what I learned were my chances of survival a few months later. Of those who do survive, about 66% have permanent brain damage.

One craniotomy, a clipped aneurysm, and who knows how many hours later, I woke up. Not knowing that I looked like Rocky Balboa after a boxing match, I asked my mom to take a picture of me. She was afraid that I would get scared when I saw myself, so she hesitated. She was trying to warn me, but I insisted. I wanted to see myself. To this day, we still laugh because even though I had a right black eye that I could not open, my face was swollen, and I had more than twenty staples in my head, when my mom went to take the picture, I gave her the biggest smile.

During my 2-week hospitalization, I experienced incredible amounts of pain. I had constant electric shocks that would travel down my legs. The pain was so high; it was hard to pay attention to anything. I could not sleep at night. I was uncomfortable and constantly complaining. Feelings of guilt and sadness started to develop, as I knew that my immediate family’s lives were also changing. The more I complained at night, the less sleep my dad would have. He would wake up every day at 5 AM to go work, despite my complaining all night. My mom, on the other hand, would wake up early to get to the hospital before my dad left. Knowing her, she probably did not sleep at all during those two weeks. My brother and sister who were living in the United States had to put their lives on hold to come to Puerto Rico. Their lives had dramatically changed without warning and for two weeks, their focus was set on my recovery and me.

Every day I was in the ICU, the team would ask me the date and the reason why I was in the hospital. Like a broken soundtrack I would repeat, “I had an aneurysm” (not knowing what that even meant) and would say the date. Because I was 19 years old, most if not all, the medical explanations were given to my parents. The physicians probably explained some things to me, but I did not understand what they were telling me.

Coming from a religious and spiritual family, prayers and doing the rosary was something I passionately held onto. Amid all the chaos, I sustained hope by praying and having support from my family and friends. Feeling that sense of unity and support helped me keep my spirits up. At the same time, being raised as a Catholic, this whole experience opened a new window that allowed my faith to grow. During the event and throughout my hospitalization, I kept a strong and direct line of communication with God. I remember how whenever I had high levels of pain, I would hold on to my rosary and pray the Hail Mary. Focusing on each bead of the rosary and trying to tune in my attention to what I was saying. This mindful practice would take my mind off the pain, allowing me to relax and focus my attention on what I was saying, while simultaneously strengthening my faith in God. Whenever I was feeling overwhelmed, I would ask God for patience and health. I asked him to give me the strength to move forward and begged him to help my family members during these hard times.

The use of creativity also provided comfort and acceptance. While I was at the hospital, I communicated with my extended family members and friends through a notebook. We called it the “traveling notebook,” as it went from person to person and then back to me. Through this traveling notebook, I was able to connect to the outside world. I was able to appreciate some sense of normalcy in the abnormal situation I was living.

After two weeks in the ICU, I was able to go home. At first, everything was different. As a teenager, life was changing and it was difficult to make sense of it all. Without knowing, what was a difficult experience was shaping my future decisions and creating a path to where I am today.

Predoctoral internship 2

I began my predoctoral internship in a rehabilitation hospital this past fall. During my first week of orientation, I remember feeling overwhelmed and highly emotional as if I was reliving experiences from my past. I was reading about the major cognitive and emotional sequelae of a brain injury including strokes and Traumatic Brain Injury. Although it triggered intense memories and emotions, reading this information allowed me to get a better sense of what I had experienced seven years earlier and to reflect on my journey and recovery. More specifically, it helped to articulate my unformulated feelings and answer many of my unanswered questions.

During the first six months after my stroke, I was impulsive, did not anticipate the consequences on my behaviors on others and myself, was more adventurous, and less anxious. I did not overthink and worry as I did before my stroke, I just did. Throughout the years, I had never understood why my behaviors changed after my brain injury. I had not been provided with education or information regarding common behavioral, emotional and cognitive symptoms that were commonly experienced following an acquired brain injury. Thus, the more I read and began to treat patients with similar medical conditions, the more aware I became.

