ANRV339-CP04-06 ARI 22 February 2008 16:40 Annu. Rev. Clin. Psychol. 2008.4:141-162. Downloaded from www.annualreviews.org by Universidad de Chile on 07/07/14. For personal use only. Neuropsychological Rehabilitation Barbara A. Wilson Cognition and Brain Sciences Unit, Medical Research Council, Addenbrooke’s Hospital, Cambridge CB2 2QQ, United Kingdom; email: barbara.wilson@mrc-cbu.cam.ac.uk Annu. Rev. Clin. Psychol. 2008. 4:141–62 Key Words First published online as a Review in Advance on December 11, 2007 brain injury, cognition, emotion, psychosocial, holistic programs The Annual Review of Clinical Psychology is online at http://clinpsy.annualreviews.org This article’s doi: 10.1146/annurev.clinpsy.4.022007.141212 c 2008 by Annual Reviews. Copyright All rights reserved 1548-5943/08/0427-0141$20.00 Abstract Neuropsychological rehabilitation (NR) is concerned with the amelioration of cognitive, emotional, psychosocial, and behavioral deficits caused by an insult to the brain. Major changes in NR have occurred over the past decade or so. NR is now mostly centered on a goal-planning approach in a partnership of survivors of brain injury, their families, and professional staff who negotiate and select goals to be achieved. There is widespread recognition that cognition, emotion, and psychosocial functioning are interlinked, and all should be targeted in rehabilitation. This is the basis of the holistic approach. Technology is increasingly used to compensate for cognitive deficits, and some technological aids are discussed. Evidence for effective treatment of cognitive, emotional, and psychosocial difficulties is presented, models that have been most influential in NR are described, and the review concludes with guidelines for good practice. 141 ANRV339-CP04-06 ARI 22 February 2008 16:40 Contents Annu. Rev. Clin. Psychol. 2008.4:141-162. Downloaded from www.annualreviews.org by Universidad de Chile on 07/07/14. For personal use only. INTRODUCTION: WHAT IS NEUROPSYCHOLOGICAL REHABILITATION? . . . . . . . . . . . . HOW HAS NEUROPSYCHOLOGICAL REHABILITATION CHANGED IN RECENT YEARS? . . . . . . . . . . . Goal Setting to Plan Rehabilitation . . . . . . . . . . . . . . . . . Cognitive, Emotional, and Psychosocial Deficits are Interlinked . . . . . . . . . . . . . . . . . . . . Increasing Use of Technology in Neuropsychological Rehabilitation . . . . . . . . . . . . . . . . . Rehabilitation Needs a Broad Theoretical Base . . . . . . . . . . . . . . COGNITIVE ASPECTS OF NEUROPSYCHOLOGICAL REHABILITATION . . . . . . . . . . . . . EMOTIONAL ASPECTS OF NEUROPSYCHOLOGICAL REHABILITATION . . . . . . . . . . . . . PSYCHOSOCIAL ASPECTS OF NEUROPSYCHOLOGICAL REHABILITATION . . . . . . . . . . . . . MODELS AND THEORETICAL APPROACHES CONTRIBUTING TO NEUROPSYCHOLOGICAL REHABILITATION . . . . . . . . . . . . . GUIDELINES FOR GOOD PRACTICE IN NEUROPSYCHOLOGICAL REHABILITATION . . . . . . . . . . . . . SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . 142 144 144 145 146 147 147 149 151 153 154 156 INTRODUCTION: WHAT IS NEUROPSYCHOLOGICAL REHABILITATION? Most people receiving rehabilitation for the consequences of brain injury have both cognitive and noncognitive problems. A typical patient in a rehabilitation center has 142 Wilson several cognitive problems such as poor attention, poor memory, and planning and organizational difficulties, together with some emotional problems such as anxiety, depression, or in some cases, post-traumatic stress disorder. The patient may exhibit behavior problems such as poor self-control or anger outbursts and may experience some subtle motor difficulties leading to reduced stamina and unsteady gait, as well as problems connected with social skills and relationships. In addition, the patient’s family members may be unable to comprehend what has happened to the person they once felt they knew and understood, and the patient will probably struggle with issues connected with the continuation of work or education. Tables 1 and 2 show the main patient groups seen by neuropsychologists working in rehabilitation and the main problems these patients face. We can define neuropsychology as the study of the relationship between brain and behavior. One of the major differences between academic neuropsychologists engaged in rehabilitation research and clinical neuropsychologists working in rehabilitation centers is the manner in which the needs of brain-injured people are determined. Academic neuropsychologists believe that detailed assessments informed by theoretical models can highlight areas that require rehabilitation. Thus, testing of different components contained in a model of language can identify a particular deficit as the area to work on in rehabilitation (Caramazza & Table 1 Main patient groups seen by neuropsychologists working in rehabilitation Main groups seen for rehabilitation Traumatic brain injury Stroke (cerebrovascular accident; CVA) Infections of the brain (e.g., encephalitis) Hypoxic brain damage Other groups sometimes seen Progressive conditions (e.g., Alzheimer’s disease, multiple sclerosis) Cerebral tumors Epilepsy (idiopathic) Annu. Rev. Clin. Psychol. 2008.4:141-162. Downloaded from www.annualreviews.org by Universidad de Chile on 07/07/14. For personal use only. ANRV339-CP04-06 ARI 22 February 2008 16:40 Hillis 1993). Clinical neuropsychologists, on the other hand, are less likely to determine rehabilitation needs through theoretically informed models and are more likely to target real-life problems identified by patients and their families. As discussed below, both approaches play a part in the rehabilitation of individuals who have sustained an insult to the brain. A good definition of rehabilitation is provided by McLellan (1991). He suggests that rehabilitation is a two-way, interactive process whereby people who are disabled by injury or disease work together with professional staff, relatives, and members of the wider community to achieve their optimum physical, psychological, social, and vocational well-being (McLellan 1991). Using McLellan’s definition as a guide, we can define cognitive rehabilitation as a process whereby people with brain injury work together with professional staff and others to remediate or alleviate cognitive deficits arising from a neurological insult. Although cognitive rehabilitation is often a major part of the work of clinical neuropsychologists, they are also increasingly involved in a wider range of issues. Thus, it could be argued, neuropsychological rehabilitation (NR) is broader than cognitive rehabilitation, as it is concerned with the amelioration of cognitive, emotional, psychosocial, and behavioral deficits caused by an insult to the brain. McLellan (1991) believed that rehabilitation, unlike surgery or drugs, is not something that is done to or given to individuals. Instead, the disabled person is part of a two-way interactive process. This view reflected a growing change in rehabilitation. For many years, persons with a disability were told what to expect in and from rehabilitation; the rehabilitation staff determined what areas to work on, what goals to set, and what was and was not achievable. Sometime in the 1980s, the philosophy began to change, at least in some centers, so that in many rehabilitation programs today, clients and families are asked about their expectations, and rehabilitation goals are discussed and negotiated between all parties Table 2 Problems faced by survivors of brain injury A. Problems faced by survivors of brain injury Motor Sensory Cognitive Behavioral Social Emotional Pain Fatigue, etc. C. Typical emotional and psycho-social problems Anxiety Depression Anger Fear Social isolation Grief Poor self-esteem Lack of confidence · · · · · · · · · · · · · · · · B. Typical cognitive problems · · · · · · · · Memory Attention Communication Planning Organization Reasoning Perception Spatial awareness D. Typical behavior problems · · · · · · · Temper outbursts Shouting Swearing Physical aggression Disinhibition Poor self control Refusal to cooperate, etc. involved. The focus of treatment is on improving aspects of everyday life and, as Ylvisaker & Feeney (2000, p. 13) say, “rehabilitation needs to involve personally meaningful themes, activities, settings and interactions.” An example of this is provided by Wilson et al. (2002), who describe the treatment of a man with both a stroke and a head injury. One of this man’s goals was to fly his model helicopter again—an important goal for him that would never have been considered 30 years ago. Tate et al. (2003), in descriptions of their service for people with brain injury, also imply that partnership is important, and Clare (2007) describes how people with dementia are encouraged to select their own targets for treatments. This is a much healthier state of affairs than providing clients with experimental or artificial material on which to work. Motivation is likely to be increased because all those involved are working on real-life problems, which also prevents generalization difficulties. Because the ultimate goal of rehabilitation is to enable people with disabilities to function as adequately as possible in their own, most appropriate, environments (Ben-Yishay 1996), real-life issues www.annualreviews.org • Neuropsychological Rehabilitation NR: neuropsychological rehabilitation Goal: the state (or change in state) that an intervention or course of action intends to achieve Stroke: a brain injury caused by a sudden interruption of blood flow 143 ANRV339-CP04-06 ARI 22 February 2008 16:40 should be at the forefront of rehabilitation programs. Acquired brain injury: a nondegenerative injury to the brain that has occurred since birth HOW HAS NEUROPSYCHOLOGICAL REHABILITATION CHANGED IN RECENT YEARS? Annu. Rev. Clin. Psychol. 