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Section 10
Recovery from Stroke:
Does Rehabilitation Counseling Have a Role to Play?

Question 10 | Test | Table of Contents

Stroke is one of the commonest causes of severe disablement." Though the evidence is not clear-cut, the general conclusion is that stroke patients do derive benefit from rehabilitation. However, depression, anxiety, isolation, poor quality of life and adjustment in the aftermath of stroke and rehabilitation is well. It is suggested that, in the aftermath of stroke and physical rehabilitation, the human emotional, psychosocial impact of sudden or unexpected disability, impairment or handicap is a distinct concept that draws together many influences which may act upon the individual and their family, affecting in the long-term, their ability to successfully interact physically and socially within the community.

In the review Trends in Rehabilitation Policy," the Audit Commission and the King’ s Fund suggest that the importance of rehabilitation is increasingly being recognized. More medical specialties include it as part of their service and it covers a wider range of aspects than simply physical functioning. In the health and social care sectors (at both a local and national level), rehabilitation is seen as a means of easing discharge from hospital, reducing inappropriate long-term placements in institutional care, improving the quality of service users lives, and offering a more cost effective use of resources. However, there is a lack of clarity in the situation, insofar as there would appear to be substantial gaps at ground level between the theory of rehabilitation, its practical application and its effectiveness as an end in itself. In the absence of addressing the longer-term emotional, psycho-social issues arising from residual disability as a consequence of stroke in a life situation, and the long-term integrated maintenance in the community, patients and their families, in the aftermath of rehabilitation, often gradually regress to a significantly lower level of functioning, which can precipitate further crisis : leading to loss of physical ability in the patient, anxiety, distress and possible burnout in the carer and even to the breakdown of family and marital relationships," yet there is still no structured provision of counseling within statutory services for individuals and their families to help them adjust to their changed circumstances.

It would appear, then, that a traditional medical approach to rehabilitation represents a linear process, from the acute stage through to discharge. However, the authors’ experience and research indicates that this does not accurately illustrate the pattern of recovery from stroke.  This is supported by disabled people too, who are calling for better rehabilitation facilities in order to help them lead more independent lives."

What is rehabilitation ?
Rehabilitation is a widely used term, but is often poorly defined. One view is that it is concerned with the ability to return to full time employment or to life as it was before the illness or incident happened. A broader view is that it involves regaining optimum health and functional ability. (An interesting definition is offered by McEachron: "Rehabilitation is a dynamic process of planned adaptive change in lifestyle in response to unplanned change imposed on the individual by disease or traumatic incident. The focus is not cure, but on living with as much freedom and autonomy as possible at every stage and in which ever direction the disability progresses.")  On the whole, whatever the definition, patients and their families are looking to rehabilitation as the main treatment that will restore independence and `normality’ after stroke. 

During the acute phase of the stroke, people want to put their faith in experienced and trusted experts who will help them make sense of the event, take all the actions necessary to ensure survival, and provide comfort and human warmth during the crisis.  However, as the acute stage passes, the increasing recognition by the patient of the physical limitations caused by the stroke may be accompanied by an expectation of a fairly quick and full recovery. Patient’ s views of recovery are based on their past experiences of physical illness or injury. These are usually `passive ’ in nature, and the notion of `cure’ is invested in the doctors, nurses and therapists.  As would be expected with such a negative life event, acute psychological reactions are often observed, including grief, anxiety, anger and depression.  However, these responses often appear to be categorized as `mood disorder ’ and referred to psychiatrists or psychologists contained within mental health and the medical model.  While only concentrating on the malfunctioning of the body and it’ s parts due to stroke, and only intervening either physically or chemically this approach often loses sight of the person as a human being. In doing so, it may ignore the complex interplay among physical, psychological, social and environmental aspects of the human condition the person and his} her family has to cope with in a life situation in the aftermath of stroke rehabilitation.

Like all chronic illness, stroke represents an assault upon many areas of everyday life, encompassing home, work, leisure and social relationships including relationships with self and others. It may shatter personal images, family life and future ambitions. Therefore, patients and/or carers are likely to have unrealistic expectations of a full recovery from the stroke event, or be in danger of falling into despair. However, when there is poor or no acceptance of the event and [it’ s] possible consequences, added to an inert expectation that they will be `made better’ , these people are often discharged from rehabilitation settings still searching for the `cure ’: life as it was before the stroke unable to incorporate `their’ stroke disability into `their’ future lives.

The primary features of this impasse, in the long-term are : the retention of the pre-stroke persona and lifestyle expectations; disappointment with recovery and an inability to move out of the `sick-role ’ , resulting with feelings of being abandoned by the professionals, the NHS and the system as a whole ; a lack of acceptance of a `new or different me’ and an inability to develop a new lifestyle and interests; post-stroke depression; guilt a belief that the stroke is a punishment for some kind of actual or imagined wrong doing in the past; and a significant degree of dependency whilst waiting for thing’s to get better.  Which adds to an already significant burden on the carer(s), families and} or resources in a community.

