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Counseling Adult Neurogenic Disordered Patients and Their Families

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Title: Counseling Adult Neurogenic Disordered Patients and Their Families


1
Counseling Adult Neurogenic Disordered Patients
and Their Families
  • Scott A. Jackson, M.S., CCC-SLP

2
A Shout Out to my Influences
  • Dr. Sonya Wilt (influenced by Virginia Satir)
  • Dr. Audrey Holland
  • Jean Glattke
  • Dr. Celeste Roseberry-McKibbin

3
Fears of Counseling
  • Its really not in our scope of practice.
  • That should be done by a psychologist.
  • I dont have enough experience to do it.
  • I never know what to say.
  • We didnt have very much training in that area
    is school.
  • I feel like I need to be doing speech stuff in
    therapythere s no time for counseling.
  • Its non-billable!

4
Scope of Practice
  • ASHAs Scope of Practice states that we as SLPs
    can/should provide counseling for those
    individuals we see for therapy with
    communication/swallowing disorders.

5
ASHA Scope of Practice
  • Clinical Services
  • Speech-language pathologists provide clinical
    services that include the following
  • prevention and pre-referral
  • screening
  • assessment/evaluation
  • consultation
  • diagnosis
  • treatment, intervention, management
  • counseling
  • collaboration
  • documentation
  • referral

6
ASHA Scope of Practice
  • Examples of these clinical services include
  • counseling individuals, families, coworkers,
    educators, and other persons in the community
    regarding acceptance, adaptation, and decision
    making about communication and swallowing

7
Why Us as SLPs?
  • Budget cuts. Many hospital/facilities are cutting
    back on services including social services, etc
  • Many insurances dont authorize
    therapy/counseling with a psychologist/social
    worker unless there is a significant depression
    associated with it.
  • Alsopeople are living longer as a result of
    better medical care/medical advancements.
    Therefore, our caseloads should increase! There
    is expected to be a huge shift in the age
    statistics of our population with elderly
    individuals increasing in numbers (the baby
    boomers).

8
Why Us as SLPs?
  • Everyone on the interdisciplinary team should be
    providing counseling to some extent.
  • Ideally social workers and psychologists are the
    most specifically trained for it.
  • How many of us have easy access to one of these?
    Outside of acute rehab facilities, most patients
    dont have easy access.

9
Why Us as SLPs?
  • MDs often dont have the time to provide
    counseling or even education to either the
    patient and/or family.
  • PT/OT are focusing on physical difficulties and
    have such limited time to do that.

10
Why Us as SLPs?
  • Anderson Marlett (2004) cites several others in
    their article Communication in Stroke The
    Overlooked Rehabilitation Tool
  • Clark (2000) and Pound et al. (1994) found that
    patients felt that it was the role of doctors and
    hospitals to provide information, explanation,
    encouragement, and advice but almost half
    believed that this need was not being met.
  • Wellwood et al. stated that over 70 of
    caregivers had to ask for information.

11
Why Us as SLPs?
  • It makes sense for us to be the ones to take a
    counseling role.
  • When asked why its easier for them to get some
    counseling in Speech Therapy, a patient of mine
    stated because you actually listen to me and
    understand me and take the time. My doctor and
    physical therapist dont give me enough time.

12
Education Vs. Counseling
  • Both are extremely important.
  • I feel most of us do a good job in the education
    partproviding patients and families information
    regarding the deficit(s).
  • Its the counseling aspect that many times gets
    overlooked or ignored.

13
Research
  • Clark, Micheal S. (2003) ran a study looking at
    education and counseling intervention for
    families after stroke.
  • Two groups. One control and one given stroke
    information and sessions with a social worker.
  • Conclusion An education and counseling
    intervention maintained family functioning, and
    in turn led to improved functional and social
    patient outcomes.

14
Research
  • Evans, R.L. et. al. (1988) had two stroke groups
    with their families.
  • One received information only and the other
    received counseling only.
  • 18 months post stroke, findings showed both
    groups significantly improved caregiver knowledge
    and stabilized some aspects of family function
    better than routine care.
  • Counseling was consistently more effective than
    education alone and resulted in better patient
    adjustment at 1 year.

