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Early and continuing Rehabilitation: Understanding the emotional and social impact of stroke


Early and continuing Rehabilitation: Understanding the emotional and social impact of stroke Understanding and assessing the impact of stroke and approaches to assist. – PowerPoint PPT presentation

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Title: Early and continuing Rehabilitation: Understanding the emotional and social impact of stroke

Early and continuing Rehabilitation
Understanding the emotional and social impact of
  • Understanding and assessing the impact of stroke
    and approaches to assist.

Introduction and learning objectives
  • This session looks at an overview of the
    psychological, emotional, and social impact of
  • It is recommended for all core, MDT staff working
    across the stroke pathway. It links to the stroke
    specific competencies on the the Stroke Specific
    Skills and Competencies framework and includes
  • Section 4 Immediate Care, specifically 4.2.6,
    for all staff to Demonstrate empathy and to
    provide support to the person and carers during
    the initial stages of the acute stroke
  • Section 5, Early and Continuing Rehabilitation
    5.1.17 Staff to be able to Explain the
    psychological, emotional, and social impact of
    stroke and incorporate assessment and
    intervention of these factors in to
  • Section 5, 5.1.4 Goal setting

Psychological presentations
  • This is the first of a module on psychological
    issues after stroke.
  • It focuses specifically on the impact of stroke
    and understanding a persons experience and
    adjustment. Approaches to help a person are also
    presented, as is the need to identify and refer
    on people who are experiencing significant
    psychological issues.

Presentations in this Module
  • The presentations in the psychological module
  • Mood screening
  • Understanding low mood and depression problems
    after stroke 
  • Helping with low mood and depression after stroke
  • Understanding people who experience anxiety
    problems after stroke
  • Managing anxiety after stroke 
  • Anger
  • Self esteem issues following stroke.
  • Loss 

The impact of stroke
  • Stroke is often a sudden health event which
    impacts immediately on how people can function.
    People have little or no preparation for the
    dramatic effects that a stroke has on their
  • People describe many reactions to the experience
    of having a stroke. Some will find it quite
    frightening, or bewildering. Some cannot remember
    the details of having a stroke, or being very
    ill, therefore these gaps in memory can be
    difficult in themselves. Some people have very
    vivid memories which may also trouble them.
  • Others may seem to cope better but are still
    obviously upset that they have suffered a stroke.

The impact of stroke
  • Many people understandably find having the
    stroke, and being in hospital a challenge. They
    have to often deal with a complex set of tasks
    from the outset (being in hospital, taking in
    information, meeting new people), and sorting
    through feelings about what has, and is happening
    to them. This is in addition to the consequences
    of the stroke itself.
  • As staff we can help by supporting people through
    the difficulties and issues they are facing. This
    takes us to be person centred and to try and work
    out the impact of the stroke for each individual,
    including the
  • Physical
  • Cognitive
  • Sensory
  • Perceptual
  • Behavioural
  • Psychological and emotional.

Person centred care from the outset our approach
  • Our support to understand the emotional impact of
    having a stroke and therefore helping a person to
    work through what has happened to them is crucial
    from the outset of having the stroke to the
    longer term.
  • The impression of the patient of how staff have
    cared for them after their stroke has an impact
    on their initial, and long term psychological
    response. Reflections of what helped/did not help
    stay with a person for a long time, therefore it
    is imperative that we all do our best to make the
    person feel understood and their needs met at all
  • Remember when you were last in hospital, or in a
    medical setting when you felt vulnerable and when
    you needed support, how your impressions of what
    care you received made an impression (either good
    or bad?).

Making sense of peoples emotions through the
stroke pathway
  • We therefore need to get to know each person,
    including how they are feeling. We try to work
    out what is important to them trying to
    accommodate their needs and choices, their likes
    and dislikes. This enables people to feel
    understood and more empowered at what is a
    difficult time in their life.
  • It is important to acknowledge with patients that
    there will be an emotional response to having a
    stroke. We can listen out for the issues that
    people may be facing and help them through the
    emotional/adjustment process after stroke. People
    may have different feelings and challenges over
    various time frames after a stroke, as will their
    family members.
  • Therefore we are helping people understand the
    psychological impact of stroke, and providing
    them with support needed to work through this.

