Rehabilitation has been defined as a process of assessment, goal setting, intervention, and reassessment. This iterative rehabilitative process is consistent with the World Health Organization’s framework for measuring health and disability, which defines disablement as the manifestation of bidirectional influences between health conditions and contextual factors. Embedded within this model is the implication that health is a complex interaction between three components: body structures and functions, activities and participation, and environmental and personal factors (i.e., contextual factors). As it were, psychologists with specialty training in rehabilitation are well equipped to provide assessment and intervention within all three health-related components. Depending on the goal of the individual, a psychologist working in rehabilitation can provide direct cognitive remediation (i.e., body structure and function), can increase social participation through the application of behavioral management principles (i.e., activities and participation), and can provide psychotherapeutic services to family members (i.e., contextual factors). The critical role that psychologists play at each stage of the rehabilitation process is reflected in the standards of the Commission on Accreditation of Rehabilitation Facilities, which necessitate the availability of psychological services across many rehabilitation contexts. The role of psychologists in the management of specific rehabilitation populations, such as military veterans or athletes with a history of traumatic brain injury (TBI), has also been formally established.
This chapter is broadly divided into two sections that represent the most common roles of psychologists in rehabilitation settings: assessment and intervention. The section on assessment is organized in such a way as to mirror the changing role of the psychologist across acute care, inpatient, and postacute rehabilitation settings, which is largely dictated by the evolving needs of clients, caregivers, and the rehabilitation team. Psychologists have advanced training in the assessment and treatment of cognitive, emotional, and behavioral problems. As such, both sections focus largely on the psychologist’s role in managing these aspects of health.
Psychological Assessment in Rehabilitation
With regard to assessment, one of the core competencies of a psychologist working in rehabilitation is the capability to select and interpret psychometric tests and measures. As such, psychologists are well prepared to explicate the complex relation between health conditions and contextual factors associated with disablement. Psychological assessment in rehabilitation serves many specific purposes including identification of cognitive, behavioral, and psychological strengths and weaknesses; quantification of adjustment to disability by the individual and family; information about treatment planning; prognostication; clinical auditing; and research. Whenever possible, rehabilitation psychologists use measures of impairment, activities, and participation with standardized administration procedures, known psychometric properties, and normative data sets. When administered by a trained professional, such measures can be applied in a straightforward manner to highlight areas of impairment, activity limitations, and participation restrictions. Psychologists can combine such data with their knowledge of medical and psychological rehabilitation principles to identify the greatest environmental or personal barrier to successful community reintegration, determine the extent to which an individual has benefited from care, evaluate the effectiveness of a rehabilitation program, and determine which administrative elements or clinical processes might best account for treatment gains.
Measurement of individualized and sometimes abstract (e.g., health-related satisfaction with life) treatment goals in rehabilitation requires a critical review of existing scales to select instruments that are most appropriate to assess the progress or success of individuals, specific treatments, or entire programs. In some cases, the development of new measures or scales may be necessary to adequately quantify progress toward a particularly unique set of goals. Psychologists’ understanding of scale development allows them to critically evaluate the psychometric quality of performance-based (e.g., cognitive) and report-based (e.g., self-, caregiver-, or clinician-rated) measures. Psychologists are well suited to weigh various test characteristics, such as reliability, validity, floor and ceiling effects, and sensitivity to change, when selecting measures for various clinical, research, or administrative purposes in rehabilitation. Generalizability is also an important consideration in test selection, especially when an individual’s performance will be used to inform real-world decisions, such as a return to driving. In addition to the high psychometric standards of many of the assessment tools used by psychologists, most of these measures allow for normative comparison so that treatment team members can better appreciate the magnitude of strengths and weaknesses identified by the psychologists. The use of such standardized measures is also thought to enhance communication among team members.
Assessment in the Acute Care Setting
In the acute care setting, the focus is typically on sustaining life through the management of emergency medical issues. Although physical, or in the case of brain injury, cognitive impairments at this stage of recovery may preclude the individual from completing most standardized psychological assessment tools, psychologists in this setting can assist in collecting information to formulate important prognostications regarding likely eventual outcome. Indeed, injury characteristics, such as duration of loss of consciousness, Glasgow Coma Scale score, and duration of posttraumatic amnesia (PTA), and premorbid demographic information, such as preinjury levels of education, socioeconomic status, and intellectual functioning, are often some of the only empirically supported data points available for use in predicting long-term outcomes of short-term inpatients. However, even small amounts of additional data obtained from simple bedside measures administered during the short-term recovery period can be of use, and psychologists and neuropsychologists can assist in obtaining this information. The ability to freely recall three words after a 24-hour delay, for example, is predictive of numerous long-term (i.e., 4 years postinjury) outcome variables, including return to productivity, quality of life, and psychosocial distress. Additionally, Dawson et al. found in their sample that of those persons with moderate or severe brain injuries whose 24-hour three word free recall ability had not returned in fewer than 3 weeks postinjury, none had returned to work at the 4-year follow-up point. Furthermore, routine monitoring for the resolution PTA during the short-term recovery period is also important because such resolution is often considered a prerequisite to inclusion in neuropsychological research and assessment.
Beyond formal cognitive testing, psychologists can assist in working with family members, friends, or caregivers to provide information and support services. Also, given their formal training in research methods, psychologists can also participate in study design and implementation involving short-term inpatients, which is particularly important given the unique opportunity and continued need for prospective rather than retrospective research paradigms in this setting. Even if formal academic output (e.g., scientific journal publications, conference presentations) is not the end goal of these research-related activities, the obtained information can be useful in tracking patient progress and outcome, treatment efficacy, and various provider-related variables at the individual and clinic- or department-wide levels.
