The ultimate outcome of TBI rehabilitation: Successful and satisfying community participation (McCabe, 2007)

Transcription

1 Steven Wheeler, Ph.D., OTR/L Associate Professor, Occupational Therapy West Virginia University School of Medicine 1. Understand the effect of impaired cognitive functioning on successful and satisfying community participation following TBI 2. Appreciate the importance of the therapeutic relationship and it s critical role in the treatment t t of executive cognitive functions 3. Understand strategies to assess and foster independent and satisfying community participation The ultimate outcome of TBI rehabilitation: Successful and satisfying community participation (McCabe, 2007) 1

2 Wide range of cognitive, physical, psychosocial, and behavioral problems commonly persist after TBI that negatively affect successful community re-entry Reduced independence in activities of daily living Need for greater reliance on others Difficulty re-engaging in occupational roles Reduced social roles Emotional distress Difficulty accessing post-acute services Philosophy of Assessment and Treatment of Executive Cognitive Functions International Classification of Functioning, Disability, and Health (WHO, 2001) Recovery From Brain Injury Rancho Los Amigos Levels of Cognitive Functioning (Hagen, 1998) X IX VIII VII VI V IV III II I VII 2

3 Hunger Thirst Sex Appropriation of Resources Control/Dominance Defense/Self-Protection/Survival Categories of Executive Cognitive Functions (Zoltan, 2007) Problem Solving Goal Setting Self- Awareness Initiation Mental Flexibility Self- Monitoring Abstraction / Generalization Planning 3

4 From: Stuss and Benson Frontal Lobe Executive Dysfunction Impaired Initiative = Abulia/Passivity/Inertia Impaired Motivation = Apathy/Indifference Impaired Planning/Organization/Sequencing g /S g Difficulties Directing Attention/Resisting Internal/External Distraction Inability to Shift Focus/Prioritize Demands= Perseveration Frontal Lobe Executive Dysfunction Impaired Impulse Control = Verbal and Behavioral Disinhibition Inability to Anticipate Consequences Impaired Awareness of/concern for Social Norms/Appropriateness Inability to Read/Indifference to Social Cues Impaired Awareness of Social Stimulus Value/Impact Upon Others 4

5 A. Need for Frontal Re-Wiring Frontal Lobes Wired by Learning History Must be re-wired via consistent application of positive and negative consequences Training process should not be so structured that executive activity on patient s part no longer required A. Complexity of impairments affecting TBI B. Self-esteem issues and fear of failure / success C. Therapeutic relationship building D. Client driven goal setting E. The value of the therapeutic community 5

6 Therapeutic Relationships and TBI Rehabilitation Key Concepts OT practitioner / client relationship serves as a central mechanism for change Collaborative approach to build clients self-efficacy and selfesteem People will work hardest for people who matter to them It is the therapist s responsibility to manage and continually strive to fortify the therapeutic relationship and to seek optimal resolutions to interpersonal events. Taylor (2008), pp. 55 6

7 Therapeutic Relationship Building Key Challenges Individual with TBI Ill-Prepared for Re-Wiring Self-Esteem is at a Low Point Client likely to Reject Needed Feedback a. Not MR/DD accustomed to independence b. Likely to Reject Feedback from Family / Resent authority 1. Relationships 2. Risk Taking 3. Success experiences 4. Interpretation of success and failure = locus of control It has long been observed that people with TBI may be less aware of the deficits resulting from their injury than people around them such as family members, doctors, and therapists (Hart et al., 2005) Commonly associated with frontal lobe and sub-cortical limbic system damage Relationship between extent of problem and severity of injury 7

8 CIQH1 CIQH2 CIQH3 Makes it tough to have a good relationship with therapists Makes it tougher to get back to work Makes it hard to establish or maintain interpersonal relationships At elevated risk for: Making poor judgment decisions Difficulty developing adequate coping skills Experiencing difficulty coping with change The Challenge of Finding a Friend The Impact of Community Based Rehabilitation on Community Participation Wheeler, Lane, McMahon (2007) Measure = Community Integration Questionnaire Community Integration - Home (1 year) Mean Graphs represent admission, 3 month, and 1 year follow during participation In community based rehabilitation. Intervention included life skills coaching, group therapy, OT, SLP and Psychology 8