2008.4:141-162. Downloaded from www.annualreviews.org by Universidad de Chile on 07/07/14. For personal use only. In some ways, NR today is similar to that provided to soldiers in Germany in World War I and in Russia and the United Kingdom in World War II. In their historical review of NR in Germany, Poser et al. (1996) remind us, “Many of the rehabilitation procedures developed in special military hospitals during World War I are still in use today in modern rehabilitation—at least to some extent” (p. 259). The vocational rehabilitation described by Poppelreuter in 1917 (translated by Zihl & Weiskrantz 1991) is not unlike that provided today. In addition, Poppelreuter (1917) argued for an interdisciplinary approach between psychology, neurology, and psychiatry, and in a paper published in 1918, he emphasized the importance of the patient’s own insight into the effects of disabilities and treatment. Goldstein (1942), also writing about the First World War, stressed the importance of cognitive and personality deficits following brain injury and touched upon what today would be called “cognitive rehabilitation strategies” (Prigatano 2005). In 1918, Goldstein (quoted by Poser et al. 1996) was concerned with decisions as to whether to try to restore lost functioning or to compensate for lost or impaired functions, and this debate is still ongoing today. During the Second World War, Luria in the (then) Soviet Union and Zangwill in the United Kingdom were both working with brain-injured soldiers. One important principle, stressed by both Luria and Zangwill, was that of functional adaptation, whereby an intact skill is used to compensate for a damaged one. Goldstein was also committed to a similar concept. Luria’s publications of 1963 and 1970 and his book with Naydin, Tsvetkova, and Vinarskaya (Luria et al. 1969) are well 144 Wilson worth reading today for the insights they offer. So too is Zangwill’s (1947) paper in which he discusses, among other things, the principles of re-education and refers to three main approaches to rehabilitation: compensation, substitution, and direct retraining. Despite these similarities in concepts, there have been major changes, four of which are addressed in this section. The first is goal setting to plan rehabilitation programs; second is a growing recognition that cognitive, emotional, and psychosocial difficulties should all be addressed in rehabilitation; third is the increasing use of technology to compensate for cognitive difficulties; and fourth is a realization that NR requires a broad theoretical base or indeed a number of theoretical bases. Goal Setting to Plan Rehabilitation The Concise Oxford Dictionary (1999) defines a goal as an “object of effort” or a “destination.” In a discussion of rehabilitation goals, Wade (1999) suggests, “A goal is the state or change in state that is hoped or intended for an intervention or course of action to achieve.” When we negotiate goals with our patients, their families, and the rehabilitation team, we are looking for something that the client/patient both will do and wants to do; this should be something that reflects the longer-term targets and indeed the steps toward them. Goals are important regulators and motivators of human performance and action (Austin & Vancouver 1996) and a desired outcome by which progress can be measured. Goal setting has been used in rehabilitation for a number of years with various diagnostic groups including people with cerebral palsy, spinal injuries, developmental learning difficulties, and acquired brain injury (McMillan & Sparkes 1999). Because goal planning is simple, focuses on practical everyday problems, is tailored to individual needs, and avoids the artificial distinction between many outcome measures and real-life functioning, it is used increasingly in rehabilitation Annu. Rev. Clin. Psychol. 2008.4:141-162. Downloaded from www.annualreviews.org by Universidad de Chile on 07/07/14. For personal use only. ANRV339-CP04-06 ARI 22 February 2008 16:40 programs. This approach provides direction for rehabilitation, identifies priorities for intervention, evaluates progress, breaks rehabilitation down into achievable steps, promotes team working, and results in better outcomes (Nair & Wade 2003). McMillan & Sparkes (1999) proposed several principles involved in the goal-planning approach. First, the patient should be engaged in setting his or her goals. Second, the goals set should be reasonable and client centered. Third, patient’s behavior when a goal is reached should be described. Fourth, the method to be used in achieving the goals should be defined in such a manner that anyone reading the plan would know what to do. In addition, goals should be specific and measurable and have a definite deadline. In most rehabilitation centers, long-term goals are those that the patient or client is expected to achieve by the time of discharge from the program, whereas short-term goals are the steps set each week or fortnight in order to achieve the long-term goals. An acronym that summarizes the main principles is SMART: Goals should be specific, measurable, achievable, realistic, and timely. The process of goal planning typically involves the allocation of a chairperson who conducts all meetings, limits meetings to the agreed upon time, clarifies for team members the aims of admission and the length of stay, actively participates as a member of the rehabilitation team, and ensures documentation is complete. The chairperson should also ensure good communication between all relevant parties, attend case conferences, coordinate reports, encourage clients, relatives, and staff members to be realistic, and make clear arguments to the relevant people for changes to the discharge date. Following a detailed assessment period, the first goal-planning meeting is held, a problem list is drawn up, and potential long-term goals are identified. The goals are then discussed with the client and the family, and the final goals are negotiated and agreed upon. Both long-term and short-term goals are documented. If it is con- sidered helpful, the client and the family members involved are given a copy of the short-term goals to be achieved by the following week or fortnight. Progress is reviewed every one or two weeks in a 30-minute meeting with the rehabilitation team. Additional short-term goals are set and, if necessary, additional long-term goals are added. If any longor short-term goals are not achieved or are only partially achieved, the reasons for this are recorded. Failure to achieve a goal is attributed to reasons in one of four main categories: (a) client/patient or carer (e.g., client unwell); (b) staff member (e.g., staff member absent through illness); (c) internal administration (e.g., transport failed to arrive); or (d ) external administration (e.g., funding withdrawn by rehabilitation purchaser) (McMillan & Sparkes 1999). Wilson et al. (2002) describe a successful goal-planning approach for a man who sustained both a head injury and a stroke. Manly (2003) discusses the targeting of functional goals in treatment. Williams (2003) says goal-setting procedures are one of the main components of programs dealing with cognitive and emotional disorders. Most British rehabilitation centers follow a goal-planning approach (Sopena et al. 2007). Further support comes from Kendall et al. (2006), whose meta-analysis suggests, “[D]irect patient involvement in neurorehabilitation goal setting results in significant improvements in reaching and maintaining those goals” (p. 465). SMART: acronym applied to goals that are specific, measurable, achievable, realistic, and timely Cognitive, Emotional, and Psychosocial Deficits are Interlinked Although cognitive deficits are, perhaps, the major focus of NR, there is a growing awareness that the emotional and psychosocial consequences of brain injury need to be addressed in rehabilitation programs. Furthermore, it is not always easy to separate cognitive, emotional, and psychosocial problems from one another. Not only does emotion affect how we think and how we behave, but also cognitive deficits can be exacerbated by www.annualreviews.org • Neuropsychological Rehabilitation 145 ARI 22 February 2008 16:40 emotional distress and can cause apparent behavior problems. Psychosocial difficulties can also result in increased emotional and behavioral problems, and anxiety can reduce the effectiveness of intervention programs. There is clearly an interaction between all these aspects of human functioning, as recognized by those who argue for the holistic approach to brain injury rehabilitation. This approach, pioneered by Diller (1976), Ben-Yishay (1978), and Prigatano (1986), is founded on the belief that the cognitive, psychiatric, and functional aspects of brain injury should not be separated from emotions, feelings, and selfesteem. Holistic programs include group and individual therapy in which patients are (a) encouraged to be more aware of their strengths and weaknesses, (b) helped to understand and accept these, (c) given strategies to compensate for cognitive difficulties, and (d ) offered vocational guidance and support. Prigatano (1994) suggests that such programs appear to result in less emotional distress, increased selfesteem, and greater productivity. Prigatano (1999, 2005) and Sohlberg & Mateer (2001) describe the importance of dealing with the cognitive, emotional, and psychosocial consequences of brain injury. Wilson et al. (2000) present a British holistic program, based on the principles of Ben-Yishay (1978) and Prigatano (1986), that is followed at the Oliver Zangwill Center for Neuropsychological Rehabilitation in Ely, Cambridgeshire. Although these programs appear to be expensive in the short term, they are probably cost-effective in the long term (see Prigatano & Pliskin 2002). Williams (2003), who is concerned with the rehabilitation of emotional disorders following brain injury, suggests that survivors are at particular risk of developing mood disorders. He argues that this is one of the key areas for development in neurological services. Alderman (2003) targets behavior disorders in work with some of the most severely disturbed brain-injured people in the United Kingdom. Annu. Rev. Clin. Psychol. 