Collaborative TherapeuticNeuropsychological AssessmentNovember 22, 2012 – 9:00a – 12:30pTad Gorske, Ph.D.Clinical Assistant ProfessorDirector, Outpatient NeuropsychologyDivision of Neuropsychology and Rehabilitation PsychologyUniversity of Pittsburgh School of Medicine, Pittsburgh Pennsylvania, USA
“The presentation of brain facts aboutspecific damages is meaningless topatients unless they can begin tounderstand how the changes in theirbrains are lived out in everydayexperiences and situations”(Varela, 1991 as stated in McInerneyand Walker, 2002)
What is CollaborativeNeuropsychology?• What is traditional neuropsychology? – Typically follows a medically based/information gathering model. – Outsider viewing a passive “object” – Reductionist – Categories, diagnoses, constructs used to explain a client. – Focus on pathology – Tester as detached observer – Sense of secrecy – Specific focus on the brain-behavior relationship
What is CollaborativeNeuropsychology? – Emanates from “Third Force” Psychology – Relational encounter – Client as “co-evaluator” – Open sharing of results – Client viewed in context – Constructs serve to understand the client holistically. – Focus on strengths and weaknesses – Test scores, categories, and classifications help patients develop an understanding of their experience, not to define it (Fischer, 1970/1994) – Blending art and science into a “human science neuro-psychology” (Fischer, 2003; italics mine).
Holistic Neuropsychology Yehuda Ben-Yashay and LeonardDiller• Roots in Kurt Goldstein’s holistic views. – A holistic theory of the organism based Gestalt Theory – “We have said that life confronts us in living organisms. But as soon as we attempt to grasp them scientifically, we must take them apart, and this taking apart nets us a multitude of isolated facts which offer no direct clue to that which we experience directly in the living organism.” Kurt Goldstein, The Organism, p. 7
Holistic NeuropsychologicalPrinciples• Empower patients and families to take an active role in the treatment process;• Believe people with neurological disabilities are more like people without neurological disabilities (ie. Go beyond the brain) ;• Convey honesty and caring in personal interactions to form a foundation for a strong therapeutic relationship;• Develop practical plans for rehabilitation; explain rehabilitation techniques in understandable language;
Holistic Neuropsychological Principles• Help patients and families understand neurobehavioral sequelae of brain injury and recovery;• Recognize change is inevitable and help families cope with change;• Every patient is important, treat with respect;• Remember that patients and families have different perspectives regarding treatment approaches.
Why do we need collaborativemodels? An identity crisis in neuropsychology (and psychology in general)?
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Neuropsychology Trends (Ruff,2003).• Period of Localization• Period of Neurocognitive Evaluation Next Period??
Forces Influencing NeuropsychologyTechnology Other Professionals Managed Care Cultural Trends
Cultural Trends• High Anxiety• Age of the Brain• Concussions• Aging of America• Mind-Body
Other Professionals• Speech, OT, Psychiatry, Counselors, Social Workers• Quick and dirty cognitive tests
• Neuropsychology is failing to distinguish itself due to: – Over-reliance on diagnosing brain behavior relationships – Narrow focus on psychometric approach – Uncertainty of roles in areas such as rehabilitation. – Lack of translation of test results into patient care – Lack of assessment advocacy (Gass and Brown, 1992; Nelson and Adams, 1997; Goldstein, S. Personal Communication)
Rise of ForensicNeuropsychology• There is a greater presence of forensic neuropsychology topics in peer reviewed journals and neuropsychology meeting programs (Sweet, et al., 2002).• Consequently there is a greater proportion of topics related to legal proceedings and malingering.• Increasing emphasis on Symptom Validity Testing.
Seeking a Balance Forensic MalingeringPatient CareRehabilitationMethods
Possibilities• Focus on the utility of neuropsychological assessment – Ensuring relevance by tailoring assessment to treatment/rehabilitative needs and outcomes – Focus on the needs of the client/consumer – Closely link assessment – feedback – intervention. – Integrate treatment planning, monitoring progress, and outcomes (Groth-Marnat, G. (1999)).
Importance of Working Alliance• There are strong links between patient- therapist collaboration and goal consensus in psychotherapy outcomes (Shick Tryon and Winograd, 2011).• Working alliance and collaboration in rehabilitation is viewed as important but less well studied.
