WINTER 2017 Volume XIV No. 1

For and about the brain injury and spinal cord injury community. Rainbow Rehabilitation Centers, Inc. RAINBOWrainbowrehab.comVISIONS Perspectives on Sexuality after TBI Exploring sexuality as an important part of recovery and improved quality of life

• INSIDE TBI Model Systems Addressing Sex and Relationships in Residential Care Facilitating Sexual Expression Sexual Sex and Decision Making • PRESIDENT'S CORNER

Dignity of Risk

By Bill Buccalo, President Rainbow Rehabilitation Centers

n this edition of RainbowVisions, we explore the client safe and supported? What are the biases and beliefs Iimportant issue of sexual expression for individuals who of the organization, caregivers and therapists, and how do have sustained brain injury. following we ensure those biases do not reflect in the treatment in brain injury is a significant problem, not unlike many of a way that conflicts with the individual’s personal choice? the commonly discussed consequences such as seizure What if the person’s choice is a bad choice? Will it result in disorders, cognitive problems, depression, psychosocial, harm, or is it just a bad choice, but their choice? or physical conditions. However, clinical professionals Additionally, health care organizations are generally argue that the rehabilitation community could do a better regulated entities and must follow certain laws which job of talking about, educating, treating and supporting typically establish standards of care and protection individuals with brain injury to address their need for requirements. Guardians providing support to individuals sexual expression. have certain rules and responsibilities they must follow When reading the articles in this issue, I cannot help and judgements they must make on behalf of the person but think about the concept of “Dignity of Risk” which represented. These matters undoubtedly weigh on generally focuses on an individual’s ability to take the professionals and organizations as they work to support risks necessary to fulfill personal choice and be self- the client along their path to live the most fulfilling lives determined—even if those choices might result in failure. possible. I first heard this phrase at a brain injury conference The issue of sexual expression can certainly raise the many years ago, and it has stuck with me ever since. question of dignity of risk. The authors touch on this as It is a powerful phrase and concept, yet sometimes well as a wide variety of related topics, consideration, and challenging for clinicians and organizations to embrace. approaches. Thank you to Rainbow employees Dr. Janice Many individuals living with brain injury face enormous White, Anne Gillingham, Jenny D’Angela, and Dr. Carolyn challenges including loss of personal control, decision Scott for your contributions to this important topic. making, and forced conformance to the rules and Lastly, I would like to thank Wayne Miller. Wayne regulations of health care institutions. is one of the finest, most thoughtful, and respected As health care professionals, we must be very careful to attorneys I have ever known. He has authored the article balance the risk to the organization in providing care with on the concept of sexual surrogacy for this issue and that of the dignity of risk afforded to those we serve. This explores not only the legal considerations but a wide can be a difficult balance, but the concept of dignity of variety of limitations to individual sexual expression in risk is at the forefront of most discussions in which I am current health care models and organizations and poses involved as they relate to the organization’s approach to thought-provoking questions. Wayne, thank you for your an individual matter. What does the client want? What are outstanding contribution to this magazine, but most the roles and responsibilities of the health care providers, importantly, thank you for your support and friendship. ❚ caregivers, therapists, guardians, and other professionals in supporting a client’s personal choice? Will we keep the Exploring sexuality as an important part of recovery and improved quality of life

Editor Barry Marshall Associate Editor/Designer Jill Hamilton-Krawczyk Email questions or comments to: [email protected] • IN THIS ISSUE

Copyright February 2017—Rainbow Rehabilitation Centers, Inc. All rights reserved. 6 Published in the United States of America. No part of this publication may be reproduced in any manner whatsoever without written permission from Rainbow Rehabilitation Centers, Inc. Contact the editor: [email protected]. 20 Features 2 Clinical News TBI Model Systems Janice White, Ph.D., CCC-SLP, CBIST 6 Therapy Corner Facilitating Sexual Expression Anne Gillingham, OTR/l, CBIST 10 Medical Corner Addressing Sex and Relationships in Residential Care Jennifer D’Angela, MS, LLP, BCBA, CCM, CBIST 16 TBI Topics Sexual Surrogacy in TBI Rehabilitation Wayne Miller, Esq. 20 TBI Topics Sex and Decision Making Carolyn Scott, Ph.D., CBIST 22 Conferences & Events News at Rainbow 24 Southfield Center Open House | Cooking Classes | Vocational Projects New Professionals at Rainbow 800.968.6644 26 rainbowrehab.com 27 Employees of the Season

Our mission is to inspire the people we serve to realize their greatest potential • CLINICAL NEWS

TBI Model Systems: Educational Resources on Sexuality Following Brain Injury

By Janice White, Ph.D., CCC-SLP, CBIST Rainbow Rehabilitation Centers

2 | RAINBOWVISIONS • WINTER 2017 exuality is important for most adults, and this is no different for those living with a traumatic brain injury (TBI). In fact, sexuality can be viewed as a vital component to maintaining and Simproving quality of life. As the vice president of clinical operations of a post-acute program, I have the unique role of not only bringing together a treatment team to address issues that arise regarding this topic but to also include the wants and needs of the persons we serve. Each treatment team member has a role to play when assisting individuals through the rehabilitation process. In this edition of RainbowVisions® we feature articles authored by members of the treatment team that will bring to light their approach to this personal aspect of care. As a clinician, I often rely on research available on sexuality and wanted to share a resource that I have found to be beneficial—Sexual Functioning and Satisfaction after Traumatic Brain Injury: An Education Manual.1 This manual is part of the The Traumatic Brain Injury Model Systems (TBIMS) program—a network of research that provides information and resources to individuals with TBI; their families, caregivers, and friends; health care professionals; and the general public.2 This article briefly reviews studies and information available in the manual. CHANGES IN SEXUAL FUNCTION FOLLOWING TBI Sexuality following brain injury can be affected in many different ways in both men and women. The reason for changes in sexual functioning are varied. They can be related to physical injury or cognitive changes, all of which can have an effect on personal relationships. Some of the changes in sexual function include but are not limited to: • Decreased desire for sexual activities – Following a traumatic brain injury (TBI), many people do not feel the urge for sexual activity as they may have before their injury. • Increase in desire for sexual activities – Increased desire, while not reported as frequently as decreased desire, can range from mild to extreme. Some individuals with TBI are not able to control their impulses and can be sexually inappropriate. • Decreased arousal – Decreased arousal refers to having the interest in sex, but the body not responding or functioning correctly. • Difficulty or inability to reach – Difficulty or inability to reach orgasm occurs in both men and women and may result in sexual activity not being satisfying.

Issues with sexuality and sexual functioning following brain injury are common but many times not addressed for various reasons

The origins for changes in sexual functioning after TBI are diverse (Fig.1, page 5). • Damage to parts of the brain – The frontal and temporal lobes are significant for sexual functioning. Damage to these parts of the brain can cause a decrease or increase in sexual desire. • Changes in brain chemistry – A TBI can significantly affect the brain’s chemistry. Too many or too few neurotransmitters—the chemicals that aid communication between different parts of the brain—can alter sexual functioning. Continued on page 4

RAINBOWREHAB.COM WINTER 2017 • RAINBOWVISIONS | 3 • CLINICAL NEWS TBI MODEL SYSTEMS

Continued from page 3 • Changes in emotion and mood – Sadness, depression • Length of stays in hospital are much shorter, and irritability can lead to a loss of interest in sex and/ so there is not enough time to treat the issue or an increased desire. These changes can have an • Many are uncomfortable discussing these issues effect on the dynamics of a relationship. • Lack of knowledge on the provider’s side • Changes in cognitive abilities – Because attention, Many times rehabilitation providers do not discuss memory and thinking skills can be affected in persons sexual functioning with patients due to discomfort. with TBI, partners may find that the individual seems The level of discomfort and knowledge deficits increase like a different person, which has an impact on desire. significantly when talking with LGBTQ populations. • Physical or mental fatigue – Fatigue, which is common However, all sexually active patients need this education after TBI, can negatively affect sexual activity. regardless of .

THE TBI MODEL SYSTEMS The TBI Model Systems (msktc.org) provide valuable information related to sexuality after brain injury. It is made up of 16 TBI Model Systems Centers across the United States. These centers focus on provision of services for TBI from onset of injury though community reintegration and contribute to a national database, participate in research, and serve as an educational resource for patients, families, health care providers and the general public.

