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14 14 NEUROLOGIC MUSIC THERAPY AND COGNITIVE TRAINING* James C. Gardiner, Ph.D. ABPN Neuropsychologist INTRODUCTION: COGNITIVE TRAINING AND THE TRANSFORMATIONAL DESIGN MODEL (TDM) Page Transformational Design Model.. Foundation Principles of Cognitive Training. ATTENTION Principles of Attention Training NMT Exercises: Attention MEMORY Principles of Memory Training NMT Exercises: Memory

15 15 EXECUTIVE FUNCTION Principles of Executive Function Training NMT Exercises: Executive Function PSYCHOSOCIAL Principles of Psychosocial Training.. NMT Exercises: Psychosocial.. REFERENCES.....

16 16 APPLICATION OF THE TRANSFORMATIONAL DESIGN MODEL TO COGNITIVE REHABILITATION Area of Cognitive Functioning: 1. Assessment 2. Treatment Goal 3. Treatment Strategy 4. NMT Approach 5. Transfer 6. Evaluation ATTENTION Digit Span Forward Improve: Focus Attention Process Training Attention & Perception Training: Homework Repeat #1 Digit Span Backward Selective Attention Musical Sensory Orientation Exercises Trail Making Test Sustained Attention Training (MSOT) Letter-Number Sequencing Alternating Attention Musical Neglect Training (MNT) Auditory Perception Training (APT) Musical Attention Control Training (MACT) MEMORY Wechsler Memory Scale Improve: Recall Repetition Memory Training: Homework Repeat #1 Recognition Association Musical Mnemonics Training (MMT) Exercises Compensation Compensation Associative Mood and Memory Training (AMMT) EXECUTIVE Wisconsin Card Sort Test Improve: Goal setting Goal setting Executive Functions Training: Homework Repeat #1

17 17 FUNCTION Delis-Kaplan Executive Planning Planning Musical Executive Function Exercises Function System Organization Organization Skill Training Training (MEFT) Mazes; Trail Making Test Execution Initiation TinkerToy Test Adjustment Problem Solving PSYCHOSOCIAL Clinical Interview Improve: Acceptance Contribution To Life Psychosocial Behavior Training Homework Repeat #1 Minnesota Multiphasic Emotions Psychotherapy Music Psychotherapy and Exercises Personality Inventory2 Stress management Relaxation Counseling (MPC) Symptom Checklist 90-R Communication Communication Training Brief Symptom Inven.-18 Social Skills Social Skill Training Thematic Apperception Test Relationships Relationship Training

18 18 Foundation Principles of Cognitive Rehabilitation Research-Based. Cognitive rehabilitation needs to be founded on sound neuropsychological principles and based on outcome research (Cicerone et al., 2000; Gordon et al., 2006; Prigitano, 1999). Effectiveness and Limitations. Several reviews of cognitive rehabilitation research (Cicerone et al., 2000; Eslinger, et al., 2002; Gordon et al., 2006; Gordon & Hibbard, 1992; Rimmele & Hester, 1987; Wilson, 2009; and) concluded that rehabilitation has a measurable impact on a person's cognitive abilities, psychological adjustment and ability to function independently. Plasticity. It is important to recognize that the brain has the ability to reorganize after an injury in order to accomplish tasks by using new neural strategies (Goodwin, 1989; Loring, 1999). Assessment. Successful cognitive rehabilitation depends on formal assessment of all cognitive factors, including attention, spatial, memory, language, executive functioning, and psychosocial adjustment (Eslinger, et al., 2002; Lezak, 1995; Prigitano, 1999; Raskin & Mateer, 2000). Immediacy. Cognitive treatment is best when delivered as soon after the neurological injury as possible. Early intervention helps prevent dysfunctional patterns (e.g., lowered self-esteem, isolation, anger, depression, and a downward trend in cognitive abilities) from forming (Kay, 1993). Shaken Sense of Self. The first issue that needs attention in neurological rehabilitation is the person s disrupted identity. Self-awareness. Rehabilitation needs to deal with disorders of self-awareness (Prigitano, 1999; Bennett, et al, 1998). Deals With the Whole Person. Kay (1993) has introduced the idea that physical, psychological, and cognitive functions influence each other to produce changes in each area, as well as changes in the functional abilities of the person.

