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PURPOSE Changes in the health care environment have brought challenges and opportunities to the field of psychology. Practitioners have been successful in modifying service models to absorb losses of financial support for behavioral health care, due to managed care and public policy changes, while simultaneously managing the growing need for these services. However, in this reactive mode of responding to evolutions in the health care system, the field of psychology has at times lost sight of the long-term vision required to promote psychology's inclusion in the health care system of the future. In particular, a focus on training psychologists and ensuring the availability of funding to support these activities must be a priority in planning for the future. This article provides an overview of federal programs that currently offer funding for psychology training, as well as other opportunities for federal funding that have been unrealized. Details regarding advocacy efforts that were required to secure available sources of funding are given, followed by consideration of strategies for taking advantage of existing resources and prioritizing advocacy for additional funding. CONCLUSION Funding for psychology training provides an avenue for increasing the number of well-trained psychologists who can serve patients' mental and behavioral health needs and thereby improve health outcomes. Moreover, capitalizing on available funding opportunities for psychology training and promoting efforts to expand these opportunities will help ensure that the field of psychology is positioned to remain an important contributor to the health care system of the future.

The US Congress faces a host of health issues that demand immediate attention. Many of these issues are of considerable importance to those persons with spinal cord injury (SCI), including the rising cost of health care and health insurance, the current budget shortfalls facing state governments, and the need for a Medicare prescription drug program. Persons with disabilities are becoming increasingly dependent on public forms of insurance, like Medicare and Medicaid, and are bearing a disproportionate share of service curtailment. Other issues relevant to persons with disabilities and health care providers are prospective payment reimbursement implementation for rehabilitation, the reauthorization of the Rehabilitation Act, and the New Freedom Initiative. Considering the political climate and the importance of such issues, the need for advocacy among professionals and consumers is greater than ever.

Objective. Research in the areas of pediatric rheumatology and pediatric chronic illness has emphasized comprehensive models of adaptation involving risk and resistance factors. This study examined adaptation, within this framework, among a large sample of children with chronic illness and children without chronic illness. Methods. A comprehensive battery of adaptation measures was administered to a sample of 107 children with juvenile rheumatoid arthritis, 114 children with insulin-dependent diabetes mellitus, and 88 healthy controls. Results. Medical diagnosis was associated with mothers' depression and a composite measure of parental (mother and father) distress and passive coping. Children's emotional and behavioral functioning was not related to medical diagnosis, but mothers' depression and parental distress were associated with child behavior problems. Conclusion. Because parental distress was associated with child functioning, interventions to ameliorate parental distress may have beneficial effects on the children's behavior and on parents' reactions to their children.

Return to work following spinal cord injury is achievable for many individuals. Interdisciplinary rehabilitation teams are ideally suited to facilitate an individual's efforts at overcoming the numerous barriers involved in returning to gainful, competitive employment. Many of these barriers are person-specific (i.e., education level), and multifaceted assessment and comprehensive vocational planning are suggested. Other barriers, such as economic disincentives and poor access to needed services, are less easily overcome. Rehabilitation professionals are encouraged to become familiar with recent health and disability policy (i.e., Americans with Disabilities Act) and become proactive in policy formation. There is a significant need for development and testing of model programs to enhance return to work for individuals with spinal cord injury.

Neuropsychological assessment is a standard procedure for rehabilitation patients with cognitive dysfunction. However, the use of neuropsychological evaluations in rehabilitation settings is limited as the most commonly used measures were originally developed for diagnostic purposes with an emphasis on localization/lateralization of lesions and description of brain-behavior relationships. As a result, the functional (versus diagnostic) utility of neuropsychological evaluations is questionable at best. Furthermore, neuropsychological evaluation in rehabilitation settings will continue to be of limited utility as long as INS-APA Division 40 guidelines continue to emphasize training in neurologic and neuroanatomic factors, with minimal attention to rehabilitation issues and resources. Several factors necessitate the use of neuropsychological evaluations for functional rather than diagnostic purposes, including advances in neuroradiological evaluation, the growth of rehabilitation facilities given increased survival rates for brain injured patients, and an associated greater need for psychological services for these patients. Suggestions are offered for improving the functional utility of neuropsychological evaluations, as well as more effective ways to train neuropsychologists in rehabilitation issues and interventions.

