A Problem Solving Approach to Cognitive Rehabilitation Karen Lindgren, Ph.D. October 24, 2012

1. A Problem Solving Approach to Cognitive Rehabilitation Karen Lindgren, Ph.D. October 24, 2012 © 2012 Bancroft | All rights reserved

2. Goals • What is problem solving? • How is problem solving relevant to community integration? • How do we teach problem solving skills?

3. Traumatic Brain Injury/Acquired Brain Injury • Traumatic Brain Injury (TBI): cerebral damage that occurs after birth, and is not directly related to a developmental disorder or a progressive damaging of the brain. Traumatic brain injury refers to a specific form of acquired brain injury (ABI) that is the result of a sudden trauma.

4. Common Symptoms after TBI • Physical symptoms • Headaches • Fatigue • Sleep • Cognitive symptoms • Memory Deficits • Word Finding Difficulty • Concentration • Processing speed • Emotional symptoms • Irritability • Depression • Unstable or inconsistent mood • Behavioral symptoms • Impulsiveness • Outbursts

5. Cognitive Symptoms are complex • Multiple pathways can result in similar symptom presentation • Lay-person language for cognitive constructs is limited • For example, what is meant by a “memory” problem?

6. Cognitive constructs are complex- Memory example • “Memory” complaints can result from: • environmental distractions/emotional interference • poor attention/slowed processing • expressive/receptive language • poor encoding • poor retrieval • accelerated forgetting • poor organization/comprehension of material (executive dysfunction)

7. Emotions • Emotions can become flat or amplified. • Neurological rage • Lack of inhibition • Trouble analyzing social situations • Difficulty with facial expression or tone of voice

8. Cognitive/Emotional/Physicalsymptoms interact • Multiple or varying symptoms • Complex symptoms combine to result in behaviors

9. Cognitive/Emotional/Physicalsymptoms interact: Overload • Common complaint in community settings • Brought on by large crowds, lots of noise, or information presented too quickly. • Inability to process external environment (cognitive) • Fatigue (physical) • Rise in emotions (emotional)

10. TBI and Quality of Life • Life satisfaction appears to steadily decline after an individual experiences a brain injury. • Injury severity has not been found to be significantly correlated with measures of life satisfaction.

11. TBI and Quality of Life • Several variables have been shown to correlate with life satisfaction in individuals who have suffered TBIs. • Marital Status • Problem Solving • Executive Functioning

12. Executive Functioning • Executive dysfunction has been repeatedly seen and documented in acquired brain injury, and is reported as one of the more common difficulties facing this population.

13. Executive Functioning • Executive functioning refers to the integration of several cognitive skills people require to adapt to novel situations and pursue their life goals, which includes planning, initiation, and regulation. • Complicated concept, involving multiple skills: • Integration of physical, emotional, and cognitive

14. Executive functioning and outcome • Executive dysfunction has been implicated with poor social outcomes following a traumatic brain injury. • Research in rehabilitation populations has found that poor executive functioning is strongly correlated with poor work adjustment.

15. Executive functioning and outcome • Why? • Components of executive functioning help us understand, adapt and respond to our environment • Promotes complex problem solving

16. Executive functioning: Problem solving Research has found a significant relationship between problem-solving ability and various forms of psychological well-being. • Specifically the effectiveness of one’s problem-solving ability has been found to moderate the relationship between stress and distress.

17. Executive functioning: Problem Solving • People who have suffered TBIs face a large variety of significant problems in their day to day life. • The cognitive skills they use to cope with problems may have been compromised by their injury. • Poor emotional control may make it difficult for persons served to tolerate problems long enough to generate solutions. • Deficits in executive functioning may make it difficult for persons served to generate alternative solutions. • These symptoms increase the importance of social problem-solving skills for individuals who have suffered a TBI.

18. Rehabilitation of problem solving skill • Two important components: • Rehabilitate Skill (Problem-Solving Skill) • Address social problem solving (problem solving orientation, problem solving style)

19. Rehabilitation of problem solving skill • Two important components: • Rehabilitate Skill (Problem-Solving Skill) • Address social problem solving (problem solving orientation, problem solving style)

20. Cognitive rehabilitation of executive dysfunction: problem solving • Resources: • Edmund Haskins, Ph.D. (2012) ACRM Cognitive Rehabilitation Manual: Translating evidence based recommendations into practice • Sohlberg& Tukstra(2011) Optimizing Cognitive Rehabilitation • Nezu, Nezu & D’Zurilla (2007) Solving Life’s Problems

21. Cognitive rehabilitation of executive dysfunction: problem solving • BI-ISIG (Task force of ACRM) recommends: • Metacognitive strategy training as a Practice Standard for rehabilitation of executive functioning after TBI • Training in formal problem solving strategies during post-acute rehabilitation as a Practice Guideline • References: Cicerone, et al 2011, Haskins, et al, 2012

22. Who is appropriate for problem solving training? • Evaluate awareness • Evaluate effectiveness of environmental support vs. internalized strategies

