Interdisciplinary Approaches to Addressing At-Risk Behaviors

in the Post-Acute Rehabilitation SettingAmy Gonshak, Ph.D.

Introductions

Amy Gonshak, Ph.D.Kentucky One Health

Frazier Rehabilitation InstituteNeuroRehab Program4912 US Highway 42

Suite 104Louisville, KY 40222

Phone: (502) 429-8640

Introductions - Frazier NeuroRehab Program description

• Intensive outpatient (2 or 3 days a week, 8:45am-3:15pm, seven 45min individual & group treatment sessions) • ST, OT, PT, and psychology• Access to KY Voc Rehab and vision therapy onsite• Physician referral and follow-up (communication!)• Full-time case management (communication!)• 4 out of 5 days include staff team conferences (communication!)• Patient, family, and team conferences as needed (communication!)• 35-40 program patients on 6 staff teams plus 30 single discipline

outpatients• Binders, Bands & Belts

Introductions - Who’s in the audience?

Survivors?

Family members?

Treatment Providers?

Introductions - Patients (and Families) who have experienced Brain Injury

Aquired Brain Injury (ABI) • Injury to the brain that

occurred after birth and is not hereditary, congenital, or degenerative• Causes: Tumor, Stroke,

Seizure, Toxic Exposure, Infections, Metabolic Disorders, Anoxia/Hypoxia, TBI • Includes injuries caused by

external assault (TBIs) and by internal assault

Traumatic Brain Injury (TBI) • Injury to the brain caused by an

external physical force• Causes: Falls, Motor Vehicle

Accidents, Assaults, Gun Shot Wounds, Sports Injuries, Work Injuries, Child Abuse, Domestic Violence, Military Actions

Impairments can be either temporary or permanent and cause partial or total functional disability

Our Patients

• ABI may result in mild, moderate, or severe impairments in one or more areas including:

• PHYSICAL: ambulation, balance, coordination, strength, endurance, sensation, vision, hearing, tasting, smelling

• COGNITIVE: communication, attention, memory, reasoning, problem-solving, judgment, organization, processing speed

• PSYCHOSOCIAL: emotional awareness and expression (arousal management), social skills, adjustment, self-identity

Psychological Challenges

• Emotional blunting, disengagement• Emotional dysregulation• Impaired interpersonal skills • Impaired sensory-perceptual functioning, sensitivity to light, sound,

stimulation• Impaired motivation, initiation, and follow-through• Loss of major roles (family and work)

Psychological Challenges (continued)• Sadness/depression, irritability/anger • Fear, anxiety, panic attacks• PTSD symptoms• Grief • Pain • Wounded sense of self: Uncertainty, loss of agency, loss of confidence

and efficacy, shame, embarrassment, self-consciousness• Comprehension, acceptance, and integration of sudden unwanted loss

and change

What are the “At-Risk” Behaviors we might expect and want to prevent?

Let’s Name Them…

Without treatment, individuals with problematic or unmanageable behaviors are the most likely to become homeless, institutionalized in a mental

facility, or imprisoned. -AACBIS

At-Risk Behaviors that impact Treatment &Community Reintegration

•Physical Safety Issues•Substance Use or Abuse

•Medication and Treatment Non-compliance• Inappropriate interpersonal interactions (aggression,

sexual)

•Return to driving or work too soon

CHARACTERISTICS of the *TEAM*

• Knowledge of medical condition/neuroanatomy• Patience• Creativity• Mental flexibility• Holistically minded• Hopeful & Inspiring• Compassionate•“Trauma-Informed”

•Tolerance and acceptance of ambiguity and frustration•Team player•Blend of patient-

centered and directive •Realistic•Self-aware•Strong executive skills

FOUNDATIONAL PRINCIPLES

*COLLABORATION**STRUCTURE*

*ACCOUNTABILITY**HOPE*

“To live without hope is to cease to live.” – Fyodor Dostoevsky

SO NOW WHAT? What Are Foundational Goals?

WITH EVERY PATIENT and FAMILY…

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•Build Resilience•Educate about Brain Injury and Recovery• Increase Self-Awareness & Self-Monitoring•Promote Wellness Behaviors•Provide Support and Validation

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Helping to Build Resilience

•Resilience is the process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress — “Bouncing Back”

•Road to resilience is likely to involve considerable emotional distress.

•Resilience can be learned and developed.

