Collaborative Therapeutic Collaborative Therapeutic Neuropsychological Neuropsychological

AssessmentAssessment

November 22, 2012 – 9:00a – 12:30pNovember 22, 2012 – 9:00a – 12:30p

Tad Gorske, Ph.D.Tad Gorske, Ph.D.Clinical Assistant ProfessorClinical Assistant ProfessorDirector, Outpatient NeuropsychologyDirector, Outpatient NeuropsychologyDivision of Neuropsychology and Rehabilitation PsychologyDivision of Neuropsychology and Rehabilitation PsychologyUniversity of Pittsburgh School of Medicine, Pittsburgh University of Pittsburgh School of Medicine, Pittsburgh Pennsylvania, USAPennsylvania, USA

““The presentation of brain facts The presentation of brain facts about specific damages is about specific damages is meaningless to patients unless meaningless to patients unless they can begin to understand they can begin to understand how the changes in their brains how the changes in their brains are lived out in everyday are lived out in everyday experiences and situations”experiences and situations”

(Varela, 1991 as stated in (Varela, 1991 as stated in McInerney and Walker, 2002)McInerney and Walker, 2002)

What is Collaborative What is Collaborative Neuropsychology?Neuropsychology?• What is traditional neuropsychology?What is traditional neuropsychology?

– Typically follows a medically based/information Typically follows a medically based/information gathering model. gathering model.

– Outsider viewing a passive “object”Outsider viewing a passive “object”– ReductionistReductionist– Categories, diagnoses, constructs used to explain a Categories, diagnoses, constructs used to explain a

client. client. – Focus on pathologyFocus on pathology– Tester as detached observerTester as detached observer– Sense of secrecySense of secrecy– Specific focus on the brain-behavior relationshipSpecific focus on the brain-behavior relationship

What is Collaborative What is Collaborative Neuropsychology?Neuropsychology?

– Emanates from “Third Force” PsychologyEmanates from “Third Force” Psychology– Relational encounterRelational encounter– Client as “co-evaluator”Client as “co-evaluator”– Open sharing of resultsOpen sharing of results– Client viewed in context Client viewed in context – Constructs serve to understand the client holistically.Constructs serve to understand the client holistically.– Focus on strengths and weaknessesFocus on strengths and weaknesses– Test scores, categories, and classifications help Test scores, categories, and classifications help

patients develop an understanding of their patients develop an understanding of their experience, not to define it (Fischer, 1970/1994)experience, not to define it (Fischer, 1970/1994)

– Blending art and science into a “human science Blending art and science into a “human science neuroneuro-psychology” (Fischer, 2003; -psychology” (Fischer, 2003; italics mineitalics mine). ).

Holistic NeuropsychologyHolistic NeuropsychologyYehuda Ben-Yashay and Leonard Yehuda Ben-Yashay and Leonard

DillerDiller• Roots in Kurt Goldstein’s holistic views.Roots in Kurt Goldstein’s holistic views.

– A holistic theory of the organism based A holistic theory of the organism based Gestalt Theory Gestalt Theory

– ““We have said that life confronts us in living We have said that life confronts us in living organisms. But as soon as we attempt to grasp organisms. But as soon as we attempt to grasp them scientifically, we must take them apart, them scientifically, we must take them apart, and this taking apart nets us a multitude of and this taking apart nets us a multitude of isolated facts which offer no direct clue to that isolated facts which offer no direct clue to that which we experience directly in the living which we experience directly in the living organism.” Kurt Goldstein, organism.” Kurt Goldstein, The Organism,The Organism, p. 7 p. 7

Holistic Neuropsychological Holistic Neuropsychological PrinciplesPrinciples• Empower patients and families to take an active Empower patients and families to take an active

role in the treatment process;role in the treatment process;

• Believe people with neurological disabilities are Believe people with neurological disabilities are more like people without neurological more like people without neurological

disabilities (ie. disabilities (ie. Go beyond the brainGo beyond the brain) ;) ;

• Convey honesty and caring in personal Convey honesty and caring in personal interactions to form a foundation for a strong interactions to form a foundation for a strong therapeutic relationship;therapeutic relationship;

• Develop practical plans for rehabilitation; Develop practical plans for rehabilitation; explain rehabilitation techniques in explain rehabilitation techniques in understandable language;understandable language;

Holistic Neuropsychological Holistic Neuropsychological PrinciplesPrinciples• Help patients and families understand Help patients and families understand

neurobehavioral sequelae of brain injury neurobehavioral sequelae of brain injury and recovery;and recovery;

• Recognize change is inevitable and help Recognize change is inevitable and help families cope with change;families cope with change;

• Every patient is important, treat with Every patient is important, treat with respect;respect;

• Remember that patients and families have Remember that patients and families have different perspectives regarding treatment different perspectives regarding treatment approaches.approaches.