Managed care has affected the delivery of services in all health care sectors, although its impact on rehabilitation has been slower to take effect. These changes have required clinicians to provide more efficient services that are demonstrated to have an impact on functional outcome. However, in order to be reimbursed for specific rehabilitation services, such as cognitive rehabilitation, it is necessary for clinicians to become more knowledgeable regarding managed care, service delivery, and reimbursement issues. This article describes the impact of managed care on health care in general and on rehabilitation specifically. In addition, current billing procedures and reimbursement issues as they relate to cognitive rehabilitation are discussed, and suggestions for ways to secure reimbursement are presented for all disciplines providing cognitive rehabilitation services.

State Medicaid programs are rapidly converting fee-for-service health delivery systems to managed care for people with disabilities. In theory, managed care models of health delivery will substantially improve the quality of care for people with disabilities, but in reality, few successful models exist. This period of transition holds both opportunities and challenges for psychologists in medical settings. Because Medicaid reforms for people with disabilities may herald similar reforms for both the public and the private sectors, psychology's response will determine its role in the future of health care delivery for this population. Changes in training and increased attention to outcomes research, innovations in practice, and advocacy will be the keys to success.

This study examined the relationships of the dispositional variables of hope, positive affectivity (PA), and negative affectivity (NA) with disease status and illness-related psychosocial functioning in a sample of 45 young adults with insulin-dependent diabetes mellitus (IDDM). Canonical analyses revealed one significant canonical function between the dispositional and psychosocial outcome variables. Primary contributors to the relationship were higher NA and lower PA and maladaptive emotional behavior. A linear multiple regression analysis using hope and affectivity as predictors failed to account for a significant proportion of variance in objective disease status as measured by hemoglobin A 1C (HbA1C). The results support previous findings that affectivity may relate to self-reported, disease-related outcome, but not necessarily to objective measures of health status. Future studies of adaptation to chronic illness should consider including measures of illness-related behaviors (e.g., adherence), as well as subjective and objective measures of health status.

The current study examined anger expression styles and their relationship to levels of depressed mood and aggressive behavior in male and female children and adolescents. Measures of anger, anger expression, and depressed mood were collected from both children and their parents. Hierarchical multiple regressions revealed that anger expression significantly predicted sadness but not aggression for females, after accounting for age and anger level. Among males, anger expression was important in predicting aggression but not sadness, whereas age and anger level best predicted sadness. These results suggest that age, anger level, and anger expression may be risk factors for depression and aggression among children and adolescents. Sex appears to be an important factor in anger expression styles and related depression and aggressive behavior.

Rehabilitation medicine represents a substantial area of growth in the healthcare industry over the course of the last two decades. Historically characterized by collaborative, interdisciplinary team approaches and the inclusion of family members in treatment, rehabilitation medicine targets restoration of functional abilities in individuals with debilitating illness or injury. Interestingly, systems /biopsychosocial frameworks that have been incorporated into other areas of medicine have been underutilized in the rehabilitation context. Systems theory and biopsychosocial approaches to rehabilitation medicine appear to have considerable value and utility in this field, particularly in light of current and proposed healthcare reform. We argue that the systems perspective, which has enjoyed success in the area of family systems medicine, can be further extended into the rehabilitation context. A systems perspective as applied to the rehabilitation setting is provided in the present article, and recommendations are made for increased involvement by systemstrained professionals from clinical, re

As demographics shift to include more elderly populations and those living with chronic medical conditions, costs for health care services continue to escalate. As a result, health care systems around the world increasingly struggle to provide cost-effective, coordinated, and quality health care to those they serve. Significant policy, procedural, and practice changes are essential in solving these growing problems. With experience in interdisciplinary teams, rehabilitation psychologists and other psychological providers have a clear vantage point from which to help guide movement toward an integrated health care model that values health promotion, prevention, and collaborative care. Psychologists can be an integral part of this new “interdisciplinary team,” but, as a profession, we must advocate for this inclusion and position ourselves to take on this new role through education and training.