19 19 Treat Emotional Factors. A key principle in neurological rehabilitation, according to Prigitano (1999), is to be aware of and provide support for emotional reactions in the clients, their families, and in rehabilitation staff members. Begin With Basics. Gordon and Hibbard (1992) emphasize that treatment must be ordered in layers, beginning with the most basic skills such as attention and concentration, then progressing to more complex skills such as memory, verbal, language, visuospatial, executive function, and social behavior. Process-specific. Good cognitive rehabilitation efforts will be process-specific or directed at individual areas of cognitive functioning such as attention, memory, executive function, etc. (Bennett et al., 1998). Compensation. Wilson (2000) emphasizes that compensation (finding a new strategy for accomplishing mental tasks) is many times necessary when recovery from a neurological injury is not complete. Education. Educating persons about the nature of and the effects of neurological injuries is an important part of cognitive rehabilitation (Kay, 1993; Prigitano, 1999; Mateer, 2000). Family Involvement. One of the key factors in the success of cognitive rehabilitation is having a strong support system. It is vital to include family members and significant others in cognitive rehabilitation. Generalization. Outcome studies with cognitive rehabilitation have shown that the effects of training in the clinic or laboratory do not necessarily carry over into the real world. Evaluation. The treatment efficacy of each cognitive rehabilitation effort needs to be carefully evaluated, not only to discover the effectiveness of the treatment offered, but to add to the scientific knowledge of the field of cognitive rehabilitation (Prigitano, 1999).

20 20 Principles of Attention Training Neuroscience Model of Attention Functioning: Posner (2004) and colleagues summarize attention s systems in the brain as: Select and Focus: ability to choose an event, focus on it, and tune out everything else. Sustain: skill in concentrating as long as necessary to complete the task at hand. Switch: ability to move attention back and for the among two or more events. Rehabilitation Model of Attention Functions. Mateer (2000) and Sohlberg & Mateer (1989) provide the most widely accepted clinical model of attention. They divide attention into the following categories: Focused, which is the ability to respond discretely to specific stimuli (Mateer, 2000, p. 79). Sustained, which is the ability to maintain a consistent behavioral response during continuous and repetitive activity (Mateer, 2000, p. 79). Selective, the skill to maintain a behavioral or cognitive set in the face of competing stimuli (Mateer, 2000, p. 79). Alternating, the ability to shift focus of attention and move between tasks (Mateer, p. 79). Divided, the ability to respond simultaneously to multiple tasks (Mateer, 2000, p. 79). Multitasking is Accomplished Through Rapid Alternating Attention, Not Divided Attention. Rehabilitation Potential. While the attention system is particularly vulnerable to injury, this system also appears to be one that can be modified with targeted intervention. (Mateer, 2000, p. 86; Cicerone et al., 2000; Rimele & Hester, 1987; Sohlberg & Mateer, 1987; Ben-Yishay, Piasetsky, & Rattok, 1987). Foundation skill. Attention is a foundation skill that is necessary for good memory, executive function, communication, and executive control (Bennett, et al., 1998). Timing. Specific attention rehabilitation is recommended during post-acute rehabilitation, but not in acute care (Cicerone et al., 2000). Therapist Involvement. Cognitive therapists need to be involved with attention rehabilitation, monitoring progress, giving feedback, and teaching strategies. Stand-alone use of computers or other machines are not recommended for rehabilitating attention skills. (Cicerone et al., 2000; Weber, 1990).

