beechwords Deborah Cerra-Tyl, Editor Summer 2012 Parting is Sweet Sorrow Under Dr. Tom Felicetti s stewardship the past 21 years, Beechwood has achieved recognition as a Center of Excellence in post-acute neuro-rehabilitation in the United States. Beechwood has become a provider of choice with a reputation for achieving excellence and highest standards in all areas of service and care in the field of brain injury rehabilitation. Dr. Felicetti s leadership shaped Beechwood s focus from being a long-term care facility to one that offers a dynamic broader continuum of care. Some of the biggest changes included bringing Dr. Tom Blash on board as the clinical director and creating senior clinician positions that reported to Dr. Blash. He also established a separate building for the Occupational and Physical Therapy departments, which enabled them to expand the OT and PT services offered to Beechwood clients, as well as to offer opportunities for internships to those studying in the field. Beechwood has achieved its fourth consecutive three-year accreditation from the Commission on the Accreditation of Rehabilitation Facilities (CARF) under the Medical Rehabilitation Division: Brain Injury Programs. This accomplishment and speaks volumes about his influence over Beechwood s commitment to quality improvement and focus on the unique needs of each person they serve. In 2011, Beechwood was named as one of the top 20 rehab hospitals in the country in the Case Management Resource Guide published by Dorland Publishing. The list is compiled by votes of individual external case managers (a source of referrals for Beechwood) who take into account the quality of programming, as well as value. Dr. Felicetti s research, published work, and personal continued on page 4 Moving Beechwood Forward Dr. Drew Nagele has joined Woods as the new Executive Director of Beechwood. Dr. Nagele has a distinguished career in creating and overseeing rehabilitation programs for children, adolescents, and adults with brain injury for several organizations, including the Drucker Brain Injury Center at MossRehab and The Children s Hospital of Philadelphia (CHOP). Dr. Nagele is a leader in the field, currently serving on the Board of Directors of the Brain Injury Association of America, and Co-Chairing the National Collaborative Regarding Children s Brain Injury. He was the Founding President of the Brain Injury Association of Pennsylvania, and is a Certified Brain Injury Specialist Trainer for the Academy for the Certification of Brain Injury Specialists (ACBIS). Dr. Nagele teaches in the Philadelphia College of Osteopathic Medicine s Post Doctoral Certificate Program in Neuropsychology, and is a frequent speaker on a wide range of topics related to brain injury prevention and rehabilitation around the country. Dr. Nagele received his BS in Psychology from Ursinus College, an MA in Community Psychology from Temple University, and a PsyD in Professional Psychology from Central Michigan University. He is a Licensed Psychologist in Pennsylvania and New Jersey.
Beyond Milieu Therapy by Thomas Felicetti, PhD Since this is my final article before I retire as Executive Director of Beechwood I want to write something about our treatment philosophy. This is surely not just my philosophy. It is an evolution of ideas from many colleagues at a number of facilities where I have had the privilege of working and studying. My career began in the Peace Corps in 1969. It continued as a House Parent, Teacher and Supervisor at Hampshire Country School in Ringe, New Hampshire, a residential school for gifted but troubled children. The Director of Hampshire Country School was Henry Patey, a true pioneer in the field. My first position managing a facility was at High Point School in the Berkshires, a facility for autistic and intellectually challenged children and adults. For the past 21 years I have been Executive Director of Beechwood, the brain injury division of Woods Services in Langhorne PA. These primary experiences all helped contribute to a philosophy that reached its maturity at Beechwood. First of all, I think leadership at therapeutic communities like Beechwood should offer a cohesive and clearly articulated set of ideas that help to charter the course. This goes beyond the sorts of things we include in mission and values statements and strategic plans. Sometimes in this field we find ourselves caught up in technical details and ever-present risk management problems and we lose sight of a unifying overarching philosophy. Long ago, Henry C. Patey referred to such overarching ideas as a conceptual framework. Milieu Therapy And in fact, the heart of Mr. Patey s Conceptual Framework at Hampshire Country School is also at the core of the belief system that we tried to develop at High Point and Beechwood; a belief system that has strong backing in evidence-based research. Henry Patey, Bruno Bettelheim, Fritz Redl among others often referred to this core construct as milieu therapy. Milieu Therapy can mean different things to different people, but it is essentially the idea that the whole 24 hours of a client s day is significant therapeutically, not just the hour spent with a given clinician. So how a person served occupies his or her entire day is meaningful and bears careful nurturance. Of prime importance is how the relationships that person encounters throughout the day make him or her feel. The deftest interpersonal therapies can be offset by a careless or unfriendly word