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

1. How to Lessen the Effect of TBI in Returning Soldiers or Civilians Helping the Person with Neurological Impairment Re-invent Themselves?

2. By Harriet Katz Zeiner, PhD Outpatient Neuropsychological Assessment and Intervention Clinic Palo Alto VA Healthcare System harriet.zeiner@va.gov

3. The CRATER Model of Psychotherapy for Persons with Neurological Impairment has 4 areas of modification of your current technique

4. Tie the performance of Cognitive Strategies or regular re-occurring tasks to physiological events such as rise time, sleep time, meal time to lower the burden on the client’s memory.

5. 2. Understand the catastrophic reaction: what do they look like when cognitively overloaded. • tie the performance of the cognitive strategy to the catastrophic reaction. • pick up the catastrophic reaction earlier.

6. 3. Externalize the problem and use triangulation- Therapist, Client and Family allied against Demon Brain Injury

7. 4. Change the source of self-esteem from personal best and a competition model to a resilience coping model

8. Become aware of neuropsychological symptoms that are influencing social interactions- and what to do about them.

9. How to modify your techniques? By presenting a theory, a method, of imbedding cognitive retraining in individual psychotherapy having the following characteristics: 1. Pick cognitive symptomatology which is most likely to elicit stimulus overload in the patient. 2. If present, always address fatigue first. 3. Address any cognitive deficits that lead to catastrophic reactions second. 4. Link the performance of verbal cognitive constructs to either dysphoric affect (the catastrophic reaction) or a physiological response to effect generalization in the community. 5. Pick additional cognitive constructs to be retrained based on upstream/downstream Lurian brain organization – or “Where in the continuum of a cognitive domain does breakdown occur?”

10. Here it is another way: What What needs a cognitive strategy? What needs to be compensated for : First, on what gives the patient the most frequent grief based on symptomatology of neurological insult 1. fatigue and 2. being overwhelmed with information coming too quickly, slowed information processing, leading to dysphoric affect (catastrophic reaction, i.e. anger, tears, flight, freezing, confusion, helpless laughter). Secondly, link the performance of a compensation or device use to either: 1. dysphoric affect (catastrophic reaction) or 2. a physiological response to increase generalization

11. How • Externalizes the symptom as belonging to the neurological insult (Demon Brain Injury). • Recognize anger at loss is not pathological, but useful if directed properly-at the neurological insult. • Re-defines the person’s source of self esteem from “ I am the fastest, best, brightest, the most competitive winner.” to “I use my cognitive compensation whenever needed, I cope most effectively.”

12. How continued • re-direct the anger constantly to the externalized neurological insult, • give a new framework for self-esteem with performing the cognitive strategy as the core strategy for coping • Stress the alliance of the patient/family/therapist/team against the neurological insult (triangulation) • Pace the learning of cognitive constructs to the patient’s new learning/memory/attention characteristics-always slower • Share the cognitive strategy with team members, family members and have everyone practice it together.

13. Don’ts • Don’t blame the patient for lack of motivation when cognitive retraining/therapy isn’t being successful. Assume that you have entered the cognitive continuum at the wrong point and correct. • Don’t assume that the Device is the therapeutic agent of change. 3. Understand why “cookbook” matching of cognitive retraining technique to gross symptom often doesn’t work. 4. Understand why cognitive retraining by diagnoses/level of severity may not be effective, although that’s where the evidence is. 5. Cognitive retraining/psychotherapy is for those with co-morbidities.

14. Holistic Integrated Neuropsych Remediation Programs Work for ABI • Prigatano, GP, Fordyce, DJ, Zeiner, HK, Roueche, RR, Pepping, M, and Wood, BC: Neuropsychological rehabilitation after closed head injury in young adults. Journal of Neurology, Neurosurgery, and Psychiatry, 47, 505-513, 1984. • Klonoff et al 1998, 2000 (11 years post discharge) • Malec, J. 2001 • Cicerone et al 2008

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

16. 1. Success in the community, work/school, best after cognitive remediation INTEGRATED with psychotherapy. • 2. The same techniques worked for a number of ABI conditions cognitive impairment after neurological insult-

17. Who is most successful after TBI: • Those who can learn to use remediations unassisted, • Those who ally with therapists, and • Those who slow the world down to what they need.

