Back to the Future: ContextSensitive Rehabilitation Following Brain Injury Tim Feeney, Ph.D. Project

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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_at_scssconsulting
.com
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Grandma Masses Rules for Success The smart
guys are the guys who learn from the other guys.
Dont get all caught up in one thing everyone
believes their thing is the best thing and
theyre usually wrong. So, shut-up and listen
and learn and change. In order to be
successful youve got to be eclectic.
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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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• Our Tasks
• Me
• Present a framework for supporting individuals
• with a variety of needs to regulate themselves
• and their learning to the greatest extent
  possible
• while being respectful of your knowledge
• and expertise in this area.
• You
• Listen
• Ask lots of questions
• Stay awake
• Make plans

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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.
  Its about people, not programs!

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Successful intervention is about establishing
a respectful relationship with someone
whos doing his or her best to tick you off
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Poodle
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Sow your seed in the morning, and in the evening
let not your hands be idle, for you do not know
which will succeed, whether this or that or
whether both will do equally well. -Ecclesiastes
116
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Dont fall victim to the tyranny of the
clock (creating routines that are logically
sequenced, not chronologically sequenced)
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You can make people do things that they just
dont want to do but the price for doing so will
be high
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An impulse is not a choice
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Functional Conceptions of Choice Free
choice Fixed choice Forced
choice Feeling the natural and logical
results of actions in the environment
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Understand the Negotiables and Non-negotiables
(most stuff is negotiable)
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The glass aint half empty, its half full!
and You can teach 1/2 empty people to become
1/2 full people THE FOCUS OF SUCCESSFUL
REHABILITATION IS ON STRENGTHS NOT IMPAIRMENTS
OR DEFICITS
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A coach gets guys to do the things they dont
want to do so they can become the players that
they want to be. - Walt Harris Were all
coaches
A good coach Alters his/her coaching to
reflect the needs of the player and
conditions of the context. Never tries to play
the game him or herself.
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Lev Vygotsky

• 1896 1934
• Student of and lecturer in literature, history,
  law, philosophy, psychology, educational
  psychology
• Author gt180 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

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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)

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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

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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

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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

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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

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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.

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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

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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

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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

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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)

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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

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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

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TWO FUNDAMENTALLY OPPOSING CONCEPTIONS OF HUMAN
REALITY
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PERSON
Motor SKills
Cognition
Language
Emotion
Volition
Behavior
Human beings are a collection of relatively
independent structures, processes, and
systems Old Rehab
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Johns Cognition
Memory
Organization
Reasoning
EF
Attention
Perception
Sequence Categorize Associate Analyze Synthesize
Arousal Select Direct/ Filter Maintain Divide
Shift
Encode/Store/Retrieve Episodic/Semantic Explicit/I
mplicit Declarative/Procedural Involuntary/Strateg
ic Working Memory/ Knowledge
Base Remote/Recent Pro/retrospective Iconic, ST,
LT
Inductive Deductive Analogical Divergent Convergen
t

• Goals for John John will
• Increase duration of maintained attention
• Increase prospective memory from 3 to 5 minutes
• Increase category naming from 3 to 5 members per
  category

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Johns Language
Phonology
Morphology
Syntax
Semantics
Pragmatics
Receptive vs. Expressive Phrase Structure
Rules Etc.
Receptive vs. Expressive Lexicon Semantic
Relations Discourse Structures
Receptive vs. Expressive Speech-act
Competence Conversational Competence Socio-ling
uistic Competence

• Goals for John John will
• Decrease mean naming latencies from 3 to 2
  seconds
• Include 5 basic story grammar elements in
  retellings
• Use politeness markers in greeting people 90

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Johns Behavior
John is the totality of his behaviors and the
systematic relationships among them
John
b1 b3 b12 b4 b1 b7 b62 b17 b17 b17 b4 b6 b9 b17
b12 b3 b8 b8 b5 b6 b17

• Goals for John John will
• Increase frequency of b3 and b12
• Decrease frequency of b17

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Alternative Understanding of Human Beings
Sarah
Pursuing personally meaningful goals
While participating in culturally valued
activities
In social, cultural, and historical contexts
Mediated as necessary by individuals with
greater expertise in that domain
Using cultural tools, such as language, category
schemes, mathematics, organizational supports,
domain-specific strategies
The future of rehab
In the presence of varied context facilitators
and barriers
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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.

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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

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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

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• 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.

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• Therefore
• All assessment and intervention must be done in a
  contextual and collaborative manner

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The Future of Assessment Contextualized
Collaborative Hypothesis-Testing
Whats the problem? (Using the two strangers in
the doorway rule)
Hypothesis Formulation (Why is s/he doing this?)
Hypothesis Selection (Begin with easiest to test
or most obvious)
Hypothesis Testing (Protocol for
experimentation Plan A - Plan B - Plan C Testing
time line)
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• Assessment informs intervention, informs
  assessment, informs intervention, informs
  assessment, informs intervention, informs
  assessment, informs intervention, informs
  assessment, informs intervention, informs
  assessment

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• Reconstructing a sense of self is the core of all
  rehabilitation efforts

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THATS WHAT I AM! THATS WHO I AM! RIGHT OR
WRONG, I CANT CHANGE THAT CARLITO (AL PACINO),
CARLITOS WAY
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Doberman
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Sense of Self Neuropsychology

• Stuss, Tulving, and colleagues
• Ventral prefrontal areas (RgtL) convergence zone
  for the neural processes that enable humans to
  construct and maintain a reasonably organized and
  stable sense of personal identity

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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)
• Ive changed Ive got my work cut out for me
  (resolve)

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Reconstructing/Constructing Identity
An Identity Map
FEELINGS
How does this person feel?
FACTS
APPEARANCE
What has this person done?
What does this person look like?
POSITIVE IDENTITY METAPHOR
GOALS
PROCEDURES
What will I need to do?
What am I trying to accomplish?
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Goal
Plan
Predict
Do
Review
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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

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Identity Mapping Cautions

• Professional competence
• Emotional fragility
• Professional imposition
• Cognitive prerequisites
• Meaningful language

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Identity Mapping Cautions

• Dangerous metaphors
• Negative use (e.g., nagging)
• Getting stuck flexibility
• Heroes and victims
• Time post injury

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The self is not something ready made but
something in continuous formation through choice
of action. - John Dewey
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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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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

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Project ApproachRationale

• Organizational impairment
• Superior involuntary learning
• Weak elaborative encoding
• Need for situated learning
• Need for errorless learning
• Need for routine learning

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Project ApproachRationale (contd)

• Internalization of mediated interaction
• Egocentrism
• Unawareness
• Intrinsic motivation
• Oppositionality
• Sense of self
• Self-esteem

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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 doesnt
  in individual cases
• 2. If it does, great
• 3. If it doesnt, 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

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FAQ (contd)

• Q2 ISNT 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

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FAQ (contd)

• 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

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FAQ (contd)

• Q4 WONT 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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Cinderella playing her accordion
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FAQ (contd)

• Q5 ISNT 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)

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FAQ (contd)

• 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)

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FAQ (contd)

• Q7 DOESNT 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

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FAQ (contd)

• 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.

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FAQ (contd)

• 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

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FAQ (contd)

• Q10 DONT 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