Sarah Walters

REC 5338

2 August 2016

Case Study Outline

I. Personal Philosophy of Therapeutic Recreation Service Delivery

My personal philosophy of therapeutic recreation service delivery is rooted in my identity as a general recreation professional and advocate. In the fall of 2013, I wrote a personal philosophy of general recreation service provision that was rooted in the idea that leisure participation is inherently and essentially valuable to human development and that leisure professionals have an obligation not only to provide opportunities for that participation but to advocate for its importance. Moreover, I spoke to a felt obligation to bring a passion for social-justice into my vocation in serving all of my community members in an equitable way. Then, I anticipated that this would mean serving the underserved based on factors such as socioeconomic status, race, and sexual identity. Now, I anticipate that this might mean serving the underserved based on factors such as physical and intellectual disability or mental health diagnosis. So, too, do I realize that a comprehensive understanding of therapeutic recreation principles will vastly improve my practice even if I choose to work in a general recreation setting with individuals who have no diagnoses of physical, intellectual, or mental health disability or disorder. The value of the therapeutic recreation practice, in my estimation, is in its combination of outcome-driven, goal-based intervention with inherently valuable leisure participation. I look forward to applying my understanding of the principles of that practice in any position I may hold, whether my title is Therapeutic Recreation Specialist or simply Recreation Specialist, as it does much to enhance the value of inclusive services I hope to provide based on my philosophy.

My professionalism will also be guided by my philosophy, particularly by the aspects of felt obligation to serve community members equitably and to advocate for leisure and the recreation/therapeutic recreation professions. I aim to honor all professional obligations stated by my credentialing organizations, NCTRC and NRPA, but to go above and beyond that in behaving not only ethically but passionately as a professional. I strongly believe that combining avocation and vocation – a natural combination when your vocation is supporting others’ avocations – enables principled, moral professional service.

I am not sure what sort of position I will hold in my first job post-graduation or what setting it might be in. As such, I cannot speak specifically about service delivery strategies or about what model of therapeutic recreation I might hope to design my practice around. However, despite not knowing exactly what I may do, I know why and how I will do it. Why is evidenced in my philosophy, stated above. How is evidenced in my practical application of technical skills related to the therapeutic recreation process, detailed below.

II. Description of Agency Setting

a. Therapeutic Recreation Model

The interdisciplinary clinical team at ResCare Premier Texas (RCP Texas) is quite small. It includes four clinicians – one each in the specialties of physical, occupational, speech-language and cognitive, and recreation therapies – and a Clinical Director. As such, the therapists work together closely to develop, evaluate, and modify treatment plans for individual participants and to execute those plans in a consistent way. Out of obligation to provide quality, cohesive services as much as out of proximity, then, these clinicians share a philosophy of treatment provision that crosses the lines between specialties and inform practice perhaps even more so than any discipline-specific model.

That shared interdisciplinary philosophy of service provision is one that emphasizes consistency and positivity in focusing on the positive progress being made by participants towards goals in which they are personally invested. As far as academic models are concerned, it is most closely embodied in the Nurtured Heart Approach (NHA) developed by Howard Glasser. While this service provision philosophy was developed by Glasser as a strategy for parents and professionals working with “intense” children, its core principles are readily applicable to “intense” adults with TBI who exhibit challenging behaviors similar to those of the youth with ADHD and ODD with whom Glasser was working. Those core principles include “refusing to energive negative behavior,” “relentlessly energiz[ing] the positive,” and “maintain[ing] total clarity about rules that demonstrate fair & consistent boundaries.” The therapeutic philosophy surrounding the application of these principles is one that is participant-centered and uses positivity rather than punishment to achieve desired outcomes. (Children’s Success Foundation, 2015)

The therapeutic recreation model that fits most readily into the larger interdisciplinary service provision philosophy is Dattilo, Kleiber, and Williams’ Self-Determination and Enjoyment Enhancement model. This model is participant-centered, emphasizing the need “to set the stage for people to enjoy themselves” by “teaching [them], regardless of the . . . degree of disabilitity, to create environments conduce to enjoyment” (p. 260). It is also readily applied in a community-based setting that focuses on community resource education and skill acquisition through active leisure participation – RCP Texas’ CTRS would readily agree with Dattilo, Kleiber, and Williams’ suggest that progress towards desired outcomes and increased independence occurs most readily “when people are encouraged and supported to become aware of themselves in leisure contexts, make decisions and choices, communicate their preferences, . . . set goals, . . . focus on internal standards, emphasize inherent rewards, listen to informative feedback, and become aware of their interests” (p. 262). Further evidence of the application of this model throughout the therapeutic recreation process at RCP Texas will be seen throughout this outline, particularly in that the philosophy of achieving functional improvements through empowering participants to establish patterns of

participation in preferred activities is the guiding principle of that process. (Dattilo, Kleiber, & Williams, 1998).

