Psychological Interventions 429available to some individuals because of restricted access,
lower socioeconomic status, or disabling aspects of the envi-
ronment (e.g., lack of public transportation, limited funds in
state Medicaid, vocational rehabilitation, or independent liv-
ing programs). Health care providers and insurance payors
vary considerably in their sensitivity to, and provision for,
assistive devices that enhance quality of life and facilitate so-
cial integration.
Similarly, people with SCI face issues that emerge as they
age. Children who incur SCI encounter many developmental
challenges that must be navigated with ample support from
family members, educational institutions, and service
providers (Apple, 2000). These issues are readily apparent in
the different interests observed between younger adults with
SCI and others older who have lived with SCI for some time
(Hart et al., 1996), and in the different stressors reported by
older and younger adults who sustain SCI (Frank et al.,
1988). The concerns and problems experienced by persons
soon after injury are notably different from those who have
lived with SCI for some time. Soon after injury, individuals
may be more concerned with restorative therapies and possi-
ble curative approaches, but those living with SCI for years
may be more interested in remedying social and interpersonal
barriers and in addressing health problems associated with
aging (Elliott & Shewchuk, 2000).
All of these changes represent developmental processes
that can be understood within the context of our model. It is
critical that we recognize the dynamic interplay between
these evolving processes over time so that we can best under-
stand adjustment following SCI. Therefore, studies of adjust-
ment should be conducted with tools that are sensitive to the
phenomenological experiences and to differences in individ-
ual trajectories of adaptation over time.
PSYCHOLOGICAL INTERVENTIONS
Decreasing “nancial support for psychosocial programs
directed at persons with disabilities in the last decade has
necessitated a shift in intervention policies from meeting
institutional goals to focusing on the opinions, goals, and as-
pirations of the person with SCI (Frank, 1997). When these
personal goals and aims are addressed, interventions are more
likely to be effective (Glueckauf & Quittner, 1992). Wright
(1983) recommended that services to people with disabilities
be designed to eliminate societal barriers, increase accommo-
dations, improve medical and psychosocial services where
indicated, develop and provide assistive devices and tech-
nologies, and aid in the learning of new skills. Community-
based services should (a) have a consumer-driven focus,
(b) be broad in income eligibility, (c) offer ”exible service
options including respite for caregivers, and (d) follow a fam-
ily systems model. For example, programs such as interper-
sonal and social skills training, and innovative interventions
such as aerobic exercise training, have been associated with
increased abilities, a sense of well-being, and acceptance of
disability among persons with SCI (Coyle & Santiago, 1995;
M. Dunn, Van Horn, & Herman, 1981; Glueckauf & Quittner,
1992; Morgan & Leung, 1980). Cognitive-behavioral inter-
ventions designed to enhance coping effectiveness may have
bene“cial effects on people•s ability to positively reappraise
their situations and to increase their sense of hope, with
corresponding improvements in psychological adjustment
(King & Kennedy, 1999).
Strategies that include family members as an integral part of
the rehabilitation process may be particularly effective (L.
Moore, 1989); moreover, these approaches may be couched
within cognitive-behavioral frameworks and delivered in inno-
vative, home-based programs (Kurylo, Elliott, & Shewchuk,
2001). Assistive devices designed for improving sexual rela-
tions among couples„including vacuum devices, injections,
and medications such as Viagra„have been found to increase
sexual activity and improve satisfaction with sexual relation-
ships among men with SCI (Richards, Lloyd, James, & Brown,
1992). Biofeedback„once considered a promising interven-
tion for regulating certain physiological functions after SCI,
particularly in applications with persons who have higher cord
lesions„deserves greater empirical scrutiny and methodolog-
ical rigor (Brucker & Bulaeva, 1996). There is also some
indication that neuropathic pain may be responsive to pharma-
cological treatment (e.g., gabapentin; Ness et al., 1998).
Formal vocational rehabilitation intervention programs
that support a return to career-related activities„broadly
de“ned to include support for independent living, assis-
tive devices, and meaningful social activities„remain im-
portant despite the constant threat of decreasing federal and
state funding. Being employed is associated with a higher
quality of life after SCI (Dowler, Richards, Putzke, Gordon,
& Tate, 2001), and there are several factors that are related to
employability following SCI (Krause et al., 1999). Behav-
ioral expertise can be vital in making reasonable and logical
allocations for these services and programs, but behavioral
and social scientists have often overlooked the direct impact
of public and health policy on the well-being of persons with
physical disability (Elliott & Frank, 2000). Psychological and
behavioral expertise is needed to inform policymakers about
the unique needs of persons with SCI; however, this will re-
quire greater collaboration and partnership with consumer
and advocacy groups and a subsequent appreciation for their
views and opinions (Olkin, 1999).