Why do we need Why do we need collaborative models?collaborative models?

An identity crisis An identity crisis in in neuropsychology neuropsychology (and psychology (and psychology in general)? in general)?

Harvard creates cyborg flesh that’s half man, half machineBy Sebastian Anthony on August 29, 2012

                                                                                                                                                                        

                                             

Neuropsychology TrendsNeuropsychology Trends(Ruff, 2003). (Ruff, 2003).

• Period of LocalizationPeriod of Localization

• Period of Neurocognitive EvaluationPeriod of Neurocognitive Evaluation

Next Period??Next Period??

Forces Influencing Forces Influencing NeuropsychologyNeuropsychology

Technology

Managed Care

Other Professionals

Cultural Trends

TechnologyTechnology

Managed Care-InsuranceManaged Care-Insurance

Cultural TrendsCultural Trends

• High AnxietyHigh Anxiety

• Age of the Brain Age of the Brain

• ConcussionsConcussions

• Aging of AmericaAging of America

• Mind-BodyMind-Body

Other ProfessionalsOther Professionals

• Speech, OT, Psychiatry, Counselors, Speech, OT, Psychiatry, Counselors, Social WorkersSocial Workers

• Quick and dirty cognitive testsQuick and dirty cognitive tests

• Neuropsychology is failing to Neuropsychology is failing to distinguish itself due to:distinguish itself due to:– Over-reliance on diagnosing brain Over-reliance on diagnosing brain

behavior relationshipsbehavior relationships– Narrow focus on psychometric approachNarrow focus on psychometric approach– Uncertainty of roles in areas such as Uncertainty of roles in areas such as

rehabilitation. rehabilitation. – Lack of translation of test results into Lack of translation of test results into

patient carepatient care– Lack of assessment advocacyLack of assessment advocacy(Gass and Brown, 1992; Nelson and Adams, (Gass and Brown, 1992; Nelson and Adams,

1997; Goldstein, S. Personal 1997; Goldstein, S. Personal Communication)Communication)

Rise of Forensic Rise of Forensic NeuropsychologyNeuropsychology• There is a greater presence of forensic There is a greater presence of forensic

neuropsychology topics in peer reviewed neuropsychology topics in peer reviewed journals and neuropsychology meeting journals and neuropsychology meeting programs (Sweet, et al., 2002). programs (Sweet, et al., 2002).

• Consequently there is a greater proportion Consequently there is a greater proportion of topics related to legal proceedings and of topics related to legal proceedings and malingering. malingering.

• Increasing emphasis on Symptom Validity Increasing emphasis on Symptom Validity Testing.Testing.

Seeking a BalanceSeeking a Balance

ForensicMalingering

Patient CareRehabilitation Methods

PossibilitiesPossibilities

• Focus on the utility of neuropsychological Focus on the utility of neuropsychological assessment assessment – Ensuring relevance by tailoring assessment to Ensuring relevance by tailoring assessment to

treatment/rehabilitative needs and outcomestreatment/rehabilitative needs and outcomes– Focus on the needs of the client/consumerFocus on the needs of the client/consumer– Closely link assessment – feedback – Closely link assessment – feedback –

intervention.intervention.– Integrate treatment planning, monitoring Integrate treatment planning, monitoring

progress, and outcomesprogress, and outcomes

(Groth-Marnat, G. (1999)). (Groth-Marnat, G. (1999)).

Working AllianceWorking Alliance

Importance of Working Importance of Working AllianceAlliance

• There are strong links between There are strong links between patient-therapist collaboration and patient-therapist collaboration and goal consensus in psychotherapy goal consensus in psychotherapy outcomes (Shick Tryon and outcomes (Shick Tryon and Winograd, 2011). Winograd, 2011).

• Working alliance and collaboration in Working alliance and collaboration in rehabilitation is viewed as important rehabilitation is viewed as important but less well studied. but less well studied.