b. Healthcare Delivery Model

ResCare Premier Texas offers “community-based residential rehabilitation and supported living services” for persons with acquired brain injuries (ResCare Premier, n. d.). The RCP Texas program is, more accurately, a set of programs – it is best explained as “a unique group of interrelated treatment facilities” that are “small, home-like residences” in which residential rehabilitation services are provided along “a comprehensive continuum of care” (ResCare Premier, n. d.). In each of the facilities along the continuum, appropriate levels of living supports, particularly related to medical needs and ADLs, are provided. Beyond that basic support, though, the focus is on integrating participants into the community in which the RCP Texas facilities are located while providing clinical supports to achieve desired outcomes related to functional improvements and increased independence. Most importantly, those desired outcomes are developed with the active input of each individual participant, allowing participants to guide their own rehabilitation processes based on their own desires and interests as informed by clinical and other program staff.

The World Health Organization defines community-based rehabilitation as a strategy “for the rehabilitation, equalization of opportunities, and social inclusion of all people with disabilities . . . through the combined efforts of people with disabilities themselves, their families, organizations, and communities” (World Health Organization, 2004, p. 2). The WHO also suggests that “rehabilitation services should no longer be imposed without the consent and participation of people who are using the services” as “rehabilitation is now viewed as a process in which people with disabilities or their advocates make decisions about what servicesthey need to enhance participation” based on “relevant information” provided by rehabilitation professionals that allows “informed decisions regarding what is appropriate” (World Health Organization, 2004, p. 3). This definition and its supporting principles align directly with the delivery model of RCP Texas.

III. Participant

a. Studied Participant’s Medical and Social History

Participant is a 25-year-old male with a diagnosis of profound sensorineural hearing impairment of congenital origin, a diagnosis of traumatic brain injury secondary to a motor vehicle accident, and symptoms of depression, decreased attention, and paranoia secondary to TBI. Participant received a left cochlear implant at age 4. In June 1998, at age 8, participant acquired a moderate TBI in an accident in which he ran into the street outside of his home and was struck by a motor vehicle traveling at approximately 25 miles per hour. His daily medications include Adderall for

attention deficit, divalproex for depression, and Seroquel for depression and paranoia.

Participant lived in his parents’ home throughout his childhood with varying levels of support and successfully completed secondary school through his local public school system’s oral/deaf program. Upon graduation, participant moved out of his parents’ home but had limited success living independently largely due to marijuana abuse. Participant had both social and legal issues related to his marijuana abuse, and it is suspected that he was involved in selling and/or distributing marijuana. Upon being asked to leave a TBI-specific assisted living program due to issues related to his marijuana abuse, participant was admitted to RCP Texas by his parents and legal guardian.

At time of admission to RCP Texas, participant’s overall functional level was Level 7 on the Rancho Los Amigos scale, as he required minimal assistance for daily living skills. Specifically, participant required moderate assistance related to behavioral function and minimal assistance related to cognitive and communicative function, but functioned independently related to gross and fine motor skills. Deficits included lack of self-awareness, grandiose thinking, tendency to isolate, paranoid thinking, trouble with budgeting and money management, and difficulty taking responsibility. History of marijuana abuse was also viewed as a barrier. In order to address the identified impairments, an interdisciplinary treatment plan was developed to include recreation therapy, speech/cognitive therapy, individual counseling and substance abuse treatment, group-based social and behavior skills therapies, and community reintegration.

Participant is expected to reach Level 9 on the Rancho Los Amigos Scale and establish a level of functional independence, requiring only supervision level assistance upon request. Expected duration of services is six months or more. Participant and legal guardian plan for discharge to an apartment in San Marcos with limited supervisory level support provided by ResCare Premier Texas’ Independent Community Living program.

b. Diagnostic Criteria and Functioning Characteristics of Traumatic Brain Injury

The majority of ResCare Premier Texas’ participants, including the studied participant, have been diagnosed with traumatic brain injury (TBI) of moderate to severe classification. A TBI is defined, simply, as a “disrupt[ion] of the normal function of the brain” caused by “a bump, blow, or jolt to the head or a penetrating head injury” (Centers for Disease Control and Prevention, January 2016). As prognosis and functioning characteristics of TBI participants varies widely, the more telling factor of a TBI diagnosis is the classification of severity of the injury. That classification is based on the use of several different diagnostic tools. The most prominent is the Glasgow Coma Scale, used to evaluate severity of TBI during the initial stages of treatment; scoring is based on eye-opening, verbal, and motor responses to stimulation. Individuals “with GCS scores of 3 to 8 are classified with a

severe TBI, those with scores of 9 to 12 are classified with a moderate TBI, and those with scores of 13 to 15 are classified with a mild TBI” (Centers for Disease Control and Prevention, February 2016). While individuals sustaining mild TBIs typically have no loss of consciousness and no lasting neurophysical or neurocognitive symptoms, individuals sustaining moderate to severe TBIs typically have short-to-long-term loss of consciousness and lasting neurophysical and neurocognitive symptoms.

