Interventions in Clinical Neuropsychology - Theory
Wilson, B. A., Winegardner, J., Van Heugten, C. M., & Ownsworth, T. (eds.) (2017).
Neuropsychological rehabilitation. The international handbook. New York: Routledge
Table of contents
1. INTRODUCTION ................................................................................................................................... 3
1. The development of neuropsychological rehabilitation: an historical examination of theoretical and
practical issues ..................................................................................................................................................... 3
2. Evidence-based treatment ............................................................................................................................... 6
3. Mechanisms of recovery after acquired brain injury ....................................................................................... 8
4. Assessment for neuropsychological rehabilitation planning ......................................................................... 11
5. Goal setting in rehabilitation ......................................................................................................................... 13
Article – Cicerone et al. (2011) – Systematic review .......................................................................................... 15
2. VISUOSPATIAL FUNCTIONS ............................................................................................................... 20
19. Rehabilitation of visual perceptual and visual spatial disorders in adults and children.............................. 20
6. Adults with non-progressive brain injury ....................................................................................................... 22
Article – Van der Kuil et al. (2018) – Compensatory navigation training .......................................................... 28
3. ATTENTION AND EXECUTIVE FUNCTIONS ....................................................................................... 32
14. Rehabilitation of attention disorders ........................................................................................................... 32
17. Rehabilitation of executive functions .......................................................................................................... 36
Article – Krasny-Pacini et al. (2014) – Systematic review GMT for EF rehabilitation ........................................ 40
4. MEMORY AND AGING ......................................................................................................................... 44
7. Adults with progressive conditions ................................................................................................................ 44
15. Rehabilitation of working memory disorders .............................................................................................. 50
16. Rehabilitation of memory disorders in adults and children ......................................................................... 53
Article – Park & Bischof (2013) .......................................................................................................................... 56
5. DEVELOPMENT .................................................................................................................................. 61
8. Children with traumatic brain injury.............................................................................................................. 61
9. Other neurological conditions affecting children .......................................................................................... 64
18. Rehabilitation of language disorders in adults and children ....................................................................... 66
20. Rehabilitation of apraxia in adults and children.......................................................................................... 71
28. Psychosocial interventions for children/working with schools and families ............................................... 73
Article – Krull et al. (2018) ................................................................................................................................. 76
6. BEHAVIOUR AND EMOTIONS ............................................................................................................ 79
11. Neuropsychological rehabilitation for psychiatric disorders ....................................................................... 79
23. Managing disorders of social and behavioural control and disorders of apathy ........................................ 83
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24. Rehabilitation of challenging behaviour in community settings: The Empowerment Behavioural
Management Approach (EBMA)........................................................................................................................ 89
25. Cognitive behavioural therapy for people with brain injury ........................................................................ 94
29. Family-based support for people with brain injury...................................................................................... 98
Chapter – Klonoff – Managing stress and avoiding burnout........................................................................... 101
7. FATIGUE AND MEASURING OUTCOME ............................................................................................ 104
31. Managing fatigue in adults after acquired brain injury ............................................................................ 104
42. Outcome measures .................................................................................................................................... 108
43. Avoiding bias in evaluating rehabilitation ................................................................................................. 109
44. Challenges in the evaluation of neuropsychological rehabilitation effects ............................................... 112
45. Summary and guidelines for neuropsychological rehabilitation ............................................................... 115
Chapter – Wilson et al. (2003) – Rehabilitation programme behavioural framework.................................... 116
8. INNOVATION IN REHABILITATION ................................................................................................. 119
34. Novel forms of cognitive rehabilitation ..................................................................................................... 119
35. Using technology to overcome impairments of mental functions............................................................. 121
36. Technology-based delivery of neuropsychological rehabilitation ............................................................. 125
37. Social robotics in dementia care ................................................................................................................ 127
Article – Bastian (2008).................................................................................................................................... 129
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1. INTRODUCTION
1. The development of neuropsychological rehabilitation: an historical examination of
theoretical and practical issues
A brief history of the growth of neuropsychological rehabilitation
Ancient Egypt
- 2500-3000 years ago.
- First descriptions of cranial structures, meninges, external surface of brain, cerebrospinal fluid (CSF) +
intracranial pulsations.
- Broca’s patient couldn’t read words aloud → first taught to read letters, then syllables. Later whole
word approach (learn to recognise few words).
