Creative Therapy
Willie, Dancing and Rehab
Kim Watkins, M.Ed.
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Do the best you can with what you have
–Theodore Roosevelt

I do not now like, and never have liked, budgets. Budgets limit what may be accomplished, as well as the fun one may have. As much as I chastise my daughter for being an “I want what I want when I want it” kind of person, it seems we are both stuck at age thirteen. (More reasonable for her–she is thirteen.) The sooner we may purchase something, be it service or item, the better. When I was a kid and told my dad I was going into human services, he told me to marry a rich man because he knew that I loved to spend money. Got my priorities straight along the way and married a math teacher for love, not money, but I still love to spend it. So I should be a stockbroker, a buyer for Saks Fifth Avenue, a photographer for Vogue–maybe in my next lifetime. But for now, I run a neurorehabilitation program that is financed at least 50% by public funding. Healthcare is not the business in which to get rich.

Public funding brings to mind funds for the indigent. It’s truly not that way. People do not understand, at least until they are injured. I didn’t understand until I was in this business. But most everyone is only their 401K, IRA, thirty hospital day stay, and sixty-certed rehab days away from public funding.

in·di·gent adj. Experiencing want or need; impoverished. Archaic.
Lacking or deficient. A needy or destitute person (Houghton Mifflin, 2000).

Insurance doesn’t necessarily get you what you expect. I am consistently appalled whenmy rehabilitation program provides services for X number of days, at a rate of X dollars and receives 25% in payment for these services–services for which each licensed therapist attends at least six years of college and has even more years of experience to proffer. I never walk into Lord and Taylor and say, “I will pay you twenty-five percent of the cost of this item.” It does not work this way–unless you are an insurance company. I have written agreements saying “this company will pay this amount for these services rendered.” These agreements are signed by a representative of the insurance company and myself. Often, these agreements are not worth the cost of the ink with which they are signed.

In the world of coverage for healthcare services, there are terms like: spend down, yearly cap, life-time max, primary deductible, secondary deductible, secondary provider, QMB eligible, funder of last resort, and whatever name for a new excuse to limit payment for services that comes out that particular year. I read an entire Medicaid manual–twice, and was unable to discern the reimbursement for a service provided. The average insurance purchaser has no comprehension of what is in store for him/her if the unimaginable happens.

The lifetime costs for one person surviving a severe traumatic brain injury (TBI) can reach $4 million (National Institutes of Health, 1989, as cited in Family Caregiver Alliance, n.d.). So if the insurance company is not paying, who is? Guess what: you are, I am, anyone who pays taxes is. Taxpayers are footing lots of bills from wars to food (guns to butter)– healthcare is somewhere in-between. Neurorehabilitation, for the length of time it requires, in most states, is way at the bottom of the in-between list.

“The average length of stay for…severely injured persons [with TBI] in acute rehab is about 55 days. Approximately 20% of survivors of severe TBI remain unresponsive for at least one month. The majority of individuals who survive a period of coma eventually regain consciousness” (Family Caregiver Alliance, n.d.). So, by discharge time, you are barely getting started.

Researchers have found that “persons who suffer a severe TBI continue to make gradual improvements in functioning for at least ten years post-injury” (Sbordone et al., 1995, as cited in Family Caregiver Alliance, n.d.). I am not contending that one should stay
in rehabilitation for ten years. I am asserting that somewhere within those ten years additional services may be necessary, and I am definitely asserting that fifty-five days just does not cut it!

Sometimes insurance companies and the medical field are the blockage to the carotid arteries of the rehabilitation system. Someone may have all the potential in the world to keep getting better, but may no longer have a method of payment. They may no longer qualify for services. I can’t give services away for free (as my boss frequently reminds me). It is heart-breaking to see someone wheel away in a chair or go home with her grandparents (who may barely be able to care for themselves), when she would be walking within a few weeks and able to live independently within a few months with additional rehabilitation. I couldn’t be more worn-out by physicians saying to patients, “You’re O.K., go back to work.” Then eight months later (way past those sixty certified days of insurance coverage), when the person injured has alienated those at work, tried all family relationships, and lost all self-esteem, formal tests reveal severe cognitive and executive function deficits and he/she finds that insurance has been maxed-out. It is said, “You get what you pay for,” but you may not know what you are and are not paying for–check your insurance policy.

Folks need to quit thinking it can’t happen to them. I have a program full of people that it “couldn’t happen to.” Be aware, be safe, and view your health insurance policy like your house or car insurance policy; prepare for the worst. If I never meet you because you are never injured, that’s okay with me, and I’m sure it’s fine with you (I am simply not that compelling). I could complain for hours about insurance companies, what they don’t cover and people living without fear of something that happens every day.