Reflecting on my hospitalization and recovery, I realize how others who have had subarachnoid hemorrhages do not have the same experiences because they share the same condition. This is true of various other neurological conditions as well. How a person reacts and adjusts to his/her injury will depend on multiple variables (e.g., personality, individual’s values and beliefs, previous experiences, interpersonal relationships, attitude, culture, spirituality, among others). When working with patients, I try to conceptualize my cases through the biopsychosocial model, reminding myself to see beyond a potential diagnosis and remembering that this is a human being with his/her own ecosystem. Just like my life altered after my injury, so did my family’s life. As a result, when conceptualizing cases, I try to remember how an individual and his/her ecosystem can be directly or indirectly impacted after an injury.

Factors like culture, access to health care, socioeconomic background, and geographical location can also influence an individual’s recovery process and the overall information and education the person receives regarding their injury. My experience as a patient in Puerto Rico and now as a rehabilitation psychology intern has highlighted the differences that exist in the health care system. I am increasingly aware and sensitive to the role an individual’s ecosystem and other contextual factors can play in health care delivery. Like me, some patients might not be aware of certain cognitive, psychological and/or behavioral difficulties they may be experiencing after an injury. This can be the result of lack of resources to provide the adequate education. Therefore, as a clinician in training, I believe in the importance of information and how it can help raise awareness and empower the patient in his/her recovery process. When I see patients, I encourage them to ask questions and try to answer the questions they might have regarding their injury. By providing information, the patient and his/her ecosystem can better understand and make meaning of what is going on and what to expect after a brain injury.

Being the private person that I am, at the beginning of my internship year I was questioning whether to self-disclose my experience. I went through a traumatic experience; however, I did not have any physical evidence of what I had been through. You cannot see my scar and I was lucky enough to recover completely. Therefore, the question was, “Should I share this information with others?” Participating in seminars about stroke, TBIs, and neurological sequelae after brain injury all made me think about whether it was appropriate to share my experience. “Would I want everyone to know what happened to me?,” “Will it change the way they perceive/look at me?,” and “Am I ready to be this vulnerable?” Meeting my fellow interns and gradually trusting them enabled me to feel comfortable enough to share my experience. I might not have shared all the details, but the gist of it, as I could relate to some of the readings that we were discussing and could provide the perspective of someone who had lived a similar experience.

It is one thing to disclose to a group of students that are going to be with you throughout the entire journey of internship, but another thing entirely to self-disclose and share personal information to supervisors, an interdisciplinary team, and patients. I noticed a change in my willingness to share. When working with supervisors, at the beginning of the internship year, I thought sharing my experience would be appropriate if it was relevant to my work. For example, discussing possible countertransference while working with a patient, or sharing my perspective on a relevant topic. However, as an intern, one of our responsibilities is to give a presentation to the psychology department on a topic of our choosing. The Director of Clinical Training suggested that I use my experience as a patient and now as a clinician in training as the topic of the presentation. This was a challenging task that I was not sure I would be able to go through with. At first, I was hesitant, unsure if I was ready to face the psychology department and openly talk about this vulnerable and private experience. The more I self-reflected, the more I convinced myself that it was a good idea and that I had to push myself to do things outside my comfort zone. I encouraged myself to work on being more open and vulnerable, experience and learn from my anxiety and challenge my negative thoughts.

As I look back, I am proud and grateful to have risen to the challenge of sharing my experience with my supervisors, peers, and other professionals in the field. Even though the process was anxiety provoking, it allowed me to grow personally and professionally, while at the same time hopefully teaching others about my experience and what it is like to be “on the other side” and topics to consider when treating patients with acquired brain injury. By opening a safe space for others to share their stories, I was able to listen to others’ experiences lived either personally or vicariously and how it influenced their decision to become healthcare providers. After my presentation, I felt content and relieved. I noticed that during supervision, some of my supervisors were more open to exploring and addressing my countertransference issues, as well as sharing opinions about using self-disclosure in a rehabilitation setting.

The internship year has opened my mind and allowed me to be more flexible, particularly with topics related to self-disclosure, vulnerability, and countertransference. Even though I do not feel comfortable in sharing my experience with patients, I can understand how other therapists could use self-disclosure to strengthen the therapeutic alliance and to normalize and validate a patient’s experience. When working with patients, I believe it is important to focus on their needs and provide a safe and comfortable space to share whatever they feel is important. However, my personal experience has definitely provided me with insights that have shaped my interventions. Having been through this life-threatening experience has deepened my sense of empathy for the recovery process in others.

