The psychological adjustment necessary for transitioning to assistive devices is an emotional whirlwind for most patients. The personal meanings for each patient vary depending on disability status, nature of the devices, and the degree of difficulty of incorporating the device into daily life. This article will review the common emotional challenges patients undergo, and will suggest a few counseling points to integrate into sessions.

Occupational and physical therapy professionals often work with patients who have a medical need for assistive devices. When you work with patients who are going through this transition, it is important to remember that, at the most fundamental level, you are entering an individual's life story. While an assistive device does assist with preserving functioning, it exists in the shadow of a loss of function. It is both a beginning and an ending.

Mobility changes have layered ramifications for many domains of living, including shopping, social outings and transportation. Patients will exhibit feelings of loss-not just loss of ability, but also loss of control. Common manifestations of loss can include anger, denial, frustration and sadness. Each patient will differ in his or her emotional reactions, their intensity, and the ways of cycling through these feelings. The introduction of assistive devices jolts the mind-body system on multiple levels, regardless of whether the patient is newly disabled, chronically disabled or elderly. It takes time to reach the stage of acceptance.

To explore the emotional dimensions of this transition, I consulted with Judith Goldberg, Director of the Initiative for Women with Disabilities at NYU Hospital for Joint Diseases. Goldberg is a rehabilitation counselor, an administrator and an individual with a disability. She has osteogenesis imperfecta (brittle bone disorder). She first shared her own experience with transitioning:

"I walked with a cane since age 10. In my early 40s, I started using crutches. I thought it would be temporary. I blocked it out at the time. What I hated about the crutches was that they made so much noise and they were cumbersome. Later, I had crutches custom made for me. It changed my whole function. On the one hand it made it easier. I was walking straighter and was much more balanced and was not falling. But I thought I blended in better with my cane; I think that was just wishful thinking. Now, my devices are just a part of me. I accept my body as it is. But some days I miss my former physical self."

The grief/loss cycle also catapults patients to a deeper level of transition?identity transition. Each person's age, life situation and previous level of functioning affect the meaning that an assistive device may have. Patients are not only adjusting to the mechanics of how to use a device, but also to a new aspect of their identity. It is common for patients to go through a psychological process called adjustment disorder. This frequently occurring condition is described in the Diagnostic and Statistical Manual of Mental Disorders (DSM IV). Adjustment disorders can be accompanied by anxiety, depression or a mix of both.

Responses from families, friends and strangers also compound the adjustment process. When patients transition to devices, it does not happen in a bubble. They go out into the world where members of society may have reactions, judgments or questions for them about their change in status. This reality impacts both the adjustment and the identity process. The OT can listen for such difficulties. Counseling referrals may be critical at this juncture.

Julie, a woman with multiple sclerosis, shares an example of what her experience was like.

"When I started to have balance problems at 37 due to MS, I started with a single cane. This was a big adjustment. I moved to a walker a year later at 38. At this point, I felt that everyone at work knew something was 'wrong' with me. The walker improved my functionality, but it was really hard. The only people I knew who used a walker were older people in my neighborhood. I felt like I was going through accelerated aging."

There are a few counseling points to keep in mind when patients are undergoing the transition to devices. First, I promote the idea of concept education. (Mathew, forthcoming) Making skillful use of a device requires an understanding of central concepts. Patients need to be educated on concepts such as function-oriented goals, energy conservation and stress management, so that they can find a realistic balance between their functionality and their limits.

Goldberg offers one example of how she conducts her counseling sessions:

"For the women in our program, I always start by validating feelings of loss, anxiety and frustration. Then I encourage them to try to focus on identifying as a woman and as a person first. I explain that devices are a means to an end. It (the device) is a part of your being that helps you get through the day. I emphasize that the device is not who you are."

Another a common concern I hear among patients is that, while OT and PT interventions are helpful on a basic level-how to use and adapt to a device to preserve functioning-the fine nuances of functionality get lost. Functional assessments should include not only the direct mechanics of how to use devices, but also ways to integrate their use into family life, work life and one's role as a citizen.

As a way to bridge this gap, I would recommend encouraging patients to keep an activity log. The world is quite a different place from the rehabilitation clinic where training takes place. Encouraging patients to keep a log of functional challenges can teach the skill of problem solving on an ongoing basis. For this intervention, it can also be helpful to engage caregivers to keep a watch out for functional issues that they observe-situations where their loved ones would need additional help.

John, a 32-year-old man with cerebral palsy, talked about how his learning curve is ongoing with his ankle-foot orthoses and crutches.

"When I started going to work in the city, I had to deal with subways, curbs, pot-holes, stairs and bad weather. I would be so stressed out about my commute, I often forgot my lunch at home. I kept going back to my OT to ask her questions about how to handle my commute. I learned that I needed a practical plan every day but also an emotional plan for when I get upset about my functioning."

OT also offers myriad adaptive solutions for the various areas of daily life: cooking, self-care and work. While these solutions do restore patient functioning, they also can be accompanied by feelings of adjustment and loss. Again, acknowledging the emotional impact of these transitions can aid in helping the patient accept new solutions to emerging limitations.

Elise, 79, shares her experience of adapting to OT solutions in different areas of her lie.

"I had my stroke at 78, after my husband died. He was no longer around to help me. My OT guided me to many adaptive devices for the kitchen and bathroom. I had all sorts of tools to cook again and also to care for myself.

I also had to add a shower chair and rod in my bathroom; my home has a lot of devices. It was a lot within a three-month period. I felt overwhelmed at first, but then I learned that these tools keep me safe and independent. Learning how to use each device safely took time and energy to get used to it."

For more information:

To learn more about concept education, contact Reji Mathew at rqm3463@nyu.edu. She will devote an entire article to concept education later in the year.

Dr. Reji Mathew is a psychotherapist/clinical instructor at the New York University. Her clinical expertise is in integrative psychotherapy, particularly cognitive behavioral skills training. Reach her via email at rqm3463@nyu.edu.

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