I don’t really mean to carry on like this, being so negative–although it has made me feel better. This is supposed to be an article about creative treatment. Ironically, the funding challenges we face in providing rehabilitation have forced us to be creative. Providing treatment on a shoestring budget requires much creativity. I know a lot about shoestrings. Being someone with expensive tastes, I have been mostly broke for the majority of my Iife. Little did I know, this lack of resources was preparing me for a vocation that I would have for years. I have made the best of it.

There is making the best of it and there is making better than the best. Making better than the best is what inspires others. Last issue, I emphasized that treatment to facilitate great outcomes must be relevant (Watkins, 2004). Oftentimes, it is most effective to provide treatment using elements of the real world and the real community to motivate: free and the best. It can’t get much better than that; Paris on a dime, silk purse, sows ear. Treatment on a shoestring. Here are some ideas.

Motor skills
How can one work on walking without parallel bars or work on balance without kinesthetic machines? Tai Bo, Tai Chi or line dancing addresses the same issues – and the Tai Bo tapes are usually in the bargain bin for $6.99. To watch folks dancing again is beyond price. To know it is addressing physical needs, from balance to motor sequencing, is central. To hear them laugh or sing along with the music makes it
worth getting out of bed each morning.

Cognitive skills
The small town in which I live publishes great big pictures of food along with prices every Wednesday. Whether you want one or not, everyone gets the paper on Wednesday (don’t ask me why, I have just accepted it as a component of rural life). With this resource, we work on meal planning and budgeting. Budgeting: starting with pictures of food and prices and moving on to grocery trips. Walking through Wal-mart is free. We have scavenger hunts at Lowe’s. We don’t buy the stuff, we just find it. With this system (after security figures out that we come in peace), one has the same experiences as shopping for the family–you just don’t have to worry about putting the stuff away when you get home. Working on how and when to spend money is critical to independence. We address budgets and expenses by creating experiences: when to pay without getting late fees; how to pay if you don’t have a checking account; when to use credit (only for REAL EMERGENCIES like medicine for your children and red shoes).

Behavioral skills
Relaxation training addresses motor sequencing, motor control and one of the most challenging issues after a brain injury, emotional control. Calming oneself in the face of a confusing world after a brain injury can make all the difference. Counting to ten only costs oxygen. Tai Chi only requires a tape and a willingness to learn. I make follow-up calls after those served have gone home. I called a participant once who had a distinctly challenging family life. I asked his wife how things were going, and she stated that she really was not sure: he’d spent the last two weeks outside, standing by the tree on one foot – chanting. Generalization for sure! How do you make it fun when you’re low on funds? We try harder. The entertainment spin works. Here’s how we do it.

Treating in groups
It’s hard to get used to treating in groups at first, but think about it–schoolteachers do it all the time. Someday, when I have some money, I will do research on those served receiving rehabilitation in groups vs. individual therapies. I’m sure I’d find it very interesting to see at what point in time those traveling through the rehab continuum optimally benefit from treatment in a group setting. I venture to say early. I must say that participants receiving feedback from someone with whom it would be easy to build an adversarial relationship (that is, your therapy-staff folks) is less productive than feedback received from peers.

The world functions in groups. Vacations. School. Church. Dancing (small group of 2). Concerts. Fireworks. Camp. Shopping. Actually there are very few things that don’t happen in groups. Observation and treatment in groups allows a clinician to assess a participant’s tolerance for noise, divided-attention, and concentration in a functional
setting. Working in groups builds awareness of our environment and others, visual-spatial orientation, and promotes accommodations to field cuts. Functionality at its finest.

Often success is all the more sweet when shared with others. Like the scene from An Officer and a Gentleman when his friend finally climbed over the wall and Richard Gere rooted him on. We don’t have Richard Gere, but we once had a Physical Therapist that was as handsome as Gere is. When there is someone to inspire, encourage, and cheer one’s accomplishment, the deed has more depth and strength.

Free stuff
My favorite free thing/person was Willie Nelson: very favorite, forever and always. What could be more therapeutic than a night outside in the middle of August listening to Willie Nelson sing? At one point, you thought you may never have fun again, but now you’re listening to the music, hands in the air, swaying with the crowd. You’re going back-stage to meet Willie–who climbed on the bus to greet those that were too tired at two in the morning to wait outside any more. You’re staying up all night like the old days. The next day EVERY SINGLE PARTICIPANT remembered what they had done the day before. It cost us some time and an e-mail to Willie’s band and crew. Free and priceless!