Even among participants diagnosed with moderate to severe TBIs, prognosis and functioning characteristics vary based on the area(s) of the brain in which the injury impacted function. However, there are many common characteristics of TBI related to impairments to physical, cognitive, and emotional function. Common physical effects of TBI include extremity weakness or spasticity, impaired gross and fine motor coordination, and impaired balance (Centers for Disease Control and Prevention, February 2016). Cognitive effects include impairment to short-term and working memory, deficits in visual and auditory attention, impairments to ability to learn new information, language difficulties such as aphasia, deficits in executive function, and deficits in general intellectual function (Barman, Chatterjee, & Bhide, 2016, p. 174). Emotional effects include symptoms of depression and anxiety, aggression, deficits in impulse control, and personality changes (Centers for Disease Control and Prevention, February 2016). A final key characteristic of moderate to severe TBI is the impairment of awareness of the above listed effects of the TBI; many individuals with TBI “may be unaware that they have suffered any injury at all,” while others “admit to some deficits but fail to perceive the likely impact of these deficits on their daily activities” (Sherer, et al., 1997, p. 380). Rehabilitation often focuses heavily on improving impairments to physical, cognitive, and emotional effects of TBI but must also address the issue of impaired self-awareness, which “significantly complicates the rehabilitation process” (Sherer, et al., 1997, p. 380).

IV. Case Report

a. Assessment of Studied Participant

1. ResCare Premier Texas Recreation Therapy Assessment

The assessment used was a non-standardized tool developed by the RCP Texas CTRS to gather information relevant to the scope of therapeutic recreation practice within RCP Texas. The development of such a tool was supported by RCP Texas’ documentation practice, which uses goal-driven, narrative-based, primarily subjective reporting and relies heavily on clinical opinion. The tool is a digital form, completed by the CTRS using information gathered through interview and observation, that requires nominal data related to participants’ diagnosis, barrier list, and medical and social histories; attitudinal data related to participants’ leisure interests; and functional data related to participants’ leisure participation. A bulk of the assessment interview is dedicated to exploring

participants’ premorbid leisure interests, determining whether those interests have been developed into a healthy leisure lifestyle post-injury or, if not, what barriers have prevented such a development, and discussing with the participant how it might be possible to establish transferrable healthy leisure participation patterns within the context of RCP Texas’ community-based residential rehabilitation model.

This tool was used in this particular case as it is the tool used in all recreation therapy assessments for new admissions to RCP Texas. While there is no validity or reliability information about this non-standardized tool, the usefulness of the information gathered is ensured by the simple fact that the tool was developed by the CTRS specifically for the purpose of informing therapeutic recreation practice within the context of RCP Texas’ rehabilitation model. As the primary goal of recreation therapy at RCP Texas is to assist participants in establishing healthy leisure lifestyles within the context of RCP Texas that can then be transferred to post-discharge settings, an assessment focusing on participant’s leisure interests addressing barriers to participation is sufficiently informative.

2. Assessment of the Studied Participant

The studied participant’s Recreation Therapy Assessment summary read:

[Participant] was outside with other participants during an arts and crafts activity. [He] was sitting off towards the back of the group and had not participated. [He] was introduced to CTRS by a Team Senior. [He] made eye contact and reached his hand out for a handshake. CTRS noted appropriate eye contact and handshake pressure. CTRS invited [participant] into the activity room and he chose a seat next to CTRS at the table. [He] expressed he felt his anxiety levels were high, however, he did not physically display an extreme level of anxiety during his assessment. [He] stared off low and to his right for most of the discussion, only making eye contact momentarily while he was speaking or if he did not understand a question asked by CTRS. [He] was courteous and polite during the assessment. At one point, [he] caught himself before using a curse word AEB stopping mid-word, covering his mouth, and stating, “I’m sorry” before selecting another word.

[He] talked about what he used and to and still likes to do in regards to recreation and leisure. His stated interests include running, hiking, exploring, shopping, going to the gym, photo editing, music making, dirt biking, going to the library, festivals, acting classes, playing and researching on the internet, and using programming apps. [He] expressed wanting to “make a gangster movie” and become a movie star. He expressed enjoying leisure both only and with friends, though “only ones he can trust.” He identified only two barriers to leisure – being at RCP and being unable to leave the program facility. He was able to identify benefits of leisure participant and, when asked how often he participates in leisure, responded, “It depends.”

[Participant] stated that he was confused about why he was at RCP Texas and continued to make comments about “weed” possibly being the reason. [He] spoke of “weed” several times, stating that he is not addicted, that it will be legalized, and that he doesn’t understand why people think “weed” is “bad.” He discussed a friend he’d had and that he wanted to help that friend “help the organization grow” and “build up customers,” implying some sort of involvement in selling/distributing “weed.”