Working Alliance inRehabilitation• A positive relationship between working alliance and outcomes has been found. Working alliance defined as• (a) the agreement between client and therapist on goals,• (b) their agreement on how to achieve these goals (common work on tasks) and• (c) the development of a personal bond between client and therapist. (Shönberger et al. 2006).
Working Alliance inRehabilitation• A good working alliance can be created with both clients who experience many problems and clients who experience comparatively few problems, as long as they are aware of the consequences of their brain injury.• Therapist’s experience of a good working alliance was influenced by the client’s experience of success. (Shönberger, et al., 2006).
Working Alliance inRehabilitation• Clients’ and therapists’ overall success ratings at program end were related to their emotional bond at program end.• Early-therapy compliance and the average amount of compliance are predictive of subjective improvement. (Shönberger, et al., 2006).
Working Alliance: Someevidence• Bieman-Copelan and Dywan (2000). Brain and Cognition, 44, 1-5.• Behavioral therapy in context of a supportive/collaborative therapeutic alliance for anosognosia.• Collaborative negotiation and trusting therapeutic relationship for behavioral goal setting.• Results indicated a significant reduction in problematic behaviors despite no increase in insight or awareness of injury.
Pegg et al., 2005• Evaluated the role of interpersonal relationship factors on patient outcomes with 28 patients with moderate to sever TBI admitted to an inpatient unit at a VAMC.• Personalized information-provision intervention.• Results: – Patients exerted greater effort in therapies – Patients increased satisfaction with rehabilitation treatment. – Significantly more improvement in cognitive FIM scores.
Interdisciplinary team workingalliance (Evans, et al., 2008).• Importance of therapeutic alliance in post acute brain injury rehabilitation (PABIR).• Sherer et al., 2007 - poor working alliance was associated with high levels of family discord, greater discrepancy between family and clinician ratings of client functioning, and poor client participation in therapies.• Treatment team members attended in-services that emphasized motivational interviewing philosophy and techniques, building rapport, reflective listening, dealing with patient resistance, making behavioral changes, stages of change, dealing with challenging clients, and assessment and treatment issues with depressed and/or suicidal patients (pg. 332).
Interdisciplinary team workingalliance (Evans, et al., 2008).• Treatment group had higher functional status and were more productive and had less dropouts, although the differences were not statistically significant.
Lane-Brown and Tate, 2010.• Single case study that evaluated an intervention utilizing external compensation and motivational interviewing to initiate and sustain goal directed activity with a TBI patient.• Demonstrated that treating specific and operationally defined goals through external compensation and motivational interviewing successfully decreased apathy.
Enhancing our patient care skills can createa ripple effect with consumers, providers,and public perception
Neuropsychology has the potential to be a leaddiscipline in understanding human beings from aholistic mind/body perspective
Comprehensive Recovery ChallengesRehabilitation• Physical Therapy • Knowledge of deficits• Occupational Therapy • Adapting to deficits• Speech Therapy • Grieving and Coping (Denial, anger,• Medical Management bargaining, depression,• Psychological/Neuropsyc acceptance). hological • Learning and re-learning• Emotional/Psychiatric • Integrating knowledge Management as into the self appropriate • Re-discovering meaning• Family Support and a sense of purpose• Case Management
Existential Issues inNeuropsychological Conditions• Awareness of change;• Emotions;• Struggle of acceptance;• Struggle to make sense and find meaning;• Struggle to reclaim/find a sense of self
“…But be that as it may, those of us who did make ithave an obligation to build again. To teach to others whatwe know, and to try with whats left of our lives to find agoodness and a meaning to this life.”(Quote from the movie “Platoon”, 1986)
How traditional neuropsychologicalassessment addresses these challenges1. Knowledge of deficits 1. Provides information on2. Adapting to deficits cognitive functioning. 2. Presents potential3. Grieving and Coping ameliorative strategies. (Denial, anger, 3. Does not directly bargaining, depression, address. acceptance). 4. Cognitive rehabilitation4. Learning and re-learning and remediation.5. Integrating knowledge 5. Presents one aspect of into the self the person (cognition).6. Re-discovering meaning 6. Does not directly address.