Assessment in the Inpatient Rehabilitation Setting
As individuals with significant physical and neurologic injuries progress from the short-term to inpatient rehabilitation settings, the role of psychologists in collecting information about the individual’s emotional, behavioral, and cognitive functioning begins to expand considerably. At this stage, psychologists can use a range of methods to collect meaningful information about individuals including interviews, behavioral observation, review of historical records, and standardized testing. All of these methods are brought to bear in the important task of assessing behavioral and emotional functioning. Careful assessment of preinjury and current psychological functioning is necessary to identify facilitators and barriers to recovery that can be addressed through individual and family interventions. As has been previously noted, success in adapting to health conditions requires that the individual can cope with stress and adapt to new demands. As discussed later, the role of the psychologist in evaluating emotional functioning in particular continues to expand in the postacute setting as individuals gain a greater appreciation for activity limitations and participation restrictions and the resulting changes in roles that may arise from their injury.
As with the acute care setting, neuropsychologists in particular typically focus their inpatient rehabilitation evaluations on individuals with known or suspected neurologic insult. Also as mentioned earlier, previous neuropsychological research has often excluded individuals from testing until they are able to demonstrate resolution of PTA, such as by obtaining scores of 76 or higher on the Galveston Orientation and Administration Test across two consecutive administrations or exhibiting the ability to freely recall three words after a 24-hour delay. Still, neuropsychologists can provide useful information in patients still experiencing PTA, which is particularly important in light of decreasing inpatient stay lengths and the concomitant increasing potential for discharge before PTA resolution. For example, the ability to simply complete a neuropsychological testing battery at 1 month after injury is associated with Disability Rating Scale and Glasgow Outcome Scale scores at 6 months after injury and was predictive of employment status at 1- and 2-year follow-up points. In addition, although individuals with PTA may perform more poorly on most neuropsychological measures, research indicates that these individuals are nonetheless often able to participate in some testing, particularly if the administered measures are relatively simple and assess a range of cognitive abilities. Although there exists some debate as to the optimal postinjury time point(s) at which to conduct a full neuropsychological evaluation, the predictive value and treatment planning utility of these assessments is significant, as is described later.
Perhaps one of the greatest strengths of neuropsychological data, owing to its psychometrically based and normatively derived status, is the ability to track statistical and clinically significant change over time. Through initiation of serial assessments of the same individual, such as at resolution of PTA and then at the 3- and 6-month and 1- and 2-year postinjury marks, the patient is able to serve as his or her own baseline. Then, by gathering a few test-related pieces of information (e.g., the pretest and posttest group means and standard deviations, the pretest and posttest score correlation coefficient), the psychologist is able to determine what a standardized measure of the size of any observed changes is, whether the changes are likely to be attributable to chance or practice effects, and in what proportion of the population as a whole or a select illness-specific subpopulation such a change is likely to occur. Indeed, brief measures of orientation and cognition (e.g., O-Log, Cog-Log ) have been developed and validated specifically for serial bedside assessment, with these instruments correlating both with later performance on formal neuropsychological assessment and Mini Mental State Examination scores. Such definitive information about change can then be used to track an individual’s recovery, to monitor for any unexpected declines in functioning or cognitive performance, and to evaluate the potential efficacy of initiated treatments. This definitive information about recovery and treatment effects is critical for the individuals, their family, treatment providers, researchers, and third-party payers.
In addition to tracking the progress of the individual over time, early neuropsychological assessment is useful in predicting long-term patient outcomes above and beyond demographic- and injury-related information. Sherer et al. reviewed a number of studies evaluating the outcome prediction potential of neuropsychological testing, finding that there was strong support for the use of early neuropsychological testing in particular (i.e., at resolution of PTA or by 1-month after injury) to predict employment status at 1 or more years after injury. Green et al. came to a somewhat similar conclusion, stating that performance on untimed neuropsychological measures (i.e., memory and executive functioning) but not timed measures at 5 months after injury was predictive of return to productivity. Particularly promising is the finding that lengthy (e.g., full-day or multiday) assessments are not always necessary because even brief neuropsychological batteries are predictive of various outcome variables, such as select scores on the Functional Independence Measure, Disability Rating Scale, and Glasgow Outcome Scale-Extended.
Along with the distinctive predictive characteristics of global neuropsychological performance regarding cognitive and functional outcome, neuropsychological assessment can also uniquely identify and quantify current cognitive functioning and potential impairment in a variety of specific domains. Depending on the type and location of neurologic insult/injury, cognitive deficits may be global or circumscribed, and neuropsychological assessment can assist in delineating the affected cognitive areas. In addition, objective cognitive testing can reveal subtle deficits in domains that may not have been expected on the basis of injury characteristics or that may not be evident without such formal assessment. In the inpatient setting, assessment of expressive and receptive language functions, basic attention, and verbal memory as a result of the potential influence of these cognitive areas on individuals’ participation in rehabilitative therapies tends to be of particular importance. Evaluation of these and other cognitive domains can also assist in determining which types of services may be most beneficial or appropriate. Occasionally, neuropsychologists may need to alter their choice of assessment instruments or adapt the administration procedures to account for the individuals’ physical and cognitive limitations (e.g., mobility difficulties, hemiparesis, visual disturbances). Such alterations can affect the interpretability of results obtained by means of these standardized measures, and, as such, the expertise of the neuropsychologist in test construction and design plays a key role in these situations in allowing them to glean what and how information gathered in nontraditional testing situations should be interpreted (see Brooks et al. for a review of neuropsychological test interpretation and related concepts). Ultimately, the testing data, combined with observational information obtained from treatment sessions with other providers, may then be useful in identifying specific areas of expected difficulty and potential supports that might most effectively remediate these challenges, alleviate disability, and allow for a smoother and more complete reintegration into the family and community on discharge.
Beyond the assessment of performance in individual cognitive domains, psychologists are often also versed in the use of instruments designed specifically to inform questions regarding capacity (e.g., medical decision-making capacity, financial capacity). Comprehensive measures, such as the Independent Living Scales, allow clinicians to compare the performances of individual patients to normative sample data stratified by level of supervision needed in various instrumental activities of daily living to determine how much day-to-day assistance may be required in these areas. Neuropsychologists have also developed domain-specific tests, such as the Financial Capacity Instrument, that allow for in-depth assessment of specific capacities and that have subsequently resulted in covalidation of rating scales that can be administered and interpreted by other health care providers (e.g., the Semi-Structured Clinical Interview for Financial Capacity ). In these ways, psychologists, particularly on educating themselves on the capacity-related laws in their state of practice, can use their skills in psychometric instrument selection and interpretation and clinical interviewing to aid physicians in making capacity-related decisions. The American Psychological Association, in a joint effort with the American Bar Association, has also released material to aid psychologists in this endeavor on a national level. As patients near the end of their inpatient stay, psychologists can combine assessment data, interview information, and capacity-related concepts to assist physiatrists and other treatment team members in determining the appropriate discharge destination level of supervision.
