Written by Dan Harren
There’s a problem with brain injury rehab that isn’t talked about very much. Durability of outcomes: Often in-patient programs will see clients perform well in the controlled setting of a rehab facility only to find that they have a lot of trouble when they return home. Old problems return and the clients and their families feel as though rehab was a waste of time.
Successful rehab is life-long. Rehab results must be durable over time.
Here are 5 things that help rehab stick:
Allowing for Things to Go Wrong
When the brain-injured client is in your program, or under your care, the natural impulse of most compassionate people is to try to make the program safe and protective. This is a good thing. However, after a certain period of time the client’s progress will plateau if the client is not allowed to take some risks. The key is to do everything you can to ensure that the client takes the risk in the safest way possible. For example, a client with behavioral and impulse-control problems requests a leave from the facility to go to a concert with her new boyfriend. If the therapists have had enough time to assess her, then they may decide to allow her to go to the concert, but with a few caveats: she must have a cell phone with her, she is asked to call in to the facility once per hour, a therapist needs to meet with the boyfriend beforehand, etc. Is it safer to deny permission to go to the concert? Yes. Is it better for the client and their quality of life? No. Will it be a valuable learning experience that can be transferred to other situations? Absolutely.
Playing to Strengths
Clients come to residential rehab because they are having challenges with certain specific areas – anger management, memory, inappropriate behaviors, etc. Those challenges must be worked on, no question. There are times, however, when a rehab team can get too focused on treating the impairments while neglecting to reinforce the client’s strengths. I think we have all done this at one time or another; I know I have. But focusing on the client’s skills or interests can yield great results. If the client enjoys music, then a lot of rehab can be done within that field. The OT could work on memorization of sheet music or lyrics, the psychologist might use music therapy for dealing with unresolved anger, and the client could learn about behavior in the context of on-stage vs off-stage, in a club vs in an office, with friends vs with co-workers, etc. When the client goes home, the goal is to feel confident and to have their self-esteem intact.
Involving the client in therapeutic decisions is critical. Developing behavioral strategies should be done in concert with the client whenever possible. Understanding the client’s rehab goals with respect to physical therapy, occupational therapy, speech and language therapy, and psychiatric care, only increases the likelihood that rehab will be successful. If the client does not feel that he or she is actively engaged in the planning and execution of rehab, then we have a problem. Rehab is not something that happens to you. Rehab is something you do. We want the client to keep doing rehab when he or she goes home!
Get routines in place early, and make sure that they are achievable. Don’t expect a client who has never woken up before 11 am to suddenly be okay with getting up at 7 am. Make the routines clear to both the rehab team and the client so that everyone is on the same page. Make sure the client is on board with these routines.
The rehab team should also be consistent across the board; scripts should be in place for communication style, language, body language, tone, how to cue, when to back off, etc. All staff should be on the same page. If even one team member plays fast and loose with the routines, then the team quickly loses traction and the client’s treatment quality suffers.
Involving family and friends
This is crucial. Whenever appropriate, involve the client’s social and familial circles. Without their involvement, transitioning home can be very challenging. How can we expect the client’s rehab outcomes to remain stable if, when they leave the program, their family and friends do not employ the routines, communication styles, and behavioral responses that were practiced in rehab? Rehab is practice for real life, and without the home and community support network being involved, translating success in rehab to real life may not go so well.
Durability of outcomes is central to defining success. Who doesn’t want to run into their client 10 years post-rehab and find them to be happy, productive, and successful? It is not only learning new skills and strategies that is important, it’s how those skills and strategies were learned. Their trajectory needs to be pointing up when the client gets home.