World War One → modern rehabilitation
- Soldiers with gunshot wounds to head.
- Goldstein (Germany): ‘Institute for Research into the Consequences of Brain Injuries’ → theory of brain-
mind relationships.
- Poppelreuter (Germany): treatment of soldiers with visuospatial + visuoperceptual disorders, also
vocational rehabilitation.
World War Two
- Physiotherapy for motor difficulties, mental institutions for cognitive/behavioural impairments.
- Luria (Soviet Union): ‘grandfather of neuropsychology’ → psychoanalytic psychology, objective
methods for assessing Freudian ideas about normalities of thoughts + effects of fatigue on mental
processes. WWII: army hospital, researching ways to compensate for psychological dysfunction in brain
damaged patients.
- Cairns (UK): the sooner wounds to head were treated, the better the prognosis. Mobile Neurosurgical
Units for operations + development of penicillin → mortality rate dropped 50%.
- Lord Nuffield (UK): developed machinery to produce metal plates used in the repair of skull damage.
- Zangwill (UK): re-education; first to categorise approaches of cognitive rehabilitation
o Compensation: reorganisation of psychological function so as to minimise/circumvent a
particular disability. Mostly spontaneous but can be due to own efforts/instructions. E.g.:
aphasia → give a slate to write; right hemiplegia → teaching to write with left hand.
o Substitution: building up of a new method of response to replace one damaged irreparably by
a cerebral lesion. Form of compensation but taken much further. E.g.: lip reading for deaf
people, Braille for blind people.
o Direct retraining (highest form): restoring of damaged functions through training.
- Cranich & Wepman: worked with language impaired people.
- Aita: post-acute head injury rehabilitation programme using interdisciplinary care system → patients
treated by team of physical + occupational therapists, psychologists, vocational specialists, social
worker, physician, case manager + relatives. Some therapeutic trials at home; also job therapy.
Yom Kippur War (1973) → Yehuda Ben-Yihsay (Israel): day treatment programme in 1975, which was forerunner
of holistic programmes.
More recent times
- Diller (USA): first cognitive rehabilitation programme.
- Goldstein + later Ben-Yishay: recognised that cognition, emotion + behaviour are interlinked, hard to
separate + should be addressed together in rehabilitation programmes → core of holistic approach.
Theoretical developments within neuropsychological rehabilitation
- Recovery: getting individual back to what one was like before injury/illness.
- Treatment: something we do/give to people (e.g., drugs).
- Rehabilitation: two-way interactive process whereby survivors of brain injury work together with
professional staff + others to achieve optimum physical, psychological, social + vocational well-being.
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Process of active change, use of all means to minimise the impact of disabling conditions + assist to
achieve desired level of autonomy and participation in society.
Early approaches to rehabilitation
- Powell (1981): 6 procedures ranging from non-intervention strategy (letting nature take its course) to
practice, to medical/biochemical/surgical treatments that can be combined with other treatments.
- Gross & Schutz: 5 steps of neuropsychological interventions, hierarchical.
1. Environmental control: patients who cannot learn.
2. Stimulus-response (S-R) conditioning: patients who can learn but cannot generalise.
3. Skill training: patients who can learn + generalise but cannot self-monitor.
4. Strategy substitution: patients who can self-monitor.
5. Cognitive cycle: patients who can learn, generalise, self-monitor + set their own goals.
→ BUT: therapists may not be able to determine whether patient can learn/generalise (e.g., can learn when in
coma) + we can teach generalisation.
Cognitive functioning
- Area where theory has been most influential in rehabilitation, especially with language + reading
disorders.
- Baddeley: model = representation that can help to understand + predict phenomena.
- Coltheart: in order to treat deficit, it’s necessary to fully understand its nature → should have in mind
how function is normally achieved; without model, can’t determine what treatment is appropriate.
- BUT: model is perhaps limited in rehabilitation because…
o Models allow us to understand nature of deficit/what is wrong, but don’t explain how to
repair.
o People undergoing rehabilitation rarely have isolated deficits, as identified by models.
o In rehabilitation, patients are more likely to require help with everyday problems, rather than
solely help with impairment identified by models.
→ Models insufficient for developing rehabilitation programmes.
