2. Grandma Masse's Rules for Success:
1. 1 Back to the Future: “Context-Sensitive” Rehabilitation Following Brain Injury Tim Feeney, Ph.D. Project Director New York Neurobehavioral Resource Project Clinical Director School and Community Support Services Schenectady, NY USA [email protected]
3. 3 My Task as I Understand It Describe a theoretical orientation to brain injury rehabilitation and describe it boldly!
Boldly, but with humility appropriate to the topic
Focus on the cognitive, social, communication, and behavioral dimensions of brain injury rehabilitation.
5. 5 Theoretical Orientation
Rehabilitation efforts should be consistent with a defensible theoretical framework, but not “theory driven”
The ultimate touchstone of rehabilitation is meaningful improvements in the lives of the individuals we serve and the significant everyday people in the everyday routines of their lives. It’s about people, not programs!
7. 7 Poodle
16. 16 Lev Vygotsky 1896 – 1934
Student of and lecturer in literature, history, law, philosophy, psychology, educational psychology
Author: >180 publications (plus additional translations and edited works) in a short career (including a respected treatise on Hamlet)
Following his death at age 37, his works were banned by Stalin for 20 years
Dramatic impact on applied psychology and education over past 20 years – in the US and elsewhere
17. 17 Lev Vygotsky: Principles Developmental (genetic) method : to understand a process/concept, one must understand its origin
Two contributors to development: biology (e.g., genetic endowment; neurological maturation) and culture (including cultural tools, such as language, category frameworks, etc., and cultural mediation/guided participation in culturally valued activities)
18. 18 Lev Vygotsky: Principles “Higher” functions (i.e., non-biological) develop via internalizing (appropriating; transposing; “in-growing”) of interaction (mediation) with more mature members of the culture (i.e., apprenticeship relationships), as the “apprentice” engages in guided participation in culturally valued activities
19. 19 Lev Vygotsky: Principles
Domain-specificity of cognitive, meta-cognitive, and volitional processes:
Higher thought is learned, (relatively) task-specific, and sociocultural: consistent with both representationalism and connectionism in contemporary cognitive science
20. 20 Lev Vygotsky: Principles 5. Language is the primary “cultural tool” to mediate everyday problem-solving activities and to create higher-order, self-regulated thought processes (cognition and volition/self-regulation).
6. Volition and deliberate self-regulation, like thinking, are internalized speech (see L. Beck studies). [Mandates an integration of cognitive and behavioral intervention approaches]
21. 21 Lev Vygotsky: Principles
Cognition is ultimately unitary: “components” of cognition are abstractions; cognitive activity in general is problem solving toward a meaningful goal while participating in culturally valued activities
Cognition/Thinking: “… serves effective action in the interpersonal and physical world, as people solve problems that inherently involve dealing with specific circumstances.” Rogoff, 1990
22. 22 Lev Vygotsky: Principles Cognition as unitary and situated:
“The need for a broad and complex conception of cognition also lies in the complex interweaving of the various aspects of cognition in the tapestry of actual, real-time cognitive functioning. Each process plays a vital role in the operation and development of each other process, affecting and being affected by it.”
Attention organization memory knowledge base reasoning
Flavell et al, (2002). Cognitive Development 4th edition.
23. 23 Lev Vygotsky: Principles Thought and emotion are inter-related and inseparable
“Thought...is not born of other thoughts. Thought has its origins in the motivating sphere of consciousness, a sphere that includes our inclinations and needs, our interests and impulses, and our affect and emotion. The affective and volitional tendency stands behind thought. Only here do we find the answer to the final “why” in the analysis of thinking.”
Compare: Recent cognitive neuroscience studies
Vygotsky, Thinking and Speech, p. 282
24. 24 Lev Vygotsky: Principles Assessment is dynamic (experimental; hypothesis testing)
9a. Static assessment: describe unaided performance
9b. Dynamic assessment: Systematically manipulate relevant variables (e.g., task modifications, coaching/cuing supports, environmental supports, motivational variables, etc) to determine:
- “Zone of Proximal Development”
- Most effective supports and teaching methods
25. 25 Lev Vygotsky: Principles Theory and practice are inseparable: Theory is ultimately tested by practice
“Clinical activity, unstructured and without the direction of a conceptual framework, is blind; models and theories, uninformed by clinical experience and therapeutic skill, are empty” Ylvisaker, 1985
26. 26 Lev Vygotsky: Principles 12. The same psychological principles apply to children and adults with disability
“The work that emphasized the dissolution of higher functions was always seen as a natural complement to the developmental work. In fact, in the late 1920s we drew no really clear cut distinction between the two approaches; our work went on simultaneously on all fronts. The kindergarten and the clinic were equally attractive avenues to approach the difficult analytic problems.” (Luria, P. 57)
27. 27 Lev Vygotsky: Summary Bottom line: Development/maturation of language, cognition, volition, and behavioral self-regulation is based on goal-directed supported participation in authentic cultural activities, mediated by social interaction with more mature members of the culture, with meaningful practice in the use of cultural “tools” (including compensatory strategies), and with demands on the “apprentice” within the “Zone of Proximal Development”.