• Physical limitations – Changes in physical abilities IMPROVING SEXUAL FUNCTIONING AFTER TBI can make sex uncomfortable, painful or challenging Issues in sexual functioning following TBI persist over to physically coordinate. Individuals may have time. A study done by Sander et al. (2012)3 assessed 58 decreased desire due to changes in their body such as women and 165 men with TBI one year after injury and hemiparesis (weakness of the entire left or right side found 29.2 percent of the participants were dissatisfied of the body), spasticity (increase muscle tone which with their overall sexual functioning. restricts ability to move muscles), etc. In addition, of those who had been sexually active • Hormonal changes – Hormonal changes as a result of during the year after injury, 55 percent reported a decrease the injury are common and may have a direct effect on in frequency of sexual activity and 34 percent reported a 3 sexual functioning and . decrease in interest in sexual activity. This study suggests that sexual functioning should play an important role in • Side effects of medication – Some medications have the rehabilitation process. side effects that can decrease desire or interfere with A patient with changes in sexual functioning can normal sexual functioning. talk with their physician and obtain a comprehensive • Self-esteem issues – Individuals may struggle with body physical examination to rule out physical causes. A image changes that contribute to lack of desire. They review of medications the person is taking can identify may feel self-conscious with their physical and mental any with sexual dysfunction as a side effect. If some of changes. the medications do affect sexual function or desire, the physician can identify other options. THE HEALTH CARE PROVIDER’S ROLE Consider the environment in advance to decrease Health care providers have a role to play in improving distractions. Partners can plan situations (dates) when the the amount and quality of therapy following TBI, but may individual is most rested and work together to problem be reluctant for the following reasons: solve any positional or physical challenges. • Some providers do not see improving sexual The client can seek psychotherapy or counseling to functioning as a priority help with emotional issues in the relationship that affect

4 | RAINBOWVISIONS • WINTER 2017 sexual activity. to specifically address sexual problems is an option in some CHANGES instances. IN It is important with all the issues being HORMONES addressed around sexuality to remember to SELF-ESTEEM/ SIDE educate individuals to practice and DEPRESSION EFFECTS OF help them obtain resources to do so. ISSUES MEDICATION Rehabilitation programs including inpatient, outpatient, home health and community-based programs should have individuals identified CAUSES who are comfortable discussing sexual topics DAMAGE TO PHYSICAL and provide the additional education and BRAIN/ OF SEXUAL OR MENTAL support to increase their expertise. That expert CHEMISTRY DYSFUNCTION FATIGUE can work to educate other staff members as well as clients and their families. AFTER TBI Sexual Functioning and Satisfaction after Traumatic Brain Injury: An Educational CHANGES IN CHANGE IN 1 Manual is an excellent resource for health EMOTION COGNITIVE care providers, clients, partners and families. AND MOOD ABILITIES This manual and other articles and studies in PHYSICAL sexuality are available at www.tbicommunity. LIMITATIONS/ org/resources/publications/sexual_ PAIN functioning_after_tbi.pdf. ❚

Figure 1. Some causes of Sexual Dysfunction after TBI

Resources 1. Sander, A. et al. “Sexual Functioning and Satisfaction after Traumatic Brain Injury: An Educational Manual,” Baylor College of Medicine (2011). 2. Sanders, A. and Maestas, K., “Sexuality After Traumatic Brain Injury,” Model Systems Knowledge Translation Center 3. Sanders, A. et al., “Sexual Functioning 1 Year After Traumatic Brain Injury: Finding From a Prospective Traumatic Brain Injury Model Systems Collaborative Study,” (2012), Archives of Physical Medicine and Rehabilitation, Vol 93, August 2012.

About the author

Janice White, Ph.D., CCC-SLP, CBIST Vice President, Clinical Operations Dr. White is responsible for overall clinical programming in all of Rainbow’s adult and pediatric programs, home and community services, outpatient services and vocational programs. She works with Rainbow’s clinical directors, therapists and case managers to ensure excellent client satisfaction rates and outcomes. Dr. White is an accomplished health care and brain injury professional with over 23 years of management and clinical experience. Janice has opened and operated several brain injury programs during her career and served in many roles including CEO of an acute rehabilitation hospital, director of an inpatient facility and a speech-language pathologist. Dr. White earned a Ph.D. in Communication Sciences and Disorders from the University of Georgia in Athens, GA.

RAINBOWREHAB.COM WINTER 2017 • RAINBOWVISIONS | 5 • THERAPY CORNER Facilitating Sexual Expression What is the Occupational Therapist’s Role?

By Anne Gillingham, OTR/l, CBIST Rainbow Rehabilitation Centers

hen a person survives a life changing event such However, there is one area of functioning that is not Was a traumatic brain injury (TBI), the treatment routinely discussed , but it is an area that is of vital team convenes with the individual to establish a importance to many people regardless of their severity treatment plan and gets to work. The team typically or type of injury. includes doctors, nurses, occupational therapists, Sexual expression has been identified as a frequent physical therapists, speech therapists, psychologists, concern for people who have sustained a TBI, and recreation therapists. All of these clinicians are but many rehabilitation professionals do not feel trained in recognizing deficits stemming from brain comfortable discussing it. Educating persons with injury and finding ways to remediate these issues. TBI and their caregivers about sexuality is part of Clinicians use a variety of approaches to address rehabilitating the entire person.1 problems including the physical strengthening of a Occupational therapy’s (OT) core value is weakened muscle, promoting relearning through the approaching each person holistically in order to meet building of new neuropathways, or using compensatory all identified therapy needs. Occupational therapists strategies to work around an issue. are experts in assessing and increasing independence Clients and their family usually identify restoring with activities of daily living (ADL); this includes independence as their top priority. The therapists all all self-care activities, such as bathing, dressing and work toward this common goal, retraining each person toileting. Increasing independence in these areas are to care for themselves again at the highest level of included in occupational therapy’s domain. Sexual independence possible. The therapists usually focus on activity is considered an activity of daily living, so walking, talking, eating, bathing, dressing, behavioral occupational therapists are uniquely qualified to regulation, and community reintegration. address deficits in this area.2

6 | RAINBOWVISIONS • WINTER 2017 What is OT’s role? An OT can recommend ways around these deficits 1. Identify barriers to sexual expression through to enable a person to express themselves sexually. This assessment and interview commonly includes presenting alternative ways to obtain a. Physical sexual satisfaction. b. Cognitive/behavioral • Decreased gross motor: different positioning, such as c. Environmental sidelying or on one’s back, use of a device mounted to a leg harness 2. Make recommendations on how to compensate for deficits that interfere with sexual expression • Decreased fine motor: built up handles or adaptive switches for devices, partner-operated devices, 3. Educate clients, therapy teams, family members and stationary or anchored devices for hands free direct care staff on sexuality and each client’s right operation to express themselves sexually, including sensitivity training • Decreased range of motion: use of bolsters, wedges, pillows for positioning, bendable device wands. Many physical deficits from TBI can commonly Assistive devices can be ordered from adult websites/ affect sexual expression stores that sell adult materials • Decreased gross motor movements: weakness, • Decreased sensation: recommend experimenting limited use of arms and legs with new types of touches, other devices for stronger • Decreased fine motor movements: weakness, stimulus limited use of hands and fingers • Ataxia, tremors or spasticity: hands free/stationary • Decreased range of motion: parts of the body do devices, incorporating massage, warm blankets for not bend and straighten to their full ability tone control, positioning • Decreased sensation: numbness, tingling • Fatigue/low endurance: rocking chairs to stimulate thrusting, propping, sidelying, energy conservation • Ataxia, tremors or spasticity: painful muscle techniques tightness, difficulty controlling body parts, shaking • Incontinence: bowel/bladder program, vinyl mattress • Fatigue and low endurance cover, sexual expression in the shower or on a shower • Incontinence: bowel and/or bladder chair • Medication side effects: commonly include erectile • Medication side effects: commonly include (ED), decreased and dizziness, dysfunction, decreased libido, dizziness, decreased • Vestibular/balance issues: can include nausea, lubrication, or premature dizziness, fall risk (It is important to discuss these side effects with the

Continued on page 8

RAINBOWREHAB.COM WINTER 2017 • RAINBOWVISIONS | 7 • THERAPY CORNER FACILITATING SEXUAL EXPRESSION

Continued from page 7 • Executive function impairment: memory and doctor. If not contraindicated, medications can be used organizational strategies, social skills training, to combat these issues.) weighing the pros and cons of online dating • Vestibular/balance issues: identify head/body An OT can work with the team to develop a plan for positions that make dizziness worse and avoid these dating including education on their rights, especially if a person is vulnerable to or exploitation. Rights There are often cognitive and behavioral include the right to choose their own and barriers to sexual expression after TBI make their own decisions about sexual activity, which can 1 • Memory: short-term and long-term memory, sometimes be in conflict with those of caregivers. working memory deficits Other areas that OTs can assist with include providing education on TBI, contraception, and safer sex. Changes • Disinhibition: difficulty considering effects of in libido and personality often occur after TBI and behaviors and comments should also be discussed. Information and resources, • Impulsivity: difficulty thinking through such as websites and reading materials should be offered. consequences before acting Encouragement to consult with a physician about physical • Poor decision making: may not plan ahead for safer symptoms such as incontinence and ED is important. sex and contraception Other resources include individual and couples mental health counseling in order to work on adjustment to the • Executive function impairment: initiation, attention, “new normal.” time management An OT who discusses potential sexual difficulties in an An OT can recommend ways around these deficits to open, matter of fact way and treats it as simply another enable sexual expression. potential symptom of the injury can set the tone for other • Memory: time management and memory assistive team members, persons with TBI, their partners and devices to assist with planning families. When addressing sexuality with individuals and • Disinhibition: role playing and education on socially their partners and caregivers, it is important to convey the appropriate interactions in the community, social message that sexual problems are solvable and do not need skills training to be embarrassing. Discussing sexual expression as an activity of daily living normalizes the topic and gives people • Impulsivity: reiterating the importance of permission to discuss it with the relevant personnel. ❚ preparation before engaging in safe sex with a partner, education on contraception and sexually References transmitted infections 1. Sander, Angelle. Integrating Sexuality into Traumatic Brain Injury Rehabilitation. Brain Injury Professional. 2009; 7(1): 8-11. • Poor decision making: rehearsal, overlearning, 2. Hattjar, Bernadette, ed. Sexuality and Occupational Therapy. Bethesda, supervised dates, education MD: American Occupational Therapy Association Press; 2012: 136-152

About the author

Anne Gillingham, OTR/l, CBIST Divisional Director Anne Gillingham serves as a Divisional Director. Her division includes a variety of adult residential homes, semi-independent residential settings and an outpatient center. Anne has worked in the brain injury field since 1995. Since joining Rainbow Rehabilitation Centers in 2000, she has worked as an occupational therapist, vocational specialist, case manager, and divisional director. Her areas of expertise include managing operations at her various facilities, program improvement, and staff training.