Building Resilience

Several factors are associated with resilienceAbility to see your strengthsSkills in communication and problem solvingCapacity to manage strong feelings and impulsesCapacity to make realistic plans and take steps to carry them outFamily and social supportGRATITUDE

Specific Strategies for a “Healing Brain”

•Brain Injury Education (Validate & Normalize)

•Review medical records with patient and family•Review Neuropsychological Testing•Groups

•Arousal Management •Breathing exercises (app-Breathe2Relax; drweil.com)

•Mindfulness/Meditation•Progressive Muscle Relaxation

•Expressive Therapy techniques•Motivational Interviewing

Trauma-Informed Care & Motivational Interviewing

Collaboration:• Partnership that honors the client’s

expertise and perspectives. Therapist provides an atmosphere that is conducive rather than coercive to change.

Evocation:• Resources and motivation for change are

presumed to reside within the client. Intrinsic motivation for change is enhanced by drawing on client’s perceptions, goals and values.

Autonomy:• Therapist affirms client’s right and capacity

for self-direction and facilitates informed choice.

Confrontation: • Counseling overrides client’s impaired

perspectives by imposing awareness and acceptance of “reality” that the client cannot see or will not admit.

Education (About How to Change): • Client is presumed to lack key knowledge,

insight, and/or skills necessary for change. Therapists attempts to address these deficits by providing requisite enlightenment.

Authority:• Therapist tells the client what he or she

must do.

Additional Strategies

•Structure and Expectations •Note Taking (use of binder)• “Advisory Board” or “outside brain(s)”•Timing and Pacing of feedback •User-friendly language•Mantras (on note cards)•Diagrams, drawings•Complementary media (youtube videos, music, art,

books, apps)

TEAMWORK!!!

• Cognition: attention, memory, problem solving, decision making, organization, path finding, goal setting• Social communication• Medication management• Pain management• Frustration tolerance• Anxiety/ “internal distraction”• Pragmatic, constructive coping• Orientation x4, time management, safety• Belts, bands, binders & bathrooms

Areas of Significant Overlap with team (ST, OT, PT)

PSYCHOLOGISTS’ UNIQUE VALUE TO PATIENTS, FAMILIES & TEAM

• Provide less structured environment for emotional processing and support• Mood monitoring and management• Grief and loss• Depression, Anxiety, Frustration tolerance/anger • Pain management• Psychotropic med recommendations

More Psychology Specific

Psychology specific (cont.)

• Health behaviors (nutrition, sleep, hydration, exercise)• Smoking cessation• Alcohol & drug use• Risk reduction/ avoidance• Meaning making/ sense of self• Coach self-advocacy, assertiveness • Family relationship dynamics – caregiver fatigue, role changes

For Patients with Co-Morbid Diagnoses

Substance Abuse, ADHD or other pre-existing learning disabilities, behavioral and mood disorders, personality disorders, conscious exaggerating of symptoms (malingering)• Make and enforce clear treatment rules (Axis II)• Modify Treatment Environment/Conditions that provoke behavior (aggression)• Monitor and Communicate about Patient’s disposition• Co-Treat• Adjunct Psychopharmacological Interventions• Protocols for Treating Patients at Risk for Self-Harm and Substance Abuse

Role of Family

Brain Injury of a family member challenges the core values and resources of the family system• Very similar emotional challenges as Patient• Balance Education with Support

• Risks for Dysfunction• Pre-morbid history of family

problems• Persistent and severe impairments

of the BI patient• Extended denial period• Lack of basic supports

• Strengths– Ability to listen, communicate,

negotiate

– Willingness to learn, grow, change

– Ability to assist BI family member/ Availability

– Spirituality

– Present-focused

– Self-care

*Self Care* for Family & Treatment Provider

• “Place the Oxygen Mask on Yourself First” – Role Model• *NURTURE yourself*: Sleep, Nutrition, Alone Time, Friendships, Intimacy,

Exercise, Leisure Activity, Mental Vacations, REAL Vacations• Limit caseload of patients with severe comorbid Dx• Use Co-Treatment as needed for complex cases• Acknowledge Inability to “cure” every patient• “Pick Your Battles”• Focus on Process vs. Outcome• Self-Reflect, Utilize Supervision/Mentorship, Personal Therapy• Ask for what you need

ABI Websites

Model Systems Knowledge Transition Centerhttp://www.msktc.org/tbi

TBI Model Systems Data and Statistical Centerhttps://www.tbindsc.org/

Brain Injury Association of Americahttp://www.biausa.org/

Brain Injury Alliance of Kentuckyhttp://www.biak.us/

ABI Websites

Mayo Clinic – stroke http://www.mayoclinic.org/diseases-conditions/stroke/basics/definition/con-20042884

MedLine Plus (has Spanish printables)http://www.nlm.nih.gov/medlineplus/stroke.html

National Stroke Associationhttp://www.stroke.org/

American Stroke Associationhttp://www.strokeassociation.org/

Thank You!