23. What Can We Do To Help Foster Effective Problem Solving? • Training in Problem Orientation • Problem Solving Skill • Training in Problem Definition • Training in Planning/Generation of Alternatives • Training in Decision Making • Training in Solution Implementation • Solution Verification or Feedback

24. What Can We Do To Help Foster Effective Problem Solving? • Training in Problem Orientation • Problem Solving Skill • Training in Problem Definition • Training in Planning/Generation of Alternatives • Training in Decision Making • Training in Solution Implementation • Solution Verification or Feedback

25. Problem Solving Skill • Well researched • Varies in the number of steps • Includes Key components: • Problem Definition (Awareness) • Planning/alternatives • Decision making • Implementing • Evaluating • For example, the Goal-Plan-Do-Review method

26. Problem Solving Skill • Teach the steps in a highly structured way • Provide maximum support • Goal for client to implement independently

27. Training in Problem Definition • Is there a problem? • What are the signs? Mood, feedback from others, change in circumstances • What is the problem? • Example: don’t have money

28. Training in Problem Definition • Example: “Don’t have money” • Skill deficit: • misplace money • impulsive with spending • poor budgeting • Interpersonal challenge: • dependent on family • Vocational concern: • need a job

29. Training in Problem Definition • Example: “Don’t have money” • Vocational concern: • need a job: • locate • apply • interview

30. Training in Problem Definition Help To: • Seek all available facts about a problem • Describe these facts in clear and objective terms • Separating facts from assumptions • Identify obstacles or conflicts that make the situation a problem • Set realistic goals

31. How? • Externalize Problems • Encourage the person served to work on problems outside of their own mind (take notes, work problems out on paper) • Visualize Solutions • Visualize both the implementation and results of solutions. • Simplification • Help persons served to help break large problems down into their smaller components

32. Slow-Down • Teach techniques that will help individuals tolerate the emotional arousal associated with working with social problems • Smiling • Yawning • Behavioral Stress Management • Deep Breathing • Guided Imagery • Progressive Muscle Relaxation

33. Training in Problem Definition • Use worksheet: • Date _________________ • What is my goal? ____________________

34. Training in Problem Definition • Use worksheet: • Date 10/24/12 • What is my goal? To obtain a part time job 10-15 hours per week

35. Training in Problem Definition • Use worksheet: • Date 10/24/12 • What is my goal? To reduce my spending by 25$ per week

36. Training in Problem Definition • Use worksheet: • Date 10/24/12 • What is my goal? To ask my sister to give me 25$ per week

37. Training in Planning • Should be taught to expand their perceived options and to defer judgment.

38. Training in Planning • What are my options? • What are my resources? • What are my barriers? • Do I need to change my goal?

39. Training in Decision Making • Maximize positive consequences and minimizes negative consequences.

40. Training in Decision Making • Which solution is best? • What is most important? • No solution is perfect • Pros and cons list • Consider outcomes, resource utilization, ease of implementation, effects of errors

41. Training in Decision Making • working asking • Pros independent easy to try • meet people focus on rehab • functional/career • Cons fatigue dependency • costs associated • mobility concerns • less rehab focus

42. Training in Decision Making • Utilize a worksheet • To solve this problem, I will: ___________________________________

43. Training in Decision Making • Utilize a worksheet • To solve this problem, I will: • Ask my sister to help me by giving me25$ per week

44. Training in Planning • How will I reach my goal? • Resources/barriers: Social, environmental, financial, cognitive, psychological • Plan details: Who, when, where, what • Anticipating barriers/problems: What are back-up plans? Is there a safety-net?

45. Training in Planning • Evaluation of each step • Resources/barriers: Social, environmental, financial, cognitive, psychological • Plan details: Who, when, where, what • Anticipating barriers/problems: What are back-up plans? Is there a safety-net?

46. Training in Planning • Use worksheet • What is my plan? _______________ • What do I need? _______________ • What are the steps? • 1. ________________________ • 2. ________________________

47. Training in Planning • Use worksheet • What is my plan? Ask my sister for 25$ per week • What do I need? Budget, planner, bank statement • What are the steps? • 1. _ask to meet with sister (evening preferred) • 2. present budget and problem with expenses exceeding income

48. Training in Planning • Go beyond the worksheet • What are the steps? • 1. ________________________ • At each step, identify resources, challenges, safety-net • Specify support to be given • Make a “larger” plan- how does this plan fit into the rehabilitation goal?

49. Training in Planning • Go beyond the worksheet • What are the steps? • 1. ask to meet with sister (evening preferred) • identify resources, challenges, safety-net: plan a meal or snacks? Ask staff for support? Role play? Challenges: sister busy/preoccupied • Specify support to be given • Make a “larger” plan- how does this plan fit into the rehabilitation goal?

50. Training in Solution Implementation and Verification • Occurs at each step • Proceed as slowly as implementation will allow • Increase mindfulness of each step (e.g., what I am doing? How am I feeling?) • Seek feedback • Are changes needed?