PSYCHOLOGICAL AND PSYCHOLOGICAL AND SOCIAL ISSUES IN SOCIAL ISSUES IN REHABILITATIONREHABILITATION

Presented by Frances Goff, Ph. Presented by Frances Goff, Ph. DD

20102010

TOPICSTOPICS

POST STROKE DEPRESSION AND POST STROKE DEPRESSION AND EMOTIONAL ISSUESEMOTIONAL ISSUES

ISSUES RELATED TO SUICIDEISSUES RELATED TO SUICIDE SUICIDE POLICY AND PROCEDURESSUICIDE POLICY AND PROCEDURES VULNERABLE PERSONALITY STYLESVULNERABLE PERSONALITY STYLES BEHAVIOR MANAGEMENT POLICYBEHAVIOR MANAGEMENT POLICY COPING AND ADJUSTMENT FOR COPING AND ADJUSTMENT FOR

PATIENTS AND FAMILIESPATIENTS AND FAMILIES

POST STROKE DEPRESSIONPOST STROKE DEPRESSION

AND EMOTIONAL AND EMOTIONAL ISSUESISSUES

DEPRESSIVE SYMPTOMSDEPRESSIVE SYMPTOMS

Depressed moodDepressed mood Loss of interestLoss of interest Feeling worthlessFeeling worthless Low self esteemLow self esteem HopelessnessHopelessness IrritabilityIrritability Thoughts of deathThoughts of death

Stroke patients Stroke patients may have may have emotional lability emotional lability or “reflex crying” or “reflex crying” or laughing or laughing inappropriatelyinappropriately

Risk Factors for Developing Risk Factors for Developing Post Stroke DepressionPost Stroke Depression

Lack of social supportLack of social support Cognitive dysfunctionCognitive dysfunction Pre stroke depressionPre stroke depression The location and the severity of the The location and the severity of the

stroke also play roles in developing stroke also play roles in developing post stroke depression.post stroke depression.

TREATMENT OF SEVERE TREATMENT OF SEVERE DEPRESSIONDEPRESSION

For those acutely For those acutely suicidal with severe suicidal with severe refractory refractory depression, depression, Electroconvulsive Electroconvulsive therapy is an therapy is an option.option.

This has been This has been shown to be shown to be effective for elderly effective for elderly patients.patients.

OTHER TREATMENTS FOR OTHER TREATMENTS FOR DEPRESSIONDEPRESSION

MedicationMedication CounselingCounseling Coping strategiesCoping strategies

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

ISSUES RELATED TO ISSUES RELATED TO SUICIDESUICIDE

RISK FACTORS FOR SUICIDERISK FACTORS FOR SUICIDE

SUBSTANCE ABUSE HOPELESSNESS

PRIOR ATTEMPT

MENTAL DISORDERIMPULSIVITY

ADDITIONAL SUICIDE RISK ADDITIONAL SUICIDE RISK FACTORSFACTORS

MALEMALE LIVING ALONELIVING ALONE

LACK OF SOCIAL LACK OF SOCIAL SUPPORTSUPPORT

EXCESSIVE ALCOHOL EXCESSIVE ALCOHOL USEUSE

SUICIDE RISKSUICIDE RISK

Persons 65 years of age or Persons 65 years of age or older are at highest risk. older are at highest risk.

White men older than 85 are White men older than 85 are at greatest risk.at greatest risk.

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

Those with borderline Those with borderline personality disorder are personality disorder are

at increased riskat increased risk

They show patterns of emotional They show patterns of emotional and behavioral instability with and behavioral instability with intense anger and feelings of intense anger and feelings of

emptiness.emptiness.

SUICIDE RISKSUICIDE RISK

POLICIES POLICIES AND AND PROCEDURESPROCEDURES

Suicide Risk Management and Suicide Risk Management and Precautions PolicyPrecautions Policy

All patients are All patients are screened within 24 screened within 24 hours of admission hours of admission for suicidal risk.for suicidal risk.

Anyone deemed at Anyone deemed at risk will be placed risk will be placed on suicide on suicide precautions.precautions.

Nursing initiates Nursing initiates Suicide Precautions Suicide Precautions on anyone at risk.on anyone at risk.

If the patient responds “yes” to If the patient responds “yes” to thoughts of suicide or self harm, the thoughts of suicide or self harm, the physician or allied health physician or allied health professional will be contacted for professional will be contacted for treatment orders.treatment orders.

The Suicide Risk Screen document is The Suicide Risk Screen document is placed under Interdisciplinary placed under Interdisciplinary Planning in the medical record.Planning in the medical record.