15
General Ideas/Thoughts
  • Like all clients we see in the Speech Therapy, we
    need to make sure to build a rapport with them.
  • Find a way to connect with them.
  • Reciprocal learning.
  • Laugh at their jokes!!!
  • Family is a great topic.so is food!
  • Dont be afraid to discuss personal things about
    yourself!

16
General Ideas/Thoughts
  • Open-Ended Questions
  • Allow a lot of latitude
  • Draw a client out
  • Encourage answers that may be more accurate
  • They can be time-consuming

17
General Ideas/Thoughts
  • Its important to try and get a sense of what
    the client/family needs in terms of
    counseling/support
  • Teacher/education provider
  • An ear/sounding board
  • Someone to help them feel calm
  • Someone to give them encouragement (cheerleader)
  • Someone to motivate them (military sergeant)
  • Find the balance as a therapist between
    providing awareness of deficits and providing
    hope.
  • Be flexible!!!!

18
General Ideas/Thoughts
  • Anderson Marlett (2004) Professionals debate
    whether their communication gives stroke
    survivors and families hope and recovery after
    stroke versus creating over-optimistic
    expectations of recovery and unrealistic
    expectations.
  • I cant predict how far your progress will go.
  • Focus on the things that they can do.
  • Let them discover with time rather than us trying
    to predict.

19
General Ideas/Thoughts
  • Family and/or Patient in Session?
  • Most counseling sessions should involve both the
    patient and family
  • However, some sessions should involve just the
    patient. Its amazing how different he/she acts
    when around family
  • Some sessions or time should be spent with just
    the family too. This is where a student intern
    comes in handy

20
General Ideas/Thoughts
  • Dont let people wander
  • Speaking of that.
  • That reminds me of something you said earlier
  • Along those lines
  • That brings up a good point

21
General Ideas/Thoughts
  • Facial Expressions
  • According to Glass (2002), 55 of nonverbal
    communication is facial
  • Frowning or looking disapproving really shuts
    people down
  • Fight those yawns!!!!!!

22
General Ideas/Thoughts
  • Eye Contact
  • People generally appreciate direct eye contact
  • However, this is very cultural if people are
    uncomfortable, we should not gaze at them

23
General Ideas/Thoughts
  • Head Nodding
  • Positive head nodding encourages a person to keep
    going and say more
  • However, too much of it can indicate that you are
    insecure and overeager to be liked

24
General Ideas/Thoughts
  • Body Posture
  • Leaning backward often conveys negative feelings
    and disinterest (this may be gender specific
    though)
  • Leaning forward indicates interest, respect, and
    liking
  • Dont cross your armsmay indicate disapproval

25
General Ideas/Thoughts
  • Silences
  • For Americans, this can be uncomfortable
  • In many cultures, silences are expected
  • Research shows that silences longer than 5
    seconds result in shorter verbalizations from
    interviewees
  • Short silences of 5 seconds or less can be
    helpful, because people are given time to think
    and are often encouraged to say more

26
General Ideas/Thoughts
  • Summaries
  • VERY useful for keeping things moving!
  • At the end of the session, it helps to highlight
    and review major points
  • Consider taking detailed notes. You can then
    refer back to them and give the patients and
    family the exact words they said.
  • This makes them feel heard and, often, specialI
    care enough to write down what they tell me.
    (Dont let them get suspicious)

27
General Ideas/Thoughts
  • Touch
  • This should be used very carefully
  • Sometimes I will briefly touch someone on the
    arm, hand, or shoulder to convey sympathy
  • When used appropriately, this is quite helpful

28
General Ideas/Thoughts
  • Self Disclosure
  • This is when we reveal something personal about
    ourselves
  • We need to keep it short
  • Often, people feel more comfortable and understood

29
General Ideas/Thoughts
  • Running Out of Time
  • Im so sorryI have another meeting in 5
    minutes. Why dont we continue during our next
    appointment so I can hear the rest of what you
    want to say?
  • I hate to cut this short, but there is another
    patient waiting. I want to hear more.
  • Some people give their business card and email
    address and encourage further communication that
    way.

