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Neuropsychological Rehabilitation Barbara A. Wilson Cognition and Brain Sciences Unit, Medical Research Council, Addenbrooke’s Hospital, Cambridge CB2 2QQ, United Kingdom; email: [email protected] Annu. Rev. Clin. Psychol. 2008. 4:141–62 First published online as a Review in Advance on December 11, 2007 The Annual Review of Clinical Psychology is online at http://clinpsy.annualreviews.org This article’s doi: 10.1146/annurev.clinpsy.4.022007.141212 Copyright c 2008 by Annual Reviews. All rights reserved 1548-5943/08/0427-0141$20.00 Key Words brain injury, cognition, emotion, psychosocial, holistic programs 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 cogni- tion, 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 cogni- tive deficits, and some technological aids are discussed. Evidence for effective treatment of cognitive, emotional, and psychosocial diffi- culties is presented, models that have been most influential in NR are described, and the review concludes with guidelines for good practice. 141 Annu. Rev. Clin. Psychol. 2008.4:141-162. Downloaded from www.annualreviews.org by Texas A&M University - College Station on 11/20/12. For personal use only.

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B. WilsonRehabilitación, principios básicos

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NeuropsychologicalRehabilitationBarbara A. WilsonCognition and Brain Sciences Unit, Medical Research Council, Addenbrooke’sHospital, Cambridge CB2 2QQ, United Kingdom;email: [email protected]

Annu. Rev. Clin. Psychol. 2008. 4:141–62

First published online as a Review in Advance onDecember 11, 2007

The Annual Review of Clinical Psychology is onlineat http://clinpsy.annualreviews.org

This article’s doi:10.1146/annurev.clinpsy.4.022007.141212

Copyright c© 2008 by Annual Reviews.All rights reserved

1548-5943/08/0427-0141$20.00

Key Words

brain injury, cognition, emotion, psychosocial, holistic programs

AbstractNeuropsychological rehabilitation (NR) is concerned with theamelioration of cognitive, emotional, psychosocial, and behavioraldeficits caused by an insult to the brain. Major changes in NR haveoccurred over the past decade or so. NR is now mostly centeredon a goal-planning approach in a partnership of survivors of braininjury, their families, and professional staff who negotiate and selectgoals to be achieved. There is widespread recognition that cogni-tion, emotion, and psychosocial functioning are interlinked, and allshould be targeted in rehabilitation. This is the basis of the holisticapproach. Technology is increasingly used to compensate for cogni-tive deficits, and some technological aids are discussed. Evidence foreffective treatment of cognitive, emotional, and psychosocial diffi-culties is presented, models that have been most influential in NRare described, and the review concludes with guidelines for goodpractice.

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Contents

INTRODUCTION: WHAT ISNEUROPSYCHOLOGICALREHABILITATION? . . . . . . . . . . . . 142

HOW HASNEUROPSYCHOLOGICALREHABILITATION CHANGEDIN RECENT YEARS? . . . . . . . . . . . 144Goal Setting to Plan

Rehabilitation . . . . . . . . . . . . . . . . . 144Cognitive, Emotional, and

Psychosocial Deficits areInterlinked . . . . . . . . . . . . . . . . . . . . 145

Increasing Use of Technology inNeuropsychologicalRehabilitation . . . . . . . . . . . . . . . . . 146

Rehabilitation Needs a BroadTheoretical Base . . . . . . . . . . . . . . 147

COGNITIVE ASPECTS OFNEUROPSYCHOLOGICALREHABILITATION . . . . . . . . . . . . . 147

EMOTIONAL ASPECTS OFNEUROPSYCHOLOGICALREHABILITATION . . . . . . . . . . . . . 149

PSYCHOSOCIAL ASPECTS OFNEUROPSYCHOLOGICALREHABILITATION . . . . . . . . . . . . . 151

MODELS AND THEORETICALAPPROACHESCONTRIBUTING TONEUROPSYCHOLOGICALREHABILITATION . . . . . . . . . . . . . 153

GUIDELINES FOR GOODPRACTICE INNEUROPSYCHOLOGICALREHABILITATION . . . . . . . . . . . . . 154

SUMMARY. . . . . . . . . . . . . . . . . . . . . . . . . 156

INTRODUCTION: WHAT ISNEUROPSYCHOLOGICALREHABILITATION?

Most people receiving rehabilitation for theconsequences of brain injury have both cog-nitive and noncognitive problems. A typ-ical patient in a rehabilitation center has

several cognitive problems such as poor at-tention, poor memory, and planning and or-ganizational difficulties, together with someemotional problems such as anxiety, depres-sion, or in some cases, post-traumatic stressdisorder. The patient may exhibit behaviorproblems such as poor self-control or angeroutbursts and may experience some subtlemotor difficulties leading to reduced staminaand unsteady gait, as well as problems con-nected with social skills and relationships. Inaddition, the patient’s family members may beunable to comprehend what has happened tothe person they once felt they knew and un-derstood, and the patient will probably strug-gle with issues connected with the continu-ation of work or education. Tables 1 and 2show the main patient groups seen by neu-ropsychologists working in rehabilitation andthe main problems these patients face.

We can define neuropsychology as thestudy of the relationship between brainand behavior. One of the major differencesbetween academic neuropsychologists en-gaged in rehabilitation research and clini-cal neuropsychologists working in rehabili-tation centers is the manner in which theneeds of brain-injured people are determined.Academic neuropsychologists believe that de-tailed assessments informed by theoreticalmodels can highlight areas that require re-habilitation. Thus, testing of different com-ponents contained in a model of languagecan identify a particular deficit as the areato work on in rehabilitation (Caramazza &

Table 1 Main patient groups seen byneuropsychologists working in rehabilitation

Main groups seen for rehabilitationTraumatic brain injuryStroke (cerebrovascular accident; CVA)Infections of the brain (e.g., encephalitis)Hypoxic brain damageOther groups sometimes seenProgressive conditions

(e.g., Alzheimer’s disease, multiple sclerosis)Cerebral tumorsEpilepsy (idiopathic)

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Hillis 1993). Clinical neuropsychologists, onthe other hand, are less likely to determinerehabilitation needs through theoretically in-formed models and are more likely to targetreal-life problems identified by patients andtheir families. As discussed below, both ap-proaches play a part in the rehabilitation ofindividuals who have sustained an insult to thebrain.

A good definition of rehabilitation is pro-vided by McLellan (1991). He suggests thatrehabilitation is a two-way, interactive processwhereby people who are disabled by injury ordisease work together with professional staff,relatives, and members of the wider commu-nity to achieve their optimum physical, psy-chological, social, and vocational well-being(McLellan 1991). Using McLellan’s definitionas a guide, we can define cognitive rehabilita-tion as a process whereby people with braininjury work together with professional staffand others to remediate or alleviate cognitivedeficits arising from a neurological insult. Al-though cognitive rehabilitation is often a ma-jor part of the work of clinical neuropsychol-ogists, they are also increasingly involved ina wider range of issues. Thus, it could be ar-gued, neuropsychological rehabilitation (NR)is broader than cognitive rehabilitation, as itis concerned with the amelioration of cogni-tive, emotional, psychosocial, and behavioraldeficits caused by an insult to the brain.