2008.4:141-162. Downloaded from www.annualreviews.org by Universidad de Chile on 07/07/14. For personal use only. ANRV339-CP04-06 146 Wilson Increasing Use of Technology in Neuropsychological Rehabilitation The increasing use of sophisticated technology such as positron emission tomography and functional magnetic resonance imaging is enhancing our understanding of brain damage (see, for example, Coleman et al. 2007). To what extent these methodologies can improve our rehabilitation programs remains to be seen. What is clear is the value of technology for reducing everyday problems of people with neurological damage. One of the major themes in rehabilitation is the adaptation of technology for the benefit of people with cognitive impairments. Computers, for example, may be used as cognitive prosthetics, as compensatory devices, as assessment tools, or as a means for training. Given the current expansion in information technology, this is likely to be an area of growth and increasing importance in NR in the next decade. One of the earliest papers referring to the use an electronic aid with a person with brain damage was that by Kurlychek (1983). This was important because the aid assisted in tackling a real-life problem, which was to teach a man to check his timetable. In 1986, Glisky and colleagues taught memory-impaired people computer terminology; as a result, one of their participants was able to find employment as a computer operator. Kirsch and colleagues (1987) designed an interactive task guidance system to assist brain-injured people in performing functional tasks. Since then, reports of successful use of technology with braininjured people have appeared in many papers. Boake (2003) includes discussion of some of the early computer-based cognitive rehabilitation programs, and Wilson et al. (2001) describe a randomized control crossover design that demonstrates it is possible to reduce the everyday problems of neurologically impaired people with memory and/or planning difficulties by using a paging system. The reminders do not always have to be specific. Based on work by Robertson et al. (1997) and Manly et al. (1999), Fish et al. (2007) found that Annu. Rev. Clin. Psychol. 2008.4:141-162. Downloaded from www.annualreviews.org by Universidad de Chile on 07/07/14. For personal use only. ANRV339-CP04-06 ARI 22 February 2008 16:40 sending general reminders to “stop, think, organize and plan” led to improvement in a prospective memory task. These content-free reminders work for people whose prospective memory problems result from executive deficits such as poor planning or divided attention difficulties. For those with severe memory problems, however, a specific reminder would be required. Virtual reality (VR) represents another technology that will likely play an increasing role in rehabilitation. VR can be used to simulate real-life situations and thus be beneficial for both assessment and treatment. Rose et al. (2005) provide a review of the way VR has been used in brain injury rehabilitation; in addition, they discuss the use of VR for the assessment and treatment of memory problems, executive deficits, visuo-spatial difficulties, and unilateral neglect. Rehabilitation Needs a Broad Theoretical Base People with brain injury are likely to face multiple problems, including cognitive, social, emotional, and behavioral, and no one model or group of models is sufficient to deal with all these issues. In order to improve cognitive, social, emotional, and behavioral functioning in the everyday life of these individuals, we should not be constrained by a single theoretical framework. Of the many theories that affect rehabilitation, four are perhaps of particular importance, namely theories of cognitive functioning, emotion, behavior, and learning. Consideration should also be given to theories of assessment, recovery, and compensation. Wilson (2002) argues for a broad-based model and provides a tentative comprehensive model of rehabilitation. Boake (2003) describes the different methodologies that influenced some of the historical figures in the field. Manly (2003) refers to numerous theories of attention that have guided treatment approaches to this difficult area. Williams (2003) is particularly influenced by cognitive behavior therapy (CBT), which is certainly one of the most carefully worked out and clinically useful models of emotion at this time. The neurobehavioral model of Wood (1987, 1990) is one that has influenced Alderman’s work in the treatment of braininjured people with severe behavior problems (Alderman 2003). In a survey of British clinical neuropsychologists working in brain injury rehabilitation, 57 different models were reported as influencing clinical practice (Sopena et al. 2007). Ethical and effective NR requires a synthesis and integration of several frameworks, theories, and methodologies to achieve its aims and ensure the best clinical practice. Virtual reality (VR): a technology that allows a user to interact with a computer-simulated environment CBT: cognitive behavior therapy Traumatic brain injury (TBI): a sudden trauma causing damage to the brain (also called head injury) COGNITIVE ASPECTS OF NEUROPSYCHOLOGICAL REHABILITATION It is worth restating that it is not easy to separate the cognitive, emotional, and psychosocial consequences of brain injury. However, because many of the studies in the literature report these three components separately, I examine them individually. Unless the brain damage is very mild, cognitive deficits are almost invariably found in survivors of an insult to the brain. Problems with memory, attention, executive functioning, and speed of information processing are the most typical difficulties faced by those who have sustained traumatic brain injury (TBI). For survivors of stroke, language problems are common after left hemisphere damage, and unilateral neglect is seen frequently after right hemisphere damage. Numerous studies have been published on the efficacy of cognitive rehabilitation, ranging from singlecase experimental designs to randomized controlled trials (RCTs). Chesnut et al. (1999) traced 2536 abstracts from articles on rehabilitation to find answers to five questions, one of which was concerned with cognitive rehabilitation. This particular report was based on 363 articles, of which 114 related to cognitive rehabilitation. The authors asked specifically, “Does the application of compensatory rehabilitation enhance www.annualreviews.org • Neuropsychological Rehabilitation 147 ARI 22 February 2008 16:40 outcomes for people who sustain TBI?” Of the 114 potential articles, only 32 reached the final selection to evaluate effectiveness; the remaining 82 articles were excluded for various reasons, such as because they were review articles that were purely descriptive, reports on studies in which there were fewer than five subjects, and so on. Of the 32 selected for evaluation, 11 were RCTs, with 5 measuring relevant health outcomes and 6 measuring intermediate outcomes. The authors of the report concluded, “along with the small size of the studies and the narrow range of interventions studied, the lack of information about the representativeness of the included patients makes it difficult to apply the findings of these studies to cognitive rehabilitation practice generally” (p. 55). In other words, the RCTs did not reveal much about the effectiveness of cognitive rehabilitation in any general sense. The cognitive rehabilitation section of the report was published separately (Carney et al. 1999). The authors state that although the desired outcome of cognitive rehabilitation is improvement in daily function, many of the outcome measures are intermediate measures rather than health outcomes. By “intermediate measures,” the authors mean test scores (123 tests of cognition were described in the studies). The question was posed as to whether improvements on test scores predict improvement in real-life function. The authors concluded that although there appeared to be some relationship between intermediate measures and employment, the association was not strong. One could argue that the use of test scores irrespective of whether they are intermediate or direct is not a good way to evaluate rehabilitation. The ultimate goal of rehabilitation is to enable people with disabilities to function as adequately as possible in their most appropriate environment, so information on changes in scores on the Wechsler scales or any other standardized test will not yield the required information. For example, JC, a densely amnesic patient (Wilson 1999), has shown no improvement on standardized tests over a 10-year period, yet he Annu. Rev. Clin. Psychol. 2008.4:141-162. Downloaded from www.annualreviews.org by Universidad de Chile on 07/07/14. For personal use only. ANRV339-CP04-06 148 Wilson is self-employed and completely independent thanks largely to excellent use of compensatory strategies. By most standards of those involved in rehabilitation, these outcomes are very good indeed, yet if standardized tests had been used as measures of success, JC would have failed dismally. Some studies address real-life functional issues. For example, Wilson et al. (2001) reported a randomized control study to evaluate a paging system in which memory-impaired patients were randomly allocated to the pager or to a waiting list. Patients and their families identified real-life problems involving tasks such as taking medication, feeding the dog, and collecting children from school. In the baseline period, these behaviors were monitored and there was no difference between the two groups. Those allocated to the paging condition then received their pagers and the same behaviors were monitored as before. The achievement of the target behaviors significantly improved, whereas those on the waiting list experienced no change. The pagers were then returned and given to the people who had been on the waiting list. This group then improved significantly. Those who had returned their pagers dropped back a little but were still better than they had been at baseline. This suggested that some learning of the target behaviors had taken place during the pager phase. Tackling real-life targets and individualizing programs within a specified framework is—or should be—the way forward in cognitive rehabilitation. Clare and colleagues (Clare et al. 1999, 2000, 2001) applied this principle to people with Alzheimer’s disease. Patients and families selected the target behaviors they wanted to achieve and a way was found to teach new information. The main strategies used in this series of studies were errorless learning and spaced retrieval. Cicerone and colleagues (2000, 2005) have carried out major investigations into the efficacy of cognitive rehabilitation. In their 2005 paper, they used search engines to locate cognitive rehabilitation studies and identified 47 Annu. Rev. Clin. Psychol. 