18. Findings • Perceived cognitive functioning/need was not a strong factor in influencing whether or not a subject used a cognitive support technology. • Emphasizing level of impairment may not help at all in getting a client to use CST. • Pre-morbid Sophisticated technology users want more freedom and autonomy than non-users post-injury. • For them, the appeal of device is freedom from others control. • Pre-morbid Minimal technology users appear to use technology (cell phones) to bring them together with others. • Appeal of CST device (different device) is social bonding.

19. One source of “personality change” is how family perceives the patient. When questioned about how their loved one has changed in personality after acquired brain injury, family members mention anger and fatigue as the sources of “personality change” after ABI. Zeiner, HK. Living with TBI: Impact on the Survivor and Their Family in Traumatic Brain Injury, Independent Study Course, Veterans Health Initiative: Traumatic Brain Injury, Department of Veterans Affairs, Employee Education System, p. 99-112, October 2003

20. A second source of personality change comes from the patient’s neurological condition.

21. Identification of the Catastrophic Reaction • Behavioral freezing/thought blocking • Behavioral appearance of confusion without verbally seeking clarification • Crying • Flight • Anger • Laughing • All six are uncomfortable emotional responses given by persons with neurological impairment when stimulus overloaded.

22. What are the sources of the catastrophic reaction, e.g. What are the cognitive symptoms that are most likely to result in stimulus overload and dysphoric affect? Some, but not all, cognitive impairments

23. What needs to be remediated first are: 1. Those cognitive symptoms which are most likely to evoke one of the six catastrophic reactions. 2. They are remediated with a verbal cognitive construct which tells the patient what is wrong and what to do about it. 3. The performance of the cognitive construct is tied to either the presence of the catastrophic reaction (dysphoric affect) or a physiological response.

24. This changes the relationship of the patient to their catastrophic reaction. • First- it is no longer a personality change or a failure- the dysphoric affect is a flag, a warning that the patient is overloaded. • The identification of the catastrophic reaction by the patient is reframed as “I am angry, so I must be overloaded. I need to simplify, avoid or delay.”

25. Patient’s learn their characteristic catastrophic reaction- pick it up as early as possible, and perform the cognitive construct to reduce stimulus overload at that moment. • These cognitive constructs are almost always tied to ways of receiving informational input- example, • “because I am slowed in processing, I need to ask you to repeat that information.”

26. A more socially acceptable version of that cognitive construct- “What you just said is really important, could you give it to me one more time so I am sure to get it.?”

27. If not tied to dysphoric affect, the catastrophic reaction, the cognitive construct is tied to a daily physiological response. This is to reduce the cognitive burden on memory. • For example, patients who use either an electronic calendar or paper memory book with a calendar- review today and tomorrow in the calendar after every meal. • The cognitive construct is ”because I have a leaky memory, I need to review today and tomorrow in my calendar after every meal.”

28. The cognitive remediation is all done in the context of a therapy which: • 1. Externalizes the neurological insult. • 2. The patient’s goal is to reduce the effect of externalized Brain Injury on the patient’s life. • 3. Change the source of satisfaction, sense of competence from “competing to be best” to “I compensate whenever necessary; I cope adequately, a resilience model. • 4. Focuses on “well-being”

29. Alliance/Resilience Model of Therapy The optimal condition for rehabilitation of neurologically impaired patients is created when the patient, family and staff are allied against “demon” brain injury. This is the triangulation necessary for optimum recovery.

30. Alliance/Resilience model is based on redirected anger. • Anger is always generated when loss is experienced. • It is adaptive, Anger creates energy to prevent collapsing in despair, and fuels the need to change. It is always present. It is natural part of the history of recovery. • It is not pathological or delusional.

31. For those with brain injury, “resilience“ is defined as “I use the latest/best compensation most effectively. • This redefines life from “be the best you can be” into, “I cope effectively but not perfectly, to all that I encounter”.

