Interdisciplinary Approaches
to Addressing At-Risk Behaviors
in the Post-Acute Rehabilitation
Setting
Amy Gonshak, Ph.D.
Introductions
Amy Gonshak, Ph.D.
Kentucky One Health
Frazier Rehabilitation Institute
NeuroRehab Program
4912 US Highway 42
Suite 104
Louisville, 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 patientcentered 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…
**************************************
***
• Build Resilience
• Educate about Brain Injury and Recovery
• Increase Self-Awareness & Self-Monitoring
• Promote Wellness Behaviors
• Provide Support and Validation
**************************************
***
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 resilience
Ability to see your strengths
Skills in communication and problem solving
Capacity to manage strong feelings and impulses
Capacity to make realistic plans and take steps to carry them out
Family and social support
GRATITUDE
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:
Confrontation:
• Partnership that honors the client’s
expertise and perspectives. Therapist
provides an atmosphere that is conducive
rather than coercive to change.
• Counseling overrides client’s impaired
perspectives by imposing awareness and
acceptance of “reality” that the client
cannot see or will not admit.
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.
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!!!
Areas of Significant Overlap with team (ST, OT, PT)
• 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
PSYCHOLOGISTS’ UNIQUE VALUE TO
PATIENTS, FAMILIES & TEAM
More Psychology Specific
• 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
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 Center
http://www.msktc.org/tbi
TBI Model Systems Data and Statistical Center
https://www.tbindsc.org/
Brain Injury Association of America
http://www.biausa.org/
Brain Injury Alliance of Kentucky
http://www.biak.us/
ABI Websites
Mayo Clinic – stroke
http://www.mayoclinic.org/diseasesconditions/stroke/basics/definition/con-20042884
MedLine Plus (has Spanish printables)
http://www.nlm.nih.gov/medlineplus/stroke.html
National Stroke Association
http://www.stroke.org/
American Stroke Association
http://www.strokeassociation.org/
Thank You!