Psychotherapy and the Process of Coping with a Brain Disorder

1. Psychotherapy and the Process of Coping with a Brain Disorder George P. Prigatano, Ph.D., ABPP-CN American Psychological Association 2015 Annual Convention August 6-9, 2015 Toronto, Ontario

2. Plan of this lecture • Briefly consider how psychotherapy became an important part of neuropsychological rehabilitation. • Disclose my biases about what makes a “difference” when psychotherapy is in fact effective. • Review a few definitions of psychotherapy which appear helpful. • Brief comments about controversies surrounding psychotherapy • Summarize an approach to psychotherapy that seems to help in the long term adjustment to a brain disorder.

3. Neuropsychological rehabilitation and psychotherapy The responsibilities of clinical neuropsychologists when helping patients with brain dysfunction: • Understanding the nature of their neuropsychological disturbances. • Remediating or compensating for those neuropsychological disturbances (if possible). • Lessening their personal suffering over those disturbances and aiding their adaptation. 1) Comments from Dr. Benjamin and his “singing” hospital. • Assisting them to make choices that improve the quality of their life. This is true for adults as well as for children (and their family members).

4. While a scientific approach is absolutely necessary for neuropsychology and brain injury rehabilitation, it is seldom sufficient for helping patients with these four problems (especially the last two). • Scientific investigation fails to address certain important aspects of human existence.

5. Scientific investigations do not adequately address: • The role of the patient’s subjective experience (their phenomenological state) in diagnosis and treatment. • Adaptive management of sex and aggression in a given society for a given individual at different stages of life (Freud). • Coping with problems associated with territoriality (McLean). • Symbols that guide people’s lives for the better or worse (Jung). • Human consciousness and man’s related search for meaning in life (Roger Sperry, Victor Frankl, Bruno Bettelheim, and C.G. Jung).

6. Therefore – the need for Principle #7: Psychotherapeutic interventions are often an important part of neuropsychological rehabilitation because they help the patients (and families) deal with their personal losses. The process, however, is highly individualized.

7. A discussion of “psychotherapy” as a series of techniques that can be used to help patients with their emotional and motivational problems after brain injury is always problematic.

8. Psychotherapy cannot proceed without knowing who this particular patient was before their injury and how the various forms of brain injury have affected them. Only when one has this information can one begin to know how to best approach a patient with their immediate and long-term adjustment problems.

9. What makes the difference? • The skill and knowledge base of the psychotherapist. • The desire of the psychotherapist to be helpful. • The capacity of the patient to pursue help and willingness to examine their life.

10. Psychotherapy defined • A personal, confidential and professional dialogue to help the patient deal with a psychological matter • Like turning the lights on – • Like delivering babies – following the natural process

11. Psychotherapy is not about happiness, it is about power. • It attempts to improve the capacity of the patient to make better decisions in their life. • Some patients get better; some do not. A lot depends on the skill and motivation to change in both the patient and in the therapist.

12. Controversies over the clinical value of psychotherapy before and after a brain injury • Schofield, W. (1964). Psychotherapy: The purchase of friendship. Englewood Cliffs, New Jersey: Prentice-Hall Inc. • Szasz, T. (1978). The myth of psychotherapy. Garden City, NY: Syracuse University Press. • “Strictly speaking, the question is not how to get cured, but how to live.” Joseph Conrad • Frank, J. D., & Frank, J. B. (1991). Persuasion & healing: A comparative study of psychotherapy (3rd ed.). Baltimore, MD: Johns Hopkins University Press.

13. An approach that may be helpful

14. What factors contribute to the patient’s emotional/motivational problems after a brain disorder? 1. Direct Effects of the Brain Disorder Examples: • Impulsive behavior • Depressed mood/affect • Reduced tolerance for frustration/easily agitated • Reduced motivation (possibility a direct consequence of impairment of the “abstract attitude”) • Reduced self-awareness of altered cognitive abilities and changes in personality/behavior.

