Psychosocial Disciplines at SPNDS Psychosocial Services Clinical - - PDF document

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MND Day

Psychosocial Services Workshop

Psychosocial Services

Patients with MND & their families

What does ‘psychosocial’ actually mean?

“Psychosocial support involves the culturally sensitive provision of psychological, social, and spiritual care” - Hodgkinson, 2008.

Psychosocial Care & MND

• Research shows that “quality of life” for patients with MND is just as dependent on

psychological condition as it is on physical condition (Macleod & Clarke, 2007).

• Research shows that many physicians and functionally based clinicians feel uncomfortable in

approaching patients to offer psychosocial support and often feel that they do not know what type of psychosocial care is needed or where to get support (Mitsumoto et al., 2005)

• Common psychosocial needs that arise for patients and families dealing with MND are:
• Caregiver wellness
• Knowledge of disease-

related issues

• Spirituality
• Coping
• Sexuality and intimacy
• Addressing the needs of

children

• End of life expectations
• Sense of purpose/Apathy
• End of life choices
• Life closure
• Dying process in ALS
• How to be present with a dying

person

• Withdrawal of ventilation
• Bereavement
• Role of health care team in

psychosocial care

• Existential Crisis

Psychosocial Disciplines at SPNDS

• Clinical Psychology
• Music Therapy
• Neuropsychology
• Pastoral Care
• Social Work

Case Study

• Meg – 48 year old woman
• Married to Tony (49)
• 2 children, Chloe (10) & Tanya (8).
• Diagnosis of bulbar onset MND
• Presenting symptoms:
• Frequent yawning, slurred speech, mild dysphagia
• Speech and swallowing a little worse
• Weight loss.
• Tongue fasciculation, wasting/weakness.
• Speech less than 100% intelligible
• No speech and poor hand function
• Mobile in powered wheel chair
• Current issues:
• Anxious about the future
• Confronted by disease progression
• Struggling to engage with services
• Concern for children and husband
• Existential issues
• Referral to Pastoral Care

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Psychology services: Assessing suicide risk

Kate Prowd (Clinical Psychologist) | Marie-Claire Davis (Neuropsychologist)

Suicide Warning Signs

Most people who suicide give warning What are possible warning signs? Observe behaviours Listen for thoughts Learn about trigger situations Ask about physical signs

How might MND make a difference to these warning signs? What about the impact of frontotemporal brain change? Stages of Suicidality

• 7. Attempt
• 7. Attempt
• 6. Intent + Method + Plan (all prepared): “I’ve just taken all my pills and you were meant to be out of the house all day

and not find me.”

• 6. Intent + Method + Plan (all prepared): “I’ve just taken all my pills and you were meant to be out of the house all day

and not find me.”

• 5. Intent + Plan (incomplete Method): “I’m going to do it tomorrow when everyone is out. I’ve got everything I need: the

pills…bourbon.”

• 5. Intent + Plan (incomplete Method): “I’m going to do it tomorrow when everyone is out. I’ve got everything I need: the

pills…bourbon.”

• 4. Intent certain (no clear Plan or Method): “I’m sick of it all, and planning to take an overdose tomorrow. As long as I

can get enough pills today.”

• 4. Intent certain (no clear Plan or Method): “I’m sick of it all, and planning to take an overdose tomorrow. As long as I

can get enough pills today.”

• 3. Method decided (no clear Plan or Intent): “I’ve thought about taking an overdose, but don’t know when, where or
• how. I probably wouldn’t go through with it.”
• 3. Method decided (no clear Plan or Intent): “I’ve thought about taking an overdose, but don’t know when, where or
• how. I probably wouldn’t go through with it.”
• 2. Active Thought: “I feel like killing myself, but I wouldn’t know how”
• 2. Active Thought: “I feel like killing myself, but I wouldn’t know how”

1.Passive thought: “My life isn’t worth much.” 1.Passive thought: “My life isn’t worth much.”

Stages of Suicidality: Questions to ask

• 1. Have you felt life wasn’t worth much?
• 2. Have you had thoughts of killing yourself?
• 3. Have you had thoughts of how you might kill yourself?
• 4. Are you definitely going ahead with these thoughts of killing yourself?
• 5. Have you worked out details of how to kill yourself (when? how? where?),

and do you fully intend to carry out this plan?