Working Alliance in Working Alliance in RehabilitationRehabilitation

• A positive relationship between working A positive relationship between working alliance and outcomes has been found. alliance and outcomes has been found. Working alliance defined as Working alliance defined as

• (a) the agreement between client and therapist (a) the agreement between client and therapist on goals, on goals,

• (b) their agreement on how to achieve these (b) their agreement on how to achieve these goals (common work on tasks) and goals (common work on tasks) and

• (c) the development of a personal bond between (c) the development of a personal bond between client and therapist. (Shönberger et al. 2006). client and therapist. (Shönberger et al. 2006).

Working Alliance in Working Alliance in RehabilitationRehabilitation• A good working alliance can be created with A good working alliance can be created with

both clients who experience many problems both clients who experience many problems and clients who experience comparatively and clients who experience comparatively few problems, as long as they are aware of few problems, as long as they are aware of the consequences of their brain injury.the consequences of their brain injury.

• Therapist’s experience of a good working Therapist’s experience of a good working alliance was influenced by the client’s alliance was influenced by the client’s experience of success. (Shönberger, et al., experience of success. (Shönberger, et al., 2006). 2006).

Working Alliance in Working Alliance in RehabilitationRehabilitation• Clients’ and therapists’ overall success Clients’ and therapists’ overall success

ratings at program end were related to ratings at program end were related to their emotional bond at program end.their emotional bond at program end.

• Early-therapy compliance and the average Early-therapy compliance and the average amount of compliance are predictive of amount of compliance are predictive of subjective improvement. (Shönberger, et subjective improvement. (Shönberger, et al., 2006). al., 2006).

Working Alliance: Some Working Alliance: Some evidenceevidence• Bieman-Copelan and Dywan (2000). Brain and Cognition, 44, 1-5. Bieman-Copelan and Dywan (2000). Brain and Cognition, 44, 1-5.

• Behavioral therapy in context of a Behavioral therapy in context of a supportive/collaborative therapeutic alliance supportive/collaborative therapeutic alliance for anosognosia. for anosognosia.

• Collaborative negotiation and trusting Collaborative negotiation and trusting therapeutic relationship for behavioral goal therapeutic relationship for behavioral goal setting. setting.

• Results indicated a significant reduction in Results indicated a significant reduction in problematic behaviors despite no increase in problematic behaviors despite no increase in insight or awareness of injury. insight or awareness of injury.

Pegg et al., 2005Pegg et al., 2005

• Evaluated the role of interpersonal relationship Evaluated the role of interpersonal relationship factors on patient outcomes with 28 patients with factors on patient outcomes with 28 patients with moderate to sever TBI admitted to an inpatient unit moderate to sever TBI admitted to an inpatient unit at a VAMC. at a VAMC.

• Personalized information-provision intervention. Personalized information-provision intervention.

• Results:Results:– Patients exerted greater effort in therapiesPatients exerted greater effort in therapies– Patients increased satisfaction with rehabilitation Patients increased satisfaction with rehabilitation

treatment. treatment. – Significantly more improvement in cognitive FIM Significantly more improvement in cognitive FIM

scores. scores.

Interdisciplinary team Interdisciplinary team working alliance (Evans, et working alliance (Evans, et al., 2008). al., 2008). • Importance of therapeutic alliance in post acute brain Importance of therapeutic alliance in post acute brain

injury rehabilitation (PABIR). injury rehabilitation (PABIR).

• Sherer et al., 2007 - poor working alliance was associated Sherer et al., 2007 - poor working alliance was associated with high levels of family discord, greater discrepancy with high levels of family discord, greater discrepancy between family and clinician ratings of client functioning, between family and clinician ratings of client functioning, and poor client participation in therapies.and poor client participation in therapies.

• Treatment team members attended in-services that Treatment team members attended in-services that emphasized motivational interviewing philosophy and emphasized motivational interviewing philosophy and techniques, building rapport, reflective listening, dealing techniques, building rapport, reflective listening, dealing with patient resistance, making behavioral changes, stages with patient resistance, making behavioral changes, stages of change, dealing with challenging clients, and of change, dealing with challenging clients, and assessment and treatment issues with depressed and/or assessment and treatment issues with depressed and/or suicidal patients (pg. 332).suicidal patients (pg. 332).

Interdisciplinary team Interdisciplinary team working alliance (Evans, et working alliance (Evans, et al., 2008). al., 2008). • Treatment group had higher functional status and Treatment group had higher functional status and

were more productive and had less dropouts, were more productive and had less dropouts, although the differences were not statistically although the differences were not statistically significant. significant.

