RICHARD L. GOLDBERG, M.D. THOMAS N. WISE, M.D. FRANCIS P. LeBUFFE, M.D.
aspects of recovery ABSTRACT: Several years' observation of both general medical wards and a stroke unit suggests that the stroke unit is far better suited to care for both the psychological and physical needs of the cerebrovascular-accident victim. The staff's team organization and its expectations from patients may be the chief factors in the stroke unit's success. Psychological effects of each unit on the patient, and their impact on recovery, are explored.
A cerebrovascular accident is a devastating event in any patient's life. The patient not only experiences deficits in cognition, perception, motility, memory, speech, and sensation, but he must also find coping mechanisms to deal with the all-too-frequent conflicts about dependency, anger, and loss associated with the sudden impairment caused by the stroke. '·7 For example, denial is frequently used by the stroke patient to afford him a much-needed buffer from the impact of his injury. 8 This defense, as
well as other primitive defenses such as projection and splitting, offers little solace to the patient or others around him. Thus, a stroke has a profound effect not only on the patient, but also on his family members and on the medical staff who are trying to treat him. 9. 10 Just as the stroke patient emerges from the acute stage of his illness to face his long-term physical disabilities and accompanying psychological problems, he is usually sent to recover in a general medical ward, which is often unequipped to cope
Dr. Goldberg is assistant professor ofpsychiatry at Georgetown University. Dr. Wise is chairman ofthe department ofpsychiatry at the Fairfax Hospital, Falls Church, Va., and Dr. LeBuffe is attending psychiatrist at Fairfax Hospital. Reprint requests to Dr. Goldberg, Department ofPsychiatry, Georgetown University Hospital, 3800 Reservoir Road, N. W, Washington, DC 20007. 316
with his needs. The result may be unnecessary frustration and even despair for both patient and staff, with the patient eventually isolated or abruptly dismissed to a nursing home. Our several years of experience as liaison psychiatrists in both general medical units and a specialized stroke unit suggest that the stroke unit provides a better psychological atmosphere for recovery from cerebrovascular accidents (CVAs). General medical unit On a general medical unit, the focus of the staff is on acute, reversible illness-especially etiologic diagnosis and specific therapy. The patient's interaction with the staff corresponds to Parsons'll classic description of the "sick role," which accords the patient the right to be relieved of his usual social responsibilities and to be cared for. In return, he must wish to become well, get competent help for his illness, and cooperate with the prescribed treatment. Although the stroke patient does not fit comfortably into this role when the acute PSYCHOSOMATICS
phase of his illness is over. he may at first be treated as ifhe does. Once the slowness of the rehabilitation process becomes evident. however, the staffs attitude toward the patient changes. The staffs sense of self-esteem. which depends on successfully controlling an acute medical condition. is threatened when faced with hemiplegia, aphasia. and other infirmities that may persist in a stroke patient long after the acute phase is controlled. Rather than acknowledge its own lack of expertise in caring for a patient with hard-to-reverse infirmities. the staff may unwittingly project its sense of helplessness and "badness" onto the patient. The stroke patient's denial of illness-a common defense. and often one with a neuropathologic basis-may be seen as evidence of the patient's wish not to get well or to cooperate with therapy. This "uncooperative" attitude angers a staff that is already guilty about its own inability to reverse a disease process. The staffs anger and guilt tend to intensify the patient's own anxiety and determination to cling to his defenses. which in turn feeds the staffs demoralizing attitude that "nothing can be done."12 As the process builds upon itself. the patient and staff become entwined in a net of despair and hopelessness. and lose their sense of humanity. People become objects. "gorks." "gomers." Finally. the patient may be left isolated, as is done frequently with the dying. Case 1 An elderly man, recovering from a cerebrovascular accident in a general medical unit, was left in a room distant from the nursing station and positioned for long periods of time in an uncomfortable manner. The staff first
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explained that lack of time for the care of such patients accounted for this type of practice. With further probing, however, the medical staff members admitted to the attitude that "they're always like that; they'll never get any better; we have to help those we can." The only solution to the situation, according to the staff, was to transfer the patient to a nursing home.
