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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 harriet.zeiner@va.gov.

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How to lessen the effect of tbi in returning soldiers or civilians l.jpg

How to Lessen the Effect of TBI in Returning Soldiers or Civilians

Helping the Person with Neurological Impairment Re-invent Themselves?


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By Civilians

Harriet Katz Zeiner, PhD

Outpatient Neuropsychological Assessment and Intervention Clinic

Palo Alto VA Healthcare System

harriet.zeiner@va.gov


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The CRATER Model of Civilians

Psychotherapy for Persons with

Neurological Impairment has 4 areas of

modification of your current technique


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2. Understand the catastrophic reaction: re-occurring tasks to physiological events

what do they look like when cognitively overloaded.

  • tie the performance of the cognitive strategy to the catastrophic reaction.

  • pick up the catastrophic reaction earlier.


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3. Externalize the problem and use triangulation- re-occurring tasks to physiological events

Therapist, Client and Family allied against

Demon Brain Injury


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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


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How to modify your techniques? influencing social interactions- and what to do about them.

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 –

or

“Where in the continuum of a cognitive domain does breakdown occur?”


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Here it is another way: What influencing social interactions- and what to do about them.

  • What needs a cognitive strategy? What needs to be compensated for :

    • First, on what gives the patient the most frequent grief based on symptomatology of neurological insult

    • 1. fatigue and

    • 2. being overwhelmed with information coming too quickly, slowed information processing, leading to dysphoric affect (catastrophic reaction, i.e. anger, tears, flight, freezing, confusion, helpless laughter).

    • Secondly, link the performance of a compensation or device use to either:

    • 1. dysphoric affect (catastrophic reaction) or

    • 2. a physiological response to increase generalization


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How influencing social interactions- and what to do about them.

  • Externalizes the symptom as belonging to the neurological insult (Demon Brain Injury).

  • Recognize anger at loss is not pathological, but useful if directed properly-at the neurological insult.

  • Re-defines the person’s source of self esteem from “ I am the fastest, best, brightest, the most competitive winner.” to “I use my cognitive compensation whenever needed, I cope most effectively.”


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How continued influencing social interactions- and what to do about them.

  • re-direct the anger constantly to the externalized neurological insult,

    • give a new framework for self-esteem with performing the cognitive strategy as the core strategy for coping

    • Stress the alliance of the patient/family/therapist/team against the neurological insult (triangulation)

    • Pace the learning of cognitive constructs to the patient’s new learning/memory/attention characteristics-always slower

    • Share the cognitive strategy with team members, family members and have everyone practice it together.


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Don’ts influencing social interactions- and what to do about them.

  • Don’t blame the patient for lack of motivation when cognitive retraining/therapy isn’t being successful. Assume that you have entered the cognitive continuum at the wrong point and correct.

  • Don’t assume that the Device is the therapeutic agent of change.

    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.


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Holistic Integrated Neuropsych Remediation Programs Work for ABI

  • Prigatano, GP, Fordyce, DJ, Zeiner, HK, Roueche, RR, Pepping, M, and Wood, BC:

    Neuropsychological rehabilitation after closed head injury in young adults. Journal of Neurology, Neurosurgery, and Psychiatry, 47, 505-513, 1984.

  • Klonoff et al 1998, 2000 (11 years post discharge)

  • Malec, J. 2001

  • Cicerone et al 2008


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A study by Klonoff et al, 2007 narrowed down the “success factors” for return to work/school even more.


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  • Who is most successful after TBI: cognitive remediation INTEGRATED with psychotherapy.

    • Those who can learn to use remediations unassisted,

    • Those who ally with therapists, and

    • Those who slow the world down to what they need.


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Findings cognitive remediation INTEGRATED with psychotherapy.

  • Perceived cognitive functioning/need was not a strong factor in influencing whether or not a subject used a cognitive support technology.

    • Emphasizing level of impairment may not help at all in getting a client to use CST.

  • Pre-morbid Sophisticated technology users want more freedom and autonomy than non-users post-injury.

