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					Section 2: The Psychosocial Effects of Stroke and
Section 9: Behavioural Problems
Section Objectives

The participant, by completion of the session, will be able to:

   Identify the effects of stroke on a person’s emotions, his sense of self and how the person sees
    his ability to cope.
   Identify the reactions the stroke survivor’s family may experience.
   Apply strategies to support the stroke survivor and the families.
   Identify the effects of stroke on a person’s behaviour.
   List common behaviours and identify triggers that precipitate the behaviour.
   Describe coping techniques that can be used to modify behaviour.

Session Time: 50 minutes. Prioritize according to learners’ expectations. Suggested times are listed for each
topic.


Teaching Resources

   Tips and Tools manual
   Tips and Tools facilitator guide
   Tips and Tools PowerPoint presentations and speaker notes
   Heart and Stroke Foundation Patient Resources
   Evaluation forms




                    Section 2 – The Psychosocial Effects of Stroke and Section 9 – Behavioural Problems   / 11   1
Use examples through the presentation to exemplify psychosocial and behavioural problems.

                                     Tips and Tools
                                       Manual
          Topic                 Section 2  Section 9                                Notes
                             (PowerPoint PowerPoint
                                Slide #)    Slide #)
Introduction                 p. 11                             Say or speak to: First we’ll look at the
                                                               emotional impact of the stroke and then at
                             (Slide # 1)
                                                               the effects of stroke on behaviour
                                                               A stroke can have a dramatic physical effect
                                                               Much attention is focused on the physical
                                                               effects of stroke sometimes overlooking
                                                               emotional impact
                                                               The time following a stroke can be an
                                                               emotional roller coaster with a wide range of
                                                               feeling
                                                               It’s good to remember that family members
                                                               may experience similar feeling
Group exercise: Ask group members to recall a client who was a stroke survivor. Then ask them to think
about how the person reacted to the stroke? Write responses on flipchart then go to slide # 3
Initial Reaction             p. 11                             Shock/disbelief is typically the first emotion
                                                               that most people feel after stroke.
                             (Slide # 4)
                                                               Statements like “Why did this happen to me?
                                                               How could this happen to me?” are common
                                                               Fear/worry/anxiety about will they survive,
                                                               have another stroke and what their life will be
                                                               like
                                                               Anger for what has happened, again why me?
                                                               Physical, cognitive limitations. How in one
                                                               moment life has changed
                                                               Frustration with limitations especially if
                                                               speech, memory loss, comprehension,
                                                               mobility, ability to do ADLs has changed
                                                               **Family/caregiver may experience the same
                                                               emotions. Whole system unbalanced
Reactions over the longer    p. 11                             Frustrated about physical limitation, with
term                                                           loss of memory, lack of ability to speak
                             (Slide # 5)
                                                               Tired as a result of the stroke and because of
                                                               the increased effort required to perform
                                                               routine activities
                                                               Disinterested in social activities and social
                                                               contact with others. This may be due to
                                                               feeling of embarrassment about the changes