2008.4:141-162. Downloaded from www.annualreviews.org by Universidad de Chile on 07/07/14. For personal use only. ANRV339-CP04-06 ARI 22 February 2008 16:40 studies that fulfilled certain inclusion criteria. They looked at several cognitive domains including attention difficulties, visuo-spatial deficits, apraxia, language and communication problems, memory deficits, executive functioning, problem solving, and awareness. On the issue of retraining versus compensation, they found that retraining was effective for some cognitive functions (for example, language), whereas compensation was necessary for others (such as memory deficits). Their overall conclusion was, “There is now a substantial body of evidence demonstrating that patients with TBI or stroke benefit from cognitive rehabilitation” (Cicerone et al. 2005, p. 1689). These authors also state, “Future research should move beyond the simple question of whether cognitive rehabilitation is effective, and examine the therapy factors and patient characteristics that optimize the clinical outcomes of cognitive rehabilitation” (p. 1681). Halligan & Wade (2005) provide a summary of much of the work on the effectiveness of rehabilitation for cognitive deficits. EMOTIONAL ASPECTS OF NEUROPSYCHOLOGICAL REHABILITATION The management and remediation of emotional consequences of brain injury have become increasingly important in recent years. Prigatano (1999) suggests that rehabilitation is likely to fail if clinicians do not deal with the emotional issues. Consequently, an understanding of theories and models of emotion is crucial to successful rehabilitation. Social isolation, anxiety, and depression are common in survivors of brain injury. Kopelman & Crawford (1996) found that 40% of 200 consecutive referrals to a memory clinic were suffering from clinical depression. Bowen et al. (1998) found that 38% of survivors of TBI experienced mood disorders. Williams et al. (2002) found that estimates of the prevalence of post-traumatic stress disorder (PTSD) following TBI range from 3% to 27%. In their own study, they found that 18% of 66 community-living survivors of TBI experienced PTSD. Gainotti (1993) distinguishes three main factors causing emotional and psychosocial problems after brain injury: those resulting from neurological factors, those due to psychological or psychodynamic factors, and those due to psychosocial factors. An example of a neurological factor is an individual with brain stem damage leading to the socalled catastrophic reaction, in which swings from tears to laughter may follow in rapid succession. Anosognosia, or lack of awareness of one’s deficits, is also frequently due to organic impairment. An important book on the topic of unawareness (Prigatano & Schacter 1991) posits several rationales for the existence of anosognosia. Gainotti (1993) also addresses unawareness in detail, and Clare & Halligan (2006) characterize some of the key clinical issues concerned with assessing and managing pathologies of subjective or conscious awareness. The second factor identified in Gainotti’s (1993) three-part classification, that is, emotional problems that are due to psychological or psychodynamic causes, includes personal attitudes toward the disability. An example is someone with an acquired dyslexia and consequent loss of self-esteem together with depression because of an inability to read. Denial is also thought to be relevant to some cases of this second type of emotional disorder. At some level, patients are aware of their disabilities but are unable to accept them. Because denial can occur in conditions without any damage to the brain, there must be (at least in some cases) nonorganic reasons for it (Gainotti 1993). PTSD also fits into this classification. Fear of what might happen in the future, panic because one cannot remember what has happened in the past few minutes, grief at loss of functioning, and reduced selfesteem because of changes in physical appearance may all contribute to emotional changes. The third category put forward by Gainotti (1993) includes problems that arise for psychosocial reasons. An example is an www.annualreviews.org • Neuropsychological Rehabilitation 149 ANRV339-CP04-06 ARI 22 February 2008 Annu. Rev. Clin. Psychol. 2008.4:141-162. Downloaded from www.annualreviews.org by Universidad de Chile on 07/07/14. For personal use only. Psychosocial functioning: encompasses work, leisure, and social relationships; overlaps with emotional well-being 150 16:40 individual who loses all his or her friends and colleagues following a brain injury and thus is very socially isolated. Social isolation is seen in up to 60% of survivors of TBI (Hoofien et al. 2001). One aspect not covered by Gainotti is the influence of premorbid personality. This is discussed by Moore & Stambrook (1995), Williams et al. (1999), and Tate (1998). Tate, however, found that premorbid personality had less effect on psychosocial functioning than did severity of injury. In understanding emotion after brain injury, we need to consider neurological, physical, and biochemical models such as those described by Robinson & Starkstein (1989). Although such models address the issue of why emotional problems arise following an insult to the brain, they do not offer much help in understanding the psychodynamic and psychosocial causes of emotional and mood disorders. Perhaps the most helpful models come from CBT. Ever since Beck’s highly influential book, Cognitive Therapy and Emotional Disorders, appeared in 1976, CBT has been one of the most important and best-validated psychotherapeutic procedures (Salkovskis 1996). A major strength of Beck’s updated model (Beck 1996) has been the development of clinically relevant theories. Beck presents several theories not only for depression and anxiety but also for panic, obsessive-compulsive disorders, and phobias. Mateer & Sira (2006) suggest that CBT is well suited for improving coping skills, helping clients to manage cognitive difficulties, and addressing more generalized anxiety and depression in the context of a brain injury. Williams et al. (2003) describe the use of CBT with two survivors of TBI. One was a young man whose girlfriend was killed in a car crash while he was driving. The other was a young woman, known as CM, who had been severely assaulted while traveling on a train (described in more detail below). Williams et al. (2003) discuss the possible mechanisms for PTSD after TBI. These conditions were once thought to be mutually exclusive because the survivor would lack a memory for the event from which to develop Wilson vivid intrusive cognitions and avoidance behaviors (Sbordone & Liter 1995). However, given that PTSD seems to occur even when there is a loss of consciousness for the event, there could be two main mediating mechanisms to suggest how trauma-related material may be processed to lead to PTSD symptoms. First, survivors may evoke “islands of memory” for their trauma, such as being trapped in a crashed car, or other secondary experiences that could fuel intrusive ruminations (McMillan 1996). Second, survivors may be reminded of elements of their trauma event when exposed to similar situations that serve to produce intrusive thoughts and fuel avoidance behaviors (Brewin et al. 1996). McNeil & Greenwood (1996) described a survivor of TBI who was hyperaroused in, and avoidant of, situations that were similar to the trauma event, a road traffic accident, even though he had no declarative memory of the event. If an event is unexpected but has biological significance and, hence, emotional salience, McNeil & Greenwood (1996) suggested, it may lead to the event being stored (or “burned in” to memory) despite disruption to areas of the brain that store declarative memories (see Markowitsch 1998). Such a view would be compatible with the concept that PTSD is caused by a conditioning of fear. The mechanism responsible is one in which traumatic experiences can be processed independently of higher cortical functions (see Bryant 2001). Analytic psychotherapy is also used in rehabilitation, particularly in the United States. Prigatano is perhaps the best-known proponent of psychotherapy treatment of individuals surviving TBI. He describes his approach (based on the milieu therapy approach of BenYishay) in Principles of Neuropsychological Rehabilitation (Prigatano 1999). Dealing with the emotional consequences of brain injury may make the difference between a successful and an unsuccessful outcome. CM, mentioned above, was stabbed through the head in the right temperoparietal area with a hunting knife while traveling on a train. She was 19 at the time and Annu. Rev. Clin. Psychol. 2008.4:141-162. Downloaded from www.annualreviews.org by Universidad de Chile on 07/07/14. For personal use only. ANRV339-CP04-06 ARI 22 February 2008 16:40 did not lose consciousness, probably because the knife did not enter her brain stem. She described feeling a pain in her head and a weight as if the carriage had fallen on top of her. She stood up and realized that something terrible had happened. She went into the next carriage where a man told her to sit down and stay still and he would get help. She felt the knife with her hand and asked if she was going to die. The man said “No” and that he would get help. At the next stop, an ambulance arrived and took her to the hospital. A few months later, she came to our rehabilitation center. She had a number of cognitive problems, including visuo-spatial issues and memory deficits, but the emotional difficulties took priority in treatment. She was anxious and avoided many social situations; she would not look at people, feared for her family, and had classic symptoms of PTSD including flashbacks and nightmares; and she refused to use public transport. Like all other patients there, she had both group and individual therapy, including a considerable amount of psychological support and treatment for the emotional problems identified (Williams et al. 2003). This involved CBT, including stress inoculation, and graduated exposure to situations she avoided. She was also treated for her cognitive difficulties, but if these had been the only problems treated, it is doubtful that she would have been able to make such a good recovery and return to a full and meaningful life. A recent study (Tiersky et al. 2005) examined the effects of a rehabilitation program offering psychotherapy and cognitive rehabilitation and compared a treatment group with a control group. The treatment group showed significantly improved emotional functioning, including lessened anxiety and depression. The authors concluded, “Cognitive behavioral psychotherapy and cognitive remediation appear to diminish psychologic distress and improve cognitive functioning among community-living persons with mild and moderate TBI” (Tiersky et al. 2005, p. 1565). PSYCHOSOCIAL ASPECTS OF NEUROPSYCHOLOGICAL REHABILITATION Considerable overlap exists between psychosocial and emotional difficulties. Indeed, one definition of a psychosocial disorder is “a mental illness caused or influenced by life experiences, as well as maladjusted cognitive and behavioral processes” (www.healthatoz.com). In brain injury rehabilitation, however, the