10/3/2016. Collaborative Therapeutic Neuropsychological Assessment

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1 Collaborative Therapeutic Neuropsychological Assessment Tad T. Gorske, Ph.D. Assistant Professor, Division of Psychology and Neuropsychology Department of Physical Medicine and Rehabilitation University of Pittsburgh School of Medicine 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 (Varella, 1991 as stated in McInerney and Walker, 2002) The Role of Neuropsychological Assessment: Historical Perspective Period of Neuropsychological Localization Period of Neurocognitive Evaluation Current Period?? What is feedback and where does it fit? Feedback is something neuropsychologists are doing; At least 71% surveyed give some type of feedback, about 46% do so in a typical minute session. That means there s probably a lot happening in those sessions!! What is happening in those sessions? The role of the neuropsychologist. What can/do we bring to the table to make the feedback sessions meaningful? Technician / Artist Neuropsychologists are challenged to expand their roles from a purely technical endeavor to a more holistic perspective. Cognitive theorist, functional anatomist 1

2 Technician / Artist Neuropsychologists are challenged to expand their roles from a purely technical endeavor to a more holistic perspective. Cognitive theorist, functional anatomist, psychotherapist, family therapist, emotional adjustment, viewing the person from a holistic perspective. the object of observation is to ascertain a network of important relations. When done properly, observation accomplishes the classical aim of preserving the manifold richness of the subject, (Luria s The Making of Mind as quoted in Christensen, Goldberg, and Bougakov, 2009). the investigation has to be carried out in a phenomenological collaboration between the neuropsychologist and the patient. (Christensen and Prigatano, 2009). Psychological testing as a therapeutic intervention Roots in existential/humanistic disciplines as a reaction to dehumanizing testing endeavor. Testing as a psychotherapeutic encounter Dr. Constance Fischer s Collaborative Individualized Assessment Dr. Stephen Finn s Therapeutic Assessment The Information Gathering / Medical Model Clinician knows best; Fragile patients; Knowledge is dangerous Collaborative Model Clinician is an expert in neuropsychology; the patient/family is the expert on themselves Patients are resilient Knowledge is power Neuropsychological Test Feedback Historically seen as optional Little consideration in the literature Gass and Brown (1992) likely the first to write about feedback and offer a method in neuropsychology. 1. Review purpose of testing using plain, simple language; 2. Describe tests as behavior samples ; 3. Explain results in terms of domains of functioning/behavior; 4. Summarize strengths and weaknesses; 5. Address diagnostic issues; 6. Make recommendations. (Gass and Brown, 1992) 2

3 Many good ideas but no clear methodology/framework. Set of guiding principles; A framework for executing those principles; An understanding of where the intervention fits in the larger treatment/rehabilitation process. A common set of principles Testing is a collaborative endeavor with examiner and patient working together; An open dialogue regarding procedures and results where patient is active participant in developing a psychological profile; Deviation from standard procedures to elucidate aspects not captured by standardization procedures; Open sharing of results. Feedback as a bridge between assessment and intervention (rehabilitation). Follows person centered rehabilitation principles: Collaborative goal setting focused on outcomes; Patient, family, therapist work together to negotiate LT goals; Emphasis therapeutic alliance; Begin with the end in mind; Goals are positive outcomes valued by patient; Interview/Assessment Sharing of results/feedback Rehabilitation/treatment Essentials of Holistic Neuropsychological Rehabilitation Feedback in Holistic Rehabilitation 1. Identify/understand causes for their inability to function adequately following an event (TBI, stroke, etc.). 2. Neurological, cognitive, and personality factors interact and influence each other. 1. Bringing information together to create a picture and then present that picture to the patient/family members to enhance understanding. 2. Through feedback we attempt to integrate these factors into a portrait of the patient. This includes the patients own perceptions of this triad. 3. Evaluate which issues can be ameliorated vs. left alone. 4. Assessing which interventions are most suitable. 3. Prioritizing that which is most important to the patient, significant others, treating providers. 4. Using interactive feedback to make recommendations most applicable to the patient. 3

4 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; 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; Be willing to refer if appropriate. (From Yehuda Ben Yishay, Ph.D. and Leonard Diller, Ph.D., James F. Malec, Ph.D., ABPP Cn, Rp. ) 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 DA , Smith s NAN grant award; Book publication in CTNA Basic Principles and Methods Initial Interview: Collaborative information gathering. Understanding the problem, Emotional experience of the problem, Pt wishes for the assessment, results, outcomes. Central Cognitive Emotional Complaint Pt wish or desire for themselves and their lives; Behavioral/cognitive reaction; Emotional response to difficulty. Testing Session (Standard Protocols); CTNA Feedback Session 1. Set agenda, introduce feedback report; 2. Develop Life Implication Questions; 3. Determine Personal Skill Profile; 4. Provide individual test results (elicit provide elicit); 5. Summarization and bridge to future goals and plans. 4

