Emotional Rehabilitation: Learning about and Living with the Emotions of a New Brain

1. Emotional Rehabilitation: Learning about and Living with the Emotions of a New Brain Tedd Judd, Phd, ABPP-CNClinical Neuropsychologist, Bellingham, WA,Teddjudd@gmail.ComPresented At:Washington State 2010 Traumatic Brain Injury ConferenceBeyond Survival: Thriving After A Traumatic Brain InjuryMay 1, 2010, Seatac, WA

2. Outline • Introduction • The Whole Person after TBI • The Content Of Emotional Rehabilitation • The Techniques Of Emotional Rehabilitation • The Social Context of Emotional Rehabilitation

3. Introduction: • Whatis Emotional Rehabilitation? • How is Emotional Rehabilitation different from psychotherapy? • Who is Emotional Rehabilitation for? • Whatchallenges does Emotional Rehabilitation address? • Why is Emotional Rehabilitation needed? • Whodoes Emotional Rehabilitation?

4. About “Neuropsychotherapy” • First use: Ellis, 1989 (Neuropsychotherapy. In D. W. Ellis & A.-L. Christensen (Eds.), Neuropsychological treatment after brain injury (pp. 241-269). Boston: KluwerAcademic Publishing.) • First book: Judd, 1999 (Neuropsychotherapy and community integration: Brain illness, emotions, and behavior. New York: Springer/Kluwer Academic/Plenum Publishers) • Second book, second sense: Grawe, 2004 (Neuropsychotherapy: How the neurosciences inform effective psychotherapy, English translation 2007, Mahwah, NJ: Lawrence Erlbaum Assoc.)

5. Neuropsychotherapy is the use of neuropsychological knowledge in the psychotherapy or counseling and related interventions for people with brain disabilities and those close to them. It is specialized in content, technique, and social context to address the emotional and behavioral issues of brain disability. What is Neuropsychotherapy?(Ellis/Judd)

6. What Challenges Does Emotional Rehabilitation Address? • Organic changes in emotional regulation • Executive dysfunctions • Adjustment to brain dysfunction • Social adjustment to disability

7. Why Is Emotional Rehabilitation Needed? • Large population with brain disabilities • Emotional/social/behavioral challenges tend to be the most disabling • Few systematic interventions available • Relatively few neuropsychologists available Antonak, et. al, 1993; Livingston & Brooks, 1988; Morton & Wehman, 1995

8. Who does Emotional Rehabilitation? Skills needed to do effective Emotional Rehabilitation: • Therapy skills—warmth, empathy, openness, reliability, etc. • Teaching skills • Knowledge of: • Emotional Rehabilitation • Brain illness behavioral and emotional changes • Rehabilitation • Community resources

9. Who does Emotional Rehabilitation? Skills NOT needed to do effective Emotional Rehabilitation: • Knowledge of how to do neuropsychological evaluations • Extensive knowledge of neurology and neuroanatomy • Research skills • Forensic skills

10. Who does Emotional Rehabilitation? Candidates for doing Emotional Rehabilitation (in at least a limited sense): • Psychotherapists • Rehabilitation team members (Social Workers, OT, PT, Speech, Nursing, Aides) • Community-Based Rehabilitation Volunteers • Teachers • Family members • People with brain injuries (self-help)

11. The Whole Person after TBI (didactic model)

12. The Whole Person after TBIPre-disability Personality • Full range of personalities and psychopathologies • Factors predisposing to brain injury/illness are overrepresented: • Substance abuse • Risk taking • Medical non-adherence

13. The Whole Person after TBIReactions to injury/illness: • Grief • Denial • Depression • Anxiety • Posttraumatic Stress Disorder • Frustration • Anger • Personal Reformation

14. The Whole Person after TBIReactions to Disability: • Grief • Denial • Depression • Anxiety • Perplexity Lezak, 1978 • Frustration • Anger • Embarrassment

15. The Whole Person after TBIOrganic Emotional Changes:

16. The Whole Person after TBIOrganic Emotional Changes: • Organically induced major psychiatric disorders • Depression • Mania • Psychosis • Obsessive-compulsive disorder

