Internship Progress in Clinical Mental Health Counseling
Ctna Australia
1. Collaborative Therapeutic
Neuropsychological Assessment
November 22, 2012 – 9:00a – 12:30p
Tad Gorske, Ph.D.
Clinical Assistant Professor
Director, Outpatient Neuropsychology
Division of Neuropsychology and Rehabilitation Psychology
University of Pittsburgh School of Medicine, Pittsburgh Pennsylvania, USA
2. “The presentation of brain facts about
specific damages is meaningless to
patients unless they can begin to
understand how the changes in their
brains are lived out in everyday
experiences and situations”
(Varela, 1991 as stated in McInerney
and Walker, 2002)
7. What is Collaborative
Neuropsychology?
• What is traditional neuropsychology?
– Typically follows a medically based/information
gathering model.
– Outsider viewing a passive “object”
– Reductionist
– Categories, diagnoses, constructs used to explain a
client.
– Focus on pathology
– Tester as detached observer
– Sense of secrecy
– Specific focus on the brain-behavior relationship
8. What is Collaborative
Neuropsychology?
– Emanates from “Third Force” Psychology
– Relational encounter
– Client as “co-evaluator”
– Open sharing of results
– Client viewed in context
– Constructs serve to understand the client holistically.
– Focus on strengths and weaknesses
– Test scores, categories, and classifications help
patients develop an understanding of their
experience, not to define it (Fischer, 1970/1994)
– Blending art and science into a “human science
neuro-psychology” (Fischer, 2003; italics mine).
9. Holistic Neuropsychology
Yehuda Ben-Yashay and Leonard
Diller
• Roots in Kurt Goldstein’s holistic views.
– A holistic theory of the organism based
Gestalt Theory
– “We have said that life confronts us in living
organisms. But as soon as we attempt to grasp them
scientifically, we must take them apart, and this taking
apart nets us a multitude of isolated facts which offer
no direct clue to that which we experience directly in
the living organism.” Kurt Goldstein, The Organism, p.
7
10. Holistic Neuropsychological
Principles
• Empower patients and families to take an active
role in the treatment process;
• Believe people with neurological disabilities are
more like people without neurological disabilities
(ie. Go beyond the brain) ;
• Convey honesty and caring in personal
interactions to form a foundation for a strong
therapeutic relationship;
• Develop practical plans for rehabilitation; explain
rehabilitation techniques in understandable
language;
11. Holistic Neuropsychological Principles
• Help patients and families understand
neurobehavioral sequelae of brain injury and
recovery;
• Recognize change is inevitable and help families
cope with change;
• Every patient is important, treat with respect;
• Remember that patients and families have
different perspectives regarding treatment
approaches.
12. Why do we need collaborative
models?
An identity crisis in
neuropsychology
(and psychology in
general)?
14. Harvard creates cyborg flesh that’s half man,
half machine
By Sebastian Anthony on August 29, 2012
21. • Neuropsychology is failing to distinguish
itself due to:
– Over-reliance on diagnosing brain behavior
relationships
– Narrow focus on psychometric approach
– Uncertainty of roles in areas such as
rehabilitation.
– Lack of translation of test results into patient
care
– Lack of assessment advocacy
(Gass and Brown, 1992; Nelson and Adams,
1997; Goldstein, S. Personal Communication)
22. Rise of Forensic
Neuropsychology
• There is a greater presence of forensic
neuropsychology topics in peer reviewed
journals and neuropsychology meeting programs
(Sweet, et al., 2002).
• Consequently there is a greater proportion of
topics related to legal proceedings and
malingering.
• Increasing emphasis on Symptom Validity
Testing.
23. Seeking a Balance
Forensic
Malingering
Patient Care
Rehabilitation
Methods
24. Possibilities
• Focus on the utility of neuropsychological
assessment
– Ensuring relevance by tailoring assessment to
treatment/rehabilitative needs and outcomes
– Focus on the needs of the client/consumer
– Closely link assessment – feedback – intervention.
– Integrate treatment planning, monitoring progress,
and outcomes
(Groth-Marnat, G. (1999)).
26. Importance of Working Alliance
• There are strong links between patient-
therapist collaboration and goal
consensus in psychotherapy outcomes
(Shick Tryon and Winograd, 2011).
• Working alliance and collaboration in
rehabilitation is viewed as important but
less well studied.
27. Working Alliance in
Rehabilitation
• A positive relationship between working
alliance and outcomes has been found.
Working alliance defined as
• (a) the agreement between client and therapist
on goals,
• (b) their agreement on how to achieve these
goals (common work on tasks) and
• (c) the development of a personal bond between
client and therapist. (Shönberger et al. 2006).