Assessment in the Postacute Rehabilitation Setting
As with the acute and inpatient care settings, psychological assessment in the postacute rehabilitation setting is dictated by the purpose of the evaluation and the condition of the individual. Although still important, assessment of the presence and severity of impairments starts to give way to the evaluation of the individual’s activity and participation and their overall health-related quality of life as they prepare to transition back to the home and community. The focus of this stage of recovery is typically on maximizing community reintegration through the identification of personal and environmental assets that can be used to overcome residual activity limitations and participation restrictions. Individuals at this stage of recovery are often living in the community and participating in outpatient care. In the case of brain injury, this outpatient care is ideally delivered through an interdisciplinary, milieu-based approach. These consumers are expected to become increasingly involved in managing their instrumental activities of daily living. Mirroring the increasingly complex demands placed on persons with injury who are transitioning back to their homes and communities, there are vast numbers of standardized psychological assessment tools available to assess the emotional, behavioral, and cognitive functioning of these higher-functioning persons. Psychological assessment tools for outpatients typically provide a much greater depth of information than brief, broad measurement tools more appropriate for assessment of inpatients who may have very significant impairments in their body functions or structures that preclude them from participating in lengthy assessments. The length of these assessment tools makes them more sensitive to subtle changes that might otherwise go unnoticed on briefer measures, which then makes them ideal for tracking changes in functioning in the postacute setting.
As individuals begin to spend less time in the treatment setting and more time living in the community, the evaluation of the quality of their social and civic life takes on greater importance. The Craig Handicap Assessment and Reporting Technique (CHART) was an attempt to create a measure of community participation that conformed to an earlier version of the International Classification of Functioning, Disability, and Health (ICF). More recently, the Participation Assessment with Recombined Tools-Objective was developed by combining items from the CHART and two other commonly used participation measures. Although these instruments provide important information about the frequency of participation in various community-based activities, broader measures of community participation and health-related quality of life incorporating the perspective of the patient are now considered to be an essential component of assessment. Patient reported outcomes are subjective in nature and inherently allow for individuals to consider their personal and cultural values when rating their overall health-related quality of life. The inclusion of the perspective of the person with injury reflects patient-centered care and may help to focus assessment and treatment on the individual’s desired outcomes.
Careful assessment of potential environmental facilitators and inhibitors is essential to optimize successful reintegration into the community. Despite the long-standing appreciation of the influence of environment on disability and participation in the field of rehabilitation, psychologists and other rehabilitation professionals have made relatively little headway in operationalizing environmental factors important to rehabilitation and developing psychometrically sound measures in this area. Recently, the ICF defined five categories of environment including products and technology; natural environment and human-made changes to environment; support and relationships; attitudes; and services, systems, and policies. Although much work remains in quantifying environment and understanding exactly how these variables influence outcome, psychologists possess a sound knowledge base regarding the influence of environmental factors on health status and tools to assist in the measurement of environment factors, such as family structure and support.
Emotional adjustment to changes in body structures and functions, activity limitations, and participation restrictions after injury can present a major challenge in inpatient and postacute rehabilitation settings. In the case of brain injury, emotional and behavioral problems may be a direct result of the injury. Although it is not entirely clear whether major psychiatric disorders are generally a response to disability following injury or whether psychiatric disorders lead to greater functional limitations following injury, the rate of psychiatric comorbidities is known to be high in rehabilitation settings. This is especially true in rehabilitation populations where the injury itself, or the context within which it occurs, is associated with psychological trauma, as is often the case in military service members.
Owing to the overlap of symptoms secondary to brain injury and psychiatric disorders, psychologists and other qualified rehabilitation specialists must carefully consider differential diagnoses when emotional and behavioral problems are evident in the rehabilitation setting. For example, depression must be distinguished from symptoms possibly related to the brain injury (e.g., apathy, irritability, pseudobulbar affect), and from other psychiatric conditions, such as adjustment disorder, normal sadness, and grief, over changes in physical or social functioning (see Dafer et al. for a review). To accomplish this, the psychologist takes into account multiple sources of information to determine if the person meets criteria for a clinical disorder, including the clinical presentation, information obtained from the clinical interview, responses to questionnaires, knowledge of brain-behavior relationships, review of medical and psychosocial history, and cultural background. Psychologists also have appropriate training and tools to assess for the presence of personality traits and psychiatric factors that may influence recovery in the inpatient and postacute settings. Recently, psychologists have also started focusing on positive psychological factors that are associated with adaptive adjustment and coping in persons recovering from physical illness. Psychologists can contribute to the rehabilitation process by assessing and monitoring negative and positive psychological factors that can affect outcome and life satisfaction in those persons participating in rehabilitation.
Assessment or reassessment of cognitive functioning also remains important in the postacute rehabilitation setting. In the inpatient care context, one of the primary applications of neuropsychological testing is the prediction of various long-term outcome-related variables such as return to work in individuals with acquired neurologic insult/injury. Conversely, as individuals transition to outpatient rehabilitation services care, somewhat less emphasis is traditionally placed on predicting outcome, in no small part because initial predictions have probably already occurred. One key exception to this shift, however, would be individuals who did not undergo neuropsychological assessment while admitted to an inpatient unit, whether as a result of lack of service availability, scheduling difficulties, incomplete resolution of PTA, or any of a host of other reasons. In these instances, neuropsychological testing retains its utility to inform long-term prognosis estimates. In addition, there are some other specific instances when predictive utility is still retained in the postacute, outpatient environment. For example, neuropsychological testing performance at 1 year after injury predicts or is associated with cognitive and functional change at up to 5 years after injury. Outside of such situations, greater emphasis is often placed on the following areas, many of which are identified by neuropsychologists as key assessment goals: monitoring progress and, relatedly, evaluating treatment response and efficacy; informing treatment plans; aiding in the assessment of capacity to return to various life activities (e.g., independent living and decision-making, work, school); providing updated feedback to individuals and family members/caregivers; and detecting novel complications or unexpected declines in functioning.
