Back to the Future: Context-Sensitive Rehabilitation Following Brain Injury Tim Feeney, Ph.D. Project Director New Y

1. 1 Back to the Future: “Context-Sensitive” Rehabilitation Following Brain InjuryTim Feeney, Ph.D.Project DirectorNew York Neurobehavioral Resource ProjectClinical DirectorSchool and Community Support ServicesSchenectady, NY USAtfeeny@scssconsulting.com

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3. 3 My Task as I Understand It Describe a theoretical orientation to brain injury rehabilitation and describe it boldly! Boldly, but with humility appropriate to the topic Focus on the cognitive, social, communication, and behavioral dimensions of brain injury rehabilitation.

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5. 5 Theoretical Orientation Rehabilitation efforts should be consistent with a defensible theoretical framework, but not “theory driven” The ultimate touchstone of rehabilitation is meaningful improvements in the lives of the individuals we serve and the significant everyday people in the everyday routines of their lives. It’s about people, not programs!

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16. 16 Lev Vygotsky 1896 – 1934 Student of and lecturer in literature, history, law, philosophy, psychology, educational psychology Author: >180 publications (plus additional translations and edited works) in a short career (including a respected treatise on Hamlet) Following his death at age 37, his works were banned by Stalin for 20 years Dramatic impact on applied psychology and education over past 20 years – in the US and elsewhere

17. 17 Lev Vygotsky: Principles Developmental (genetic) method : to understand a process/concept, one must understand its origin Two contributors to development: biology (e.g., genetic endowment; neurological maturation) and culture (including cultural tools, such as language, category frameworks, etc., and cultural mediation/guided participation in culturally valued activities)

18. 18 Lev Vygotsky: Principles “Higher” functions (i.e., non-biological) develop via internalizing (appropriating; transposing; “in-growing”) of interaction (mediation) with more mature members of the culture (i.e., apprenticeship relationships), as the “apprentice” engages in guided participation in culturally valued activities

19. 19 Lev Vygotsky: Principles Domain-specificity of cognitive, meta-cognitive, and volitional processes: Higher thought is learned, (relatively) task-specific, and sociocultural: consistent with both representationalism and connectionism in contemporary cognitive science

20. 20 Lev Vygotsky: Principles 5. Language is the primary “cultural tool” to mediate everyday problem-solving activities and to create higher-order, self-regulated thought processes (cognition and volition/self-regulation). 6. Volition and deliberate self-regulation, like thinking, are internalized speech (see L. Beck studies). [Mandates an integration of cognitive and behavioral intervention approaches]

21. 21 Lev Vygotsky: Principles Cognition is ultimately unitary: “components” of cognition are abstractions; cognitive activity in general is problem solving toward a meaningful goal while participating in culturally valued activities Cognition/Thinking: “… serves effective action in the interpersonal and physical world, as people solve problems that inherently involve dealing with specific circumstances.” Rogoff, 1990

22. 22 Lev Vygotsky: Principles Cognition as unitary and situated: “The need for a broad and complex conception of cognition also lies in the complex interweaving of the various aspects of cognition in the tapestry of actual, real-time cognitive functioning. Each process plays a vital role in the operation and development of each other process, affecting and being affected by it.” Attention organization memory knowledge base reasoning Flavell et al, (2002). Cognitive Development 4th edition.

23. 23 Lev Vygotsky: Principles Thought and emotion are inter-related and inseparable “Thought...is not born of other thoughts. Thought has its origins in the motivating sphere of consciousness, a sphere that includes our inclinations and needs, our interests and impulses, and our affect and emotion. The affective and volitional tendency stands behind thought. Only here do we find the answer to the final “why” in the analysis of thinking.” Compare: Recent cognitive neuroscience studies Vygotsky, Thinking and Speech, p. 282

24. 24 Lev Vygotsky: Principles Assessment is dynamic (experimental; hypothesis testing) 9a. Static assessment: describe unaided performance 9b. Dynamic assessment: Systematically manipulate relevant variables (e.g., task modifications, coaching/cuing supports, environmental supports, motivational variables, etc) to determine: - “Zone of Proximal Development” - Most effective supports and teaching methods

25. 25 Lev Vygotsky: Principles Theory and practice are inseparable: Theory is ultimately tested by practice “Clinical activity, unstructured and without the direction of a conceptual framework, is blind; models and theories, uninformed by clinical experience and therapeutic skill, are empty” Ylvisaker, 1985