15. 2. Indirect Effect of the Brain Disorder Examples: • Feeling “stupid”/humiliated/incompetent which leads to feelings of self-doubt, depression, and self harm • Resistance to change behavior or attitudes secondary to impaired cognitive functioning • Increased defensiveness about behavioral limitations which are a source of considerable anxiety (i.e., denial/repression) and may represent avoidance of the catastrophic reaction

16. 3. Longstanding Characterological Features of the Patient’s Personality which Interact with the Direct and Indirect Consequences of a Brain Disorder. Examples: • Honesty vs. social and personal deceptiveness • Hardworking attitude vs. “getting by” with minimal effort • Stable interpersonal relationships vs. unstable or immature interpersonal relationships • Adaptive vs. nonadaptive coping skills for handling anxiety and depression

17. A Few Examples • Patient with “true” seizures who also has PNES when the present interpersonal situation becomes overwhelming (long standing difficulties successfully managing anxiety). • Patient who is progressively impulsive as his Parkinson’s Disease advances, but who also acted impulsively to manage anxiety in the past. Discussion of this raises considerable anxiety and “cognitive” confusion. • Patient with vascular dementia who had considerable difficult honestly discussing major interpersonal difficulties prior to the onset of his dementing condition. The combination of this premorbid personality characteristic with his present cognitive impairments makes it very challenging to manage his suicidal depression. • Patient with cerebral hemorrhage who remains excessively dependent on his wife pre and post vascular insult—resistance to change key features of the marital relationship despite ongoing frustrations.

18. Levels of Psychotherapeutic Interventions • Symptom Reduction e.g. Mohr et al. (2012) A randomized trial of stress management for the prevention of new brain lesions in MS. Neurology, 79, 412-419. • Reduction of problematic behaviors that emerge as a consequence of adjustment issues associated with a brain disorder (e.g., addictions) e.g. Tweedly et al. (2012) Investigation of the effectiveness of brief interventions to reduce alcohol consumption following traumatic brain injury. Journal of Head Trauma Rehabilitation, 27, 331-341. • Dealing with a “damaged sense of self” and improving quality of life e.g. Klonoff and Lage (1991) Narcissistic injury in patients with traumatic brain injury. Journal of Head Trauma Rehabilitation, 6,11-21. • Re-establishing meaning in life after a brain disorder e.g. Prigatano (1991) Disordered mind, wounded soul: The emerging role of psychotherapy in rehabilitation after brain injury. Journal of Head Trauma Rehabilitation, 6, 1-10.

19. Treatment Size Effects: Oversimplification, but important trends for persons without a brain disorder 1. Medication to reduce depression for persons .31 without a brain disorder 2. CBT and related therapies .58-1.0 3. Psychodynamic therapies .69-1.8 Shedler, J. (2010) The efficacy of psychodynamic psychotherapy American Psychologist, 65, 98-109

20. Impact of the Therapeutic Alliance on treatment outcomes for persons without a brain disorder • e.g. Martin et al. (2000) Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review. Journal of Consulting and Clinical Psychology, 68, 438-450 Estimated Size Effect .22

21. Clinical Reality: Pervasive resistance to change behavior and beliefs during the course of psychotherapy even with reasonable insight into one’s motivations • The Pleasure Principles/Re-visited • Pleasure/secondary gain in the symptom

22. The importance of the patient’s subjective experience in the process of adaptation The patient’s subjective experience of how they were affected by their brain injury, and their pre- and post-injury personality characteristics greatly influence the process and outcome of rehabilitation and psychotherapy. This is reflected in their: • choice of words and interpretation of life events • dreams • spontaneous artwork • favorite music • favorite metaphors about life • favorite fairy tales

25. Group Psychotherapy In group psychotherapy we sit Wondering where in life we can fit, Which of our feelings should we admit? And which hold with bridle and bit? Once some of us on the head were hit. Sometimes we feel we were hit by shit. Some of us had good jobs that we quit; Are we able to do more than knit? When we fail again, our teeth we grit, Sometimes words are hard to spit, Is there more to life than this big pit?

26. “Fairy tales are more than true: not because they tell us that dragons exist, but because they tell us that dragons can be beaten.” - G. K. Chesterton

27. Newcome (2002) cited several of Goldstein’s contributions that make him the great precursor of our current activities

28. Goldstein’s (1938) book: The Organism • Pathology produces a breakdown of organization of the organism that reduces its range of capability.