17. Executive Dysfunctions:Behavior Regulation

18. Executive Dysfunctions: Behavioral Drive

19. The Content of Emotional Rehabilitation Fundamental Principles: • The Continuum of Responsibility • Emotional Rehabilitation • Self-Awareness • The New Self

20. The Content of Emotional RehabilitationThe Continuum of ResponsibilityAcute Condition Caregiver’s share Share of responsibility for the behavior of the person with brain disability Share of the person with brain disability time onset

21. The Content of Emotional RehabilitationThe Continuum of Responsibility Executive Function Rehabilitation Schema • Accommodate Externally (schedules, cues, reminders, written procedures, restrictions) • Build Awareness • Retrain Self-regulation (problem-solving schemata, social skills, alarms, PDAs) • Generalize Self-regulation train in other settings (home, school, work, community) • Fade External Compensations

22. The Content of Emotional RehabilitationEmotional Rehabilitation • Accessible metaphor • Demystify process • Reduce guilt and blame • Define roles • Skill-learning model

23. You have a new brain. It doesn’t handle emotions the way it used to. You need to learn how it functions now and how to get along in the world with the way it functions now.

24. Learning how to live with your new brain takes time and practice. Each time you have an emotional problem it’s a chance to learn how your new brain is working. We’re here to help.

25. Emotional rehabilitation helps bridge the gap between: • Behavior management and psychotherapy • Psychotherapy and cognitive rehabilitation • The cognitive and the emotional sides of executive functions

26. Emotional rehabilitation needs to enlist the aid of the social context of the person with a brain disability so as to: • Carry out training in the appropriate target social/emotional contexts • Make those contexts more hospitable to the person with the disability • Support and empower family and others in dealing with the changes in their loved one

27. The Content of Emotional RehabilitationImproving Self-Awareness Use Evaluation to Guide Intervention Overestimation of Disability Due to: • Depression • Catastrophizing • Lack of knowledge of recovery Underestimation of Disability Due to: • Anosognosia • Lack of experience • Impaired reasoning and generalization • Denial

28. The Content of Emotional RehabilitationImproving Self-Awareness Distinguish Knowledge from Action Crosson, et al, 1989 • Intellectual awareness(I can repeat what I’ve been told about my disabilities, but don’t quite believe it) • Emergent awareness(I can recognize my errors in retrospect or when happening) • Anticipatory awareness (I can plan to use compensations to avoid problems)

29. The Content of Emotional RehabilitationImproving Self-Awareness • Supportive confrontation • Avoid struggle • Take perspective of person with brain disability • Work with who they trust

30. The Content of Emotional RehabilitationImproving Self-Awareness Feedback Tools • Mirrors • Photos • Audio tapes • Videotapes • Work samples • Writing samples • Arts and crafts products

31. The Content of Emotional RehabilitationImproving Self-Awareness • Testing feedback • Medical Records • Self-Monitoring Exercises • Games • Educational Materials • Group Therapy • Supported Failure • Real-Life Experiences • Don’t say “I told you so”

32. The Content of Emotional RehabilitationThe New Self • Not necessarily better or worse, just different • Discover who the new self is • Rethink abilities • Rethink goals • Rethink relationships

33. The Techniques of Emotional RehabilitationCuing technologies: Uses • Emotional control • Procedures and routines • Stressful events • Reminders • Behavior Flash Cards • Explanations to others • Incidental functions

34. The Techniques of Emotional RehabilitationCuing technologies: Emotional Control Example MY ANXIETY SIGNS • Tapping fingers, foot • Fast breathing, heart • Sweating • Tense muscles • Fussing and fidgeting RELAXING BREAK • Alone, quiet, dark • Close eyes • Breathe slowly, deeply • Relax muscles • Let go of worried thoughts • Picture beach

35. The Techniques of Emotional RehabilitationCuing technologies: Therapy Procedure Example ACTIVE LISTENING Quiet, alone with other person No TV, radio, music Not doing anything else Face other person, eye contact Don't interrupt or react (bite tongue) Repeat other person's feelings

36. The Techniques of Emotional RehabilitationCuing technologies: Stressful Event Example PUBLIC SPEAKING Use written outline Practice alone and with friend Have friend in audience Short relaxation before going on "I can do it! I know my stuff. They are friendly and want to hear me." Find friend in audience Speak to back of room Slowly and clearly Smile!