Seven years ago, I experienced a ruptured aneurysm. Who would have thought that that experience was going to be the catalyst for my interest in neuropsychology and rehabilitation psychology? Reflecting on meaning in life, reevaluating my priorities and values, and focusing on what was most important helped sustain me through my initial recovery. Focusing on what I could do and the blessings I had, rather than dwelling on what I had lost helped the healing process. Life comes with vicissitudes, hard moments, and moments of pure joy. We might not always have the answers or understand some of our life’s experiences, but with time, things start to make sense. As Victor Frankl’s (2019) emphasized, people do not get to choose their difficulties, but have the freedom to choose their attitudes and responses and maintain a sense of dignity. I am deeply grateful that I was able to fully recover, learn invaluable lessons that I apply in my clinical work, and have a long-term goal of closing the gap in Puerto Rico’s healthcare system.

Clinical practice implications

• Encourage the use of journaling to provide a safe space for patients to express intense emotions without feeling judged. Journaling is an effective way to self-reflect, detach, let go, and move forward with a sense of agency. Explore ways to channel creativity. Posters with affirmations, pictures, and “traveling notebooks” are effective ways for patients to stay motivated and connected with the outside world while they are in the hospital. Inquire about a patient’s religious preference. If applicable, use the information to help him/her connect with his/her spirituality to identify values, attitudes, and beliefs. • Encourage discussion about the pros and cons of the patient disclosing their medical condition to their friends, classmates, and family members. Questions to explore include “What they would want to disclose or not disclose?”, “With whom?”, “What fears and anxieties might they have about disclosing?”, and “What are the potential risks and benefits of disclosing?” Foster self-reflection, hope, and optimism by asking open-ended questions such as, “What do I have control over?,” “Is there anything positive that can come out of this situation?,” and “Am I holding onto something I need to let go of?”

Clinical and training implications

The rehabilitation psychology interns’ reflections above provide first-hand accounts of serious conditions requiring acute medical and rehabilitation care. Their insights and experiences provide invaluable implications for clinical work and supervision. The clinical practice recommendations have relevance for all practitioners working with trainees with medically ill patients and supply fuel for thought for healthcare clinicians at all levels of experience.

Supervision

The collaborative and open nature of the relational model of supervision is well suited to the fast-paced nature of a rehabilitation setting wherein members of the multidisciplinary team are continuously faced with uncertainty, and unexpected intense emotional reactions, while having to make moment-to -moment decisions based on incomplete information (Gordon et al., 2011). The model assumes that two distinct personalities exist in supervision, each with their own values, vulnerabilities, conflicts, blind spots, biases, and propensity to seek approval and recognition (Rock, 1997; Slavin, 1998). Among the primary aims of supervision are helping the trainee to develop their ability to contextualize and reframe the client’s experience, trust in their clinical intuition and judgment, and gain confidence in their clinical voice.

Common clinical issues arising in supervision as confronted by rehabilitation interns include questions regarding self-disclosure to clients, supervisors, or colleagues, challenges in communication with client, family, and treatment team, and existential issues provoked by acute life events such as hope in the face of uncertainty, meaning in life, and spirituality (Gordon et al., 2021). Internship programs can further facilitate a safe and collaborative environment for trainees to reflect on these experiences with didactic seminars, readings, and discussions beginning early on in the training year and addressing trauma, death and dying issues, and gaining awareness of personal values and countertransference reactions in a medical setting (Buechler, 2019; Gordon et al., 2009, 2011; Yalom, 2008). In addition, readings and seminars that provide a first-person perspective of the patient or family experience play a vital role in rehabilitation training programs (Crimmins, 2000; McKenna, 2016).

Communication

Communication with patients and family in pediatric care has been a controversial topic and constitutes an area of increasing recognition and importance. As highlighted in the narratives above, a common clinical dilemma may include what and how much information physicians should convey to pediatric patients about their illness, condition, treatment, and prognosis.