McLellan (1991) believed that rehabilita-tion, unlike surgery or drugs, is not somethingthat is done to or given to individuals. Instead,the disabled person is part of a two-way inter-active process. This view reflected a growingchange in rehabilitation. For many years, per-sons with a disability were told what to ex-pect in and from rehabilitation; the rehabili-tation staff determined what areas to work on,what goals to set, and what was and was notachievable. Sometime in the 1980s, the phi-losophy began to change, at least in some cen-ters, so that in many rehabilitation programstoday, clients and families are asked abouttheir expectations, and rehabilitation goals arediscussed and negotiated between all parties

Table 2 Problems faced by survivors of brain injury

A. Problems faced by B. Typical cognitive problemssurvivors of brain injury· Motor · Memory· Sensory · Attention· Cognitive · Communication· Behavioral · Planning· Social · Organization· Emotional · Reasoning· Pain · Perception· Fatigue, etc. · Spatial awareness

C. Typical emotional and D. Typical behavior problemspsycho-social problems· Anxiety · Temper outbursts· Depression · Shouting· Anger · Swearing· Fear · Physical aggression· Social isolation · Disinhibition· Grief · Poor self control· Poor self-esteem · Refusal to cooperate, etc.· Lack of confidence

NR:neuropsychologicalrehabilitation

Goal: the state (orchange in state) thatan intervention orcourse of actionintends to achieve

Stroke: a braininjury caused by asudden interruptionof blood flow

involved. The focus of treatment is on im-proving aspects of everyday life and, asYlvisaker & Feeney (2000, p. 13) say, “reha-bilitation needs to involve personally mean-ingful themes, activities, settings and inter-actions.” An example of this is provided byWilson et al. (2002), who describe the treat-ment of a man with both a stroke and a headinjury. One of this man’s goals was to fly hismodel helicopter again—an important goalfor him that would never have been consid-ered 30 years ago. Tate et al. (2003), in descrip-tions of their service for people with brain in-jury, also imply that partnership is important,and Clare (2007) describes how people withdementia are encouraged to select their owntargets for treatments. This is a much health-ier state of affairs than providing clients withexperimental or artificial material on whichto work. Motivation is likely to be increasedbecause all those involved are working onreal-life problems, which also prevents gen-eralization difficulties. Because the ultimategoal of rehabilitation is to enable people withdisabilities to function as adequately as pos-sible in their own, most appropriate, envi-ronments (Ben-Yishay 1996), real-life issues

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Acquired braininjury: anondegenerativeinjury to the brainthat has occurredsince birth

should be at the forefront of rehabilitationprograms.

HOW HASNEUROPSYCHOLOGICALREHABILITATION CHANGEDIN RECENT YEARS?

In some ways, NR today is similar to that pro-vided to soldiers in Germany in World War Iand in Russia and the United Kingdom inWorld War II. In their historical review ofNR in Germany, Poser et al. (1996) remindus, “Many of the rehabilitation procedures de-veloped in special military hospitals duringWorld War I are still in use today in mod-ern rehabilitation—at least to some extent”(p. 259). The vocational rehabilitation de-scribed by Poppelreuter in 1917 (translatedby Zihl & Weiskrantz 1991) is not unlikethat provided today. In addition, Poppelreuter(1917) argued for an interdisciplinary ap-proach between psychology, neurology, andpsychiatry, and in a paper published in 1918,he emphasized the importance of the patient’sown insight into the effects of disabilitiesand treatment. Goldstein (1942), also writingabout the First World War, stressed the im-portance of cognitive and personality deficitsfollowing brain injury and touched upon whattoday would be called “cognitive rehabilita-tion strategies” (Prigatano 2005). In 1918,Goldstein (quoted by Poser et al. 1996) wasconcerned with decisions as to whether to tryto restore lost functioning or to compensatefor lost or impaired functions, and this debateis still ongoing today.

During the Second World War, Luria inthe (then) Soviet Union and Zangwill in theUnited Kingdom were both working withbrain-injured soldiers. One important princi-ple, stressed by both Luria and Zangwill, wasthat of functional adaptation, whereby an in-tact skill is used to compensate for a damagedone. Goldstein was also committed to a sim-ilar concept. Luria’s publications of 1963 and1970 and his book with Naydin, Tsvetkova,and Vinarskaya (Luria et al. 1969) are well

worth reading today for the insights they of-fer. So too is Zangwill’s (1947) paper in whichhe discusses, among other things, the princi-ples of re-education and refers to three mainapproaches to rehabilitation: compensation,substitution, and direct retraining.

Despite these similarities in concepts,there have been major changes, four of whichare addressed in this section. The first isgoal setting to plan rehabilitation programs;second is a growing recognition that cogni-tive, emotional, and psychosocial difficultiesshould all be addressed in rehabilitation; thirdis the increasing use of technology to compen-sate for cognitive difficulties; and fourth is arealization that NR requires a broad theoret-ical base or indeed a number of theoreticalbases.

Goal Setting to Plan Rehabilitation

The Concise Oxford Dictionary (1999) defines agoal as an “object of effort” or a “destination.”In a discussion of rehabilitation goals, Wade(1999) suggests, “A goal is the state or changein state that is hoped or intended for an inter-vention or course of action to achieve.” Whenwe negotiate goals with our patients, theirfamilies, and the rehabilitation team, we arelooking for something that the client/patientboth will do and wants to do; this shouldbe something that reflects the longer-termtargets and indeed the steps toward them.Goals are important regulators and motiva-tors of human performance and action (Austin& Vancouver 1996) and a desired outcome bywhich progress can be measured.

Goal setting has been used in rehabilita-tion for a number of years with various diag-nostic groups including people with cerebralpalsy, spinal injuries, developmental learn-ing difficulties, and acquired brain injury(McMillan & Sparkes 1999). Because goalplanning is simple, focuses on practical every-day problems, is tailored to individual needs,and avoids the artificial distinction betweenmany outcome measures and real-life func-tioning, it is used increasingly in rehabilitation

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programs. This approach provides directionfor rehabilitation, identifies priorities for in-tervention, evaluates progress, breaks rehabil-itation down into achievable steps, promotesteam working, and results in better outcomes(Nair & Wade 2003).

McMillan & Sparkes (1999) proposed sev-eral principles involved in the goal-planningapproach. First, the patient should be en-gaged in setting his or her goals. Second, thegoals set should be reasonable and client cen-tered. Third, patient’s behavior when a goalis reached should be described. Fourth, themethod to be used in achieving the goalsshould be defined in such a manner that any-one reading the plan would know what todo. In addition, goals should be specific andmeasurable and have a definite deadline. Inmost rehabilitation centers, long-term goalsare those that the patient or client is expectedto achieve by the time of discharge from theprogram, whereas short-term goals are thesteps set each week or fortnight in order toachieve the long-term goals. An acronym thatsummarizes the main principles is SMART:Goals should be specific, measurable, achiev-able, realistic, and timely.