37. The Techniques of Emotional RehabilitationCuing technologies: behavior Flash Cards Stop and Think

38. The Techniques of Emotional RehabilitationCuing technologies: Introduction Card Example To my friends: My stroke makes me cry and laugh at times when I am not feeling particularly upset or amused. Please don't be frightened by it, and remember that I'm still the same me underneath that. Sometimes when I cry I will look up, or when I laugh I will rub my mouth. That helps me control it. Thanks for your understanding. Emilio

39. The Techniques of Emotional RehabilitationCuing technologies Tips on Use • Individualize • Brief, concrete, action words, imperatives • First person or trusted authority figure • Colors • Multiple copies • Retain a copy on file

40. The Techniques of Emotional RehabilitationCue Cards Tips on Use: Where to put them • Wallet • Purse • Arm of wheelchair • Mirror • Refrigerator • Steering wheel • Time Out place • Back of door • School notebook • Computer monitor • Pocket • Kitchen table

41. The Techniques of Emotional RehabilitationCuing technologies Tips on Use:(Rick Parenté) • Screen Savers • Personal Digital Assistants and Watches • Coffee mugs • T-shirts • Make them rhyme • Initial letter mnemonics • Use graphics

42. The Techniques of Emotional RehabilitationChoosing Cuing Technologies • Appropriate • Appealing • Affordable • Accessible • Acceptable

43. The Techniques of Emotional RehabilitationSelf-Introduction Letter Purposes • Improve self-awareness • Commitment to rehabilitation • Future planning • Social rehearsal • Consolidate the experience • Consolidate self-image • Communicate needs

44. The Techniques of Emotional RehabilitationSelf-Introduction Letter Contents 1 • Introduction, purpose   • Story of the accident or illness • What happened? • Why did it happen? • How did you experience it? • How do you feel about it? • What you are doing about it (lawsuit, forgiveness, health changes, prayer)?

45. The Techniques of Emotional RehabilitationSelf-Introduction Letter Contents 2 • Current challenges: • Physical challenges. • Thinking difficulties. • Emotional changes. • Life changes (work, family, hobbies, recreation, social life, spiritual life)

46. The Techniques of Emotional RehabilitationSelf-Introduction Letter Contents 3 • What other people should NOT think (e.g., not crazy, stupid, or fragile). • How they can help. • How they should treat you. • What you would like them NOT to do. • Feel free to talk with you about it. • Thanks for understanding.

47. The Techniques of Emotional RehabilitationSelf-Introduction Letter Variations on Exercise Application • Coauthor the letter (therapist, family, friend) • Read the letter aloud • Paraphrase the letter • Make notes from the letter then present from notes • Practice in group therapy, with another person, on video or audiotape

48. Working with the Social NetworkFamily and Friends Roles in Emotional Rehabilitation • Informants about behavior, pre-disability personality, environment of recovery • Collaborators in treatment • Participants in support groups • Recipients of education, counseling, therapy • Support, advocacy • Interdependence—being family, motivation, the reason for doing things

49. Working with the Social NetworkFamily and FriendsTechniques of Family Education • Answering questions • Modeling • Coaching • Mentoring • Individually written materials • Printed materials • Visual aids • Socratic dialogue • Story telling • Metaphor • Support groups • Group discussion • Lectures • Videos • Teaching to teach others • Observing testing • Test results (drawings, writing samples, scores)

50. Working with the Social NetworkCircles of Support • Voluntary • Stable group of community members organized to help one person with a disability • Community based • Person with disability chooses members • Purpose is to help person with disability realize dreams • Not constrained by professional or institutional agendas and rules