neuropsychotherapy for patients with brain damage: is it really

Tedd Judd, Phd, ABPP-CNClinical Neuropsychologist, Bellingham, WA,

[email protected] Presented At:

Washington State 2010 Traumatic Brain Injury

ConferenceBeyond Survival: Thriving After

A Traumatic Brain InjuryMay 1, 2010, Seatac, WA

Emotional Rehabilitation: Learning about and

Living with the Emotions of a New Brain

mailto:[email protected]

Outline

Introduction The Whole Person after TBI The Content Of Emotional

Rehabilitation The Techniques Of Emotional

Rehabilitation The Social Context of Emotional

Rehabilitation

Introduction: What is Emotional Rehabilitation? How is Emotional Rehabilitation different from

psychotherapy? Who is Emotional Rehabilitation for? What challenges does Emotional Rehabilitation

address? Why is Emotional Rehabilitation needed? Who does Emotional Rehabilitation?

About “Neuropsychotherapy” First use: Ellis, 1989 (Neuropsychotherapy. In D. W.

Ellis & A.-L. Christensen (Eds.), Neuropsychological treatment after brain injury (pp. 241-269). Boston: Kluwer Academic Publishing.)

First book: Judd, 1999 (Neuropsychotherapy and community integration: Brain illness, emotions, and behavior. New York: Springer/Kluwer

Academic/Plenum Publishers) Second book, second sense: Grawe, 2004

(Neuropsychotherapy: How the neurosciences inform effective psychotherapy, English translation 2007, Mahwah, NJ: Lawrence Erlbaum Assoc.)

WHAT IS NEUROPSYCHOTHERAPY?(Ellis/Judd)

Neuropsychotherapy is the use of neuropsychological knowledge in the psychotherapy or counseling and related interventions for people with brain disabilities and those close to them. It is specialized in content, technique, and social context to address the emotional and behavioral issues of brain disability.

What Challenges Does Emotional Rehabilitation Address? Organic changes in emotional

regulation Executive dysfunctions Adjustment to brain dysfunction Social adjustment to disability

Why Is Emotional Rehabilitation Needed?

Large population with brain disabilities Emotional/social/behavioral challenges

tend to be the most disabling Few systematic interventions available Relatively few neuropsychologists

available

Antonak, et. al, 1993; Livingston & Brooks, 1988; Morton & Wehman, 1995

Who does Emotional Rehabilitation?Skills needed to do effective Emotional

Rehabilitation: Therapy skills—warmth, empathy,

openness, reliability, etc. Teaching skills Knowledge of:

Emotional RehabilitationBrain illness behavioral and emotional changesRehabilitation Community resources

Who does Emotional Rehabilitation?

Skills NOT needed to do effective Emotional Rehabilitation:

Knowledge of how to do neuropsychological evaluations

Extensive knowledge of neurology and neuroanatomy

Research skills Forensic skills

Who does Emotional Rehabilitation?

Candidates for doing Emotional Rehabilitation (in at least a limited sense):

Psychotherapists Rehabilitation team members (Social

Workers, OT, PT, Speech, Nursing, Aides) Community-Based Rehabilitation Volunteers Teachers Family members People with brain injuries (self-help)

The Whole Person after TBI (didactic model)

Pre-Illness Personality

Reactions to:

InjuryIllness

Organic Changes to Personality,

Emotions

The Whole Person after TBI

Pre-disability Personality Full range of personalities and

psychopathologies Factors predisposing to brain

injury/illness are overrepresented:Substance abuseRisk takingMedical non-adherence


Reactions to injury/illness:

Grief Denial Depression Anxiety

Posttraumatic Stress Disorder

Frustration Anger Personal

Reformation


Reactions to Disability: Grief Denial Depression Anxiety

Perplexity Lezak, 1978

Frustration Anger Embarrassment

The Whole Person after TBI Organic Emotional Changes:

Function Increased Decreased

Emotional Communication

Reflex crying, laughingAutomatic cursing

Monotone voiceMasked face

Emotional Reactivity

Labile emotionsImpulsive angerCatastrophic reactions

Indifference

The Whole Person after TBI Organic Emotional Changes: Organically induced major psychiatric

disordersDepressionManiaPsychosisObsessive-compulsive disorder

Executive Dysfunctions:Behavior RegulationDimension Undercontrolled Overcontrolled

Activity regulation, attention, prioritization

Distractible, off task Overfocused, rigid

Self-awareness Unaware of problems (anosognosia)

Overly self-critical, catastrophizes

Self-correction Does not learn from mistakes

Overlearns from mistakes (avoidant)

Trust Gullible Paranoid

Executive Dysfunctions: Behavioral DriveDimension Undercontrolled Underdriven, deficient

Abstraction Vague Concrete

Activation Impulsive, disinhibited Passive, lack of initiation

Emotional control Labile Flat affect, abulia

Activity maintenance Perseverative, intense Impersistent

The Content of Emotional Rehabilitation

Fundamental Principles: The Continuum of Responsibility Emotional Rehabilitation Self-Awareness The New Self

The Content of Emotional Rehabilitation The Continuum of ResponsibilityAcute Condition

Caregiver’s share

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The Content of Emotional Rehabilitation The Continuum of Responsibility

Executive Function Rehabilitation Schema

1. Accommodate Externally (schedules, cues, reminders, written procedures, restrictions)

2. Build Awareness 3. Retrain Self-regulation (problem-solving

schemata, social skills, alarms, PDAs)4. Generalize Self-regulation train in other

settings (home, school, work, community)5. Fade External Compensations


Emotional Rehabilitation Accessible metaphor Demystify process Reduce guilt and blame Define roles Skill-learning model

You have a new brain. It doesn’t handle emotions

the way it used to. You need to learn how it

functions now and how to get along in the world

with the way it functions now.

Learning how to live with your new brain takes time and practice.

Each time you have an emotional problem it’s a chance to learn how your new brain is working.

We’re here to help.

Emotional rehabilitation helps bridge the gap between: Behavior management and

psychotherapy Psychotherapy and cognitive

rehabilitation The cognitive and the emotional

sides of executive functions

Emotional rehabilitation needs to enlist the aid of the social context of the person with a brain disability so as to:

Carry out training in the appropriate target social/emotional contexts

Make those contexts more hospitable to the person with the disability

Support and empower family and others in dealing with the changes in their loved one


Improving Self-AwarenessUse Evaluation to Guide Intervention

Overestimation of Disability Due to: Depression Catastrophizing Lack of knowledge of recovery

Underestimation of Disability Due to: Anosognosia Lack of experience Impaired reasoning and generalization Denial


Improving Self-Awareness

Distinguish Knowledge from Action Crosson, et al, 1989

Intellectual awareness (I can repeat what I’ve been told about my disabilities, but don’t quite believe it)

Emergent awareness (I can recognize my errors in retrospect or when happening)

Anticipatory awareness (I can plan to use compensations to avoid problems)



Supportive confrontation Avoid struggle Take perspective of

person with brain disability

Work with who they trust



Feedback Tools Mirrors Photos Audio tapes Videotapes Work samples Writing samples Arts and crafts products


Improving Self-Awareness Testing feedback Medical Records Self-Monitoring Exercises Games Educational Materials Group Therapy Supported Failure Real-Life Experiences Don’t say “I told you so”


The New Self Not necessarily better or worse, just

different Discover who the new self is Rethink abilities Rethink goals Rethink relationships

The Techniques of Emotional Rehabilitation

Cuing technologies: Uses Emotional control Procedures and routines Stressful events Reminders Behavior Flash Cards Explanations to others Incidental functions


Cuing technologies: Emotional Control Example MY ANXIETY SIGNS Tapping fingers, foot Fast breathing, heart Sweating Tense muscles Fussing and fidgeting

RELAXING BREAK Alone, quiet, dark Close eyes Breathe slowly, deeply Relax muscles Let go of worried

thoughts Picture beach


Cuing technologies: Therapy Procedure Example

ACTIVE LISTENING

Quiet, alone with other person

No TV, radio, music

Not doing anything else

Face other person, eye contact

Don't interrupt or react (bite tongue)

Repeat other person's feelings


Cuing technologies: Stressful Event Example PUBLIC SPEAKINGUse written outlinePractice alone and with friendHave friend in audienceShort relaxation before going on"I can do it! I know my stuff. They are friendly and want to hear

me."Find friend in audienceSpeak to back of roomSlowly and clearlySmile!