SUICIDAL IDEATION OR SUICIDAL IDEATION OR INTENTINTENT

PATIENTS MAY MAKE STATEMENTS PATIENTS MAY MAKE STATEMENTS ABOUT WANTING TO DIE OR ABOUT WANTING TO DIE OR WISHING THEY DID NOT HAVE TO GO WISHING THEY DID NOT HAVE TO GO ON. ON.

YOU DO NOT HAVE TO MAKE THE YOU DO NOT HAVE TO MAKE THE EVALUATION AS TO THE EVALUATION AS TO THE SERIOUSNESS OF THE STATEMENTSSERIOUSNESS OF THE STATEMENTS

REPORT SUCH STATEMENTS TO THE REPORT SUCH STATEMENTS TO THE NURSE IN CHARGENURSE IN CHARGE

PROCEDUREPROCEDURE

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

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

Suicide precautions include:Suicide precautions include:

One-to-one observationsOne-to-one observations Following safety guidelines for Safe Following safety guidelines for Safe

EnvironmentEnvironment DocumentationDocumentation

Suicide precautions involve one-to-Suicide precautions involve one-to-one observation by a staff member.one observation by a staff member.

A staff member must be with the A staff member must be with the patient at all times. patient at all times.

The patient is not left alone with The patient is not left alone with family members.family members.

In addition to one-to-one observation,In addition to one-to-one observation,

suicide precautions include: suicide precautions include: documentation by nursing in documentation by nursing in

Progress Notes at least one time per Progress Notes at least one time per shift and shift and

documentation every 15 minutes on documentation every 15 minutes on Suicide Precaution Flow Sheet.Suicide Precaution Flow Sheet.

Documentation includes: Documentation includes:

BehaviorBehavior MoodMood Verbal ExpressionsVerbal Expressions Patient ActivityPatient Activity Patient LocationPatient Location

Safe EnvironmentSafe Environment

Patient is placed in close proximity to nursing Patient is placed in close proximity to nursing station.station.

Room searched each evening. Items from home Room searched each evening. Items from home are checked.are checked.

All potentially harmful items are removed from All potentially harmful items are removed from the immediate environment – corded the immediate environment – corded appliances not medically necessary, wire appliances not medically necessary, wire hangers, cans and bottles, plastic bags, belts, hangers, cans and bottles, plastic bags, belts, razors, shoelaces and drawstrings.razors, shoelaces and drawstrings.

Dietary to send paper plates and plastic utensils.Dietary to send paper plates and plastic utensils.Housekeeping carts not left unattended.Housekeeping carts not left unattended.

Discharge Planning for Patient Discharge Planning for Patient With Suicidal Ideation or IntentWith Suicidal Ideation or Intent Family members are educated regarding Family members are educated regarding

support (remove firearms, lethal support (remove firearms, lethal medications).medications).

Physician or allied health professional will Physician or allied health professional will determine need for outpatient behavioral determine need for outpatient behavioral health.health.

Information regarding community Information regarding community resources provided by Case Manager.resources provided by Case Manager.

VULNERABLE PERSONALITY VULNERABLE PERSONALITY STYLESSTYLES

Vulnerable Personality Vulnerable Personality StylesStyles

STYLESTYLE TRAITSTRAITS REACTIONREACTION

OverachieveOverachieverr

Esteem Esteem derived from derived from workwork

Catastrophic Catastrophic if drop in if drop in performanceperformance

DependentDependent Need to be Need to be taken care taken care ofof

More More dependentdependent

Vulnerable Personality Vulnerable Personality StylesStyles

STYLESTYLE TRAITSTRAITS REACTIONREACTION

Borderline Borderline PersonalityPersonality

Instability, fear Instability, fear of of abandonmentabandonment

Disorganiza-Disorganiza-tion, despair, tion, despair, self-self-destructivedestructive

AntisocialAntisocial Manipulative, Manipulative, irresponsible, irresponsible, lyinglying

Lack of Lack of responsibility responsibility for recoveryfor recovery

Vulnerable Personality Vulnerable Personality StylesStyles

STYLESTYLE TRAITSTRAITS REACTIONREACTION

Self Self CenteredCentered

Wants Wants admirationadmiration

Over-Over-entitlemententitlement

HistrionicHistrionic Attention Attention seeking, seeking, emotionalityemotionality

Dramatic, Dramatic, blamingblaming

Vulnerable Personality Vulnerable Personality StylesStyles

STYLESTYLE TRAITSTRAITS REACTIONREACTION

Somatically Somatically focusedfocused

Focus of Focus of physical physical complaintscomplaints

Focus on Focus on physical physical complaintscomplaints

General General personality personality disordersdisorders

Can’t do what Can’t do what is best for self is best for self in long runin long run