• 6. Have you done things to get this plan ready to carry out? What? When?

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Grading Suicide Risk

Use a risk assessment tool to get a sense of whether the risk is: The Red Flag indicators

Protective Factors

Can reduce the risk of suicide Examples Important to identify what gives hope or security Should be included in any management plan Protective factors are no guarantee of full protection from risk A ‘no self-harm’ contract is not protective

Now it’s your turn…

1) Divide yourselves into groups of three 2) Participant 1 conducts the suicide risk assessment 3) Participant 2 role plays as Meg presenting in a state of “low”, “moderate”, or “high” risk. Try to avoid telling your group which category you are in. 4) Participant 3 uses the suicide risk assessment tool to gauge Meg’s level of suicide risk

Inform family/significant others

What to do next…?

HIGH RISK? HIGH RISK? MODERATE/LOW RISK? MODERATE/LOW RISK?

Liaise with GP/treating Physician to determine if an Assessment Order should be made Contact nearest psychiatric triage service to arrange psychiatric admission If psychiatric triage accepts admission, transfer directly If psychiatric triage refuses admission, follow plan for moderate/low risk Document the management plan Devise an interim safety plan Refer for treatment and management services (e.g., public mental health services, private psychiatry, local counselling services) Determine date you will review risk Document the management plan Notify patient’s current health services (e.g. GP) Inform family/significant others

Finding the right psychiatric service for your area…

For ADULTS aged 18 to 65: http://www.health.vic.gov.au/mentalhealth/services/adult/ For OLDER ADULTS aged over 65yrs: http://www.health.vic.gov.au/mentalhealth/services/aged/index.htm For CHILDREN AND ADOLESCENTS aged up to 18yo: http://www.health.vic.gov.au/mentalhealth/services/child/index.htm

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Safety plans

Warning signs Make my environment safe My reasons for living Things I can do by myself Connect with people and places Family and friends I can talk to Professional supports

Duty of Care

• We have a Duty of Care to ensure no harm

comes to the person we are assisting; to take all reasonable steps to care.

• Duty of Care applies to all staff, regardless of

qualifications or experience.

• Duty of Care overrides confidentiality and

privacy.

Social Work Social Work

• Psycho-social assessment looks at the following

areas:

• Identify patient/family expectations and goals
• Family and social networks
• Community supports
• Adjustment to illness
• Initial assessment may be documented on the

social work assessment tool

Planning Ahead

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Planning ahead

• Need to plan ahead in anticipation of need for

community supports

• Discuss the different type of services available in the

community including;

• interim support options
• short term options and
• long term options.

Facilitate communication

Facilitation of communication in extremely stressful situations

• between patient and family
• between different family members
• between family and team
• external service providers
• coordinate Family meetings

Family Meetings

Improving communication will improve family satisfaction as well as quality of care Whilst there are a number of strategies that can be utilised to improve communication, research indicates that family meetings have shown to be an effective form

• f improving communication

Family Meetings

To explore family expectations/concerns For clear communication around goals of care/treatment/discharge planning

This can include

exploring family expectations or concerns clear communication around goals of care/treatment managing complex family relationships Information sharing discharge planning

Tips…

• Choose appropriate setting/space, appoint a facilitator
• Seek feedback from family: ask what their understanding of the

illness/condition is

• Have a structure to the meeting, but also let it flow
• Conclude with a clear summary of plans and who is responsible for actions
• Documentation

Rules of good communication

TELL them what they want to know EXPLORE fears (e.g. pain, mode of dying, grief of leaving, what lies beyond) REASSURE (symptom control, walk alongside) EXPLAIN to families and loved ones, remember that while you may do this every day, this is one of the few times that most of these family members will be in this situation.

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Factors to consider when referring for services Emerging Pathways

National Disability Insurance Scheme

• and

My Aged Care

• The players – External providers

Client

RDNS

Carer Support

THE CHALLENGES OF BEING A CARER

• financial hardship through loss of paid work hours and superannuation contributions
• detriments to health and wellbeing when putting the needs of others first
• social isolation and relationship pressures
• disadvantage in careers, education
• ongoing commitment; loss of spontaneity and independence
• lack of acknowledgement of role

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HELPING THE CARERS – KNOWING THE SYSTEM

Often the biggest issue for carers is not being familiar with “the system”. Knowing entitlements, which services are available and who to contact is vital. Unfortunately, people often become overwhelmed and unable to move forward. Social Workers are able to give information and support, and advocate for carers to enable them to find their way through the maze.