28. Working Alliance in
Rehabilitation
• A good working alliance can be created with
both clients who experience many problems and
clients who experience comparatively few
problems, as long as they are aware of the
consequences of their brain injury.
• Therapist’s experience of a good working
alliance was influenced by the client’s
experience of success. (Shönberger, et al.,
2006).
29. Working Alliance in
Rehabilitation
• Clients’ and therapists’ overall success ratings at
program end were related to their emotional
bond at program end.
• Early-therapy compliance and the average
amount of compliance are predictive of
subjective improvement. (Shönberger, et al.,
2006).
30. Working Alliance: Some
evidence
• Bieman-Copelan and Dywan (2000). Brain and Cognition, 44, 1-5.
• Behavioral therapy in context of a
supportive/collaborative therapeutic alliance for
anosognosia.
• Collaborative negotiation and trusting
therapeutic relationship for behavioral goal
setting.
• Results indicated a significant reduction in
problematic behaviors despite no increase in
insight or awareness of injury.
31. Pegg et al., 2005
• Evaluated the role of interpersonal relationship factors
on patient outcomes with 28 patients with moderate to
sever TBI admitted to an inpatient unit at a VAMC.
• Personalized information-provision intervention.
• Results:
– Patients exerted greater effort in therapies
– Patients increased satisfaction with rehabilitation
treatment.
– Significantly more improvement in cognitive FIM
scores.
32. Interdisciplinary team working
alliance (Evans, et al., 2008).
• Importance of therapeutic alliance in post acute brain
injury rehabilitation (PABIR).
• Sherer et al., 2007 - poor working alliance was
associated with high levels of family discord, greater
discrepancy between family and clinician ratings of client
functioning, and poor client participation in therapies.
• Treatment team members attended in-services that
emphasized motivational interviewing philosophy and
techniques, building rapport, reflective listening, dealing
with patient resistance, making behavioral changes,
stages of change, dealing with challenging clients, and
assessment and treatment issues with depressed and/or
suicidal patients (pg. 332).
33. Interdisciplinary team working
alliance (Evans, et al., 2008).
• Treatment group had higher functional status and were
more productive and had less dropouts, although the
differences were not statistically significant.
34. Lane-Brown and Tate, 2010.
• Single case study that evaluated an
intervention utilizing external
compensation and motivational
interviewing to initiate and sustain goal
directed activity with a TBI patient.
• Demonstrated that treating specific and
operationally defined goals through
external compensation and motivational
interviewing successfully decreased
apathy.
35. Enhancing our patient care skills can create
a ripple effect with consumers, providers,
and public perception
36. Neuropsychology has the potential to be a lead
discipline in understanding human beings from a
holistic mind/body perspective
38. Comprehensive Recovery Challenges
Rehabilitation
• Physical Therapy • Knowledge of deficits
• Occupational Therapy • Adapting to deficits
• Speech Therapy • Grieving and Coping
(Denial, anger,
• Medical Management bargaining, depression,
• Psychological/Neuropsyc acceptance).
hological • Learning and re-learning
• Emotional/Psychiatric • Integrating knowledge
Management as into the self
appropriate • Re-discovering meaning
• Family Support and a sense of purpose
• Case Management
39. Existential Issues in
Neuropsychological Conditions
• Awareness of change;
• Emotions;
• Struggle of acceptance;
• Struggle to make sense and find meaning;
• Struggle to reclaim/find a sense of self
40. “…But be that as it may, those of us who did make it
have an obligation to build again. To teach to others what
we know, and to try with what's left of our lives to find a
goodness and a meaning to this life.”
(Quote from the movie “Platoon”, 1986)
41. How traditional neuropsychological
assessment addresses these challenges
1. Knowledge of deficits 1. Provides information on
2. Adapting to deficits cognitive functioning.
2. Presents potential
3. Grieving and Coping ameliorative strategies.
(Denial, anger,
3. Does not directly
bargaining, depression, address.
acceptance).
4. Cognitive rehabilitation
4. Learning and re-learning and remediation.
5. Integrating knowledge 5. Presents one aspect of
into the self the person (cognition).
6. Re-discovering meaning 6. Does not directly
address.
42. How collaborative neuropsychological
assessment addresses these challenges
1. Knowledge of deficits 1. Provides information on cognitive
functioning and seeks individual
2. Adapting to deficits application.
2. Presents potential ameliorative
3. Grieving and Coping strategies and seeks out the
(Denial, anger, individuals own resources for
change.
bargaining, depression, 3. Address a person’s experience
acceptance). and reactions to information
provided; balances education and
4. Learning and re-learning the I-Thou interaction.
5. Integrating knowledge 4. Cognitive rehabilitation and
remediation and works to
into the self motivate internalization.