term is more often used to refer to psychosocial outcomes such as work, friendships, and community activities. In other words, psychosocial functioning is close to “participation” as defined by the International Classification of Functioning, Disability and Health (World Health Org. 2001). Wade (2005) says that the World Health Organization (WHO) framework “was developed as a means of describing the totality that is the experience of illness” (p. 32). The framework consists of four levels: pathology, impairment, activity, and participation. Thus, in the case of a brain-injured person, the pathology might be damage to the cerebral cortex and the resulting impairment might be a poor memory. This, in turn, causes limitations to the person’s everyday activities; so, for example, s/he is unable to remember appointments. This problem might affect the extent of participation in the person’s social environment, causing difficulties with work, the duties of parenthood, or the ability to engage in leisure activities. The WHO model also considers three major contexts influencing behavior: personal, physical, and social contexts. Wade (2005) says these contexts “might be considered to affect the interactions between pathology and impairment, impairment and activities and activities and participation” (p. 34). Personal context includes the relevant characteristics of an individual such as expectations, beliefs, and attitudes. Physical context refers to the environment in which the individual finds himself or herself, and social context refers to the culture in which the individual functions. All these factors contribute to the quality of life www.annualreviews.org • Neuropsychological Rehabilitation WHO: World Health Organization 151 ARI 22 February 2008 16:40 as experienced by the person with a disability. For the purposes of this review, psychosocial problems are seen as synonymous with the WHO definition of participation. Twenty-first century rehabilitation programs are typically concerned with psychosocial adjustment to disability (Sopena et al. 2007, Yates 2003). Included in this category are employment or other productive activity, social relationships, and leisure. Some believe that the psychosocial problems associated with TBI may actually be the major challenge of rehabilitation (Morton & Wehman 1995). Survivors of brain injury face problems of social isolation and decreased leisure activities, thus creating a renewed dependence on their family members. Karlovits & McColl (1999) interviewed 11 survivors of severe brain injury to discover impediments to reintegration into the community. Nine stressors were identified: orientation, transportation, living situation, loss of independence, relationships, loneliness, routine, problems with studying, and work. Much of the focus of post acute rehabilitation is on helping people to return to a productive lifestyle (Petrella et al. 2005). Indeed, the success of NR programs is often measured by such outcomes. Lack of productivity, particularly employment, decreases the opportunity for individuals with brain injury to develop social contacts and leisure activities, which in turn contributes to depression and low self-esteem. In contrast, engagement in paid and nonpaid productive activities, such as volunteering or homemaking, has a beneficial impact on community integration (Petrella et al. 2005). Return to work is one of the major goals that clients in brain-injury rehabilitation programs want to achieve. A number of studies have addressed the issue of returning to work after rehabilitation. Failure to succeed at work is associated with poor self-awareness, impaired executive functioning, and poor metacognition (Ownsworth & Fleming 2005). In a multicenter study, Walker et al. (2006) found that that those who were employed prior to the onset of their brain Annu. Rev. Clin. Psychol. 2008.4:141-162. Downloaded from www.annualreviews.org by Universidad de Chile on 07/07/14. For personal use only. ANRV339-CP04-06 152 Wilson injury, in comparison with those who were unemployed, were more likely to work after rehabilitation. The type of occupation also influenced return to work: Those in professional or managerial jobs were more likely to return to work than were those in other positions. In another meta-analysis, Kendall et al. (2006) said, “[T]he use of a narrow definition of return-to-work (i.e., full-time competitive work only) produced more apparent unemployment than an inclusive definition (i.e., any competitive work or productive activity)” (p. 149). Although this is not surprising, it highlights the fact that a return to full-time employment after severe brain injury is not always achievable and, in rehabilitation, we need to consider a range of productive activities for our patients/clients. In the words of Kendall et al. (2006), “The definition of employment and the nature of preinjury employment is crucial to any interpretation of returnto-work in TBI. The current study also highlights the importance of measuring employment outcomes using multiple points over time, rather than single data points or first return-to-work” (p. 149). In an examination of the effects of rehabilitation on return to work for military personnel, Cullen et al. (2007) found moderate evidence to support the view that inpatient rehabilitation results in successful return to work and return to duty for the majority of military service members. They also suggested that increasing the intensity of rehabilitation not only reduced the length of stay but also improved short-term functional outcomes. Turner-Stokes et al. (2005) also found strong evidence to support the claim that intensive rehabilitation led to more functional gains than did lessintensive rehabilitation. In summary, people who are given intensive rehabilitation have an improved likelihood of returning to work, and the definition of “return to work” should be expanded to include part-time work and other meaningful functional activities rather than simply full-time competitive work. Social isolation is common after TBI, in part because of deficits in social skills Annu. Rev. Clin. Psychol. 2008.4:141-162. Downloaded from www.annualreviews.org by Universidad de Chile on 07/07/14. For personal use only. ANRV339-CP04-06 ARI 22 February 2008 16:40 (McDonald 2003). An increase in social skills and social relationships should be one of the major goals for rehabilitation. Some studies have shown that it is possible to achieve these goals ( Johnson & Davis 1998, Ownsworth et al. 2000, Ylvisaker et al. 2005). In their work with stroke patients, Haslam et al. (2007) found that the number of social groups people belonged to before their stroke predicted their sense of well-being after the stroke and that this was a result of them being more likely to retain membership of more groups. Another study looking at personal relationships is that of Wood & Rutterford (2005), who found that five factors predicted problems with social relationships. These were (a) loss of self-control (e.g., aggression, social and/or sexual disinhibition), (b) emotional dysfunction (e.g., mood swings, quick temper), (c) adynamia (e.g., lack of motivation for leisure activities, fatigue, loss of libido, loss of social interests), (d ) personality change (e.g., obsessiveness), and (e) cognitive dysfunction (e.g., memory loss, attention/concentration difficulties, organization and planning problems). These are all factors that are or should be addressed in rehabilitation. Another area of research is leisure. A Danish study by Engberg & Teasdale (2004) found that maintenance of leisure-time interests and general life satisfaction was poorer in survivors of a cerebral lesion compared with patients with a cranial fracture. A French study (Quintard et al. 2002) looked at late outcome and satisfaction of life of 79 patients with severe TBI. Up to 85% were independent in activities of daily living, 55% were independent in social life, but only 36% were satisfied with leisure activities. In some rehabilitation programs, leisure goals are among the most common goals set. For example, Bateman et al. (2005) looked at 680 goals set for 95 clients at the Oliver Zangwill Center in the United Kingdom. The most common goals were connected with managing activities of daily living (248); leisure goals (154) came second jointly with goals pertaining to understanding the consequences of brain injury, followed by goals connected with work or study skills (119). It is clear that rehabilitation for psychosocial difficulties is an important part of the care of survivors of brain injury. Physical difficulties are less likely to affect the quality of life of a brain-injured person than are the cognitive, emotional, and psychosocial sequelae, so these should be the focus of rehabilitation programs. In the words of Khan et al. (2003), “Cognitive and behavioral changes, difficulties maintaining personal relationships and coping with school and work are reported by survivors as more disabling than any residual physical deficits” (p. 290). A collection of papers on biopsychosocial approaches in neurorehabilitation edited by Williams & Evans (2003) summarizes much of the work tackled in this field. NeuroPage: a reminding system using radio-paging technology MODELS AND THEORETICAL APPROACHES CONTRIBUTING TO NEUROPSYCHOLOGICAL REHABILITATION Most neuropsychologists working in rehabilitation believe that treatment should be driven by theory, although they may also believe that theories are not necessarily sufficient on their own. For example, NeuroPage, a paging system for helping memory-impaired people remember everyday tasks, was developed by an engineer with no knowledge of psychological theory who had a son with a severe TBI (Hersch & Treadgold 1994). Even though it is not theoretically driven, NeuroPage has led to theoretically driven questions such as the effect of executive functioning on successful use of the pager (Fish et al. 2007). Perhaps the most influential models and theories in NR over the past two decades are those of cognition, emotion, behavior, and learning. Models of cognitive functioning that have proved useful in rehabilitation include language, reading (Howard 2005, Mitchum & Berndt 1995), memory (Baddeley 1992, 2007), attention (Robertson 1999), and www.annualreviews.org • Neuropsychological Rehabilitation 153 ARI 22 February 2008 16:40 perception (Bruce & Young 1986). Given the increasing recognition of the importance of addressing emotional and psychosocial difficulties, emotional models are essential