Look at this quote from Linda about the immediate
impact of stroke
  • When I was in the hospital and it began to dawn
    in me what had happened to me I was trying to
    make out what was going to happen. I could not
    feel the left hand side of my body and could not
    move it. Everyone was telling me that things will
    improve, but you dont know whether they are just
    saying that, or is it really going to get better?
    I was wondering how I was going to manage, and
    how I was going to be there for my daughters. It
    was scary. Theres no other words to describe it,
    just being afraid of what was ahead.

Exercise what emotions and challenges may
people experience at the acute, early
rehabilitation in the longer term after stroke.
Time phase following Stroke How may the person who has had a stroke be feeling? And what issues may they be facing? How may the family member for the person be feeling? And what issues may they be facing?
Early rehabilitation
Continuing rehabilitation and in the longer term
Model of time phases and feelings after stroke
Time phase following stroke How may the person who has had a stroke be feeling? Issues faced. How may the person who has had a stroke may be feeling? Issues faced.
Acute Anxiety, disorientated, fear, embarrassed at asking for help, tearful. Worry, fear as to what will happen, tiredness.
Early rehabilitation Effort at getting better, low. Trying to keep going but worried, down
Continuing rehabilitation and in the longer term Struggle between hope for recovery and reality Role of a caregiver emerges
Adjustment models
  • It is clear that people will have many feelings
    and challenges after stroke and these will vary
    from individual to individual and across the
    stroke journey. Some people for example feel
    instantly shocked, where others feel fine
    psychologically immediately after stroke but
    become low and anxious upon their return home.
  • Some authors liken the emotional adjustment to
    stroke as being similar to the process of
    grieving following bereavement. Wilkinson (1995)
    suggested that patients may go through a number
    of stages, emotionally processing and making
    sense of the stroke. Within each stage people may
    have a number of feelings, thoughts, behaviours
    and physiological responses.

Stage models of Adjustment
  • Please note that not everyone will go through the
    stages in sequence, and some will stay in one
    stage for a long time, e.g. anger, or skip
    between stages.

Explaining adjustment and individual reactions to
  • We can explain to people that they may go through
    an emotional adjustment reaction as described. By
    doing this we may help to normalise the
    psychological reactions to stroke and the process
    of adjustment.
  • People often unconsciously focus on the loss that
    a stroke has presented them with, whilst at other
    times they may focus on getting on with restoring
    what they can in life. This process is like our
    minds considering or working through two sides
    of a coin grieving the things we have lost,
    whilst re-building what we can.
  • We sometimes wonder why people react differently
    to stroke. This is likely to be a complex matter
    the interaction of the stroke and the person
    themselves. This is explained in the following

Adjustment can be influenced by the stroke
persons make up and the stroke itself
Two examples
  • Lets look at two people who experienced a left
    PACS, ostensibly with similar stroke symptoms.
  • Beth and Alex, both had stroke effects which
    included hemiparesis in the right side of their
    body and mild speech and language difficulties.
  • Taking Beth, prior to the stroke Beth spent a lot
    of time with her supportive family and had a
    number of friends. She enjoyed music, cooking and
    trips out with the family. She had always
    considered herself to have a good life and was
    reasonably optimistic and flexible in her
    approach to her life. Beth adjusted reasonably
    well to the stroke. Her family and friends
    remained very important to her and she resumed
    some hobbies. Naturally she was frustrated at
    times with her limitations caused by the stroke
    but accepted help (for example around cooking).
    She took every opportunity to get out!