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RAINBOWREHAB.COM WINTER 2017 • RAINBOWVISIONS | 9 • MEDICAL CORNER

Addressing Sex and Relationships in Residential Care

By Jennifer D’Angela, MS, LLP, BCBA, CCM, CBIST Rainbow Rehabilitation Centers

hen a person with a traumatic brain injury (TBI) moves into a supervised residential setting, Wmany activities that seemed effortless before their injury now seem impossible—going to the store, eating whenever and whatever they want, sleeping in, having a relationship or even having an uninterrupted half-hour. Think about what it would be like to have to tell a potential romantic partner that you are part of a residential program—or having to ask another person to stay out of your room for a while because you need some privacy, only to be told that you have to leave your door open? Providers, clinicians, guardians and other supports can help by educating themselves and helping the people they serve enjoy aspects of romantic and sexual relationships while maintaining safety and supervision, regardless of their cognitive or physical challenges. When sexual and relationship needs are met, individuals may enjoy a better mood and better quality of life. When the topic of sex and dating is mentioned in a rehabilitation setting, you will often hear statements similar to, “Joe doesn’t need to think about dating right now—he needs to concentrate on his therapy.” Maslow’s Hierarchy of Needs,1 a popular motivational theory in psychology, suggests that humans cannot focus on higher-order needs until more basic needs such as sexual needs, socialization and intimacy are met (Fig.1, page 12). In clinical practice, it is rarely effective to try to convince someone that they should put sex and dating on hold until other goals are met. Sex and dating are part of reestablishing social connections after an injury—a part of recovery that is as important as self-care, vocational rehabilitation and community reintegration. While concerns about emotional and physical safety in sex and dating must be acknowledged and addressed, clinical assessment and education can empower individuals and their families to enjoy aspects of relationships that will improve quality of life.

Continued on page 12

10 | RAINBOWVISIONS • WINTER 2017 RAINBOWREHAB.COM WINTER 2017 • RAINBOWVISIONS | 11 • MEDICAL CORNER ADDRESSING SEX & RELATIONSHIPS

Continued from page 10 Education: If the skills assessment reveals that additional Clinically, there are several considerations when education is needed, it is the responsibility of the treatment assessing the appropriateness of dating or sexual team to provide it. Depending on the physical and relationships: cognitive needs of the individual, every member of the interdisciplinary team has something to contribute. Person-centered goals: What are the person’s goals for the romantic relationship or sexual experience? For example: Persons with traumatic brain injury have the same range Physical therapy – Positioning and coping with physical of interests that people have outside of a rehabilitation challenges setting. They may be interested in a committed, long-term Occupational therapy – Hygiene and safety assessment romantic relationship, or even something as for assistive devices simple as using assistive devices. Psychology – Preparing for changes in sexual functioning Amount of supervision needed: With the person’s goals after injury, either due to medications or the injury itself, in mind, what is the highest level of independence they can STI education, relationship counseling safely achieve in the area of relationships and dating? Can they be left alone safely for short periods of time? Safety Nursing – must always be considered in a structured rehabilitation Consent/Guardianship: Is the person able to provide their setting. own consent or is there a guardian involved? Any aspect Skills Assessment/Assessment of Functioning: of sex or dating that involves another person may require Assessment of skills can be tailored to the goal the person a call to a guardian for consent. Guardian consent is not has in mind. If a person wants to ask another person needed to provide assistive devices or if the person chooses to dinner, a full assessment of sexual knowledge is not to view pornographic material. However, if a guardian needed. Both physical and cognitive challenges must be states that they do not want the person represented to considered if a personal wishes to engage in sexual activity. have access to this material, the treatment team should not Areas of assessment may include sexually transmitted provide it. infections (STI) prevention, use, hygiene and the Continued on page 14 need for discretion.

Figure 1. Maslow’s Hierarchy of Needs SELF- ACTUALIZATION morality, creativity, spontaneity, acceptance, experience purpose, meaning and inner potential

SELF-ESTEEM confidence, achievement, respect of others, the need to be a unique individual

LOVE AND BELONGING friendship, family, intimacy, sense of connection

SAFETY AND SECURITY health, employment, property, family and social stability

PHYSIOLOGICAL NEEDS breathing, food, water, shelter, clothing, sleep

12 | RAINBOWVISIONS • WINTER 2017 Breaking Down Barriers to Sex and Dating Below are some examples of scenarios that commonly occur in residential settings and some options for person-centered planning:

SCENARIO: Tina is a 25-year-old who is single and was sexually active with her fiancée before sustaining a traumatic brain injury. She has weakness in her upper and lower extremities and uses a walker. She requires 24-hour supervision in a residential facility due to fall-risk. Her fiancée ended their relationship when Tina had her accident, and she has had trouble finding a sexual partner. She tells her psychologist that she would like help getting an assistive device and would like to have private time to use it in her room. OPTIONS: • The psychologist can make a referral to occupational therapy to help Tina find an assistive device that works well for her while considering the weakness in her extremities. • Assess the ability for Tina to be left alone for short periods of time in light of the fall-risk. • Education can be provided to direct care staff to ensure that they are comfortable and understand Tina’s need for private time.

SCENARIO: James and Mary met at a vocational workshop. They have been dating exclusively for five months, and they want to have sex. Both James and Mary live in supervised residential facilities and have legal guardians. Both of the facilities they live in do not have space where they can spend private time together. OPTIONS: • The guardians for James and Mary can sign them out to get a hotel room. • Because James uses a walker, physical therapy can contact the hotel to make sure that it’s accessible and safe. • The nurse/therapist can talk with James and Mary about birth control options and prevention of STIs.

SCENARIO: Kelly lives in a semi-independent program and has independent community access. She has been online dating and tells her psychologist that she wants to meet one of the men for dinner. Her treatment team is concerned about her safety. OPTIONS: • Educate the treatment team—Kelly already has independent community access and is trusted to make safe decisions when out alone. • Educate Kelly about safe internet dating. • The program can provide Kelly with a safety net in case she needs to leave her date—a contact person, a plan and a ride home.

RAINBOWREHAB.COM WINTER 2017 • RAINBOWVISIONS | 13 • MEDICAL CORNER ADDRESSING SEX & RELATIONSHIPS

Continued from page 12 Partner Assessment: When assisting an individual ■ Typically, the person may only visit with their date in with sex and dating, the appropriateness of the partner the common area at a residential facility—they may they select must be considered. Due to the vulnerability choose to meet their date at a hotel, if indicated. of many residents, treatment teams must do their due ■ Many guardians and treatment team members diligence to help promote a safe situation and help avoid are uncomfortable with dating during a sign-out. non-therapeutic situations. However, once it has been established that a person Once goals have been established, supervision needs are is safe to be left alone for a certain length of time, we explored, a skills assessment is completed, education is must trust that they are able to make good decisions provided and consent is obtained, relationships and dating during the unsupervised time. can be added to the treatment program. The process is labor intensive but well worth the value it can provide to Sex and dating in the residential setting can get people in terms of quality of life. complicated. Treatment team members and supports may Here are some ideas for incorporating sex and dating be concerned that the relationship may be detrimental to into a treatment plan by level of supervision: the person’s rehabilitation program—and talking about 24-hour Supervision another person’s sexual needs can be uncomfortable. ■ Dining out with staff supervision. Employees sit at a However, the people in our care deserve a mature, caring different table while maintaining visual supervision in and direct approach to addressing their sexual needs and ❚ order to give the person as much privacy as possible. hopefully improving their quality of life. ■ Self expression in the supervised residential setting— the person may require programming that allows Reference 1. June 16, 2012 · Posted in Psychology, A Theory of Human Motivation, them to have private time, if this is safe. For mental A. H. Maslow (1943), Originally Published in Psychological Review, 50, health professionals, dialogue about sexual needs 370-396 should begin at admission. The person may feel uncomfortable talking about their sexual needs at first, so it should be revisited as rapport is established. Sign-in/Sign-out ■ If a person has a community access program in which they can sign-out of a residential setting for a short period of time, they may meet a date at a place that is on their approved list of community destinations, usually a restaurant or movie theatre.

About the author

Jennifer D’Angela, MS, LLP, BCBA, CCM, CBIST Mental Health Clinical Lead Jennifer D’Angela earned an Master of Science in Clinical Behavioral Psychology at Eastern Michigan University in 1999. She joined Rainbow in 2003 and earned her Board Certified Behavior Analyst credential in 2009. Jennifer has worked at Rainbow as a Case Manager and Behavior Analyst and is currently the Clinical Lead for Mental Health. Her interests include person-centered planning and using behavior analysis to improve the lives of people living with traumatic brain injuries.

14 | RAINBOWVISIONS • WINTER 2017 GENESEE COUNTY RESIDENTIAL PROGRAM Discover Specialized Residential Programming in Genesee County!

