Coping with severe amnestic and behavioral disorders in early neurological rehabilitation: An interdisciplinary, neuropsychological milieutherapy Dipl.-Psych

Coping with severe amnestic and behavioral disorders in early neurological rehabilitation:

An interdisciplinary, neuropsychological milieutherapy

Dipl.-Psych. M. PoplutzKlinische Neuropsychologin GNP und PTK

Psychologische PsychotherapeutinSupervisorin GNP und PTK

Prague 2013

Contents

Neuropsychological disorders und ressources of challenging patients

Milieutherapy in neuropsychology– literature

A therapeutic milieu in early rehabilitationOrganization of clinic

Design of environment

Interdisciplinary network

Structure of day and week

Integration of patient's family

Controling behavior disturbances: e.g. shouting, irritation or aggression, lack of social distance

Outcome

M. Poplutz, RehaNova Köln 2013

neuropsychological deficits

severe memory disorders, anterograde amnesia

severe disturbance of action (apraxia, dysexecutive syndrome)

unawareness

restlessness

anxiety

irritation and aggressive behavior

disinibition of (social-)behavior

communication disorders (aphasia, non-aphasic)

no motor disturbances or not main problem

=> danger for self or others requires protectionM. Poplutz, RehaNova Köln 2013

neuropsychological ressources

frequently preserved, at least partially:

old retrograde memories (also concerning adequate behaviour)

working memory

routines of every-day-life

implicit learning


A therapeutic milieu in neuropsychologyUSA:- Prigatano: NRP in Oklohoma City, - Ben-Yishay: in Israel and New York, both in 1980ies, later phase of rehab, community based,

Deutschland: - Kühne: IRP, since 1988, 3-months-program based on Ben-Yishay in rehabiltation clinic, late phase of rehab (Asklepios Klinik Schauffling)- Gauggel: “neuropsychological competence and compensation training program” (1997, 1998) - Peschke: milieutherapy in rehabilitation clinic, 1990ies, based on Prigatano, early phase of rehab (Burgau)- Schoof-Tams: neuropsychological therapy in training-flat of rehabilitation clinic and in nursing home, therapeutic community, appr. 2000 (Klinik Westend, Bad Wildungen)


A therapeutic milieu in early neurological rehabilitation?

life in hospital is far away from every-day-life

constructing a therapeutic milieu bydesigning the environmentinterdisciplinary network of contents and methods of therapy

therapeutic behavior of all team members

familiy therapy

patients can learn ina structured, secure environment

every-day-like situations

a social group of patients and team members

forming a framework for individually adjusted therapy of different professions


organization in RehaNova Köln

“one ward - one team“

doctor, nurses, therapists (physiotherapy, ergotherapy, speechtherapy, neuropsychology)

neuropsychologist as “head of therapy” on protecting ward

rooms for therapy on ward

maximum 16 patients on protecting ward

Important organizational framework:

time for internal training and external supervision, team building

selection of team members: willing and personally abel to deal with challenging patients

support from leaders of hospital


protected ward

closed doors=> protection for patients and others

Free to move inside => less control=> less fixation => less aggression

But: “closing the door” is not enough!


basic principles of milieutherapy

what a patient learned in the therapy of one profession is taken over and carried out by other professions

repeat frequently and in the same way, building new routines (drill&practice)

all team members show consistent behavior towards patients (and, after training, of familiy members too)

step by step increase of demands and independence, positive feedback

principles of learning used by everybody (e.g. errorless learning, vanishing cues, chaining)


design of environment

quiet surrounding and calm people

lockable doors to rooms (kitchen, work and therapy rooms) and to patients wardrobes

inscriptions and labels everywhere

visual cues

decoration of ward according to season or events, celebrating feasts together


Network of contents and methods: e.g. memorybook

important information must become repeatable!

=> The memorybook

one place for all notes!

Used by all: therapists, family, visitors, nurses, doctors ....


structure of day and week

structure of day, regularly and as near to life at home as possible (e.g. wash and dress in the morning, meals, activities, TV together in the evening)

structure of week by periodical groups (e.g. buy food and cook together, physical activity, orientation, crafts and occupation)

printed plan for the week, written plan for each day in memorybook, prepared in the morning

leisure with volunteer: e.g. go for a walk, buy a newspaper, drink a coffee and chat


milieutherapy - integrating family and friends

flyer on arrival

personal talk with nearest relative or caregiver by doctor, nurse and therapists

questionaire, information about patients life

training and psychological support for family members (individual or group): psychoeducation, coping with new situation and changed behavior, psychotherapy

visit of ergo- or physiotherapists at home

“testing the limits” at home on weekend

self-help group for family members after discharge with neuropsychologist


milieutherapy - coping with challenging behavior

Two principles:

shaping behavior of patients by behavior of team members

team members are a „model“ of adequate behavior

=> requires training of team, self-control and learning from each other


milieutherapy - shaping of behavior

How do we deal with inadequate behavior of our patients?

(brainstorming in team of nurses and therapists 03/2009)

treating with appreciation, respect and kindness

offering a therapeutic relation

giving praise and positive feedback

talking calmly, with few emotion in voice

short and clear statements

deescalation

constantly keeping an eye on patients interaction, early intervention


milieutherapy - shaping of behavior

signals of adequate social distance (e.g. “Sie” and surname in German language)

empathy, feeling ourselves into patients, who live just in “here and now”: give information to help orientate him-/herself before action

give patient enough time to rest and relax

shaping of medication:feedback from therapists and nurses to doctors concerning behavioral effects of drugs, and viceversa concerning changes of medication


behavioral disturbances – aggression possible reasons

fighting means “no” and leads to self-efficacy

disinhibition after „frontal“ lesion

wrong estimation of a situation due to amnesia

disturbed perception of body and body position

psychotic symptoms, delusion

anxiety

depression

tired, worn-out, attentional deficits M. Poplutz, RehaNova Köln 2013

behavioral disturbances – shoutingpossible reasons

anxiety, loneliness

in need and no other means of communcation:e.g.: aphasia, tetraparesis, apraxia

disinhibition

amnesia, disturbed time-estimation

psychotic symptoms

pain e.g. hypersensitivity, neuropathic pain (thalamic lesions!), long time in same position

Overcharge, need of rest


What to do?for patients

identify reasons or trigger, change or stop as far as possible, satisfy needs

medication! feedback between doctors and rest of staff!

adjust demands: watch out carefully, how is patient today, right now, need of rest during therapy or caregiving?

appreciation and professional relation ... “in spite of it all“

for team

mutual relief, also emotionally, supervision

self-protection first! call out loud for help in a threatening situation, keep distance, space to turn away, second person

time-out for team, relief for ears, relatives can help

male/female, better or worse?M. Poplutz, RehaNova Köln 2013

What to do? interaction teammember - patient

• deescalation

• control of nonverbal signals, „body-talk“

• calm voice, short sentences, few emotions in voice

• try not to attend to inadequate behavior but to adequate,beware of intermitting reinforcement

• after unpleasant actions with patient end interaction with something positive (stabilize relation)

• rather short, but more frequent therapy dates

environment• few diversion, quiet, structured surrounding

• change or leave situation to stop inadequate behavior


Thank you

to all the former and present team members on protected ward 4, who took part in the development and continuity of the treatment concept . Every colleague gives life to these ideas in his or her daily work with our patients and their families.

and

to YOU for your attention!


Documents

Coping with severe amnestic and behavioral disorders in early neurological rehabilitation: An interdisciplinary, neuropsychological milieutherapy Dipl.-Psych