NoncompliancNoncompliancee

Lack of Lack of motivationmotivation

BEHAVIOR BEHAVIOR MANAGEMENTMANAGEMENT

POLICY AND PROCEDUREPOLICY AND PROCEDURE

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

We Use These Groups of We Use These Groups of Behavioral Procedures:Behavioral Procedures:

Antecedent ControlAntecedent Control Techniques That Increase Techniques That Increase

Appropriate BehaviorsAppropriate Behaviors Techniques That Decrease Techniques That Decrease

Inappropriate BehaviorsInappropriate Behaviors

ENVIRONMENTAL ENVIRONMENTAL CONTRIBUTIONSCONTRIBUTIONS

TOO MUCH NOISETOO MUCH NOISE TOO MANY VISITORSTOO MANY VISITORS SLEEP DEPRIVATIONSLEEP DEPRIVATION

With use of antecedent control, theseWith use of antecedent control, these

problems are anticipated and prevented.problems are anticipated and prevented.

Getting Started with Behavior Getting Started with Behavior ProgramProgram

The Informed Consent The Informed Consent for Behavioral for Behavioral Management Plan form Management Plan form is signed by the patient is signed by the patient or family member and or family member and is also signed by the is also signed by the neuropsychologist neuropsychologist representing the representing the treatment teamtreatment team

Copy is placed in Copy is placed in medical recordmedical record

We do not use these:We do not use these:

Food or beverages Food or beverages as reinforcersas reinforcers

Any kind of Any kind of punishmentpunishment

Modeling is used to Modeling is used to assist the patient in assist the patient in learning new learning new behaviorsbehaviors

Reinforcement is Reinforcement is given for given for approximating the approximating the new behaviornew behavior

Decreasing Inappropriate Decreasing Inappropriate BehaviorsBehaviors

Give verbal Give verbal feedback that the feedback that the behavior or behavior or verbalization is verbalization is inappropriateinappropriate

Give suggestion for Give suggestion for alternative behavior alternative behavior or verbalizationor verbalization

Give positive Give positive reinforcementreinforcement

Most Frequently Used Most Frequently Used TechniquesTechniques

Behavioral Behavioral Contract for Full Contract for Full Participation or for Participation or for Increasing Increasing Participation in Participation in therapiestherapies

Positive Positive reinforcement reinforcement TechniquesTechniques

COPING AND ADJUSTMENT FOR COPING AND ADJUSTMENT FOR PATIENTS AND FAMILIESPATIENTS AND FAMILIES

Assisting Patients and Assisting Patients and Families in Coping with Families in Coping with

Disabling ConditionsDisabling Conditions

Family Members and CopingFamily Members and Coping

Remember that families are Remember that families are traumatizedtraumatized

Help by offering education repetitively Help by offering education repetitively because unable to process adequately because unable to process adequately when traumatizedwhen traumatized

Realize family members differ in Realize family members differ in ability to provide support. Some ability to provide support. Some provide emotional, some practicalprovide emotional, some practical

Negative Attempts to CopeNegative Attempts to Cope

1. Denial (refusal to acknowledge 1. Denial (refusal to acknowledge painful thoughts and feelings such as painful thoughts and feelings such as poor prognosis.); useful in beginning poor prognosis.); useful in beginning for some.for some.

2. Withdrawal (isolating self and being 2. Withdrawal (isolating self and being silent); although, some must work silent); although, some must work through problems alone at firstthrough problems alone at first

Negative CopingNegative Coping

3. Acting out (extreme anger, 3. Acting out (extreme anger, violence, alcohol and drug use, violence, alcohol and drug use, infidelity, over-eating, infidelity, over-eating, noncompliance)noncompliance)

4. Passive aggression (Expressing 4. Passive aggression (Expressing anger indirectly – may feel resistant , anger indirectly – may feel resistant , hostile or resentful.)hostile or resentful.)

Encourage Positive CopingEncourage Positive Coping

1. Affiliation (turning to family, friends, 1. Affiliation (turning to family, friends, church, support groups)church, support groups)

2. Self assertion (encourage patient to 2. Self assertion (encourage patient to express thoughts and feelings directly)express thoughts and feelings directly)

3. Spirituality3. Spirituality 4. Taking care of self4. Taking care of self 5. Sublimation and altruism (later in 5. Sublimation and altruism (later in

recovery)recovery)