or look from the housekeeper or receptionist. In his use of Milieu Therapy, Bettelheim concerned himself (Among other things) with the humaneness of the physical surroundings. As Mr. Patey looked at the milieu, he more closely examined the web of relationships that support the clients. Are these relationships positive? Are they family-like? Are they substantial? Are they life affirming? When I worked at Hampshire and later ran High Point School I began to realize additionally that the network of relationships in a milieu is not limited to our top-down relationships with the clients, but also to the encounters among staff. When we think about relationships in this way, for example, how the Executive Director treats an Intern is as important as how he or she treats higher ranking management staff or therapists because every human encounter either adds to or subtracts from the respectfulness of the overall environment. Careless words and condescending speech can cause verbal pollution. All of these relationships in the microcosm of a specific therapeutic community seep into what Jung described as the collective unconscious Again, just looking at our small Beechwood world there is a collective unconscious here or a kind of aura. Is this aura or atmosphere tilted toward compassion, service, joy and humor or is it tilted toward wariness and anxiety? Does it feel good to be in our community? Since the current health care climate in America presents so much to be anxious about, this is not a question to be answered flippantly and if the emphasis here does lean toward compassion and respect this is something to guard and treasure but not boast about. Relationships all the way Around Earlier I used the word top down to describe an aspect of our relationships with clients at Hampshire Country School. But at High Point School and later in a more mature and careful way at Beechwood, some of my staff and I began to understand that top-down relationships are limited and perhaps even fictional. Yes, there is the commonly held bureaucratic fiction that there is a hierarchy at Beechwood with me at the top and this mutually held fiction is extremely important for getting things done and maintaining order. But aside from the need to put ourselves in hierarchical categories called a chain of command so that we can make the trains run on time, getting too attached to these categories limits our awareness and dulls our capacity to truly meet one another as human beings. 2
This relates, as I said, to our staff-staff relationships and also critically to our staff-client relationships. If we put the clients in a box called disabled and ourselves in another box called non-disabled we severely limit our capacity to see the rich humanity of the people we serve here. We are also being delusional if we permanently place the staff-client relationship in these boxes. As the eminent Emory University ethicist John Banja contends, we all become disabled at some point, so you cannot talk about disabled and non disabled only about disabled and temporarily able-bodied. And here I think the discussion moves a bit beyond milieu therapy as we pose the following question: If positive relationships power milieu therapy, how do we bring ourselves to the point where we are personally truly capable of positive relationships? How does one become that kind of person? When Categories Become Pigeonholes Humans have a brilliant talent for placing things in categories to help make sense of the world. Some of this categorizing is extremely useful. We already talked about how maintaining the fiction of a hierarchy in an organization cultivates a chain of command that is a useful for getting things done. Similarly, having a category for a speeding bus helps to avoid walking in front of that bus. And it has been pointed out many times that early man s ability to classify animal tracks was most helpful in hunting for food and equally useful in avoiding being hunted for food. The problem arises when we see these categories as hard and fast; when we forget that these categories are just human constructs. At that point we rob ourselves of a deeper awareness of the other. My dog is a good example. If I view her only in her category of dog I will certainly tend to her basic needs, but it will dull my awareness of how deeply she is a member of our family and a valued presence in our neighborhood. In this context it is interesting to note that one of the fundamental Zen Koans is: Does a dog have the Buddha nature? Koans are conundrums which are basically impervious to typical reasoning methods and are meant to shock us out of our tendency for over-analysis, over-categorization and mental chatter. Attachments as Obsessions We form attachments throughout life; attachment to others, attachment to material comforts, attachment to our sense of a permanent self, attachment to feeling well etc. Many philosophers see these attachments (especially when they turn into obsessions or thirsts ) as presenting another barrier to deeper mutual understanding and even to happiness itself. This is because over-attachment to something usually leads to dread of loss of that thing. If we enjoy wealth, we bring misery or at least mental distraction by clinging to that wealth and living in fear that it will be taken from us. One serious attachment especially germane in our field is the attachment to the illusion that everything will remain permanent. We understand logically that really the only thing permanent