26. 26 Lev Vygotsky: Principles 12. The same psychological principles apply to children and adults with disability “The work that emphasized the dissolution of higher functions was always seen as a natural complement to the developmental work. In fact, in the late 1920s we drew no really clear cut distinction between the two approaches; our work went on simultaneously on all fronts. The kindergarten and the clinic were equally attractive avenues to approach the difficult analytic problems.” (Luria, P. 57)

27. 27 Lev Vygotsky: Summary Bottom line: Development/maturation of language, cognition, volition, and behavioral self-regulation is based on goal-directed supported participation in authentic cultural activities, mediated by social interaction with more mature members of the culture, with meaningful practice in the use of cultural “tools” (including compensatory strategies), and with demands on the “apprentice” within the “Zone of Proximal Development”. This is apprenticeship teaching and applies to child development generally, to regular education, to professional and vocational training, and to teaching/ rehabilitating individuals, including adults, with disability

28. 28 Lev Vygotsky: General Orientation to Rehabilitation Include individuals with and without disability in culturally valued activities Focus on strengths (versus impairment) Prevent secondary disability caused by lack of meaningful participation Facilitate effective, individualized compensations within culturally valued participation, with expert mediation of learning tasks Ensure adequate practice and systematic reduction of supports

29. 29 TWO FUNDAMENTALLY OPPOSING CONCEPTIONS OF HUMAN REALITY

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35. 35 Rehabilitation Goals Sarah will successfully complete ___ meaningful task, with ___ supports, possibly using ___ “tools/strategies”, in ___ context (setting, people, activities), in order to achieve ___ goal. Possibly focusing intervention attention on some specific aspects of cognition, communication, social skills, behavioral self-regulation, or educational/vocational skills – aspects that are either particularly weak or particularly important for Sarah.

36. 36 APPRENTICESHIP TEACHING: A Foundation for Context-Sensitive Rehabilitation CONTEXT Natural context; perhaps projects with a meaningful goal Social, collaborative activity Success due to collaboration; no need for errors Non-hierarchical organization of tasks

37. 37 REHABILITATION AS APPRENTICESHIP TEACHING TASK STRUCTURE Engagement in guided observation Collaborative, goal-oriented work, with supports as needed Learner contributes as much as possible Ongoing coaching, encouragement, modeling, brainstorming, etc. Supports systematically withdrawn and/or task difficulty increased Transfer guaranteed because of context and procedures

38. 38 Traditional assessment (office-bound assessment) is a notoriously inaccurate indicator of abilities in both the long and short term. Even tests purported to assess functioning post-injury are often incorrect. The tester becomes the “prosthetic frontal lobe.”

39. 39 Therefore: All assessment and intervention must be done in a contextual and collaborative manner

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41. 41 Assessment informs intervention, informs assessment, informs intervention, informs assessment, informs intervention, informs assessment, informs intervention, informs assessment, informs intervention, informs assessment

42. 42 Reconstructing a sense of self is the core of all rehabilitation efforts

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44. 44 Doberman

45. 45 Sense of Self: Neuropsychology Stuss, Tulving, and colleagues: Ventral prefrontal areas (R>L): convergence zone for the neural processes that enable humans to construct and maintain a reasonably organized and stable sense of personal identity

46. 46 SENSE OF SELF FOLLOWING ACQUIRED BRAIN INJURY Perplexity Unawareness or denial: Retention of preinjury self-concept Fragmentation “I am a victim” (passivity; depression) “I refuse to be a victim” (anger; aggression) “I’ve changed; I’ve got my work cut out for me” (resolve)

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49. 49 “IDENTITY MAPPING” Identification of goals Identification of image, hero, metaphor Organization of identity description [Creation of “identity map”] Supported practice Modification of others’ support behavior Possibly meaningful project

50. 50 Identity Mapping: Cautions Professional competence Emotional fragility Professional imposition Cognitive prerequisites Meaningful language

51. 51 Identity Mapping: Cautions Dangerous metaphors Negative use (e.g., “nagging”) Getting stuck; flexibility Heroes and victims Time post injury

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53. 53 IDENTITY CONSTRUCTION Helping individuals with disability construct a sense of personal identity that is: Satisfying/compelling Organized Adequately realistic AND that includes the hard strategic effort needed to be successful with a disability

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57. 57 Project Approach Meaningful goal; product Deep processing Planning and organizing Meaningful context for practice Integration of activity over time Integration of several contexts Expert role Helper/producer role

58. 58 Project Approach:Rationale Organizational impairment Superior involuntary learning Weak elaborative encoding Need for situated learning Need for errorless learning Need for routine learning

59. 59 Project ApproachRationale (cont’d) Internalization of mediated interaction Egocentrism Unawareness Intrinsic motivation Oppositionality Sense of self Self-esteem