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RAINBOWREHAB.COM WINTER 2017 • RAINBOWVISIONS | 15 • TBI TOPICS

Sexual Surrogacy in TBI Rehabilitation

By Wayne Miller, Esq. Miller & Tischler, P.C.

any years ago, a young man came to me with a peculiar request. “Lenny” was an 18 year old who had sustained a severe Mtraumatic brain injury (TBI) three years earlier. Lenny was left with severe physical and cognitive deficits. He had been in residential rehabilitation for a long time. In a voice quavering both with emotion and ataxia, Lenny said to me: “Wayne, can you get me a girl? You know what I mean!” I told Lenny that of course I knew what he meant, but that I could not honor his request. Despite what people think of lawyers, I was not in the business of soliciting prostitutes for my clients. So, I was forced to disappoint Lenny. But I have never stopped thinking about our conversation. This article is dedicated to Lenny and the many other young men and women who I have had the privilege to represent, and who have had similar requests and needs that have gone unfulfilled in our TBI rehabilitation system. TBI affects every aspect of human function, including the physical, cognitive, emotional and behavioral. Individuals like Lenny are often left with significant functional and behavioral impairment. In particular, individuals with TBI are often unable to maintain “normal” social relationships. Old friends no longer come around. often end in divorce. New friends and intimate relationships are difficult or impossible to develop. Ultimately, is often a casualty of TBI. Simpson et al. describes the breadth of the problem: Sexual health concerns are widespread after suffering a traumatic brain injury (TBI), including difficulties with sexual functioning, negative , and an interaction between broader relationship problems and sexual difficulties, with rates reaching as high as 50 percent.1,2 The result of this inability to develop friendships and maintain social and sexual intimacy: profound isolation and loneliness.3 At this point, I refer the reader to the story of Mark O’Brien, dramatized in the movie The Sessions, starring John Hawkes and Helen Hunt. Mark was confined to a bulky wheelchair with an Iron Lung due to polio. Mr. O’Brien chronicles his struggles with this isolation and despair in

16 | RAINBOWVISIONS • WINTER 2017 The Sun Magazine, May 1990, Issue 174.4 In particular, Mr. The issue of sexuality is often treated with ‘benign O’Brien describes his need for physical and sexual contact. neglect,’ and a survey in 1990 found that 51 percent of His story is moving and worth a read. staff in brain injury programs took a reactive approach, Conventional rehabilitation programming addresses addressing sexuality issues only when raised by an sexual issues, but largely in the form of conventional individual. Reflecting this, only small proportions (ranging counseling. Some rehabilitation programs include from nil to 15 percent) of people with TBI and their family activities such as pet therapy and gardening. These are members report that rehabilitation health professionals laudable. Yet, for those with profound physical and/ made inquiries about whether they had any sexual or cognitive impairments, conventional therapeutic concerns during their rehabilitation episode.7 approaches are often insufficient to actually achieve an There are a host of reasons as to why sexual issues go . For those persons, something more unaddressed in TBI rehabilitation settings. As long ago as is required. The purpose of this article is to discuss the 1990, Davis et al commented: The purpose of this article is to discuss the expanded availability of services addressing problems of sexual intimacy in our TBI patients. expanded availability of services addressing problems Societal discomfort with the topic of sexuality and of sexual intimacy in our TBI population. In particular, ambiguous institutional policies and norms also have expanded availability of sexual surrogacy services is negative impact on unfettered sexual rehabilitation. advocated. The majority of people with TBI are young males (age For an individual who is un-partnered, sexual problems 15 to 24 years), many of whom are just learning about may be a preventive factor in forming a meaningful expressing their sexuality. Concomitantly, there is minimal relationship. Yet, effective therapy, according to early sex training—formal or informal—concerning sexuality therapy pioneers, requires a cooperative partner with for rehabilitation professionals involved in the care of whom to undergo the therapeutic process. Surrogate individuals with TBI. Thus, the combination of (1) the lack Partner Therapy (SPT) is designed to provide the of information concerning sexuality ramifications after individual in sex therapy with a proxy partner with whom TBI, (2) a population that is highly concerned about sexual to experience this process.5,6 matters, and (3) institutional and professional discomfort in dealing with the topic has significant impact on the TRADITIONAL TBI REHABILITATION rehabilitative process.8 PROGRAMMING DOES NOT ADDRESS SEXUAL The “institutional and professional discomfort” NEEDS IN A COMPREHENSIVE FASHION mentioned by Davis includes concerns over civil and Standard components of TBI rehabilitation programs criminal liability exposure and concern over insurance can include: custodial care, physical therapy, occupational reimbursements. These will be discussed in greater detail therapy, speech-language pathology, nursing oversight below. and medical management. Residential TBI programs also commonly offer opportunities for socializing and COMMON APPROACHES TO SEXUAL community access, including outings to restaurants REHABILITATION and movies. However, therapy addressing a person’s Common approaches to sexual rehabilitation include sexual needs is often missing from formal rehabilitation discussion of sexuality in the context of conventional programming: talk therapy. This is certainly appropriate. However,

RAINBOWREHAB.COM WINTER 2017 • RAINBOWVISIONS | 17 • TBI TOPICS SEXUAL SURROGACY

particularly in the case of severe TBI, talk therapy is services may be confused with simple . The inadequate. As the humorist P.J. O’Rourke once said, differences will be discussed below in the section on “There’s a difference between information and knowledge. legal issues. For now, let us discuss what sexual surrogacy It’s the difference between Christy Turlington’s phone services are and how they may be of benefit to persons number and Christy Turlington.” with TBI. The following discussion is necessarily limited. Talking can only take an individual so far. For severely The reader is invited to access the expanding literature on injured persons, talking takes them nowhere. In order the subject of sexual surrogacy.10 to experience whatever sexual function remains, the At its core, Sexual Surrogate Therapy involves three individual must participate in sexual activity. The problem actors: the therapist; the surrogate; and the client. As might is that individuals who are severely injured are unable to be expected, the therapist supervises the therapy, including access their sexuality in a “normal” manner: the work of the surrogate. In other words, sexual contact To summarize, sexual dysfunction following TBI may by the surrogate is done in the context of a comprehensive be due to one or more factors, including injury to specific sex therapy regimen. Rosenbaum describes the process as brain regions, neurochemical changes related to this used in an Israeli clinic:11 pathology, endocrinologic abnormalities, medications, Surrogate Partner Therapy (SPT) is part of a ‘therapy secondary medical conditions, physical limitations, triangle’ and consists of sessions between the therapist and cognitive deficits, emotional difficulties, behavioral deficits client, the surrogate and the client, and the therapist and and interpersonal difficulties.9 the surrogate, at which the therapist provides guidance to Sexual needs continue, but TBI sequelae impede the the surrogate. The conclusion of the therapy also signifies individual’s ability to satisfy those needs. Traditional the end of the relationship between the client and the rehabilitation programming does not adequately address surrogate. the inability to obtain sexual satisfaction. This discussion The surrogate, therefore, is not a therapist but acts as is not meant to demean or diminish the importance of a mentor with whom the client experiences a social and conventional therapy regarding hygiene, etiquette and intimate connection, improved relationship forming other social competencies. Rather, such conventional behaviors, reduced anxiety, and increased self-confidence therapy may be insufficient in cases of severe physical and/ about sexual functioning. The surrogate-client sessions or behavioral problems. include exercises in communication, relaxation, sensual In the absence of rehabilitation programming that and sexual touching, and social skills training. adequately addresses sexual needs, sympathetic friends or Surrogate therapy uses a graduated approach— family may seek the services of a prostitute for their family beginning with casual contact, progressing to sexual member. Apart from the obvious legal and safety issues, contact, and often involving .11 prostitution is generally not conducted in a therapeutic Critical elements of this unique therapy include: environment, i.e., the sexual services of the prostitute 1. Placement of sexual contact in the context of are not connected to a supervised and goal-oriented conventional therapy and therapeutic goals: therapeutic regimen. For many, sexual needs simply go SPT is a recognized behavioral intervention with sex unmet. therapy and assists, but does not replace, sex therapy, Accordingly, in order to include sexuality as part of the which is essentially a psychotherapeutic modality.11 rehabilitation process for individuals after TBI, the term 2. Conduct of sexual therapy under the supervision of a 9 rehabilitation needs to be broadened. trained therapist: Critical to the surrogacy treatment paradigm A BROADENED THERAPEUTIC APPROACH TO is training. In the (R. Aloni) sex therapy clinic, IMPAIRED SEXUAL FUNCTIONING: SEXUAL sex therapists working with surrogates received SURROGACY specialized training, and surrogates receive Neither reaction, ignoring sexual needs or resorting specialized training as well.11 to prostitutes unconnected to a therapeutic regimen, 3. Extensive training and screening of surrogates in the is optimal. As part of a broadened concept of TBI incredibly delicate, discreet and personal therapy: rehabilitation, let us consider Sexual Surrogacy Therapy as Surrogates undergo a careful screening process an adjunct to conventional rehabilitation programming. before selection. They are expected to display First, what is Sexual Surrogacy Therapy? Sexual surrogacy confidence, positive self and body image, warmth,

18 | RAINBOWVISIONS • WINTER 2017 Sexual surrogacy may thus be a most useful method to facilitate adjustment to severe functional impairment and to address the profound isolation and loneliness that is a hallmark of TBI.

