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emotional rehabilitation learning about and living with the emotions of a new brain
Emotional Rehabilitation: Learning about and Living with the Emotions of a New Brain

Tedd Judd, Phd, ABPP-CNClinical Neuropsychologist, Bellingham, WA,Teddjudd@gmail.ComPresented At:Washington State 2010 Traumatic Brain Injury ConferenceBeyond Survival: Thriving After A Traumatic Brain InjuryMay 1, 2010, Seatac, WA

outline
Outline
  • Introduction
  • The Whole Person after TBI
  • The Content Of Emotional Rehabilitation
  • The Techniques Of Emotional Rehabilitation
  • The Social Context of Emotional Rehabilitation
introduction
Introduction:
  • Whatis Emotional Rehabilitation?
  • How is Emotional Rehabilitation different from psychotherapy?
  • Who is Emotional Rehabilitation for?
  • Whatchallenges does Emotional Rehabilitation address?
  • Why is Emotional Rehabilitation needed?
  • Whodoes Emotional Rehabilitation?
about neuropsychotherapy
About “Neuropsychotherapy”
  • First use: Ellis, 1989 (Neuropsychotherapy. In D. W. Ellis & A.-L. Christensen (Eds.), Neuropsychological treatment after brain injury (pp. 241-269). Boston: KluwerAcademic Publishing.)
  • First book: Judd, 1999 (Neuropsychotherapy and community integration: Brain illness, emotions, and behavior. New York: Springer/Kluwer Academic/Plenum Publishers)
  • Second book, second sense: Grawe, 2004 (Neuropsychotherapy: How the neurosciences inform effective psychotherapy, English translation 2007, Mahwah, NJ: Lawrence Erlbaum Assoc.)
what is neuropsychotherapy ellis judd

Neuropsychotherapy is the use of neuropsychological knowledge in the psychotherapy or counseling and related interventions for people with brain disabilities and those close to them. It is specialized in content, technique, and social context to address the emotional and behavioral issues of brain disability.

What is Neuropsychotherapy?(Ellis/Judd)

what challenges does emotional rehabilitation address
What Challenges Does Emotional Rehabilitation Address?
  • Organic changes in emotional regulation
  • Executive dysfunctions
  • Adjustment to brain dysfunction
  • Social adjustment to disability
why is emotional rehabilitation needed
Why Is Emotional Rehabilitation Needed?
  • Large population with brain disabilities
  • Emotional/social/behavioral challenges tend to be the most disabling
  • Few systematic interventions available
  • Relatively few neuropsychologists available

Antonak, et. al, 1993; Livingston & Brooks, 1988; Morton & Wehman, 1995

who does emotional rehabilitation
Who does Emotional Rehabilitation?

Skills needed to do effective Emotional Rehabilitation:

  • Therapy skills—warmth, empathy, openness, reliability, etc.
  • Teaching skills
  • Knowledge of:
    • Emotional Rehabilitation
    • Brain illness behavioral and emotional changes
    • Rehabilitation
    • Community resources
who does emotional rehabilitation1
Who does Emotional Rehabilitation?

Skills NOT needed to do effective Emotional Rehabilitation:

  • Knowledge of how to do neuropsychological evaluations
  • Extensive knowledge of neurology and neuroanatomy
  • Research skills
  • Forensic skills
who does emotional rehabilitation2
Who does Emotional Rehabilitation?

Candidates for doing Emotional Rehabilitation (in at least a limited sense):

  • Psychotherapists
  • Rehabilitation team members (Social Workers, OT, PT, Speech, Nursing, Aides)
  • Community-Based Rehabilitation Volunteers
  • Teachers
  • Family members
  • People with brain injuries (self-help)
the whole person after tbi pre disability personality
The Whole Person after TBIPre-disability Personality
  • Full range of personalities and psychopathologies
  • Factors predisposing to brain injury/illness are overrepresented:
    • Substance abuse
    • Risk taking
    • Medical non-adherence
the whole person after tbi reactions to injury illness
The Whole Person after TBIReactions to injury/illness:
  • Grief
  • Denial
  • Depression
  • Anxiety
  • Posttraumatic Stress Disorder
  • Frustration
  • Anger
  • Personal Reformation
the whole person after tbi reactions to disability
The Whole Person after TBIReactions to Disability:
  • Grief
  • Denial
  • Depression
  • Anxiety
  • Perplexity Lezak, 1978
  • Frustration
  • Anger
  • Embarrassment
the whole person after tbi organic emotional changes1
The Whole Person after TBIOrganic Emotional Changes:
  • Organically induced major psychiatric disorders
    • Depression
    • Mania
    • Psychosis
    • Obsessive-compulsive disorder
the content of emotional rehabilitation
The Content of Emotional Rehabilitation

Fundamental Principles:

  • The Continuum of Responsibility
  • Emotional Rehabilitation
  • Self-Awareness
  • The New Self
the content of emotional rehabilitation the continuum of responsibility acute condition
The Content of Emotional RehabilitationThe Continuum of ResponsibilityAcute Condition