Lane-Brown and Tate, 2010.Lane-Brown and Tate, 2010.• Single case study that evaluated an Single case study that evaluated an

intervention utilizing external compensation intervention utilizing external compensation and motivational interviewing to initiate and motivational interviewing to initiate and sustain goal directed activity with a TBI and sustain goal directed activity with a TBI patient. patient.

• Demonstrated that treating specific and Demonstrated that treating specific and operationally defined goals through operationally defined goals through external compensation and motivational external compensation and motivational interviewing successfully decreased apathy.interviewing successfully decreased apathy.

Enhancing our patient care skills can Enhancing our patient care skills can create a ripple effect with consumers, create a ripple effect with consumers, providers, and public perceptionproviders, and public perception

Neuropsychology has the potential to be a Neuropsychology has the potential to be a lead discipline in understanding human lead discipline in understanding human beings from a holistic mind/body perspectivebeings from a holistic mind/body perspective

Holistic Neuropsychology in Holistic Neuropsychology in RehabilitationRehabilitation

Comprehensive RehabilitationComprehensive Rehabilitation

• Physical TherapyPhysical Therapy

• Occupational TherapyOccupational Therapy

• Speech TherapySpeech Therapy

• Medical ManagementMedical Management

• Psychological/Psychological/Neuropsychological Neuropsychological

• Emotional/Psychiatric Emotional/Psychiatric Management as Management as appropriateappropriate

• Family SupportFamily Support

• Case ManagementCase Management

Recovery ChallengesRecovery Challenges

• Knowledge of deficitsKnowledge of deficits• Adapting to deficitsAdapting to deficits• Grieving and Coping Grieving and Coping

(Denial, anger, (Denial, anger, bargaining, depression, bargaining, depression, acceptance).acceptance).

• Learning and re-learningLearning and re-learning• Integrating knowledge Integrating knowledge

into the selfinto the self• Re-discovering meaning Re-discovering meaning

and a sense of purposeand a sense of purpose

Existential Issues in Existential Issues in Neuropsychological Neuropsychological ConditionsConditions• Awareness of change;Awareness of change;

• Emotions; Emotions;

• Struggle of acceptance; Struggle of acceptance;

• Struggle to make sense and find Struggle to make sense and find meaning;meaning;

• Struggle to reclaim/find a sense of Struggle to reclaim/find a sense of selfself

“…But be that as it may, those of us who did make it have an obligation to build again. To teach to others what we know, and to try with what's left of our lives to find a goodness and a meaning to this life.” (Quote from the movie “Platoon”, 1986)

How traditional neuropsychological How traditional neuropsychological assessment addresses these assessment addresses these challengeschallenges

1.1. Knowledge of deficitsKnowledge of deficits

2.2. Adapting to deficitsAdapting to deficits

3.3. Grieving and Coping Grieving and Coping (Denial, anger, (Denial, anger, bargaining, depression, bargaining, depression, acceptance).acceptance).

4.4. Learning and re-Learning and re-learninglearning

5.5. Integrating knowledge Integrating knowledge into the selfinto the self

6.6. Re-discovering meaningRe-discovering meaning

1.1. Provides information on Provides information on cognitive functioning. cognitive functioning.

2.2. Presents potential Presents potential ameliorative strategies. ameliorative strategies.

3.3. Does not directly address.Does not directly address.4.4. Cognitive rehabilitation Cognitive rehabilitation

and remediation.and remediation.5.5. Presents one aspect of Presents one aspect of

the person (cognition).the person (cognition).6.6. Does not directly address.Does not directly address.

How collaborative neuropsychological How collaborative neuropsychological assessment addresses these assessment addresses these challengeschallenges1.1. Knowledge of deficitsKnowledge of deficits

2.2. Adapting to deficitsAdapting to deficits

3.3. Grieving and Coping Grieving and Coping (Denial, anger, (Denial, anger, bargaining, depression, bargaining, depression, acceptance).acceptance).

4.4. Learning and re-Learning and re-learninglearning

5.5. Integrating knowledge Integrating knowledge into the selfinto the self

6.6. Re-discovering meaningRe-discovering meaning

1.1. Provides information on cognitive Provides information on cognitive functioning and seeks individual functioning and seeks individual application.application.

2.2. Presents potential ameliorative Presents potential ameliorative strategies and seeks out the strategies and seeks out the individuals own resources for individuals own resources for change.change.