Head injury constitutes a significant public health concern. Despite increasing recognition of the morbidity and mortality associated with head injury, there exist few statewide estimations of the prevalence and public perception of head injury. Knowledge of the public's perception can facilitate the funding and planning for the treatment and rehabilitation of persons with head injury. This study was undertaken for this purpose by the Missouri Head Injury Advisory Council and consisted of a stratified sampling of 1123 Missourians in a statewide telephone poll. The results revealed that the general public has an accurate perception of head injury and that knowledge improved as a function of direct experience with head injury.

Individuals sustaining spinal cord injury often display initial distress followed by relatively effective coping allowing effective participation in rehabilitation. For those patients who continue to display significant symptoms of subjective distress or objective behavioral disturbance, behavior management interventions may help the individual cope with the demands of rehabilitation. A range of intervention strategies, drawn from many theories of behavior are needed to address the range of problems that occur. In the approach described in this article, traditional behavior modification programs, recruitment of family, and patient-community meetings are considered as behavior management strategies. Those strategies are considered with respect to three broad areas of behavioral disturbance: (1) problems of attitude, (2) disorders of mood, and (3) disturbances of character. Behavior management is conceptualized as a method of affirming the patient's autonomy, independence, and self-determination. Suggestions are made regarding program development.

Legislative advocacy is a prerequisite for the development of research and community services benefiting individuals with traumatic brain injury (TBI). Dr Mitchell Rosenthal and other leaders in rehabilitation began the process of advocating for TBI services more than 25 years ago, before many in the field fully appreciated the necessity of these efforts. Since that time, substantial gains have been made through advocacy efforts on behalf of individuals with TBI and their families. This article provides an overview of the TBI advocacy movement, highlighting federal legislation resulting in appropriations for TBI services and protecting the rights of individuals with TBI. Key government entities engaged in developing states' TBI infrastructure and providing services to individuals with TBI and their families are also discussed. In addition to celebrating some of the successes that were initiated by the efforts of Dr Rosenthal and other visionaries, select shortcoming of current legislation is noted to provide insights regarding future advocacy needs.

Examined the relation of hope to occupational burnout among 81 nurses in chronic-care rehabilitation units. Hypothesizing from Snyder's (1989) model of hope in the reality negotiation process, it was predicted that hope would be significantly predictive of three separate components of burnout. Nurse burnout was assessed with the Maslach Burnout Inventory (Maslach & Jackson, 1981). Separate regression equations revealed higher levels of hope to be signficantly associated with lower emotional exhaustion and depersonalization, and greater personal accomplishment

This study examined the long-term impact of a five component spinal cord injury prevention program presented to adolescents. A sample of 445 teenagers who attended a junior high school in which an educational intervention was presented three years earlier and a control group of 379 students who had not been exposed to the intervention completed a questionnaire assessing their safety knowledge, attitudes, and self-reported behaviors. Total scores on the questionnaire between treatment and control groups differed significantly. Students in the treatment group reported significantly more frequent seat belt use, stronger belief that seat belts were important to their safety, lower likelihood of riding with friends who had been drinking, higher rates of friends' use of seat belts, greater awareness of the age group most likely to be injured, and increased knowledge that they could prevent spinal cord injury.