Caregiver’s share

Share of responsibility for the behavior of the person with brain disability

Share of the person with brain disability

time

onset

the content of emotional rehabilitation the continuum of responsibility
The Content of Emotional RehabilitationThe Continuum of Responsibility

Executive Function Rehabilitation Schema

  • Accommodate Externally (schedules, cues, reminders, written procedures, restrictions)
  • Build Awareness
  • Retrain Self-regulation (problem-solving schemata, social skills, alarms, PDAs)
  • Generalize Self-regulation train in other settings (home, school, work, community)
  • Fade External Compensations
the content of emotional rehabilitation emotional rehabilitation
The Content of Emotional RehabilitationEmotional Rehabilitation
  • Accessible metaphor
  • Demystify process
  • Reduce guilt and blame
  • Define roles
  • Skill-learning model
slide23

You have a new brain. It doesn’t handle emotions the way it used to. You need to learn how it functions now and how to get along in the world with the way it functions now.

slide24

Learning how to live with your new brain takes time and practice. Each time you have an emotional problem it’s a chance to learn how your new brain is working. We’re here to help.

emotional rehabilitation helps bridge the gap between
Emotional rehabilitation helps bridge the gap between:
  • Behavior management and psychotherapy
  • Psychotherapy and cognitive rehabilitation
  • The cognitive and the emotional sides of executive functions
slide26
Emotional rehabilitation needs to enlist the aid of the social context of the person with a brain disability so as to:
  • Carry out training in the appropriate target social/emotional contexts
  • Make those contexts more hospitable to the person with the disability
  • Support and empower family and others in dealing with the changes in their loved one
the content of emotional rehabilitation improving self awareness
The Content of Emotional RehabilitationImproving Self-Awareness

Use Evaluation to Guide Intervention

Overestimation of Disability Due to:

  • Depression
  • Catastrophizing
  • Lack of knowledge of recovery

Underestimation of Disability Due to:

  • Anosognosia
  • Lack of experience
  • Impaired reasoning and generalization
  • Denial
the content of emotional rehabilitation improving self awareness1
The Content of Emotional RehabilitationImproving Self-Awareness

Distinguish Knowledge from Action Crosson, et al, 1989

  • Intellectual awareness(I can repeat what I’ve been told about my disabilities, but don’t quite believe it)
  • Emergent awareness(I can recognize my errors in retrospect or when happening)
  • Anticipatory awareness (I can plan to use compensations to avoid problems)
the content of emotional rehabilitation improving self awareness2
The Content of Emotional RehabilitationImproving Self-Awareness
  • Supportive confrontation
  • Avoid struggle
  • Take perspective of person with brain disability
  • Work with who they trust
the content of emotional rehabilitation improving self awareness3
The Content of Emotional RehabilitationImproving Self-Awareness

Feedback Tools

  • Mirrors
  • Photos
  • Audio tapes
  • Videotapes
  • Work samples
  • Writing samples
  • Arts and crafts products
the content of emotional rehabilitation improving self awareness4
The Content of Emotional RehabilitationImproving Self-Awareness
  • Testing feedback
  • Medical Records
  • Self-Monitoring Exercises
  • Games
  • Educational Materials
  • Group Therapy
  • Supported Failure
  • Real-Life Experiences
  • Don’t say “I told you so”
the content of emotional rehabilitation the new self
The Content of Emotional RehabilitationThe New Self
  • Not necessarily better or worse, just different
  • Discover who the new self is
  • Rethink abilities
  • Rethink goals
  • Rethink relationships
the techniques of emotional rehabilitation cuing technologies uses
The Techniques of Emotional RehabilitationCuing technologies: Uses
  • Emotional control
  • Procedures and routines
  • Stressful events
  • Reminders
  • Behavior Flash Cards
  • Explanations to others
  • Incidental functions
the techniques of emotional rehabilitation cuing technologies emotional control example
The Techniques of Emotional RehabilitationCuing technologies: Emotional Control Example

MY ANXIETY SIGNS

  • Tapping fingers, foot
  • Fast breathing, heart
  • Sweating
  • Tense muscles
  • Fussing and fidgeting

RELAXING BREAK

  • Alone, quiet, dark
  • Close eyes
  • Breathe slowly, deeply
  • Relax muscles
  • Let go of worried thoughts
  • Picture beach
the techniques of emotional rehabilitation cuing technologies therapy procedure example
The Techniques of Emotional RehabilitationCuing technologies: Therapy Procedure Example

ACTIVE LISTENING

Quiet, alone with other person

No TV, radio, music

Not doing anything else

Face other person, eye contact

Don't interrupt or react (bite tongue)

Repeat other person's feelings

the techniques of emotional rehabilitation cuing technologies stressful event example
The Techniques of Emotional RehabilitationCuing technologies: Stressful Event Example

PUBLIC SPEAKING

Use written outline

Practice alone and with friend

Have friend in audience

Short relaxation before going on

"I can do it! I know my stuff. They are friendly and want to hear me."