                    Section 2 – The Psychosocial Effects of Stroke and Section 9 – Behavioural Problems   / 11   2
                                     Tips and Tools
                                      Manual
          Topic                Section 2  Section 9                                 Notes
                             (PowerPoint PowerPoint
                               Slide #)    Slide #)
                                                               in physical appearance, lack of ability to speak
                                                               or be understood, etc.
                                                               Grief-stricken over the loss of abilities, over
                                                               how they feel about themselves and how they
                                                               perceive others feel about them
                                                               Depressed. Approximately half of survivors
                                                               experience some degree of depression. It may
                                                               be caused by changes in the brain that occur
                                                               after a stroke, and/or by knowing that they
                                                               have lost some of their ability to do some
                                                               things they did before the stroke.
                                                               Anxious. Survivors often have many
                                                               concerns after a stroke. All of these worries
                                                               can create anxiety –a normal reaction to
                                                               changes that occur after a stroke. As the
                                                               Survivor adapts, the anxiety usually lessen
Group exercise (cont’d): Remember that Stroke Survivor that you were thinking of, what type of support
helped him to cope? Either write responses on flipchart or just allow group to say out loud before
proceeding to next slide.
How Can You Help the         p. 12                             Stroke Survivors have to find new ways to
Survivor                                                       give meaning back to their lives. You can
                             (Slide # 6)
                                                               help by:
                                                                   Being supportive and offering
                                                                    encouragement
                                                                   Allowing the Survivor to be as
                                                                    independent as possible
                                                                   Telling the Survivor when she is doing
                                                                    well – positive feedback
                                                                   Gently offer information and assistance
                                                                    to the Survivor to enable her to become
                                                                    more independent
                                                                   Be aware of and observe for signs of
                                                                    depression or other emotions that
                                                                    negatively affect the Survivor
                                                                   Concerns about a Survivor’s mood
                                                                    should be reported to you supervisor.
Group exercise (cont’d): Again going back to the Stroke Survivor, can you recall the person’s
family/support system? What were their reactions?
Reaction of the Survivor’s   p. 12                             Stress from having their household routines
Family                                                         disrupted or from having to cope with thins at
                             (Slide # 7)
                                                               home that they did not have to worry about

                    Section 2 – The Psychosocial Effects of Stroke and Section 9 – Behavioural Problems   / 11    3
                                       Tips and Tools
                                        Manual
          Topic                  Section 2  Section 9                                 Notes
                               (PowerPoint PowerPoint
                                 Slide #)    Slide #)
                                                                 before the stroke
                                                                 Worry that their loved one will have a fall or
                                                                 another stroke
                                                                 Sadness, anger or frustration over loss of a
                                                                 social life and time to themselves
                                                                 Guilt over their loved one being in hospital or
                                                                 a nursing home while they can live in their
                                                                 own home, or guilt over doing something for
                                                                 themselves instead of always spending time
                                                                 with their loved one
                                                                 Grief similar to how they would feel if a loved
                                                                 one had died (loss of the person the Stroke
                                                                 Survivor used to be before the stroke)
Group exercise (cont’d): Can you recall things you or other people did to help the family cope?
How you can assist the         p. 12                                 Be supportive and encouraging
Survivor’s Family
                               (Slide # 8)                           Caregiver’s need to know that they are
                                                                      seen as doing their best so offering
                                                                      positive feedback goes a long way
                                                                     Gently offer information and assistance
                                                                      to the family, don’t take over
                                                                     Observe for signs of stress or other
                                                                      emotions that could negatively impact the
                                                                      family. Report concerns to the
                                                                      appropriate person
                                                                     While you should allow family members
                                                                      to participate in the survivor’s care it’s
                                                                      also important to encourage them to take
                                                                      time for themselves. Balancing self-care
                                                                      and care for the survivor is important.
Specific Behaviours                            p. 59             This section will look at:
                                               (Slide # 3)           How stroke can affect behaviour
                                                                     What causes loss of emotional control
                                                                 Then we will review the more common post
                                                                 stroke behaviours such as:
                                                                     Social isolation or withdrawal of the
                                                                      Stroke Survivor
                                                                     Angry outbursts or aggressive behaviour
                                                                     Lack of interest or motivation


                      Section 2 – The Psychosocial Effects of Stroke and Section 9 – Behavioural Problems     / 11   4
                                     Tips and Tools
                                       Manual
         Topic                  Section 2  Section 9                                 Notes
                              (PowerPoint PowerPoint
                                Slide #)    Slide #)
                                                                    Frustration
                                                                And finally
                                                                    Lack of social judgement
How stroke affects                            p. 59             (Slide #4)
behaviour
                                              (Slide # 4)       Here are a few principles
                                              (Slide # 5)           How stroke affects the survivor is unique
                                                                     to each situation. So is the stroke’s effect
                                                                     on the survivor’s behaviour.
                                                                    The stroke may have caused cognitive or
                                                                     perceptual problems that are the
                                                                     underlying cause of negative behaviours
                                                                    It is important to understand the
                                                                     underlying cause of the behaviour for an
                                                                     intervention strategy to be helpful
                                                                (Slide #5)
                                                                    Damage to the brain caused by the stroke
                                                                     can cause survivors to have less control
                                                                     over their emotions.
                                                                Group question: Think back on your
                                                                experience with Stroke Survivors and their
                                                                families. Often you will hear family members
                                                                say that the Stroke Survivor “was not like that
                                                                before the stroke”…What kind of behaviours
                                                                were they referring to?