30
DEFENSE MECHANISMS
  • A. Rationalization
  • Logical but untrue explanation of an attitude or
    behavior that allows an individual to explain why
    an expectation has not occurred
  • Rationalization not only prevents anxiety, it may
    also protect self-esteem and self-concept. When
    confronted by success or failure, people tend to
    attribute achievement to their own qualities and
    skills while failures are blamed on other people
    or outside forces.

31
DEFENSE MECHANISMS
  • B. Displacement
  • Person transfers hostile feelings from the person
    or problem that caused the hostile feelings onto
    a safe person or object
  • Rather than express our anger in ways that could
    lead to negative consequences (like arguing with
    our boss), we instead express our anger towards a
    person or object that poses no threat (such as
    our spouses, children, or pets).

32
DEFENSE MECHANISMS
  • C. Projection
  • The person shifts responsibility to someone else
    feelings or motives that belong to the individual
    are attributed to another person
  • For example, if you have a strong dislike for
    someone, you might instead believe that he or she
    does not like you.

33
DEFENSE MECHANISMS
  • D. Reaction Formation
  • People experience emotions that are so shocking
    or contrary to their previous thoughts that the
    new feelings are considered unacceptable
    individuals develop positive attitudes that are
    opposed to their new, shocking, real feelings
    about a subject
  • An example would be treating someone you strongly
    dislike in an excessively friendly manner in
    order to hide your true feelings.

34
DEFENSE MECHANISMS
  • E. Repression
  • People consciously keep thoughts and feelings
    under control and out of view of others they may
    hold their true feelings inside and even deny
    them
  • F. Suppression
  • Like repression, only the person is not conscious
    of emotions or feelings--these are unconscious

35
Disarming an Angry Person
  • Compliment the person on something they did right
  • Disarm them by finding something to agree with
  • Encourage people to talk openly about why they
    are angry
  • Feedback and negotiation
  • Acknowledge their anger/frustration

36
Change
  • As we age, we face many changes. This is the case
    for even healthy individuals.
  • One of my clients put it this way
  • Part of growing old is letting go of the things
    that you love.

37
Change
  • Now imagine, in addition to growing old, how some
    also suffer from a medical event, accident, or
    decline that may results in mild-severe and
    acute/chronic life-changes.
  • Some examples include
  • Stroke (aphasia dysarthria dysphagia)
  • Dementia (AD PD)
  • TBI

38
Commonality
  • Neurogenic disordered patients all have suffered
    a loss!
  • It can be a loss of communication skills,
    swallowing skills, social activities, memory,
    identity, roles in the family, etc
  • It may be beneficial to include stages of grief
    with your counseling.

39
Stages of Grief
  • The stages are
  • Denial
  • Example - "I feel fine." "This can't be
    happening, not to me!"
  • Anger
  • Example - "Why me? It's not fair!" "NO! NO! How
    can you accept this!"
  • Bargaining
  • Example - "Just let me live to see my children
    graduate." "I'll do anything, can't you stretch
    it out? A few more years."
  • Depression
  • Example - "I'm so sad, why bother with
    anything?" "I'm going to die . . . What's the
    point?"
  • Acceptance
  • Example - "It's going to be OK." "I can't fight
    it, I may as well prepare for it."

40
Stages of Grief
  • DenialAt first, we tend to deny the loss has
    taken place, and may withdraw from our usual
    social contacts. This stage may last a few
    moments, or longer.

41
Stages of Grief
  • AngerThe grieving person may then be furious at
    the person who inflicted the hurt (even if she's
    dead), or at the world, for letting it happen. He
    may be angry with himself for letting the event
    take place, even if, realistically, nothing could
    have stopped it.

42
Stages of Grief
  • BargainingNow the grieving person may make
    bargains with God, asking, "If I do this, will
    you take away the loss?"