9 Life Satisfaction and TBI Wheeler, Lane, and McMahon (2007) Mean Life Skills Coaching SWLS Scores Baseline versus Follow-up SWLS1A SWLS1B Mean Comparison Subject SWLS Scores Baseline versus Follow-up SWLS2A SWLS2B Treatment in intensive life skills as part of a community re-entry program versus non-treatment controls at baseline and 12 week follow-up. Significant improvements in home management and productivity noted at 12 weeks in treatment group. Life Satisfaction and TBI 1 Year Follow-up Clients making biggest functional gains and highest life satisfaction at 1 year were those with decreased satisfaction at 12 week period. Mean Satisfaction with Life - 1 Year SWLS1 SWLS2 SWLS3 Recognizing limitations tougher when self-esteem and self-confidence issues present Awareness deficits may be complicated by psychological denial Requires trusting therapeutic relationship with clinician fear of failure / success Requires participation and failure on behalf of client 9

10 Neurological recovery requires struggle/ effort If struggle is too difficult, client will become overwhelmed/defeated Goal of therapist is to break down tasks into manageable goals that carry a high likelihood of success If relationships are always great during the therapy process functional improvements may not be occurring A word of caution While patient self-awareness is generally felt to be beneficial fiil or even required for successful fl rehabilitation, improvements in awareness have also been linked with emotional distress (Sohlberg et al., 1998). 10

11 In many cases, things may need to get worse before they get better Overcoming awareness deficits through success and failures Goal Setting = cornerstone of effective rehabilitation Goals to empower clients to actively participate and improve performance Difficulties with personal goal setting is common with frontal lobe injury Setting personal improvement goals hindered by selfawareness deficits Help clients feel organized and have a focus Provide motivation and encourage participation in rehabilitation Provide concrete and meaningful way to evaluate effectiveness of programs Difficult to establish client centered treatment goals when client presents with self awareness deficits 11

12 Development of awareness of problems and realistic goal targets result of: Rapport building Provision of feedback from therapist about performance Performing familiar tasks with client 1. Be unconditional 2. Be client-centered 3. Be credible 4. Be consistent 5. Adhere to professional boundaries TBI client often show little interest in how others perceive them Frontal lobes connect behavior to associated emotional states If person can t feel what the impact of their behavior has on others, they re indifferent to behavior 12

13 Group members do start to care about what others think of them so group begins to have a profound impact on behavior Positive behavior = immediate positive feedback from friends Unacceptable behavior = will receive immediate critical feedback from same group The Value of Group Activities 1) Facilitate assessment of social behaviors social microcosm 2) Provides environment for receiving feedback regarding inappropriate social behaviors 3) Provides forum for practicing skills related to social competence 4) Provides motivating environment for goal setting 13

14 The motivating impact of achievable goals Small goals less likely to be accepted by family Measuring Community Participation 14

15 Verbal Disinhibition Goal Setting Assessment of behavior, frequency, antecedents, consequences Therapeutic Relationship Building Ongoing nonverbal cuing by therapist Participation in social activities Group / family / caregiver feedback Client Self-Cues Is it appropriate? Is it my business? It is relevant? Does it pertain to topic? Will people think more or less of me? Is it sexual? Hostile? Rude? Is it repetitive? Have I said it before? Conclusions Executive cognitive functions significantly impact successful community participation / re-entry following TBI Evaluation includes determination of success and satisfaction in participation of home and community tasks and subsequently, impact of executive cognitive functions Assessment and treatment challenges associated with self-awareness deficits Participation in unstructured daily activities facilitates awareness of deficits and fosters learning / rehabilitation Therapeutic relationship and client / family participation central to optimal program outcome 15

16 Thank you Center for Outcomes Measurement in Brain Injury. - source of scales / questionnaires Doig, E. Fleming, J., Cornwell, P., & Kuipers, P. (2009). Qualitative exploration of a client-centered, goaldirected approach to community based occupational therapy for adults with traumatic brain injury. American Journal of Occupational Therapy, 63(5), Malia, K., Bewick, K., Raymond, M., and Bennet, T. (2002). Executive Functions. Austin, TX: Pro-Ed. Unsworth, C. (1999). Cognitive and Perceptual Dysfunction: A Clinical Reasoning Approach to Evaluation and Treatment. Philadelphia, PA: FA Davis Wheeler, S., Lane, S., and McMahon, B. (2007). Community participation and life satisfaction following intensive, community based, rehabilitation using a life skills training approach. Occupational Therapy Journal of Research, 27(1), World Health Organization (2001). The International Classification of Functioning, Disability, and Health. Geneva: WHO. 16