                                                                Let’s see what the slide says:
                                                                    Mood swings
                                                                    Short fuse: It doesn’t take much to
                                                                     provoke them
                                                                    Stubborn
                                                                    More selfish or demanding
                                                                    Become indifferent or disinterested in
                                                                     things
                                                                Obviously these changes can be upsetting to
                                                                family and friends.




                     Section 2 – The Psychosocial Effects of Stroke and Section 9 – Behavioural Problems   / 11     5
                                   Tips and Tools
                                     Manual
          Topic               Section 2    Section 9                               Notes
                            (PowerPoint PowerPoint
                              Slide #)     Slide #)
Loss of emotional control               p. 59, 60                 Many Stroke Survivors will have less
                                            (Slide # 5)            control over their emotions; this is
                                                                   referred to as “emotional ability”
                                            (Slide # 6)            Although people who have had s stroke
                                                                   have good reason to feel angry or
                                                                   depressed, excessive crying (or laughing)
                                                                   is often due to brain injury and isn’t
                                                                   directly connected with perceived losses.
                                                              What you can do to help:
                                                                  Double check with the survivor to find
                                                                   out if he is really feeling the emotion he is
                                                                   expressed or whether it is unrelated to
                                                                   how he feels.
                                                                  If the Stroke Survivor looses control of
                                                                   his emotions you can try to minimize
                                                                   embarrassment or disruptive behaviour
                                                                   by redirecting or distracting him.
                                                                  Normalize the loss of control by stating
                                                                   that this often happens to people who’ve
                                                                   had a stroke

                                                              Vignette: Mr. Tomas has experienced a loss
                                                              of emotional control after his stroke. He now
                                                              finds it difficult to watch the nightly news, as
                                                              the stories make him cry uncontrollably. His
                                                              PSW helps him by distracting him when his
                                                              sadness distresses him. He will ask him if he
                                                              wants to have a snack, or if his favourite show
                                                              is on next. This makes it easier for
                                                              Mr. Tomas to stop crying.




                   Section 2 – The Psychosocial Effects of Stroke and Section 9 – Behavioural Problems    / 11     6
                                      Tips and Tools
                                        Manual
          Topic                  Section 2    Section 9                               Notes
                               (PowerPoint PowerPoint
                                 Slide #)     Slide #)
Social Isolation or                        p. 60                     Many survivors experience diminished
Withdrawal                                                            self-image, self-esteem and confidence –
                                               (Slide # 7)
                                                                      feelings of depression or despair as they
                                               (Slide # 8)            come to realize their losses.
                                                                      -   lack of meaning or purpose.
                                                                      -   feel helpless, and have a sense of little
                                                                          control over their environment and
                                                                          life
                                                                 A survivor may regain the ability to perform
                                                                 many ADLs yet seem to have lost interest in
                                                                 living. As one survivor put it, “There’s more
                                                                 to life than relearning how to pull on your
                                                                 pants.
                                                                 Assisting the survivor to again take art in
                                                                 life(as she chooses) is one of the most
                                                                 important things you can do
                                                                 What you can do to help:
                                                                     If at all possible, find out your survivor’s
                                                                      interests. Learn what matters to the
                                                                      survivor, What activities are most
                                                                      important? What brings her enjoyment?
                                                                      Assist the survivor to regain pursuits and
                                                                      activities of interest.
                                                                     Encourage the survivor to participate in
                                                                      her care as best she can
                                                                     Get her involved in discussions and
                                                                      decisions
                                                                     Modify the environment to encourage
                                                                      and support independence.
                                                                     Encourage and support the Stroke
                                                                      survivor to be involved in social activities.
                                                                      Recognize that attendance can be the first
                                                                      step in participation.
                                                                     Create opportunities for the Stroke
                                                                      Survivor to talk about the good things in
                                                                      her life, the good memories
                                                                     Support the survivor in her contact with
                                                                      her faith community if appropriate.