3.3. Address a person’s experience and Address a person’s experience and reactions to information provided; reactions to information provided; balances education and the I-Thou balances education and the I-Thou interaction.interaction.

4.4. Cognitive rehabilitation and Cognitive rehabilitation and remediation and works to motivate remediation and works to motivate internalization.internalization.

5.5. Presents one aspect of the person Presents one aspect of the person (cognition) and considers it within (cognition) and considers it within the context of the whole person. the context of the whole person.

6.6. Looks toward the future and what Looks toward the future and what all this means for the person. all this means for the person.

History of History of Neuropsychological Neuropsychological

Testing as a Therapeutic Testing as a Therapeutic InterventionIntervention

Luria’s Neuropsychological Luria’s Neuropsychological Investigation (LNI)Investigation (LNI)

• Loose conceptual basis, not an actual precursor. Loose conceptual basis, not an actual precursor. • A qualitative and flexible interviewing method for diagnosing A qualitative and flexible interviewing method for diagnosing

brain lesions.brain lesions.• The value of LNI:The value of LNI:

– Provides a thorough individualized neuropsychological Provides a thorough individualized neuropsychological assessment in which the cognitive functions and assessment in which the cognitive functions and psychological responses of the individual can be psychological responses of the individual can be ascertained. ascertained.

– Provides the opportunity to identify strengths and deficits. Provides the opportunity to identify strengths and deficits. – LNI principles can be implemented throughout the LNI principles can be implemented throughout the

rehabilitation process which includerehabilitation process which include• Hypothesis testingHypothesis testing• A collaborative working relationship with the patient’A collaborative working relationship with the patient’

• Feedback to enhance awareness. Feedback to enhance awareness. Christensen, Anne-Lise (1975); Christensen, A.L. and Christensen, Anne-Lise (1975); Christensen, A.L. and

Caetano, C. (1999)Caetano, C. (1999)

Neuropsychological Test Neuropsychological Test Feedback ResearchFeedback Research• No empirical studies but some recommendationsNo empirical studies but some recommendations• Neuropsychological test feedback provides Neuropsychological test feedback provides

useful information about cognitive strengths and useful information about cognitive strengths and weaknesses,weaknesses,

• Clients find the information useful,Clients find the information useful,• Results apply to clients everyday life and Results apply to clients everyday life and

concernsconcerns• Facilitates the development of useful and Facilitates the development of useful and

applicable interventionsapplicable interventions((Gass & Brown, 1992; Pope, 1992; Crosson, 2000; Bennet-Levy et al., Gass & Brown, 1992; Pope, 1992; Crosson, 2000; Bennet-Levy et al.,

1994). 1994).

Recommended method for Recommended method for providing information providing information (Gass & (Gass & Brown, 1992)Brown, 1992)

1.1. Review the purpose of testing in plain, Review the purpose of testing in plain, simple languagesimple language

2.2. Tests are “behavior samples” of Tests are “behavior samples” of functional domainsfunctional domains

3.3. Explain in terms of behavioral Explain in terms of behavioral functioningfunctioning

4.4. Summarize strengths and weaknessesSummarize strengths and weaknesses5.5. Address diagnostic issuesAddress diagnostic issues6.6. Make recommendationsMake recommendations

Limited empirical evidenceLimited empirical evidence

• Case Studies (Malla et al., 1997; Rose, Case Studies (Malla et al., 1997; Rose, 1998)1998)

• Conceptual articles (Allen et al., 1986)Conceptual articles (Allen et al., 1986)

• Provision of medical information which Provision of medical information which included neuropsychological tests included neuropsychological tests (Pegg, Auerbach, Seel, Buenaver, (Pegg, Auerbach, Seel, Buenaver, Kiesler, and Plybon, 2005). Kiesler, and Plybon, 2005).

Background of Psychological Testing as Background of Psychological Testing as a Therapeutic Interventiona Therapeutic Intervention

Therapeutic/Individualized Therapeutic/Individualized Models of AssessmentModels of Assessment

Collaborative Individualized Collaborative Individualized Assessment (Fischer, 1994)Assessment (Fischer, 1994)

• Based on phenomenological psychology.Based on phenomenological psychology.

• Assessor works collaboratively to Assessor works collaboratively to understand a client’s unique worldviewunderstand a client’s unique worldview

• Tests, scores, categories, and Tests, scores, categories, and classifications serve to develop a classifications serve to develop a hermeneutic understanding of the person.hermeneutic understanding of the person.