This is apprenticeship teaching and applies to child development generally, to regular education, to professional and vocational training, and to teaching/ rehabilitating individuals, including adults, with disability
28. 28 Lev Vygotsky: General Orientation to Rehabilitation Include individuals with and without disability in culturally valued activities
Focus on strengths (versus impairment)
Prevent secondary disability caused by lack of meaningful participation
Facilitate effective, individualized compensations within culturally valued participation, with expert mediation of learning tasks
Ensure adequate practice and systematic reduction of supports
29. 29 TWO FUNDAMENTALLY OPPOSING CONCEPTIONS OF HUMAN REALITY
35. 35 Rehabilitation Goals Sarah will successfully complete ___ meaningful task, with ___ supports, possibly using ___ “tools/strategies”, in ___ context (setting, people, activities), in order to achieve ___ goal.
Possibly focusing intervention attention on some specific aspects of cognition, communication, social skills, behavioral self-regulation, or educational/vocational skills – aspects that are either particularly weak or particularly important for Sarah.
36. 36 APPRENTICESHIP TEACHING: A Foundation for Context-Sensitive Rehabilitation CONTEXT
Natural context; perhaps projects with a meaningful goal
Social, collaborative activity
Success due to collaboration; no need for errors
Non-hierarchical organization of tasks
37. 37 REHABILITATION AS APPRENTICESHIP TEACHING TASK STRUCTURE
Engagement in guided observation
Collaborative, goal-oriented work, with supports as needed
Learner contributes as much as possible
Ongoing coaching, encouragement, modeling, brainstorming, etc.
Supports systematically withdrawn and/or task difficulty increased
Transfer guaranteed because of context and procedures
38. 38 Traditional assessment (office-bound assessment) is a notoriously inaccurate indicator of abilities in both the long and short term.
Even tests purported to assess functioning post-injury are often incorrect. The tester becomes the “prosthetic frontal lobe.”
39. 39 Therefore:
All assessment and intervention must be done in a contextual and collaborative manner
41. 41 Assessment informs intervention, informs assessment, informs intervention, informs assessment, informs intervention, informs assessment, informs intervention, informs assessment, informs intervention, informs assessment
42. 42 Reconstructing a sense of self is the core of all rehabilitation efforts
44. 44 Doberman
45. 45 Sense of Self: Neuropsychology Stuss, Tulving, and colleagues:
Ventral prefrontal areas (R>L): convergence zone for the neural processes that enable humans to construct and maintain a reasonably organized and stable sense of personal identity
46. 46 SENSE OF SELF FOLLOWING ACQUIRED BRAIN INJURY Perplexity
Unawareness or denial: Retention of preinjury self-concept
“I am a victim” (passivity; depression)
“I refuse to be a victim” (anger; aggression)
“I’ve changed; I’ve got my work cut out for me” (resolve)
49. 49 “IDENTITY MAPPING” Identification of goals
Identification of image, hero, metaphor
Organization of identity description
[Creation of “identity map”]
Modification of others’ support behavior
Possibly meaningful project
50. 50 Identity Mapping: Cautions Professional competence
51. 51 Identity Mapping: Cautions Dangerous metaphors
Negative use (e.g., “nagging”)
Getting stuck; flexibility
Heroes and victims
Time post injury
53. 53 IDENTITY CONSTRUCTION Helping individuals with disability construct a sense of personal identity that is:
AND that includes the hard strategic effort needed to be successful with a disability
57. 57 Project Approach Meaningful goal; product
Planning and organizing
Meaningful context for practice
Integration of activity over time
Integration of several contexts
58. 58 Project Approach: Rationale Organizational impairment
Superior involuntary learning
Weak elaborative encoding
Need for situated learning
Need for errorless learning
Need for routine learning
59. 59 Project Approach Rationale (cont’d) Internalization of mediated interaction
Sense of self
60. 60 FAQ: CONTEXT-SENSITIVE REHABILITATION Q1: IF TX IS CONTEXTUALIZED, WILL TRANSFER NOT BE NARROW??