As individuals proceed through outpatient treatment, regular reassessment of their neuropsychological status is a useful tool for measuring cognitive recovery and comparing it with expected recovery trajectories. The 3- and 6-month postinjury marks in particular can be important periods for formal cognitive evaluation as a result of the relatively rapid early spontaneous recovery that may occur and represent assessment points specifically recommended by neuropsychologists following moderate-to-severe TBI. Such testing allows for updated information to be provided to treatment team members, family/caregivers, and the individuals themselves regarding cognitive strengths and persisting impairments. In addition, if recovery does not go as expected (e.g., if regression is observed), neuropsychological assessment allows for delineation of the nature of the decline and can thereby aid in identifying its potential cause. Neuropsychological reassessment, then, allows for continued monitoring of cognitive status and ongoing refinement of prognosis, which can be particularly important given that data can indicate that persisting impairments may change in both severity and type over the extended recovery period, such as from global dysfunction to disruption of specific cognitive domains.
In a related manner, by virtue of its objective and norm-referenced nature, neuropsychological reassessment also allows for evaluation of treatment efficacy through single-case design methods, such as A-B-A-B, or multiple baseline designs (see Levine and Downey-Lamb for a review). Treatments not resulting in the anticipated improvements can then be identified, and possible patient-related factors contributing to these situations (e.g., previously unidentified cognitive or emotional difficulties) can be targeted for intervention. Neuropsychological reassessment also allows for adjustments in treatment goals on the basis of the individual’s true recovery relative to that which may have initially been predicted. Even in the case of mild TBI, neuropsychological testing can be beneficial to treatment planning: research tentatively suggests that results from a screening of executive functioning are predictive of patient-reported cognitive functioning and ability after participation in an outpatient treatment program. Because early intervention by means of provision of education can be useful in decreasing postconcussive symptoms in this population, identification of individuals at risk for greater perceived long-term cognitive dysfunction may be useful in detecting patients who require more in-depth early intervention efforts.
With interventions often targeting increased independence and participation in meaningful activities as goals, neuropsychological assessment can specifically assist in making progress toward these end points. As discussed earlier, acute neuropsychological data have been shown to provide additional predictive ability in returning to work above and beyond patient demographics and injury characteristics. Neuropsychological assessment has also been shown to differentiate between individuals who have returned to work and those who have not, and in that way potentially identifies those cognitive abilities that are highly important as individuals pursue reemployment. In addition, eligibility for work-related programs such as vocational rehabilitation may require in-depth documentation of cognitive status, and receipt of academic accommodations for those individuals wishing to return to school or to receive technical training may also necessitate such formal assessment. In this way, outpatient neuropsychological evaluations directly assist in helping individuals to qualify for such services and can inform these programs as to particular supports that may be necessary (e.g., extra time to complete tasks and access to reduced-distraction environments for individuals exhibiting attention and processing speed impairments). Similarly, for individuals initially determined to be incapable of living independently or managing medical and financial decisions, neuropsychological reassessment allows for continued monitoring of status in these respects. As cognitive abilities improve, testing can aid in determining when it is appropriate and safe for individuals to assume increased responsibilities in these life domains. Finally, although there are more directly ecologically valid means of assessing or predicting an individual’s driving ability, neuropsychological assessment has some utility in this regard and, at the least, can provide additional information to accompany a formal driving evaluation.
Another unique aspect of outpatient evaluations is that as emphasis shifts from critical to rehabilitative care, there exists increased potential for involvement in litigation. In such instances, rehabilitation professionals can be asked to fill dual roles, such as care provider and fact or expert witness; it is thus of paramount importance in the outpatient setting that physicians, psychologists, and other providers clarify their role as being of clinical or litigation-related service delivery. Patient involvement in litigation presents numerous challenges to care providers, such as a heightened risk for and vulnerability to feigning or exaggerating cognitive and physiological impairments. Indeed, estimates of the proportion of individuals seen for assessment in medicolegal or disability claims-related contexts suspected of exhibiting disingenuous symptom reports or suboptimal effort range from approximately 30% to upward of 70%, which is substantially higher than that observed in general medical contexts. As such, neuropsychologists have developed numerous measures of effort and engagement that are supported by significant amounts of research indicating their accuracy and appropriateness for use in various populations, and thereby resulting in multiple professional organizations recommending their use in all neuropsychological evaluations. Thus, neuropsychologists can fill a unique role by providing objectively informed statements regarding the validity or invalidity of testing data.
Although psychologists play an essential role in selecting and administering appropriate measures of cognition, emotion, and behavior based on characteristics of the individual and the purpose of the assessment, their most important role may be the translation of information obtained by these measures into actionable plans to address specific concerns regarding community reintegration and health-related quality of life. Malec describes a process for collaborating with individuals to create measurable, achievable goals that take into account the values of the client. The process essentially involves working with the individual to identify goals and the intermediate steps necessary to attain each goal. Given their expertise in promoting positive change in behavior, psychologists are well positioned to assist individuals in progressing toward their goals, especially where the modification of contextual factors of the person (e.g., coping style) and environment (e.g., supports and relationships) are essential to the attainment of the individual’s goals.
Psychological Management of Cognitive, Emotional, and Behavioral Problems
The role of psychologists in the rehabilitation setting goes beyond simply assessing and reporting results. One of the greatest values of psychologists in a rehabilitation setting is their expertise with interventions for cognitive, emotional, and behavioral problems. The following sections describe the evidence base with respect to treatment of cognitive, emotional, and behavioral problems in the rehabilitation setting. When available, existing evidence-based recommendations for specific interventions are provided. Intensity of services varies by type of rehabilitation setting, and this is addressed for each of the interventions discussed. The goal of this section is not to enable the reader to carry out interventions but to be an educated consumer of psychological and neuropsychological intervention services to make appropriate referral of patients.