A recent review in this area concluded that physician communication typically preferences treatment features to the exclusion of emotional or distressing aspects of the situation (Seth, 2010). While families and medical staff may feel this helps avoid undue distress and fear, many pediatric patients report that fear of the unknown is an even a greater stressor. Further, parents frequently report that healthcare teams do not involve them in decisions as much as desired, do not talk in understandable terms, and do not provide a sufficient amount of information (Michelson et al., 2017), When young patients feel the gravity of their situation but lack crucial details or information, this can lead to loss of autonomy, frustration, fear to ask questions, and feeling isolated and distressed.

Hsiao et al. (2007) identified five domains of physician communication to be salient and influential, including building rapport, showing effort and competence, exchanging information, being available, and involving child and parents appropriately in the care. Furthermore, domains deemed unhelpful and potentially harmful were being rude or arrogant, not establishing rapport, being insensitive to sharing news about the child, not sharing information resulting in loss of trust, and revising treatment plans without preparing the child and their family.

Overall, the literature highlights frequent and common gaps in physician communication with pediatric patients and their families. Implementation of the aforementioned five domains can benefit the child in feeling included and aware of their condition and treatment, as well as the physician and parents in making difficult decisions. Therapists can further assist pediatric patients and their family members engage in effective communication with their physicians and team members.

Communication of neuropsychological findings

Given that children and young adults with neurological conditions often require a comprehensive neuropsychological evaluation, pediatric neuropsychologists may be in the unique position of communicating how a child’s medical diagnosis may impact neurocognitive, emotional, and social functioning. Thus, neuropsychologists may play a critical role as team members communicating important information about functional difficulties to the patients and families. As a result, there are numerous challenges for neuropsychologists to navigate including choosing how to talk to the patient in a developmentally appropriate way, how much information to disclose, and how best to assist with the emotional impact of the information conveyed to patient and their family.

Effective communication of neuropsychological assists patients and families to better understand strengths, weaknesses and implications of test results for future functioning (Rosado et al., 2018). Neuropsychological feedback typically includes explicit recommendations for patients and caregivers. Importantly, feedback can also foster a sense hope and provide a sense of empowerment through advocating for the patient (Postal & Armstrong, 2013). Sensitive but clear communication about neurological injury even when it is traumatic or life threatening can have major benefits for children and their family’s long-term psychological well-being (Stein et al., 2019).

Baron (2018) provided strategies for feedback including communicating results simply, defining terminology, incorporating parent restatement, providing examples of strengths and weaknesses, and encouraging questions. Establishing trust with all parties involved and allowing for open communication and the ability to ask questions is key. Direct, clear information that avoids technical jargon while not being overly simplistic is also vital (Postal & Armstrong, 2013; Stein et al., 2019).

There may be tension between providing sufficient information and allowing a process of gradual discovery and acceptance (Postal & Armstrong, 2013). As noted, it is vital to meet the patient and family at the appropriate stage of recovery, staying attuned to their readiness to receive information and when to address certain issues. For example, patients early in recovery may require communication about safety needs and immediate concerns while later patients may require signal readiness for more nuanced discussion of active rehabilitation, treatment motivation, or the impact of illness or disability on their own life trajectory.

Self-disclosure

While intentional self-disclosures have the potential to deepen the therapeutic relationship, they can be risky. Thus, self-disclosure in a supervisor-supervisee relationship can have a positive impact on the supervisory alliance and the supervisee’s impact with their patients, as well as guide the supervisee in learning appropriate and beneficial self-disclosure. Staples-Bradley et al. (2019) posit that supervisees will feel more comfortable and competent in self-disclosing to supervisors when provided with a positive supervisory relationship, reassurance that the self-disclosure will not result in a negative evaluation, exploration of the motivation, timing, and impact of the specific self-disclosure, and support for the self-disclosure to reinforce and reduce future hesitancy. Furthermore, the practice of self-disclosure to supervisors can help the supervisee in problem solving with their patients, promote development as a clinician, and enhance clinical judgment in a therapeutic relationship.