The process of goal planning typically in-volves the allocation of a chairperson whoconducts all meetings, limits meetings to theagreed upon time, clarifies for team membersthe aims of admission and the length of stay,actively participates as a member of the re-habilitation team, and ensures documentationis complete. The chairperson should also en-sure good communication between all rele-vant parties, attend case conferences, coordi-nate reports, encourage clients, relatives, andstaff members to be realistic, and make cleararguments to the relevant people for changesto the discharge date. Following a detailed as-sessment period, the first goal-planning meet-ing is held, a problem list is drawn up, andpotential long-term goals are identified. Thegoals are then discussed with the client andthe family, and the final goals are negoti-ated and agreed upon. Both long-term andshort-term goals are documented. If it is con-

SMART: acronymapplied to goals thatare specific,measurable,achievable, realistic,and timely

sidered helpful, the client and the familymembers involved are given a copy of theshort-term goals to be achieved by the fol-lowing week or fortnight. Progress is reviewedevery one or two weeks in a 30-minute meet-ing with the rehabilitation team. Additionalshort-term goals are set and, if necessary, addi-tional long-term goals are added. If any long-or short-term goals are not achieved or areonly partially achieved, the reasons for thisare recorded. Failure to achieve a goal is at-tributed to reasons in one of four main cate-gories: (a) client/patient or carer (e.g., clientunwell); (b) staff member (e.g., staff memberabsent through illness); (c) internal admin-istration (e.g., transport failed to arrive); or(d ) external administration (e.g., fund-ing withdrawn by rehabilitation purchaser)(McMillan & Sparkes 1999).

Wilson et al. (2002) describe a success-ful goal-planning approach for a man whosustained both a head injury and a stroke.Manly (2003) discusses the targeting of func-tional goals in treatment. Williams (2003) saysgoal-setting procedures are one of the maincomponents of programs dealing with cog-nitive and emotional disorders. Most Britishrehabilitation centers follow a goal-planningapproach (Sopena et al. 2007). Further sup-port comes from Kendall et al. (2006), whosemeta-analysis suggests, “[D]irect patient in-volvement in neurorehabilitation goal settingresults in significant improvements in reach-ing and maintaining those goals” (p. 465).

Cognitive, Emotional, andPsychosocial Deficits are Interlinked

Although cognitive deficits are, perhaps, themajor focus of NR, there is a growing aware-ness that the emotional and psychosocialconsequences of brain injury need to beaddressed in rehabilitation programs. Fur-thermore, it is not always easy to separate cog-nitive, emotional, and psychosocial problemsfrom one another. Not only does emotion af-fect how we think and how we behave, but alsocognitive deficits can be exacerbated by

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emotional distress and can cause apparent be-havior problems. Psychosocial difficulties canalso result in increased emotional and behav-ioral problems, and anxiety can reduce the ef-fectiveness of intervention programs. Thereis clearly an interaction between all these as-pects of human functioning, as recognized bythose who argue for the holistic approach tobrain injury rehabilitation. This approach, pi-oneered by Diller (1976), Ben-Yishay (1978),and Prigatano (1986), is founded on the be-lief that the cognitive, psychiatric, and func-tional aspects of brain injury should not beseparated from emotions, feelings, and self-esteem. Holistic programs include group andindividual therapy in which patients are (a) en-couraged to be more aware of their strengthsand weaknesses, (b) helped to understand andaccept these, (c) given strategies to compen-sate for cognitive difficulties, and (d ) offeredvocational guidance and support. Prigatano(1994) suggests that such programs appear toresult in less emotional distress, increased self-esteem, and greater productivity. Prigatano(1999, 2005) and Sohlberg & Mateer (2001)describe the importance of dealing with thecognitive, emotional, and psychosocial con-sequences of brain injury. Wilson et al. (2000)present a British holistic program, basedon the principles of Ben-Yishay (1978) andPrigatano (1986), that is followed at the OliverZangwill Center for Neuropsychological Re-habilitation in Ely, Cambridgeshire. Althoughthese programs appear to be expensive in theshort term, they are probably cost-effectivein the long term (see Prigatano & Pliskin2002).

Williams (2003), who is concerned withthe rehabilitation of emotional disorders fol-lowing brain injury, suggests that survivors areat particular risk of developing mood disor-ders. He argues that this is one of the keyareas for development in neurological ser-vices. Alderman (2003) targets behavior dis-orders in work with some of the most severelydisturbed brain-injured people in the UnitedKingdom.

Increasing Use of Technology inNeuropsychological Rehabilitation

The increasing use of sophisticated technol-ogy such as positron emission tomographyand functional magnetic resonance imaging isenhancing our understanding of brain dam-age (see, for example, Coleman et al. 2007).To what extent these methodologies can im-prove our rehabilitation programs remains tobe seen. What is clear is the value of technol-ogy for reducing everyday problems of peoplewith neurological damage. One of the majorthemes in rehabilitation is the adaptation oftechnology for the benefit of people with cog-nitive impairments. Computers, for example,may be used as cognitive prosthetics, as com-pensatory devices, as assessment tools, or as ameans for training. Given the current expan-sion in information technology, this is likelyto be an area of growth and increasing impor-tance in NR in the next decade. One of theearliest papers referring to the use an elec-tronic aid with a person with brain damagewas that by Kurlychek (1983). This was im-portant because the aid assisted in tackling areal-life problem, which was to teach a manto check his timetable. In 1986, Glisky andcolleagues taught memory-impaired peoplecomputer terminology; as a result, one of theirparticipants was able to find employment asa computer operator. Kirsch and colleagues(1987) designed an interactive task guidancesystem to assist brain-injured people in per-forming functional tasks. Since then, reportsof successful use of technology with brain-injured people have appeared in many papers.Boake (2003) includes discussion of some ofthe early computer-based cognitive rehabili-tation programs, and Wilson et al. (2001) de-scribe a randomized control crossover designthat demonstrates it is possible to reduce theeveryday problems of neurologically impairedpeople with memory and/or planning difficul-ties by using a paging system. The remindersdo not always have to be specific. Based onwork by Robertson et al. (1997) and Manlyet al. (1999), Fish et al. (2007) found that

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sending general reminders to “stop, think,organize and plan” led to improvement in aprospective memory task. These content-freereminders work for people whose prospec-tive memory problems result from execu-tive deficits such as poor planning or dividedattention difficulties. For those with severememory problems, however, a specific re-minder would be required.

Virtual reality (VR) represents anothertechnology that will likely play an increasingrole in rehabilitation. VR can be used to sim-ulate real-life situations and thus be benefi-cial for both assessment and treatment. Roseet al. (2005) provide a review of the way VRhas been used in brain injury rehabilitation;in addition, they discuss the use of VR for theassessment and treatment of memory prob-lems, executive deficits, visuo-spatial difficul-ties, and unilateral neglect.