When asked about his impairments and desire to make improvements, [participant] expressed he felt he should be in an apartment where staff come by only once a day and help him pay bills, get out into the community, and get to various activities. He did state that he “has problems focusing.” Finally, he expressed that he thinks he is “wasting [his] time in this place.”

CTRS observed attention deficit AEB [participant]’s ease of distraction by any noise or motion and request to go to “a more private place.” CTRS observed sporadic thinking and cyclic thought patterns, as well as a tendency to describe moments in time rather than general ideas or complete thoughts. During the interview, CTRS needed to ask [him] to repeat himself several times due to low speech volume and observed continuous wringing or motioning of hands.

CTRS recommends individual recreation therapy services 1 time per week for 1 hour each for a minimum of 90 days after admission. CTRS will provide individualized support as needed and notification of community opportunities as appropriate.

b. Therapeutic Plan Recommended for Studied Participant

Current recreation therapy treatment goals and objectives for the studied participant are:

1. [Participant] will identify and participate in healthy leisure outlets of interest in order to create leisure stability.

a. During each weekly individual recreation therapy session, [participant] will develop a plan for the subsequent session including activity, location, and schedule with minimal assistance.

b. [Participant] will independently arrange transportation and supervision for a weekly visit to the San Marcos Library.

c. [Participant] will acquire a tablet computer during this service period.

2. [Participant] will consistently demonstrate suitable social skills in all interactions.

a. During each weekly individual recreation therapy session, [participant] will provide appropriate, on-topic responses to questions from CTRS and TR Intern on 90% of opportunities with minimal assistance.

b. [Participant] will attend weekly “Stress Management” group therapy sessions on 6 out of 8 opportunities.

c. During individual recreation therapy sessions involving community outings, [participant] will appropriately initiate and complete interactions with customer service representatives on 100% of opportunities with no assistance.

The participant’s goals were developed based on information gathered during the initial assessment, as well as on discussions with the treatment team and with the participant. The first goal was selected based on participant’s history of unhealthy leisure participation related to marijuana abuse and the need to establish alternative, healthy leisure patterns. The second goal was selected based on an historic tendency to isolate, participant’s implication that he had struggled to maintain healthy relationships, and CTRS’ observation of social anxiety and generally poor social skills during assessment interview. These goals were also selected because the treatment team determined that developing alternatives to marijuana use and improving social skills would be primary requirements for discharge.

While the general concept of each objective has remained consistent throughout participant’s time at RCP Texas, the degree and intensity of each objective has been revised periodically based on his progress. Like the goals which they fall under, these objectives are also rooted in information gathered during the initial assessment.

Current objectives under goal one are based on the participant’s expressed leisure interests and the expectation that he be able to independently identify and arrange opportunities for participating in those activities of interest before being discharged. The first objective, specifically, delineates the fulfillment of that expectation quite generally. The second and third objectives are related to particular activities of interest.

Similarly, current objectives under the second goal are based on the expectation that the participant be able to communicate appropriately in all settings before being discharged. The first objective considers a particular social skill addressed in the context of individual therapy as it is most relevant to and measurable in one-on-one or small group conversations involved the CTRS directly. The second objective is related to the participant’s involvement in group-based social skills therapy and the expectation that he participates consistently in order to receive the desired benefits. The third objective addresses a need to improve confidence in interactions

with unfamiliar conversation partners and an expectation that the participant be able to communicate independently in the community.

c. Implementation of Therapeutic Plan for Studied Participant

1. Intervention Strategy Used in the Studied Case

The primary intervention strategy used in this case was community integration through active leisure participation. The design of this strategy was, essentially, to involve the participant in a preferred leisure activity within the community during each individual recreation therapy session, increasing his responsibility for initiating and arranging that involvement as he progressed. This strategy shifted the therapeutic emphasis away from developing leisure participation skills, with which the participant was already functionally independent, to establishing a consistent pattern of healthy leisure participation and a strong foundation of familiarity with community resources. This strategy was particularly appropriate as the participant planned to discharge to the San Marcos area and would therefore be able to maintain the established leisure participation patterns using those community resources identified. This strategy was also appropriate as it facilitated progress towards both treatment goals – creating leisure stability and improving social skills – through the therapeutic processing of practical experiences.

2. Evidence Supporting the Use of the Studied Intervention Strategy

The central aim of a community integration treatment intervention is “to restore the individual balance between the demands of living independently, societal participation, and emotional well-being, taking into account each patient’s capacities and limitations” (Geursten, et al., 2012, p. 909). This aim is guided by the understanding that the ultimate goal of TBI rehabilitation is, essentially, a level of functional independence evidenced by successful community reintegration (Martelli, Zasler, & Tiernan, 2012). It is also driven by the evidence-based belief that community-based participation results in “more effective learning and increased gains in independence and productivity” because it is conducted “in the natural settings where individuals must adapt” in order to achieve increased independence (Martelli, Zasler, & Tiernan, 2012, p. 3). As learning becomes more effective and independence improves due to the setting of the intervention, so too are those benefits more sustainable because they were achieved in the community in which the participant has been reintegrated.