Buechler (2019) views self-disclosure as a way that therapists express their most important convictions, values, and priorities in life. We are inevitably disclosing information to our clients including what we attend to or not attend to in sessions, our nonverbal communication, what we remember or forget from previous sessions, and how we deal with empathic failures and mistakes (Buechler, 2019).

Hope

Hope helps children and families to face the reality of medical conditions by drawing upon internal sources of strength and stability in times of crisis (Freire et al., 2015). Hope is associated with increased optimism and improved self-esteem, and is an important precondition for resilience after aversive life events (Bonanno, 2021). Parents with more hope are better at problem-solving (Snyder, 2005). Additionally, with hope, the child and family can better adapt and adhere to treatment, promoting a better quality of life. Thus, hope is essential to well-being for the child and the family, and can play a protective role factor against potential feelings of loss of control when facing chronic and life-threatening medical conditions (Gordon et al., 2021).

Ways to promote hope in pediatric care include providing honest communication about the child’s medical condition and exploring sources of spirituality and strength, which further support family members to create meaning, find comfort, and make decisions (Hexem et al., 2011; Robinson et al., 2006). Additionally, providers can facilitate hope by asking the child where they find their inner strength (Remen, 2000) and encouraging the child to imagine how they will be in 3 or 6 months from now (Gordon et al., 2021).

Meaning in life, spirituality, and creativity

Meaning in Life (MIL), spirituality, and creativity have been documented as crucial parts to successful and adaptive recovery, and played significant roles in the recovery narratives shared above. MIL involves a felt sense of purpose and a feeling that one makes a difference in the world (Hill, 2018). Victor Frankl’s (2019) explores MIL by shifting emphasis away from the question of “what can one expect from life?” and toward “what does life expect from us?” Thus, Frankl suggests that life implies questions about meaning, purpose, and fulfillment.

As noted in the second vignette, spirituality can be facilitated through prayer and creativity. Prayer provides a sense of safety, a way to ask for guidance or help, and space to express hopes or fears. Prayer is a coping strategy to let go of the fear of the unknown and ineffectual attempts to control life into the control of a caring higher power. Creativity involves bringing something new into being and a heightened degree of engagement, intensity, and passion (May, 1975)

Concluding thoughts

During the second predoctoral intern’s aforementioned presentation, a question was posed to the group, made up of supervisors, training directors, physicians, and students to answer anonymously via web vote: How many of you have entered this field due to first-hand experience with a medical condition? Thirty percent of the group checked yes. This frequency of response was an important reminder of how Harry Stack Sullivan (1953) would say, we all are “simply humans” who have lives and experiences outside of being clinicians. However, separating one from the other would be impractical and even unskillful, as our experiences directly and indirectly inform our skills as clinicians. The frequency with which clinicians at a large academic medical center endorsed first-hand experience with a medical condition is an important reminder to be compassionate and aware of the hidden or silent scars that our colleagues may carry. We suggest prudence, care, and mindfulness when responding to team members, interns, patients, and families. It is possible to both engage and educate in order to provide the holistic and nurturing experience patients and families deserve. Rehabilitation clinicians can set the pace for open communication, self-reflection, hope, and growth.

To be compassionate, sensitive and mindful individuals, colleagues, and providers, we must use appropriate and effective communication, be open to disclosing in supervision, plan and prepare neuropsychological feedback, carry hope, and facilitate creativity, spirituality, and MIL. As psychologists, we can strive to model healthy communication and support our colleagues in adjacent fields. With the above perspectives and suggestions in mind, patients may feel understood, informed, and even hopeful for recovery, treatment, and prognosis. By sustaining an open training environment, predoctoral interns with and without a history of serious illness or injury will find validation for their experiences and support for the development of their clinical voice and professional identity.

Biographies

Robert M. Gordon is a Clinical Associate Professor at New York University Grossman School of Medicine and consultant to the Postdoctoral Fellow Training He was the Director of Intern Training at Rusk Rehabilitation for 34 years. He has published in the areas of existential-relational approaches with patients with medical conditions during COVID-19, ethics, supervision, pain management, and the use of projective testing in neuropsychology. He is a member of the Hospital, Health and Addiction Workers, Patient and Families Working Group at the APA Interdivisional Task Force on the Pandemic.

