Neuropsychosocial Intervention: The Practical Treatment of Severe Behavioral Dyscontrol After Acquired Brain Injury

221 Pages·2003·3.37 MB·English

by  Robert L. Karol

Neuropsychosocial Intervention
The Practical Treatment of Severe Behavioral Dyscontrol after Acquired
Brain Injury
http://avaxhome.ws/blogs/ChrisRedfield
Neuropsychosocial
Intervention
The Practical Treatment of Severe
Behavioral Dyscontrol after
Acquired Brain Injury
ROBERT L.KAROL
CRC PRESS
Boca Raton London New York Washington, D.C.
This edition published in the Taylor & Francis e-Library, 2005.
“To purchase your own copy of this or any of Taylor & Francis or Routledge’s collection of
thousands of eBooks please go to www.eBookstore.tandf.co.uk.”
Library of Congress Cataloging-in-Publication Data
Karol, Robert L.
Neuropsychosocial intervention: the practical treatment of severe behavioral dyscontrol
after acquired brain injury/Robert L.Karol.
p. cm.
Includes bibliographical references and index.
ISBN 0-8493-1244-2 (alk. paper)
1. Brain damage—Patients—Rehabilitation. 2. Combined modality therapy. 3.
Psychology, Pathological. I. Title.
RC387.5.K376 2003
616.8′043–dc21 2003043492
This book contains information obtained from authentic and highly regarded sources. Reprinted
material is quoted with permission, and sources are indicated. A wide variety of references are
listed. Reasonable efforts have been made to publish reliable data and information, but the
author and the publisher cannot assume responsibility for the validity of all materials or for the
consequences of their use.
Neither this book nor any part may be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopying, microfilming, and recording, or by any
information storage or retrieval system, without prior permission in writing from the publisher.
The consent of CRC Press LLC does not extend to copying for general distribution, for
promotion, for creating new works, or for resale. Specific permission must be obtained in
writing from CRC Press LLC for such copying.
Direct all inquiries to CRC Press LLC, 2000 N.W.Corporate Blvd., Boca Raton, Florida 33431.
Trademark Notice: Product or corporate names may be trademarks or registered trademarks,
and are used only for identification and explanation, without intent to infringe.
Visit the CRC Press Web site at www.crcpress.com
© 2003 by CRC Press LLC
No claim to original U.S. Government works
ISBN 0-203-50814-9 Master e-book ISBN
ISBN 0-203-58555-0 (Adobe eReader Format)
International Standard Book Number 0-8493-1244-2 (Print Edition)
Library of Congress Card Number 2003043492
Dedication
for
Gwendolyn Barnes-Karol, with love forever and ever.
No manner of written communication can convey the
debt I owe her or the admiration I hold for her. She is
brilliant and selfless. Yet, she asks for no recognition.
Her greatest satisfaction comes from helping others. She
is naturally empathic. She holds my soul together.
Preface
Motor vehicle accidents. Falls down stairs. Sports collisions. Strokes. Falls off
ladders. Drug overdoses. Heart attacks. Muggings. Near drownings. In a brief
moment, sometimes a split second, a person’s concerns about tomorrow change
from the groceries, the rent, a date, mowing the lawn, a promotion, or paying the
bills to survival. And then the groceries, the rent... become important again.
Except this time, one has cognitive problems and cannot remember important
concerns or one has emotional difficulties and is depressed and irritable.
Beyond these symptoms of cognitive deficits and emotional challenges lies
behavioral dyscontrol. Behavioral dyscontrol cannot be ignored, because it
interferes with all other treatment and any possibility of success in life after brain
injury. Yet behavioral dyscontrol is the problem therapists, families, and persons
with brain injury find the most difficult to address. Most therapists are poorly
prepared to treat behavioral dyscontrol, particularly when it is severe in nature.
Hence, persons with brain injury who exhibit severe behavioral problems may be
locked in jail or state hospitals.
This book describes an intervention methodology to address behavioral
dyscontrol, even when the behavior is severe. The therapy is called
neuropsychosocial treatment. Neuropsychosocial treatment changes the world to
fit the needs of persons with brain injury. It is an environmental intervention that
focuses on the behavior of the people whom persons with brain injury encounter
and the physical environment that they inhabit. Therapists create this
environment after they formulate an understanding of the phenomenology of
behavioral dyscontrol for each person with brain injury based upon an
examination of neurological, cognitive, adjustment, and environmental variables.
