Problem solving after brain injury with bancroft

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Survivors of brain injury often have deficits in their problem solving abilities. Yet good problem-solving skills are essential to achieving community integration and increased levels of independence. This webinar will introduce you to the rehabilitation of problem-solving abilities – a complex but essential set of skills. You will learn the cognitive tasks involved in problem-solving, and methods for remediating these abilities – both in therapy sessions and in the community.
INSTRUCTOR: Karen Lindgren, Ph.D., Neuropsychologist, Bancroft Brain Injury Rehabilitation
http://www.bancroft.org/brain-injury/for-professionals

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Problem solving after brain injury with bancroft

  1. 1. A Problem Solving Approach to Cognitive Rehabilitation Karen Lindgren, Ph.D. October 24, 2012© 2012 Bancroft | All rights reserved
  2. 2. Goals• What is problem solving?• How is problem solving relevant to community integration?• How do we teach problem solving skills? 2
  3. 3. Traumatic Brain Injury/AcquiredBrain InjuryTraumatic Brain Injury (TBI): cerebral damage that occurs after birth, and is not directly related to a developmental disorder or a progressive damaging of the brain. Traumatic brain injury refers to a specific form of acquired brain injury (ABI) that is the result of a sudden trauma.
  4. 4. Common Symptoms after TBIPhysical symptoms• Headaches• Fatigue• SleepCognitive symptoms• Memory Deficits• Word Finding Difficulty• Concentration• Processing speedEmotional symptoms• Irritability• Depression• Unstable or inconsistent moodBehavioral symptoms• Impulsiveness• Outbursts
  5. 5. Cognitive Symptoms are complex• Multiple pathways can result in similar symptom presentation• Lay-person language for cognitive constructs is limited• For example, what is meant by a “memory” problem? 5
  6. 6. Cognitive constructs are complex-Memory example“Memory” complaints can result from: environmental distractions/emotional interference poor attention/slowed processing expressive/receptive language poor encoding poor retrieval accelerated forgetting poor organization/comprehension of material (executive dysfunction)
  7. 7. EmotionsEmotions can become flat or amplified. Neurological rage Lack of inhibition Trouble analyzing social situations Difficulty with facial expression or tone of voice
  8. 8. Cognitive/Emotional/Physicalsymptoms interactMultiple or varying symptomsComplex symptoms combine to result in behaviors 8
  9. 9. Cognitive/Emotional/Physicalsymptoms interact: Overload• Common complaint in community settings• Brought on by large crowds, lots of noise, or information presented too quickly. Inability to process external environment (cognitive) Fatigue (physical) Rise in emotions (emotional)
  10. 10. TBI and Quality of LifeLife satisfaction appears to steadily decline after an individual experiences a brain injury.Injury severity has not been found to be significantly correlated with measures of life satisfaction.
  11. 11. TBI and Quality of LifeSeveral variables have been shown to correlate with life satisfaction in individuals who have suffered TBIs. Marital Status Problem Solving Executive Functioning
  12. 12. Executive FunctioningExecutive dysfunction has been repeatedly seen and documented in acquired brain injury, and is reported as one of the more common difficulties facing this population.
  13. 13. Executive Functioning• Executive functioning refers to the integration of several cognitive skills people require to adapt to novel situations and pursue their life goals, which includes planning, initiation, and regulation.• Complicated concept, involving multiple skills: • Integration of physical, emotional, and cognitive
  14. 14. Executive functioning andoutcome• Executive dysfunction has been implicated with poor social outcomes following a traumatic brain injury.• Research in rehabilitation populations has found that poor executive functioning is strongly correlated with poor work adjustment.
  15. 15. Executive functioning andoutcomeWhy?Components of executive functioning help us understand, adapt and respond to our environmentPromotes complex problem solving
  16. 16. Executive functioning: ProblemsolvingResearch has found a significant relationshipbetween problem-solving ability and various formsof psychological well-being. Specifically the effectiveness of one’s problem-solving ability has been found to moderate the relationship between stress and distress.
  17. 17. Executive functioning: ProblemSolvingPeople who have suffered TBIs face a large variety of significant problems in their day to day life.The cognitive skills they use to cope with problems may have been compromised by their injury. Poor emotional control may make it difficult for persons served to tolerate problems long enough to generate solutions. Deficits in executive functioning may make it difficult for persons served to generate alternative solutions.These symptoms increase the importance of social problem- solving skills for individuals who have suffered a TBI.