Interventions for Cognitive Problems
Impaired Awareness
Impaired awareness can be one of the most challenging consequences of brain injury for rehabilitation staff, as well as for family members and other caregivers. Impaired awareness refers to the lack of ability to recognize deficits resulting from injury to the brain. In contrast to denial, which is a psychological defense, impaired awareness is a neurologically based problem, resulting directly from damage to the brain; however, denial and impaired awareness can coexist because persons with brain injury can have awareness of some deficits and not others or may be partially aware of specific deficits. Persons with impaired awareness may seem to have no understanding of limitations, which may affect their motivation to participate in therapies and to follow through with medical recommendations. Despite this, their impaired awareness cannot be interpreted as lack of motivation because this implies an intentional component that is not present. Conflicts with staff and family members often occur when they interpret the individual’s behavior as representing poor motivation or denial, when it is in fact as a result of impaired awareness. Research has shown that persons with TBI are more likely to have impaired awareness for cognitive and emotional problems as opposed to physical problems.
Impaired awareness is not an all-or-nothing phenomenon. Persons can have more or less awareness of deficits. Crosson et al. described a hierarchy of awareness levels that has implications for the level of intervention needed. Intellectual awareness refers to the basic understanding that abilities are reduced relative to preinjury and that this reduction in abilities may affect everyday functional activities. Emergent awareness refers to the ability to recognize a problem in real time—when it is happening. For example, persons with brain injury may be able to tell you that they have a problem getting off the topic when speaking (intellectual awareness) but may have difficulty recognizing when they are actually doing it (emergent awareness). Anticipatory awareness refers to the ability to predict that a particular problem may occur in specific situations and settings. For example, persons with intact anticipatory awareness would predict that they are likely to get off the topic when speaking with others at a party and could think through and plan strategies to help reduce the problem. Emergent and anticipatory awareness are task dependent and context dependent, meaning that they can be affected by demands of tasks and the environment.
Because impaired awareness can represent a safety risk, the most basic level of neuropsychological intervention, particularly during inpatient rehabilitation, is to assess the impact on everyday safety and to modify the environment to reduce the risk. For more specific interventions in impaired awareness, neuropsychological treatments should be tailored to the individual needs and level of awareness exhibited by the person with injury. Fleming and Ownsworth recommend selecting performance tasks that will demonstrate the problem to the person with injury and providing an opportunity for feedback and education. Persons with impaired awareness can still benefit from experience and from procedural learning, and thus they may be asked to perform tasks a certain way or to use a specific compensatory strategy, even though they may not understand the reason for this. Therapeutic alliance plays an important role in their willingness to do so, and staff should not underestimate the importance of developing good rapport in the rehabilitation environment. Having the person with injury predict his or her own performance on tasks and then chart the predictions against the actual performance is also a powerful therapeutic tool. The neuropsychologist can then assist the person in developing strategies to improve performance. This performance-based focus can eliminate the need for arguing with the person about whether he or she has a “memory problem” or some other “problem.”
In the outpatient setting, impairments in emergent or anticipatory awareness are most typical. Holistic, milieu-oriented therapy environments, including both group and individual therapies, are a way to address impaired awareness. In group therapies, persons with impaired awareness can learn by observing the behavior of others and providing feedback that could then be used to monitor their own behavior. Because intervention in impaired awareness is an underlying component of nearly all rehabilitation therapies, conducting randomized controlled trials to demonstrate the effectiveness of awareness interventions is difficult. In their systematic review of cognitive rehabilitation effectiveness, Cicerone et al. recommended the use of metacognitive strategies to improve executive functioning, including awareness as a practice standard for persons with TBI and stroke. Metacognition refers to the ability to be aware of one’s own cognitive functions, and metacognitive strategies are those that improve one’s ability to self-monitor and alter cognitive functions. Awareness has been shown to improve following training that combines therapist feedback with experiential learning in which clients predict, monitor, and evaluate their own performance. Similar training has been shown to improve cognitive aspects of instrumental activities of daily living performance, as well as ability to self-regulate behavior. Neuropsychologists working to improve awareness in persons with brain injury will typically use these empirically based metacognitive strategies.
Attention
Impaired attention is an almost universal consequence of brain injury, regardless of type and severity. Attention is a multidimensional concept, and different aspects of attention can be affected after injury. When intervention is determined, viewing attention as a hierarchical construct is helpful. The most basic level of attention is focused attention, which is the ability to respond discretely to specific sensory stimuli. For example, the ability to observe a bird against a backdrop of trees would be focused attention. Sustained attention is the ability to maintain a consistent behavioral response during continuous, repetitive activity. Examples of everyday sustained attention are maintaining attention during a therapy exercise or playing a board game. A higher level of attention is selective attention, which is the ability to maintain cognitive or behavioral set in the face of competing or distracting stimuli. An example is being able to attend to a conversation at a party while other conversations can be heard in the background. Alternating attention refers to the ability to shift focus between tasks that have different cognitive or behavioral requirements. This ability is otherwise known as cognitive flexibility. An example is being able to shift between cooking a meal and helping a child with homework. The highest level on the attention hierarchy is divided attention. This refers to the ability to respond spontaneously to multiple task demands. Examples are driving while carrying on a phone conversation or taking care of a baby while working on the computer. A person who has impairments at one of the lower levels of attention will necessarily have impairment at all of the higher levels as well.
In the rehabilitation setting, a person with impaired focused attention will be unable to attend to therapies, regardless of circumstances. A patient with intact focused attention and impaired sustained attention may be able to attend to therapy for very short intervals but be unable to maintain attention for an entire 30-minute therapy session. The individual with intact sustained attention and impaired selective attention will be able to sustain attention for the duration of a therapy session, provided that there are minimal distractions. If the individual is working in a noisy or crowded environment, attention is likely to be diverted. Impairments in alternating or divided attention are usually the most difficult to detect in an everyday setting. These impairments can be subtle and only manifest in cognitively challenging contexts. The structured rehabilitation setting will often not create the necessary challenges for these deficits to emerge, yet persons with brain injury may notice these problems when they return to their homes and communities and attempt to resume preinjury activities.
