Transcript PSYCHOLOGICAL AND SOCIAL ISSUES IN REHABILITATION

PSYCHOLOGICAL AND
SOCIAL ISSUES IN
REHABILITATION
Presented by Frances Goff, Ph. D
2010
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

POST STROKE DEPRESSION

AND EMOTIONAL
ISSUES
DEPRESSIVE SYMPTOMS







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
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.

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.

OTHER TREATMENTS FOR
DEPRESSION
Medication
 Counseling
 Coping strategies


The combination of
antidepressants and
counseling have been
found to be the most
effective treatment
ISSUES RELATED TO SUICIDE
RISK FACTORS FOR SUICIDE
PRIOR ATTEMPT
MENTAL DISORDER
SUBSTANCE ABUSE
IMPULSIVITY
HOPELESSNESS
ADDITIONAL SUICIDE RISK
FACTORS

MALE

LIVING ALONE

LACK OF SOCIAL
SUPPORT

EXCESSIVE ALCOHOL
USE
SUICIDE RISK
Persons 65 years of age or older
are at highest risk. White men
older than 85 are at greatest risk.

More than 90% of persons who commit
suicide have a psychiatric diagnosis.
Those with borderline
personality disorder are at
increased risk
They show patterns of emotional and
behavioral instability with intense
anger and feelings of emptiness.
SUICIDE RISK

POLICIES
AND
PROCEDURES
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.

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.

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

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.

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.
Suicide precautions include:
One-to-one observations
 Following safety guidelines for Safe
Environment
 Documentation

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.

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.
Documentation includes:





Behavior
Mood
Verbal Expressions
Patient Activity
Patient Location
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.
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.

VULNERABLE PERSONALITY
STYLES
Vulnerable Personality Styles
STYLE
Overachiever
Dependent
TRAITS
Esteem
derived from
work
Need to be
taken care of
REACTION
Catastrophic if
drop in
performance
More
dependent
Vulnerable Personality Styles
STYLE
Borderline
Personality
Antisocial
TRAITS
REACTION
Instability, fear of Disorganizaabandonment
tion, despair,
self-destructive
Manipulative,
Lack of
irresponsible,
responsibility
lying
for recovery
Vulnerable Personality Styles
STYLE
TRAITS
REACTION
Self Centered
Wants
admiration
Over-entitlement
Histrionic
Attention
seeking,
emotionality
Dramatic,
blaming
Vulnerable Personality Styles
STYLE
Somatically
focused
General
personality
disorders
TRAITS
REACTION
Focus of
physical
complaints
Can’t do what is
best for self in
long run
Focus on
physical
complaints
Noncompliance
Lack of
motivation
BEHAVIOR
MANAGEMENT
POLICY AND PROCEDURE

The treatment team,
led by the
neuropsychologist,
makes the decision to
implement an
individual behavior
management
program.
We Use These Groups of
Behavioral Procedures:
Antecedent Control
 Techniques That Increase Appropriate
Behaviors
 Techniques That Decrease Inappropriate
Behaviors

ENVIRONMENTAL
CONTRIBUTIONS
TOO MUCH NOISE
 TOO MANY VISITORS
 SLEEP DEPRIVATION

With use of antecedent control, these
problems are anticipated and prevented.
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
We do not use these:
Food or beverages as
reinforcers
 Any kind of
punishment

Modeling is used to
assist the patient in
learning new
behaviors
 Reinforcement is
given for
approximating the
new behavior

Decreasing Inappropriate
Behaviors
Give verbal feedback
that the behavior or
verbalization is
inappropriate
 Give suggestion for
alternative behavior
or verbalization
 Give positive
reinforcement

Most Frequently Used Techniques
Behavioral Contract
for Full Participation
or for Increasing
Participation in
therapies
 Positive reinforcement
Techniques

COPING AND ADJUSTMENT FOR
PATIENTS AND FAMILIES
Assisting Patients and Families in
Coping with Disabling Conditions
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

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

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.)

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)