  18. 18. Rehabilitation of problemsolving skillTwo important components: Rehabilitate Skill (Problem-Solving Skill) Address social problem solving (problem solving orientation, problem solving style) 18
  19. 19. Rehabilitation of problemsolving skillTwo important components: Rehabilitate Skill (Problem-Solving Skill) Address social problem solving (problem solving orientation, problem solving style) 19
  20. 20. Cognitive rehabilitation ofexecutive dysfunction: problemsolvingResources:Edmund Haskins, Ph.D. (2012) ACRM Cognitive Rehabilitation Manual: Translating evidence based recommendations into practiceSohlberg & Tukstra (2011) Optimizing Cognitive RehabilitationNezu, Nezu & D’Zurilla (2007) Solving Life’s Problems 20
  21. 21. Cognitive rehabilitation ofexecutive dysfunction: problemsolvingBI-ISIG (Task force of ACRM) recommends:• Metacognitive strategy training as a Practice Standard for rehabilitation of executive functioning after TBI• Training in formal problem solving strategies during post-acute rehabilitation as a Practice GuidelineReferences: Cicerone, et al 2011, Haskins, et al, 2012 21
  22. 22. Who is appropriate for problemsolving training?• Evaluate awareness• Evaluate effectiveness of environmental support vs. internalized strategies 22
  23. 23. What Can We Do To Help FosterEffective Problem Solving?• Training in Problem OrientationProblem Solving Skill• Training in Problem Definition• Training in Planning/Generation of Alternatives• Training in Decision Making• Training in Solution Implementation• Solution Verification or Feedback
  24. 24. What Can We Do To Help FosterEffective Problem Solving?• Training in Problem OrientationProblem Solving Skill• Training in Problem Definition• Training in Planning/Generation of Alternatives• Training in Decision Making• Training in Solution Implementation• Solution Verification or Feedback
  25. 25. Problem Solving Skill• Well researched• Varies in the number of steps• Includes Key components: • Problem Definition (Awareness) • Planning/alternatives • Decision making • Implementing • Evaluating For example, the Goal-Plan-Do-Review method 25
  26. 26. Problem Solving SkillTeach the steps in a highly structured wayProvide maximum supportGoal for client to implement independently 26
  27. 27. Training in Problem Definition• Is there a problem? • What are the signs? Mood, feedback from others, change in circumstances• What is the problem? • Example: don’t have money
  28. 28. Training in Problem DefinitionExample: “Don’t have money”Skill deficit:misplace moneyimpulsive with spendingpoor budgetingInterpersonal challenge:dependent on familyVocational concern:need a job 28
  29. 29. Training in Problem DefinitionExample: “Don’t have money”Vocational concern:need a job: locate apply interview 29
  30. 30. Training in Problem DefinitionHelp To:Seek all available facts about a problemDescribe these facts in clear and objective termsSeparating facts from assumptionsIdentify obstacles or conflicts that make the situation a problemSet realistic goals
  31. 31. How?Externalize Problems Encourage the person served to work on problems outside of their own mind (take notes, work problems out on paper)Visualize Solutions Visualize both the implementation and results of solutions.Simplification Help persons served to help break large problems down into their smaller components
  32. 32. Slow-DownTeach techniques that will help individuals tolerate the emotional arousal associated with working with social problems Smiling Yawning Behavioral Stress Management Deep Breathing Guided Imagery Progressive Muscle Relaxation
  33. 33. Training in Problem DefinitionUse worksheet:Date _________________What is my goal? ____________________ 33
  34. 34. Training in Problem DefinitionUse worksheet:Date 10/24/12What is my goal? To obtain a part time job 10-15 hours per week 34
  35. 35. Training in Problem DefinitionUse worksheet:Date 10/24/12What is my goal? To reduce my spending by 25$ per week 35
  36. 36. Training in Problem DefinitionUse worksheet:Date 10/24/12What is my goal? To ask my sister to give me 25$ per week 36
  37. 37. Training in PlanningShould be taught to expand their perceived options and to defer judgment.
  38. 38. Training in Planning• What are my options?• What are my resources?• What are my barriers?Do I need to change my goal? 38
  39. 39. Training in Decision MakingMaximize positive consequences and minimizes negative consequences.