Reinforcement systems
Receiving credit for one’s work gives rehabilitation a functional relationship to “the real world.” After a brain injury it takes a lot to learn to walk again, or follow a schedule, or participate in the entire rehabilitation system. Motivation may wane for even the most hearty but may also be lacking as a direct result of the injury. Reinforcement systems come in real handy. And it doesn’t have to be costly: praise and recognition are free, for example. It is important when developing reinforcement systems that one honors the ‘basics’ (one’s rights) and uses the ‘extras’ (the perks) as reinforcement. Inalienable rights like a cup of coffee (caffeinated please!) and ice cream should never be compromised for the reinforcement system.

Volunteer work
Tom Sawyer Therapy–Volunteering for the Parks and Recreation Department–painting a wrought iron fence each morning for a week. Volunteering at a nursing home–painting fingernails and cleaning wheel chairs. Young people making old people smile. Moving boxes at a shelter. Helping others that have less. These activities instill purpose and pride in the helper, as well as benefit the receiver.

Art
Studying Monet and Van Gogh, when basic life activities remind you (repeatedly) about your cognitive deficits, helps the self-esteem. Replication of Monet and Van Gogh helps the fine motor skills.

The Web
I once developed two entire curriculums from the ERIC (Educational Resources Information Center) website. Conflict Resolution Solutions and Nutrition (How Marlboro Reds are not necessarily the best breakfast) with adaptations to make it appropriate for those served. It required web searches, ink, and paper. Weeks of material were produced. This took time and a used three ring binder.

Risks
To make it work, one must take risks. A talented program director and I took one of the most violent participants I’d ever treated to the state fair. Because he had a brain injury did not mean that he did not have a right to attend the state fair. Cost–four dollars. He was in a wheelchair and while at the fair, the tire came off of his chair. Two very kind state-fair types who were passing by had the chair lifted up with the participant in it and put the wheel back on its rim before we could say “look out!” The participant kept his hands folded the entire time and said “Thanks” when they were through. Kindness is universal and free.

Karaoke
(I know, I know.) One person said, well, sang his first words post-injury by singing into a Karaoke machine. It must have been something about the microphone, because Pretty Woman never sounded so good–even when Roy Orbison sang it.

Nostalgia
Being a nostalgia buff–and thinking that others also need to be–we used a book that someone gave my brother, which he never read (he’s way more into technology than the 30’s, 40’s and 50’s), to develop an entire curriculum about Route 66. The participants traveled the “Mother Road” via pictures, maps, landmarks, and favorite eating and sleeping sites. We worked on memory, problem-solving and math skills. It worked!

Dressing up
Remember how you loved this as a child? One participant dresses like Santa every year. He makes everyone smile. It brings joy to others, to children, to all
of those served. Dress-up seems like kid stuff. It’s not.

Talking about the past Memory.
Telling personal stories about the important events of the past. Where were you when Kennedy and Elvis died, the Gulf War began, Carter was elected, John Lennon was shot, the space shuttle exploded, New York blacked-out, the Twin Towers fell? All these memories elicit emotion, discussion, and retrieval of other memories–memories about the past. A current favorite opener for me is, “What was wrong with disco?” When we get past the initial “it s____s,” there islaughter and memories of John Travolta, the Bee Gees, slinky shirts and floors with flashing lights. This works on word retrieval, pragmatics, and memory. And folks go around humming the theme song to Saturday Night Fever.

Fun, cheap, and still therapeutic
Adopting a highway is free–and you get your name on a sign. It entails walking on uneven terrain, safety awareness, balance, pragmatics and strength. It also cleans up your town.

Fishing addresses the same issues. There is a one-time cost of a pole and license. You get to stand by a reservoir, pond or lake and enjoy the peace and quiet. And you might even catch a fish.

Watermelon seed-spitting contests are something to see. It works on oral-motor skills and visual-spatial relations (kind of ignores pragmatics, although one is required to take turns). It makes people laugh. Laughter is important to getting better. There’s something fundamental and therapeutic about laughing again.

While jotting down notes for this column, I kept blending, confusing, mixing the notions of creativity in therapy and therapy on a shoestring. Like a shoestring these two concepts sometimes intertwine. The main components are budgets and basic things-to-never-skimp-on, like coffee, ice cream and insurance!

References

Houghton Mifflin Company (2000). American heritage dictionary (4th ed.). Retrieved August, 2004, from http://dictionary.reference.com/search?q=indigent

Family Caregiver Alliance (n.d.). Selected traumatic brain injury statistics. Retrieved August, 2004, from Family Caregiver Alliance Web site:
http://www.caregiver.org/caregiver/jsp/content_node.jsp?nodeid=441

Watkins, K. (2004, Summer). Relevance. Premier Outlook, 4(2), 53-56.

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