in NR. One of the most important of these, CBT, is discussed above. Models and theories from behavioral psychology have been employed in NR for more than 40 years. They have provided some of the most useful and influential theoretical contributions to rehabilitation, not only for the understanding, management, and remediation of disruptive behaviors, but also for the remediation of cognitive deficits (Wilson et al. 2003). Behavioral theories are valuable in NR because they inform assessment, treatment, and the measurement of rehabilitation efficacy. Learning theory is one of the cornerstones of behavior therapy and behavior modification, with the other main theoretical influences coming from biological, cognitive, and social psychology (Martin 1991). There is little doubt, though, that the original behavioral treatments grew out of learning theory. Eysenck (1964), for example, defined behavior therapy as “the attempt to alter human behavior and emotion in a beneficial manner according to the laws of modern learning theory” (p. 1). Believing that the purpose of rehabilitation is to help people achieve their optimum level of physical, psychological, social, and vocational functioning, Wilson (2002) attempted to synthesize a number of approaches and models used in rehabilitation to reflect the complexity of the field and the range of issues to be dealt with. Wilson published a provisional model of cognitive rehabilitation in which she argued that one model, or one group of models such as those from cognitive neuropsychology, is insufficient to (a) determine what needs to be rehabilitated, (b) plan appropriate treatment for neuropsychological impairments, and (c) evaluate response to rehabilitation. Rehabilitation is one of many fields that need a broad theoretical base incorporating frameworks, theories, and mod- Annu. Rev. Clin. Psychol. 2008.4:141-162. Downloaded from www.annualreviews.org by Universidad de Chile on 07/07/14. For personal use only. ANRV339-CP04-06 154 Wilson els from a number of different areas. Constraint of rehabilitation workers to one model could lead to poor clinical practice because important aspects of patients’ lives could be neglected. GUIDELINES FOR GOOD PRACTICE IN NEUROPSYCHOLOGICAL REHABILITATION Although there are no definitive trials to support the holistic approach, it has probably been subjected to more evaluation studies than have other approaches (e.g., Cicerone et al. 2004, Diller & Ben-Yishay 2002) and, at present, is probably the most effective clinically (Cicerone et al. 2007). Most holistic programs are concerned with increasing a client’s awareness, alleviating cognitive deficits, developing compensatory skills, and providing vocational counseling. All such programs provide a mixture of individual and group therapy. This approach possibly could be improved by incorporating ideas and practical applications from learning theory, such as task analysis, baseline recording, monitoring, and the implementation of single-case experimental designs to individual treatment programs. Another potential improvement would be referring to cognitive neuropsychological models in order to identify cognitive strengths and weaknesses in more detail to explain observed phenomena and make predictions about cognitive functioning. Prigatano (1999) lists 13 principles of NR derived from a holistic approach, and there is no doubt that his work has considerably influenced current rehabilitation practice. These principles are described in Table 3. The Oliver Zangwill Center, influenced by Prigatano’s approach, bases its NR on six core components that are described here to illustrate the principles of good clinical practice in NR. More detail on the components is available from the Oliver Zangwill Web site, www.ozc.nhs.uk. ANRV339-CP04-06 Table 3 ARI 4 5 Annu. Rev. Clin. Psychol. 2008.4:141-162. Downloaded from www.annualreviews.org by Universidad de Chile on 07/07/14. For personal use only. 6 7 8 9 10 11 12 13 16:40 Summary of Prigatano’s 13 principles of neuropsychological rehabilitation Principle No. 1 2 3 22 February 2008 Principle Begin with the patient’s subjective or phenomenological experience. The symptoms presented are a mixture of premorbid cognitive and personality characteristics together with the neuropsychological changes resulting from the brain pathology. Neuropsychological rehabilitation focuses on both the remediation of higher cerebral disturbances and their management in interpersonal situations. Neuropsychological rehabilitation helps patients observe their behavior to teach them about the direct and indirect effects of brain injury. Failure to study the interaction of cognition and personality leads to an inadequate understanding of many issues. Little is known about how to retrain cognitive dysfunction, but general guidelines of cognitive remediation can be specified. Psychotherapeutic interventions help patients (and families) deal with their personal losses. Working with patients who have dysfunctional brains produces affective reactions in the patient’s family and the rehabilitation staff. Appropriate management of these reactions facilitates adaptation. Each neuropsychological rehabilitation program is a dynamic entity. The team needs to maintain a dynamic, creative effort. Failure to identify those patients who can and cannot be helped creates a lack of credibility. Disturbances in self-awareness after brain injury are often poorly understood and poorly managed. Competent patient management and planning depend on understanding mechanisms of recovery and deterioration. The rehabilitation of patients with higher cerebral deficits requires both scientific and phenomenological approaches. 1. Provide a Therapeutic Milieu Derived from Ben-Yishay’s concept of the therapeutic milieu (Ben-Yishay 1996), the therapeutic milieu in holistic rehabilitation refers to the organization of the complete environment (physical, organizational, and social aspects) to maximize support for the process of adjustment and to increase social participation. The milieu embodies a strong sense of mutual cooperation and trust, which underpins the working alliance between client and clinicians. 2. Establish Meaningful and Functionally Relevant Goals for Rehabilitation Meaningful functional activity refers to all day-to-day activities that form the basis for social participation. These can be categorized into vocational, educational, recreational, social, and independent living realms. It is through participation in these areas that individuals gain a sense of purpose and mean- ing in their lives. Although it is probably not thought about consciously in everyday life, activity enables individuals to achieve certain aims or ambitions that are personally significant and thereby contributes to the sense of identity. 3. Ensure Shared Understanding The notion of shared understanding comes from the use of formulation in clinical practice (Butler 1998). A formulation is seen as a map or guide to intervention that combines a model derived from established theories and best evidence with the client’s and family’s personal views, experiences, and stories. This concept, which should be applied to all individual clinical work, influences the way the rehabilitation experience is organized as a whole. The shared understanding concept incorporates team philosophy, including shared team vision, explicit values, and goals. Understanding of research and theory, www.annualreviews.org • Neuropsychological Rehabilitation Therapeutic milieu: the organization of the environment to ensure maximum support to the process of adjustment and to increase social participation 155 ANRV339-CP04-06 ARI 22 February 2008 16:40 sharing knowledge and experience with other professionals and families, peer audit of the service, and the views and contributions of past clients are additional aspects of the shared understanding ideal. 4. Apply Psychological Interventions Annu. Rev. Clin. Psychol. 2008.4:141-162. Downloaded from www.annualreviews.org by Universidad de Chile on 07/07/14. For personal use only. Psychological interventions are based upon certain ways of understanding feelings and behavior. Specific psychological models (particularly those described above) are used to guide work depending upon the specific needs of the individual. Approaches from these models provide ways team members can engage patients/clients in positive change and the tackling of specific problems. 5. Manage Cognitive Impairments Through Compensatory Strategies and Retraining Skills Compensatory strategies are alternative ways to enable individuals to achieve a desired objective when an underlying function of the brain is not operating effectively. Compensatory approaches to managing impairments take a number of forms, including: 156 cognitive compensation (e.g., using visual imagery to compensate for a defective verbal memory, using a mental routine for managing impulsivity or anger, and clarifying to ensure effective communication); enhanced learning—techniques such as errorless learning or spaced retrieval that lead to more effective learning of new knowledge or skills; external aids (e.g., using a diary for managing memory problems, checklists to remember exercise routines, alarms to increase attention to tasks, cue cards for keeping on track during conversation); and environmental adaptations—modifying relevant environments in order to reduce cognitive demands (e.g., working in a quiet, nondistracting room to aid Wilson concentration, holding important conversations when less fatigued). Retraining is undertaken to improve performance of a specific function of the brain or to improve performance on a particular task or activity. Retraining also helps to address skills lost through lack of use, e.g., through not being at work since an injury. 