21 21 NEUROLOGIC MUSIC THERAPY (NMT) COGNITIVE REHABILITATION (CR) EXERCISE TITLE: SELECTIVE ATTENTION NMT Technique Used: Music Attention Control Training (MACT) Cognitive Area and Skill Targeted: Attention, selective Goal For Daily Living: Each participant will be able to successfully select a stimulus from the environment, stay focused on that stimulus, respond appropriately, and exclude input from competing stimuli. Clientele Description: Anyone who desires and needs to improve attention skills. Session Type: Group (2-15 persons) Equipment Needed: A variety of percussion instruments Step-By-Step Procedures: 1. The group is seated in a circle. 2. Rhythm instruments are distributed to the group. 3. Two persons are chosen from the group---a leader and a heckler. 4. Using drums or other rhythm instruments, the group leader plays a simple, sustained rhythm. 5. The group members are invited to join with the rhythm. 6. The heckler, who is given a loud, distinct instrument, attempts to disrupt the rhythm by playing a rhythm that is contrary to that of the leader. 7. The leader ends the rhythm. 8. Other group members are given the opportunity to be the leader and the heckler. 9. The group discusses the experience, from three angles being a group member, being a heckler, and being a leader. Adaptation #1: 1. Select two leaders and divide the group into two subgroups by numbering off etc. 2. Instruct all the #1s to follow leader #1 and all the #2s to follow leader #2. 3. Have each of the two leaders play a different rhythm for the group members to follow. 4. After the rhythms have finished, have the group discuss the experience.

22 22 NEUROLOGIC MUSIC THERAPY (NMT) COGNITIVE REHABILITATION (CR) EXERCISE TITLE: ALTERNATING ATTENTION NMT Technique Used: Musical Attention Control Training (MACT) Cognitive Area and Skill Targeted: Attention, alternating Goal For Daily Living: Each participant will be able to alternate focusing his or her attention back and forth between two stimuli. Clientele Description: Anyone who desires and needs to improve attention skills. Session Type: Group (2-15 persons) Equipment Needed: A variety of percussion instruments Step-By-Step Procedures: 1. Arrange the group in a horse shoe shape and pass out rhythm instruments. 2. Have two leaders sitting facing the group. 3. Leader #1 will teach rhythm pattern #1. 4. Leader #2 will teach rhythm pattern #2. 5. Leader #1 will start the group and lead it through a few bars of the rhythm and stop. Without missing a beat, Leader #2 will lead the group with his or her rhythm, then stop after a few bars. Leader #1 will then begin again. They will switch back and forth until both leaders stop. Plan For Generalizing This Skill Into Everyday Life: The following homework assignment will be given to help the participants increase their everyday skill in alternating attention:

23 Play two songs at the same time. Listen to one for a few seconds, while you tune out the other one. Then switch your attention to the other song while you tune out the first one. Keep changing back and forth between the two songs. 23

24 24 THE HERE-AND-NOW SONG (A Chant, accompanied by rhythm instruments) I m Livin In The NOW, The HERE-AND-NOW! (Repeat) I Say To Myself, HERE S WHAT I M DOING! (Repeat) And Then I Say, THAT S WHAT I DID! (Repeat) The Past is Gone,

25 25 LET IT GO! (Repeat) I m Livin In The NOW, The HERE-AND-NOW! (Repeat)