    • For them, the appeal of device is freedom from others control.

  • Pre-morbid Minimal technology users appear to use technology (cell phones) to bring them together with others.

    • Appeal of CST device (different device) is social bonding.


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    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


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    Identification of the Catastrophic Reaction patient’s neurological condition.

    • Behavioral freezing/thought blocking

    • Behavioral appearance of confusion without verbally seeking clarification

    • Crying

    • Flight

    • Anger

    • Laughing

    • All six are uncomfortable emotional responses given by persons with neurological impairment when stimulus overloaded.


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    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


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    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.


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    • This changes the relationship of the patient to their catastrophic reaction.

    • First- it is no longer a personality change or a failure- the dysphoric affect is a flag, a warning that the patient is overloaded.

    • The identification of the catastrophic reaction by the patient is reframed as

      “I am angry, so I must be overloaded. I need to simplify, avoid or delay.”


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    • Patient’s learn their characteristic catastrophic reaction- pick it up as early as possible, and perform the cognitive construct to reduce stimulus overload at that moment.

    • These cognitive constructs are almost always tied to ways of receiving informational input- example,

    • “because I am slowed in processing, I need to ask you to repeat that information.”


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    • If not tied to dysphoric affect, the catastrophic reaction, the cognitive construct is tied to a daily physiological response. This is to reduce the cognitive burden on memory.

    • For example, patients who use either an electronic calendar or paper memory book with a calendar- review today and tomorrow in the calendar after every meal.

    • The cognitive construct is ”because I have a leaky memory, I need to review today and tomorrow in my calendar after every meal.”


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    The cognitive remediation is all done in the context of a therapy which:

    • 1. Externalizes the neurological insult.

    • 2. The patient’s goal is to reduce the effect of externalized Brain Injury on the patient’s life.

    • 3. Change the source of satisfaction, sense of competence from “competing to be best” to “I compensate whenever necessary; I cope adequately, a resilience model.

    • 4. Focuses on “well-being”


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    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.


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    • Alliance/Resilience model is based on redirected anger. therapy which:

    • Anger is always generated when loss is experienced.

    • It is adaptive, Anger creates energy to prevent collapsing in despair, and fuels the need to change. It is always present. It is natural part of the history of recovery.

    • It is not pathological or delusional.


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    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


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    Some Neuropsych Tips Caregivers Should Know (as in train the trainer)

    • They cannot multitask-now a one trick pony

    • Inside/ outside line moved (gum-balling, seems rude, hurtful)

    • Lack ideas

    • Initiation difficulty (broken ignition, broken starter)


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    Dependency- When the Survivor Can But Doesn’t Do Something (as in train the trainer).

    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.


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    He or She who does the task- that’s whose brain is being re-wired.

    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”



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    Additional Early Issues to work on: Cognitive Impairment

    • How to not be overwhelmed by the world.

    • Impulsivity and delay.

    • Gumballing, or the line between what’s an inside thought, what’s an outside thought-private versus public thoughts.

    • Beginning, middle and end of behavior chain.


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    • I’d like to present to you the cognitive symptoms that are most often used in NPI Clinic at PAVA for cognitive treatment.

    • This is a clinic that performs 6-8 hour neuropsychological assessments on persons with cognitive impairments, not so much for diagnostics, as for treatment recommendations.

    • About 25 % of the patients are then seen in individual therapy/cognitive remediation by the therapist, who also co-treats with their family member if possible.


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    Problems in fatigue: most often used in NPI Clinic at PAVA for cognitive treatment.

    • loss of regular day/night cycle

    • poor sleep

    • doing with conscious effort what the rest of us do automatically-

      concept of mental energy budget


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    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.


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    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.


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    All thinking requires some expenditure of mental energy. day/night cycle.

    Cognitions such as:

    paying attention,

    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.


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    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.


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    • 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


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    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.


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    Problems With Sequencing: minimize choice. This saves mental energy. Every activity has a beginning, middle and an end.

    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.


