Neuropsychological Assessment and Rehabilitation: Person Centered Principles and Methods Presented at The Brain Injury Association of Pennsylvania Annual Conference on June 23, 2009. Presenters Mick Sittig, Ph.D. Rehabilitation Psychologist, ReMed of Pittsburgh Tad T. Gorske, Ph.D. Assistant Professor, Physical Medicine and Rehabilitation, University of Pittsburgh
The presentation of brain facts about specific damages is meaningless to patients unless they can begin to understand how the changes in their brains are lived out in everyday experiences and situations (Varella, 1991 as stated in McInerney and Walker, 2002)
Comprehensive Rehabilitation Physical Therapy Occupational Therapy Speech Therapy Medical Management Psychological/Neuropsychological Emotional/Psychiatric Management as appropriate Family Support Case Management
The Role of Neuropsychological Assessment: Historical Perspective Period of Neuropsychological Localization Period of Neurocognitive Evaluation Current Period??
Technician / Artist Neuropsychologists are challenged to expand their roles from a purely technical endeavor to a more holistic perspective. Cognitive theorist, functional anatomist
Technician / Artist Neuropsychologists are challenged to expand their roles from a purely technical endeavor to a more holistic perspective. Cognitive theorist, functional anatomist, psychotherapist, family therapist, emotional adjustment, viewing the person from a holistic perspective.
Holistic Neuropsychological Principles 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; Be willing to refer if appropriate.
Collaborative Therapeutic Neuropsychological Assessment (Gorske and Smith, 2009) A collaborative method of interviewing and providing feedback from neuropsychological assessment; Enlists the patient/family as an active collaborator; Empowers patients/families to be caretakers of their own cognitive health.
Collaborative Therapeutic Neuropsychological Assessment (Gorske and Smith) 1. Comprehensive Neuropsychological Assessment 2. Referral question, records review, behavioral observations, clinical interview, quantitative and qualitative assessment.
Collaborative Therapeutic Neuropsychological Assessment (Gorske and Smith) The Information Gathering / Medical Model Clinician knows best; Fragile patients; Knowledge is dangerous Collaborative Model Clinician is an expert in neuropsychology; the patient/family is the expert on themselves Patients are resilient Knowledge is power
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 Motivational Interviewing. The CTNA adopts and adapts the MI Personalized Feedback Report
CTNA Feedback Session Two primary components 1. Provide information from neuropsychological test results 2. Interact with clients in a collaborative manner consistent with TA and MI.
CTNA Personalized Feedback 1. Introduction Provide feedback report; explain session purpose; facilitate collaboration and empathic understanding 2. Develop Questions Develop 2 or 3 well defined questions the client hopes the results can answer 3. Explain how strengths and weaknesses are determined Percentiles, determine criteria for strength or weakness
CTNA Personalized Feedback 4. 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 Feedback 5. Summarize results and provide recommendations Summary and key question Ask permission to provide recommendations Make recommendations
Pilot Study Results Adherence Rates p =.042, cohen's d =.78 (.02-1.55) NAFI (n = 14); TAU (n = 14) 100 90 80 70 60 50 40 30 20 10 0 NAFI 71% TAU 48% S1
Pilot Study Results: D&A Use NAFI = 6; TAU = 5 30 Day Alcohol Use 10 9 8 7 6 5 4 3 7.13 5.46 3.4 NAFI TAU 2 1 0 0 Baseline 30 Day
Pilot Study Results: D&A Use 30 Day Drug Use 7 6 5 4 3 2 4.73 3.43 NAFI TAU 1 0 Baseline 30 Day 0.66 0.40
Pilot Study Results: Depression NAFI = 7; TAU = 5 30 Day Depression HRSD-25 25 20 22.2 21.2 20.21 15 10 11.4 NAFI TAU 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.
Neuropsychological Treatment Education and Referral Psychotherapy Family Interventions Support Groups Behavior Management Cognitive Rehabilitation
Cognitive Recovery and Rehabilitation Recovery. A multi-stage process. Continues for years. Differs for each person.
Long-term impact on functioning. Depends on severity of the injury, functions affected, personal meaning of the injury, resources available, and areas not affected by the injury. Cognition. Attention Concentration Memory Speed of Processing
Long-term impact on functioning. Depends on severity of the injury, functions affected, personal meaning of the injury, resources available, and areas not affected by the injury. Confusion Perseveration Impulsiveness Language Processing Executive functions
The Cognitive Grid Strategy Development and Implementation. Best Learning Mode. To-Do s
Other Physical Changes Physical paralysis/spasticity Chronic pain Sensory/Perceptual. Seizures. Control of bowel and bladder
Other Physical Changes Sleep disorders Loss of stamina Appetite changes Regulation of body temperature Menstrual difficulties
Social-Emotional. Dependent behaviors Emotional lability Lack of motivation Irritability
Social-Emotional. Aggression Depression Disinhibition Denial/lack of awareness Spread-of-Effect. Deviance Disavowal. Stigma Management. Sick-Role Retention.
Recovery vs. Improvement Permanence of Change. Physical recovery Reeducation of the individual Environmental modifications
Generalization Issue(s) Disposition Residence Social milieu Productivity
Resource Utilization Resource Book Support Groups Referrals Follow-ups
The Presenters Dr. Mick Sittig is a rehabilitation psychologist at ReMed in Pittsburgh, Pennsylvania. Re Med offers specialized programs in outpatient, inpatient, and residential brain injury rehabilitation. See their website at www.remed.com Dr. Tad Gorske is a clinical neuropsychologist in the outpatient neuropsychology clinic in the Division of Neuropsychology and Rehabilitation Psychology at the Department of Physical Medicine and Rehabilitation in the University of Pittsburgh School of Medicine. See their website at www.rehabmedicine.pitt.edu