Rehabilitation Needs a BroadTheoretical Base

People with brain injury are likely to facemultiple problems, including cognitive, so-cial, emotional, and behavioral, and no onemodel or group of models is sufficient to dealwith all these issues. In order to improve cog-nitive, social, emotional, and behavioral func-tioning in the everyday life of these indi-viduals, we should not be constrained by asingle theoretical framework. Of the manytheories that affect rehabilitation, four areperhaps of particular importance, namely the-ories of cognitive functioning, emotion, be-havior, and learning. Consideration shouldalso be given to theories of assessment, recov-ery, and compensation. Wilson (2002) arguesfor a broad-based model and provides a ten-tative comprehensive model of rehabilitation.Boake (2003) describes the different method-ologies that influenced some of the historicalfigures in the field. Manly (2003) refers to nu-merous theories of attention that have guidedtreatment approaches to this difficult area.Williams (2003) is particularly influenced bycognitive behavior therapy (CBT), which is

Virtual reality(VR): a technologythat allows a user tointeract with acomputer-simulatedenvironment

CBT: cognitivebehavior therapy

Traumatic braininjury (TBI): asudden traumacausing damage tothe brain (also calledhead injury)

certainly one of the most carefully workedout and clinically useful models of emotionat this time. The neurobehavioral model ofWood (1987, 1990) is one that has influencedAlderman’s work in the treatment of brain-injured people with severe behavior problems(Alderman 2003). In a survey of British clinicalneuropsychologists working in brain injuryrehabilitation, 57 different models were re-ported as influencing clinical practice (Sopenaet al. 2007). Ethical and effective NR requiresa synthesis and integration of several frame-works, theories, and methodologies to achieveits aims and ensure the best clinical practice.

COGNITIVE ASPECTS OFNEUROPSYCHOLOGICALREHABILITATION

It is worth restating that it is not easyto separate the cognitive, emotional, andpsychosocial consequences of brain injury.However, because many of the studies inthe literature report these three componentsseparately, I examine them individually. Un-less the brain damage is very mild, cognitivedeficits are almost invariably found in sur-vivors of an insult to the brain. Problems withmemory, attention, executive functioning,and speed of information processing are themost typical difficulties faced by those whohave sustained traumatic brain injury (TBI).For survivors of stroke, language problemsare common after left hemisphere damage,and unilateral neglect is seen frequentlyafter right hemisphere damage. Numerousstudies have been published on the efficacy ofcognitive rehabilitation, ranging from single-case experimental designs to randomizedcontrolled trials (RCTs).

Chesnut et al. (1999) traced 2536 abstractsfrom articles on rehabilitation to find answersto five questions, one of which was concernedwith cognitive rehabilitation. This particularreport was based on 363 articles, of which114 related to cognitive rehabilitation. Theauthors asked specifically, “Does the applica-tion of compensatory rehabilitation enhance

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outcomes for people who sustain TBI?” Ofthe 114 potential articles, only 32 reached thefinal selection to evaluate effectiveness; the re-maining 82 articles were excluded for variousreasons, such as because they were review ar-ticles that were purely descriptive, reports onstudies in which there were fewer than fivesubjects, and so on. Of the 32 selected for eval-uation, 11 were RCTs, with 5 measuring rele-vant health outcomes and 6 measuring inter-mediate outcomes. The authors of the reportconcluded, “along with the small size of thestudies and the narrow range of interventionsstudied, the lack of information about the rep-resentativeness of the included patients makesit difficult to apply the findings of these studiesto cognitive rehabilitation practice generally”(p. 55). In other words, the RCTs did not re-veal much about the effectiveness of cognitiverehabilitation in any general sense.

The cognitive rehabilitation section of thereport was published separately (Carney et al.1999). The authors state that although thedesired outcome of cognitive rehabilitationis improvement in daily function, many ofthe outcome measures are intermediate mea-sures rather than health outcomes. By “in-termediate measures,” the authors mean testscores (123 tests of cognition were describedin the studies). The question was posed as towhether improvements on test scores predictimprovement in real-life function. The au-thors concluded that although there appearedto be some relationship between intermedi-ate measures and employment, the associa-tion was not strong. One could argue that theuse of test scores irrespective of whether theyare intermediate or direct is not a good wayto evaluate rehabilitation. The ultimate goalof rehabilitation is to enable people with dis-abilities to function as adequately as possiblein their most appropriate environment, so in-formation on changes in scores on the Wech-sler scales or any other standardized test willnot yield the required information. For ex-ample, JC, a densely amnesic patient (Wilson1999), has shown no improvement on stan-dardized tests over a 10-year period, yet he

is self-employed and completely independentthanks largely to excellent use of compen-satory strategies. By most standards of thoseinvolved in rehabilitation, these outcomes arevery good indeed, yet if standardized tests hadbeen used as measures of success, JC wouldhave failed dismally.

Some studies address real-life functionalissues. For example, Wilson et al. (2001) re-ported a randomized control study to evaluatea paging system in which memory-impairedpatients were randomly allocated to the pageror to a waiting list. Patients and their familiesidentified real-life problems involving taskssuch as taking medication, feeding the dog,and collecting children from school. In thebaseline period, these behaviors were mon-itored and there was no difference betweenthe two groups. Those allocated to the pag-ing condition then received their pagers andthe same behaviors were monitored as be-fore. The achievement of the target behav-iors significantly improved, whereas those onthe waiting list experienced no change. Thepagers were then returned and given to thepeople who had been on the waiting list. Thisgroup then improved significantly. Those whohad returned their pagers dropped back a lit-tle but were still better than they had been atbaseline. This suggested that some learningof the target behaviors had taken place duringthe pager phase.

Tackling real-life targets and individualiz-ing programs within a specified frameworkis—or should be—the way forward in cog-nitive rehabilitation. Clare and colleagues(Clare et al. 1999, 2000, 2001) applied thisprinciple to people with Alzheimer’s disease.Patients and families selected the target be-haviors they wanted to achieve and a way wasfound to teach new information. The mainstrategies used in this series of studies wereerrorless learning and spaced retrieval.

Cicerone and colleagues (2000, 2005) havecarried out major investigations into the effi-cacy of cognitive rehabilitation. In their 2005paper, they used search engines to locate cog-nitive rehabilitation studies and identified 47

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studies that fulfilled certain inclusion crite-ria. They looked at several cognitive domainsincluding attention difficulties, visuo-spatialdeficits, apraxia, language and communicationproblems, memory deficits, executive func-tioning, problem solving, and awareness. Onthe issue of retraining versus compensation,they found that retraining was effective forsome cognitive functions (for example, lan-guage), whereas compensation was necessaryfor others (such as memory deficits). Theiroverall conclusion was, “There is now a sub-stantial body of evidence demonstrating thatpatients with TBI or stroke benefit from cog-nitive rehabilitation” (Cicerone et al. 2005,p. 1689). These authors also state, “Future re-search should move beyond the simple ques-tion of whether cognitive rehabilitation iseffective, and examine the therapy factorsand patient characteristics that optimize theclinical outcomes of cognitive rehabilitation”(p. 1681). Halligan & Wade (2005) provide asummary of much of the work on the effec-tiveness of rehabilitation for cognitive deficits.