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    Change in pre-morbid learning/memory characteristics-(usually patient is unaware of this):

    • Reduction of learning span for new material

    • no longer able to operate in 50% range of ability- cannot smooth out behavior

    • poor retrieval unless over-learned

    • Reduced memory consistency/efficiency


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    Retraining Impulsivity 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.


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    Learning/Memory: teaching new characteristics characteristics-(usually patient is unaware of this):

    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.


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    Learning/Memory: teaching new characteristics characteristics-(usually patient is unaware of this):

    Registration

    • working span (no. of bits or chunks)

    • effect of overage

    • no. of verbal stage commands (1,2,3)

    • Sawtooth learning curve of acquisition

    • New limits of asymptote (not 100%)

    • Massed vs. distributed practice

    • What was premorbid learning style

    • Passive vs. active learner (groups material)

    • Fatigability (effect on accuracy)

    • Over learning (repetitions to 100%, reps to over learning)


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    Compensation for Reduced Learning Ability characteristics-(usually patient is unaware of this):

    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.


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    Work with calendar in notebook/PDA characteristics-(usually patient is unaware of this):

    • Review today/tomorrow in calendar after meals

    • How to break down tasks for calendar


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    Planning Aids for characteristics-(usually patient is unaware of this):Cognitive Disorders

    Attention Control Systems

    brainaid.com


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    Cue Card characteristics-(usually patient is unaware of this):

    • Focus only on current activity

    • Automatically jumps to Cue Card

    • Cues include pictures and sounds (from camera and voice recorder)

    • Keeps cueing until user responds

    • Different levels of cues: subtle to explicit


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    Learning/Memory: teaching new characteristics characteristics-(usually patient is unaware of this):

    Verbal compensations:

    • I’m sorry, you are rushing ahead too fast for me. Please slow down.

    • I didn’t catch that. Please repeat what you said.

    • Because of my memory problem, I need to use my notebook.

    • Because of my leaky memory, I need to review today and tomorrow in my notebook calendar after each meal.


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    Notebook Stuff characteristics-(usually patient is unaware of this):

    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


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    Verbal Compensations For Poor Memory characteristics-(usually patient is unaware of this):

    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.


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    Verbal Compensations For Poor Memory and Anger Outbursts characteristics-(usually patient is unaware of this):

    That’s an important idea- Give me some time to think about it and I will get back to you later.


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    Initiation Compensations characteristics-(usually patient is unaware of this):

    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


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    Problem solving (non interpersonal Content): Additional Constructs

    • When I don’t know what to do , I need to say, can you help me?

    • Because I have trouble with new problems, I need to ask someone to help me break this into steps.

    • When solving a problem, I have a tendency to not see the big picture, and I get caught by detail. I should check with someone before deciding.

    • I should talk my way through the problem while solving it, this tends to make me aware of additional things I know to solve the problem.


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    Problems in social appropriateness: Constructs

    • Inability to de-center in conversation

    • Inability to read others emotional expressions

    • Inability to read complex social situations visually

    • Inability to negotiate (de-centering and multi-track)

    • Line between inside thought/outside thought has moved. (Gumballing)

    • Age of injury/insult precluded learning some social schema (Shank and Abelson)


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    Trouble Reading Other’s Emotions 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?”


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    Social Problem Solving Constructs

    Negotiating:

    • State the other persons main point. What do they want?

    • State your point. What do you want?

    • State a sentence which includes half of what they want and half of what you want.


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    Social Compensation’s Constructs

    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.


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    Social Problem Solving Constructs

    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.


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    Conclusions Constructs

    • 1. Work on that which results in stimulus overload.

    • 2. Link performance of a cognitive strategy to patient’s catastrophic reaction.

    • 3. Link performance of a cognitive strategy to a physiological response.

    • 4. Externalize the neurological insult and triangulate the patient/family/therapist against it.

    • 5. Work to change the source of self-esteem from a “competitive best” model to a resilience (performance of the construct whenever needed) model.


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    5:1 rule becomes 8:1 Constructs

    Say 8 positive things for every “correction” you

    Offer- to everyone.