What these sustainable acquired benefits are, specifically, depends upon the desired outcomes for an individual participant. However, there is significant evidence that commonly desired outcomes related to leisure participation are achievable through this intervention. In a review of studies of community integration interventions, Cattelani, Zettin, and Zoccolotti (2010) identified a

pattern of significant improvements to engagement in leisure activities and degree of social involvement related to participation in those activities. Brown, Gordon, and Spielman (2003) found that participants in their studied community integration intervention saw positive outcomes related to frequency of participation in leisure activities and time spent participating in leisure activities and to related functions necessary for recreation participation such as independently accessing transportation and accessing places where participants could meet people with whom they could participate in leisure. Fleming and colleagues (2011) found that the most essential benefit of leisure-based community integration was that it enabled participants to continue recreation participation, and therefore continue to receive the benefits of that participation, while in rehabilitation facilities, a finding related concisely in their conclusion statement:

“Leisure participation of individuals with ABI significantly decreased during both inpatient and outpatient rehabilitation. This indicates that re-engagement in age-appropriate and relevant leisure activities needs to be addressed during the rehabilitation phase to improve participation and future outcomes in this domain. However, this does not imply that the desired goal is to improve frequency and activity participation to pre-morbid levels; rather the desired longer term outcome is satisfaction with leisure participation.” (p. 816).

This finding counteracts the commonly held belief that “diversionary” recreation participation, or participation for the sake of participation, has limited therapeutic benefits for long-term rehabilitation participants. On the contrary, it is essential for achieving those therapeutic benefits, particularly when desired benefits are related to establishing or re-establishing a healthy leisure lifestyle, as in the case of the studied participant.

3. Relating the Studied Intervention to Desired Outcomes

As mentioned previously, the intervention strategy used was effective in that it allowed progress towards both treatment goals through practical experience and consistent but subtle therapeutic processing of that experience. One example of such progress was seen in an individual recreation therapy session summarized in a progress note:

Due to a scheduling conflict, a trip to see The Purge: Election Year at Alamo Drafthouse was rescheduled from late June. [Participant]’s hearing aid battery died just before departing for the theatre, but he requested that we still see the movie. He explained that he “enjoys being deaf” and still engaged CTRS and Intern in conversation, teaching us bits of ASL to supplement lip-reading. Upon arriving at the theatre, [participant] appropriately interacted with ticket booth staff and requested an accommodation while completing the transaction. He chose closed

captioning glasses over sound amplifying headphones. On the drive back from the theatre, [participant] initiated a discussion about the relevance of the movie’s plot to current events and respected requests not to discuss politics on too personal a level. Participant not only responded appropriately to questions when asked but followed responses with return questions to keep our conversation flowing.

This session’s experience with planning and participating in a healthy leisure activity, practicing social skills, and processing during casual conversation contributed to the achievement of several objectives, also summarized in the quoted progress note:

1a. During each weekly individual recreation therapy session, [participant] will develop a plan for the subsequent session including activity, location, and schedule with minimal assistance.Status: Achieved/Continue. [Participant] independently requested outings to movies at Starplex and Alamo Drafthouse, the batting cage, Half Price Books, and Dairy Queen. His naming of specific locations indicated progress towards identifying not only an activity but a specific community resource for participating in that activity. On each occasion, he coordinated scheduling with CTRS and TR Intern successfully. [Participant] required minimal assistance to search movie times and to find an indoor batting cage in the area.

2a. During each weekly individual recreation therapy session, [participant] will provide appropriate, on-topic responses to questions from CTRS and TR Intern on 90% of opportunities with minimal assistance.Status: Achieved/Continue. [Participant] provided appropriate, on-topic responses on 90% of occasions during this service period. During one session, [participant] became visibly distressed during a conversation and was unable to provide clarifying information after telling a wandering, incomplete story. However, during other sessions, participant led engaging discussions, responding to and asking questions appropriately to move conversations along.

2c. During individual recreation therapy sessions involving community outings, [participant] will appropriately initiate and complete interactions with customer service representatives on 100% of opportunities with no assistance.Status: In Progress/Continue. [Participant] appropriately interacted with customer service representatives at Dairy Queen and at the movie theatres, but required prompting from CTRS to initiate interactions.

The participant may have benefitted from identifying leisure activity opportunities and planning them hypothetically in a facility-based leisure awareness intervention, and could have developed social skills in interactions with CTRS and TR Intern during those facility-based sessions. However, the benefits seem to be multiplied significantly by the real-world experience of

participating in planned leisure and practicing social skills during that participation, as well as by the possibility of conversational, real-world therapeutic processing.