26 26 Principles of Memory Rehabilitation Neuroscience Model of Memory Systems: Schacter, Wagner, & Buckner (2000): Working memory holds information for a few seconds until it is not needed. Semantic memory recalls information about the world. Episodic memory recalls personal experiences and events. Perceptual Representation System analyzes and compares new information. Procedural memory learns and recalls motor and cognitive skills. Functional Model of Memory Functioning. Memory theorists have included the following elements in their models of memory functioning: Sensory memory saves information in near-perfect form for a very short time, to hold information for selection and processing by the working memory system. (Parente & Anderson- Parente, 1989, p. 56). Working memory gives the ability to hold and manipulate information (Mateer, Sohlberg, & Cromean, 1987; Parente & Anderson-Parente, 1989; Schacter, Wagner, & Buckner, 2000; Baddeley, 2002). Semantic memory provides access to a wide range of organized information, including facts, concepts, and vocabulary (Schacter, Wagner, & Buckner, 2000, p. 632; Mateer, Sohlberg, & Comeam, 1987). Episodic memory stores and retrieves information about personal experiences (Schacter, Wagner, & Buckner, 2000). Procedural memory gives the ability to learning motor and mental skills (Schacter, Wagner, & Buckner, 2000). Prospective memory intitiates a specific action at a future designated time (Sohlberg et al., 1992, p.129). Conditions for Memory Training. Before commencing, memory rehabilitation must consider the nature of the patient s memory loss, other cognitive abilities, physical difficulties, social status, emotional state, and readiness for treatment (Tate, 1997; Laaksonen, 1994). Foundations For Memory Training. Sensory memory training begins with basic sensory skills in order to provide a foundation for improved memory (Parente & Anderson-Parente, 1989). Attention training is used to provide a foundation for better memory skills (Sohlberg & Mateer, 1989; Parente & Anderson- Parente, 1989; Kapur & Graham, 2002). Severe memory impairment. For persons with severe memory impairment, cognitive rehabilitation will not likely restore memory functioning (Cicerone et al, 2000; Rimmele & Hester, Persons with

27 27 severe memory deficits can benefit from environmental restructuring and compensation strategies (Wilson, 2000). Emotions. Memory and emotional functioning are closely linked in the brain (Markowitsch, 2000).

28 28 Compensation Strategies. Memory compensation strategies have proven effective. (Cicerone et al., 2000). Prosthetic memory aids are often used to compensate for memory loss. They include checklists, notebooks, electronic devices, recorders, computers, etc. (Parente & Anderson-Parente, 1989). Notebooks have been shown to be the most effective strategy in compensating for memory loss (Zencius, Wesolowski, & Burke, 1990 Domain-specific training with memory remediation replicates the demands of the real-world setting where the skills will later be used (Parente & Anderson-Parente, 1989). A-R-R-O-W B-A-S-E-S can be used to summarize and recall the major principles of memory functioning: Act on it---pay attention and be active. Repeat it over and over. Rhythm---make it bounce! Order the information so that it is meaningful to you. Write it down if necessary. Break up the practice sessions; rest, then practice more. Associate it with something familiar to you. Sense the information--see, hear, touch, taste, or smell it. Emotions---develop strong feelings about it. Sleep---use the power of deep sleep to enhance memory

29 29 A-R-R-O-W B-A-S-E-S M E M O R Y S O N G To the tune of Twinkle, Twinkle, Little Star Music by Wolfgang Amadeus Mozart Lyrics by James Gardiner, Beth Donelan, Sandy Machiels, and the Community Transitions Staff Act, Repeat, Repeat, Repeat, Rhythm, Order, Write It Neat. Break It Up, Associate, Sense It And Emotiate, Sleep On It And You ll Recall, A-R-R-O-W B-A-S-E-S Does It All!

30 30 NEUROLOGIC MUSIC THERAPY (NMT) COGNITIVE REHABILITATION (CR) EXERCISE TITLE: LEARNING NAMES NMT Technique Used: Musical Mnemonics Training (MMT) Cognitive Area(s) and Skill(s) Targeted: Memory: Ability to recall names of persons they have met Goal For Daily Living: Group members will be able to recall the names of group members after the session. Their ability to recall the names of new persons they meet after the session will also be increased. Clientele Description: Anyone who desires and needs to improve memory skills. Session Type: Group (2-15 persons) Equipment Needed: A variety of percussion instruments Step-By-Step Procedures: 1. Pass out rhythm instruments. 2. Warm up the group with rhythm practice. 3. Demonstrate how rhythms can be applied to names. Example: George Washington, John F. Kennedy, and names of admired persons supplied by group members. 4. Leader demonstrates how her/his own name can be put to rhythm by starting rhythm, saying name repeatedly to rhythm, then stopping the group. 5. Each group member (a) makes up a rhythm to their name, (b) leads the group in chanting their name to the rhythm, and (c) stops the group with a signal when they are done. 6. When learning the names of others in the group, each group member (a) looks at the person whose name is being learned, (b) carefully studies the features of the person s face, (c) follows the rhythm on her or his own musical instrument, and (d) chants the name of the person.

