1.3.1.1

The medical evaluation

The medical evaluation is performed at the outset by the Physical and readaptation medicine (PRM) hospital practitioner serving as coordinator of outpatient care, takes place in the presence of a UEROS staff member and is based upon the European Brain Injury Scale (EBIS) . The attendant medical recommendations, whether they involve therapeutic adaptations or supplementary explorations, will be applied over the course of the training program. After discharge, the same coordinating physician will systematically provide follow-up consultation.

1.3.1.2

The neuropsychological evaluation

The initial interview is devoted to reconstitution of the trainee’s medical history and personal biography. Cognitive evaluation is then carried out with standard tools. At the outset, global efficiency is assessed by means of the WASI-IV scale. The different memory capacities are quantified by the memory span measured in the MEM III test, the Grüber and Buschke test, the California Verbal Learning test and the Baddeley Doors and People test. The Rey Figure test is likewise administered. Attentional abilities are evaluated by the Zimmermann and Finn neuropsychological test battery, the D2 test and the BAMS-T. Language use is assessed by the Boston Diagnostic Aphasia Examination (BDAE), the Deloche and Hannequin oral denomination test (DO 80) and verbal fluency exercises. Praxia and gnosia are subjected to exploration only if need be. Executive functions are evaluated by means of the Trail Making test, the Martin shopping test, Shallice’s Six Element test, the Wisconsin Card Sorting test and the Tower of London test.

Neurobehavioral evaluation is performed with the GREFEX dysexecutive syndrome battery . The relevant data are collected by the neuropsychologist and the occupational psychologist.

Ecological evaluation is based on the Multiple Errands Test (MET) elaborated by Shallice and Burgess in 1991 , which is administered in a specially adapted form on a shopping street not far from the UEROS premises.

Specific cognitive objectives are determined once the neuropsychological evaluation process has been completed.

As a step towards retraining, as soon as the patient is admitted, his work on a date book serving as a memory aid gets underway.

1.3.1.3

The occupational evaluation

This evaluation focuses on the functional impact on daily life of the cognitive impairments; it consequently deals with everyday activities and consists largely in ecological tests.

During the initial individual interview, the trainee is asked to assess his degree of autonomy in daily life and, more precisely, to describe a day typifying the rhythm of his usual routine. His educational level is assessed through testing devised by the French distance learning school (CNED) and, if necessary, ascertained by the online learning portal of the French public education regional organ (GRETA). This evaluation of the trainee’s knowledge, abilities and vocational experience is supplemented by the EVAL3 software .

In addition to this psycho-technical evaluation, we carry out a functional evaluation involving several routine, “ecological” tasks: use of a phone book, a calendar, a washing machine; dealing with administrative documents and orienteering; woodwork and cooking. The cooking session is assessed according to widely used criteria. The trainee selects his menu, draws up a shopping list, makes a price estimate and plans out the meal itself (tasks to undertake/instructions to give, time management). In some cases, particularly when the trainee’s chosen vocational orientation is cooking-based, culinary therapy testing is carried further, with a video recording meant to foster impairment awareness and to facilitate the upcoming retraining program.

Sports abilities are also specifically evaluated. Individual physical drills are designed to assess motor skills, while team sport activities necessitating cognitive and behavioral adaptation are videotaped. Grading is qualitative as regards adaptation, memory, self-control, initiative, motivation and respect for both the rules of the game and for fellow players, while it is quantitative as concerns the different aspects of motor skills, ranging from 0 (no difficulty) to 4 (extreme difficulty).

This phase of evaluation is concluded by establishment of the International Classification of Functioning, Disability and Health (ICF) quotation, which is commonly employed as a medico-social reference.

1.3.1.4

The psychological evaluation

An interview with the clinical psychologist of the medical network allows for assessment of the psychological repercussions of the traumatic event and its impact on the trainee and his family. The trainee is constantly reminded of the psychologist’s availability throughout the training period. Outpatient intervention is offered if need be.

1.3.1.5

The social evaluation

The social worker assesses where the trainee stands in society and pays particular attention to his degree of autonomy in everyday organization and money management. If necessary, the social worker contacts the relevant social protection and outpatient social welfare services.

1.3.1.6

The vocational evaluation

Carried out by the occupational psychologist, the evaluation consists firstly in a one-hour clinical interview and secondly in creation of a “portrait” of the trainee over eight hours by means of a tool created at the Limoges UEROS. It is supplemented by two standardized tests: Holland’s personality inventory and the French classification of professional interests .