EMOTIONAL ASPECTS OFNEUROPSYCHOLOGICALREHABILITATION

The management and remediation of emo-tional consequences of brain injury have be-come increasingly important in recent years.Prigatano (1999) suggests that rehabilitationis likely to fail if clinicians do not deal withthe emotional issues. Consequently, an under-standing of theories and models of emotionis crucial to successful rehabilitation. Socialisolation, anxiety, and depression are com-mon in survivors of brain injury. Kopelman &Crawford (1996) found that 40% of 200 con-secutive referrals to a memory clinic were suf-fering from clinical depression. Bowen et al.(1998) found that 38% of survivors of TBIexperienced mood disorders. Williams et al.(2002) found that estimates of the prevalenceof post-traumatic stress disorder (PTSD) fol-lowing TBI range from 3% to 27%. Intheir own study, they found that 18% of 66

community-living survivors of TBI experi-enced PTSD.

Gainotti (1993) distinguishes three mainfactors causing emotional and psychosocialproblems after brain injury: those result-ing from neurological factors, those due topsychological or psychodynamic factors, andthose due to psychosocial factors. An exam-ple of a neurological factor is an individualwith brain stem damage leading to the so-called catastrophic reaction, in which swingsfrom tears to laughter may follow in rapid suc-cession. Anosognosia, or lack of awareness ofone’s deficits, is also frequently due to organicimpairment. An important book on the topicof unawareness (Prigatano & Schacter 1991)posits several rationales for the existence ofanosognosia. Gainotti (1993) also addressesunawareness in detail, and Clare & Halligan(2006) characterize some of the key clini-cal issues concerned with assessing and man-aging pathologies of subjective or consciousawareness.

The second factor identified in Gainotti’s(1993) three-part classification, that is, emo-tional problems that are due to psychologicalor psychodynamic causes, includes personalattitudes toward the disability. An example issomeone with an acquired dyslexia and con-sequent loss of self-esteem together with de-pression because of an inability to read. De-nial is also thought to be relevant to somecases of this second type of emotional disor-der. At some level, patients are aware of theirdisabilities but are unable to accept them. Be-cause denial can occur in conditions withoutany damage to the brain, there must be (atleast in some cases) nonorganic reasons for it(Gainotti 1993). PTSD also fits into this clas-sification. Fear of what might happen in thefuture, panic because one cannot rememberwhat has happened in the past few minutes,grief at loss of functioning, and reduced self-esteem because of changes in physical appear-ance may all contribute to emotional changes.

The third category put forward byGainotti (1993) includes problems that arisefor psychosocial reasons. An example is an

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Psychosocialfunctioning:encompasses work,leisure, and socialrelationships;overlaps withemotional well-being

individual who loses all his or her friends andcolleagues following a brain injury and thus isvery socially isolated. Social isolation is seenin up to 60% of survivors of TBI (Hoofienet al. 2001). One aspect not covered byGainotti is the influence of premorbid person-ality. This is discussed by Moore & Stambrook(1995), Williams et al. (1999), and Tate (1998).Tate, however, found that premorbid person-ality had less effect on psychosocial function-ing than did severity of injury. In understand-ing emotion after brain injury, we need toconsider neurological, physical, and bio-chemical models such as those described byRobinson & Starkstein (1989). Although suchmodels address the issue of why emotionalproblems arise following an insult to the brain,they do not offer much help in understandingthe psychodynamic and psychosocial causes ofemotional and mood disorders. Perhaps themost helpful models come from CBT.

Ever since Beck’s highly influential book,Cognitive Therapy and Emotional Disorders, ap-peared in 1976, CBT has been one of the mostimportant and best-validated psychothera-peutic procedures (Salkovskis 1996). A ma-jor strength of Beck’s updated model (Beck1996) has been the development of clinicallyrelevant theories. Beck presents several theo-ries not only for depression and anxiety butalso for panic, obsessive-compulsive disor-ders, and phobias. Mateer & Sira (2006) sug-gest that CBT is well suited for improvingcoping skills, helping clients to manage cog-nitive difficulties, and addressing more gen-eralized anxiety and depression in the contextof a brain injury. Williams et al. (2003) de-scribe the use of CBT with two survivors ofTBI. One was a young man whose girlfriendwas killed in a car crash while he was driv-ing. The other was a young woman, knownas CM, who had been severely assaulted whiletraveling on a train (described in more detailbelow). Williams et al. (2003) discuss the pos-sible mechanisms for PTSD after TBI. Theseconditions were once thought to be mutuallyexclusive because the survivor would lack amemory for the event from which to develop

vivid intrusive cognitions and avoidance be-haviors (Sbordone & Liter 1995). However,given that PTSD seems to occur even whenthere is a loss of consciousness for the event,there could be two main mediating mecha-nisms to suggest how trauma-related materialmay be processed to lead to PTSD symptoms.First, survivors may evoke “islands of mem-ory” for their trauma, such as being trappedin a crashed car, or other secondary experi-ences that could fuel intrusive ruminations(McMillan 1996). Second, survivors may bereminded of elements of their trauma eventwhen exposed to similar situations that serveto produce intrusive thoughts and fuel avoid-ance behaviors (Brewin et al. 1996). McNeil& Greenwood (1996) described a survivor ofTBI who was hyperaroused in, and avoidantof, situations that were similar to the traumaevent, a road traffic accident, even thoughhe had no declarative memory of the event.If an event is unexpected but has biologicalsignificance and, hence, emotional salience,McNeil & Greenwood (1996) suggested, itmay lead to the event being stored (or “burnedin” to memory) despite disruption to areasof the brain that store declarative memories(see Markowitsch 1998). Such a view wouldbe compatible with the concept that PTSD iscaused by a conditioning of fear. The mecha-nism responsible is one in which traumatic ex-periences can be processed independently ofhigher cortical functions (see Bryant 2001).Analytic psychotherapy is also used in reha-bilitation, particularly in the United States.Prigatano is perhaps the best-known propo-nent of psychotherapy treatment of individu-als surviving TBI. He describes his approach(based on the milieu therapy approach of Ben-Yishay) in Principles of Neuropsychological Reha-bilitation (Prigatano 1999).

Dealing with the emotional consequencesof brain injury may make the difference be-tween a successful and an unsuccessful out-come. CM, mentioned above, was stabbedthrough the head in the right tempero-parietal area with a hunting knife while trav-eling on a train. She was 19 at the time and

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did not lose consciousness, probably becausethe knife did not enter her brain stem. She de-scribed feeling a pain in her head and a weightas if the carriage had fallen on top of her. Shestood up and realized that something terriblehad happened. She went into the next carriagewhere a man told her to sit down and stay stilland he would get help. She felt the knife withher hand and asked if she was going to die. Theman said “No” and that he would get help. Atthe next stop, an ambulance arrived and tookher to the hospital.

A few months later, she came to our reha-bilitation center. She had a number of cogni-tive problems, including visuo-spatial issuesand memory deficits, but the emotional dif-ficulties took priority in treatment. She wasanxious and avoided many social situations;she would not look at people, feared for herfamily, and had classic symptoms of PTSDincluding flashbacks and nightmares; and sherefused to use public transport. Like all otherpatients there, she had both group and in-dividual therapy, including a considerableamount of psychological support and treat-ment for the emotional problems identified(Williams et al. 2003). This involved CBT,including stress inoculation, and graduatedexposure to situations she avoided. She wasalso treated for her cognitive difficulties, butif these had been the only problems treated,it is doubtful that she would have been ableto make such a good recovery and return to afull and meaningful life.