the ability to connect easily as well as to have well- PROBLEMS IN PROVIDING SEXUAL SERVICES developed social skills. They undergo an initial TO PATIENTS interview in order to be accepted to the training If sexual surrogacy services are beneficial, why aren’t they course and must also pass several psychological in common use? There is a host of reasons: legal; ethical; screening tests. The goals of the screening are to religious/moral; insurance/reimbursement. Perhaps the determine the candidate’s integrity, trustworthiness, foremost of these reasons is the legal concern that sexual discretion, and ability to receive guidance and surrogacy services are “prostitution.” Prostitution is clearly feedback and to follow up accordingly. The screening illegal in most places. Here is the Michigan statute: also rules out psychopathology or inappropriate A person 16 years of age or older who accosts, personality traits or motivations.11 solicits, or invites another person in a public place 4. Screening of patients, i.e., this therapy is not for or in or from a building or vehicle, by word, gesture, everyone: or any other means, to commit prostitution or to do We acknowledge as well that there are any other lewd or immoral act, is guilty of a crime contraindications for SPT. We do not recommend punishable as provided in section 451.14 SPT for individuals who appear easily capable In addition to the act of prostitution, Michigan law renders of establishing relationships, those already in illegal those who support prostitution services, i.e., in the committed partner relationships, persons who have a vernacular, the “pimp” and the “bordello”: history or suspected history of psychiatric instability, Any person who knowingly accepts, receives, levies, or those who believe that SPT is an opportunity to or appropriates any money or valuable thing without experience sex in a risk-free environment.12 consideration from the proceeds of the earnings of As such, sexual therapy using surrogates holds great any person engaged in prostitution, or any person, promise to address this last frontier in TBI rehabilitation: knowing a person to be a prostitute, who lives or The therapy with a surrogate is an emotional derives support or maintenance, in whole or in part, experience and process in which the individual from the earnings or proceeds of the prostitution receives forms of sexual gratification while relearning of a prostitute, or from money loaned or advanced social and interpersonal skills and thus improving to or charged against a prostitute by any keeper or their quality of life. Inherent in the surrogate manager or inmate of a house or other place where process is an emotional experience that is not prostitution is practiced or allowed, is guilty of a available in other forms of sexual therapy that can felony punishable by imprisonment for not more facilitate the opportunity for the person to learn new than 20 years.15 behaviors and to improve verbal and non-verbal These penalties are obviously a stark warning against communication. It is also an opportunity for the engaging in “prostitution.” So we know that “prostitution” individuals to learn more about their intimate needs is illegal. But what then is “prostitution”? The word itself and to experience warmth and pleasure from being is not defined in the Michigan statute. We have to look with a partner in an intimate situation.13 at case law to define the term and to thereby know what Sexual surrogacy may thus be a most useful method to is illegal. Michigan cases apply a dictionary definition of facilitate adjustment to severe functional impairment and prostitution: to address the profound isolation and loneliness that is a Continued on page 28 hallmark of TBI.

RAINBOWREHAB.COM WINTER 2017 • RAINBOWVISIONS | 19 • TBI TOPICS

Sex and Decision Making

By Carolyn Scott, Ph.D., CBIST Rainbow Rehabilitation Centers

s noted in other articles in this issue, sexual intimacy situations such as meeting a new potential partner in an is an important part of human expression. The unsafe environment. Others may require additional time Ajob of rehabilitation specialists is to enable clients to make and voice their decision about what activities to reach maximal functioning while recognizing and they want to engage in during a date. Furthermore, when addressing deficits that may interfere with their ability to individuals lack awareness of their deficits, they may return to their level of functioning prior to their injury. overestimate their ability to handle their own affairs. Common cognitive complaints after TBI include Given these cognitive deficits, persons with TBI may impaired memory, attention, be vulnerable in situations and executive skills. INDIVIDUALS WITH DISABILITIES ARE of sexual expression. Cognitive deficits can be Research on individuals with expressed functionally in 4 TO 10 TIMES disabilities has demonstrated many ways. If we focus that this population is four simply on how cognition can MORE LIKELY TO BECOME A VICTIM to 10 times more likely to affect independence in sexual OF VIOLENCE, ABUSE, OR NEGLECT become a victim of violence, expression, there are multiple abuse, or neglect than examples. individuals without disabilities.1 An individual with impaired memory may forget to use Therefore, to help protect individuals who may be birth control or a condom which could help protect against potentially vulnerable from harm, it is important to sexually transmitted infections (STIs). They may have understand whether someone who has had a significant difficulty planning ahead so that they fail to pack their TBI possesses the ability to make decisions about engaging medications when leaving for a date. in sexual intimacy. Capacity evaluations, a specialized After TBI, individuals may be more impulsive and assessment designed to measure an individual’s ability to demonstrate poor judgment which can lead to risky make decisions for themselves, can help achieve this goal.

20 | RAINBOWVISIONS • WINTER 2017 Psychologists are well equipped to conduct capacity A clinical interview and assessment of cognitive evaluations where functional abilities, diagnoses, abilities can help clarify an individual’s knowledge and cognition, psychiatric and emotional health, and values reasoning as it relates to their desire to have sex. Similarly, and preferences should be considered.2 Additionally, the questioning to ensure that the individual is entering the psychologist should consider potential risk as well as relationship voluntarily is important. A number of tools ways that an individual could be supported to maximize have been designed to help in the assessment process. Lists functioning.2 This may mean providing additional of these can be found in Assessment of Older Adults with information (such as education about STIs) or assistive Diminished Capacity 2 as well as other sources. devices to enhance their ability to make decisions for While not addressed here in detail, the behavioral and themselves. Lyden3 notes that it may be helpful to speak to emotional consequences of TBI may influence a person’s individuals (family, staff members, etc.) knowledgeable of ability to make decisions about sexual expression and must the client. be part of a capacity evaluation. Furthermore, capacity Instead of taking an “all or nothing” approach to to make decisions may vary over time as individuals gain capacity, psychologists and the legal system have begun to new knowledge or self-awareness or if cognitive status focus more on capacity in specific domains. For example, changes. Therefore, re-assessment may be necessary to an individual may have the capacity to testify in court, help individuals meet their needs while minimizing risk. enter contracts, consent to medical care, and/or consent to Rehabilitation professionals must consider the safety of sexual expression. While laws vary from state to state, in potentially vulnerable adults. At the same time, decisions general, three basic factors must be evaluated to determine about capacity to engage in sexual relationships must be if someone has the ability to consent to sex.2 carefully considered so as not to unnecessarily limit an ❚ • Knowledge of the relevant facts, including risks individual’s right to expression. and benefits.2 This may include information about avoiding STIs and , basic anatomy and References physiology, how to determine if your partner desires 1. Petersilia, JR. Crime victims with developmental disabilities: a review essay. Criminal Justice & Behavior 2001; 28(6):655–94. sexual activity, appropriate situations for sexual 2. Assessment of older adults with diminished capacity: A handbook for expression, etc. psychologists. American Bar Association Commission on Law and Aging • Understanding or rational reasoning that reveals a – American Psychological Associate; 2008:1-186. http://www.apa.org/ pi/aging/programs/assessment/capacity-psychologist-handbook.pdf. decision that is consistent with the individual’s values Accessed (1/13/2017). 2 (competence). 3. Lyden, M. Assessment of sexual consent capacity. Sexual Disability 2007; • Voluntariness2 – Individuals make the choice to 25:3-20. engage in sexual activity without undue coercion or persuasion.

About the author

Carolyn A. Scott, Ph.D., CBIST Psychologist Dr. Scott earned her Ph.D. in Clinical Psychology at Wayne State University. After an internship at the John D. Dingell VA Medical Center, she completed specialized post-doctoral training in Neuropsychology and Rehabilitation Psychology at the Rehabilitation Institute of Michigan. While there, Dr. Scott worked on both an inpatient and outpatient basis with individuals who had experienced traumatic brain injuries, stroke, spinal cord injuries, and other neurological and orthopedic conditions. In addition to other responsibilities, Dr. Scott provides individual and team consultation services along with brief and expanded neuropsychological evaluations at Rainbow Rehabilitation Centers, Inc.