31 31 Variations: 1. Have each person form an association device for their name, then have them share it with the group musically with action included. 2. Help each person form a melody for their name and use the melody to teach their name to the group through singing. Plan For Generalizing This Skill Into Everyday Life: 1. Introduce a new person to the group. Help each group member work on a strategy for recalling the new person s name. 2. Ask each client to meet three new persons before the next group session, learn each person s name, and report back to the group.

32 32 NEUROLOGIC MUSIC THERAPY (NMT) COGNITIVE REHABILITATION (CR) EXERCISE TITLE: NAME THAT TUNE, HOTSEAT VERSION NMT Technique Used: Musical Mnemonics Training (MMT) Cognitive Area(s) and Skill(s) Targeted: Attention: Ability to focus and sustain attention. Memory: Ability to recall auditory and verbal information. Executive Function: Ability to make decisions and initiate behavior. Psychosocial: Ability to appropriately communicate with other persons. Goal For Daily Living: Participants will be able to listen attentively to important information and appropriately initiate actions regarding the information in a social setting. Clientele Description: Anyone who desires and needs to improve cognitive and interpersonal skills. Session Type: Group (2-15 persons) Equipment Needed: An electronic music player with speakers and a wide variety of recorded songs. Step-By-Step Procedures: 1. Group members take turns sitting in the Hot Seat, where they listen to one song and are asked to recall the title, artist and (if appropriate) composer of the song. 2. Three points are awarded for each correct answer (title, artist, composer). 3. If the person does not know any of the answers, they can ask the audience, and choose what they think is the best answer from the audience. If it is correct, they are awarded two points. 4. If the audience member is not correct, the contestant is then given two possible answers, and if they guess the right one, they are awarded one point. 5. After all group members have been given an equal number of opportunities in the Hot Seat, the points are tallied. The person with the most points wins.

33 33 Variations: 1. Present the group with categories of music such as big band, country/western, rock-n-roll, classical, blues, gospel, jazz, Latin, etc. When each person comes to the Hot Seat, they try to identify a song played from the category they choose. 2. If the title to the song is sung by the artist, the group leader (with forewarning to the group) points to the music speakers at the time the title is sung, in order to give group members a cue to concentrate on the music to identify the title.

34 34 NEUROLOGIC MUSIC THERAPY (NMT) COGNITIVE REHABILITATION (CR) EXERCISE TITLE: NAME THAT TUNE, TEAM VERSION NMT Technique Used: Musical Mnemonics Training (MMT) Cognitive Area(s) and Skill(s) Targeted: Attention: Ability to focus and sustain attention. Memory: Ability to recall auditory and verbal information. Executive Function: Ability to make decisions inhibit, and initiate behavior. Psychosocial: Ability to appropriately communicate with other persons. Goal For Daily Living: Participants will be able to listen attentively to important information and appropriately initiate actions regarding the information in a social setting. Clientele Description: Anyone who desires and needs to improve cognitive and interpersonal skills. Session Type: Group (2-15 persons) Equipment Needed: An electronic music player with speakers and a wide variety of recorded songs. Step-By-Step Procedures: 1. Ask for volunteers for team captains. Have one for every 3-4 persons in the group. 2. Have captains choose up sides until everyone is chosen. 3. Assemble groups so that all members in each group can face each other and hear the music. 4. Play a song for all groups to hear. 5. When someone knows one or more of three possible pieces of information about the song (title, artist, and composer), they tell the team captain, who raises his or her hand. The first team captain to raise a hand gets called on for an answer. 6. The team gets one point for each correct answer (title, artist, or composer). If the answer is incorrect, the remaining teams compete for the chance to identify the song correctly.