60. 60 FAQ: CONTEXT-SENSITIVE REHABILITATION Q1: IF TX IS CONTEXTUALIZED, WILL TRANSFER NOT BE NARROW?? A1: Possibly. But a CONSTRUCTIVE dilemma is associated with C-SR and transfer: 1. With C-SR, either reasonable transfer occurs (with or without special effort) or it doesn’t in individual cases 2. If it does, great 3. If it doesn’t, at least the person has acquired useful knowledge or skill in some relevant context 4. Therefore, there is a positive outcome in either case A2: Compare: Normal child development

61. 61 FAQ (cont’d) Q2: ISN’T IT IMPOSSIBLE TO TRAIN A PERSON IN EVERY CONCEIVABLE CONTEXT?? A1: Correct; that is obviously impossible. However, see answer to Q1. A2: Professionals delivering C-SR create alliances with everyday support people in a variety of settings to ensure training and support are as widely distributed as possible

62. 62 FAQ (cont’d) Q3: IS IT NOT EXPENSIVE AND INEFFICIENT TO DELIVER SERVICES IN MULTIPLE CONTEXTS?? A1: Yes! But “context-sensitive” services can be delivered in a clinic and/or via occasional consultation and/or via apprenticeship relationships with local support staff. The point is to somehow organize the everyday routines of the person with disability and the intervention and supports provided by everyday people. There are multiple ways to do this. A2: NYS DOH Medicaid Waiver Program: Apprenticeship Program

63. 63 FAQ (cont’d) Q4: WON’T CONTEXT SUPPORTS CREATE ONGOING DEPENDENCE AND HELPLESSNESS?? A1: No, not if supports are well-conceived and reduced systematically A2: How to help without creating helplessness: The “Goldilocks’ Accordion” Theory of Support: - Not too much; not too little; just right - adjusted in an ongoing way to coincide with growing competence and with stressors, such as transitions, new responsibilities, increasing demands, etc

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65. 65 FAQ (cont’d) Q5: ISN’T C-SR HARD TO STUDY?? A1: Yes. But it is unscientific and unethical to use an intervention simply because that intervention is easy to study. “Tails Must Not Wag Dogs!!” A2: A variety of research designs are possible A3: Designs MUST include: (1) real-world measures of functioning, (2) long-term interventions, (3) attention to context, (4) engagement of individual and everyday people, (5)

66. 66 FAQ (cont’d) Q6: IS IT SCIENTIFIC TO SUPPORT OR REJECT AN INTERVENTION USING EVIDENCE DERIVED FROM STUDIES OF OTHER POPULATIONS?? A1: In selected cases, yes. Cross-population inferences are valid if: 1. The two populations are nominally different, but functionally and pathologically identical 2. The two populations are genuinely different, but the same with respect to all considerations relevant to the intervention 3. An intervention theme emerges across many (all) studied populations (e.g., sharply limited transfer)

67. 67 FAQ (cont’d) Q7: DOESN’T THE SUCCESS OF COMPUTERIZED TRAINING PROGRAMS LIKE “FAST FORWORD” LEND SUPPORT TO COGNITIVE TRAINING EXERCISES? A1: No; the goal of the program is acquisition of specific domains of linguistic knowledge (phonology, semantics). There is a fundamental difference between (1) teaching specific content skills and knowledge and (2) training purportedly content-less cognitive processes

68. 68 FAQ (cont’d) Q8: DOES C-SR INTERVENTION REQUIRE A CHANGE IN ASSESSMENT PRACTICES? A1: Perhaps. C-SR requires at least systematic exploration of context facilitators and stressors, and hypothesis-testing exploration of potential context-relative supports and teaching/interaction styles.

69. 69 FAQ (cont’d) Q9: IS C-SR APPLICABLE TO INPATIENT REHABILITATION?? A1: Yes, in two ways: 1. Inpatient staff should focus on post-discharge settings and activities with the goal of developing effective supports and well trained support individuals in those settings 2. Meaningful activities and projects can be included as an essential component of inpatient rehabilitation, from the perspective of cognition, communication, education, vocation, and executive self-regulation

70. 70 FAQ (cont’d) Q10: DON’T THE MANY DOUBLE DISSOCIATIONS IDENTIFIED BY COGNITIVE NEURO-SCIENTISTS SUPPORT PROCESS-SPECIFIC INTERVENTION?? A1: No. Analogy: 1. Cognitive neuro-linguists have identified many double dissociations within language 2. Nevertheless, it is possible to embrace an integrated, functional theory of language 3. The best supported theory of language intervention is “interactionist”: 3a. Interaction among components of language 3b. Interaction between the language learner and the social context of communication