a problem solving approach to cognitive rehabilitation karen lindgren, ph.d. october 24, 2012 ©...
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A Problem Solving Approach to Cognitive Rehabilitation Karen Lindgren, Ph.D.
October 24, 2012
© 2012 Bancroft | All rights reserved
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Goals
• What is problem solving?• How is problem solving relevant to
community integration?• How do we teach problem solving
skills?
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Traumatic Brain Injury/Acquired Brain Injury
Traumatic Brain Injury (TBI): cerebral damage that occurs after birth, and is not directly related to a developmental disorder or a progressive damaging of the brain. Traumatic brain injury refers to a specific form of acquired brain injury (ABI) that is the result of a sudden trauma.
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Common Symptoms after TBIPhysical symptoms• Headaches• Fatigue• SleepCognitive symptoms• Memory Deficits • Word Finding Difficulty• Concentration• Processing speedEmotional symptoms• Irritability• Depression• Unstable or inconsistent moodBehavioral symptoms• Impulsiveness • Outbursts
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Cognitive Symptoms are complex• Multiple pathways can result in
similar symptom presentation• Lay-person language for cognitive
constructs is limited• For example, what is meant by a
“memory” problem?
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Cognitive constructs are complex- Memory example“Memory” complaints can result from:
environmental distractions/emotional interferencepoor attention/slowed processingexpressive/receptive languagepoor encodingpoor retrievalaccelerated forgettingpoor organization/comprehension of material (executive dysfunction)
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EmotionsEmotions can become flat or
amplified. Neurological rageLack of inhibitionTrouble analyzing social situations
Difficulty with facial expression or tone of voice
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Cognitive/Emotional/Physicalsymptoms interactMultiple or varying symptoms
Complex symptoms combine to result in behaviors
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Cognitive/Emotional/Physicalsymptoms interact: Overload• Common complaint in community
settings• Brought on by large crowds, lots of
noise, or information presented too quickly.Inability to process external environment (cognitive)Fatigue (physical)Rise in emotions (emotional)
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TBI and Quality of Life
Life satisfaction appears to steadily decline after an individual experiences a brain injury.
Injury severity has not been found to be significantly correlated with measures of life satisfaction.
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TBI and Quality of Life
Several variables have been shown to correlate with life satisfaction in individuals who have suffered TBIs.
Marital StatusProblem Solving Executive Functioning
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Executive Functioning
Executive dysfunction has been repeatedly seen and documented in acquired brain injury, and is reported as one of the more common difficulties facing this population.
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Executive Functioning
• Executive functioning refers to the integration of several cognitive skills people require to adapt to novel situations and pursue their life goals, which includes planning, initiation, and regulation.
• Complicated concept, involving multiple skills:• Integration of physical, emotional, and
cognitive
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Executive functioning and outcome• Executive dysfunction has been
implicated with poor social outcomes following a traumatic brain injury.
• Research in rehabilitation populations has found that poor executive functioning is strongly correlated with poor work adjustment.
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Executive functioning and outcomeWhy?Components of executive functioning
help us understand, adapt and respond to our environment
Promotes complex problem solving
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Executive functioning: Problem solvingResearch has found a significant relationship between problem-solving ability and various forms of psychological well-being.
Specifically the effectiveness of one’s problem-solving ability has been found to moderate the relationship between stress and distress.
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Executive functioning: Problem SolvingPeople who have suffered TBIs face a large variety of
significant problems in their day to day life.
The cognitive skills they use to cope with problems may have been compromised by their injury.
Poor emotional control may make it difficult for persons served to tolerate problems long enough to generate solutions.
Deficits in executive functioning may make it difficult for persons served to generate alternative solutions.
These symptoms increase the importance of social problem-solving skills for individuals who have suffered a TBI.