Designed to delineate a person’s identity, the “portrait” is composed of ten parts:

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  after indicating his civil identity and level of studies, the trainee describes the circumstances surrounding his traumatic event and distinguishes what he wishes from what he does not wish to divulge to a future employer;

  
  
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  he then gives definition to his personal objectives and their underlying motivations;

  
  
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  after that, in the part entitled “who I see and how I represent work”, he enumerates the professions exercised by those around him and states how he perceives them (attraction or lack of interest);

  
  
• •
  

  the trainee is then provided with an opportunity to retrace his life story by placing on parallel tracks his personal or emotional pathway and his educational and vocational pathways. The aim is to observe his professional itinerary through the lens of key events in his life and thereby better comprehend his personal development and reestablish a continuum between his life prior to brain injury, what happened in the aftermath, and his projects yet to come. For the benefit of trainees who immediately feel comfortable with this approach, the pathway is presented as a “frieze of life”. This part of the portrait should be seen not only as a skills assessment but also as a psychodynamic translation of a personal career path. It may likewise be considered as an approach taking the trainee’s identity into account in such a way as to allow him to achieve grounding in reality without being drawn back to the past;

  
  
• •
  

  the work placements once carried out by the subject are inventoried, as are the subjects piquing his interest at school and the skills he acquired outside the educational system. Once he perceives his different learning experiences from a distance, he is called upon to pinpoint his strengths, which will bolster his self-image, along with his weaknesses, of which he shall remain aware throughout the training period;

  
  
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  the same approach is implemented with regard to the different jobs held by the subject, the aim being to determine the main lessons to be drawn from these professional steps and stages. If need be, the social worker will supplement the job list with the corresponding pay slips;

  
  
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  in this part, extracurricular activities and personal accomplishments are highlighted;

  
  
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  these elements and items shall all contribute to the elaboration of a standard résumé in chronological order;

  
  
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  the trainee will then proceed to an assessment of his present-day physical, intellectual, social and overall personal skills;

  
  
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  the ultimate phase of “portrait” building consists in elaborating a realistic vocational project. While the portrait has been sketched out in detail during the evaluation, it will be finalized only over the course of the retraining period.

1.3.1.7

Conclusion and report on the evaluation

The evaluation is concluded by determination of the MPAI quotation , which is a standardized medico-social clinical reference assessing initial physical and cognitive skills, along with the capacity for adaptation and participation that will condition social reintegration.

The different members of the staff help to define the objectives of the training period and go on to provide the trainee with feedback on the evaluation and the objectives, which are subsequently discussed individually with the UEROS coordinator and the neuropsychologist. In close conjunction with the trainee, they think over the objectives so as to set up milestones in the reintegration process and underscore the overall purpose of the project. The objectives also constitute material facilitating coping and paving the way to acceptance of accident sequelae.

The trainee is asked to note his objectives in his training record booklet, which he will use throughout the training period as he puts into writing his accomplishments, his observations and a running commentary. The booklet will attest to the pathways taken by the trainee, and they will enable him to assess his development in terms of the goals to be reached and, more specifically, as regards his accomplishment of the personal project ( Fig. 1 ).

An example of trainee’s weekly self-evaluation with regard to the objectives defined in conjunction with the team at the outset of the program and put into written form in his “trainee’s booklet”.

A written report on the evaluation results will be sent to the attendant physicians and to the MDPH, and will also be explained to the trainee’s relatives.

1.3.2.1

Cognitive retraining

1.3.2.1.3

Psycho-education through “stimulation groups”

From the very outset, we strongly encourage investment of the trainee in his retraining program. One of the factors limiting investment is the difficulty encountered by trainees in their apprehension of the brain itself with its structures and functions; as a result, they are ill-equipped to analyze the consequences of their brain injury, not to mention the objectives put forward by the UEROS center. That is why we have elaborated an educational program dealing with the cognitive functions, its aim being to render accessible the ideas put forward during the evaluation and to render meaningful the different activities proposed to the trainee. The program is carried out through weekly 90-minute “stimulation” sessions. Each week, several major themes are taken up: human anatomy, memory, attention, the executive functions, mental flexibility, language, logic and reasoning. Tangible support for these discussions consists in the information sheets drawn up by the neuropsychologist and the occupational therapist ( Fig. 2 ). During the second and final part of the session, the lessons derived from the first part are systematically put into practice either through parlor games calling upon memory, attention, self-control, mental flexibility or language, or through more conventional psycho-technical drills and exercises enlivened by the emulation characterizing the functioning of a group.