• Reflects a “human-science psychology”. Reflects a “human-science psychology”.

Therapeutic Assessment (Finn, Therapeutic Assessment (Finn, 1992; 1997)1992; 1997)

• Psychological assessment as a Psychological assessment as a therapeutic intervention,therapeutic intervention,

• Tester is an active participantTester is an active participant

• Rooted in humanistic psychologyRooted in humanistic psychology

• Influenced by collaborative Influenced by collaborative assessmentassessment

The Next Generation of The Next Generation of Client Centered FeedbackClient Centered Feedback

Motivational Motivational InterviewingInterviewing

Motivational Interviewing Motivational Interviewing Principles (Miller and Rollnick, Principles (Miller and Rollnick, 2002)2002)• A method of dialogue designed to A method of dialogue designed to

enhance client’s intrinsic motivation enhance client’s intrinsic motivation to make changes in behavior. to make changes in behavior.

• Heavily rooted in Roger’s Client Heavily rooted in Roger’s Client Centered Therapy. Centered Therapy.

• Originally developed with alcoholics Originally developed with alcoholics but expanded to drug addiction and but expanded to drug addiction and health behavior change. health behavior change.

• Strongly based on the Rogerian Strongly based on the Rogerian approachapproach

• Non-directive/directive interventionNon-directive/directive intervention• Empathy and unconditional regard are Empathy and unconditional regard are

the crux of MIthe crux of MI• Exploring and resolving ambivalence Exploring and resolving ambivalence

about making changes is a key goalabout making changes is a key goal• Works to develop a discrepancy Works to develop a discrepancy

between real and ideal self (values between real and ideal self (values and behavior; who a client is versus and behavior; who a client is versus who they want to be). who they want to be).

• Associated with the stages of change. Associated with the stages of change.

MI Method for Giving MI Method for Giving FeedbackFeedback• Elicit – Provide – ElicitElicit – Provide – Elicit• Using OARSUsing OARS

– Open ended questionsOpen ended questions– AffirmationsAffirmations– Reflections Reflections – SummarizationsSummarizations

• Goal is to help clients work through Goal is to help clients work through and resolve ambivalence in order to and resolve ambivalence in order to move through the stages of change. move through the stages of change.

The NAFIThe NAFI

• OriginsOrigins– Neuropsychological TestingNeuropsychological Testing– Personal Feedback Report (Project MATCH, Personal Feedback Report (Project MATCH,

Dual Diagnosis Adherence Strategies, WPIC)Dual Diagnosis Adherence Strategies, WPIC)– Anecdotal ObservationsAnecdotal Observations

• Pilot StudyPilot Study

• Development of the Feedback ReportDevelopment of the Feedback Report

• NIDA funded study 2004 – 2008.NIDA funded study 2004 – 2008.

Neuropsych Feedback Recommendations

Collaborative/Therapeutic Assessment

Motivational Interviewing

NAFI

Pilot Study ResultsPilot Study Results

NAFITAU

S1

71%

48%

0102030405060708090

100

Adherence Ratesp = .042, cohen's d = .78 (.02-1.55)

NAFI (n = 14); TAU (n = 14)

Pilot Study Results: D&A UsePilot Study Results: D&A UseNAFI = 6; TAU = 5NAFI = 6; TAU = 5

30 Day Alcohol Use

0

3.4

5.46

7.13

0

12

34

5

67

89

10

Baseline 30 Day

NAFI

TAU

Pilot Study Results: D&A UsePilot Study Results: D&A Use

30 Day Drug Use

0.66

3.43

0.40

4.73

0

1

2

3

4

5

6

7

Baseline 30 Day

NAFI

TAU

Pilot Study Results: DepressionPilot Study Results: DepressionNAFI = 6; TAU = 5NAFI = 6; TAU = 5

30 Day DepressionHRSD-25

20.21

11.4

22.221.2

0

5

10

15

20

25

Baseline 30 Day

NAFI

TAU

Patient ResponsesPatient Responses

• ““The assessment was helpful to me. I learned a lot about The assessment was helpful to me. I learned a lot about myself…I would have done it without being paid.”myself…I would have done it without being paid.”

• ““Allowed me to see why I may be reluctant to participate in Allowed me to see why I may be reluctant to participate in groups.”groups.”