Aria B. Grillo is completing her doctorate degree in Clinical Child Psychology doctorate program at Ferkauf Graduate School of Psychology, Yeshiva University and her pediatric neuropsychology internship at NYU Langone Medical Center working within the Fink Integrated Behavioral Health team of Hassenfeld Children’s Hospital. Aria has co-authored articles, presented at conferences, and successfully defended her dissertation focusing on the development of a text-based support program for Neonatal Intensive Care Unit (NICU) parents. Aria’s interests include working with children and their families living with medical and mental health comorbid diagnoses, anxiety and mood disorders, depression and psychological trauma utilizing an integrated informed approach combining CBT, DBT-A, and humanistic psychology lenses. Aria’s work is informed by her commitment to the importance of protective factors including resiliency, hope, parent-child relationships, social and community supports. Aria will begin her postdoctoral fellowship at New York Presbyterian Hospital in the Fall working in child and adolescent inpatient and outpatient services.

Natalia S. Bernal-Fernandez was born and raised in San Juan, Puerto Rico. Natalia is completing her doctorate in Clinical Psychology at Albizu University, San Juan Campus in Puerto Rico and her psychology internship year at NYU Langone Rusk Rehabilitation. Her areas of interest include cognitive rehabilitation, neuropsychological evaluations, and health disparities particularly in the Latinx population. Natalia’s dissertation was on Multidisciplinary Service Program: Cognitive Rehabilitation as an Intervention for Puerto Rican Patients between the Ages of 25 to 49 Years with Cognitive Impairment Related to Chemotherapy Treatment. She will begin her postdoctoral fellowship training at Mount Sinai’s Clinical Neuropsychology and Rehabilitation Research Fellowship Program in the Fall.

Taylor D. Groth earned her PhD in Clinical Psychology from Derner School of Psychology at Adelphi University. She completed her internship in pediatric rehabilitation and neuropsychology at NYU Rusk, and is currently a post-doctoral fellow at NYU Rusk. Her clinical and research interests include psychotherapy process and outcome in children and adolescents, and pediatric neuropsychology. Taylor has a number of publications in journals including the journal of Psychotherapy; Psychotherapy Integration; Professional Psychology: Research and Practice; and Journal of Child and Adolescent Trauma. Additionally, Taylor published an award-winning paper in the journal of Suicide and Life-Threatening Behavior. This paper, “Psychologists’ willingness to provide services to individuals at risk of suicide,” earned the APA Division 29 Mathilda B. Canter Education and Training Award (2018) for papers addressing education, supervision, or training of psychotherapists.

Jed N. McGiffin completed his doctoral training in clinical psychology at Teachers College, Columbia University under the research mentorship of Dr. George A. Bonanno in the Loss, Trauma, and Emotion Lab. Dr. McGiffin’s research interests lie at the intersection of psychology and medicine, including risk and resilience factors associated with psychological adjustment following acute medical events, as well as the broader process of adaptation to acquired disability. He completed his psychology predoctoral internship at Rusk Rehabilitation, NYU Langone Health and is currently a second-year psychology. His postdoctoral fellow in Advanced Rehabilitation Research and Training (NIDILRR) at Rusk Rehabilitation under the mentorship of Dr. Joseph F. Rath.

Kenneth D. Hartline received his Doctor of Psychology degree in clinical psychology from Pepperdine University’s Graduate School of Education and Psychology in Malibu, CA. He is Board Certified in Clinical Neuropsychology. He completed his APA-accredited internship at Rusk Rehabilitation at NYU Langone Medical Center in New York. Dr. Hartline completed a two-year postdoctoral fellowship in pediatric clinical neuropsychology at Children’s Hospital Los Angeles, where he trained in pediatric traumatic brain injury and epilepsy. Following his training, he was an Assistant Professor of Neurology at the University of Southern California’s Keck School of Medicine. He is currently a pediatric neuropsychologist and supervisor of psychology at Rusk Rehabilitation at NYU Langone Orthopedic Hospital. His areas of research interests and publications include pediatric rehabilitation following head injury and cognitive functioning in individuals with neurological disorders including epilepsy.