Problem solving after brain injury with bancroft

A Problem Solving Approach to Cognitive Rehabilitation Karen Lindgren, Ph.D.

October 24, 2012

© 2012 Bancroft | All rights reserved

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.

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

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)

EmotionsEmotions can become flat or

amplified. Neurological rageLack of inhibitionTrouble analyzing social situations

Difficulty with facial expression or tone of voice

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)

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.

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

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.

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

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.

Executive functioning and outcomeWhy?Components of executive functioning

help us understand, adapt and respond to our environment

Promotes complex problem solving

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.

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.

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

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

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

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

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

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

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.

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.

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

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

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

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?

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

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)

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

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

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.

Our Core ValuesResponsible Empathetic Supportive Passionate Empowered Committed Trustworthy

R E S P E C T

By 2014 our distinct ability to deliver high quality individualized services in modern living, learning and working environments will exceed stakeholder expectations and secure Bancroft as the region’s elite provider of services to people with intellectual and developmental disabilities and brain injuries.

Our Vision

Our Mission