                      Section 2 – The Psychosocial Effects of Stroke and Section 9 – Behavioural Problems    / 11     7
                                  Tips and Tools
                                    Manual
         Topic               Section 2  Section 9                                 Notes
                           (PowerPoint PowerPoint
                             Slide #)    Slide #)
                                                             Judy had a stroke 18 months ago. She has
                                                             some rt. Sided weakness that has caused the
                                                             muscles on one side of her face to droop. As
                                                             a result, she feels very self-conscious and has
                                                             been reluctant to go out.

                                                             Her support worker encourages her to go out,
                                                             first to quite, familiar places. Little by little,
                                                             Judy has become less self-conscious and has
                                                             taken a greater interest in going out.
Angry Outbursts or                         p. 61                 Like everyone, stroke survivors may have
Aggressive Behaviour                                              angry outbursts. Though not common,
                                           (Slide # 9)
                                                                  some survivors may be physically
                                           (Slide # 10)           aggressive toward family or support staff.
                                           (Slide # 11)           They may refuse to comply with
                                                                  directions and/or have a difficult time
                                                                  getting over anger. During these times, it
                                                                  may be difficult to reason with the
                                                                  survivor as it is with any angry person.
                                                                  With the help of the survivor it may be
                                                                  possible to identify triggers for this
                                                                  outburst.
                                                             Triggers come from many sources here are
                                                             some examples:
                                                                 Frustration over the inability to perform
                                                                  certain tasks
                                                                 Embarrassment from being incontinent
                                                                 It could be from pain from an affected
                                                                  arm or leg
                                                                 Frustrated at the inability to communicate
                                                             What you can do to help:
                                                                 With the help of the Survivor identify
                                                                  triggers and try to resolve them
                                                                 Learn the Survivor’s routine and how she
                                                                  likes things done
                                                                 If the situation is upsetting the Survivor
                                                                  remove her
                                                                 Try to redirect the Survivor’s attention
                                                                 Try to alternate easy and more e difficult
                                                                  tasks so that the Survivor can experience
                                                                  success and feel like she has

                  Section 2 – The Psychosocial Effects of Stroke and Section 9 – Behavioural Problems   / 11      8
                                      Tips and Tools
                                        Manual
          Topic                  Section 2  Section 9                                 Notes
                               (PowerPoint PowerPoint
                                 Slide #)    Slide #)
                                                                      accomplished something
                                                                     To reduce risk of alarm or surprise
                                                                      approach from the unaffected side
                                                                     Prior to doing something to or with the
                                                                      client explain what you are going to do
                                                                     If you know that an activity causes
                                                                      frustration offer support or assistance
                                                                     Make sure pain is addressed.
Lack of interest or                            p. 61                 Lethargy is a term that can be used
motivation                                                            interchangeably Many Survivors with rt.
                                               (Slide # 12)
                                                                      Hemisphere damage can appear to have
                                                                      lost interest in performing daily and
                                                                      leisure activities. When an attempt is
                                                                      unsuccessful, survivors may seem to
                                                                      easily give up. They may seem to resist
                                                                      encouragement to try, or to try again
                                                                 What you can do to help
                                                                     Learn what interests the survivor.
                                                                      Wherever possible, adapt the activities as
                                                                      necessary to encourage interest and
                                                                      participation
                                                                     Praise the Survivor when she expressed
                                                                      interest in an activity.
                                                                     Recognizing that attendance is the first
                                                                      step in participation, support any
                                                                      involvement in activities.
                                                                     If the Survivor’s first attempt at an
                                                                      activity does not go well encourage them
                                                                      to try again. Remember not to force or
                                                                      embarrass a Survivor who refuses.
                                                                      Instead, try later.
                                                                 Vignette: Harry had a stroke almost a year
                                                                 ago. Although he experienced very little loss
                                                                 of mobility, he seemed to lose all interest in
                                                                 previous pastime. His support worker has
                                                                 helped him to attend social events. She is
                                                                 careful to encourage him to participate in
                                                                 activities that he can easily do, so as to reduce
                                                                 the risk of frustration.