43
Stages of Grief
  • DepressionThe person feels numb, although anger
    and sadness may remain underneath.

44
Depression
  • Men vs. Women in terms of depression
  • Men tend to show their depression via anger and
    anxiety
  • Women tend to show their depression via sadness
    and moping

45
Depression
  • Organic depression vs. depression from loss
  • Since our neurogenic patients have all suffered a
    loss of some sort, it is logical to assume that
    there will be some depression because of that
    loss.
  • However, depression (or part of it) may also be a
    part of changes that occur in the brain as a
    result of injury (ie., stroke). This is organic
    depression.
  • Pts may benefit from understanding this.

46
Depression and Meds
  • Many patients are reluctant to start
    antidepressants.
  • I feel it is our job to help them understand how
    depression may also impact their performance and
    therapy progress.
  • Meds may help clear away the fog.

47
Stages of Grief
  • AcceptanceThis is when the anger, sadness and
    mourning have tapered off. The person simply
    accepts the reality of the loss.

48
Loss of Identity/Loss of Self
  • Most of the adults we see for therapy have
    suffered a traumatic event that has caused many
    changes.
  • They feel a sense of lossa loss of identitya
    loss of self.
  • Some of these changes happen rapidly (CVA) and
    some slowly (PD, AD)

49
Loss of Identity/Loss of Self
  • The person whom the client once knew is no longer
    present to him/her.
  • Areas that help define us may include
  • Communication
  • Memories
  • Socialization
  • Family Role
  • Career/job Role
  • Hobbies/interests

50
Domains of Self
  • Barbara Shadden, PhD _at_ Univ. of Ark.
  • From Advance November 2008
  • People draw from at least four domains of self to
    tell their life story
  • 1. Biographical
  • 2. Role-based
  • 3. Interactional
  • 4. Cultural

51
Domains of Self
  • Biographical Domain
  • Facts of a persons life
  • Age
  • Marital Status
  • Children
  • Pets
  • Profession
  • Surface self

52
Domains of Self
  • Role-based Domain
  • Household/family duties such as
  • Driving
  • Bill paying
  • Cooking
  • Cleaning

53
Domains of Self
  • Interactional Domain
  • Also known as relational domain
  • Dr. Shadden states that self is constantly
    created with other people, the interaction part
    of the puzzle is huge.
  • Typically our interactions change with whomever
    we are communicating with (ie., spouse, neighbor,
    children)

54
Domains of Self
  • Cultural Domain
  • How do you fit into the world around you?
  • Shadden Cultural and self get to the big
    picture of policies and practices that help or
    hinder the social engagement of a person with a
    communication impairment.
  • Ie., Are some restaurants more friendly and
    accommodating?

55
The Pie of I
  • Dr. Sonya Wilt (who has been influenced by
    Virginia Satir) talks about the importance of
    discussing role changes in therapy as part of
    counseling.
  • She uses a pie graph. I have named it The Pie of
    I.
  • Barbara Shadden calls this Role-based Domain

56
Counseling for Loss of Self
  • We must help redefine oneself or recreate his/her
    Role!
  • Help them realize that they are still that same
    personthat same piebut with just different
    pieces.
  • The pieces may shift and become smaller or
    larger, but for the most part, they are still
    there.
  • Other slices might also be created.
  • Some may even need to be removed to some degree.

57
Prior to Event
58
After Event
59
Health-care Professional Communication with
Patients/family
  • Bendz 2000 professionals communicate about
    bodily impairment, problems of reduced functions,
    and treatment of patients disease, whereas
    stroke survivors portray themselves as
    individuals with a life in society that they wish
    to recapture.
  • Stroke survivors portray themselves as
    individuals w/ a position in society that they
    are trying to recapture, whereas the medical care
    personnel categorize them by their deficits.