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Rehabilitation of problem solving skillTwo important components:
Rehabilitate Skill (Problem-Solving Skill)Address social problem solving (problem solving orientation, problem solving style)
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Rehabilitation of problem solving skillTwo important components:
Rehabilitate Skill (Problem-Solving Skill)Address social problem solving (problem solving orientation, problem solving style)
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Cognitive rehabilitation of executive dysfunction: problem solvingResources:Edmund Haskins, Ph.D. (2012) ACRM
Cognitive Rehabilitation Manual: Translating evidence based recommendations into practice
Sohlberg & Tukstra (2011) Optimizing Cognitive Rehabilitation
Nezu, Nezu & D’Zurilla (2007) Solving Life’s Problems
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Cognitive rehabilitation of executive dysfunction: problem solvingBI-ISIG (Task force of ACRM)
recommends:• Metacognitive strategy training as a
Practice Standard for rehabilitation of executive functioning after TBI
• Training in formal problem solving strategies during post-acute rehabilitation as a Practice Guideline
References: Cicerone, et al 2011, Haskins, et al, 2012
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Who is appropriate for problem solving training?• Evaluate awareness• Evaluate effectiveness of
environmental support vs. internalized strategies
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What Can We Do To Help Foster Effective Problem Solving?
• Training in Problem OrientationProblem Solving Skill• Training in Problem Definition• Training in Planning/Generation of
Alternatives• Training in Decision Making• Training in Solution Implementation • Solution Verification or Feedback
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What Can We Do To Help Foster Effective Problem Solving?
• Training in Problem OrientationProblem Solving Skill• Training in Problem Definition• Training in Planning/Generation of
Alternatives• Training in Decision Making• Training in Solution Implementation • Solution Verification or Feedback
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Problem Solving Skill
• Well researched• Varies in the number of steps• Includes Key components:
• Problem Definition (Awareness)• Planning/alternatives• Decision making• Implementing• EvaluatingFor example, the Goal-Plan-Do-Review method
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Problem Solving Skill
Teach the steps in a highly structured way
Provide maximum supportGoal for client to implement
independently
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Training in Problem Definition
• Is there a problem?• What are the signs? Mood, feedback from
others, change in circumstances
• What is the problem?• Example: don’t have money
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Training in Problem DefinitionExample: “Don’t have money”Skill deficit: misplace moneyimpulsive with spendingpoor budgeting
Interpersonal challenge: dependent on family
Vocational concern: need a job
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Training in Problem DefinitionExample: “Don’t have money”Vocational concern: need a job:
locateapplyinterview
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Training in Problem Definition
Help To:Seek all available facts about a
problemDescribe these facts in clear and
objective termsSeparating facts from assumptionsIdentify obstacles or conflicts that
make the situation a problemSet realistic goals
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How?Externalize ProblemsEncourage the person served to work on
problems outside of their own mind (take notes, work problems out on paper)
Visualize SolutionsVisualize both the implementation and
results of solutions.
SimplificationHelp persons served to help break large
problems down into their smaller components
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Slow-Down
Teach techniques that will help individuals tolerate the emotional arousal associated with working with social problems
SmilingYawning Behavioral Stress Management
Deep BreathingGuided ImageryProgressive Muscle Relaxation
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Training in Problem DefinitionUse worksheet:
Date _________________What is my goal? ____________________
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Training in Problem DefinitionUse worksheet:
Date 10/24/12What is my goal? To obtain a part
time job 10-15 hours per week
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Training in Problem DefinitionUse worksheet:
Date 10/24/12What is my goal? To reduce my
spending by 25$ per week
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Training in Problem DefinitionUse worksheet:
Date 10/24/12What is my goal? To ask my sister to
give me 25$ per week
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Training in Planning
Should be taught to expand their perceived options and to defer judgment.
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Training in Planning
• What are my options?• What are my resources?• What are my barriers?
Do I need to change my goal?
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Training in Decision Making
Maximize positive consequences and minimizes negative consequences.