How collaborative neuropsychologicalassessment addresses these challenges1. Knowledge of deficits 1. Provides information on cognitive functioning and seeks individual2. Adapting to deficits application. 2. Presents potential ameliorative3. Grieving and Coping strategies and seeks out the (Denial, anger, individuals own resources for change. bargaining, depression, 3. Address a person’s experience acceptance). and reactions to information provided; balances education and4. Learning and re-learning the I-Thou interaction.5. Integrating knowledge 4. Cognitive rehabilitation and remediation and works to into the self motivate internalization.6. Re-discovering meaning 5. Presents one aspect of the person (cognition) and considers it within the context of the whole person. 6. Looks toward the future and what
History of Neuropsychological Testing as a Therapeutic Intervention
Luria’s Neuropsychological Investigation (LNI)• Loose conceptual basis, not an actual precursor.• A qualitative and flexible interviewing method for diagnosing brain lesions.• The value of LNI: – Provides a thorough individualized neuropsychological assessment in which the cognitive functions and psychological responses of the individual can be ascertained. – Provides the opportunity to identify strengths and deficits. – LNI principles can be implemented throughout the rehabilitation process which include • Hypothesis testing • A collaborative working relationship with the patient’• Feedback to enhance awareness.Christensen, Anne-Lise (1975); Christensen, A.L. and Caetano, C. (1999)
Neuropsychological TestFeedback Research• No empirical studies but some recommendations• Neuropsychological test feedback provides useful information about cognitive strengths and weaknesses,• Clients find the information useful,• Results apply to clients everyday life and concerns• Facilitates the development of useful and applicable interventions(Gass & Brown, 1992; Pope, 1992; Crosson, 2000; Bennet-Levy et al., 1994).
Recommended method forproviding information (Gass & Brown, 1992)1. Review the purpose of testing in plain, simple language2. Tests are “behavior samples” of functional domains3. Explain in terms of behavioral functioning4. Summarize strengths and weaknesses5. Address diagnostic issues6. Make recommendations
Limited empirical evidence• Case Studies (Malla et al., 1997; Rose, 1998)• Conceptual articles (Allen et al., 1986)• Provision of medical information which included neuropsychological tests (Pegg, Auerbach, Seel, Buenaver, Kiesler, and Plybon, 2005).
Background of Psychological Testing as a Therapeutic Intervention
Therapeutic/Individualized Models of Assessment
Collaborative IndividualizedAssessment (Fischer, 1994)• Based on phenomenological psychology.• Assessor works collaboratively to understand a client’s unique worldview• Tests, scores, categories, and classifications serve to develop a hermeneutic understanding of the person.• Reflects a “human-science psychology”.
Therapeutic Assessment (Finn,1992; 1997)• Psychological assessment as a therapeutic intervention,• Tester is an active participant• Rooted in humanistic psychology• Influenced by collaborative assessment
The Next Generation of Client Centered Feedback Motivational Interviewing
Motivational Interviewing Principles(Miller and Rollnick, 2002)• A method of dialogue designed to enhance client’s intrinsic motivation to make changes in behavior.• Heavily rooted in Roger’s Client Centered Therapy.• Originally developed with alcoholics but expanded to drug addiction and health behavior change.
• Strongly based on the Rogerian approach• Non-directive/directive intervention• Empathy and unconditional regard are the crux of MI• Exploring and resolving ambivalence about making changes is a key goal• Works to develop a discrepancy between real and ideal self (values and behavior; who a client is versus who they want to be).• Associated with the stages of change.
MI Method for Giving Feedback• Elicit – Provide – Elicit• Using OARS – Open ended questions – Affirmations – Reflections – Summarizations• Goal is to help clients work through and resolve ambivalence in order to move through the stages of change.
The NAFI• Origins – Neuropsychological Testing – Personal Feedback Report (Project MATCH, Dual Diagnosis Adherence Strategies, WPIC) – Anecdotal Observations• Pilot Study• Development of the Feedback Report• NIDA funded study 2004 – 2008.