A recent study (Tiersky et al. 2005) exam-ined the effects of a rehabilitation programoffering psychotherapy and cognitive rehabil-itation and compared a treatment group witha control group. The treatment group showedsignificantly improved emotional function-ing, including lessened anxiety and depres-sion. The authors concluded, “Cognitivebehavioral psychotherapy and cognitive re-mediation appear to diminish psychologicdistress and improve cognitive functioningamong community-living persons with mildand moderate TBI” (Tiersky et al. 2005,p. 1565).

WHO: WorldHealth Organization

PSYCHOSOCIAL ASPECTS OFNEUROPSYCHOLOGICALREHABILITATION

Considerable overlap exists between psy-chosocial and emotional difficulties. In-deed, one definition of a psychosocialdisorder is “a mental illness caused or in-fluenced by life experiences, as well as mal-adjusted cognitive and behavioral processes”(www.healthatoz.com). In brain injury re-habilitation, however, the term is more oftenused to refer to psychosocial outcomes such aswork, friendships, and community activities.In other words, psychosocial functioning isclose to “participation” as defined by the Inter-national Classification of Functioning, Disabilityand Health (World Health Org. 2001). Wade(2005) says that the World Health Organi-zation (WHO) framework “was developed asa means of describing the totality that is theexperience of illness” (p. 32). The frameworkconsists of four levels: pathology, impairment,activity, and participation. Thus, in the case ofa brain-injured person, the pathology mightbe damage to the cerebral cortex and the re-sulting impairment might be a poor memory.This, in turn, causes limitations to the person’severyday activities; so, for example, s/he is un-able to remember appointments. This prob-lem might affect the extent of participation inthe person’s social environment, causing diffi-culties with work, the duties of parenthood, orthe ability to engage in leisure activities. TheWHO model also considers three major con-texts influencing behavior: personal, physical,and social contexts. Wade (2005) says thesecontexts “might be considered to affect theinteractions between pathology and impair-ment, impairment and activities and activi-ties and participation” (p. 34). Personal con-text includes the relevant characteristics of anindividual such as expectations, beliefs, andattitudes. Physical context refers to the en-vironment in which the individual finds him-self or herself, and social context refers to theculture in which the individual functions. Allthese factors contribute to the quality of life

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as experienced by the person with a disabil-ity. For the purposes of this review, psychoso-cial problems are seen as synonymous with theWHO definition of participation.

Twenty-first century rehabilitation pro-grams are typically concerned with psychoso-cial adjustment to disability (Sopena et al.2007, Yates 2003). Included in this categoryare employment or other productive activ-ity, social relationships, and leisure. Somebelieve that the psychosocial problems associ-ated with TBI may actually be the major chal-lenge of rehabilitation (Morton & Wehman1995). Survivors of brain injury face prob-lems of social isolation and decreased leisureactivities, thus creating a renewed depen-dence on their family members. Karlovits &McColl (1999) interviewed 11 survivors of se-vere brain injury to discover impediments toreintegration into the community. Nine stres-sors were identified: orientation, transporta-tion, living situation, loss of independence, re-lationships, loneliness, routine, problems withstudying, and work. Much of the focus of postacute rehabilitation is on helping people toreturn to a productive lifestyle (Petrella et al.2005). Indeed, the success of NR programsis often measured by such outcomes. Lackof productivity, particularly employment, de-creases the opportunity for individuals withbrain injury to develop social contacts andleisure activities, which in turn contributes todepression and low self-esteem. In contrast,engagement in paid and nonpaid productiveactivities, such as volunteering or homemak-ing, has a beneficial impact on community in-tegration (Petrella et al. 2005).

Return to work is one of the majorgoals that clients in brain-injury rehabilita-tion programs want to achieve. A numberof studies have addressed the issue of re-turning to work after rehabilitation. Failureto succeed at work is associated with poorself-awareness, impaired executive function-ing, and poor metacognition (Ownsworth &Fleming 2005). In a multicenter study, Walkeret al. (2006) found that that those who wereemployed prior to the onset of their brain

injury, in comparison with those who wereunemployed, were more likely to work afterrehabilitation. The type of occupation alsoinfluenced return to work: Those in profes-sional or managerial jobs were more likely toreturn to work than were those in other posi-tions. In another meta-analysis, Kendall et al.(2006) said, “[T]he use of a narrow defini-tion of return-to-work (i.e., full-time compet-itive work only) produced more apparent un-employment than an inclusive definition (i.e.,any competitive work or productive activity)”(p. 149). Although this is not surprising, ithighlights the fact that a return to full-timeemployment after severe brain injury is notalways achievable and, in rehabilitation, weneed to consider a range of productive activ-ities for our patients/clients. In the words ofKendall et al. (2006), “The definition of em-ployment and the nature of preinjury employ-ment is crucial to any interpretation of return-to-work in TBI. The current study alsohighlights the importance of measuring em-ployment outcomes using multiple pointsover time, rather than single data points orfirst return-to-work” (p. 149). In an examina-tion of the effects of rehabilitation on returnto work for military personnel, Cullen et al.(2007) found moderate evidence to supportthe view that inpatient rehabilitation results insuccessful return to work and return to dutyfor the majority of military service members.They also suggested that increasing the in-tensity of rehabilitation not only reduced thelength of stay but also improved short-termfunctional outcomes. Turner-Stokes et al.(2005) also found strong evidence to sup-port the claim that intensive rehabilitationled to more functional gains than did less-intensive rehabilitation. In summary, peoplewho are given intensive rehabilitation havean improved likelihood of returning to work,and the definition of “return to work” shouldbe expanded to include part-time work andother meaningful functional activities ratherthan simply full-time competitive work.

Social isolation is common after TBI,in part because of deficits in social skills

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(McDonald 2003). An increase in social skillsand social relationships should be one of themajor goals for rehabilitation. Some studieshave shown that it is possible to achieve thesegoals ( Johnson & Davis 1998, Ownsworthet al. 2000, Ylvisaker et al. 2005). In theirwork with stroke patients, Haslam et al. (2007)found that the number of social groups peo-ple belonged to before their stroke predictedtheir sense of well-being after the strokeand that this was a result of them beingmore likely to retain membership of moregroups.

Another study looking at personal rela-tionships is that of Wood & Rutterford (2005),who found that five factors predicted prob-lems with social relationships. These were(a) loss of self-control (e.g., aggression, so-cial and/or sexual disinhibition), (b) emotionaldysfunction (e.g., mood swings, quick tem-per), (c) adynamia (e.g., lack of motivation forleisure activities, fatigue, loss of libido, loss ofsocial interests), (d ) personality change (e.g.,obsessiveness), and (e) cognitive dysfunction(e.g., memory loss, attention/concentrationdifficulties, organization and planning prob-lems). These are all factors that are or shouldbe addressed in rehabilitation.