4. Schedule of Treatment Sessions and Skill Progression

The studied participant received one individual recreation therapy session per week throughout his treatment program. Each of these weekly sessions was scheduled for the RCP Texas standard minimum of one hour but often ran longer due to the nature of the community-and-activity-based intervention. Also due to the nature of the intervention, sessions throughout his treatment program were structured very similarly. However, as the participant made progress toward his treatment goals, there was a progression towards higher expectations related to relevant treatment objectives.

For example, both an individual recreation therapy session in the first month of the participant’s treatment program and in the sixth month of his program may have involved going to the theatre to see a movie. However, in the first month, the participant would have done little more than see the movie – the CTRS would have suggested a movie, chosen the theatre, selected an appropriate movie time, contacted program staff to schedule the session, and conducted transactions at the movie ticket booth and concessions stand. By the sixth month, the participant would have been instrumental in the process of seeing the movie – he would have suggested the movie, chosen the theatre, selected an appropriate movie time, communicated with the CTRS to schedule the session, conducted transactions at the movie ticket booth and concessions stand, and engaged the CTRS in a discussion about the movie’s plot on the drive back to the program.

5. Activity Selection, Purpose, and Modification

Activities were selected based upon information provided in the assessment interview regarding participant’s leisure interests and, as the treatment program progressed, based on the participant’s direct input. The purpose of completing selected activities was to establish participation in preferred leisure activities, familiarize the participant with community resources for participation, and practice social skills in practical settings. As the focus of the intervention was, in fact, on establishing independent leisure participation and practicing social skills, both within the context of existent community settings, no modifications were necessary.

d. Evaluation of Outcomes of Therapeutic Plan for Studied Participant

1. Progress Note for Studied Participant

An example progress note in the format used at RCP Texas is included on the following page of this document.

2. Discharge Summary Note for Studied Participant

A draft discharge summary in the format used at RCP Texas is included on the page following the example progress note.

Participant: Program: TBP South DOB: Service Period: July 2016Diagnosis: TBI Physician: J. Wesley Wallis, MDDOI: 6/1998 Therapist: Ashley Franks, CTRS

Sarah Walters, TR Intern

Impairments: Hearing impairment, lack of self-awareness, grandiose thinking, tendency to isolate, paranoid thinking, trouble with budgeting and money management, difficulty taking responsibility, substance abuse

Subjective/Objective: [Participant] received individual recreation therapy services 5 times this service period. 7/8/2016: Due to a scheduling conflict, a trip to see The Purge: Election Year at Alamo Drafthouse was rescheduled from late June. [Participant]’s hearing aid battery died just before departing for the theatre, but he requested that we still see the movie. He explained that he “enjoys being deaf” and still engaged CTRS and Intern in conversation, teaching us bits of ASL to supplement lip-reading. Upon arriving at the theatre, [participant] requested an accommodation and chose closed captioning glasses over sound amplifying headphones. On the drive back from the theatre, [participant] initiated a discussion about the relevance of the movie’s plot to current events and respected requests not to discuss politics on too personal a level. Participant not only responded appropriately to questions when asked but followed responses with return questions to keep our conversation flowing.7/11/2016: Visited the San Marcos Library to exchange DVDs and use WiFi. [Participant] exhibited safe internet use and interacted appropriately with the librarian at the front desk. During the drive back to the program, [participant] explained to CTRS and TR Intern that he thought he had made significant progress since arriving at ResCare but acknowledged that he still needed help before he’d be ready to live in an apartment. CTRS and TR Intern agreed and encouraged [participant] to discuss what progress he still wanted to make.7/18/2016: Visited Dairy Queen and Half Price Books. With prompting from CTRS to initiate, [Participant] appropriately completed transaction at Dairy Queen. At Half Price Books, [he] independently held to an agreed upon 20-minute time limit and found CTRS and TR Intern to remind us it was time to go. During the return trip to the program, something in our conversation reminded [participant] of an estranged friend, prompting a disconnected and incomplete story about their falling out. He was visibly shaken by the conversation and was unable to clarify or reflect upon details of the story when asked by CTRS. His mood remained low upon returning to the program despite having expressed several times that he was “having a great day” prior to his telling the story.7/23/16: Visited the Austin Batting Cages. [Participant] independently gathered a bat and helmet upon arrival and spent 30 minutes batting, picking up the balls to reload the pitching machine as necessary with the help of CTRS and TR Intern. After leaving the cages, [participant] requested that we stop at Whataburger to eat but changed his mind when we passed a Wendy’s. While eating, a TV showing the news seemed to prompt him to ask CTRS and TR Intern about political views, but respectfully changed the topic when both expressed that they weren’t comfortable with the question.

Assessment: [Participant]’s progress during July 2016 service period was as follows:

1a. During each weekly individual recreation therapy session, [participant] will develop a plan for the subsequent session including activity, location, and schedule with minimal assistance.Status: Achieved/Continue. [Participant] independently requested outings to several movies, the batting cage, Half Price Books, and Dairy Queen. His naming of specific locations indicated progress towards identifying not only an activity but a community resource for participating in that activity. On each occasion, he coordinated scheduling with CTRS and TR Intern successfully. [Participant] required minimal assistance to search movie times and to find an indoor batting cage in the area.