In their systematic reviews of the research on interventions to improve attention, Cicerone et al. concluded that there is insufficient evidence to recommend direct attention training during the acute recovery period, including inpatient rehabilitation. Although direct attention training may not be effective during inpatient rehabilitation, environmental modifications can help to decrease the impact of impaired attention on functional activities. For persons with impaired sustained attention, therapy sessions should be broken down into shorter sessions or a break should be allowed partway through a standard session. When returning to a task following a break, it is usually necessary to remind the individual of what was being worked on and to repeat instructions. If a person has impairment in selective attention, distractibility can be partly reduced by conducting therapy or providing medical/nursing education in a quiet room that is apart from the distractions of the inpatient unit or therapy gym. It is important to note that persons with impaired selective attention are distracted by internal thoughts and feelings as well as by external stimuli. Therefore, even in a quiet environment, they may be distracted by bodily sensations or competing thoughts. In these cases, redirection to the task at hand, with repetition of instructions as needed, is usually the best action. If impairments in alternating or divided attention become apparent in the rehabilitation environment, they can be managed by having patients work on only one task at a time. It is best to keep the materials for other tasks out of their working space. It is also helpful to ensure that procedures and education sessions are not occurring in parallel. For example, if the physician is providing education, it is best not to have a nurse or resident checking their blood pressure or dressing a wound while the physician is talking.
More direct forms of attention intervention are most successful in the postacute, outpatient setting. On the basis of the existing research evidence, Cicerone et al. recommend direct attention training in the postacute period as a practice standard. Attention Process Training is a form of attention training in which clients complete a series of hierarchical computer tasks to improve attention. The levels of task complexity parallel the levels of attention (e.g., focused, sustained). The person with injury must master tasks at one level before moving on to the next level. This type of hierarchical attention training has demonstrated effectiveness for improving performance on cognitive tasks of attention in persons with TBI and stroke. The computer tasks that have shown effectiveness have involved systematic, hierarchical training. There is no evidence for the effectiveness of nonhierarchical computer training in improving attention. Therefore simply playing computer games or working on simple computer tasks may have no direct benefit on attention.
It should also be noted that although attention training improves performance on cognitive tasks of attention, generalization to real-world activities may be limited. Cicerone et al. recommend supplementing direct attention training with training in compensatory strategies (such as use of checklists or memory notebooks) and metacognitive strategies (such as self-monitoring, self-verbalization, and problem-solving) to improve generalization to real-world activities. Direct therapist contact is necessary for all of these types of training. As stated by Cicerone et al., reliance on computer tasks without the assistance or guidance of a therapist is not recommended for improving attention following brain injury.
Memory
Memory problems are among the most frequent complaints of persons with brain injury. Memory problems in everyday life may be caused by deficits in attention and processing speed, as well as directly by memory impairment. The most typical manifestations of memory problems in everyday life include difficulty keeping track of belongings, forgetting what needs to be done (e.g., appointments, chores, questions to ask a doctor), forgetting how to get to places, forgetting what people have told them or what they have learned, and forgetting how to do something (i.e., procedures). Assessing self-report of everyday memory functioning is an important supplement to formal neuropsychological assessment. Persons who perform well on memory assessment conducted in a structured setting may still experience difficulties in everyday situations outside of testing. Similarly, persons who perform poorly on formal memory tests may not report functional memory problems because they have learned to use compensatory strategies that reduce the impact of memory impairments in their everyday lives. In addition to formal memory assessment, a comprehensive interview about memory functioning in everyday life will provide the foundation for treatment planning to address memory impairments.
Interventions targeting memory can be classified into two broad areas: restorative and compensatory. Restorative treatments are based on the idea that memory abilities can be restored through practice, and they typically include systematic training and repetitive drills. Computer exercises focused on improving memory are often used. Unfortunately, there is minimal empirical evidence for the effectiveness of restorative treatments targeting memory. According to recent systematic reviews, they are not recommended in either the inpatient or outpatient settings for persons with TBI or stroke because their effectiveness has not been demonstrated.
Training in use of compensatory memory strategies has demonstrated effectiveness for improving memory performance and everyday memory functioning following TBI and stroke. The goal of compensatory memory strategy training is to help persons with injury develop ways to “get around” memory impairment so that they can accomplish functional goals. The premise is that functional memory can improve with strategy use, even if the person continues to exhibit memory impairment on formal testing. Compensatory strategies can be classified as internal or external. Internal strategies rely on internal processes to learn and remember information. Examples include visual imagery, rehearsal, and organization (e.g., trying to remember information by forming an acronym). Research has shown that internal memory strategies are effective for improving performance on neuropsychological tests of memory ; however, generalization to real-world memory tasks has not been demonstrated. A further limitation of these strategies is their reliance on cognitive abilities of the person with injury, including attention and organization. Use of these strategies may tax an already compromised cognitive capacity in persons with moderate to severe memory impairment and therefore may be more appropriate for persons with mild memory impairment.
In contrast to internal strategies, external memory strategies rely on cues outside of persons to remind them of important information. External memory strategies can be paper based or electronic. Examples of paper-based aids are memory notebooks, planners/organizers, and checklists. Electronic aids include mobile phones and portable digital voice recorders. Memory notebooks and daily journals have demonstrated effectiveness for reducing everyday memory failures. Several small studies and case studies have demonstrated the potential of electronic memory aids for improving performance on a variety of everyday memory tasks, including remembering to take medications and keeping track of tasks to complete.
On the basis of their systematic review of the literature, Cicerone et al. recommended memory strategy training, using either internal or external strategies, as standard practice for persons with mild to moderate memory impairment. Persons with more severe memory impairment are likely to have difficulty learning and applying these strategies. Therefore Cicerone et al. recommended training in the use of external memory strategies with direct application to functional activities as a practice guideline for persons with severe memory impairment.