The treatment model this book describes differs from traditional interventions
in two ways. First, construction of a new environment is the treatment. In
traditional treatment, environmental manipulation is used for insight acquisition,
skill building, or contingency management. Second, neuropsychosocial
intervention works even when the above therapies fail.
This book describes procedures that are based on over 20 years of clinical
work with persons with brain injury, 10 of those years specializing in the
treatment of behavioral dyscontrol. During that time, the treatment methodology
that this book details has been used to successfully address very severe
vi
behavioral dyscontrol by persons with brain injury. Persons with brain injury are
living in the community today, rather than in jail or a state hospital, because of
neuropsychosocial intervention. This book offers therapists a methodology for
treatment that works, even with seemingly intractable cases. Of course, therapists
may also find the information here helpful to treat less severe behavioral
dyscontrol, either alone or in conjunction with traditional therapies.
This book provides an integrated approach for the treatment of behavioral
dyscontrol. In contrast, behavioral management techniques are usually presented
as a list of strategies as if they were items on a menu. The author of this book
believes that such a cookbook approach fails to give therapists guidance in how
to organize treatment. For this reason, this book rebalances case
conceptualization and techniques. The usual presentation of behavioral
interventions focuses on interventions that are too simplistic for true cases of
severe behavioral dyscontrol. The author has seen an overwhelming number of
cases where therapists have applied various simplistic behavioral strategies, often
documented in detailed behavioral management plans numerous pages in length,
that do not work. These plans either lack an overall case conceptualization or
consist of behavioral tactics that are inadequate. This book, in contrast, presents
an integrated approach that includes treatment philosophy and concrete
application.
In addition, this book includes discussion of professional issues for therapists
who work with persons with brain injury who exhibit behavioral dyscontrol. The
application of any behavioral treatment requires very skillful therapists. These
therapists face continual professional and emotional hurdles, as treating severe
behavioral dyscontrol is difficult work. However, too often, behavioral
interventions are presented as if they were a matter of simply implementing
textbook tactics. Then, treatment fails when therapists ignore real-world case
issues such as treatment setbacks, disruptive families, therapists being hit, team
discord, financial concerns, confusion about professional roles, etc. This book
interweaves discussion of such issues into the material on clinical work.
Chapter 1 presents the neuropsychosocial approach and outlines its parameters.
It contrasts this approach with traditional treatment procedures, noting the
problems that therapists have when applying traditional interventions for persons
with brain injury. It also discusses the social penalty of inadequate treatment of
behavioral dyscontrol.
Chapter 2 reviews cognitive variables that therapists must consider in order to
understand behavioral dyscontrol. Too often, therapists devise behavioral plans
without careful consideration of cognitive data. Therefore, the emphasis in this
chapter is a clinical one: how to link knowledge about cognitive deficits to
observed behavioral dyscontrol.
Chapter 3 discusses adjustment factors that have an impact on behavioral
dyscontrol. The chapter relates issues of adjustment directly to behavioral
dyscontrol. The intent is for therapists to accurately consider adjustment
variables that influence the expression of behavioral dyscontrol.
vii
In Chapter 4, therapists will learn the importance of integrating all information
at their disposal into a conceptualization of behavioral dyscontrol for each person
with brain injury. The chapter discusses the types of team functioning that
facilitate the ability of therapists to accurately conceptualize raw observations.
Finally, the chapter presents common phenomenological variables that therapists
are likely to encounter as they integrate cognitive and emotional data.
Dr. Laura McDaniels provides concrete core behavior plans in Chapter 5.
These plans give therapists a place to start for 18 typical problem behaviors.
They are intended as initial departure points from which therapists can construct
individualized neuropsychosocial environments. In this chapter, Dr. McDaniels
also discusses some common modifications of the core plans.
Dr. Robert Sevenich discusses the integration of medication management and
neuropsychosocial treatment in Chapter 6. This chapter provides valuable
information on an integrated approach for therapists and physicians alike. This
chapter will help nonphysician therapists design behavioral treatment with
consideration of both the benefit of pharmacological intervention on behavioral
dyscontrol and the impact of medications on the application of behavioral
treatment. Similarly, this chapter will assist physicians in adequately adjusting
medication in light of behavioral plan implementation. Furthermore, Dr.