35 7. If anyone calls out an answer without going through the team captain, that team is disqualified for that song. 8. An alarm will be set to go off when the allotted time for the session is up. The team with the most points when the alarm goes off wins. 35

36 36 Principles of executive function rehabilitation Definition. Executive function refers to a person s ability to formulate goals; to initiate behavior; to anticipate the consequences of actions; to plan and organize behavior according to spatial, temporal, topical, or logical sequences; and to monitor and adapt behavior to fit a particular task or context. (Cicerone et al., 2000, p. 1605). Anatomical Correlates. It is generally accepted that executive function is controlled primarily from the frontal lobes of the brain. Process Assessment. A detailed process analysis of the subject s problem-solving difficulty is necessary, in order to propose a plan of action to improve executive functioning. (Goldstein & Levin, 1987). Outcome Effectiveness. The best studies conducted in the area of executive functioning rehabilitation provide strong evidence that executive control skills improve as a result of formal problem-solving strategy training (Cicerone et al., 2000). Improvement with Music Therapy: A recent study by Thaut, et al. (2009) demonstrated that one session of Neurologic Music Therapy improved ability to switch back and forth between two mental concepts. Summary Strategy for Improving Executive Conrol: 1. Increase the client s awareness of the deficit. 2. Help the client observe the deficit in action. 3. Teach the person to prevent the behavior from happening.

37 37 NEUROLOGIC MUSIC THERAPY COGNITIVE REHABILITATION EXERCISE TITLE: GOAL SETTING SUPPORT NMT Technique Used: Musical Executive Function Training (MEFT) Cognitive Area and Skill Targeted: Executive Function: Goal Setting Goal For Daily Living: Each participant will be able to think ahead, set and reach a goal of her or his choice by receiving social support. Clientele Description: Anyone who desires to improve goal setting. Session Type: Group (2-15 persons) Equipment Needed: A variety of rhythm instruments in containers ready for easy distribution to the group. Step-By-Step Procedures: 1. In a group setting, assist the members in setting specific, behavioral goals of their choosing. 2. Distribute drums or other percussion instruments to the group members. 3. Assist each group member in developing a rhythm that allow them to chant her or his goal to the group. 4. Help the group join in the rhythm, chanting the goal with the person. 5. Process the thoughts of the group members after the goal chanting exercise.

38 38 NEUROLOGIC MUSIC THERAPY (NMT) COGNITIVE REHABILITATION (CR) EXERCISE TITLE: GETTING ORGANIZED NMT Technique Used: Musical Executive Function Training (MEFT) Cognitive Area and Skill Targeted: Executive Function: Planning and Organization Goal For Daily Living: Participants will be able to encounter a disorganized situation, decide how to organize it, put the various components in order, use the objects for a meaningful purpose, and restore the objects to a meaningful order. Clientele Description: Anyone who desires and needs to improve executive function skills. Session Type: Group (2-15 persons) Equipment Needed: A variety of rhythm instruments, a basket to hold the instruments, and a table surface for organizing the instruments. Step-By-Step Procedures: 1. Place a plastic tub full of a variety of percussion instruments on a table. 2. Assign one to three (depending on the size of the group) group members to organize the instruments on the table. 3. Have them each choose an instrument, then together decide on and practice a rhythm. 4. Next, they choose an instrument for each group member, distribute the instruments, and teach the rhythm to the group. 5. After the group learns the rhythm, the two group members gather the instruments and place them back in order on the table. 6. Place the instruments back into the tub. 7. One to three more group members are chosen, and 2 through 6 are repeated.

39 39 Plan For Generalizing This Skill Into Everyday Life: 1. The group will discuss how the skills learned in the session can be used in everyday life. 2. The group members will be given a series of homework assignments to strengthen their organization skills (see following).

