How to Lessen the Effect of TBI in Returning Soldiers or Civilians. Helping the Person with Neurological Impairment Re-invent Themselves?. By. Harriet Katz Zeiner, PhD Outpatient Neuropsychological Assessment and Intervention Clinic Palo Alto VA Healthcare System email@example.com.
Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.
Helping the Person with Neurological Impairment Re-invent Themselves?
Harriet Katz Zeiner, PhD
Outpatient Neuropsychological Assessment and Intervention Clinic
Palo Alto VA Healthcare System
The CRATER Model of Civilians
Psychotherapy for Persons with
Neurological Impairment has 4 areas of
modification of your current technique
such as rise time, sleep time, meal time
to lower the burden on the client’s memory.
2. Understand the catastrophic reaction: re-occurring tasks to physiological events
what do they look like when cognitively overloaded.
3. Externalize the problem and use triangulation- re-occurring tasks to physiological events
Therapist, Client and Family allied against
Demon Brain Injury
4. Change the source of self-esteem from re-occurring tasks to physiological events
personal best and a competition model to a
resilience coping model
By presenting a theory, a method, of imbedding cognitive retraining in individual psychotherapy having the following characteristics:
1. Pick cognitive symptomatology which is most likely to elicit stimulus overload in the patient.
2. If present, always address fatigue first.
3. Address any cognitive deficits that lead to catastrophic reactions second.
4. Link the performance of verbal cognitive constructs to either dysphoric affect (the catastrophic reaction) or a physiological response to effect generalization in the community.
5. Pick additional cognitive constructs to be retrained based on upstream/downstream Lurian brain organization –
“Where in the continuum of a cognitive domain does breakdown occur?”
3. Understand why “cookbook” matching of cognitive retraining technique to gross symptom often doesn’t work.
4. Understand why cognitive retraining by diagnoses/level of severity may not be effective, although that’s where the evidence is.
5. Cognitive retraining/psychotherapy is for those with co-morbidities.
Neuropsychological rehabilitation after closed head injury in young adults. Journal of Neurology, Neurosurgery, and Psychiatry, 47, 505-513, 1984.
A study by Klonoff et al, 2007 narrowed down the “success factors” for return to work/school even more.
One source of “personality change” is how family perceives the patient.
When questioned about how their loved one has changed in personality after acquired brain injury, family members mention anger and fatigue as the sources of “personality change” after ABI.
Zeiner, HK. Living with TBI: Impact on the Survivor and Their Family in Traumatic Brain Injury, Independent Study Course, Veterans Health Initiative: Traumatic Brain Injury, Department of Veterans Affairs, Employee Education System, p. 99-112, October 2003
What are the sources of the catastrophic reaction, e.g. What are the cognitive symptoms that are most likely to result in stimulus overload and dysphoric affect?
Some, but not all, cognitive impairments
What needs to be remediated first are: are the cognitive symptoms that are most likely to result in stimulus overload and dysphoric affect?
1. Those cognitive symptoms which are most likely to evoke one of the six catastrophic reactions.
2. They are remediated with a verbal cognitive construct which tells the patient what is wrong and what to do about it.
3. The performance of the cognitive construct is tied to either the presence of the catastrophic reaction (dysphoric affect) or
a physiological response.
“I am angry, so I must be overloaded. I need to simplify, avoid or delay.”
“What you just said is really important, could you give it to me one more time so I am sure to get it.?”
The cognitive remediation is all done in the context of a therapy which:
Alliance/Resilience Model of Therapy therapy which:
The optimal condition for rehabilitation of neurologically impaired patients is created when the patient, family and staff are allied against “demon” brain injury. This is the triangulation necessary for optimum recovery.
To Get Change With a Cognitive Strategy, “I use the latest/best compensation most effectively.
You Have to Have Three Parts to the Cognitive Construct
1.What is the specific problem (closely related to a basic unit of brain function)
2.What you have to do to correct the specific problem
3. Both must be learned by the Patient
Think of the survivor’s brain as Swiss cheese. There is plenty of good cheese — intact circuits that were unaffected by the injury. But now there are a few “holes” where cells were injured or destroyed.
