PSYCHOLOGICAL AND SOCIAL ISSUES IN REHABILITATION

1. PSYCHOLOGICAL AND SOCIAL ISSUES IN REHABILITATION Presented by Frances Goff, Ph. D 2010

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

3. POST STROKE DEPRESSION • AND EMOTIONAL ISSUES

4. 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

5. Risk Factors for Developing Post Stroke Depression • Lack of social support • Cognitive dysfunction • Pre stroke depression • The location and the severity of the stroke also play roles in developing post stroke depression.

6. TREATMENT OF SEVERE DEPRESSION • For those acutely suicidal with severe refractory depression, Electroconvulsive therapy is an option. • This has been shown to be effective for elderly patients.

7. OTHER TREATMENTS FOR DEPRESSION • Medication • Counseling • Coping strategies

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

9. ISSUES RELATED TO SUICIDE

10. RISK FACTORS FOR SUICIDE IMPULSIVITY

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

12. SUICIDE RISK Persons 65 years of age or older are at highest risk. White men older than 85 are at greatest risk.

13. More than 90% of persons who commit suicide have a psychiatric diagnosis.

14. Those with borderline personality disorder are at increased risk They show patterns of emotional and behavioral instability with intense anger and feelings of emptiness.

15. SUICIDE RISK • POLICIES AND PROCEDURES

16. Suicide Risk Management and Precautions Policy • All patients are screened within 24 hours of admission for suicidal risk. • Anyone deemed at risk will be placed on suicide precautions. • Nursing initiates Suicide Precautions on anyone at risk.

17. If the patient responds “yes” to thoughts of suicide or self harm, the physician or allied health professional will be contacted for treatment orders. • The Suicide Risk Screen document is placed under Interdisciplinary Planning in the medical record.

18. 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

19. PROCEDURE • The staff member to whom suicidal ideation or intent was verbalized or who observed at-risk behavior notifies the Charge Nurse immediately, while ensuring that the patient remains safe.

20. The Charge Nurse or Nurse Manager will initiate Suicide Precautions. The Physician is contacted for orders for Suicide Precautions. When contacting the Physician, orders are also obtained for Neuropsychologist or for Psychiatrist. Case Manager is notified. Patient and family are educated regarding the Policy and Procedures.

21. Suicide precautions include: • One-to-one observations • Following safety guidelines for Safe Environment • Documentation

22. Suicide precautions involve one-to-one observation by a staff member. • A staff member must be with the patient at all times. • The patient is not left alone with family members.

23. In addition to one-to-one observation, suicide precautions include: • documentation by nursing in Progress Notes at least one time per shift and • documentation every 15 minutes on Suicide Precaution Flow Sheet.

24. Documentation includes: • Behavior • Mood • Verbal Expressions • Patient Activity • Patient Location

25. Safe Environment Patient is placed in close proximity to nursing station. Room searched each evening. Items from home are checked. All potentially harmful items are removed from the immediate environment – corded appliances not medically necessary, wire hangers, cans and bottles, plastic bags, belts, razors, shoelaces and drawstrings. Dietary to send paper plates and plastic utensils. Housekeeping carts not left unattended.

26. Discharge Planning for Patient With Suicidal Ideation or Intent • Family members are educated regarding support (remove firearms, lethal medications). • Physician or allied health professional will determine need for outpatient behavioral health. • Information regarding community resources provided by Case Manager.

27. VULNERABLE PERSONALITY STYLES

28. Vulnerable Personality Styles

29. Vulnerable Personality Styles

30. Vulnerable Personality Styles

31. Vulnerable Personality Styles

32. BEHAVIOR MANAGEMENT POLICY AND PROCEDURE

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

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

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

36. 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

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

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

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

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

41. COPING AND ADJUSTMENT FOR PATIENTS AND FAMILIES

42. Assisting Patients and Families in Coping with Disabling Conditions

43. 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

44. 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

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

46. 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 altruism (later in recovery)