29. The Organism • When the person does not adapt and adjust to these changes, they experience a “catastrophic reaction” with anxiety and agitation. • Inability to perform up to one’s own expectation is perceived as an existential threat.

30. The Organism • On the other hand, organisms have capability for active reconstruction and adjustment to catastrophic losses which can be facilitated through environmental modification and support in a transformative process.

31. The Organism • Successful adaptation involves withdrawal to a more limited range which can be managed by a redistribution of reduced energies, thus reclaiming as much wholeness and “meaning” as the new circumstances will allow. • This involves a transformation of identity and the willingness to accept change.

32. IDENTITY ACCEPTANCE CONTROL MASTERY AWARENESS ENGAGEMENT Overall model of brain injury rehabilitation provided by Goldstein & Ben-Yishay’s work (Ben-Yishay and Prigatano, 1990)

33. An example of what Goldstein was talking about: O’Brien, K. P., & Prigatano, G. P. (1991). Supportive psychotherapy with a patient exhibiting alexia without agraphia. Journal of Head Trauma Rehabilitation, 6(4), 44–55.

34. Essential ingredients of neuropsychological rehabilitation • Establishment of a therapeutic milieu • Cognitive retraining • Psychotherapeutic interventions • Productive work trials • Family involvement and education • Management of the rehabilitation staff

35. Clinical Guidelines: Specific ways psychotherapy can be beneficial to a person with a brain disorder. • Establishing a relationship with the person so they do not “feel alone” with the problem. • Helping the patient understand how the brain disorder has directly affected some (not all) of their abilities. • Helping the patient understand what an indirect effect of a brain disorder (or injury) is, particularly the catastrophic reaction.

36. Guiding the person to make adaptive choices in light of the direct and indirect effects of their brain a. To accomplish this often requires an understanding of the person’s psychosocial history and their core psychodynamics (which may not always be obvious). b. It requires an adequate working therapeutic alliance, which is a necessary but insufficient condition for change c. A good knowledge of the neuropsychological status of the patient.

37. Speaking to the person about their feelings and subjective experiences as it relates to three key existential questions: • Will I be normal again? • Why did this happen to me? • Is life worth living after my brain disorder? • Helping the patient remain productive in life and establish and maintain love relationships while fostering their individuality at each stage of the lifespan (i.e. relating to symbols of work, love, and play).

38. Efficient Commitment Cooperative Intimacy Effective Passion Reliable A model for work presented to brain-dysfunctional patients. A model regarding love.

40. Spontaneous drawing/dream of a woman who could not successfully deal with her hemiparesis after moderate TBI.

41. A recurring dream

42. The slow, arduous and non-dramatic effective psychotherapy of a young man who suffered cerebral anoxia (bilateral cerebral dysfunction). “I guess you’re right.”

43. PHILOSOPHICAL PATIENCE IN THE FACE OF SUFFERING SOCIAL RE-INTEGRATION CONTROL MASTERY AWARENESS ENGAGEMENT Prigatano, G.P. (1999), Principles of Neuropsychological Rehabilitation, Oxford University Press, New York.

44. “The treatment of patients suffering from brain damage must aim at two goals. Firstly, eliminating the damage, retraining the lost functions and reducing the mechanisms which have been built to protect the individual against catastrophe and anxiety. Secondly, helping the patient to bear without resentment the restrictions which are necessary. From this latter aspect it becomes evident that psychotherapy is essential in the treatment of all patients with organic defects.” • Goldstein, 1954, p. 143

45. “You cannot be a sourpuss and be rehabilitated.” (Yehuda Ben-Yishay, Degendorf, Germany, 1993)

46. Research from the Frostig Center (As reviewed by Waber, 2011) What differentiated children with a history of LD who were “successful” as young adults? • Realistic adaptations to their learning problems. • Greater self-awareness of their problems and how they affected them. • Being “proactive” and persevering. • More “emotionally stable.” • Had effective supports (family members, other supportive adults or peers) and used those supports well. Goldstein Ben-Yishay, Prigatano and many others Premorbid personality characteristics The role of psychotherapy Good fortune in life

47. Lou and Evelyn Grubb Center for Lifespan Neuropsychological Rehabilitation

48. Questions and Answers