RAINBOWREHAB.COM WINTER 2017 • RAINBOWVISIONS | 21 • 2017 CONFERENCES & EVENTS

March March 7 CMSA Detroit Dinner Conference Burton Manor – Livonia, MI cmsadetroit.org March 9 CMAA Vendor Night Lansing Center – Lansing, MI [email protected] March 11 AACIL Annual Gala Benefit Celebration UM Biomedical Science Bldg. – Ann Arbor, MI annarborcil.org/2017gala March 14 MI ARN Annual All Day Conference Laurel Manor – Livonia, MI miarn.org March 14 MBIPC Annual Executive Luncheon MSU University Club – East Lansing, MI mbipc.org March 29-April 1 IBIA World Congress/NABIS Sheraton Hotel – New Orleans internationalbrain.org April April 20 WMBIN Symposium Prince Conference Center – Grand Rapids, MI maryfreebed.com April 27 CMSA Detroit Dinner Conference Location TBD cmsadetroit.org April 27-28 ICLE Annual No-Fault Summit The Inn at St. John’s – Plymouth, MI icle.org April 29 BIAMI Legacy Society Spring Tribute Dinner Suburban Collection Showplace – Novi, MI biami.org May May 10 BIAMI Capitol Day State Capitol Building – Lansing, MI biami.org May 11-12 Michigan Guardianship Conference Radisson Hotel – Lansing, MI michiganguardianship.org May 18 DMC/RIM Spring Symposium The Dearborn Inn – Dearborn, MI rimrehab.org June June 6 CMSA Detroit Dinner Conference Burton Manor – Livonia, MI cmsadetroit.org June 26-30 CMSA Annual Conference & Expo Austin Convention Center – Austin, TX cmsa.org July July 11 BIAMI Eastern Michigan Golf Outing St. John’s Golf Course – Plymouth, MI biami.org

22 | RAINBOWVISIONS • WINTER 2017 MBIPC Michigan Brain Injury Provider Council RINC Rehabilitation & Insurance Nursing Council meetings

Registration at 11:30 a.m. • Lunch at Noon Learn Over Lunch Presentation begins at 12:45 p.m. Watch for changes and updates Meeting times are noon – 1:30 p.m. (Registration at 11:30 a.m.) on the NEW RINC Detroit website! Cost: MBIPC Member $25 / Non-member $60 (web development still in progress) For information call 810.229.5880

April 11, 2017 Topic: The injured Pituitary Gland: Hormone Deficiencies that can Influence Medical Status and Rehabilitation Progress Speaker: Dr. Jennifer Doble Location: Schoolcraft College, Livonia, MI

May 9, 2017 Topic: Value Laden Beliefs – Psychology of Disability and the Structure of Treatment Intervention Speaker: Dr. Martin Waalkes rincdetroit.com Location: Calvin College, Prince Conference Center, Grand Rapids, MI

June 13, 2017 Topic: Neuroscience of Addictive Disorders Speaker: Dr. Belal Hegazy Location: Schoolcraft College, Livonia, MI

RINC meetings are presented the third Friday of each month. For updates on meetings, visit For more information on meetings and membership contact rainbowrehab.com or mbipc.org Diane Malley: 248.568.5555 [email protected]

NOTICE: The conferences and events information listed on these pages is dated information. For the most up-to-date information on industry-related conferences and events, please visit: rainbowrehab.com.

RAINBOWREHAB.COM WINTER 2017 • RAINBOWVISIONS | 23 • NEWS AT

Rainbow opens newest residence in Southfield

On November 17, Rainbow hosted an open house to showcase our newest facility located in Southfield, MI. The Southfield Center is a 14-bed residence that is fully accessible with on-site dining services, comfortable family visiting areas, a recreation room and on-site therapy areas. The bedrooms are well appointed for personal safety and comfort. Some of the rooms are outfitted with Hill-Rom electric hospital beds. These beds are equipped with smart bed technology enabled with the NaviCare Nurse Call system. All of the rooms have custom, voice-activated call buttons. Further, the rooms feature Wi-Fi throughout, flat panel TVs, private baths, built-in cabinets with pullouts, wheelchair accessible drawers and more. To schedule a tour, call 800-968-6644 and speak with anyone in Admissions or send an email to [email protected].

Making meals healthier and tastier for our clients For better nutrition and tastier meals for our clients, Rainbow employees are training with Chef Evelyn Stokes (far left), founder of I Eat Super, a Detroit-based company dedicated to introducing people to healthier lifestyles. Chef Stokes is teaching employees how to make easy, healthy meals at our residential facilities. In each class, employees get hands-on experience preparing an entire meal consisting of a main dish, side dishes and dessert. They are then given the recipes for future use. Chef Stokes also reviews proper use of kitchen utensils, appliances and food safety.

24 | RAINBOWVISIONS • WINTER 2017 Spreading warmth to those who need it most

Employees at Rainbow’s Vocational Rehab Campus in Ypsilanti, MI created a hat and scarf tree using client- made scarves and hats. The idea is that people in the local community can take them if needed, especially during the recent cold weather we experienced. They estimate 50 items have been taken since the tree was stocked before Christmas. Twenty hats, scarves and gloves were also donated to a mission in Farmington Hills, MI by those at RIPROC, Rainbow’s vocational center for young adults.

ƒ Employees were pleased to find this note tucked under the front door thanking them for providing the hats and scarves to those in need.

Holiday boutiques featured client-made items The recent holiday boutiques set up by the Vocational Program were a great success. They were organized throughout December at each of Rainbow’s treatment centers and at the Livonia Corporate Center. The boutiques featured an assortment of holiday decorations, craft items and wearable art made by clients. Some of the clients also helped run the boutique by assisting shoppers with their purchases, answering questions and bagging up the items.

March is Brain Injury Awareness Month The Brain Injury Association of America (BIAA) leads the nation in observing Brain Injury Awareness Month by conducting an awareness campaign in March each year. The theme for the 2015–2017 campaign is: Not Alone. The campaign provides a platform for educating the general public about the incidence of brain injury and the needs of people with brain injuries and their families. The campaign also lends itself to outreach within the brain injury community to de-stigmatize the injury, empower those who have survived, and promote the many types of support that are available.

RAINBOWREHAB.COM WINTER 2017 • RAINBOWVISIONS | 25 • NEWS AT New Professionals

Deborah Bush, RN Kent Johnson Nurse Case Manager Desktop Support Tech Deborah is joining Rainbow as the Nurse Case Kent joins the IT Department in Livonia, MI as Manager at Rainbow’s new Southfield Center in a Desktop Support Tech. He previously served Southfield, MI. Deborah graduated from Wayne at Medview Services, Phillips Service Industries State University in Detroit and spent 20 years and SME. He earned a Bachelor of Arts from the employed at a hospital in Detroit. University of Windsor and a PC Support and Development Analyst certificate from St. Clair College, both in Windsor, Ontario.

Andrea Garrett, BS, CTRS Kristian Powell Residential Program Manager Human Resources Assistant Andrea joins us as the Residential Program Kristian joins the Human Resources Department Manager for the new Southfield Center in in Livonia, MI as an HR Assistant. She Southfield, MI. She has worked in brain injury previously served as a call center manager rehabilitation for 17 years with the past five for the Detroit Department of Transportation years spent working as a therapy manager and the transportation manager for Rehab at the University of Maryland Rehabilitation Transportation. Institute in Baltimore, MD. She earned a Bachelor of Science in Therapeutic Recreation at Eastern Michigan University in Ypsilanti, MI. Reese Robinson Stephanie Huhn, MA, LLP Desktop Support Tech Admissions Manager Reese joins the IT Department in Livonia, MI as Stephanie joins Rainbow as an Admissions a Desktop Support Tech. He was previously a Manager working out of the corporate center in Desktop Support Team Lead at Visalus Sciences Livonia, MI. She previously was Assistant Clinical in Troy, MI. He earned a Bachelor of Science in Director and Neurorehab Psychologist at a TBI Information Technology from Oakland University day treatment program. She also worked as in Rochester, MI. a psychotherapist (inpatient and outpatient) working with co-occurring disorders. Stephanie received her undergraduate degree from Michigan State University in East Lansing, MI and a master’s degree from The Michigan School of Alex Schull, MA, EP-C Professional Psychology in Farmington Hills, MI. Exercise Physiologist Alex joins Rainbow as an Exercise Physiologist at the Ypsilanti Treatment Center in Ypsilanti, MI. Jae Hou He recently graduated from Central Michigan Director of Business Intelligence University in Mt. Pleasant, MI where he earned Jae comes to Rainbow as Director of Business a Bachelor of Science and a Master of Arts in Intelligence working at the corporate center in Exercise Physiology. He has also served as an Livonia, MI. He has over 20 years of experience assistant strength and conditioning coach, a in all facets of software development across human physiology graduate teaching assistant several vertical markets including health care. and was involved in two athletic internships at He’s been involved in the successful deployment the University of Michigan. of multiple enterprise level business intelligence initiatives turning raw business data into actionable insight-including a cell phone-based Amy Slauter, RN, BSN scheduling system for health care professionals Nurse Case Manager and near real-time reporting of key operational Amy joins Rainbow as a Nurse Case Manager performance metrics. Jae earned a Bachelor of working with the team at the NeuroRehab Math in Computer Science/Information Systems Campus in Farmington Hills, MI. She most at the University of Waterloo in Ontario, Canada. recently worked as a Nursing Case Manager at a hospice facility and as a nurse at a local hospital. She earned her degrees at Oakland University in Rochester, MI.

26 | RAINBOWVISIONS • WINTER 2017 Kaitlin Thomas, BS, RD Edward J. Wryobeck Dietitian Senior Business Analyst Kaitlin joins us as a Registered Dietitian working Edward joins Rainbow as a Senior Business at the Ypsilanti Treatment Center in Ypsilanti, Analyst working at the corporate center in MI. She is responsible for nutrition assessments, Livonia, MI. He has 30 years of experience nutrition counseling and nutrition education performing analysis and implementing software to clients and staff. She previously worked as a applications. Edward attended the University of Dietetic Intern at a local hospital. Houston.