• ““Helped me narrow in on specific steps I need to take with my Helped me narrow in on specific steps I need to take with my therapist re: depression and addiction. Identified couple things therapist re: depression and addiction. Identified couple things we can work on.”we can work on.”

• ““I am so pleased that I participated in the study. It was right on. I am so pleased that I participated in the study. It was right on. M- allowed me to share during the process, which really M- allowed me to share during the process, which really assisted with my overall understanding of the feedback.” assisted with my overall understanding of the feedback.”

• First presentation at The Society for First presentation at The Society for Personality Assessment, Spring 2006. Personality Assessment, Spring 2006. – Diane Engelman, Ph.D.Diane Engelman, Ph.D.– Steven R. Smith, Ph.D.Steven R. Smith, Ph.D.– Tad Gorske, Ph.D.Tad Gorske, Ph.D.

Collaborative Therapeutic Collaborative Therapeutic Neuropsychological Assessment, Neuropsychological Assessment, 2009. 2009.

Methods of Collaborative Methods of Collaborative NeuropsychologyNeuropsychology

• Demystify the neuropsychological Demystify the neuropsychological assessment process: assessment process: Provide feedback report; Provide feedback report; explain session purpose; facilitate collaboration and explain session purpose; facilitate collaboration and empathic understandingempathic understanding

• Answer what the individual wants to know Answer what the individual wants to know (If you can).(If you can).

• Explain how strengths and weaknesses are Explain how strengths and weaknesses are determined.determined.

• Ensure an understanding of the information Ensure an understanding of the information provided. provided.

Methods of Collaborative Methods of Collaborative NeuropsychologyNeuropsychology

• Ensure the information relates to the Ensure the information relates to the persons experience;persons experience;

Or if it doesn’tOr if it doesn’t

• Explore the discrepancy.Explore the discrepancy.

• Summarize what has been discussed.Summarize what has been discussed.

• Make suggestionsMake suggestions

• Look to the future.Look to the future.

CTNACTNA

• The spirit of the CTNA lies in Collaborative The spirit of the CTNA lies in Collaborative and Therapeutic Assessment Modelsand Therapeutic Assessment Models– Open sharing; explore results contextually; use Open sharing; explore results contextually; use

results to facilitate empathic understandingresults to facilitate empathic understanding

• The framework for conducting the CTNA is The framework for conducting the CTNA is drawn from MI.drawn from MI.

• The CTNA adopts and adapts the MI The CTNA adopts and adapts the MI Personalized Feedback ReportPersonalized Feedback Report

CTNA Feedback SessionCTNA Feedback Session

Two primary componentsTwo primary components

1.1. Provide information from Provide information from neuropsychological test resultsneuropsychological test results

2.2. Interact with clients in a Interact with clients in a collaborative manner consistent collaborative manner consistent with TA and MI.with TA and MI.

CTNA Personalized CTNA Personalized FeedbackFeedback1.1. IntroductionIntroduction

• Provide feedback report; explain session purpose; Provide feedback report; explain session purpose; facilitate collaboration and empathic understandingfacilitate collaboration and empathic understanding

2.2. Develop QuestionsDevelop Questions• Develop 2 or 3 well defined questions the client Develop 2 or 3 well defined questions the client

hopes the results can answerhopes the results can answer

3.3. Explain how strengths and weaknesses are Explain how strengths and weaknesses are determineddetermined

• Percentiles, determine criteria for strength or Percentiles, determine criteria for strength or weaknessweakness

CTNA Personalized CTNA Personalized FeedbackFeedback4.4. Feedback about strengths and Feedback about strengths and

weaknessesweaknesses• ElicitElicit: What skills did the client : What skills did the client

use to complete the test.use to complete the test.• ProvideProvide: Therapist provides : Therapist provides

information on the cognitive skill information on the cognitive skill test(s) examine.test(s) examine.

• ElicitElicit: Therapist elicits reactions : Therapist elicits reactions from the clients and applies from the clients and applies results to their real life. results to their real life.