The recommendations of Cicerone et al. have direct applicability for intervening in memory within both inpatient and outpatient settings. During inpatient rehabilitation, many persons will have memory impairment that is severe enough to preclude them from benefitting from memory strategy training. Providing these patients with a memory notebook or other memory aid may have minimal impact unless they participate in intensive training sessions with a therapist to help them learn to use it. Researchers have found that it can take persons with severe TBI months to learn to use a memory notebook adequately. Understandably, therapists feel responsible for providing assistance to persons with memory impairment while they are in the inpatient unit, which should be encouraged; however, assistance should be given in accordance with the individual’s capacity to benefit from the intervention. For persons who are still exhibiting PTA, meaning that they have not begun to form day-to-day memories, rehabilitation staff should consistently provide them with orienting information (e.g., place, time, and what happened/why they are in the hospital) throughout the day. Maintaining a white board in the room with information on the names of their therapists, physician, and nurse, and the times of their therapies, is also recommended. If rehabilitation staff think that a memory notebook should be given to all patients, it is important that a family member or significant other be trained in how to use the strategy and in how to prompt the person with injury to use it regularly. Without the assistance of a family member or other caregiver, persons with injury are unlikely to learn to use the notebook and apply it in their home and community environments.
In the outpatient setting, neuropsychologists are more likely to assist persons with injury in developing compensatory strategies to reduce the impact of memory impairment on their daily lives. Because one compensatory strategy may not work for everyone, it is best to present different choices (e.g., memory notebook, checklist, phone calendar, and reminders) and have the persons with injury select the one that best fits their needs and preferences. Training with real-world memory tasks, such as remembering questions to ask a physician or remembering when to get their prescriptions refilled, is more likely to result in generalizability to their home and community environments. If possible, training should occur in their everyday environment. If this is not possible, simulated real-world tasks can be used. Involvement of family members/caregivers in training helps to ensure success.
Problem-Solving
Problem-solving deficits have long been noted as a problem for persons with brain injury. Impairments can manifest at any level of problem-solving, including analyzing problem situations, generating potential solutions, evaluating alternatives, choosing a solution, and evaluating the real-world consequences of solutions. Researchers have shown that problem-solving is a multidimensional ability and is related to speed of processing. Brain injury results in slowed processing of information so that the normal demands of everyday life cannot be adequately processed, leading to difficulty with analyzing information and solving problems. Problem-solving deficits can have a negative impact on almost every aspect of daily functioning and social roles, affecting abilities such as how to prioritize financial commitments, how to decide between two possible medical treatments, how to care for a sick child, and how to make new friends or deal with conflict between family members.
Interventions to improve problem-solving have generally been grouped under the heading of executive function interventions because problem-solving is an aspect of executive functioning. Relative to other executive functions (such as goal planning and organization), there has been a substantial amount of research on cognitive rehabilitation interventions to improve problem-solving skills. On the basis of the existing research evidence, Cicerone et al. have recommended training in formal problem-solving strategies as a practice guideline for persons with TBI in the outpatient, postacute setting. The best evidence is for interventions that combine the use of self-monitoring and emotional regulation for effective problem-solving orientation with training in systematic analysis and solution of problems. Some neuropsychologists may address problem-solving by training people to self-monitor periodic progress toward goals, otherwise known as goal management training. This type of intervention actually addresses multiple aspects of executive function, including problem-solving. Cicerone et al. recommend that the problem-solving training be conducted with direct application to real-word situations and functional activities. Therefore neuropsychologists should individualize the problem-solving training so that it is directly applicable to the everyday problem situations that clients encounter.
Interventions for Emotional and Behavioral Problems
Emotional Problems
Psychotherapeutic interventions in civilian rehabilitation settings often focus on treating depression and anxiety disorders because these are the most common emotional problems experienced by rehabilitation populations. Numerous studies have documented high rates of depression and anxiety disorders among rehabilitation populations, including TBI, stroke, and spinal cord injury. Posttraumatic stress disorder is an especially common psychiatric comorbidity in service members and veterans with a history of combat-related mild TBI. Emotional problems are important targets of interventions in rehabilitation settings because they can have a negative impact on participation in therapy and are associated with poorer functional outcomes. The relation between emotional problems and functional outcomes is somewhat complicated. For example, postinjury depression may contribute to reduced participation as a result of an individual’s withdrawal from activities and interests, or an inability to participate in activities and interest as a result of injury-related deficits may contribute to the development and maintenance of depression. Longitudinal studies in persons with TBI suggest that the experience of functional limitations precedes the development of later depression. Despite the frequency and impact of emotional changes after brain injury, there is relatively limited evidence regarding the effectiveness of psychological and pharmacologic interventions for mental health conditions following acquired brain injury, such as TBI and stroke. Pharmacologic interventions for poststroke depression have some support in the literature, although prescribers must also weigh the risk of increased adverse events. Although definitive practice guidelines are not available regarding the use of pharmacologic interventions for emotional problems secondary to acquired brain injury, recommendations based on current standards of practice have been published (see Jorge and Arciniegas for an example).
This section focuses on three types of psychological interventions that may be used in rehabilitation settings: cognitive behavioral, behavioral, and supportive. Cognitive-behavioral therapies (CBTs) are based on the theory that thoughts, emotions, and behaviors are founded on an underlying belief system and that emotional symptoms arise from negative, maladaptive, underlying beliefs. Cognitive aspects of these interventions include increasing awareness of cognitive distortions and their impact on one’s emotional and interpersonal functioning. Persons are trained to identify and evaluate the validity of maladaptive beliefs so that they can challenge such dysfunctional belief structures and generate more adaptive beliefs. Behavioral components of CBT include monitoring of one’s mood and its relation to activity levels, behavioral activation strategies such as activity scheduling, and behavioral experiments aimed at testing beliefs and developing new learning experiences that will produce more adaptive and prosocial behaviors.
Behavioral interventions do not attempt to identify and modify maladaptive beliefs and thoughts, which is one of the key components of CBT. Instead, behavioral therapies focus on helping patients identify current patterns of coping and how they may exacerbate emotional symptoms, and develop improved coping patterns and greater access to reinforcing and pleasant life events. Specific life situations and how they serve to maintain emotional distress are discussed, as well as “new” behaviors that could potentially improve mood. Some of the behavioral strategies frequently used in this type of therapy are similar to those discussed earlier, including activity scheduling to increase the number of reinforcing events. Functional activities that are associated with feelings of accomplishment, pleasure, or both are examples of reinforcing events. Graded task assignments, in which actions are broken down into smaller, more manageable steps, and therapist-client role play are other techniques that may be used.
