Collaborative Therapeutic Neuropsychological Assessment

Tad T. Gorske, Ph.D.Assistant Professor, Division of Psychology and NeuropsychologyDepartment of Physical Medicine and RehabilitationUniversity of Pittsburgh School of Medicine

CTNA: What is it?

• A method for giving feedback from neuropsychological test results that is based on client-centered principles (Gorske & Smith, 2009);

• Roots in Dr. Stephen Finn’s Therapeutic Assessment and Dr. Connie Fischer’s Individualized Assessment;

• Framework based on Motivational Interviewing Principles for giving information, advice, and feedback.

How did CTNA come about?

• Gorske’s anecdotal observations with mentally ill substance abusers;

• Steven Smith’s experiences conducting neuropsychological assessments and feedback with adolescents and their families;

• Feedback and guidance from mentors and colleagues;

• Formal studies: NIDA - DA017273-01, Smith’s NAN grant award;

• Book publication in 2009.

CTNA Basic Principles and Methods

• Initial Interview: Collaborative information gathering;

• Testing Session (Standard Protocols);• CTNA Feedback Session

– Set agenda, introduce feedback report;– Develop Life Implication Questions;– Determine Personal Skill Profile;– Provide individual test results (elicit – provide –

elicit);– Summarization and bridge to future goals and plans.

Essential Interpersonal Skills

• The clinician is continually striving to:– Maintain a collaborative stance, even in the face

of discrepant or challenging information;– Using essential client centered-directive

interpersonal skills based on Motivational Interviewing:

• Expressing empathy;• Using OARS (open ended questions; affirmations

reflections; summaries);• Rolling with resistance;• Striving to dance instead of wrestle with your

patient(s).

Contemporary Developments in Neuropsychological Test Feedback

• Feedback in cases of poor effort (Carone, Iverson, and Bush, 2010).

• “Feedback that Sticks: The Art of Effectively Communicating Neuropsychological Assessment Results” (Postal & Armstrong, 2013).

• Feedback to older adults (Pachana, Squelch, and Paton, 2010).

• Motivational Interviewing in Neuropsychology in the rehabilitation process (Suarez, 2010).

• Role of CTNA approaches in situations where intervention is required for patients with deteriorating decision making processes (Lucas, 2010).

Outcome Studies

• Tharinger and Pilgrim (2012) investigated the effects of receiving neuropsychological assessment findings in the form of therapeutic “fables” on clinical outcomes with children and their families.

• Longley, Tate, and Brown (2012) investigated the psychological benefit of neuropsychological test feedback to patients with multiple sclerosis while looking at the type of patients who benefitted most from feedback.

Why do we need CTNA?

• Create a model/standard for the field;

• Enhance patient satisfaction;

• Enhance referral source satisfaction;

• Enhance the role of neuropsychology in treatment/rehabilitation process (ie. We don’t just look at a bunch of numbers).

What sets us apart?

Feedback Process

Data

Teaching

What sets us apart?

Feedback Process

DataTeachingPsychometricsPersonalityBrain-BehaviorRelationshipsFamily IssuesPsychotherapy ProcessMedical KnowledgeBio-Psycho-Social

Lessons from the Clinic

• Have a plan but be flexible;

• Have a construct for your interpretation but be prepared to abandon it;

• Be ready for anything;

• Being person centered does not mean you don’t present reality;

• Be prepared to go in an entirely different direction;

• Don’t be afraid to be a therapist within reasonable limits;

• Don’t rigidly follow the CTNA feedback process;

• Don’t be afraid to say, “I don’t know.”

Future Research: Some friendly suggestions

• Ask, what treatment, by whom, is most effective for this individual with that specific problem, and under which set of circumstances?” (Paul, 1967).

– Patients with a reasonable degree of insight or a family member who can benefit from the information.

– Education/Re-Education about the neurological recovery process (ie. the patient/family member who feels that recovery is “finished”).

– When there is a strong emotional component to a patients’ clinical presentation.

• Balancing standard versus individualized goals/treatment outcomes.

• More qualitative studies.

Case Samples

• Brain Injury

• The Case of Amy Part 2

Selected References

• Carone, D.A., Iverson, G.L., & Bush, S.S. (2010). A model to approaching and providing feedback to patients regarding invalid test performance in clinical neuropsychological evaluations. The Clinical Neuropsychologist, 24(5), 759 – 778.

• Finn, S.E. (2007). In Our Clients’ Shoes: Theory and Techniques of Therapeutic Assessment. Lawrence Erlbaum Associates, Mahwah New Jersey.

• Finn, S.E., Fischer, C.T., & Handler, L (Eds.). (2012). Collaborative/Therapeutic Assessment: A Casebook and Guide. John Wiley and Sons, Inc., Hoboken, New Jersey.

• Fischer, C. T. (1970). The testee as co-evaluator. Journal of Counseling Psychology, 17(1), 70-76.

• Fischer, C. T. (1994). Individualizing Psychological Assessment (2nd ed.): Lawrence Erlbaum Associates.

• Gass, C. S., & Brown, M. C. (1992). Neuropsychological test feedback to patients with brain dysfunction. Psychological Assessment, 4(3), 272-277.

• Gorske, T. (2008). Therapeutic neuropsychological assessment: A humanistic model and case example. Journal of Humanistic Psychology, 48(3), 320 – 339.

• Gorske, T.T. & Smith, S.R. (2009). Collaborative Therapeutic Neuropsychological Assessment. Springer Science + Business Media, LLC.

• Longley, W.A., Tate, R., & Brown, R. (2012). A protocol for measuring the direct psychological benefit of neuropsychological assessment with feedback in Multiple Sclerosis. Brain Impairment, 13(2), 238 – 255.

• Longley, W.A., Tate, R., Brown, R., & Contini, E. (2013). Neuropsychological Assessment with Feedback Tends to Reduce Distress and Improve Social Confidence in Patients with Multiple Sclerosis: Preliminary Results from a Randomised Controlled Trial. Abstract submitted to Progress in MS Research Conference, November 14 – 15th, Sydney Australia.

• Miller, W.R., & Rollnick, S. (1991/2002). Motivational Interviewing: Preparing people to change. New York: Guilford Press.

• Pachana, N.A., Squelch, N.S., and Paton, H. (2010). The importance of feedback and communication strategies with older adults: therapeutic and ethical considerations. In Casebook of Clinical Geropsychology: International Perspective on Practice. Pachana, N., Laidlaw, K., and Knight, B. (Eds). Oxford University Press Inc. New York.

• Postal, K., & Armstrong, K. (2013). Feedback that Sticks: The Art of Effectively Communicating Neuropsychological Assessment Results. Oxford University Press. New York, New York.

• Suarez, M. (2010). Application of Motivational Interviewing to Neuropsychology Practice: A New Frontier for Evaluation and Rehabilitation. In The Little Black Book of Neuropsychology, Schoenberg, M.R. and Scot, J.G. (Eds.). Springer Science+ Business Media, LLC, New York, NY.

• Tharinger, D. J., Finn, S. E., Wilkinson, A. D., DeHay, T., Parton, V., Bailey, E., et al.(2008). Providing psychological assessment feedback to children through individualized fables. Professional Psychology: Research and Practice, 39, 610–618.

• Tharinger, D.J., & Pilgrim, S. (2012). Parent and child experiences of neuropsychological assessment as a function of child feedback by individualized fable. Child Neuropsychology, 18(3), 228 – 241.

Tad T. Gorske, Ph.D.gorskett@upmc.edu