Learning
- Baddeley:
o Theory of rehabilitation needs a model of learning.
o In rehabilitation, there’s difficulty distinguishing between learning + memory.
▪ Memory (at east episodic memory): ability to recall personally experienced events.
▪ Learning: any system/process that results in modification of behaviour by experience.
- Goodkin: one of the first to explicitly advocate behavioural techniques with brain injure adults →
behavioural strategy operant conditioning initially applied to motor problems, later to dysphasia to
improve language skills, in late 1970s to cognitive problems.
- Nowadays, behavioural approaches are used in rehabilitation to reduce/compensate for cognitive
deficits (memory, perceptual, language + reading disorders). These behavioural modification
techniques are incorporated into cognitive rehabilitation because they provide structure, a way of
analysing cognitive problems, means of assessing everyday manifestation of cognitive problems + a
means of evaluating efficacy of treatment; also supply us with many strategies which can be adapted to
particular rehabilitation purposes.
Emotion
- Understanding of theories + models of emotion is crucial to successful rehabilitation.
- Cognitive behavioural therapy (CBT): one of most important + best validated psychotherapeutic
procedures. Strengths:
o Many clinically relevant theories for multiple disorders
o Suited for improving coping skills
o Helps clients to manage cognitive difficulties.
o Addresses more generalised anxiety and depression.
- Compassion focused therapy (CFT): emphasises emotional experience associated with psychological
problems. Draws on social, evolutionary (especially attachment theory) + neurophysiological
approaches to change disturbed feelings.
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o Vs. CBT: different focus → CFT promotes the development of emotions as kindness, support,
care, encouragement + validation as part of psychological interventions, especially when high
in self-criticism → identify self-criticism + help people refocus on self-compassion.
- Analytic psychotherapy (Prigatano): when given together with cognitive rehabilitation, then improved
emotional functioning, incl. lessened anxiety + depression → diminish psychologic distress + improve
cognitive functioning.
Assessment
- Systematic collection, organisation + interpretation of information about a person + his/her situation.
- Theories used in assessment:
o Psychometric approach based on statistical analysis.
o Localisation approach: assessing which brain parts are damaged.
o Assessments derived from theoretical models of cognitive functioning.
o Definition of syndrome through exclusion of other explanations (e.g., failure to recognise
objects in agnosia due to poor eyesight + impaired naming ability).
o Ecologically valid assessments which predict problems in everyday life.
- BUT: assessments can’t give sufficient details of the everyday problems. We need to know:
o What problems are causing the greatest difficulty.
o What coping strategies are used.
o Whether problems are exacerbated by anxiety or depression.
o If this person can return to work etc.
→ Use more functional/behavioural procedures, incl. direct observation, self-report measures of
interviewing techniques.
Identity
- Social identity theory (Tajfel & Turner): person’s self-concept derived from his/her perceived
membership of relevant social group → group memberships are integral to our sense of self + are not
easily separable (e.g., forced to give up work → lose professional identity → loss of self-esteem). Less
social support, quality of life + sense of well-being.
o Stroke survivors: membership of multiple groups buffer people against negative effects of
brain injury.
o Brain injury can affect virtually any aspect of functioning and, at deepest level, can alter one’s
sense of self or essential qualities that define who we are.
- Theory of self-categorisation (Jetten et al., 2012): group memberships are integral to our sense of self +
are not easily separable.
- ‘Y’ shaped model (Gracey et al., 2009): a complex + dynamic set of biological, psychological + social
factors interact to determine the consequences of acquired brain injury → integration of psychosocial
adjustment, awareness + well-being, attempt to reduce discrepancy between old ‘me’ and new ‘me’.
Holistic approach
- Ben-Yishay & Prigatano (1990): model of hierarchical stages in holistic approach through which patient
must work in rehabilitation:
o Stages (in order): engagement, awareness, mastery, control, acceptance + identity.
o Goal: integrate cognitive, social, emotional + functional aspects of brain injury given that how
we feel affects how we behave + how we think.
- Holistic approaches are concerned with:
o Increasing individual’s awareness of what has happened to him/her.
o Increasing acceptance + understanding of what has happened.
o Providing strategies/exercises to reduce cognitive problems.
o Developing compensatory skills.
o Providing vocational counselling.
- Include both group + individual therapy.
- Evidence for effectiveness after moderate/severe traumatic brain injury (TBI).
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