6. Re-discovering meaning 5. Presents one aspect of the
person (cognition) and considers
it within the context of the whole
person.
6. Looks toward the future and what
46. Luria’s Neuropsychological
Investigation (LNI)
• Loose conceptual basis, not an actual precursor.
• A qualitative and flexible interviewing method for diagnosing brain
lesions.
• The value of LNI:
– Provides a thorough individualized neuropsychological assessment
in which the cognitive functions and psychological responses of the
individual can be ascertained.
– Provides the opportunity to identify strengths and deficits.
– LNI principles can be implemented throughout the rehabilitation
process which include
• Hypothesis testing
• A collaborative working relationship with the patient’
• Feedback to enhance awareness.
Christensen, Anne-Lise (1975); Christensen, A.L. and
Caetano, C. (1999)
47. Neuropsychological Test
Feedback Research
• No empirical studies but some recommendations
• Neuropsychological test feedback provides
useful information about cognitive strengths and
weaknesses,
• Clients find the information useful,
• Results apply to clients everyday life and
concerns
• Facilitates the development of useful and
applicable interventions
(Gass & Brown, 1992; Pope, 1992; Crosson, 2000; Bennet-Levy et al.,
1994).
48. Recommended method for
providing information (Gass & Brown, 1992)
1. Review the purpose of testing in plain,
simple language
2. Tests are “behavior samples” of
functional domains
3. Explain in terms of behavioral functioning
4. Summarize strengths and weaknesses
5. Address diagnostic issues
6. Make recommendations
49. Limited empirical evidence
• Case Studies (Malla et al., 1997; Rose,
1998)
• Conceptual articles (Allen et al., 1986)
• Provision of medical information which
included neuropsychological tests (Pegg,
Auerbach, Seel, Buenaver, Kiesler, and
Plybon, 2005).
52. Collaborative Individualized
Assessment (Fischer, 1994)
• Based on phenomenological psychology.
• Assessor works collaboratively to
understand a client’s unique worldview
• Tests, scores, categories, and
classifications serve to develop a
hermeneutic understanding of the person.
• Reflects a “human-science psychology”.
53. Therapeutic Assessment (Finn,
1992; 1997)
• Psychological assessment as a therapeutic
intervention,
• Tester is an active participant
• Rooted in humanistic psychology
• Influenced by collaborative assessment
55. Motivational Interviewing Principles
(Miller and Rollnick, 2002)
• A method of dialogue designed to
enhance client’s intrinsic motivation to
make changes in behavior.
• Heavily rooted in Roger’s Client Centered
Therapy.
• Originally developed with alcoholics but
expanded to drug addiction and health
behavior change.
56. • Strongly based on the Rogerian approach
• Non-directive/directive intervention
• Empathy and unconditional regard are the
crux of MI
• Exploring and resolving ambivalence
about making changes is a key goal
• Works to develop a discrepancy between
real and ideal self (values and behavior;
who a client is versus who they want to
be).
• Associated with the stages of change.
57. MI Method for Giving Feedback
• Elicit – Provide – Elicit
• Using OARS
– Open ended questions
– Affirmations
– Reflections
– Summarizations
• Goal is to help clients work through and
resolve ambivalence in order to move
through the stages of change.
58. The NAFI
• Origins
– Neuropsychological Testing
– Personal Feedback Report (Project MATCH,
Dual Diagnosis Adherence Strategies, WPIC)
– Anecdotal Observations
• Pilot Study
• Development of the Feedback Report
• NIDA funded study 2004 – 2008.
60. Pilot Study Results
Adherence Rates
p = .042, cohen's d = .78 (.02-1.55)
NAFI (n = 14); TAU (n = 14)
100
90
80 71%
70
60
50 48%
40
30
20
10
0
S1
NAFI
TAU
61. Pilot Study Results: D&A Use
NAFI = 6; TAU = 5
30 Day Alcohol Use
10
9
8
7 7.13
6
5.46 NAFI
5
TAU
4
3.4
3
2
1
0 0
Baseline 30 Day
62. Pilot Study Results: D&A Use
30 Day Drug Use
7
6
5
4.73
4 NAFI
3.43
3 TAU
2
1
0.66
0.40
0
Baseline 30 Day
63. Pilot Study Results: Depression
NAFI = 6; TAU = 5
30 Day Depression
HRSD-25
25
22.2
20 21.2 20.21
15 NAFI
TAU
11.4
10
5
0
Baseline 30 Day
64. Patient Responses
• “The assessment was helpful to me. I learned a lot about myself…I
would have done it without being paid.”