6. Work Closely with Families and Carers Families and carers sometimes report feeling like an afterthought in rehabilitation. Recent policy (National Service Framework for Long Term Conditions, Dep. Health, London, 2004) highlights how families and carers experience a significant burden following acquired brain injury and recommends provision of support. Many kinds of support can be offered, for example, providing information, furnishing opportunities for peer support, involving family and carers in rehabilitation, and providing individual family consultation or therapy. SUMMARY Following definitions of neuropsychology, rehabilitation, and NR, this review discusses some of the ways the field has changed in recent years. The particular focus is on (a) goal setting as a way of structuring rehabilitation, (b) the realization that the emotional and psychosocial consequences of brain injury are as important as the cognitive consequences, (c) the increasing use of technology in rehabilitation, and (d ) a recognition that a wide range of theoretical models and approaches is needed to inform the assessment and treatment of people who have survived a brain injury. The three main components of NR—cognitive, emotion, and psychosocial functioning—are looked at in more detail. Given that how we feel affects how we think, how we behave, and how we interact with others, all three functions need to be addressed in any rehabilitation program. Evidence is provided to show that difficulties in ANRV339-CP04-06 ARI 22 February 2008 16:40 these areas can be reduced through NR. Because the field is broad and complex, clinicians need to be informed by a number of models and theories to reduce the everyday problems faced by people who have survived brain injury. Some of the most influential models and theoretical approaches used to plan rehabilitation are described, particularly those relevant to cognitive functioning, emotion, behavior, and learning. The review concludes with recommendations for good practice in the rehabilitation of people with brain injury. SUMMARY POINTS Annu. Rev. Clin. Psychol. 2008.4:141-162. Downloaded from www.annualreviews.org by Universidad de Chile on 07/07/14. For personal use only. 1. Neuropsychological rehabilitation (NR) is concerned with the amelioration of cognitive, emotional, psychosocial, and behavioral deficits caused by an insult to the brain. 2. The main purpose of NR is to enable people to return to their own most appropriate environments; for this reason, meaningful goals should be set in the areas of vocation, education, recreation, social relationships, and independent living. 3. Although cognitive deficits are perhaps the major focus of NR, emotional and psychosocial consequences of brain injury need to be addressed in rehabilitation programs. There is an interaction between these different functions, and it is not always easy to separate them from one another. 4. Technology is increasingly used to help people compensate for cognitive difficulties. Some technological aids are described and evaluated. 5. NR requires a broad theoretical base and some of the most influential models and theories influencing current practice are described. 6. Evidence is provided to show that NR can reduce difficulties in the three main areas of cognitive, emotional, and psychosocial functioning. 7. Suggested guidelines for good clinical practice are outlined. DISCLOSURE STATEMENT The author is not aware of any biases that might be perceived as affecting the objectivity of this review. LITERATURE CITED Alderman N. 2003. Rehabilitation of behaviour disorders. See Wilson 2003, pp. 171–96 Austin JT, Vancouver JB. 1996. Goal constructs in psychology: structure, process, and content. Psychol. Bull. 120(3):338–75 Baddeley AD. 1992. Memory theory and memory therapy. In Clinical Management of Memory Problems, ed. BA Wilson, N Moffat, pp. 1–31. London: Chapman & Hall Baddeley M. 2007. Analysing herding: insights from neuroeconomics and social psychology. Presented to Queens’ Econ. Semin., Cambridge Univ., May Bateman A, Brentnall S, Evans J, Gartland D, Gracey F, et al. 2005. Outcomes of intensive neuropsychological rehabilitation: the relationship between the Dysexecutive Questionnaire (DEX) and European Brain Injury Questionnaire (EBIQ) and SMART goals attainment. 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Rehabil. 10:465–84 Petrella L, McColl MA, Krupa T, Johnston J. 2005. Returning to productive activities: perspectives of individuals with long-standing acquired brain injuries. Brain Injury 19:643–55 Poppelreuter W. 1917. Disturbances of Lower and Higher Visual Capacities Caused by Occipital Damage: With Special Reference to the Psychopathological, Pedagogical, Industrial Implications. Transl. J Zihl, L Weiskrantz, 1991. Oxford, UK: Oxford Univ. Poser U, Kohler JA, Schönle PW. 1996. Historical review of neuropsychological rehabilitation in Germany. Neuropsychol. Rehabil. 6:257–78 Prigatano GP. 1986. Personality and psychosocial consequences of brain injury. In Neuropsychological Rehabilitation after Brain Injury, ed. GP Prigatano, DJ Fordyce, HK Zeiner, JR Roueche, M Pepping, BC Wood, pp. 29–50. Baltimore/London: The John Hopkins Univ. Press Wilson Annu. Rev. Clin. Psychol. 2008.4:141-162. Downloaded from www.annualreviews.org by Universidad de Chile on 07/07/14. For personal use only. ANRV339-CP04-06 ARI 22 February 2008 16:40 Prigatano GP. 1994. Individuality, lesion location, and psychotherapy after brain injury. In Brain Injury and Neuropsychological Rehabilitation, ed. A-L Christensen, BP Uzzell, pp. 173–86. Hillsdale, NJ: Erlbaum Prigatano GP, ed. 1999. Principles of Neuropsychological Rehabilitation. New York: Oxford Univ. Press Prigatano GP. 2005. A history of cognitive rehabilitation. See Halligan & Wade 2005, pp. 3–10 Prigatano GP, Pliskin N, eds. 2002. Clinical Neuropsychology and Cost-Outcome Research: An Introduction. Hove, UK: Psychol. Press Prigatano GP, Schacter DL, eds. 1991. Awareness of Deficit After Brain Injury. New York: Oxford Univ. Press Quintard B, Croze P, Mazaux JM, Rouxel L, Joseph PA, et al. 2002. Satisfaction of life and late psychosocial outcome after severe brain injury: a nine-year follow-up study in Aquitaine. Ann. Readapt. Med. Phys. 45:456–65 Robertson IH. 1999. 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Cognitive Rehabilitation: An Integrative Neuropsychological Approach. New York: Guilford Sopena S, Rous R, Wilson BA. 2007. Neuropsychological rehabilitation: What is it all about? Brain Impair. 8:70 (Abstr.) Tate RL. 1998. “It is not only the kind of injury that matters, but the kind of head”: the contribution of premorbid psychosocial factors to rehabilitation outcomes after severe traumatic brain injury. Neuropsychol. Rehabil. 8:1–18 Tate RL, Strettles B, Osoteo T. 2003. Enhancing outcomes after traumatic brain injury: a social rehabilitation approach. See Wilson 2003, pp. 137–69 Tiersky LA, Anselmi V, Johnston MV, Kurtyka J, Roosen E, et al. 2005. A trial of neuropsychologic rehabilitation in mild-spectrum traumatic brain injury. Arch. Phys. Med. Rehabil. 86:1565–74 Turner-Stokes L, Disler PB, Nair A, Wade DT. 2005. Multi-disciplinary rehabilitation for acquired brain injury in adults of working age. Cochrane Database Syst. Rev. 2005(3):Art. No. CD004170 Wade DT. 1999. Goal planning in stroke rehabilitation: why? what? how? evidence. Top. Stroke Rehabil. 6(22):1–42 Wade DT. 2005. Applying the WHO ICF framework to the rehabilitation of cognitive deficits rehabilitation. See Halligan & Wade 2005, pp. 31–42 Walker WC, Marwitz JH, Kreutzer JS, Hart T, Novack TA. 2006. Occupational categories and return to work after traumatic brain injury: a multicenter study. Arch. Phys. Med. Rehabil. 87:1576–82 www.annualreviews.org • Neuropsychological Rehabilitation Describes 13 principles of rehabilitation for those following the holistic approach. Addresses the cost implications of neuropsychological rehabilitation. Considers the relationship between preinjury occupational category and return to work. 161 ANRV339-CP04-06 ARI 22 February 2008 Annu. Rev. Clin. Psychol. 2008.4:141-162. Downloaded from www.annualreviews.org by Universidad de Chile on 07/07/14. For personal use only. Provides a valuable resource on assessment and management of emotional and psychosocial problems. Describes a series of case studies with long-term follow-ups (winner of the British Psychological Society’s 2003 book award). Provides a synthesized model of the many factors to be considered in neuropsychological rehabilitation. 162 16:40 Williams WH. 2003. Neuro-rehabilitation and cognitive behaviour therapy for emotional disorders in acquired brain injury. See Wilson 2003, pp. 115–36 Williams WH, Evans JJ, eds. 2003. Biopsychosocial Approaches in Neurorehabilitation: Assessment and Management of Neuropsychiatric, Mood and Behavioural Disorders. A Special Issue of Neuropsychological Rehabilitation. Hove, UK: Psychol. Press Williams WH, Evans JJ, Needham P, Wilson BA. 2002. Neurological, cognitive and attributional predictors of post-traumatic stress symptoms after traumatic brain injury. J. Trauma Stress 15(5):397–400 Williams WH, Evans JJ, Wilson BA. 1999. Outcome measures for survivors of acquired brain injury in day and outpatient neurorehabilitation programmes. Neuropsychol. Rehabil. 9:421– 36 Williams WH, Evans JJ, Wilson BA. 2003. Neurorehabilitation for two cases of post-traumatic stress disorder following traumatic brain injury. Cogn. Neuropsychiatry 8:1–18 Wilson BA. 1999. Case Studies in Neuropsychological Rehabilitation. New York: Oxford Univ. Press Wilson BA. 2002. Towards a comprehensive model of cognitive rehabilitation. Neuropsychol. Rehabil. 12:97–110 Wilson BA, ed. 2003. Neuropsychological Rehabilitation: Theory and Practice. Lisse, The Netherlands: Swets & Zeitlinger Wilson BA, Emslie HC, Quirk K, Evans JJ. 2001. Reducing everyday memory and planning problems by means of a paging system: a randomised control crossover study. J. Neurol. Neurosurg. Psychiatry 70:477–82 Wilson BA, Evans JJ, Brentnall S, Bremner S, Keohane C, Williams H. 2000. The Oliver Zangwill Centre for Neuropsychological Rehabilitation: a partnership between health care and rehabilitation research. In International Handbook of Neuropsychological Rehabilitation, ed. A-L Christensen, BP Uzzell, pp. 231–46. New York: Kluwer Acad./Plenum Wilson BA, Evans JJ, Keohane C. 2002. Cognitive rehabilitation: a goal-planning approach. J. Head Trauma Rehabil. 17(6):542–55 Wilson BA, Herbert CM, Shiel A, eds. 2003. Behavioural Approaches in Neuropsychological Rehabilitation: Optimising Rehabilitation Procedures. Hove, UK: Psychol. Press Wood RL, ed. 1987. Brain Injury Rehabilitation: A Neurobehavioural Approach. London: Croom Helm Wood RL. 1990. Towards a model of cognitive rehabilitation. In Cognitive Rehabilitation in Perspective, ed. RL Wood, I Fussey, pp. 3–25. London: Taylor & Francis Wood RL, Rutterford NA. 2005. Psychosocial adjustment 17 years after severe brain injury. J. Neurol. Neurosurg. Psychiatry 77(1):1–4 World Health Org. 2001. International Classification of Functioning, Disability and Health. Geneva, Switz.: WHO Yates PJ. 2003. Psychological adjustment, social enablement and community integration following acquired brain injury. Neuropsychol. Rehabil. 