PSYCHOLOGICAL AND SOCIAL ISSUES IN REHABILITATION

1. PSYCHOLOGICAL AND SOCIAL ISSUES IN REHABILITATION Presented by Frances Goff, Ph. D October 27 and 29, 2009

2. TOPICS • POST STROKE DEPRESSION AND EMOTIONAL ISSUES • ISSUES RELATED TO SUICIDE • VULNERABLE PERSONALITY STYLES • BEHAVIOR MANAGEMENT POLICY • COPING AND ADJUSTMENT FOR PATIENTS AND FAMILIES

3. Depressed mood Loss of interest Feeling worthless Low self esteem Hopelessness Irritability Thoughts of death Stroke patients may have emotional lability or “reflex crying” or laughing inappropriately DEPRESSIVE SYMPTOMS

4. Risk Factors for Developing Post Stroke Depression • Location debatable • Severity debatable • Lack of social support • Cognitive dysfunction • Pre stroke depression

5. SUICIDE RISK FACTORS MALE LIVING ALONE LACK OF SOCIAL SUPPORT EXCESSIVE ALCOHOL USE

6. TREATMENTS • Medication • Counseling • Coping strategies

7. The combination of antidepressants and counseling have been found to be the most effective treatment

8. SUICIDAL IDEATION OR INTENT • PATIENTS MAY MAKE STATEMENTS ABOUT WANTING TO DIE OR WISHING THEY DID NOT HAVE TO GO ON. • YOU DO NOT HAVE TO MAKE THE EVALUATION AS TO THE SERIOUSNESS OF THE STATEMENTS • REPORT SUCH STATEMENTS TO THE NURSE IN CHARGE

9. YOUR RESPONSIBILITY • IF YOU HEAR A PATIENT VERBALIZE SELF HARM STATEMENTS, OR YOU OBSERVE LIFE-THREATENING OR SELF-INJURIOUS BEHAVIOR, YOU MUST TAKE ACTION! THE PROCEDURE IS TO NOTIFY THE NURSE WHO IS IN CHARGE.

10. Nursing has a Suicide Risk Management and Precautions policy • We are in the process of integrating the Interdisciplinary Suicide Precaution policy with the Nursing Suicide Risk Management and Precautions policy • Additional features will be presented by Nursing • An Initial Screening Form will be utilized.

11. Patient is placed in close proximity to nursing station. One-to-one staffing if ordered All potentially harmful items are removed from the immediate environment – corded appliances not medically necessary, cans and bottles, plastic bags, belts, razors, shoelaces and drawstrings. Dietary to send paper plates and plastic utensils. Housekeeping carts not left unattended.

12. If the patient remains in the Rehabilitation Hospital, services for treatment by the neuropsychologist is intensive. • At discharge, an appointment with behavioral health is made. • Family members are educated regarding support. • They are asked to remove firearms.

13. Vulnerable Personality Styles

14. Vulnerable Personality Styles

15. Vulnerable Personality Styles

16. Vulnerable Personality Styles

17. BEHAVIOR MANAGEMENT POLICY AND PROCEDURE

18. The treatment team, led by the neuropsychologist, makes the decision to implement an individual behavior management program.

19. We Use These Groups of Behavioral Procedures: • Antecedent Control • Techniques That Increase Appropriate Behaviors • Techniques That Decrease Inappropriate Behaviors

20. ENVIRONMENTAL CONTRIBUTIONS • TOO MUCH NOISE • TOO MANY VISITORS • SLEEP DEPRIVATION With use of antecedent control, these problems are anticipated and prevented.

21. Getting Started with Behavior Program • The Informed Consent for Behavioral Management Plan form is signed by the patient or family member and is also signed by the neuropsychologist representing the treatment team • Copy is placed in medical record

22. We do not use these: • Food or beverages as reinforcers • Any kind of punishment

23. Modeling is used to assist the patient in learning new behaviors • Reinforcement is given for approximating the new behavior

24. Decreasing Inappropriate Behaviors • Give verbal feedback that the behavior or verbalization is inappropriate • Give suggestion for alternative behavior or verbalization • Give positive reinforcement

25. Most Frequently Used Techniques • Behavioral Contract for Full Participation or for Increasing Participation in therapies • Positive reinforcement Techniques

26. Assisting Patients and Families in Coping with Disabling Conditions

27. Family Members and Coping • Remember that families are traumatized • Help by offering education repetitively because unable to process adequately when traumatized • Realize family members differ in ability to provide support. Some provide emotional, some practical

28. Negative Attempts to Cope • 1. Denial (refusal to acknowledge painful thoughts and feelings such as poor prognosis.) Useful in beginning for some. • 2. Withdrawal (isolating self and being silent) although some must work through problems alone at first

29. Negative Coping • 3. Acting out (extreme anger, violence, alcohol and drug use, infidelity, overeating, noncompliance) • 4. Passive aggression (Expressing anger indirectly – may feel resistant , hostile or resentful.)

30. Encourage Positive Coping • 1. Affiliation (Turning to family, friends, church, support groups) • 2. Self assertion (Encourage patient to express thoughts and feelings directly) • 3. Spirituality • 4. Taking care of self • 5. Sublimation and altrusism (Later in recovery)