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Training in Decision MakingWhich solution is best?• What is most important?• No solution is perfect• Pros and cons list
• Consider outcomes, resource utilization, ease of implementation, effects of errors
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Training in Decision Making
working askingPros independent easy to try
meet people focus on rehab
functional/careerCons fatigue
dependencycosts associated mobility concernsless rehab focus
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Training in Decision MakingUtilize a worksheet
To solve this problem, I will: ___________________________________
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Training in Decision MakingUtilize a worksheet
To solve this problem, I will:Ask my sister to help me by giving me25$ per week
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Training in Planning
How will I reach my goal?Resources/barriers: Social, environmental, financial, cognitive, psychological• Plan details: Who, when, where,
what• Anticipating barriers/problems:
What are back-up plans? Is there a safety-net?44
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Training in Planning
Evaluation of each step• Resources/barriers: Social,
environmental, financial, cognitive, psychological
• Plan details: Who, when, where, what
• Anticipating barriers/problems: What are back-up plans? Is there a safety-net?45
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Training in Planning
Use worksheet
What is my plan? _______________What do I need? _______________What are the steps?
1. ________________________ 2. ________________________
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Training in Planning
Use worksheet
What is my plan? Ask my sister for 25$ per week
What do I need? Budget, planner, bank statement
What are the steps?1. _ask to meet with sister (evening preferred)
2. present budget and problem with expenses exceeding income
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Training in Planning
Go beyond the worksheetWhat are the steps?
1. ________________________ At each step, identify resources,
challenges, safety-netSpecify support to be givenMake a “larger” plan- how does this
plan fit into the rehabilitation goal?48
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Training in PlanningGo beyond the worksheetWhat are the steps?
1. ask to meet with sister (evening preferred)
identify resources, challenges, safety-net: plan a meal or snacks? Ask staff for support? Role play? Challenges: sister busy/preoccupied
Specify support to be givenMake a “larger” plan- how does this
plan fit into the rehabilitation goal?
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Training in Solution Implementation and Verification
• Occurs at each step• Proceed as slowly as
implementation will allow• Increase mindfulness of each step
(e.g., what I am doing? How am I feeling?)
• Seek feedback• Are changes needed?
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Training in Solution Implementation and Verification
Expanded concepts of did the plan “work”:
• What worked?• What didn’t work?• How did I do? (Expand this concept)
• Teaching opportunity for meta-cognition- track barriers to effective problem solving
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Training in Solution Implementation and Verification
Worksheet:
How did I do? (utilize rating scale, not “all or nothing”)
How did I feel?What did I do well?What would I change? (internal as
well as external)
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What Can We Do To Help Foster Effective Problem Solving?
• Training in Problem OrientationProblem Solving Skill• Training in Problem Definition• Training in Planning/Generation of
Alternatives• Training in Decision Making• Training in Solution Implementation • Solution Verification or Feedback
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Walk Client through process• Implement consistently, every time• Use written work sheets• Use memorization of steps• Apply to new, real situations• Apply to therapeutic, constructed
situations• Identify client strengths and
challenges: meta-cognition54
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Implement, implement, implement• Virtually any situation is
appropriate for problem solving skill development
• Consider targeting one area at a time:• Medical• Vocational• Budgeting
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Implement, implement, implement• Target in session first
• Teach the steps• Apply to real situations with 1:1 support• Apply to modified situations with 1:1 support
• Support out of session with maximum support
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Implement, implement, implement• In community situations, fade
support, not focus• Gradual fade
• Preset for steps, potential problems• Encourage review each step • Develop strategies to address related
cognitive challenges (e.g., internal/external strategies for memory)
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For Us
As professionals, we to should attempt to utilize many of the same problem solving strategies when faced with challenging problems from persons served.
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To ensure that every person is given opportunities for lifelong learning and fulfillment.
We do this by altering perceptions, and by supporting those with intellectual and developmental challenges and acquired brain injuries in achieving their life goals as valued and respected members of our world.
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