Cuing technologies: behavior Flash Cards

Stop and Think


Cuing technologies: Introduction Card Example

To my friends:My stroke makes me cry and laugh at times when I am not feeling particularly upset or amused. Please don't be frightened by it, and remember that I'm still the same me underneath that. Sometimes when I cry I will look up, or when I laugh I will rub my mouth. That helps me control it. Thanks for your understanding.

Emilio


Cuing technologiesTips on Use

Individualize Brief, concrete, action words, imperatives First person or trusted authority figure Colors Multiple copies Retain a copy on file


Cue Cards Tips on Use: Where to put them Wallet Purse Arm of wheelchair Mirror Refrigerator Steering wheel

Time Out place Back of door School notebook Computer monitor Pocket Kitchen table


Cuing technologies Tips on Use: (Rick Parenté)

Screen Savers Personal Digital Assistants and Watches Coffee mugs T-shirts Make them rhyme Initial letter mnemonics Use graphics


Choosing Cuing Technologies

Appropriate Appealing Affordable Accessible Acceptable


Self-Introduction Letter

Purposes Improve self-awareness Commitment to rehabilitation Future planning Social rehearsal Consolidate the experience Consolidate self-image Communicate needs



Contents 1 Introduction, purpose Story of the accident or illness

What happened?Why did it happen?How did you experience it? How do you feel about it?What you are doing about it (lawsuit,

forgiveness, health changes, prayer)?



Contents 2 Current challenges:

Physical challenges.Thinking difficulties.Emotional changes.Life changes (work, family, hobbies,

recreation, social life, spiritual life)



Contents 3 What other people should NOT think (e.g.,

not crazy, stupid, or fragile). How they can help. How they should treat you. What you would like them NOT to do. Feel free to talk with you about it. Thanks for understanding.



Variations on Exercise Application

Coauthor the letter (therapist, family, friend) Read the letter aloud Paraphrase the letter Make notes from the letter then present

from notes Practice in group therapy, with another

person, on video or audiotape

Working with the Social Network

Family and Friends

Roles in Emotional Rehabilitation Informants about behavior, pre-disability

personality, environment of recovery Collaborators in treatment Participants in support groups Recipients of education, counseling, therapy Support, advocacy Interdependence—being family, motivation,

the reason for doing things

Working with the Social NetworkFamily and FriendsTechniques of Family Education Answering questions Modeling Coaching Mentoring Individually written

materials Printed materials Visual aids Socratic dialogue Story telling

Metaphor Support groups Group discussion Lectures Videos Teaching to teach

others Observing testing Test results (drawings,

writing samples, scores)


Circles of Support Voluntary Stable group of community members

organized to help one person with a disability

Community based Person with disability chooses members Purpose is to help person with disability

realize dreams Not constrained by professional or

institutional agendas and rules


Community Resources

Client centered Be creative Enlist natural helpers Make home visits Go into the community

Emotional Rehabilitation: Summary

Emotional Rehabilitation uses cognitive compensations and family and community resources to help people rehabilitate from the emotional, behavioral, and social challenges resulting from brain disabilities. It is specialized in content, technique, and social context.

neuropsychotherapy for patients with brain damage: is it really

Documents

emotional rehabilitationcuing technologies

effective emotional rehabilitation

emotional rehabilitationthe continuum

emotional rehabilitation address

emotional rehabilitation needed

emotional rehabilitation

emotional rehabilitationself

tbiorganic emotional