1b. [Participant] will independently arrange transportation and supervision for one visit to the San Marcos Library per week of this service period.Status: In Progress/Continue. [Participant] successfully arranged transportation and supervision for trips to the library in 3 out of 4 weeks during this service period. He was unable to do so in the final week of the service period due to a situation that prevented program staff from providing transportation and supervision.

1c. [Participant] will acquire a tablet computer during this service period.Status: Achieved/Revise. [Participant] successfully budgeted for a tablet computer and arranged a visit to Best Buy to purchase the tablet.

2a. During each weekly individual recreation therapy session, [participant] will provide appropriate, on-topic responses to questions from CTRS and TR Intern on 90% of opportunities with minimal assistance.Status: Achieved/Continue. [Participant] provided appropriate, on-topic responses on 90% of occasions during this service period. During one session, [participant] became visibly distressed during a conversation and was unable to provide clarifying information after telling a wandering, incomplete story. However, during several other sessions, participant led engaging discussions, responding to and asking questions appropriately to move conversations along.

2b. [Participant] will attend weekly “Stress Management” group therapy sessions on 2 out of 3 opportunities during the July service period.Status: Achieved/Revise. [Participant] attended two of the three “Stress Management” sessions held in July, but missed the final session at no fault of his own. He later apologized for missing the final session and explained that his staff were under the impression that the group had ended the previous week.

2c. During individual recreation therapy sessions involving community outings, [participant] will appropriately initiate and complete interactions with customer service representatives on 100% of opportunities with no assistance.Status: In Progress/Continue. [Participant] appropriately interacted with customer service representatives at Dairy Queen and at the movie theatre, but required prompting from CTRS to initiate interactions.

Plan: Continue individual recreation therapy services. [Participant] will be encouraged to attend “Healthy Relationships” group beginning August 10, 2016 for 8 weeks. Revised treatment objectives for the August 2016 service period include:

2b. [Participant] will attend weekly “Healthy Relationship” group therapy sessions on 3 out of 4 opportunities during the August service period.

1c. [Participant] will use his tablet computer to independently download and watch a movie.

Expected Duration of Recreation Therapy: Individual recreation therapy services to be provided through December 2016.Intensity of Recreation Therapy: 1 hour IndividualIntensity of Recreation Therapy: 1 hour GroupFrequency of Recreation Therapy: Individual recreation therapy services and group recreation therapy services 1 time per week each.Summary: CTRS recommends [participant] continue to receive individual recreation therapy services 1 time per week for 1 hour each session in order to continue progress on his treatment goals and objectives. CTRS also recommends that [participant] attend “Healthy Relationships” group beginning August 8, 2016 for 8 weeks. CTRS will provide individualized support as needed and notify of community opportunities as appropriate.

_____________________________________________________ _____________ Sarah Walters, TR Intern Date

Participant: Program: Hutchison Place DOB: Service Period: December 2016Diagnosis: TBI Physician: J. Wesley Wallis, MDDOI: 6/1998 Therapist: Ashley Franks, CTRS

Sarah Walters, TR Intern

Impairments: Hearing impairment, lack of self-awareness, grandiose thinking, tendency to isolate, paranoid thinking, trouble with budgeting and money management, difficulty taking responsibility, substance abuse

Subjective/Objective: [Participant] received individual recreation therapy services 3 times this service period. 12/5/16: Saw a theatre production put on by the Texas State drama program. When another patron was using his cell phone during the performance, [participant] quietly pointed it out to CTRS who was then able to notify an usher. After the performance, [participant] stated that he would like to begin acting classes once he left ResCare.12/12/16: Observed an acting class at BriteLites Studio in Austin. After the class was over, [participant] initiated a conversation with the instructor about his experience and acting philosophy. [He] asked for information about upcoming classes and pricing.12/19/16: Visited the Sights and Sounds festival. Throughout the outing, [participant] reflected on progress made while at ResCare Premier and willingly engaged with CTRS in discussion about maintaining that progress once he moved to his apartment. [Participant] initiated conversation with couple standing in line behind us and shared an appropriate level of information about himself and his situation when asked.

Assessment: [Participant]’s progress during December 2016 service period was as follows:

1a. [Participant] will independently develop plans for weekly individual recreation therapy sessions including activity, location, and schedule.Status: Achieved/Discontinue. [Participant] independently planned an activity for each of his three individual recreation therapy sessions during this period, identifying the locations and making scheduling adjustments with the CTRS as necessary.

1b. [Participant] will independently visit the San Marcos Library one time per week this service period.Status: Achieved/Discontinue. [Participant] successfully used CARTS to travel to the library time during each week of this service period. He continues to consistently return movies on time and has had no problems with inappropriate internet use.