                      Section 2 – The Psychosocial Effects of Stroke and Section 9 – Behavioural Problems   / 11     9
                                   Tips and Tools
                                     Manual
          Topic               Section 2    Section 9                               Notes
                            (PowerPoint PowerPoint
                              Slide #)     Slide #)
Frustration due to                      p. 62                 Exercise: Charades: Have a person from the
communication difficulty                                      group try to get another group member to
                                            (Slide # 13)
                                                              guess a phrase without speaking. Phrase: “I
                                                              would kill for a Tim Horton’s coffee”. After
                                                              the exercise debriefs both the sender and the
                                                              receiver of the message re: how they felt.
                                                                  It can be fun to play a game of Charades
                                                                   but you can imagine how frustrated you
                                                                   would be if this were a permanent
                                                                   method of communication.
                                                              What you can do to help
                                                                  Observe the survivor to assess what she
                                                                   actually can do and understand.
                                                                   Underestimation can lead to frustration
                                                                   or anger; overestimation may lead you to
                                                                   believe the survivor is being deliberately
                                                                   uncooperative.
                                                                  Communication problems may become
                                                                   impossible to overcome if there is too
                                                                   little time or opportunity
                                                                  Use whatever works, short simple
                                                                   messages, supported communication
                                                                   techniques, and pantomime. Yes/No
                                                                   cards, word lists and picture cards may be
                                                                   helpful

                                                              Resource: Circulate picture cards.
Lack of social judgement                    p. 62                 Social judgement refers to the survivor’s
                                            (Slide # 14)           ability to guide and check his own
                                                                   behaviour. This means doing the right
                                                                   thing at the right time. Examples of
                                                                   impaired social judgment can include:
                                                                   -   saying the wrong thing at the wrong
                                                                       time
                                                                   -   Changes in personality. A shy
                                                                       survivor may become immodest or
                                                                       talkative survivor quite. She may
                                                                       become more rigid in her behaviour
                                                                       and personality. A survivor who
                                                                       once was neat now may care little
                                                                       about personal appearance.
                                                              Many of these difficulties result from

                   Section 2 – The Psychosocial Effects of Stroke and Section 9 – Behavioural Problems   / 11 10
                                   Tips and Tools
                                     Manual
          Topic               Section 2  Section 9                                 Notes
                            (PowerPoint PowerPoint
                              Slide #)    Slide #)
                                                              problems with memory and other cognitive
                                                              problems.
                                                              What you can do to help:
                                                                  It’s important not to make the situation
                                                                   worse by putting the Survivor in
                                                                   situations that require him to make social
                                                                   judgements that exceed his capabilities.
                                                                  Feedback helps the survivor recognize
                                                                   inappropriate behaviours and learn a
                                                                   better way of conducting herself.
                                                                  Always praise appropriate or desired
                                                                   behaviours. Make sure that your praise is
                                                                   specific and adult in tone.
                                                                  Be matter-of-fact and non-punitive when
                                                                   identifying inappropriate behaviours.
                                                                   Offer options for alternate behaviour.
Handouts: There are two handouts for this session. Both are entitled “Specific Behaviours After Stroke”
and summarize the behaviours and approaches discussed in the presentation.




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