13:291–306 Ylvisaker M, Feeney T. 2000. Reconstruction of identity after traumatic brain injury. Brain Impair. 1:12–28 Ylvisaker M, Turkstra L, Coelho C. 2005. Behavioral and social interventions for individuals with traumatic brain injury: a summary of the research with clinical implications. Semin. Speech Lang. 26:256–67 Zangwill OL. 1947. Psychological aspects of rehabilitation in cases of brain injury. Br. J. Psychol. 37:60–69 Wilson AR339-FM ARI 5 March 2008 23:50 Annual Review of Clinical Psychology Annu. Rev. Clin. Psychol. 2008.4:141-162. Downloaded from www.annualreviews.org by Universidad de Chile on 07/07/14. For personal use only. Contents Volume 4, 2008 Ecological Momentary Assessment Saul Shiffman, Arthur A. Stone, and Michael R. Hufford p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p1 Modern Approaches to Conceptualizing and Measuring Human Life Stress Scott M. Monroe p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 33 Pharmacotherapy of Mood Disorders Michael E. Thase and Timothey Denko p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 53 The Empirical Status of Psychodynamic Therapies Mary Beth Connolly Gibbons, Paul Crits-Christoph, and Bridget Hearon p p p p p p p p p p p p p 93 Cost-Effective Early Childhood Development Programs from Preschool to Third Grade Arthur J. Reynolds and Judy A. Temple p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p109 Neuropsychological Rehabilitation Barbara A. Wilson p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p141 Pediatric Bipolar Disorder Ellen Leibenluft and Brendan A. Rich p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p163 Stress and the Hypothalamic Pituitary Adrenal Axis in the Developmental Course of Schizophrenia Elaine Walker, Vijay Mittal, and Kevin Tessner p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p189 Psychopathy as a Clinical and Empirical Construct Robert D. Hare and Craig S. Neumann p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p217 The Behavioral Genetics of Personality Disorder W. John Livesley and Kerry L. Jang p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p247 Disorders of Childhood and Adolescence: Gender and Psychopathology Carolyn Zahn-Waxler, Elizabeth A. Shirtcliff, and Kristine Marceau p p p p p p p p p p p p p p p p275 vii AR339-FM ARI 5 March 2008 23:50 Should Binge Eating Disorder be Included in the DSM-V? A Critical Review of the State of the Evidence Ruth H. Striegel-Moore and Debra L. Franko p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p305 Behavioral Disinhibition and the Development of Early-Onset Addiction: Common and Specific Influences William G. Iacono, Stephen M. Malone, and Matt McGue p p p p p p p p p p p p p p p p p p p p p p p p p p p325 Psychosocial and Biobehavioral Factors and Their Interplay in Coronary Heart Disease Redford B. Williams p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p349 Annu. Rev. Clin. Psychol. 2008.4:141-162. Downloaded from www.annualreviews.org by Universidad de Chile on 07/07/14. For personal use only. Stigma as Related to Mental Disorders Stephen P. Hinshaw and Andrea Stier p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p367 Indexes Cumulative Index of Contributing Authors, Volumes 1–4 p p p p p p p p p p p p p p p p p p p p p p p p p p p395 Cumulative Index of Chapter Titles, Volumes 1–4 p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p397 Errata An online log of corrections to Annual Review of Clinical Psychology chapters (if any) may be found at http://clinpsy.AnnualReviews.org viii Contents Annual Reviews It’s about time. Your time. It’s time well spent. New From Annual Reviews: Annual Review of Organizational Psychology and Organizational Behavior Volume 1 • March 2014 • Online & In Print • http://orgpsych.annualreviews.org Annu. Rev. Clin. Psychol. 2008.4:141-162. Downloaded from www.annualreviews.org by Universidad de Chile on 07/07/14. For personal use only. Editor: Frederick P. Morgeson, The Eli Broad College of Business, Michigan State University The Annual Review of Organizational Psychology and Organizational Behavior is devoted to publishing reviews of the industrial and organizational psychology, human resource management, and organizational behavior literature. Topics for review include motivation, selection, teams, training and development, leadership, job performance, strategic HR, cross-cultural issues, work attitudes, entrepreneurship, affect and emotion, organizational change and development, gender and diversity, statistics and research methodologies, and other emerging topics. Complimentary online access to the first volume will be available until March 2015. Table of Contents: • An Ounce of Prevention Is Worth a Pound of Cure: Improving Research Quality Before Data Collection, Herman Aguinis, Robert J. Vandenberg • Burnout and Work Engagement: The JD-R Approach, Arnold B. Bakker, Evangelia Demerouti, Ana Isabel Sanz-Vergel • Compassion at Work, Jane E. Dutton, Kristina M. Workman, Ashley E. Hardin • Constructively Managing Conflict in Organizations, Dean Tjosvold, Alfred S.H. Wong, Nancy Yi Feng Chen • Coworkers Behaving Badly: The Impact of Coworker Deviant Behavior upon Individual Employees, Sandra L. Robinson, Wei Wang, Christian Kiewitz • Delineating and Reviewing the Role of Newcomer Capital in Organizational Socialization, Talya N. Bauer, Berrin Erdogan • Emotional Intelligence in Organizations, Stéphane Côté • Employee Voice and Silence, Elizabeth W. Morrison • Intercultural Competence, Kwok Leung, Soon Ang, Mei Ling Tan • Learning in the Twenty-First-Century Workplace, Raymond A. Noe, Alena D.M. Clarke, Howard J. Klein • Pay Dispersion, Jason D. Shaw • Personality and Cognitive Ability as Predictors of Effective Performance at Work, Neal Schmitt • Perspectives on Power in Organizations, Cameron Anderson, Sebastien Brion • Psychological Safety: The History, Renaissance, and Future of an Interpersonal Construct, Amy C. Edmondson, Zhike Lei • Research on Workplace Creativity: A Review and Redirection, Jing Zhou, Inga J. Hoever • Talent Management: Conceptual Approaches and Practical Challenges, Peter Cappelli, JR Keller • The Contemporary Career: A Work–Home Perspective, Jeffrey H. Greenhaus, Ellen Ernst Kossek • The Fascinating Psychological Microfoundations of Strategy and Competitive Advantage, Robert E. Ployhart, Donald Hale, Jr. • The Psychology of Entrepreneurship, Michael Frese, Michael M. Gielnik • The Story of Why We Stay: A Review of Job Embeddedness, Thomas William Lee, Tyler C. Burch, Terence R. Mitchell • What Was, What Is, and What May Be in OP/OB, Lyman W. Porter, Benjamin Schneider • Where Global and Virtual Meet: The Value of Examining the Intersection of These Elements in Twenty-First-Century Teams, Cristina B. Gibson, Laura Huang, Bradley L. Kirkman, Debra L. Shapiro • Work–Family Boundary Dynamics, Tammy D. Allen, Eunae Cho, Laurenz L. Meier Access this and all other Annual Reviews journals via your institution at www.annualreviews.org. Annual Reviews | Connect With Our Experts Tel: 800.523.8635 (us/can) | Tel: 650.493.4400 | Fax: 650.424.0910 | Email: service@annualreviews.org Annual Reviews It’s about time. Your time. It’s time well spent. New From Annual Reviews: Annual Review of Statistics and Its Application Volume 1 • Online January 2014 • http://statistics.annualreviews.org Annu. Rev. Clin. Psychol. 2008.4:141-162. Downloaded from www.annualreviews.org by Universidad de Chile on 07/07/14. For personal use only. Editor: Stephen E. Fienberg, Carnegie Mellon University Associate Editors: Nancy Reid, University of Toronto Stephen M. Stigler, University of Chicago The Annual Review of Statistics and Its Application aims to inform statisticians and quantitative methodologists, as well as all scientists and users of statistics about major methodological advances and the computational tools that allow for their implementation. It will include developments in the field of statistics, including theoretical statistical underpinnings of new methodology, as well as developments in specific application domains such as biostatistics and bioinformatics, economics, machine learning, psychology, sociology, and aspects of the physical sciences. Complimentary online access to the first volume will be available until January 2015. table of contents: • What Is Statistics? Stephen E. Fienberg • A Systematic Statistical Approach to Evaluating Evidence from Observational Studies, David Madigan, Paul E. Stang, Jesse A. Berlin, Martijn Schuemie, J. Marc Overhage, Marc A. Suchard, Bill Dumouchel, Abraham G. Hartzema, Patrick B. Ryan • High-Dimensional Statistics with a View Toward Applications in Biology, Peter Bühlmann, Markus Kalisch, Lukas Meier • Next-Generation Statistical Genetics: Modeling, Penalization, and Optimization in High-Dimensional Data, Kenneth Lange, Jeanette C. Papp, Janet S. Sinsheimer, Eric M. Sobel • The Role of Statistics in the Discovery of a Higgs Boson, David A. van Dyk • Breaking Bad: Two Decades of Life-Course Data Analysis in Criminology, Developmental Psychology, and Beyond, Elena A. Erosheva, Ross L. Matsueda, Donatello Telesca • Brain Imaging Analysis, F. DuBois Bowman • Event History Analysis, Niels Keiding • Statistics and Climate, Peter Guttorp • Statistical Evaluation of Forensic DNA Profile Evidence, Christopher D. Steele, David J. Balding • Climate Simulators and Climate Projections, Jonathan Rougier, Michael Goldstein • Probabilistic Forecasting, Tilmann Gneiting, Matthias Katzfuss • Bayesian Computational Tools, Christian P. Robert • Bayesian Computation Via Markov Chain Monte Carlo, Radu V. Craiu, Jeffrey S. Rosenthal • Build, Compute, Critique, Repeat: Data Analysis with Latent Variable Models, David M. Blei • Structured Regularizers for High-Dimensional Problems: Statistical and Computational Issues, Martin J. Wainwright • Using League Table Rankings in Public Policy Formation: Statistical Issues, Harvey Goldstein • Statistical Ecology, Ruth King • Estimating the Number of Species in Microbial Diversity Studies, John Bunge, Amy Willis, Fiona Walsh • Dynamic Treatment Regimes, Bibhas Chakraborty, Susan A. Murphy • Statistics and Related Topics in Single-Molecule Biophysics, Hong Qian, S.C. Kou • Statistics and Quantitative Risk Management for Banking and Insurance, Paul Embrechts, Marius Hofert Access this and all other Annual Reviews journals via your institution at www.annualreviews.org. Annual Reviews | Connect With Our Experts Tel: 800.523.8635 (us/can) | Tel: 650.493.4400 | Fax: 650.424.0910 | Email: service@annualreviews.org