Ironically. unrestrained optimism can also be dangerous. The medical staff sometimes tries to alleviate its sense of helplessness by giving the patient too much hope that he can really "do something" about his illness that the staff cannot do. In order to boost his morale. the staff may falsely reassure him that he looks well. or may even withhold discouraging information. While guarded optimism in light doses can help a patient maintain the sometimes necessary coping mechanism of denial. in larger doses it tends to support unrealistic expectations of recovery. which impede the patient's participation in rehabilitation programs. The patient who expects quick and easy progress can fail to appreciate the small improvements brought about by physical therapy. Unable to deal with the possibility that his disabled limbs might not be restored to their original function. the patient may reject physiotherapy altogether. Case 2 A 60-year-old businessman suffered a stroke that left him with mild expressive aphasia and right upper-extremity paralysis. He began to receive messages from the staff that his "will" could overcome his deficit. At first he refused occupational and physical therapy and tried to assert his "will" instead. After this failed to produce any improvement, he reluctantly par-
ticipated in occupational and physical therapy. He was told by the medical staff that if he worked hard enough, his limb function would improve in six months. He worked virtually day and night on his exercises. When he was discharged from the hospital, both he and the staff felt optimistic about his prospects for recovery. Six months later, however, the patient appeared extremely distressed and depressed that his efforts alone did not bring the improved function he had been led to expect.
Modifying staff expectations does not solve the problem entirely. for most teams on a general ward are not organized to meet the particular needs of the stroke patient. Vertically structured-with the physicians heading a staff of residents. interns. nurses, and social workers-most of these teams tend to encourage a dependent mode of functioning. Staff members may thus displace the stroke patient's problems upon an appointed leader. who is usually the attending physician or senior unit resident. They may resent. criticize. or attack this leader for failing to keep "such patients" off their unit. Chronic disruptive conflict between physicians and nurses can all too frequently result. Stroke unit The CVA patient may be better served at a specialized stroke unit. such as the one at the Fairfax Hospital. in Falls Church, VaY The unit consists of an eight-bed ward. divided equally between intensive care and intermediate care. Admitted to the unit by general practitioners. internists. and neurologists. patients are placed under the charge of a large nursing staff consisting of a nursing care supervisor. 317
II registered nurses, four licensed practical nurses, and one hospital aide, all of whom participate in ongoing educational programs in the care and rehabilitation of the stroke patient. The hospital's department of physical medicine and rehabilitation provides evaluation services and physical therapy, occupational therapy, and speech therapy, as indicated. A 9O-minute psychosocial case conference is held every week in the unit's activity room and is attended by nurses, physical therapists, occupational therapists, the unit social worker, one or more psychiatrists, and occasionally other physicians. One of the psychiatrists interviews a patient who is preselected by the nursing staff. Following the interview, all in attendance are encouraged to discuss the patient's manner of coping with the stroke. If formal psychiatric consultation is requested by the attending physician, it is carried out separately from the conference. Homogeneous population The homogeneousness of the patient population allows the unit staff to be more intimately acquainted with the sometimes unique biologic, social, and psychological difficulties of the stroke patient. Stroke unit staff soon learn that the classic medical approach of "doing something" by correcting deviations of internal milieu cannot be their only goal. "Doing something" also includes rehabilitation programs designed to enhance the function of impaired tissues and to replace lost capabilities with new ones. 14 Even relatively small gains in a patient's cognitive, motor, sensory, or memory functions are seen by the stroke unit's staff as large rewards for its work. Thus, the staff 320
can care for the patient without sinking into despair. Intimate familiarity with the difficulties of the stroke patient that cuts across many specialties tends to shape the stroke unit structurally into what Brodsky calls a "comprehensive decision-making system." IS This system goes beyond focal interest in a cluster of signs and systems, to examine many aspects of the patient's physical, psychological, and social structure. The concept of a team composed of individuals capable of dealing with each other and with particular components of the patient's illness experience becomes central to the function of a stroke unit. Each specialist in such a system contributes his judgment and skills to the team's overall prescription for the patient so that each feels indispensable to the multi-pronged treatment program. The stroke team at the Fairfax Hospital is centripetal in structure, with the nursing staff at the core and the other professionals as spokes of the wheel. Such a structure discourages the dependent mode of group functioning by deemphasizing the role of the physician and stressing the nurses' importance in the stroke patient's treatment and recovery. There is ample opportunity in this approach to rehabilitation nursing for the fulfillment of the staff's various psychological needs. Mothering role The stroke unit staff at the Fairfax Hospital, for example, feels that caring for a stroke patient is an opportunity to assist in a "rebirth." While not consciously attempting to infantilize their patients, the staff often sees the stroke patient in need of good mothering-that is, assist-
ing and supporting or frustrating a patient as needed to encourage maximal development of new skills. In describing the qualities that make a good stroke unit nurse, the nursing staff frequently mentions maternal qualities, such as patience, the ability to tolerate a mess, and being comfortable in touching patients. The nurses feel greatly rewarded when the patient responds positively to their supportive care. The nurse's mothering role also carries potential dangers, however. The nurse may come to rely so much on gratitude from her patients that she may have difficulty in receiving angry messages from them, which may tempt her to be too prompt in suggesting the transfer of angry patients to a longterm nursing facility. Or she may unwittingly inspire patients to displace onto their fellow patients the anger they feel toward her or other staff members. The nurse's mothering role may also create problems when the patient's discharge from the hospital approaches. Although the stroke unit staff works hard to rehabilitate its patients, the staff may experience difficulty with the impending separation and may unduly augment the patient's anxiety about functioning outside the hospital.