  40. 40. Training in Decision MakingWhich solution is best?• What is most important?• No solution is perfect• Pros and cons list • Consider outcomes, resource utilization, ease of implementation, effects of errors 40
  41. 41. Training in Decision Making working askingPros independent easy to try meet people focus on rehab functional/careerCons fatigue dependency costs associated mobility concerns less rehab focus 41
  42. 42. Training in Decision MakingUtilize a worksheetTo solve this problem, I will:___________________________________ 42
  43. 43. Training in Decision MakingUtilize a worksheetTo solve this problem, I will:Ask my sister to help me by giving me25$ per week 43
  44. 44. Training in PlanningHow will I reach my goal?Resources/barriers: Social, environmental,financial, cognitive, psychological• Plan details: Who, when, where, what• Anticipating barriers/problems: What are back- up plans? Is there a safety-net? 44
  45. 45. Training in PlanningEvaluation of each step• Resources/barriers: Social, environmental, financial, cognitive, psychological• Plan details: Who, when, where, what• Anticipating barriers/problems: What are back- up plans? Is there a safety-net? 45
  46. 46. Training in PlanningUse worksheetWhat is my plan? _______________What do I need? _______________What are the steps? 1. ________________________ 2. ________________________ 46
  47. 47. Training in PlanningUse worksheetWhat is my plan? Ask my sister for 25$ per weekWhat do I need? Budget, planner, bank statementWhat are the steps? 1. _ask to meet with sister (evening preferred) 2. present budget and problem with expenses exceeding income 47
  48. 48. Training in PlanningGo beyond the worksheetWhat are the steps? 1. ________________________At each step, identify resources, challenges, safety- netSpecify support to be givenMake a “larger” plan- how does this plan fit into the rehabilitation goal? 48
  49. 49. Training in PlanningGo beyond the worksheetWhat are the steps? 1. ask to meet with sister (evening preferred)identify resources, challenges, safety-net: plan a meal or snacks? Ask staff for support? Role play? Challenges: sister busy/preoccupiedSpecify support to be givenMake a “larger” plan- how does this plan fit into the rehabilitation goal? 49
  50. 50. Training in SolutionImplementation and Verification• Occurs at each step• Proceed as slowly as implementation will allow• Increase mindfulness of each step (e.g., what I am doing? How am I feeling?)• Seek feedback• Are changes needed?
  51. 51. Training in SolutionImplementation and VerificationExpanded concepts of did the plan “work”:• What worked?• What didn’t work?• How did I do? (Expand this concept)• Teaching opportunity for meta-cognition- track barriers to effective problem solving
  52. 52. Training in SolutionImplementation and VerificationWorksheet:How did I do? (utilize rating scale, not “all or nothing”)How did I feel?What did I do well?What would I change? (internal as well as external)
  53. 53. What Can We Do To Help FosterEffective Problem Solving?• Training in Problem OrientationProblem Solving Skill• Training in Problem Definition• Training in Planning/Generation of Alternatives• Training in Decision Making• Training in Solution Implementation• Solution Verification or Feedback
  54. 54. Walk Client through process• Implement consistently, every time• Use written work sheets• Use memorization of steps• Apply to new, real situations• Apply to therapeutic, constructed situations• Identify client strengths and challenges: meta- cognition 54
  55. 55. Implement, implement,implement• Virtually any situation is appropriate for problem solving skill development• Consider targeting one area at a time: • Medical • Vocational • Budgeting 55
  56. 56. Implement, implement,implement• Target in session first • Teach the steps • Apply to real situations with 1:1 support • Apply to modified situations with 1:1 support • Support out of session with maximum support 56
  57. 57. Implement, implement,implement• In community situations, fade support, not focus• Gradual fade • Preset for steps, potential problems • Encourage review each step • Develop strategies to address related cognitive challenges (e.g., internal/external strategies for memory) 57
  58. 58. For UsAs professionals, we to should attempt to utilizemany of the same problem solving strategies whenfaced with challenging problems from personsserved.
  59. 59. Our MissionTo ensure that every person is given opportunities for lifelong learningand fulfillment.We do this by altering perceptions, and by supporting those withintellectual and developmental challenges and acquired brain injuries inachieving their life goals as valued and respected members of our world. Our VisionBy 2014 our distinct ability to deliver high quality individualized services inmodern living, learning and working environments will exceed stakeholderexpectations and secure Bancroft as the region’s elite provider of services topeople with intellectual and developmental disabilities and brain injuries. Our Core ValuesResponsible Empathetic Supportive Passionate Empowered Committed Trustworthy RESPECT59

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