Employees of the Season Summer 2016

Rehabilitation Assistants Residential Program Therapy Staff Arbor: Judy Struble Oakland Center: Adrienne Swick Managers Tina Kowalski Ann Arbor Apartments: Pamela Scott, Oakland Townhouses: Whitney Perry Heidi Aldridge Katherine Jester Jessica Lupone Shady Lanes: Cynthia Pride, Katrina Miller Julie Lowe Belleville: Shanice Cheeks-Houston Angel Hudson, Lavell Smith Debbie Trumbull Alyssa Portelli Bemis: Stefayne Rushlow Southbrook: Chantel Fluker Laurie Shipley Laurie Cooke Brookside: Ernest Ndagije Textile: Autumn Wurts Cassandra Rice Lori Heltunen Carpenter: Shelbi Lee, Heidi Oborne Whittaker: Kayla Taylor, Chelsea Lupone Stacy Henson Jennifer D’Angela Crane: Cheryl Sterling Woodsides: Maria Sakofske, Kelli Frye, Cereste Duprat-Fabre Elwell: MiEisha Mack Sarah Middleton Williams Rehab Transportation Christine Zimmermann Farmington: Sade Brown, YTC: Christina Dulaney Cheyanne Brown Julie Blasko Darlajhi Davis, Antonio Howard Summer Program: Shadell Wilcox, Andrea Sweet Garden City Apts: Christopher Thomas Jaron Brown, Tanille Scott, Shanita Blevins, Professional/ Gill: Toya Moore Charlotte Langford Administrative Staff Maintenance Home Care: Iva Vaughn, Alicia Horton, Mary Mitchell Team Katrina Williams, Roberta Wendt, Rainbow U: AnnMarie Calderone Jill Hamilton-Krawczyk Jason Rosentreter Sandra Haygood, Veronica Kimble RIPCO: Cynthia Forbing, Terrell Brazier Katelyn Kortwright Dennis Dauphinais Maple: Carrie Farmer RIPROC: Cesar Cruz Julie O’Bradovich Charles Allen NRC: Barbara Putman-Williams, Derek Besco Ryan Kovacs Princess Gardner, Dawn Wing, Mia Hancock, Tricia Seddon Ron Keen Catherine Orban, Melanie Williams, Joe Wurmlinger Bob Adams Renetta Adams Lisa Hildebrandt Bill Carlton Perry Keith Please join us in congratulating these outstanding employees!

RAINBOWREHAB.COM WINTER 2017 • RAINBOWVISIONS | 27 • TBI TOPICS SEXUAL SURROGACY

Continued from page 19 Prostitution is performing an act of sexual are required [to] have an external source of steady intercourse for hire, or offering or agreeing to employment and income earning ability.19 perform an act of sexual intercourse or any unlawful One can easily appreciate the distinctions suggested sexual act for hire.16 by Rosenbaum. However, while therapeutic surrogacy Michigan case law expands on this definition to services may be done for the most noble purposes, the include sexual acts other than intercourse. For example, a legal question remains as to whether the “sexual” part of Michigan case held that of a customer’s sexual surrogacy services is prostitution. Put bluntly: is penis by direct manual contact, in exchange for money, is sexual surrogacy the provision of sex for money? I am not prostitution.17 aware of any case law in Michigan respecting the difference Advocates of sexual surrogacy attempt to distinguish between prostitution and sexual surrogacy in a therapeutic surrogacy from prostitution on the basis of a variety context. That is to say, there does not appear to be any case of factors tied to the therapeutic purposes and benign law on this point. This suggests that sexual surrogates have intentions of surrogacy. Rosenbaum argues that sexual never been prosecuted (a conviction is what leads to the surrogacy is not just “sex;” but rather is in the context of a appeal that then becomes a precedential case). But the fact broader therapeutic regimen: that sexual surrogates have not been prosecuted does not The argument that surrogacy is not unlike mean that they could not be prosecuted: prostitution represents an insufficient understanding Sexual surrogacy tends to pop up in the media every of the surrogacy relationship. Data by Noonan, who few years and receives a disproportionate amount interviewed 54 sex surrogates, found that 87 percent of attention considering how rare it is. In the U.S., of the time spent with clients was spent in non-sexual according to one estimate, there may be no more activities, which included providing education, than 25 professional surrogates practicing. Given relaxation, emotional support, and coaching. The this information, it seems unlikely that someone idea of using surrogates as escorts or people with would get arrested for sexual surrogacy. However, whom patients indulge in sexual fantasies or use the grey area in which it exists is not really a benefit, had been summarily rejected by early and even if it has never happened before, seeing pioneers who claimed that this a sexual surrogate or practicing sexual surrogacy arrangement would damage the self-image of clients carries the risk of arrest in any state where there is who may attain the social stigma of being a person no clear legal exemption.20 who paid for the services of an escort.18 Thus legal uncertainty continues to surround the Rosenbaum adds that the purposes of the surrogate and provision of sexual surrogacy. While one may not be the prostitute are very different: prosecuted for engaging in sexual surrogacy, the risk of Additionally, while the goal of the prostitute is prosecution remains. Note again Michigan statute MCL to gratify specific sexual desires in exchange for 750.457 discussed above. This potentially exposes not only monetary reward, surrogates take an active role in the surrogate but also the therapist and facility to criminal a therapeutic process. Surrogates, in contrast, use responsibility for sexual surrogacy. therapeutic techniques and consistently report back In addition to the potential for criminal prosecution, to the sex therapist on the therapy’s progress, acting the uncertain legal status of sexual surrogacy creates to prevent failure at critical junctures. Escorts act an impediment to insurance reimbursement. For according to the demands of the client, whereas example, Michigan’s auto no-fault insurance law requires surrogates act in accordance with the demands of that services be “lawfully rendered” in order to be therapeutic goals under professional guidance of a compensable.21 Whether or not prosecution occurs, therapist. A surrogate’s motivation differs from that insurers may resort to this “lawfully rendered” doctrine to of an escort in that they see themselves as part of a avoid payment. therapeutic process rather than a participant in an This legal uncertainty over criminal prosecution and isolated sexual experience. Furthermore, surrogates insurance reimbursement hinders the development of are invested in the therapy’s success. Surrogates, sexual surrogacy as a viable and needed component of as opposed to sex workers who generally provide TBI rehabilitation. It is my hope that this article will help sexual gratification in exchange for financial gain, promote a movement to recognize the need for a more

28 | RAINBOWVISIONS • WINTER 2017 The majority of people with TBI are young males, many of whom are just learning about expressing their sexuality.

certain legal and reimbursement status of sexual surrogacy the role of surrogate. As such, one can anticipate the need services. Such certainty is essential so that surrogates, for greater attention being paid to the mental health of the therapists and facilities can offer these services free of surrogate with greater accommodations being made in the fear of criminal prosecution and confident of insurance workplace. According to Rosenbaum: reimbursement. Early sex therapy literature raised concerns regarding the emotional experience of the surrogate FUTURE DIRECTION partner. Masters and Johnson endorsed limited use The above discussion focuses on the legality of providing of surrogacy because of the stress of playing a role in sexual surrogate services. Once legal and reimbursement which the surrogate’s needs were left unmet and no issues are resolved, a host of other issues will remain to emotional bonds were formed.22 be considered in the ordinary course of providing such Rosenbaum concludes that modern sexual surrogate therapy. This is hardly an exhaustive review of those issues, therapy is conducted in a manner that enables the therapist but a few will be mentioned. to address the needs of both the client and the surrogate. First is the TBI rehabilitation facility’s exposure to civil The surrogate is not expected to be devoid of emotion liability for failure to provide a safe workplace and one free or attachment.23 It will be imperative to recognize the of . One can immediately appreciate emotional needs of the surrogate as well as of the patient. this concern when one of the primary duties of the sexual A third area of concern is that of professional ethics. surrogate employee is to provide sexual services. Sexual relationships between psychotherapists and A second area of concern is the emotional vulnerabilities patients have been characterized as the “cardinal sin of and sensibilities of the sexual therapist and sexual therapy” and an “extreme transgression.”24 Yet the central surrogate. Emotional fatigue (a/k/a “burn out”) is a tool of sexual surrogate therapy is the structured and challenge to any profession that requires continuous and supervised use of sexual relationships. This will require committed caring. While many other professions require the development of new ethics. Just as important, this the utmost sensitivity to patient needs, few if any other will require an effective method of monitoring ethical professions include the level of intimacy that is inherent in compliance.