is change, but we often live as if nothing can change and nothing must change. In brain injury (And obviously this is not exclusive to brain injury) those who accept their changed circumstances post-brain injury and make the necessary adjustments to their new condition tend to have healthier, happier and more productive outcomes than those who do not or cannot. In the literature on falling, as just one example, we are beginning to see that if poor balance or gait is coupled by a refusal or inability to adopt compensatory strategies such as proper use of seatbelts in wheelchairs, techniques for walking over uneven surfaces or willingness to call on friends for assistance as needed, the risk of falling and re-injury is higher. Mindfulness vs. Inattention I previously referred to mental chatter. This is inevitable. If one meditates or practices Yoga, one becomes more acutely aware of how thoughts and feelings arise, recede and how our thought processes careen from one idea to the next. Mindfulness (Maintaining a calmly focused awareness of where you are in the here and now) is a way of stilling some of that chatter. Mindfulness should help open the door to being more deeply aware of the person in front of you. The opposite of mindfulness is gross inattention which is especially problematic in a caregiving situation. As an extreme example, having an argument on a cell phone with someone while supervising a client will cause grave inattention on the part of the caregiver and can even result in tragedy. On a simpler level, if we are together and our minds are constantly wandering, we are robbing one another of our full presence. This kind of inattention is often taken as a sign that something is wrong with the relationship and that a new partner will solve the problem. This may be so or the real problem may that we have once again forgotten how to listen and that it is time to clear the fog and pay attention. Martyrdom is not Therapy; Take Care of Yourself. Have Fun Finally, many aspects of this philosophy encourage care givers (And all of us) to work on our capacity for focus, attention vigilance and clarity of thought in the present moment. But these qualities are not incompatible with personal enjoyment and fulfillment. In fact, truly being in the here and now can bring with it a kind of joy, even playfulness. There is no need for grim martyrdom to cloud the therapeutic encounter. For the learner there is also good evidence that play actually promotes learning and development. This is known as incidental learning. So if our Physical and Occupational Therapists, for example, simply work with our population on balance or gait in didactic, sometimes painful, 3
exercise sessions, they will meet with resistance. Therefore they have developed rather ingenious methods for making therapy a game. In motor control group, teams of clients might compete in soccer matches or baseball games. The teams are simply looking to outscore the opponent, but the therapists have laced the game with balance challenges, sometimes even devising barriers that clients must step on or over in order to kick the ball. Other examples of incidental learning opportunities here involve Yoga groups, Myo-Fascial release and use of the Wii. In Speech and Neuro-Education Cognitive groups, there are all kinds of games and mental challenges to promote organization of thought, planning, memory, social judgment, sequencing and so forth. Back in the PT and OT Departments, instead of just putting a person who needs to stand and stretch in a standing box and seeing how long he or she can endure, the therapist will stand the client in a box and spread a card game or scrabble game on a tray. The client is standing, but really in her mind she is just playing cards or beating the therapist at scrabble. And this is important; they are often playing this game with someone they really like which brings us back to the original notion of relationships. If staff and client are really enjoying themselves and are absorbed in the game and each other and a barrier between them dissolves, we are on the way to a healthy and therapeutic atmosphere. Long ago, at the beginning of my career at Hampshire, I was frustrated with the students lack of outdoor physical activity. I asked Henry Patey if he could recommend any techniques to bring the clients out. He replied: What do you like to do, Mr. Felicetti? It took me a few seconds to respond because that was the last question I was expecting. How was what I like to do relevant to the mission of helping the clients? I like soccer a lot I finally answered hesitantly. All right, Mr. Felicetti, take a soccer ball and go out to the soccer field and start playing with other staff that like soccer. Let the students know that they are free to play, too, This was the beginning of the soccer program at Hampshire Country School. Fundamentally, the Marksman Aims at Himself. (From Zen in the Art of Archery) In the end, your capacity to form productive relationships or lead a productive life is sharpened when you work on yourself. So my final suggestion is do whatever you need to do to be relaxed, happy, focused and freed from as much mental clutter as possible. Nutrition, rest, exercise, insight, clarity of values, hiking in the woods, yoga, meditation, a humane livelihood, a positive attitude or just a good day at the ballpark with friends, may all be good starts. Positive relationships are not phenomena to be forced or to be forged mirthlessly out