  • Alex had been a man who had always been
    independent. He had prided himself on educational
    achievement and had been proud of his abilities.
    He sometimes called himself a perfectionist.
    Alex retired some years ago and was waiting for
    his wife to retire before going travelling. Alex
    and his wife had one child who lived abroad. Alex
    and his wife described themselves as relatively
    self contained and although they had friends they
    didnt spend a lot of time with them.
  • Alex struggled to come to terms with his stroke.
    He wanted a full recovery and found it hard to
    settle for less. He felt cheated that this had
    happened to him. His wife felt the same way.
  • This shows how two individuals can react
    differently to a stroke based upon their
    attributes as shown in the table. No one person
    is right or wrong, as we rarely can change our
    attributes. This simply helps us to understand
    and empathise with a persons reaction to their

Helping Approaches
  • The next section of the presentation looks at the
    skills we use to help people psychologically
    after a stroke. All staff can and should use
    these core skills and by using them we are
    helping the patients and their families
    throughout the stroke journey.
  • Specific techniques including listening skills,
    problem solving, activity scheduling and goal
    setting as recommended in a stepped care model
    for psychological issues following stroke are

A note on the use of our core psychological
  • The Accelerating Stroke Improvement (ASI)
    guidelines for assisting with psychological care,
    specify that the culture of stroke teams across
    the pathway needs to be a psychologically
    informed culture, and as such it should be
    recognized that staff (not just specialist mental
    health staff) should spend time with patients
    exploring and supporting the impact of the
    stroke, as a matter of their job. It is asserted
    that this should be seen as a valid use of time.
  • Also it states that mental health needs should
    have equal status with physical health problems
    following stroke.

The Stepped care approach for providing
psychological care in stroke level 1 skills are
approaches for all staff to use.
Helping approaches 1. Use core counselling skills
  • Rogers (1957) outlined core counselling
    conditions, which were considered essential
    ingredients for a therapeutic relationship. These
    skills are still as relevant today and we use
    them to help a person feel understood after a
    stroke. They include
  • Empathy - Empathy is the ability to stand in the
    patients shoes
  • Genuineness - To be real, natural and open
  • Warmth - Remaining open. Not showing
    defensiveness or blame the patient or others for
  • Unconditional Positive Regard - Accepting and
    valuing the person, regardless of their
    background. Cconveying positive regard and
    respect for them.
  • Remember your non verbal behaviour is as
    important as what you say in your communication
    with others!

Using these core skills, examples
  • Warmth - Remaining open. Ask people how they are
    feeling and whether they have particular emotions
    or thoughts. For example you could say some
    people feel quite worried after a stroke, is
    there anything that is worrying you? or Some
    people feel quite sad and down after a stroke, do
    you ever feel that way?.
  • Empathy - Talk to people about the impact of a
    stroke and let them tell their stroke story.
    Work to understand their perspective and show
    true empathy whilst giving encouragement and some

Helping approaches 2 Problem solving
  • Once we are aware of the things that are
    important to a person we can begin to look at
    what may help them. Little things as well as big
    things can be addressed. For example a person not
    getting their hair done as usual in a morning may
    seem like a significant issue to them, as someone
    may feel like (s)he wants to avoid visitors as
    (s)he doesnt feel (look) right.
  • Being on a ward can also be hard, therefore
    problem solving any activity that helps being
    mindful of hobbies and attachments, and offering
    time off the ward when possible. All these things
    can help a person to have a better day and will
    make people more psychologically cared for.
  • Control and choice are key things that people
    need to regain as soon as possible following a
    stroke. This may be around small things such as
    where people eat their meals, to a patient
    wanting to take control of their medication.

Problem solving exercise
  • With patients we can use problem solving
    templates to guide our interventions. This is
    described below.
  • Take a sheet of paper and write down the
    important issues or problems, brainstorm possible
    solutions and then pick one and try it. Remember
    if people feel down they are less likely to see
    solutions there fore more help may be required.

Problem/ important Issues for the person Possible Solutions Best available solution- to try

Helping Approaches 3 weekly therapy timetables
and scheduling activity
  • Having achievable and meaningful goals each day
    and each week helps people to feel that they can
    achieve something and that their week has some
    predictability. This is particularly important
    once past the acute phase after stroke.
  • People can also plan around the sessions of
    rehabilitation, for example relatives and friends
    can plan their visits and can plan positive
    events in a day for an individual, for example
    taking them out, watching a favourite programme,
    having a special friend call. If there are
    volunteers on the ward this can help them
    organise their activities.
  • This model is adopted by services in the region
    such as in Newcastle where every stroke patient
    is scheduled their therapy on a weekly timetable.
    Feedback is very positive.