Another area of research is leisure. ADanish study by Engberg & Teasdale (2004)found that maintenance of leisure-time inter-ests and general life satisfaction was poorerin survivors of a cerebral lesion comparedwith patients with a cranial fracture. A Frenchstudy (Quintard et al. 2002) looked at late out-come and satisfaction of life of 79 patientswith severe TBI. Up to 85% were indepen-dent in activities of daily living, 55% were in-dependent in social life, but only 36% weresatisfied with leisure activities. In some reha-bilitation programs, leisure goals are amongthe most common goals set. For example,Bateman et al. (2005) looked at 680 goals setfor 95 clients at the Oliver Zangwill Centerin the United Kingdom. The most commongoals were connected with managing activi-ties of daily living (248); leisure goals (154)came second jointly with goals pertaining to

NeuroPage: areminding systemusing radio-pagingtechnology

understanding the consequences of brain in-jury, followed by goals connected with workor study skills (119).

It is clear that rehabilitation for psychoso-cial difficulties is an important part of the careof survivors of brain injury. Physical difficul-ties are less likely to affect the quality of lifeof a brain-injured person than are the cog-nitive, emotional, and psychosocial sequelae,so these should be the focus of rehabilitationprograms. In the words of Khan et al. (2003),“Cognitive and behavioral changes, difficul-ties maintaining personal relationships andcoping with school and work are reported bysurvivors as more disabling than any residualphysical deficits” (p. 290).

A collection of papers on biopsychosocialapproaches in neurorehabilitation edited byWilliams & Evans (2003) summarizes muchof the work tackled in this field.

MODELS AND THEORETICALAPPROACHES CONTRIBUTINGTO NEUROPSYCHOLOGICALREHABILITATION

Most neuropsychologists working in rehabili-tation believe that treatment should be drivenby theory, although they may also believethat theories are not necessarily sufficient ontheir own. For example, NeuroPage, a pagingsystem for helping memory-impaired peo-ple remember everyday tasks, was developedby an engineer with no knowledge of psy-chological theory who had a son with a se-vere TBI (Hersch & Treadgold 1994). Eventhough it is not theoretically driven, Neu-roPage has led to theoretically driven ques-tions such as the effect of executive function-ing on successful use of the pager (Fish et al.2007). Perhaps the most influential modelsand theories in NR over the past two decadesare those of cognition, emotion, behavior,and learning. Models of cognitive function-ing that have proved useful in rehabilita-tion include language, reading (Howard 2005,Mitchum & Berndt 1995), memory (Baddeley1992, 2007), attention (Robertson 1999), and

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perception (Bruce & Young 1986). Given theincreasing recognition of the importance ofaddressing emotional and psychosocial diffi-culties, emotional models are essential in NR.One of the most important of these, CBT,is discussed above. Models and theories frombehavioral psychology have been employed inNR for more than 40 years. They have pro-vided some of the most useful and influen-tial theoretical contributions to rehabilitation,not only for the understanding, management,and remediation of disruptive behaviors, butalso for the remediation of cognitive deficits(Wilson et al. 2003). Behavioral theories arevaluable in NR because they inform assess-ment, treatment, and the measurement of re-habilitation efficacy.

Learning theory is one of the cornerstonesof behavior therapy and behavior modifica-tion, with the other main theoretical influ-ences coming from biological, cognitive, andsocial psychology (Martin 1991). There is lit-tle doubt, though, that the original behav-ioral treatments grew out of learning theory.Eysenck (1964), for example, defined behav-ior therapy as “the attempt to alter humanbehavior and emotion in a beneficial man-ner according to the laws of modern learningtheory” (p. 1).

Believing that the purpose of rehabilitationis to help people achieve their optimum levelof physical, psychological, social, and voca-tional functioning, Wilson (2002) attemptedto synthesize a number of approaches andmodels used in rehabilitation to reflect thecomplexity of the field and the range of is-sues to be dealt with. Wilson published aprovisional model of cognitive rehabilitationin which she argued that one model, or onegroup of models such as those from cognitiveneuropsychology, is insufficient to (a) deter-mine what needs to be rehabilitated, (b) planappropriate treatment for neuropsychologi-cal impairments, and (c) evaluate response torehabilitation. Rehabilitation is one of manyfields that need a broad theoretical base in-corporating frameworks, theories, and mod-

els from a number of different areas. Con-straint of rehabilitation workers to one modelcould lead to poor clinical practice becauseimportant aspects of patients’ lives could beneglected.

GUIDELINES FOR GOODPRACTICE INNEUROPSYCHOLOGICALREHABILITATION

Although there are no definitive trials to sup-port the holistic approach, it has probablybeen subjected to more evaluation studiesthan have other approaches (e.g., Ciceroneet al. 2004, Diller & Ben-Yishay 2002) and,at present, is probably the most effective clin-ically (Cicerone et al. 2007). Most holistic pro-grams are concerned with increasing a client’sawareness, alleviating cognitive deficits, de-veloping compensatory skills, and providingvocational counseling. All such programs pro-vide a mixture of individual and group therapy.This approach possibly could be improvedby incorporating ideas and practical applica-tions from learning theory, such as task analy-sis, baseline recording, monitoring, and theimplementation of single-case experimentaldesigns to individual treatment programs. An-other potential improvement would be refer-ring to cognitive neuropsychological modelsin order to identify cognitive strengths andweaknesses in more detail to explain observedphenomena and make predictions about cog-nitive functioning.

Prigatano (1999) lists 13 principles of NRderived from a holistic approach, and there isno doubt that his work has considerably influ-enced current rehabilitation practice. Theseprinciples are described in Table 3.

The Oliver Zangwill Center, influencedby Prigatano’s approach, bases its NR on sixcore components that are described here toillustrate the principles of good clinical prac-tice in NR. More detail on the components isavailable from the Oliver Zangwill Web site,www.ozc.nhs.uk.

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Table 3 Summary of Prigatano’s 13 principles of neuropsychological rehabilitation

Principle No. Principle1 Begin with the patient’s subjective or phenomenological experience.2 The symptoms presented are a mixture of premorbid cognitive and personality characteristics together

with the neuropsychological changes resulting from the brain pathology.3 Neuropsychological rehabilitation focuses on both the remediation of higher cerebral disturbances and

their management in interpersonal situations.4 Neuropsychological rehabilitation helps patients observe their behavior to teach them about the direct

and indirect effects of brain injury.5 Failure to study the interaction of cognition and personality leads to an inadequate understanding of

many issues.6 Little is known about how to retrain cognitive dysfunction, but general guidelines of cognitive

remediation can be specified.7 Psychotherapeutic interventions help patients (and families) deal with their personal losses.8 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.9 Each neuropsychological rehabilitation program is a dynamic entity. The team needs to maintain a

dynamic, creative effort.10 Failure to identify those patients who can and cannot be helped creates a lack of credibility.11 Disturbances in self-awareness after brain injury are often poorly understood and poorly managed.12 Competent patient management and planning depend on understanding mechanisms of recovery and

deterioration.13 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 thetherapeutic milieu (Ben-Yishay 1996), thetherapeutic milieu in holistic rehabilitationrefers to the organization of the complete en-vironment (physical, organizational, and so-cial aspects) to maximize support for theprocess of adjustment and to increase socialparticipation. The milieu embodies a strongsense of mutual cooperation and trust, whichunderpins the working alliance between clientand clinicians.