of duty and swallowed as bitter pills. Such relationships take effort but not exertion. These relationships will just happen if your own inner conditions are right or to paraphrase Aldous Huxley, if you have opened the doors to perception. If those inner conditions are favorable, the milieu will invent itself and the soccer program will be game-on. Parting is Sweet Sorrow continued from page 1 achievements in the field of brain injury are extensive. He is well-respected among his peers as evidenced when the American Congress of Rehabilitative Medicine awarded him the distinction of Fellow. During the fall 2011 meeting of the BI-ISIG, Brain Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine (ACRM), he was honored with a lifetime achievement award indicating that his contributions have had an enduring impact upon the enhancement of brain injury rehabilitation, treatment and education. His most recent honor came when his alma mater, Hunter College, installed him into its Hall Of Fame. Hunter, an esteemed and historic college in the City University of New York (CUNY) network, bestows this honor on alumni whose careers reflect Outstanding Professional Achievement. Dr. Tom Felicetti has served his profession, Beechwood, and our entire organization with distinction. 4
Performance Measurement and Management And Performance Improvement Stakeholder Satisfaction Exceptional Stakeholder Appreciation Continues To Soar Dr. Thomas Blash, Clinical Director The Committee on Accreditation of Rehabilitation Facilities (CARF) continuously sharpens the yardstick it uses to appraise facilities. This CARFenhancement process frequently results in a refinement of values coupled with the introduction of new terminology. Previously, the title of CARF-approved quality enrichment documents was Information Management and Performance Improvement (IM&PI). CARF has replaced this terminology in its newest standards manual (2012) and IM&PI has been replaced with PMM & PI or Performance Measurement and Management and Performance Improvement. Beechwood Rehabilitation Services (BRS) has always committed to providing the persons we serve with top quality programs within a community which encourages individuality, autonomy, competency and growth. In part we measure this dedication to our ideals by assessing stakeholder satisfaction semiannually. We do our measurements between January and June and July and December of each year. Since the last decade of the twentieth century, BRS has measured the satisfaction of the persons served, their family members, and their funders. We measure Individual, Family, and Funder Satisfaction with a nine-point scale. Ratings between 9 and 7, 6 and 4, and 3 and 1 represent satisfaction exceeding, meeting, or disappointing our stakeholders. During the interim between January and June of 2012, 85 persons served 38 family members and 45 funding representatives returned stakeholder satisfaction surveys. The results of their feedback are depicted in the table and chart below: 9 P O I N T S C A L E 9 8 7 6 5 4 3 2 1 0 STAKEHOLDER SATISFACTION January through June 2012 585 586 587 CLAS APTS OTPA BVC APS WSI Residential Programs, Outpatient Program, Vocational Programs INDV SERVED FAMILY MEMBRS FUNDERS AVG Satisfaction Ratings: 7-9 Services exceeded expectations, 4-6 Services meet expectations, 1-3 Below expectations REHABILITATION SERVICES A Community-Integrated Brain Injury Program An Affiliated Service of Woods Services, Inc. Program Locations in PA 1-800-782-3299 www.beechwoodrehab.org Beechwood does not discriminate in services or employment on the basis of race, color, religion, sex, national origin, age, marital status, or presence of a non-job related medical condition or handicap 5
Staff Share Expertise Many Beechwood staff have been presenters at conferences over the past several months to include: Delaware Brain Injury Association annual conference: Tracy Brown, Senior Physical Therapist, gave a presentation titled, Myofacial Release, that was moderated by Dr. Tom Felicetti Dr. Felicetti was on the Conference Planning Committee National Physical Therapy annual conference: PT Intern, Traci McClintock presented a poster on Effectiveness of Standardized Balance Outcome Measures in the Chronic Traumatic BrainInjury Population. Beechwood was the field site for the research that was conducted by Thomas Jefferson Rehab Hospital that resulted in this poster presentation. International Association of Rehabilitation Professionals Pennsylvania/New Jersey Chapters annual conference: Dawn Scheidell, Director of Vocational Services, and Linda Geldner, Supervisor of Vocational Services, presented The Use of the Vocational Rating Scale: From Sheltered to Competitive Employment. Dr. Tom Felicetti was the moderator. Brain Injury Association of Pennsylvania annual conference: Deborah Cerra-Tyl, director of program development and admissions and Dr. Drew Nagele, executive director were conference co-chairs for the 12th year. Nabila Enam, Occupational Therapist, presented, Gentle Yoga as a Therapeutic Intervention with Brain Injury Population, with Dr. Felicetti as moderator. Dr. Tom Felicetti participated on a panel with colleagues from the American Congress of Rehabilitation Medicine and presented on, Falls Prevention for Persons with Brain Injury: The research of the American Congress of Rehabilitation Medicine. Rehabilitation Services 469 East Maple Avenue Langhorne, PA 19047 Non-Profit Org. U.S. Postage PAID Langhorne, PA Permit No. 27