Sevenich reviews specific classes of medications from a clinical perspective as
they relate to behavioral management after brain injury.
Chapter 7 tackles the challenge of community placement. First, it addresses
the crucial concept of feeling dependent that persons with brain injury must
confront. Then, it reviews why there is an inadequate supply of residential
options. Next, this chapter reviews how placement sites need to function to
handle behavioral concerns and to implement a neuropsychosocial environment.
Chapter 7 ends with a discussion of variables that therapists need to consider
when preparing to handle episodes of aggression. Therapists need to be ready if
their behavioral management plan does not work in every instance. This chapter
guides therapists in preparing for unexpected events.
Finally, Chapter 8 presents clinical scenarios that highlight the application of
the neuropsychosocial approach. These vignettes bring to life how therapists can
assess and conceptualize behavioral dyscontrol and then devise treatment. The
vignettes are intended to let therapists see how the process of neuropsychosocial
treatment takes shape.
This book was written with the intent of filling a gap in the treatment of
behavioral dyscontrol after brain injury. The author’s hope is that therapists who
apply neuropsychosocial treatment will expand their current armamentarium for
addressing behavioral dyscontrol. They will have a coherent way to
conceptualize treatment. They will be prepared to integrate cognitive and
adjustment variables into a comprehensive model of a phenomenology of
behavioral dyscontrol for each case. Therapists will be able to develop and apply
concrete behavior plans while considering the advantages of coordinated
medication management. Such an approach will enable therapists to apply their
viii
expertise in community settings. Finally, they will be better prepared if
everything does not work perfectly.
When this book was conceived, it was designed to appeal to a wide range of
therapists and others concerned about the need of persons with brain injury to
have good behavioral performance. The book’s intent is to help psychologists,
neuropsychologists, nurses, occupational therapists, physical therapists, speech
and language pathologists, behavioral analysts, chaplains, recreational therapists,
and other therapists design better treatment. Its goal is also to give physicians
information to better integrate their knowledge with behavioral intervention. For
social workers, case managers, and third-party representatives, this book should
provide insight into what is possible in behavioral management with their
assistance as well as what is not feasible. Finally, for family members and
persons with brain injury, this book should give hope, tempered by realism. With
your help, there is a treatment methodology that works.
Robert L.Karol
Bethesda Rehabilitation Hospital
Acknowledgments
Books always represent the combined effort of numerous people, a point with
which I became reacquainted on almost a daily basis as I wrote this book. Sadly,
acknowledgements inadequately capture the debt I owe so many people. So, to
all the following people, I am sorry that the words here cannot do justice to the
feelings I have for all of you who contributed to the creation of this book. Your
support was crucial to my being able to complete this book and enjoy the
experience.
Foremost in my mind are all the persons with brain injury who have taught me
about brain injury. I am better able to help other persons with brain injury
because of the wisdom I have gained over the years from persons with brain
injury about what works and what does not work. In essence, therapists are a
conduit of accumulated experience from many past clients to the next person
needing help. With this in mind, I hope that this book will further pass on that
accumulated knowledge.
It is impossible for me to contemplate persons with brain injury without
recognizing the Brain Injury Association of Minnesota. Over the years, the
volunteers, staff, and members of the Board of Directors have contributed greatly
to my perspectives on persons with brain injury. I wish to acknowledge the
impact on me of Fran Conklin, Chris Duff, Baba Finch, Tom Code, Ellie Hands,
Robin Landy, Craig Martinson, Katie O’Brien, Dr. Bill O’Dowd, Chuck
Ramsbacher, Ardis Sandstrom, and Dr. Carole Wedel Sellars.
I have also had the advantage of working with excellent people at the Minnesota
Department of Human Services; in particular, Sharyl Helgeson and Michelle
Long. The ideas in this book are mine, not theirs, but our discussions, both
agreements and disagreements, have been very important to me. Also, I want to
recognize Mark Kinde at the Minnesota Department of Health for his efforts in
data collection on behalf of persons with brain injury.
Kerry Burak and Lori Huffman have my gratitude for providing background
information and thoughts about community placements. They are very
experienced and knowledgeable. Of course, I take full responsibility for my
interpretation of the information they provided.
I have benefited greatly from my professional association with organizations
and people who have contributed to my knowledge of the challenges that persons