1c. [Participant] will independently budget for planned recreation activities using a web-based budgeting application.Status: Achieved/Discontinue. [Participant] successfully predicted costs of planned recreation activities and spent no more than the predicted amount.

2a. During each weekly individual recreation therapy session, [participant] will provide appropriate, on-topic responses to questions from CTRS on 100% of opportunities with no assistance.Status: Achieved/Discontinue. [Participant] provided appropriate, on-topic responses on all occasions during this service period. His turn-taking also continues to improve, as he consistently follows an appropriate response with a return question.

2b. [Participant] will attend weekly “Community Living” group therapy sessions on 3 out of 3 occasions during the December service period.Status: Achieved/Discontinue. [Participant] attended 3 of the 3 “Community Living” sessions held in December and actively participated in each session, frequently providing feedback to questions of other participants.

2c. [Participant] will appropriately initiate conversation with a new conversation partner during at least one individual recreation therapy session involving a community outing.Status: Achieved/Discontinue. While waiting in a line at Sights and Sounds, [Participant] appropriately greeted a couple standing behind us and asked them whether they had ever attended the festival before.

Plan: Discontinue recreation therapy services and discharge from ResCare Premier Texas.

Expected Duration of Recreation Therapy: Individual recreation therapy services to be discontinued.Intensity of Recreation Therapy: IndividualIntensity of Recreation Therapy: GroupFrequency of Recreation Therapy: Recreation therapy services to be discontinued.Summary: As he has met expectations for discharge by achieving all goals and therefore completed his treatment plan, CTRS recommends [participant] be discharged from recreation therapy services as well as from ResCare Premier Texas’ Hutchison Place program. CTRS concurs with the treatment team recommendation that [participant] be discharged to an apartment in San Marcos to live independently while continuing to receive supervisory level support as requested through ResCare Premier Texas’ Independent Community Living program, as well as the recommendation that this support be limited to weekly medical check-ins, monthly budgetary check-ins, and infrequent transportation. CTRS also supports the recommendation that [he] continue to attend individual counseling and substance abuse sessions through his current provider but receive no other therapy services.

In regards to leisure participation specifically, CTRS recommends [participant] continue to use CARTS to independently access the community and maintain participation in community-based recreation activities such as visiting the library to borrow DVDs, running at the Activity Center or Greenbelt, seeing movies at the Starplex theatre, and attending local events. Participation in home-based leisure activities such as using his computer to make music, edit photos, and research interesting topics as well as working on his movie script should also be maintained. CTRS also recommends [participant] establish participation in acting classes or an acting club. CTRS sees no need for referral to continued recreation therapy services or other support services specific to leisure participation.

_____________________________________________________ _____________ Sarah Walters, TR Intern Date

3. Case Study Reflection

I do not think that there was any one aspect of this Case Study Outline assignment that I would not have otherwise considered or completed during the course of my internship. I feel that I was sufficiently exposed to the aspects of the APIE process as a whole and individually throughout my time at ResCare. I also feel that I dedicated a considerable amount of brain space to pondering my own thoughts on the TR profession and process as well as the function of that profession and process within a community-based model such as ResCare’s and with a diagnosis so complex as TBI. That said, I still found the process of developing the Case Study Outline to be thoroughly valuable. That value was in being forced to consider the breadth of the entire process as well as the depth of each detailed piece – in seeing both the forest and its trees. Sure, it would have been possible to demonstrate competency across the process based on applied learning rather than on a written report, but the process of developing the report pushed me to reflect on the lessons of that applied learning and on the true purpose of developing that competency in ways I would not otherwise have done. I could have gone without writing these pages, but I am grateful that I was required to do the writing!

Beyond being pushed to reflect on the learning I have done and on my purpose for doing that learning, this process also allowed me the chance to consider a case from admission to discharge. Unfortunately, though I did complete several admission assessments, there was not a participant admitted during my tenure who was recommended for recreation therapy services. On top of that, due to the long average length of stay even for “short” term participants at ResCare, I did not see a participant with whom I worked for a significant period of time discharged. So, in choosing a participant to report on and then carefully considering an admission summary prepared before my arrival, reflecting upon a treatment plan developed and implemented with my input, and preparing a hypothetical discharge summary addressing events that will occur after my departure, I was able to see the APIE process from start to finish for one individual case. That, I think, may have been the most valuable part of this process for me specifically.

If I had this Case Study to do all over again, I would certainly begin preparing it in the early weeks of my internship rather than in the days before it was due. I think that I still benefited thoroughly from the assignment and was able to do a deal of thoughtful reflection, but it would have been neat to begin formally considering my philosophy as a therapeutic recreation specialist as well as the context of my formative initial experience with therapeutic recreation practice from the get-go. If done in bits and pieces throughout the semester, I might have thought of it as an enlightening experience throughout my writing rather than exclusively during the typing of this reflection section.

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