If you can do a task and you allow your spouse to do it because he or she is “faster”- their brain gets the benefit, and you get the “cost”
For that moment they view you as “patient” not “spouse”
Order of Cognitive Remediation for Most Patients with Cognitive Impairment
Additional Early Issues to work on: Cognitive Impairment
Problems in fatigue: most often used in NPI Clinic at PAVA for cognitive treatment.
concept of mental energy budget
Management Strategy Disturbed Sleep/Wake Cycle. most often used in NPI Clinic at PAVA for cognitive treatment. In addition to medication, the treatment for sleep cycle disruption is to artificially impose a rigid bedtime and rise time on the patient. Choose a total sleep time, which is 1 to 1.5 hours longer than the patient’s pre-morbid length of sleep at night. Patients must go to bed at a set bedtime, whether or not they fall asleep. They need to rise at a set rise time and not nap during the next day, even if very tired.
It takes about 3 weeks to establish a new artificial day/night cycle.
It must be applied 7 days/week.
After the three weeks, patients can be allowed afternoon naps, but the schedule must be maintained. If the artificial pattern is broken, it always takes about three weeks to re-establish again.
All thinking requires some expenditure of mental energy. day/night cycle.
Cognitions such as:
switching attentional focus to a new person,
keeping up with the topic of conversation,
organizing an answer to a question,
making a decision,
trying to decide what to do next,
organizing your day’s activities in the morning
All cost mental energy.
Many of the cognitive functions, which are automatic and reflexive for people without BI, require 2-3 times the mental effort to accomplish for people with BI. This is due to the fact that people with BI often have to think about, and do with conscious effort, what the rest of the world does automatically, without thinking.
• Make as many activities as possible into a routine to minimize choice. This saves mental energy. • Do not fill up the days with scheduled activities, do one important thing/day
How to Compensate for the Symptom of Fatigue. minimize choice. This saves mental energy. • Make important decisions when the person has the greatest amount of mental energy, usually in the morning. Schedule patients with BI in the morning.• Make as many activities as possible into a routine to minimize choice. This saves mental energy. • Do not fill up the your day with scheduled activities.Do one important thing/day• The use of an organizer, either written, taped or electronic is essential.
Sometimes, people with BI drop off the “end” response.
They begin, do the middle, then begin something else, do the middle, then begin something else, etc.
By the end of the day-they have been busy, but they completed nothing.
Change in pre-morbid learning/memory characteristics-(usually patient is unaware of this):
If you are highly impulsive, you are jumping into action before your brain can size up what to do.
So, count (silently) to 4 before you answer or do anything.
The primary memory compensation: Patient knowing the characteristics of new memory functioning and that he/she needs to take steps to compensate for the changes.
When learning a new task, pay attention to how many steps the survivor can easily learn at once. Break multi-step tasks into groups of 2 or three steps. Over learn those before moving on to the next 2 steps.
Work with calendar in notebook/PDA characteristics-(usually patient is unaware of this):
Attention Control Systems
Don’t journal-use the calendar section as memory for what to do, what to bring, what to do today for tomorrow
Review today and tomorrow in the calendar after each meal
Put down cognitive retraining statements
Could you refresh my memory? What were we talking about?
What you are saying is very important. Could you repeat it for me?
Learn how many steps are your limit- Do Not Exceed.
That’s an important idea- Give me some time to think about it and I will get back to you later.
Because my “starter” is broken, I will make a comment or say something every time my family gets together (or I am in any social group).
Others judge us by our verbal output- if your talking has decreased, others will assume
silence= less smarts
Problems in social appropriateness: Constructs
Because I have trouble (spatially) reading other peoples faces, I need to ask how they are feeling to read them correctly.
Make like a psychologist and sprinkle your speech with “So how do you feel about that?”
Caretaking spouses often feel unappreciated for their extraordinary efforts.
Writing a couple of phrases of appreciation “You are such a wonderful partner, I’m so lucky to have you”. Or “Have I told you I love you?” in the patient’s memory book or electronic organizer every few days, (which the patient reviews after each meal) can make a spouse feel that their efforts are noticed.
Problem determining what is an outside and what is an inside thought-
Often patient exhibits “gumballing”- speaking thoughts, with no awareness of impact.
Counting delay plus “Is this an inside or an outside thought?” helps. What really helps is informing family that they are hearing the patient’s thoughts.
5:1 rule becomes 8:1 Constructs
Say 8 positive things for every “correction” you
Offer- to everyone.