Pilot Study Results Adherence Rates p = .042, cohens d = .78 (.02-1.55) NAFI (n = 14); TAU (n = 14) 100 90 80 71% 70 60 50 48% 40 30 20 10 0 S1 NAFI TAU
Pilot Study Results: D&A UseNAFI = 6; TAU = 5 30 Day Alcohol Use10 9 8 7 7.13 6 5.46 NAFI 5 TAU 4 3.4 3 2 1 0 0 Baseline 30 Day
Pilot Study Results: D&A Use 30 Day Drug Use765 4.734 NAFI 3.433 TAU21 0.66 0.400 Baseline 30 Day
Pilot Study Results: DepressionNAFI = 6; TAU = 5 30 Day Depression HRSD-25 25 22.2 20 21.2 20.21 15 NAFI TAU 11.4 10 5 0 Baseline 30 Day
Patient Responses• “The assessment was helpful to me. I learned a lot about myself…I would have done it without being paid.”• “Allowed me to see why I may be reluctant to participate in groups.”• “Helped me narrow in on specific steps I need to take with my therapist re: depression and addiction. Identified couple things we can work on.”• “I am so pleased that I participated in the study. It was right on. M- allowed me to share during the process, which really assisted with my overall understanding of the feedback.”
• First presentation at The Society for Personality Assessment, Spring 2006. – Diane Engelman, Ph.D. – Steven R. Smith, Ph.D. – Tad Gorske, Ph.D.
Methods of CollaborativeNeuropsychology• Demystify the neuropsychological assessment process: Provide feedback report; explain session purpose; facilitate collaboration and empathic understanding• Answer what the individual wants to know (If you can).• Explain how strengths and weaknesses are determined.• Ensure an understanding of the information provided.
Methods of CollaborativeNeuropsychology• Ensure the information relates to the persons experience; Or if it doesn’t• Explore the discrepancy.• Summarize what has been discussed.• Make suggestions• Look to the future.
CTNA• The spirit of the CTNA lies in Collaborative and Therapeutic Assessment Models – Open sharing; explore results contextually; use results to facilitate empathic understanding• The framework for conducting the CTNA is drawn from MI.• The CTNA adopts and adapts the MI Personalized Feedback Report
CTNA Feedback SessionTwo primary components1. Provide information from neuropsychological test results2. Interact with clients in a collaborative manner consistent with TA and MI.
CTNA Personalized Feedback1. Introduction • Provide feedback report; explain session purpose; facilitate collaboration and empathic understanding1. Develop Questions • Develop 2 or 3 well defined questions the client hopes the results can answer1. Explain how strengths and weaknesses are determined • Percentiles, determine criteria for strength or weakness
CTNA Personalized Feedback4. Feedback about strengths and weaknesses • Elicit: What skills did the client use to complete the test. • Provide: Therapist provides information on the cognitive skill test(s) examine. • Elicit: Therapist elicits reactions from the clients and applies results to their real life.
CTNA Personalized Feedback5. Summarize results and provide recommendations Summary and key question Ask permission to provide recommendations Make recommendations
Future Implications• Clinical: A high degree of utility for consultation, initiating therapy, working with “sticking points” in therapy, rehabilitation planning.• Teaching: Developing students into “human-science” practitioners, researchers, and teachers.• Research: Learn outcomes, factors influencing effectiveness, manual development.
Case #1: Multiple Concussions• Caucasian female, early 20’s;• Recent very mild hit to the head;• Increase in PCS: headache, mental fogginess, dizziness, nausea, balance problems, fatigue, drowsiness, sensitivity to light and noise, mood changes, feeling slowed down, difficulty concentrating, difficulty remembering, and visual problems• Hx of two prior concussions over 5 year span since her teen years.• Doctor told her she had a “catastrophic reaction.”
Case #1: Multiple Concussions• No significant medical issues• Extensive psychiatric hx:• Mental Status – MMSE = 30 – Clock drawing was normal – BDI = 22 – BAI = 26
COWA FAS = 55 82 Animal = 28 79Boston Naming 57/60 58TestTrailmaking B 41 sec., 1 error 87Stroop C/W Test Word = 100 45 Color = 81 58 Color Word = 52 79 Interference = 7 77WCST-64 Categories = 5 Average Total Errors = 6 94 Perseverative Errors = 5 47 Trials to first category = Average 10
Main themes in CTNA session• Discrepancy between how she felt vs objective evidence;• Negative thoughts and beliefs about herself and her capabilities;• Underlying perfectionism;• After session became more open to considering psychological/emotional vs brain injury as causing her distress.
• My thanks to all the participants, Dr. Fiona Bardenhagen and the Australian Psychological Society for inviting me to your conference.My contact information Tad T. Gorske, Ph.D Clinical Assistant Professor Division of Neuropsychology and Rehabilitation Psychology UPMC Mercy 1400 Locust Street, Suite G138 Pittsburgh, PA USA 15219 Gorskett@upmc. edu
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