c... 3 A 56-year-old newspaper publisher suffered a severe myocardial infarction while visiting in Virginia, and entered the emergency room where he had to be resuscitated three times. He survived with right-sided hemiplegia due to an embolism. When his cardiac condition stabilized, he was transferred to the stroke unit, where the hemiplegia improved gradually. Because of the improvement, as well as his very attractive personality, he soon
became a favorite of the stroke unit staff. As the time approached for his transfer to a rehabilitation center near his home in a neighboring state. the staff and the patient began verbalizing to one another the difficulty they would experience in saying "goodbye." The patient became acutely anxious about what the place where he would be staying next might have in store for him. His anxiety diminished as the staff members began to deal more effectively with their feelings about the separation.
The stroke unit staff may also fall into other traps. Because of the intensive and specialized care provided on the unit, a rational criterion for keeping the patient there is the continuing improvement of his functions. Failure to improve may constitute a direct threat to the esteem and the efficiency of the stroke
unit staff and may occasionally result in premature dismissal from the unit-just as failure to obtain a "cure" may cause dismissal from a general medical unit. The specialized nature of the stroke unit may itself have the negative effect of restricting the staffs ability to cope with a wide range of emotional and diagnostic concerns. For example, while there is considerable depth of understanding about the psychological sequelae of strokes of various types, the patients' individual personalities are sometimes scantily considered. It is not unusual for a patient's personality to be described as "a typical right hemi." Similarly, small changes in strength and speech are noted promptly, but a positive VORL and FTA in a patient whose stroke may be secondary to luetic
disease, may be mentioned only in passing during a conference.
Despite some difficulties it may have in dealing with its patients, the stroke unit staff appears to develop healthier and more realistically optimistic expectations for stroke patients than the staffs of the general medical units with which we consulted. The stroke unit's success in nurturing such expectations seems to enhance the efficiency with which its members work with patients and with one another. Although comparative data on morbidity and mortality outcome are not yet available, our clinical observations suggest that the specialized stroke unit is better suited than the general medical unit for the 0 care of the stroke patient.
6. Robins AH: Are stroke patients more depressed than other disabled subjects? J Chronic Dis 21:479-482, 1976. 7. Borden WA: Psychological aspects of stroke: Patient and family. Ann Inlern Mad 57:689692,1962. 8. Levine J, Zigler E: Denial and self-image in stroke, lung, cancer, and heart disease patients. J Consu/l Clin Psycho/43:751-757, 1975. 9. Oradei OM, Waite NS: Admission conference for families of stroke palients. SOcial Casework. 10:21-26, 1975. 10.0'Altlilti JG, Wertz GW: Rehabilitating the stroke patient through patient-family groups. Inl J Group Psycholher 24:323-332. 1974.
11. Parsons T: The Social Syslem. New York, Free Press, 1951. 12. Holtman JE: "Nothing can be done." Urban Life and CU/lure 3(1): 53-70, 1974. 13. Goshi F: The Fairfax Hospital sUoke unit, progressive and intensive care. a five years' experience. Read before the Second World Congress of the International Rehabilitation Medicine Association. Mexico City, Nov 1974. 14. Bruetman ME, Gordon EE: Rehabilitating the stroke patient at the general hosp~al. PosIgradMed41:2"-2'5,197'. 15. Brodsky CH: Decision making and role shifts as they alteet the consul1ation interface. ArCh Gen Psychialry 23:559-565, 1970.
REFERENCES ,. Dahlberg CC. Jalte J: SIroke: A Doclor's Personal Account of His Recovery. New York, WW Norton, 1971. 2. Fisher SH: PsychiaUic considerations of cerebral vascular disease. Am J Cardio/7:379385. 1961. 3. Adams GF, Hurw~z CJ: Mental barriers to recovery from strokes. Lancel 2:533-537. 1963. 4. Shapiro LN, McMahon AW: Rehabilitation statemate. Arch Gen Psychialry 15: 173-177, 1966. 5. Oradei OM, Waite NS: Group psychotherapy with stroke patienls during the immediale recovery phase. Am J Orlhopsychiatry 44:386-395, 1974.
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