A1: Possibly. But a CONSTRUCTIVE dilemma is associated with C-SR and transfer:
1. With C-SR, either reasonable transfer occurs (with or without special effort) or it doesn’t in individual cases
2. If it does, great
3. If it doesn’t, at least the person has acquired useful knowledge or skill in some relevant context
4. Therefore, there is a positive outcome in either case
A2: Compare: Normal child development
61. 61 FAQ (cont’d) Q2: ISN’T IT IMPOSSIBLE TO TRAIN A PERSON IN EVERY CONCEIVABLE CONTEXT??
A1: Correct; that is obviously impossible. However, see answer to Q1.
A2: Professionals delivering C-SR create alliances with everyday support people in a variety of settings to ensure training and support are as widely distributed as possible
62. 62 FAQ (cont’d) Q3: IS IT NOT EXPENSIVE AND INEFFICIENT TO DELIVER SERVICES IN MULTIPLE CONTEXTS??
A1: Yes! But “context-sensitive” services can be delivered in a clinic and/or via occasional consultation and/or via apprenticeship relationships with local support staff. The point is to somehow organize the everyday routines of the person with disability and the intervention and supports provided by everyday people. There are multiple ways to do this.
A2: NYS DOH Medicaid Waiver Program: Apprenticeship Program
63. 63 FAQ (cont’d) Q4: WON’T CONTEXT SUPPORTS CREATE ONGOING DEPENDENCE AND HELPLESSNESS??
A1: No, not if supports are well-conceived and reduced systematically
A2: How to help without creating helplessness: The “Goldilocks’ Accordion” Theory of Support:
- Not too much; not too little; just right
- adjusted in an ongoing way to coincide with growing competence and with stressors, such as transitions, new responsibilities, increasing demands, etc
65. 65 FAQ (cont’d) Q5: ISN’T C-SR HARD TO STUDY??
A1: Yes. But it is unscientific and unethical to use an intervention simply because that intervention is easy to study. “Tails Must Not Wag Dogs!!”
A2: A variety of research designs are possible
A3: Designs MUST include: (1) real-world measures of functioning, (2) long-term interventions, (3) attention to context, (4) engagement of individual and everyday people, (5)
66. 66 FAQ (cont’d) Q6: IS IT SCIENTIFIC TO SUPPORT OR REJECT AN INTERVENTION USING EVIDENCE DERIVED FROM STUDIES OF OTHER POPULATIONS??
A1: In selected cases, yes. Cross-population inferences are valid if:
1. The two populations are nominally different, but functionally and pathologically identical
2. The two populations are genuinely different, but the same with respect to all considerations relevant to the intervention
3. An intervention theme emerges across many (all) studied populations (e.g., sharply limited transfer)
67. 67 FAQ (cont’d) Q7: DOESN’T THE SUCCESS OF COMPUTERIZED TRAINING PROGRAMS LIKE “FAST FORWORD” LEND SUPPORT TO COGNITIVE TRAINING EXERCISES?
A1: No; the goal of the program is acquisition of specific domains of linguistic knowledge (phonology, semantics). There is a fundamental difference between (1) teaching specific content skills and knowledge and (2) training purportedly content-less cognitive processes
68. 68 FAQ (cont’d) Q8: DOES C-SR INTERVENTION REQUIRE A CHANGE IN ASSESSMENT PRACTICES?
A1: Perhaps. C-SR requires at least systematic exploration of context facilitators and stressors, and hypothesis-testing exploration of potential context-relative supports and teaching/interaction styles.
69. 69 FAQ (cont’d) Q9: IS C-SR APPLICABLE TO INPATIENT REHABILITATION??
A1: Yes, in two ways:
1. Inpatient staff should focus on post-discharge settings and activities with the goal of developing effective supports and well trained support individuals in those settings
2. Meaningful activities and projects can be included as an essential component of inpatient rehabilitation, from the perspective of cognition, communication, education, vocation, and executive self-regulation
70. 70 FAQ (cont’d) Q10: DON’T THE MANY DOUBLE DISSOCIATIONS IDENTIFIED BY COGNITIVE NEURO-SCIENTISTS SUPPORT PROCESS-SPECIFIC INTERVENTION??
A1: No. Analogy:
1. Cognitive neuro-linguists have identified many double dissociations within language
2. Nevertheless, it is possible to embrace an integrated, functional theory of language
3. The best supported theory of language intervention is “interactionist”:
3a. Interaction among components of language
3b. Interaction between the language learner and the social context of communication