Neuropsychotherapy for patients with brain damage: is it really ...

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Neuropsychotherapy for patients with brain damage: is it really ...

  1. 1. Emotional Rehabilitation: Learning about and Living with the Emotions of a New Brain
  2. 2. Outline  Introduction  The Whole Person after TBI  The Content Of Emotional Rehabilitation  The Techniques Of Emotional Rehabilitation  The Social Context of Emotional Rehabilitation
  3. 3. 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?
  4. 4. 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.)
  5. 5. 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.
  6. 6. What Challenges Does Emotional Rehabilitation Address?  Organic changes in emotional regulation  Executive dysfunctions  Adjustment to brain dysfunction  Social adjustment to disability
  7. 7. 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
  8. 8. Who does Emotional Rehabilitation? Skills needed to do effective Emotional Rehabilitation:  Therapy skills—warmth, empathy, openness, reliability, etc.  Teaching skills  Knowledge of:  Emotional Rehabilitation  Brain illness behavioral and emotional changes  Rehabilitation  Community resources
  9. 9. 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
  10. 10. 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)
  11. 11. The Whole Person after TBI (didactic model) Pre-Illness Personality Reactions to: Injury Illness Organic Changes to Personality, Emotions
  12. 12. The Whole Person after TBI Pre-disability Personality  Full range of personalities and psychopathologies  Factors predisposing to brain injury/illness are overrepresented:  Substance abuse  Risk taking  Medical non-adherence
  13. 13. The Whole Person after TBI Reactions to injury/illness: Grief Denial Depression Anxiety Posttraumatic Stress Disorder Frustration Anger Personal Reformation
  14. 14. The Whole Person after TBI Reactions to Disability: Grief Denial Depression Anxiety PerplexityLezak, 1978 Frustration Anger Embarrassment
  15. 15. The Whole Person after TBI Organic Emotional Changes: Function Increased Decreased Emotional Communication Reflex crying, laughing Automatic cursing Monotone voice Masked face Emotional Reactivity Labile emotions Impulsive anger Catastrophic reactions Indifference
  16. 16. The Whole Person after TBI Organic Emotional Changes:  Organically induced major psychiatric disorders  Depression  Mania  Psychosis  Obsessive-compulsive disorder
  17. 17. Executive Dysfunctions: Behavior Regulation Dimension 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
  18. 18. Executive Dysfunctions: Behavioral Drive Dimension Undercontrolled Underdriven, deficient Abstraction Vague Concrete Activation Impulsive, disinhibited Passive, lack of initiation Emotional control Labile Flat affect, abulia Activity maintenance Perseverative, intense Impersistent
  19. 19. The Content of Emotional Rehabilitation Fundamental Principles:  The Continuum of Responsibility  Emotional Rehabilitation  Self-Awareness  The New Self
  20. 20. The Content of Emotional Rehabilitation The Continuum of Responsibility Acute ConditionCaregiver’s share Share of the person with brain disability onset time
  21. 21. 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
  22. 22. The Content of Emotional Rehabilitation Emotional RehabilitationAccessible metaphor Demystify process Reduce guilt and blame Define roles Skill-learning model
  23. 23. Emotional rehabilitation helps bridge the gap between:  Behavior management and psychotherapy  Psychotherapy and cognitive rehabilitation  The cognitive and the emotional sides of executive functions
  24. 24. 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
  25. 25. The Content of Emotional Rehabilitation Improving Self-Awareness Use 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
  26. 26. The Content of Emotional Rehabilitation 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)
  27. 27. The Content of Emotional Rehabilitation Improving Self-Awareness Supportive confrontation Avoid struggle Take perspective of person with brain disability Work with who they trust
  28. 28. The Content of Emotional Rehabilitation Improving Self-Awareness Feedback Tools  Mirrors  Photos  Audio tapes  Videotapes  Work samples  Writing samples  Arts and crafts products
  29. 29. The Content of Emotional Rehabilitation 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”
  30. 30. The Content of Emotional Rehabilitation The New Self  Not necessarily better or worse, just different  Discover who the new self is  Rethink abilities  Rethink goals  Rethink relationships
  31. 31. The Techniques of Emotional Rehabilitation Cuing technologies: Uses Emotional control  Procedures and routines  Stressful events  Reminders  Behavior Flash Cards  Explanations to others  Incidental functions
  32. 32. The Techniques of Emotional Rehabilitation 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
  33. 33. The Techniques of Emotional Rehabilitation 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
  34. 34. The Techniques of Emotional Rehabilitation Cuing technologies: Stressful Event Example PUBLIC SPEAKING Use written outline Practice alone and with friend Have friend in audience Short relaxation before going on "I can do it! I know my stuff. They are friendly and want to hear me." Find friend in audience Speak to back of room Slowly and clearly Smile!
  35. 35. The Techniques of Emotional Rehabilitation Cuing technologies: behavior Flash Cards Stop and Think
  36. 36. The Techniques of Emotional Rehabilitation 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
  37. 37. The Techniques of Emotional Rehabilitation Cuing technologies Tips on Use  Individualize  Brief, concrete, action words, imperatives  First person or trusted authority figure  Colors  Multiple copies  Retain a copy on file
  38. 38. The Techniques of Emotional Rehabilitation 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
  39. 39. The Techniques of Emotional Rehabilitation 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
  40. 40. The Techniques of Emotional Rehabilitation Choosing Cuing Technologies  Appropriate  Appealing  Affordable  Accessible  Acceptable
  41. 41. The Techniques of Emotional Rehabilitation Self-Introduction Letter Purposes  Improve self-awareness  Commitment to rehabilitation  Future planning  Social rehearsal  Consolidate the experience  Consolidate self-image  Communicate needs
  42. 42. The Techniques of Emotional Rehabilitation Self-Introduction Letter 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)?
  43. 43. The Techniques of Emotional Rehabilitation Self-Introduction Letter Contents 2 Current challenges:  Physical challenges.  Thinking difficulties.  Emotional changes.  Life changes (work, family, hobbies, recreation, social life, spiritual life)
  44. 44. The Techniques of Emotional Rehabilitation Self-Introduction Letter 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.
  45. 45. The Techniques of Emotional Rehabilitation Self-Introduction Letter 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
  46. 46. 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
  47. 47. Working with the Social Network Family and Friends Techniques 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)
  48. 48. Working with the Social Network 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
  49. 49. Working with the Social Network Community Resources Client centered Be creative Enlist natural helpers Make home visits Go into the community
  50. 50. 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.

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