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A fourth area of concern is the therapeutic “end game” therapy or any future social intimate relationship of sexual rehabilitation. This article has advocated with a partner is doubtful. A young person may even for a broader and more comprehensive view of TBI benefit from the intensive experience of surrogate rehabilitation to include the use of sexual surrogates. therapy in ways we are unable to measure or predict.26 But we must face the question: when and under what The reference to “graduating” from sex therapy to a call circumstances is therapy finished? This depends of course girl is interesting and reflects the apparently more casual on the goals of therapy. The Israeli experience discussed in attitude to sex in Israel than in this country. However, the Rosenbaum and Aloni articles suggests a goal-oriented the use of maintenance therapy instead of a call girl has therapy focused on improving behaviors in part through interesting implications as well. Would maintenance the use of sexual therapy. therapy then be simply another word for “prostitution”? But what if the goal is simply to give pleasure to someone This leads us to the final area to be discussed in this who has no other way to achieve it? Stated another way: article: that of the morality of providing sexual services in what are the rehabilitation goals for an individual with a the clinical fashion described. I am extremely aware that TBI who has severe physical and cognitive impairment? there are those who would object on moral grounds to the Is there a realistic goal for “rehabilitation?” Can sexual provision of sexual surrogacy services. The distinctions surrogacy services be considered appropriate as between sexual surrogacy and prostitution discussed by “maintenance therapy” as is done with therapy for other Rosenbaum above may be regarded by some as facile forms of physical dysfunction? In such programming and puerile but not persuasive. Whether or not sexual we look to quality of life issues as opposed to achieving surrogacy is prostitution, it includes sexual acts outside the improved function. sanctity of . I am fully aware of the strong views Aloni suggests that sexual surrogacy therapy may held by some on this issue. However, those who disapprove encompass both goals: a rehabilitation goal of improving of sexual surrogacy are not required to indulge in this function; and a maintenance goal of sustaining a process. I would hope that those views would not be used reasonable quality of life. As to rehabilitation, Aloni states: to impede therapy for those who do not share a morality The therapy with a surrogate is an emotional that disapproves of sexual surrogacy. experience and process in which the person with My own view of the morality of sexual surrogate services a TBI receives forms of sexual gratification while to the severely disabled is that it is an act of compassion relearning social and interpersonal skills and thus and mercy. Everything we do in the rehabilitation improving quality of life. Inherent in the surrogate professions is to facilitate adjustment to the wreckage process is an emotional experience that is not wrought by TBI. But we don’t do nearly enough to available in other forms of sexual therapy that can address the sexual needs of individuals with TBI. We facilitate the opportunity for the individual to learn must do more. I would hope that this article starts a new behaviors and to improve verbal and non-verbal more purposeful discussion of the use of sexual surrogate communication. It is also an opportunity for the therapy. When persons like Lenny come to me in the persons with TBI to learn more about their intimate future, I want to be able to offer them a legal and viable needs and to experience warmth and pleasure from alternative to loneliness and despair. As Brian Wilson of being with a partner in an intimate situation. These the Beach Boys wrote: behaviors may then generalize in providing more appropriate behaviors to real life situations, like being Love and mercy, that’s what you need tonight ❚ with a ‘call girl’ if other forms of relationships are not So, love and mercy to you and your friends tonight. available.25 As to maintenance, Aloni states: Surrogate therapy can also be considered as an option for individuals with Very Limited Functional Ability (VLFA) even when future maintenance surrogate

30 | RAINBOWVISIONS • WINTER 2017 References 1. Simpson G, Long E. An evaluation of and information 14. Michigan Case Law 750.448 resources and their provision to adults with traumatic brain injury. 15. Michigan Case Law 750.457 Journal of Head Trauma Rehabilitation. 2004; 19:413. 16. People v Warren, 449 Mich 341, 345 (1995), fn9. 2. Ducharme S. Providing sexuality services in head injury rehabilitation centers: issues in staff training. International Journal of Adolescent 17. People v Warren, 449 Mich 347 (1995), fn9. Medicine & Health. 1994; 2:180. 18. Rosenbaum T, Aloni R, Heruti R. Surrogate partner therapy: ethical 3. Davis D, Schneider LK. Ramifications of traumatic brain injury for considerations in . Journal of Sex Medicine. 2014: sexuality. Journal of Head Trauma Rehabilitation. 1990; 5:31, 34. 11:325. 4. http://thesunmagazine.org/issues/174/on_seeing_a_sex_surrogate? 19. Rosenbaum T, Aloni R, Heruti R. Surrogate partner therapy: ethical considerations in sexual medicine. Journal of Sex Medicine. 2014: 5. Rosenbaum T, Aloni R, Heruti R. Surrogate partner therapy: ethical 11:325. considerations in sexual medicine. Journal of Sex Medicine. 2014: 11:322. 20. http://sexuality.about.com/od/sexualhealthqanda/a/Are-Sex- Surrogates-Legal-In-The-United-States.htm 6. 4. Aloni R, Keren O, Katz S. Sex therapy surrogate partners for individuals with very limited functional ability following traumatic brain injury. Sex 21. Michigan Case Law 500.3157 and Disability. 2007: 25: 127. 22. Rosenbaum T, Aloni R, Heruti R. Surrogate partner therapy: ethical 7. Simpson G, Long E. An evaluation of sex education and information considerations in sexual medicine. Journal of Sex Medicine. 2014: resources and their provision to adults with traumatic brain injury. 11:325. Journal of Head Trauma Rehabilitation. 2004; 19:416. 23. Rosenbaum T, Aloni R, Heruti R. Surrogate partner therapy: ethical 8. Davis D, Schneider LK. Ramifications of traumatic brain injury for considerations in sexual medicine. Journal of Sex Medicine. 2014: sexuality. Journal of Head Trauma Rehabilitation. 1990; 5:31, 32. 11:326. 9. Aloni R, Keren O, Katz S. Sex therapy surrogate partners for individuals 24. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry (2009). 9th with very limited functional ability following traumatic brain injury. Sex ed: 2772. and Disability. 2007: 25: 126. 25. Aloni R, Keren O, Katz S. Sex therapy surrogate partners for individuals 10. http://www.surrogatetherapy.org/ with very limited functional ability following traumatic brain injury. Sex and Disability. 2007: 25: 132. 11. Rosenbaum T, Aloni R, Heruti R. Surrogate partner therapy: ethical considerations in sexual medicine. Journal of Sex Medicine. 2014: 26. Aloni R, Keren O, Katz S. Sex therapy surrogate partners for individuals 11:322-323. with very limited functional ability following traumatic brain injury. Sex and Disability. 2007: 25: 133. 12. Rosenbaum T, Aloni R, Heruti R. Surrogate partner therapy: ethical considerations in sexual medicine. Journal of Sex Medicine. 2014: 11:327. 13. Aloni R, Keren O, Katz S. Sex therapy surrogate partners for individuals with very limited functional ability following traumatic brain injury. Sex and Disability. 2007: 25: 132.

About the author

Wayne Miller, Esq. Miller & Tischler, P.C. Wayne Miller is a graduate of the University of Michigan and Wayne State University School of Law. Licensed to practice law in Michigan since 1980, he has specialized in the legal issues relating to the victims of motor vehicle accidents. Wayne and the firm specialize in cases involving catastrophic injury, including the rights of the injured, their families, and their professional service providers. He has served as an Adjunct Professor of Law at Wayne Law School, where he has taught the class in Michigan’s no-fault auto insurance law since 1998. The textbook used in the three Michigan law schools that teach no-fault insurance is co-authored by Wayne. He has been included in the “Best Lawyers in America” since 2005, and was named the “Most Respected Advocate” by the Michigan Defense Trial Counsel in 2007. Additionanally, he has been honored by Michigan Lawyers Weekly as a 2015 “Leader in the Law.”

RAINBOWREHAB.COM WINTER 2017 • RAINBOWVISIONS | 31 One Thousand Words

We are proud to announce we have officially cut the ribbon on the Southfield Center—Rainbow’s newest residential facility located in Southfield, MI. The special occasion was celebrated with employees, health care professionals and community members from the metro Detroit area. Stay tuned for more updates!

800.968.6644 [email protected] Locations rainbowrehab.com GENESEE COUNTY Oakland Treatment Center THROUGHOUT MICHIGAN Genesee Treatment Center 32715 Grand River Ave., Farmington, MI 48336 Home Care 5402 Gateway Centre Dr., Suite B, Flint, MI 48507 T: 248.427.1310 F: 248.427.1309 T: 800.968.6644 T: 810.603.0040 F: 810.603.0044 Southfield Center Functional Recovery / Home and OAKLAND COUNTY 25285 W. Eleven Mile Rd., Southfield, MI 48033 Community -Based Rehabilitation Farmington Hills Treatment Center T: 810.603.0040 F: 810.603.0044 WASHTENAW COUNTY 28511 Orchard Lake Rd., Suite A Ypsilanti Treatment Center Rehab Transportation® Farmington Hills, MI 48334 5570 Whittaker Rd., Ypsilanti, MI 48197 A wholly owned subsidiary of Rainbow Rehabilitation Centers T: 248.306.3170 F: 248.306.3197 T: 734.482.1200 F: 734.482.5212 T: 800.306.6406 NeuroRehab Campus® WAYNE COUNTY 25911 Middlebelt Rd., Farmington Hills, MI 48336 Rainbow Corporate Headquarters T: 248.471.9580 F: 248.471.9540 17187 N. Laurel Park Dr., Suite 160, Livonia, MI 48152 T: 734.482.1200 F: 734.482.3202

32 | RAINBOWVISIONS • WINTER 2017 Rainbow Rehabilitation Centers SOUTHFIELD CENTER The new Southfield Center offers comprehensive rehabilitation services provided by professionals who specialize in caring for individuals who have been injured. The program focuses on treating medically stable individuals with: Traumatic brain injuries • Spinal cord injuries Neurologic impairments • Orthopedic injuries • Co-morbidities The Southfield Center is conveniently located in Southfield, MI, close to medical facilities, community activities and major freeways. The fully-accessible facility boasts numerous amenities including: Beautifully appointed 14-bed living environment • Fully accessible private rooms and baths Cable TV, phone and Internet availability in each bedroom • On-site dining services Therapy areas on-site • A large patio deck, perfect for outdoor activities

If you would like to tour Rainbow’s newest premier facility, give us a call at 800.968.6644 Presorted Standard U.S. Postage PAID 17187 N. Laurel Park Drive, Suite 160 Permit 991 Livonia, Michigan 48152 Ypsilanti, MI

INSIDE: Let’s talk about sex... Discussions on sexuality following TBI

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Day treatment designed around "U" A therapeutic approach to day treatment programming for residential and outpatient clients Rainbow U is adding more options than ever in more places than ever! Our day treatment program has has expanded to more treatment centers with programs now offered in Washtenaw, Oakland and Genesee Counties. Contact a member of the admissions team today to learn more about this innovative and popular program! 800.968.6644