An example of the psycho-educational support employed in the stimulation group.

This “psycho-educational” activity allows trainees to distance themselves from the initial traumatism, to become more precisely aware of their disabilities and of situations in which they are likely to fail, and to gradually internalize their retraining objectives. These sessions are particularly appreciated insofar as they reinforce the therapeutic community by creating and maintaining a culture of trust and stimulation that avoids projecting difficulties directly onto the trainee and helps to enhance his self-esteem.

1.3.2.2

Behavioral retraining and psycho-social rehabilitation

Two other forms of group management are designed to promote social rehabilitation. Each week, trainees are made to alternate between a “communication” group and a “speaking-out” group.

It should be mentioned that each group session is doubly evaluated, once by the moderator and once by the trainees themselves. At the end of each session, they open up their record booklets and fill out a self-evaluation form in which they note their interest in the theme, their participation in the discussion and their behavior as part of the group. As for the staff members, they share their observations during a weekly “wrap-up” meeting. Comparison between the trainee’s assessment and the staff’s assessment sheds light not only on potential cognitive or behavioral difficulties, but also on the degree of awareness of their existence. These different points are dealt with in more depth during individual sessions.

1.3.2.3

Autonomy reinforcement

The holistic management conceptions put into practice at the Limoges UEROS involve all aspects of autonomy in daily life. While the front-line professionals are the occupational therapists, social workers and family finance counselors also assume key roles. We insist on comprehensive retraining as regards hygiene, daily management tasks and mastering a budget. Work is carried out either individually or in groups.

The social and family finance counselor coaches groups taking up themes as varied as food, addictions, contraception, budgets and insurance. The trainees benefit from written support in the form of documents compiled by the departmental health education committee or the French syndical family confederation.

As for the occupational therapists, their efforts are centered on trainee autonomy from a vocational standpoint. Computer use and automobile driving are two basic skills that greatly matter when following through on a professional project. As concerns driving, we offer assistance with the administrative formalities, and when it is necessary to relearn the highway code and undertake a road test, we work hand in hand with our driving school partners, all of whom are particularly sensitized to the difficulties stemming from brain injury. A driving simulator has recently been added to these different forms of organization.

1.3.2.4

The vocational reintegration

1.5.1.1

The priority given to ecological tasks

Numerous executive function-training techniques are put into practice day in and day out by means of the ecological tasks favored by the staff. For example, in their technical workshops our occupational therapists apply problem resolution tenets, time pressure management as proposed by Fasotti , and the goal management training described by Robertson . On the other hand, task performance prediction and Luria’s verbal mediation strategy are only rarely used.

As regards culinary therapy, it is applied in a less formalized manner than with Chevignard et al. . Its goal consists not only in improved cognitive functioning, but also in experiencing the pleasure of sharing the fruits of one’s efforts in a meal partaken in common.

Our retraining program frequently resorts to games and entertainment as integral components of a rehabilitation strategy. The few available studies on game-like formats in cognitive retraining have generally reported positive results. Such formats may alleviate the stress inherent to evaluation settings while usefully resorting to varied strategies of exploration, imitation and repetition.

1.5.1.2

The uses of targeted behavioral remediation

The feedback principle is widely employed in our UEROS center through individual sessions, group therapy and videotape. The interest of feedback in therapeutic guidance has been repeatedly shown in the literature . The feedback we strive to encourage is direct, respectful, empathetic and meaningful for the person(s) involved.

In addition, metacognition and self-control are reinforced in accordance with the principle known as “self-monitoring training” , in which the trainee is systematically asked to comment on his behavior and to compare his observations to the team members’ evaluations. In the end, his judgment is enhanced and he is able to anticipate and to adjust his reactions.

Group therapy has already been shown to improve social communication skills in brain-injured persons . In our experience, regularly scheduled sessions, particularly in the “communication” and “speaking-out” groups, facilitate procedural behavioral retraining through observance and context-based reiteration of the social rules conducive to communication. According to Sohlberg et al. , behavior may improve without alteration of self-awareness, and some persons are able to learn compensatory strategies through recourse to implicit and procedural memories without necessarily apprising themselves of the interest of these strategies.