CTNA Personalized CTNA Personalized FeedbackFeedback

5.5. Summarize results and provide Summarize results and provide recommendationsrecommendations

Summary and key questionSummary and key question Ask permission to provide Ask permission to provide

recommendationsrecommendations Make recommendationsMake recommendations

Clinical Applications of CTNAClinical Applications of CTNA

1.1. Brain Injury Education and RehabilitationBrain Injury Education and Rehabilitation

2.2. Lifestyle change counselingLifestyle change counseling

3.3. Psychological conditionsPsychological conditions

Cautionary NotesCautionary Notes

1.1. Profound cognitive impairment (ie. Profound cognitive impairment (ie. dementia)dementia)

2.2. Poor effort (forensic, malingering, Poor effort (forensic, malingering, disability, etc.)disability, etc.)

Future ImplicationsFuture Implications

• ClinicalClinical:: A high degree of utility for A high degree of utility for consultation, initiating therapy, working consultation, initiating therapy, working with “sticking points” in therapy, with “sticking points” in therapy, rehabilitation planning. rehabilitation planning.

• TeachingTeaching:: Developing students into Developing students into “human-science” practitioners, “human-science” practitioners, researchers, and teachers. researchers, and teachers.

• ResearchResearch:: Learn outcomes, factors Learn outcomes, factors influencing effectiveness, manual influencing effectiveness, manual development.development.

Case ExamplesCase Examples

Case #1: Multiple Case #1: Multiple ConcussionsConcussions• Caucasian female, early 20’s;Caucasian female, early 20’s;

• Recent very mild hit to the head;Recent very mild hit to the head;• Increase in PCS: Increase in PCS: headache, mental fogginess, dizziness, headache, mental fogginess, dizziness,

nausea, balance problems, fatigue, drowsiness, sensitivity to light nausea, balance problems, fatigue, drowsiness, sensitivity to light and noise, mood changes, feeling slowed down, difficulty and noise, mood changes, feeling slowed down, difficulty concentrating, difficulty remembering, and visual problemsconcentrating, difficulty remembering, and visual problems

• Hx of two prior concussions over 5 Hx of two prior concussions over 5 year span since her teen years. year span since her teen years.

• Doctor told her she had a Doctor told her she had a “catastrophic reaction.”“catastrophic reaction.”

Case #1: Multiple Case #1: Multiple ConcussionsConcussions• No significant medical issuesNo significant medical issues

• Extensive psychiatric hx: Extensive psychiatric hx:

• Mental StatusMental Status– MMSE = 30MMSE = 30– Clock drawing was normalClock drawing was normal– BDI = 22BDI = 22– BAI = 26BAI = 26

Vocabulary 13 84

Matrix Reasoning 15 95

Digits Forward 12 75Digits Backward 13 84Letter Number Sequencing 12 75

Trailmaking A 15 sec., 0 errors 95Digit Symbol – Coding

12 75

CVLT-II Trial 1 = 7Trial 5 = 16

Total Trials = 71Learning Slope = 1.8

Short Delay Free Recall = 16Long Delay Free Recall = 16

Retention = 0%Recognition Hits = 16

Discrimination = 4

328498709494505084

Rey Complex Figure Copy = 35/36Immediate = 26/36

Delay = 27/36Recognition = 20

Average626914

COWA FAS = 55Animal = 28

8279

Boston Naming Test

57/60 58

Trailmaking B 41 sec., 1 error 87Stroop C/W Test Word = 100

Color = 81Color Word = 52Interference = 7

45587977

WCST-64 Categories = 5Total Errors = 6

Perseverative Errors = 5Trials to first category =

10

Average9447

Average

Main themes in CTNA Main themes in CTNA sessionsession• Discrepancy between how she felt vs Discrepancy between how she felt vs

objective evidence;objective evidence;

• Negative thoughts and beliefs about Negative thoughts and beliefs about herself and her capabilities;herself and her capabilities;

• Underlying perfectionism;Underlying perfectionism;

• After session became more open to After session became more open to considering psychological/emotional vs considering psychological/emotional vs brain injury as causing her distress. brain injury as causing her distress.

• My thanks to all the participants, Dr. My thanks to all the participants, Dr. Fiona Bardenhagen and the Australian Fiona Bardenhagen and the Australian Psychological Society for inviting me to Psychological Society for inviting me to your conference. your conference.

My contact informationMy contact informationTad T. Gorske, Ph.DTad T. Gorske, Ph.DClinical Assistant Professor Clinical Assistant Professor Division of Neuropsychology and Rehabilitation Division of Neuropsychology and Rehabilitation

PsychologyPsychologyUPMC MercyUPMC Mercy1400 Locust Street, Suite G1381400 Locust Street, Suite G138Pittsburgh, PA USA 15219Pittsburgh, PA USA 15219Gorskett@upmc. eduGorskett@upmc. edu