Example of a weekly timetable
Day/ Time Mon Tues Wed Thurs Fri Sat Sun
AM 8-9
PM 1-2
Timetable for patient Annie
Day/Time Monday Tuesday Wednesday Thursday
8-9am Dressing practice (with OT) Dressing practice Dressing practice Dressing practice
10-11am Speech therapy Physio session Speech therapy Crafts with volunteers
11-12 noon rest Film run by volunteers Dr ward round rest
1-2pm Physio session Speech therapy Physio session Physio session with family
2-3pm visitors Go out with family visitors Home visit
Helping approaches 4 Goal setting SMART goals
  • This links a little with problem solving and
    activity scheduling but asks the patient to take
    more control of setting goals. The SMART
    framework helps people to make goals more
    tangible and person centred, planning goals that
  • Specific
  • Measurable
  • Achievable
  • Realistic
  • Targeted
  • Remember SMART goals can help improve peoples
    mood, introducing the concept of mastery and
    pleasure in each day, and each week, based upon
    peoples needs and likes/dislikes.

Helping approaches 5 Identification of
Psychological problems in addition to adjustment
to stroke
  • Our role as health professionals is to try and
    assist people to cope with the stroke and to find
    ways to help them. Most people will have some
    psychological reaction and in many instances this
    is normal and people will cope with the
    significant life event of stroke with support,
    although there will be ups and downs along the
  • Our role is also to assist with the
    identification of people who may be suffering
    more distressing psychological reactions such as
    clinical depression or anxiety which require
    identification and management as they so
    negatively impact upon peoples lives.
  • Research has suggested that early identification
    and alleviation of psychological distress is
    essential in order to prevent more serious
    psychological difficulties developing that can
    impact on recovery and overall outcome.

If untreated, psychological disorders lead to
higher levels of
  • Mortality
  • Suicide
  • Long term disability and institutionalisation
  • Hospital readmission
  • Higher utilisation of outpatient services
  • Patient distress.
  • See House et al, (2001), Morris et al, (1993)

Identifying difficulties
  • The range of psychological issues which can be
    experienced by our patients after stroke may
  • Depression (30 of patients will suffer from
    depression at some point post stroke and a
    significant proportion of these remain
    potentially undiagnosed or inadequately treated
    Hackett et al, 2005).
  • Anxiety Rates for anxiety following stroke have
    been estimated to be between 22-28 in the acute
    stage and at follow-up, that means one in four
    patients are anxious.
  • Emotionalism
  • Adjustment disorder
  • Anger problems
  • Problems with social re-integration
  • Family problems.

Management of difficulties
  • People who experience such psychological symptoms
    appreciate the identification and help offered to
    deal with the problem that is causing them
  • Staff can sensitively inform people that these
    are common difficulties after stroke, and that
    the problems are amenable to intervention, with
    support available.
  • Levels of intervention (including referral on to
    a service) should be determined by the
    psychological problem faced. Health professionals
    such as psychologists, doctors, occupational
    therapists and nurses are there to assist in
    assessment and management of the problem.
    Community support groups can also be very helpful
    to people, as are informational resources.

  • Psychological support should always be a priority
    in providing care after a stroke. Helping people
    to be able to express their feelings, thoughts,
    fears and frustrations following stroke can help
    them a lot. This includes acknowledgement of the
    physical limitations, the emotional and social
    impact of a stroke and considers the process of
    adjustment with the individual and family.
  • We are looking to understand and help each
    individual through a difficult time in their
  • Models help us to understand that people will go
    through feelings and challenges throughout the
    stroke journey.
  • Intervention approaches (core skills) are
    important to use, based on understanding the
    person and the impact of stroke. This can help us
    to plan goals and interventions to help them.
  • Inclusion of the family is also key in order to
    support the person and also to help the family
    through the difficulties faced.

A final word on the positive effect of
psychological support
  • Psychological support puts you back together
    again. The timing cant be predictedsometimes
    its when you come out into your real world after
    hospital or it may be two - or more years later
    when you discover that you will not make a full
    recoveryits about reinvention and finding
  • Psychological support is provided by every member
    of the team at every encounter with the patient
    and their family.
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