60
Health-care Professional Communication with
Patients/family
  • Our goal in stroke communication, from the
    outset, should be to support individuals and
    families in creating a positive post-stroke
    identity. Four key factors have been correlated
    with the improved outcome in stroke and are also
    associated with improving self-image and
    identity. They include
  • Family support
  • Ability to solve problems
  • Social support
  • Perceived control

61
Health-care Professional Communication with
Patients/family
  • Life after stroke is about rebuilding,
    re-establishing, or recreating a coherent sense
    of self, and the roles that fit this new
    identity.
  • Ellis-Hill Horn (2000) When individuals
    cannot create a clear sense of future self, they
    experience anxiety and become unsure how to
    actindividuals who have had a stroke may settle
    for a restricted future self with limited
    physical and social activity, because this is
    what they expect of a life with a disability.

62
Health-care Professional Communication with
Patients/family
  • Professionals cannot redefine identity for stroke
    survivors and their families after stroke. Stroke
    survivors and families must do that work on their
    own, with the collaboration of professionals.

63
Counseling for Loss of Self
  • Couple or Family Counseling
  • Since most of the domains contain aspects related
    to the individuals family/spouse, it is
    important to include them as well.
  • They also need to understand the pie pieces.
  • They will be an integral part of helping him/her
    re-create or re-establish ones self.

64
Prior to Event
65
After Event
66
Relationships
  • Maintaining relationships
  • Vanhook (2009)
  • Maintenance of relationships within the family
    and those within the community provide a support
    system for anyone with a chronic illness. When
    these relationships become estranged, there are
    both physiological and psychological
    manifestations.

67
Relationships
  • The relationship change for both stroke survivors
    and their families is sudden.
  • Pound et al. (1998) did a qualitative study
    showing the descriptions of relationships
    post-stroke vary from support to alienation.
  • The variation is not explained as a consequence
    of the stroke findings indicate that the
    previous state of the relationship influences the
    relationships after stroke.

68
Counseling for Loss of Self
  • Support groups may be very beneficial. They
    provide
  • Emotional support
  • Practice with their impairments
  • A sense of belonging/Community
  • A chance to be ones self
  • A chance to create/re-establish ones self

69
Support Groups
  • Mackenzie Chang (2002) found statistical
    significance between high social support and
    functional abilities at the end of 3 months.
    Those stroke survivors perceiving less social
    support experience a decline in function
  • Online resources/groups can also be great for
    stroke survivors and families.

70
Counseling at Various Levels of Care
  • The focus of our counseling may differ greatly
    depending on the LOC.
  • As the patient progresses through the various
    LOCs, their counseling needs will change.
  • At the ICU, we may focus mainly on the education
    part of counseling. We tend to treat and street
    people.
  • Many times, its not until outpatient therapy
    that feelings about loss of self and role changes
    come out.

71
Cultural Religious Considerations
  • We all must be aware of and sensitive to the
    various cultures and religions.
  • Some religions and cultures view disease,
    disabilities, accidents as fate. This will impact
    how we do therapy and counseling.
  • Some frown upon physical contact.
  • Some religions may find it difficult to listen to
    a females ideas versus a males.
  • Some cultures find it rude to question authority.
    They may agree with you verbally, but truly
    dont.
  • Some may seek other, non-westernized, treatments.
  • Roles may vary greatly within different cultures.
  • Family support may also vary.

72
How can I bill for this?
  • I feel that your entire session should not be
    spent doing counseling.
  • You need to balance with your other therapy
    tasks.
  • This doesnt mean that you cant use counseling
    as part of therapy.
  • I sometimes even make a goal to include
    counseling aspects (ie., Pt. will have zero
    paraphasias during a dialogue regarding his/her
    relationships.)

73
Referring On
  • We need to know that we are limited in our
    abilities to serve as the clients sole
    counselor.
  • Often, we need to be sure and refer them on for a
    psychology consult or social worker.
  • Talk to the MD. Let him/her know of your
    concerns.
  • Social services may also be a great resource.

74
Dr. Robert Buckmans Quote
  • the skill and effort that we put into our
    clinical communication (counseling) does make an
    indelible impression on our patients, their
    families, and their friends. If we do it badly,
    they may never forgive us if we do it well they
    may never forget us.

75
Questions!
76
Case Examples
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