• “Allowed me to see why I may be reluctant to participate in groups.”
• “Helped me narrow in on specific steps I need to take with my
therapist re: depression and addiction. Identified couple things we
can work on.”
• “I am so pleased that I participated in the study. It was right on. M-
allowed me to share during the process, which really assisted with
my overall understanding of the feedback.”
65. • First presentation at The Society for
Personality Assessment, Spring 2006.
– Diane Engelman, Ph.D.
– Steven R. Smith, Ph.D.
– Tad Gorske, Ph.D.
67. Methods of Collaborative
Neuropsychology
• Demystify the neuropsychological
assessment process: Provide feedback report;
explain session purpose; facilitate collaboration and
empathic understanding
• Answer what the individual wants to know
(If you can).
• Explain how strengths and weaknesses
are determined.
• Ensure an understanding of the
information provided.
68. Methods of Collaborative
Neuropsychology
• Ensure the information relates to the
persons experience;
Or if it doesn’t
• Explore the discrepancy.
• Summarize what has been discussed.
• Make suggestions
• Look to the future.
69. CTNA
• The spirit of the CTNA lies in Collaborative
and Therapeutic Assessment Models
– Open sharing; explore results contextually;
use results to facilitate empathic
understanding
• The framework for conducting the CTNA is
drawn from MI.
• The CTNA adopts and adapts the MI
Personalized Feedback Report
70. CTNA Feedback Session
Two primary components
1. Provide information from
neuropsychological test results
2. Interact with clients in a collaborative
manner consistent with TA and MI.
71. CTNA Personalized Feedback
1. Introduction
• Provide feedback report; explain session purpose;
facilitate collaboration and empathic understanding
1. Develop Questions
• Develop 2 or 3 well defined questions the client
hopes the results can answer
1. Explain how strengths and weaknesses are
determined
• Percentiles, determine criteria for strength or
weakness
72. CTNA Personalized Feedback
4. Feedback about strengths and
weaknesses
• Elicit: What skills did the client
use to complete the test.
• Provide: Therapist provides
information on the cognitive skill
test(s) examine.
• Elicit: Therapist elicits reactions
from the clients and applies results
to their real life.
73. CTNA Personalized Feedback
5. Summarize results and provide
recommendations
Summary and key question
Ask permission to provide recommendations
Make recommendations
75. Future Implications
• Clinical: A high degree of utility for consultation,
initiating therapy, working with “sticking points” in
therapy, rehabilitation planning.
• Teaching: Developing students into
“human-science” practitioners, researchers, and
teachers.
• Research: Learn outcomes, factors
influencing effectiveness, manual development.
77. Case #1: Multiple Concussions
• Caucasian female, early 20’s;
• Recent very mild hit to the head;
• Increase in PCS: headache, mental fogginess, dizziness,
nausea, balance problems, fatigue, drowsiness, sensitivity to light and
noise, mood changes, feeling slowed down, difficulty concentrating, difficulty
remembering, and visual problems
• Hx of two prior concussions over 5 year
span since her teen years.
• Doctor told her she had a “catastrophic
reaction.”
78. Case #1: Multiple Concussions
• No significant medical issues
• Extensive psychiatric hx:
• Mental Status
– MMSE = 30
– Clock drawing was normal
– BDI = 22
– BAI = 26
79. Vocabulary 13 84
Matrix Reasoning 15 95
Digits Forward 12 75
Digits Backward 13 84
Letter Number
Sequencing 12 75
Trailmaking A 15 sec., 0 errors 95
Digit Symbol – 12 75
Coding
81. COWA FAS = 55 82
Animal = 28 79
Boston Naming 57/60 58
Test
Trailmaking B 41 sec., 1 error 87
Stroop C/W Test Word = 100 45
Color = 81 58
Color Word = 52 79
Interference = 7 77
WCST-64 Categories = 5 Average
Total Errors = 6 94
Perseverative Errors = 5 47
Trials to first category = Average
10
82. Main themes in CTNA session
• Discrepancy between how she felt vs
objective evidence;
• Negative thoughts and beliefs about
herself and her capabilities;
• Underlying perfectionism;
• After session became more open to
considering psychological/emotional vs
brain injury as causing her distress.
83. • My thanks to all the participants, Dr. Fiona
Bardenhagen and the Australian
Psychological Society for inviting me to your
conference.
My contact information
Tad T. Gorske, Ph.D
Clinical Assistant Professor
Division of Neuropsychology and Rehabilitation Psychology
UPMC Mercy
1400 Locust Street, Suite G138
Pittsburgh, PA USA 15219
Gorskett@upmc. edu