40 40 ORGNIZATION SONG (To the tune Rock Around The Clock ) Plan it out, Do it right, Check on it, and Clean it up. Plan it out, Do it right, Check on it, and Clean it up. We are (I am) very organized tonight (today)! (Repeat)

41 41 NEUROLOGIC MUSIC THERAPY (NMT) COGNITIVE REHABILITATION (CR) EXERCISE TITLE: PROBLEM-SOLVING & ADJUSTMENT NMT Technique(s) Used: Musical Executive Function Training (MEFT); Problem-Solving Cognitive Area(s) and Skill(s) Targeted: Executive Function: Adjustment Goal For Daily Living: Participants will be able to effectively adjust when events do not go according to the original plan. Clientele Description: Anyone who desires and needs to improve attention/memory/cognitive/interpersonal skills. Session Type: Group (2-15 persons) Equipment Needed: A variety of rhythm instruments in containers ready for easy distribution to the group. Step-By-Step Procedures: 1. Hand out rhythm instruments to the group. 2. Explain the purpose and goal of the exercise. 3. Choose a group member to lead the group in a rhythm of their choice. 4. Choose another group member to be the nonconformist, who will play a different rhythm and try to disrupt the group. 5. Start the group process, initiated by the leader. 6. The disruptor begins a different rhythm. 7. The leader s job is to get the nonconformist to produce the rhythm being presented to the group. 8. Repeat 3-7 until every group member has had the opportunity to perform. Variations: Plan For Generalizing This Skill Into Everyday Life: Participants will be given a homework assignment designed to increase their problem-solving skills in everyday life.

42 42 Principles of psychosocial rehabilitation Model. Kay (1993) proposes that rehabilitation professionals educate patients and their families about symptoms, assist in managing a gradual process of improvement, involve the family or significant other in treatment, validate the subjective experience of the patient, help reestablish the shaken sense of self (p. 83), and treat the emotional problems at the same time as the cognitive difficulties. Group treatment is recommended for dealing with many psychosocial difficulties, including lack of social skills, communication problems, and emotional problems (Guzik, 1987). Social Skill Training. Giles and Clark-Wilson (1993) provide a comprehensive outline of methods for improving social skills after neurological injury. They advocate breaking behaviors into small components for attention in therapy, using behavioral techniques, using role playing, giving feedback from the group and leaders, and generalization of the behaviors into real-life settings. Nonverbal Communication Training. Giles and Clark-Wilson (1993) stress the importance of remediating non-verbal communication in the following areas: facial expression, gaze, gesture, posture and orientation, interpersonal space, proximity, physical contact, language-free elements of speech, and appearance. Conversational skills. In teaching social interaction abilities, Giles and Clark-Wilson (1993) advocate helping clients build skills in: social routines, attracting attention, initiating conversations, maintaining dialogue, listening, questioning, responding, and closing conversations. Dealing With Emotions. Depression is common with neurological injury and can be treated with medications, psychotherapy, cognitive therapy, behavioral interventions, grief management, group psychotherapy, and family interventions (Prigitano, 1999; Raskin & Stein, 2000). Other common emotional difficulties associated with neurological injury include anxiety, posttraumatic stress (Hovland & Raskin, 2000), irritability, and anger (Hovland & Mateer, 2000).Anger and frustration can be managed through environmental controls, cognitive behavior therapy, teaching coping strategies, and selfmonitoring. Family Intervention. Prigitano (1999) also considers it vital to work with family members who are involved in neurological rehabilitation.

43 43 NEUROLOGIC MUSIC THERAPY (NMT) COGNITIVE REHABILITATION (CR) EXERCISE TITLE: HOW THE BRAIN FUNCTIONS NMT Technique(s) Used: Musical Executive Function Training (MEFT) Cognitive Area(s) and Skill(s) Targeted: Attention: Ability to focus, alternate, and divide attention Memory: Ability to recall information that has recently been acquired. Executive Function: Initiation, reasoning, inhibition. Psychosocial: Emotional adjustment, communication skills, social support. Goal For Daily Living: 1. Each participant will appreciate the complexity and miraculous nature of the brain. 2. Each participant will understand how various sections of the brain work together to accomplish tasks. 3. Clients will increase their confidence in their mental abilities. Clientele Description: Anyone who desires and needs to improve cognitive functioning and interpersonal skills. Session Type: Group (6 or more persons)

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