2. Establish Meaningful and FunctionallyRelevant Goals for Rehabilitation

Meaningful functional activity refers toall day-to-day activities that form the basisfor social participation. These can be cate-gorized into vocational, educational, recre-ational, social, and independent living realms.It is through participation in these areas thatindividuals gain a sense of purpose and mean-

Therapeuticmilieu: theorganization of theenvironment toensure maximumsupport to theprocess ofadjustment and toincrease socialparticipation

ing in their lives. Although it is probably notthought about consciously in everyday life,activity enables individuals to achieve certainaims or ambitions that are personally signif-icant and thereby contributes to the sense ofidentity.

3. Ensure Shared Understanding

The notion of shared understanding comesfrom the use of formulation in clinical prac-tice (Butler 1998). A formulation is seen asa map or guide to intervention that com-bines a model derived from established the-ories and best evidence with the client’s andfamily’s personal views, experiences, and sto-ries. This concept, which should be appliedto all individual clinical work, influences theway the rehabilitation experience is organizedas a whole. The shared understanding con-cept incorporates team philosophy, includ-ing shared team vision, explicit values, andgoals. Understanding of research and theory,

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sharing knowledge and experience with otherprofessionals and families, peer audit of theservice, and the views and contributions ofpast clients are additional aspects of the sharedunderstanding ideal.

4. Apply Psychological Interventions

Psychological interventions are basedupon certain ways of understanding feelingsand behavior. Specific psychological mod-els (particularly those described above) areused to guide work depending upon the spe-cific needs of the individual. Approaches fromthese models provide ways team members canengage patients/clients in positive change andthe tackling of specific problems.

5. Manage Cognitive ImpairmentsThrough Compensatory Strategies andRetraining Skills

Compensatory strategies are alternativeways to enable individuals to achieve a desiredobjective when an underlying function of thebrain is not operating effectively. Compen-satory approaches to managing impairmentstake a number of forms, including:

� cognitive compensation (e.g., using vi-sual imagery to compensate for a defec-tive verbal memory, using a mental rou-tine for managing impulsivity or anger,and clarifying to ensure effective com-munication);

� enhanced learning—techniques such aserrorless learning or spaced retrievalthat lead to more effective learning ofnew knowledge or skills;

� external aids (e.g., using a diary for man-aging memory problems, checklists toremember exercise routines, alarms toincrease attention to tasks, cue cards forkeeping on track during conversation);and

� environmental adaptations—modifyingrelevant environments in order to re-duce cognitive demands (e.g., workingin a quiet, nondistracting room to aid

concentration, holding important con-versations when less fatigued).

Retraining is undertaken to improve per-formance of a specific function of the brain orto improve performance on a particular taskor activity. Retraining also helps to addressskills lost through lack of use, e.g., throughnot being at work since an injury.

6. Work Closely with Families and Carers

Families and carers sometimes report feel-ing like an afterthought in rehabilitation. Re-cent policy (National Service Framework forLong Term Conditions, Dep. Health, London,2004) highlights how families and carers ex-perience a significant burden following ac-quired brain injury and recommends provi-sion of support. Many kinds of support can beoffered, for example, providing information,furnishing opportunities for peer support, in-volving family and carers in rehabilitation, andproviding individual family consultation ortherapy.

SUMMARY

Following definitions of neuropsychology, re-habilitation, and NR, this review discussessome of the ways the field has changedin recent years. The particular focus is on(a) goal setting as a way of structuring re-habilitation, (b) the realization that the emo-tional and psychosocial consequences of braininjury are as important as the cognitive conse-quences, (c) the increasing use of technologyin rehabilitation, and (d ) a recognition thata wide range of theoretical models and ap-proaches is needed to inform the assessmentand treatment of people who have surviveda brain injury. The three main componentsof NR—cognitive, emotion, and psychoso-cial functioning—are looked at in more de-tail. Given that how we feel affects how wethink, how we behave, and how we interactwith others, all three functions need to beaddressed in any rehabilitation program. Ev-idence is provided to show that difficulties in

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these areas can be reduced through NR. Be-cause the field is broad and complex, cliniciansneed to be informed by a number of modelsand theories to reduce the everyday problemsfaced by people who have survived brain in-jury. Some of the most influential models and

theoretical approaches used to plan rehabilita-tion are described, particularly those relevantto cognitive functioning, emotion, behavior,and learning. The review concludes with rec-ommendations for good practice in the reha-bilitation of people with brain injury.

SUMMARY POINTS

1. Neuropsychological rehabilitation (NR) is concerned with the amelioration of cogni-tive, 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 appropriateenvironments; 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 psy-chosocial consequences of brain injury need to be addressed in rehabilitation pro-grams. There is an interaction between these different functions, and it is not alwayseasy 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 andtheories influencing current practice are described.

6. Evidence is provided to show that NR can reduce difficulties in the three main areasof 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 ofthis review.

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Annual Review ofClinical Psychology

Volume 4, 2008Contents

Ecological Momentary AssessmentSaul Shiffman, Arthur A. Stone, and Michael R. Hufford � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �1

Modern Approaches to Conceptualizing and Measuring HumanLife StressScott M. Monroe � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 33

Pharmacotherapy of Mood DisordersMichael E. Thase and Timothey Denko � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 53

The Empirical Status of Psychodynamic TherapiesMary Beth Connolly Gibbons, Paul Crits-Christoph, and Bridget Hearon � � � � � � � � � � � � � 93

Cost-Effective Early Childhood Development Programs fromPreschool to Third GradeArthur J. Reynolds and Judy A. Temple � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �109

Neuropsychological RehabilitationBarbara A. Wilson � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �141

Pediatric Bipolar DisorderEllen Leibenluft and Brendan A. Rich � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �163

Stress and the Hypothalamic Pituitary Adrenal Axis in theDevelopmental Course of SchizophreniaElaine Walker, Vijay Mittal, and Kevin Tessner � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �189

Psychopathy as a Clinical and Empirical ConstructRobert D. Hare and Craig S. Neumann � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �217

The Behavioral Genetics of Personality DisorderW. John Livesley and Kerry L. Jang � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �247

Disorders of Childhood and Adolescence: Gender andPsychopathologyCarolyn Zahn-Waxler, Elizabeth A. Shirtcliff, and Kristine Marceau � � � � � � � � � � � � � � � �275

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Should Binge Eating Disorder be Included in the DSM-V? A CriticalReview of the State of the EvidenceRuth H. Striegel-Moore and Debra L. Franko � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �305

Behavioral Disinhibition and the Development of Early-OnsetAddiction: Common and Specific InfluencesWilliam G. Iacono, Stephen M. Malone, and Matt McGue � � � � � � � � � � � � � � � � � � � � � � � � � � �325

Psychosocial and Biobehavioral Factors and Their Interplayin Coronary Heart DiseaseRedford B. Williams � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �349

Stigma as Related to Mental DisordersStephen P. Hinshaw and Andrea Stier � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �367

Indexes

Cumulative Index of Contributing Authors, Volumes 1–4 � � � � � � � � � � � � � � � � � � � � � � � � � � �395

Cumulative Index of Chapter Titles, Volumes 1–4 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �397

Errata

An online log of corrections to Annual Review of Clinical Psychology chapters (if any)may be found at http://clinpsy.AnnualReviews.org

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