• Practical support
• Financial support
• Emotional support
• Other specialist carer support services such as Carers Victoria, Carer Services

Why Music? Why use music therapy with patients with MND?

Research shows that music therapy can be beneficial when working with people with MND and their families. Common ways in which music therapy is utilised include:

• Legacy work with patient and family
• Music assisted relaxation to assist NIV implementation and use
• Facilitating opportunities for meaningful connections and activities between

patient and family/carers

• Speech confidence – Neurologic Music Therapy
• Expression, choice and identity

Tuned In Program

How & What

What is it?

• Tuned in is a program for people and family/carers
• f people with PND.
• It is especially beneficial for those who have trouble

joining in meaningful activities with others. How does it work?

• Carers are trained by a music therapist to use

simple, proven music-based activities to create enjoyable and meaningful times together.

• The music therapist designs a program for the

individual person that fits with their needs and interests.

Benefits

“Tuned In” can help you to…

• Feel more connected with each other
• Spend enjoyable and meaningful time in a

shared activity

• Can facilitate interaction between children

& parents

• Calm and focus the person when they are

upset or agitated

• Help the person to be more motivated to

participate in activities

• Provide a different way for the person to

communicate or express themselves

ACTIVITY TIME

Music Assisted Relaxation & NIV

What is music assisted relaxation?

• Music Assisted Relaxation (MAR)

uses live or recorded music and spoken instructions to promote a deep state of relaxation, also known as the ‘relaxation response’.

• MAR programs are constructed by

a music therapist, in consultation with clients and family to address individual needs and preferences.

Benefits

Music Assisted Relaxation can:

• Lower physiological and

psychological symptoms of stress and anxiety

• Can create a routine of relaxation

around events that regularly cause stress, so that the body is trained to relax when it hears specific music.

• Patients have said that using MAR

with NIV (Non – invasive ventilation) improved their experience of using the ventilation machine and helped them relax and get to sleep.

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HYPOTHESIS Pastoral Dx EXPERIMENT Pastoral Intervention EFFICACY Response (Immediate) EVIDENCE Feedback Existential distress, communication frustration and anxiety. PC Ax

• general + exploration of

distress.

• Trial meditation/visualization

exercise (general base). Calm/relaxed. Reported to PN & Clinpsych.

• Agitation abated,

“much better”. Is response to meditation/visualization repeatable and learnable? Teach practice and homework to personalize locus of meditation /visualization. Involve family. Promotes client and family

• wnership – shared story, life

review. Identifies place of personal and family importance. MND - Clinician knowledge. As disease progresses will need external prompts and likely assistance. More life review.

• Embed place and significance.
• Identify music.
• Name meditation.
• Focal point for commencing

meditation. ‘Smiling sun token’ given. Further sessions booked. Clinpsych reports benefits and encourage to record self. Personalized CD needed for long term maintenance of therapeutic meditation use to address anxiety. CD recorded at CHCB with technical help from MT.

• CD cover tactile (thick brocade

cloth) to assist with identification CD delivered to home. Pt and spouse trial together. Spouse reports in, excited – “Where ever did you get it…felt like we were there.”

• CD in cover and

smiling sun lanyard are part of every inpatient stay. Token often worn around neck or hung

• n window by bed.

EOL stage - CD and meditation practice now too complex; but symbolic resonance remains as potent source of comfort. Reference to mental image and token bring calm and comfort. “Off to --- Island”. PT keen to show he has token with him and to request to wear same. Sessions close with donning of lanyard (smiling sun token). Enduring legacy – ‘Smiling sun hangs on bed post on PT’s side.

• Card & a jar of pickles.

Conclusion

Key Messages

Refer Early Psychosocial disciplines are pivotal in order to maximise quality of life It is not a linear process, disciplines may be actively involved at different points along the patient and families journey One size does not fit all – it is a needs based, preferences based system All of us play a role in the psychosocial wellbeing of our patients and families

Questions?