Supportive psychotherapy is another type of intervention that may be used in rehabilitation settings. The focus of this intervention, similar to all psychotherapeutic interventions, is on improving psychological functioning and reducing distress and dysfunction in the context of a positive therapeutic relationship. Frequently used techniques include communicating acceptance and empathy, providing opportunities to share thoughts and feelings in a secure environment, validating experiences, offering reassurance and suggestions when appropriate, encouraging use of supports, and providing psychoeducation. Behavioral and cognitive-behavioral techniques may also be used. Finally, another technique that may be incorporated in psychotherapy to help alleviate anxiety is progressive relaxation, which involves focused attention to breathing, visualization of a pleasant and relaxing image, and tightening and relaxing of different muscle groups.
There is a growing body of literature investigating CBTs and behavioral interventions in rehabilitation populations with some promising findings, especially for CBT for psychosocial issues in persons with spinal cord injury. Researchers have urged caution when implementing CBT in persons with cognitive impairment, however, including persons with stroke or TBI because those impairments can negatively affect their ability to learn and apply cognitive-behavioral techniques. For example, there is insufficient evidence to support practice recommendations regarding specific psychological treatments for individuals with a history of brain injury. As a result, adaptations to the structure and content of psychological interventions, such as provision of supplementary written materials, built-in repetition of key concepts, focus on concrete goals, and decreased emphasis on self-directed, higher-level reasoning skills play an important role in the development and implementation of these treatments in individuals receiving rehabilitative care. Findings to date suggest that persons with cognitive deficits can participate in and show benefit from these adapted interventions.
There are several factors that are taken into account when psychotherapeutic services are implemented in acute rehabilitation settings, including the nature and severity of the emotional problem, the presence and severity of cognitive deficits, previous experience with psychotherapy, and the length of stay. For example, with respect to length of stay, initiation of brief, focused supportive psychotherapy may be more appropriate for persons admitted for a relatively short period of time, with referrals for additional psychotherapy made at discharge. In this example, a CBT intervention may not be appropriate because there may not be sufficient time for appropriate implementation. With respect to cognition, CBT will likely be more effective for persons with intact cognition, whereas supportive psychotherapy may be more appropriate for persons with severe cognitive deficits.
Psychological treatment for emotional problems is also a key component of postacute rehabilitation programs, and there is evidence that participation in these programs is associated with improved outcomes including community integration, life satisfaction, self-efficacy, and emotional functioning. The factors that affect treatment planning in the acute phase noted earlier also affect planning in postacute rehabilitation settings. These programs often offer group interventions in addition to individual interventions; thus treatment planning must also take these different formats into account. There are several advantages to group interventions, including increased opportunities for imitative behaviors, interpersonal learning, altruism, and decreased sense of social isolation, as well as cost-effectiveness. However, the individual’s strengths and weaknesses will be important to consider when readiness to participate in a group intervention is determined. For example, persons with significant behavioral control issues or cognitive deficits may benefit from individual interventions initially. As cognition and behavioral control improve, they may then benefit from participation in a group intervention.
Emotional problems do not occur in a vacuum. In other words, they can have a significant impact on an individual’s compliance and motivation with rehabilitation in both acute and postacute settings, which can negatively affect outcomes. In cases in which a client’s anxiety or depression is interfering with participation in therapy, the psychologist may provide cotreatment with physical and occupational therapists to address the emotional issues that may be serving as a barrier to engagement or participation in the therapy.
Behavioral Problems
Behavioral problems arising in rehabilitation settings, such as agitation, disinhibition, aggression, and impulsivity, can be frustrating and distressing for family members and rehabilitation care providers and may contribute to poor compliance and cooperation with therapies. A combination of pharmacologic and nonpharmacologic interventions may be required for treatment of these issues. However, medication side effects such as increased sleepiness could also interfere with participation in therapies. The use of physical restraints may lead to injuries and contribute to increased agitation. This section focuses on behavioral interventions implemented by psychologists as part of a collaborative, multidisciplinary approach to treating behavioral problems following brain injury. Numerous studies have demonstrated the effectiveness of these interventions, and they have been proposed as a treatment guideline for certain rehabilitation populations, such as adults with behavior disorders following TBI.
The first step in planning and executing an effective behavioral intervention to treat a problem behavior is the completion of an individualized functional behavioral analysis. This analysis establishes the function of a behavior through careful observation of the actual problem behavior and examination of the antecedents to and the consequences of the behavior via direct patient observation and interviews with rehabilitation care providers, family, and patients, if appropriate. The problem behavior should be described in terms of its nature (e.g., yelling, throwing objects), frequency, severity, and duration. Observation of potential antecedents entails attention to both the individual’s “internal” experience (e.g., pain, poor comprehension) and characteristics of the external environment (e.g., places, events, time of day, people) that occur before the problem behavior. Observation of consequences involves attention to events that occur immediately after the problem behavior, including events, the reactions of others, gains, and losses.
Consequences that increase the probability of a behavior are referred to as reinforcements and are described as “positive” (e.g., receiving something the individual finds meaningful or important) or “negative” (e.g., removal or withdrawal from an aversive environment). Consequences that decrease the probability of a behavior are referred to as punishments . Contextual factors, such as diagnosis, stage of recovery, medications, nature and severity of cognitive deficits, and sleep cycle, should also be considered when an analysis of problem behaviors in persons with brain injury is completed.
Information obtained from the functional behavioral analysis will contribute to the development of hypotheses regarding the situations or events that predict the behavior and the consequences that maintain the behavior. The problem behavior can then be addressed through manipulation of the antecedents to prevent the problem behavior from occurring or through contingency management, which is the systematic and planned manipulation of consequences that are designed to increase or decrease specific behaviors. Some examples of response prevention and contingency management techniques are presented in Tables 4-1 and 4-2 .
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