5 Set Agenda/Introduce Feedback Report Check in/life Implication Questions What does the patient want to know/referral question; How do they hope to use this information; Be flexible. Determine personal skill profile Understanding norm based scores; Conversation about normality ; Providing information Elicit provide elicit It s less important to follow the method than it is to a) constantly gauge patient reactions and understanding and b) be able to apply the test skill to daily life. Summarize bridge to the future Partly depends on what the patient wants and their own goals; Specific rehabilitation strategies; Motivating to work in rehabilitation/medicine/treatment; Lifestyle changes; Openness to education; Changing perception of the future 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). 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. 5

6 Contemporary Developments in Neuropsychological Test Feedback Feedback in cases of over reporting and normal cognitive profile (Carone, 2016). Feedback as a key part of the assessment process with therapeutic benefits for patients and family members receiving epilepsy care (Wilson, et al., 2015). Punzi (2015). Suggestions on how neuropsychological assessment might be conducted in substance abuse treatment. 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 Connery, Peterson, Baker, & Kirkwood(2016). Impact of pediatric neuropsychological consultation in mild traumatic brain injury: a model for providing feedback after invalid performance. Hansson, Hansson, Danielsson & Domellof (2015). Evaluate therapeutic effects of a collaborative therapeutic approach with children suspected of having neurodevelopmental disorders. 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 Data Teaching Psychometrics Personality Brain Behavior Relationships Family Issues Psychotherapy Process Medical Knowledge Bio Psycho Social 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. 6

7 Brain Injury Case Samples Selected References The Case of Amy Part 2 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), Dominic A. Carone (2016): But the Scores Don't Show How I Really Function: A Feedback Method to Reveal Cognitive Distortions Regarding Normal Neuropsychological Test Performance, Applied Neuropsychology: Adult, DOI: / Christensen, A.L., Goldberg, E., & Bougakov, D. (2009). Luria s Legacy in the 21 st Century. Oxford University Press, NY NY. Christensen, A.L. and Prigatano (2009). The Bedside Neuropsychological Examination and Luria s Influence. In Christensen, A.L., Goldberg, E., & Bougakov, D. (2009). Luria s Legacy in the 21 st Century. Oxford University Press, NY NY. Amy K. Connery, Robin L. Peterson, David A. Baker & Michael W. Kirkwood (2016): The impact of pediatric neuropsychological consultation in mild traumatic brain injury: a model for providing feedback after invalid performance, The Clinical Neuropsychologist, DOI: / 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), 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), Gorske, T. (2008). Therapeutic neuropsychological assessment: A humanistic model and case example. Journal of Humanistic Psychology, 48(3), Gorske, T.T. & Smith, S.R. (2009). Collaborative Therapeutic Neuropsychological Assessment. Springer Science + Business Media, LLC. Anita Hansson, Lina Hansson, Ingela Danielsson & Erik Domellöf (2016) Short and Long Term Effects of Child Neuropsychological Assessment With a Collaborative and Therapeutic Approach: A Preliminary Study, Applied Neuropsychology: Child, 5:2, ,DOI: / 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), 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 th, Sydney Australia. McInerney, Robert Garfield; Walker, Monica M. Toward a method of neurophenomenological assessment and intervention. The Humanistic Psychologist, Vol 30(3), 2002, 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. Elisabeth H. Punzi (2015) Neuropsychological Assessment in Substance Abuse Treatment Focusing on the Effects of Substances and on Neuropsychological Assessment as a Collaborative Process, Smith College Studies in Social Work, 85:2, , DOI: / Smith, S., Wiggins, C., & Gorske, T. (2007). A survey of psychological assessment feedback practices. Assessment, 14(3), 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, 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), Wilson, S.J., Baxendale, S., Barr, W., Hamed, S., Langfitt, J., Samson, S., Watanabe, M., Baker, G., Helmstaedter, C., Hermann, B.P., Smith, M.L. (2015). Indications and expectations for neuropsychological assessment in routine epilepsy care: Report of the ILAE Neuropsychology Task Force, Diagnostic Methods Commission, Epilepsia, 56(5): Yehuda, Ben Yishay and Diller, L. (2009). Handbook of Holistic Neuropsychological Rehabilitation: Outpatient Rehabilitation of Traumatic Brain Injury. Oxford University Press, Inc. NY NY. Financial Disclosure I have/have no financial relationships to disclose: Employee of: University of Pittsburgh Consultant for: N/A Stockholder in: N/A Research support from: N/A Honoraria from: National Academy of Neuropsychology 7