32. To Get Change With a Cognitive Strategy, You Have to Have Three Parts to the Cognitive Construct 1.What is the specific problem (closely related to a basic unit of brain function) 2.What you have to do to correct the specific problem 3. Both must be learned by the Patient

33. At the same time, the family receives cognitive retraining (as in train the trainer) • Preferably, from the same therapist seeing the patient.

34. Some Neuropsych Tips Caregivers Should Know • They cannot multitask-now a one trick pony • Inside/ outside line moved (gum-balling, seems rude, hurtful) • Lack ideas • Initiation difficulty (broken ignition, broken starter)

35. Dependency- When the Survivor Can But Doesn’t Do Something. Think of the survivor’s brain as Swiss cheese. There is plenty of good cheese — intact circuits that were unaffected by the injury. But now there are a few “holes” where cells were injured or destroyed.

36. He or She who does the task- that’s whose brain is being re-wired. If you can do a task and you allow your spouse to do it because he or she is “faster”- their brain gets the benefit, and you get the “cost” For that moment they view you as “patient” not “spouse”

37. Order of Cognitive Remediation for Most Patients with Cognitive Impairment

38. Additional Early Issues to work on: • How to not be overwhelmed by the world. • Impulsivity and delay. • Gumballing, or the line between what’s an inside thought, what’s an outside thought-private versus public thoughts. • Beginning, middle and end of behavior chain.

39. I’d like to present to you the cognitive symptoms that are most often used in NPI Clinic at PAVA for cognitive treatment. • This is a clinic that performs 6-8 hour neuropsychological assessments on persons with cognitive impairments, not so much for diagnostics, as for treatment recommendations. • About 25 % of the patients are then seen in individual therapy/cognitive remediation by the therapist, who also co-treats with their family member if possible.

40. Problems in fatigue: • loss of regular day/night cycle • poor sleep • doing with conscious effort what the rest of us do automatically- concept of mental energy budget

41. Establish a day/night cycle.

42. Management Strategy Disturbed Sleep/Wake Cycle. In addition to medication, the treatment for sleep cycle disruption is to artificially impose a rigid bedtime and rise time on the patient. Choose a total sleep time, which is 1 to 1.5 hours longer than the patient’s pre-morbid length of sleep at night. Patients must go to bed at a set bedtime, whether or not they fall asleep. They need to rise at a set rise time and not nap during the next day, even if very tired.

43. It takes about 3 weeks to establish a new artificial day/night cycle. It must be applied 7 days/week. After the three weeks, patients can be allowed afternoon naps, but the schedule must be maintained. If the artificial pattern is broken, it always takes about three weeks to re-establish again.

44. All thinking requires some expenditure of mental energy. Cognitions such as: paying attention, switching attentional focus to a new person, keeping up with the topic of conversation, organizing an answer to a question, making a decision, trying to decide what to do next, organizing your day’s activities in the morning All cost mental energy.

45. Many of the cognitive functions, which are automatic and reflexive for people without BI, require 2-3 times the mental effort to accomplish for people with BI. This is due to the fact that people with BI often have to think about, and do with conscious effort, what the rest of the world does automatically, without thinking.

46. • Make as many activities as possible into a routine to minimize choice. This saves mental energy. • Do not fill up the days with scheduled activities, do one important thing/day

47. How to Compensate for the Symptom of Fatigue.• Make important decisions when the person has the greatest amount of mental energy, usually in the morning. Schedule patients with BI in the morning.• Make as many activities as possible into a routine to minimize choice. This saves mental energy. • Do not fill up the your day with scheduled activities.Do one important thing/day• The use of an organizer, either written, taped or electronic is essential.

48. Problems With Sequencing:Every activity has a beginning, middle and an end. Sometimes, people with BI drop off the “end” response. They begin, do the middle, then begin something else, do the middle, then begin something else, etc. By the end of the day-they have been busy, but they completed nothing.

49. Change in pre-morbid learning/memory characteristics-(usually patient is unaware of this): • Reduction of learning span for new material • no longer able to operate in 50% range of ability- cannot smooth out behavior • poor retrieval unless over-learned • Reduced memory consistency/efficiency

50. Retraining Impulsivity If you are highly impulsive, you are jumping into action before your brain can size up what to do. So, count (silently) to 4 before you answer or do anything.