Finally, there is evidence that a combination of group-based and person-to-person interventions is likely to durably enhance performances, behavior and psycho-social well-being .

1.5.1.3

The preponderance of education

As has been reported by Ownsworth et al. , psycho-education in a group setting brings about significant improvement in self-awareness and psycho-social functioning, years after the brain injury.

1.5.1.4

The fostering of trainee awareness

Self-awareness is a highly complex phenomenon encompassing neuro-cognitive and psychological factors along with the influence exerted by the socio-cultural environment. The interventions carried out in our UEROS center represent attempts to put into practice the biopsycho-social (BPS) model of Fleming and Ownsworth by targeting the different areas in which metacognition plays a role.

Improved self-awareness is a key element in successful rehabilitation and a predictive factor with regard to employability . Prigatano has observed that the most successful subjects in his reintegration program are those who evaluate the consequences of their brain injury as does the rehabilitation team, while the subjects who fail are those whose evaluations of the consequences of their brain injury are underestimations in comparison with those of the rehabilitation team.

In the Limoges center, work on self-awareness is initiated during the preliminary evaluation and structured when the trainee’s portrait is drawn up and his efforts at self-evaluation are recorded in the diary-like training booklet.

1.5.1.5

The psychotherapeutic approach

Psychotherapy after brain injury is composed of a wide range of practices based on a number of techniques designed to improve self-awareness and foster self-acceptance through a realistic perspective on the many difficulties experienced subsequent to brain injury. According to Klonoff , on the one hand holistic management is integrally constitutive of one of these techniques, and on the other hand psychotherapy for the brain-injured employs neurophysiological tools aimed at enhancing both disability awareness and communication pragmatics. Cross-fertilization involving psychotherapy and neuropsychology is a major characteristic of management for the brain-injured .

Ever since its creation in 1978, one of the original features of the Limousin network has consisted in its being rooted in a psychodynamics-based psychiatric culture closely associating brain and psyche . With this in mind, its teams have gradually been sensitized to a double reference applying the breakthroughs achieved by the pioneers of holistic management and taking into account the emotional vicissitudes and the coping strategies characterizing the traumatic adventure.

Staff members are uniformly receptive to the psychological facts; along with the holistic dimension characterizing our establishment, their sensibility explains why our psychotherapeutic management is not isolated, but rather tends to permeate the comprehensive program we have to offer.

1.5.2.1

In keeping with the precepts of American models

The holistic management carried out in the Limoges UEROS corresponds to the criteria put forward at the 1994 American consensus conference : multidisciplinary team, program contents encompassing cognitive functions, psychological factors and the socio-environmental context, rehabilitation partially undertaken in a therapeutic community, development of a therapeutic alliance between team and patient, approaches adapted to the life experience of the brain-injured person, and involvement of his family.

The group dynamics practiced in our UEROS center follow the blueprint of the milieu-oriented rehabilitation programs elaborated by Ben Yishai and Prigatano . Since the trainees feel accepted in a peer-based or therapeutic community, their interactions constitute a source of reassurance, stimulation and mutual assistance.

Contrarily to the aforementioned programs, family involvement is practiced not on a daily basis within the walls of our UEROS structure, but only occasionally, at key junctures in the patient’s development such as the decision on his admission to the UEROS, feedback from the evaluation phase, and definition of his professional project.

1.5.2.2

Some comparison with the other French evaluation, retraining, social and vocational orientation units facilities

Due to the lack of precise data pertaining to the other French UEROS centers, it is difficult to draw direct comparisons. While the list of retraining centers compiled by the different UEROS establishments includes workshops similar to those existing in Limoges, especially as regards the notion of a stimulation group and workshops encouraging free expression, the psycho-education feature is relatively absent.

In France, the first team to have rigorously applied the principles of holistic management was that of Mulhouse, and it initially did so through two programs, Delta (social reintegration) and Omega (vocational reintegration), and then through the first French UEROS establishment, which opened its doors in 1997. Today’s UEROS programs in Limoges and Mulhouse have in common their approach to group management in terms not only of cognitive retraining, but also in the framework of behavioral rehabilitation and a psychotherapeutic approach. At both centers, accompaniment takes on the form of guidance as well as regularly scheduled meetings involving the team, the trainee and his family. On the other hand, post-reintegration follow-up in Mulhouse is more systematic if not standardized, featuring a phone conversation with the supervisor at least once a week, and subsequently once a month.