The reality of working with this patient group is that the current pattern of fragmented rehabilitation takes place across a range of professional groups and agencies.  Each has its own model and perspective for practice, but there is no meta-structure to guide the process as a whole. It needs to be said, a patient’ s experience of stroke and rehabilitation is not fragmented but is a fully encompassing life event. There is clearly a need for a model of integrated rehabilitation which can be adapted by each professional involved, yet which provides a coherent overview of the process of recovery from the
patients perspective.

Is there an alternative ?
It is suggested that an approach to stroke rehabilitation that observes directly and specifically the person as well as the physical functional outcome would be, at least, as effective.  There is a well established body of research indicating the primary elements of an effective model for rehabilitation.  Models of holistic, multidisciplinary and integrated treatment usually display the following  features :
(1) The patient, carer and professionals need to know the nature of the problems and be familiar with the process of rehabilitation. Without this knowledge it is impossible for anyone in the system to match the needs of the patient with an effective means of rehabilitation.
(2) Based upon this knowledge, effective strategies can be developed for treating the disabilities of the patient. Effective rehabilitation incorporates not only the patient but also the supporting structures, i.e. carer, family, mobility, transport, finance and housing.
(3) The most positive outcomes in rehabilitation are accompanied by acceptance of the reality of stroke and it’s effects, along with a more active engagement in the process of rehabilitation, from the perspective of both the patient and significant others.

From this perspective then, rehabilitation is defined as a process of adjustment to change such that order and meaning can be re-discovered in a life situation.  The focus of rehabilitation counselling is to facilitate the patients moving through periods of emotional adjustment and grieving during the physical rehabilitation phase. It is proposed that being sensitive to the patients agenda and honouring his or her experience is a fundamental premise of the rehabilitation process.

Areas where rehabilitation counselling could be effective:
- Supporting provision of services to carry out treatment, assessed as necessary, to promote the recovery of the stroke patient and to support the carer and/or family through that process.
- Continued availability of education, verbal and written information for all groups.
- Continued availability of time for counselling and support for the patient, carer and family.
- Continued availability of adequate multi-agency support services in the community.

Key Points
Education- the giving of information that may empower patient and carer knowledge, to make informed choices that enable involvement in the rehabilitation programme.
Support - communication within client groups, carer groups and professionals.
Counselling - client groups, carer groups, family groups, and individual (one to one) therapy: focusing on brief, person-centred counselling that looks at the human losses within the stroke event and the rehabilitation process and to facilitate the way through all the changes.

Facilitation of the patients and carers emotional adjustment through counselling may enhance other aspects of the rehabilitation programme and outcome. However, in using this approach, there would need to be closely integrated multidisciplinary working across professional boundaries, with a continuous and active dialogue. Rehabilitation would certainly need to be client centred not service centred, and be dictated primarily by a model of re-education and psycho-social adjustment within the context of good quality medical care and physical rehabilitation. So, the two could work very nicely hand in hand. Rehabilitation counseling would provide the long neglected aspect of emotional rehabilitation to complement the emphasis on physical rehabilitation of stroke.

Thorne emphasizes the points well in her seminal work on the experiences of people living with chronic illness: Chronic illness is much larger than simply curing ¼ it has to do with the very essence of human aspirations and meanings. People do not become less human, less interesting or less deserving because they have un-resolvable disabling conditions. Rather they continue to learn to adapt and to live their lives as well as they can manage. In other words, they seek a state of health that represents their best effort within the specific challenges of their condition. And helping people to achieve this health is, after all, what the healthcare system is supposed to be about.

Recovery from stroke
Despite the knowledge base of research evidence supporting the crucial roles played by psycho-social variables in determining the extent of `recovery ’ following stroke, it would appear that studies which have attempted to evaluate packages of rehabilitation, of which counselling was a part have not provided clear and unequivocal evidence of it’ s effectiveness, or indeed, the lack of it. Given that other mainstream rehabilitation programmes, notably coronary care, oncology and pain clinics in the UK incorporate rehabilitation counselling techniques with effect, " there are a number of reasons why now it is essential to evaluate the outcome of person-centred disability rehabilitation counselling practice for this patient group.

Firstly, unless there is clear information available about the likely results of counselling intervention from short-term rehabilitation through long-term adaptation, people who have suffered a stroke will not receive optimum treatment. Second, rehabilitation practice based solely on clinical, physical functional outcome is no longer acceptable, and thirdly, given the current financial situation in the health service, and the number of people with stroke, there is a reluctance to purchase services without clear evidence of it’ s efficacy.  The practice of medicine has always depended on doctor’ s and nurse’ s. The therapy professions have grown up to supply new kinds of skills. Certainly, the medical commitment to stroke rehabilitation is more positive now, and the specialized skills of occupational therapy and physiotherapy can hardly be in doubt, but it has to be recognized that there is a need for far more than physical therapy. The person with a stroke may have many requirements and, therefore, may need other specialized interventions to meet those needs. To that end, an evaluative research initiative is at present ongoing and will be reported at a later date.
-White MA; Johnstone AS; Disability And Rehabilitation 2000 Feb 15; Vol. 22 (3), pp. 140-3

Personal Reflection Exercise #3
The preceding section contained information about the role of rehabilitation counseling in stroke recovery.  Write three case study examples regarding how you might use the content of this section in your practice.

How does McEachron define rehabilitation? To select and enter your answer go to Test

Section 11
Table of Contents