Diagnosing mood disorders in chronic illness is problematic. Under-standing the value of individual symptoms in predicting depression is one approachto this problem. The contribution of individual symptoms to the diagnoses of majordepressive disorder (MDD) was examined in 82 patients with confirmed rheuma-toid arthritis (RA) and a control sample of ISO university employees. Comparisonsbetween DSM-HI and DSM-EQ-R rates of MDD were derived using the Inventoryto Diagnose Depression (IDD). It was found that cognitive-affective symptomssuch as dysphoric mood, acknowledgment of guilt, and suicidal ideation were themost efficient predictors of MDD. According to DSM-IH-R criteria, 16% of the RAsample met criteria for diagnosis of MDD, while 27% of the R A sample met criteriaaccording to the DSM-1H. RA patients reported that their arthritis affected theirmood at least occasionally. Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory disease thataffects approximately 1% of the population (Zvaifler, 1988). In addition to thepain and physical disability that are principal features of the illness (Potts,Weinberger, & Brandt, 1984), a variety of psychological factors has beenidentified as concomitant to disease(Anderson, Bradley, Young, McDaniel, W Frank et al., 1988; Rimon, 1974; Rimon & Laakso, 1984;Zaphiropoulos & Burry, 1974).The assessment and diagnosis of depression in RA has been questioned onclosely interrelated, conceptual, and methodological grounds. First, the few earlystudies citing the prevalence of depression in RA (e.g., Bishop et al., 1987;Zaphiropoulos & Burry, 1974) utilized instruments that were not designed todiagnose depression. These instruments contain many somatic items that arecommon to both depression and chronic illness (Turk, Rudy, & Stieg, 1987).Researchers in these studies typically have used self-report instruments such asREHABILITATION PSYCHOLOGY Vol. 36, No. 4,1991

Cognitive deficits associated with closed head injury (CHI) have been well studied. Less attention has been directed to the emotional consequences of CHI and subsequent attempts to cope with major life events. CHI typically constitutes a catastrophic injury, yet few studies have examined coping strategies used by individuals after CHI or the effects of CHI on family functioning that may mediate coping. Previous workers have speculated that time since injury is a crucial determinant of coping; however, this has not been investigated with regard to CHI. In this preliminary investigation, 40 patients with CHI were compared with 17 neurologically intact controls. The CHI group was divided into two groups according to time since injury. It was found that patients with CHI used information seeking as their most dominant coping strategy regardless of their time since injury. Patients with CHI had higher family cohesion scores than control subjects. Implications of these findings for psychological response to CHI are discussed.

Survivors of severe closed head injury (CHI) were compared with neurologically normal matched controls on measures of short-term memory processes. The results indicate that patients with CHI took longer to scan their short-term memory than controls, and this increased disproportionately as the memory load increased. The number of errors made in scanning short-term memory increased for patients with CHI, suggesting inefficient as well as slow scanning. These differences were present despite equivalent memory span between groups. The results of this study have implications for day to day memory processes that require manipulation of information in short-term memory.

Spinal Cord Injury, J. Scott Richards et al Limb Amputation, Bruce Rybarczyk et al Traumatic Brain Injury, Mitchell Rosenthal and Joseph Ricker Stroke, Bruce Caplan and Steve Moelter Geriatric Issues, Peter A. Lichtenberg and Susan E. MacNeill Neuromuscular and Musculoskeletal Disorders in Children, Dennis C. Harper and David B. Peterson Brain Injuries, David R. Patterson and Greg R. Ford Multiple Sclerosis, Gerald M. Devins and Zachary Shnek Chronic Pain, Daniel M. Doleys Hearing and Vision Loss, Robert Q. Pollard, Jr. et al Psychiatric Rehabilitation, Gary R. Bond and Sandra G. Resnik Functional Status and Quality of Life Measures, Allen Heinemann Assessment of Psychopathology and Personality in Persons with Disabilities, Cynthia L. Padnitz et al Evaluating Outcomes Research - Statistical Concerns and Clinical Relevance, Mary J. McAweeney Neuropsychological Assessment, Tim Conway and Bruce Crosson Forensic Psychological Evaluation in Rehabilitation, Brick Johnstone et al Patients with Brain Tumors, Marc W. Haut et al Paediatric Neuropsychology, Janet E. Farmer and Laura Muhlenbruck Alcohol and Traumatic Disability, Charles H. Bombardier Postacute Brain Injury Rehabilitation, James F. Malec and Jennie L. Ponsford Neuroimaging and Rehabilitation Outcome, Erin Bigler Rehabilitation Based on Behavioural Neuroscience, Edward Taub and Gitendra Uswatte Disability and Vocational Behaviour, Edna Mora Symanski Injury Prevention, Frank A. Fee and Dawn A. Bouman Social Support and Adjustment to Disability, Kathleen Chwalisz and Alan Vaux Caregiving in Chronic Disease and Disability, Richard Shewchuk and Timothy R. Elliott Social Psychological Issues in Disability and Rehabilitation, Dana S. Dunn The Disability and Rehabilitation Experience - an African American Example, Faye Z. Belgrave and S. Lisbeth Jarama Prospective Payment Systems, Kristopher J. Hagglund et al Education in Rehabilitation and Healthcare Psychology - Principles and Strategies for Unfiying Subspecialty Training, Robert L. Glueckauf Ethics in Rehabilitation Psychology - Historical Foundations, Basic Principles and Contemporary Issues Stephanie L. Hanson et al Drawing New Horizons for Rehabilitation Psychology, Timothy R. Elliott and Robert G. Frank.