Find friend in audience

Speak to back of room

Slowly and clearly

Smile!

the techniques of emotional rehabilitation cuing technologies behavior flash cards
The Techniques of Emotional RehabilitationCuing technologies: behavior Flash Cards

Stop and Think

the techniques of emotional rehabilitation cuing technologies introduction card example
The Techniques of Emotional RehabilitationCuing technologies: Introduction Card Example

To my friends:

My stroke makes me cry and laugh at times when I am not feeling particularly upset or amused. Please don't be frightened by it, and remember that I'm still the same me underneath that. Sometimes when I cry I will look up, or when I laugh I will rub my mouth. That helps me control it. Thanks for your understanding. Emilio

the techniques of emotional rehabilitation cuing technologies
The Techniques of Emotional RehabilitationCuing technologies

Tips on Use

  • Individualize
  • Brief, concrete, action words, imperatives
  • First person or trusted authority figure
  • Colors
  • Multiple copies
  • Retain a copy on file
the techniques of emotional rehabilitation cue cards tips on use where to put them
The Techniques of Emotional RehabilitationCue Cards Tips on Use: Where to put them
  • Wallet
  • Purse
  • Arm of wheelchair
  • Mirror
  • Refrigerator
  • Steering wheel
  • Time Out place
  • Back of door
  • School notebook
  • Computer monitor
  • Pocket
  • Kitchen table
the techniques of emotional rehabilitation cuing technologies tips on use rick parent
The Techniques of Emotional RehabilitationCuing technologies Tips on Use:(Rick Parenté)
  • Screen Savers
  • Personal Digital Assistants and Watches
  • Coffee mugs
  • T-shirts
  • Make them rhyme
  • Initial letter mnemonics
  • Use graphics
the techniques of emotional rehabilitation choosing cuing technologies
The Techniques of Emotional RehabilitationChoosing Cuing Technologies
  • Appropriate
  • Appealing
  • Affordable
  • Accessible
  • Acceptable
the techniques of emotional rehabilitation self introduction letter
The Techniques of Emotional RehabilitationSelf-Introduction Letter

Purposes

  • Improve self-awareness
  • Commitment to rehabilitation
  • Future planning
  • Social rehearsal
  • Consolidate the experience
  • Consolidate self-image
  • Communicate needs
the techniques of emotional rehabilitation self introduction letter1
The Techniques of Emotional RehabilitationSelf-Introduction Letter

Contents 1

  • Introduction, purpose  
  • Story of the accident or illness
    • What happened?
    • Why did it happen?
    • How did you experience it?
    • How do you feel about it?
    • What you are doing about it (lawsuit, forgiveness, health changes, prayer)?
the techniques of emotional rehabilitation self introduction letter2
The Techniques of Emotional RehabilitationSelf-Introduction Letter

Contents 2

  • Current challenges:
    • Physical challenges.
    • Thinking difficulties.
    • Emotional changes.
    • Life changes (work, family, hobbies, recreation, social life, spiritual life)
the techniques of emotional rehabilitation self introduction letter3
The Techniques of Emotional RehabilitationSelf-Introduction Letter

Contents 3

  • What other people should NOT think (e.g., not crazy, stupid, or fragile).
  • How they can help.
  • How they should treat you.
  • What you would like them NOT to do.
  • Feel free to talk with you about it.
  • Thanks for understanding.
the techniques of emotional rehabilitation self introduction letter4
The Techniques of Emotional RehabilitationSelf-Introduction Letter

Variations on Exercise Application

  • Coauthor the letter (therapist, family, friend)
  • Read the letter aloud
  • Paraphrase the letter
  • Make notes from the letter then present from notes
  • Practice in group therapy, with another person, on video or audiotape
working with the social network family and friends
Working with the Social NetworkFamily and Friends

Roles in Emotional Rehabilitation

  • Informants about behavior, pre-disability personality, environment of recovery
  • Collaborators in treatment
  • Participants in support groups
  • Recipients of education, counseling, therapy
  • Support, advocacy
  • Interdependence—being family, motivation, the reason for doing things
working with the social network family and friends techniques of family education
Working with the Social NetworkFamily and FriendsTechniques of Family Education
  • Answering questions
  • Modeling
  • Coaching
  • Mentoring
  • Individually written materials
  • Printed materials
  • Visual aids
  • Socratic dialogue
  • Story telling
  • Metaphor
  • Support groups
  • Group discussion
  • Lectures
  • Videos
  • Teaching to teach others
  • Observing testing
  • Test results (drawings, writing samples, scores)
working with the social network circles of support
Working with the Social NetworkCircles of Support
  • Voluntary
  • Stable group of community members organized to help one person with a disability
  • Community based
  • Person with disability chooses members
  • Purpose is to help person with disability realize dreams
  • Not constrained by professional or institutional agendas and rules
working with the social network community resources
Working with the Social NetworkCommunity Resources
  • Client centered
  • Be creative
  • Enlist natural helpers
  • Make home visits
  • Go into the community
emotional rehabilitation summary
Emotional Rehabilitation: Summary

Emotional Rehabilitation uses cognitive compensations and family and community resources to help people rehabilitate from the emotional, behavioral, and social challenges resulting from brain disabilities. It is specialized in content, technique, and social context.