Although depression has been widely studied among persons with spinal cord injury, the ubiquitous and unsophisticated use of the term and presumptions about its manifestations in the rehabilitation setting have needlessly encumbered the understanding and treatment of depression. Major themes and issues in the study, measurement, and treatment of depression among persons with spinal cord injury are reviewed. Greater precision is recommended in distinguishing diagnosable depression from displays of negative affect, anxiety, distress, and dysphoria. Correlates of depressive behavior among persons with SCI are surveyed, and guidelines for research and practice in the SCI setting are explicated.

Objective. Family resources and coping skills are important to adaptation to pediatric chronic illness. Psychological and educational interventions have been found to enhance the coping skills of children with juvenile rheumatic disease (JRD) and their families. We examined the efficacy of a 3-day family retreat as a multidisciplinary, comprehensive treatment. Methods. Children with JRD and their caregivers completed questionnaires assessing the children's behavioral and emotional functioning, pain, strain on caregivers' work and leisure activities, and caregivers' psychological distress before and 6 months after the family retreat. Principal caregivers were both parents for 16 children, mothers only for 10 children, and an aunt for 1 child. Results. Improvements were found in children's emotional functioning, strain on caregivers' work, and strain on caregivers' leisure activities. Reductions in reported pain were not consistently revealed. Conclusions. Family retreats are an efficacious, multidisciplinary approach to helping families of children with JRD cope with the disease and its manifestations. Importantly, retreats offer a comprehensive intervention package that might not be available to families on an individual basis.

Objective. Children and adolescents with juvenile rheumatoid arthritis (JRA) often report pain as a major symptom that affects their daily activities. Little is known about the factors that contribute to pain, however. Demographic, disease status, and social-psychologic variables were used to predict pain of JRA. Methods. Participants were 37 girls and 23 boys who were 7 to 17 years old. Measures included the Hopelessness Scale for Children, the Sadness Scale from the Differential Emotions Scale—IV, and the Social Support Questionnaire-Revised. A pain visual analogue scale served as the criterion measure. Results. Reported pain was modestly correlated with disease duration and age. A hierarchical regression indicated that the predictor variables accounted for a modest amount of variance in pain scores. Conclusions. The results suggest that the factors contributing to pain in children with JRA are different from those in adults with rheumatoid arthritis (RA). Research is needed to identify the psychologic and socioenvironmental variables that influence pain among children with JRA.

Functional outcome after traumatic brain injury (TBI) is thought to be dependent upon effective social support and avoidance of depressive episodes. Research indicates that post-injury changes often occur in the family's functioning, hence impacting the family's ability to provide the needed social support. Social support, in turn, has been hypothesized to work as a buffer between significant life event and levels of depressive symptoms. Thus poor social support after a TBI, due to changes in family functioning, could result in depressive episodes for the person with a TBI. This paper empirically examines this question by investigating whether social support is predictive of depression in persons who have sustained a TBI. Thirty-nine persons who had sustained TBI were interviewed to assess their family functioning, perceived social support, and current depressive symptomatology. The results showed that the effective use of problem-solving and behavioural coping strategies by the family in response to TBI was significantly related to lower levels of depression in the person who sustained the TBI. However, perceived social support was not predictive of depression.

Depression frequently is diagnosed in persons with chronic illness or following the onset of disability. The overlap of symptoms of many chronic illnesses and disabling conditions with depression may lead to an overestimation of depression in such populations. Some investigators have proposed revised criteria for diagnosing depression in these conditions without an understanding of the contribution of diagnostic criteria in disabling conditions. This study investigated the nature of depressive symptom criteria constellations by individually factor analyzing the Inventory to Diagnose Depression (based on DSM-III diagnostic criteria) in spinal cord injury (n = 134), rheumatoid arthritis (n = 78), student (n = 140), and community (n = 150) groups. A four-factor solution emerged, with the first factor labeled "dysphoria" being represented by symptoms of negative self-evaluations, depressed affect, and suicidal ideation. The results indicate that a core element of the syndrome of depression is dysphoria, which suggests that the contribution of somatic items may be less important to the identification of the depressive syndrome in chronic illness.

Locus of control (LOC) beliefs, long thought important in adjustment to persistent pain, were studied among 160 subjects (67 males and 93 females) referred to a comprehensive pain rehabilitation program. The subscale structure of the Multidimensional Health Locus of Control (MHLC) was factorially replicated in our sample. Three unique MHLC profile clusters were identified for both males and females. Among men, cluster assignment was related to age only. The younger male patients reported a stronger internal attributional style. Older male patients relied more heavily on both chance and powerful other factors. Among women, cluster assignment was related to the use of coping strategies. For example, patients with high internal scores only, reflecting a strong internal orientation towards self-management of health care needs, were more likely to utilize Information-Seeking, Self-Blame, and Threat Minimization coping strategies than patients with high scores on both the Internal and Powerful Other factors. It appears that the presence of both Internal and Powerful Other health attributional styles is associated with less frequent use of cognitive self-management techniques. In understanding the LOC scores it is important to rely on pattern analysis of scores. Implications for clinical treatment are discussed.

Closed head injury (CHI) results in significant memory dysfunction. Although the disabling aspects of memory impairment after CHI have been recognized, little attention has been focused on the theoretical nature of these memory problems. A means of examining semantic sensitivity to the importance of the ideas presented in the Wechsler Memory Scale-Revised Logical Memory subtest was developed. Subjects with CHI were sensitive to the semantic structure of the stories, but lost more important information at a faster rate than controls. Differences in recall, dependent on the passage, suggested that the two stories in the Wechsler Memory Scale-Revised are not equivalent.

SummaryMuch of what is known about the psychological response to amputation is derived from studies of veterans. Most recent amputees come from a different group; they are typically older and have experienced medical problems prior to their amputation. In order to investigate the effects of age and time since amputation on psychological response, 66 amputees were assessed by the Symptom Checklist-90, Beck Depression Inventory and interviewed. When classified by time since amputation and by age, the results indicate that older amputees exhibited less depression and fewer psychological symptoms: in contrast, younger amputees evidenced increased depression and psychological symptomatology the longer the time since their amputation.

Adjustment to spinal cord injury has traditionally been assumed to be accompanied by depression. Yet contemporary research has failed to support this view and has provided evidence that depression is maladaptive in rehabilitation and adjustment. This paper reviews and integrates this literature. Methodological and theoretical perspectives are discussed. Recommendations for future research are proposed, and implications for clinical practice are addressed.

In the initial study, 48 subjects of the total (N = 63) ultimately used, were assigned to one of three treatments: (a) four hypnotic sessions with a booster, (b) two hypnotic sessions, or (c) two hypnotic and two behavioral sessions with a booster. A follow-up group was later recruited composed of 15 subjects who received four hypnotic sessions and a booster session with less time between sessions. The results indicated no difference in smoking cessation 6 months after treatment regardless of the frequency, length between sessions, or addition of behavioral methods. Successful subjects were more educated, less able to utilize their imagination, and had fewer smokers at home.

Differential responses to depressed male and female spinal-cord-injured persons were assessed using an analogue model. Forty male and 53 female undergraduates listened to a scripted audiotape interview of either a male or a female individual with a spinal cord injury who was either depressed or not depressed. There were no significant effects for subject gender, and, regardless of the sex of the target person, the depressed individual was rated less attractive, competent, and desirable. However, the depressed female elicited the least desire for future interaction. Although there were no target gender differences in attractiveness for the depressed condition, the nondepressed male with a spinal cord injury was viewed as significantly less attractive than his female counterpart.