Psychotherapeutic Interventions for Adults

with Brain Injury or Stroke

Psychotherapeutic Interventions
for Adults with Brain Injury or
Stroke: A Clinician’s Treatment
Resource

Edited by

Karen G. hanger, Ph.D.,

Linda Laatsch, Ph.D., &
Lisa Lewis, Ph.D.

Psychosocial Press
Madison, Connecticut
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Copyright © 1999, Psychosocial Press

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Library of Congress Cataloging-in-Publication Data

t
Psychotherapeutic interventions for adults with brain injury or stroke
: a clinician’s treatment resource / edited by Karen G. Langer, Linda
Laatsch & Lisa Lewis,
p. cm.
Includes bibliographical references and indexes.
ISBN 1-887841-23-7
L Brain—Wounds and injuries—Treatment. 2. Cerebrovascular
disease—Patients—Rehabilitation. 3. Psychotherapy. I. Langer,
Karen G. II. Laatsch, Linda.
[DNLM: 1. Psychotherapy—methods. 2. Brain Injuries—psychology.
3. Cerebrovascular Disorders—psychology. 4. Depression—therapy.
5. Transference (Psychology). WM 420 P97424 1999]
RC387.5.P77 1999
616.89T4—dc21
DNLM/DLC
for Library of Congress
99-24556
CIP

Manufactured in the United States of America

 Table of Contents

Contributors vii
Introduction xi

Part I. Background, History, and Ethical Considerations

1. Neuropsychological Impairment: Challenges for
Therapeutic Intervention
Robert W. Sury and Mary Sano 3

2. A History of Psychotherapy with Patients with

Brain Injury
Laurence Miller 27

3. Ethical Challenges
Robert M. Gordon 45

Part II. Emotional Factors and Defensive Functioning:

Diagnostic and Conceptual Issues in Treatment
4. Awareness and Denial in Psychotherapy
Karen G. Langer 75

5. Depression and Its Diagnosis and Treatment

Robert W. Butler and Paul Satz 97

6. Transference and Countertransference in

Psychotherapy with Adults Having Traumatic
Brain Injury
Lisa Lewis 113

Part III. Interplay of Psychotherapy and Cognitive

Remediation in Individual Treatment
7. Application of Cognitive Rehabilitation Techniques
in Psychotherapy
Linda Laatsch 131

v
VI Contents

8. Dealing with Rationalization and Unawareness in

the Treatment of Visual Inattention
Joseph Weinberg and Leonard Diller 149

Part IV. Specialized Treatment Applications for Specific

Population Needs
9. Group Psychotherapy
Donna M. Langenbahn, Rose Lynn Sherr,
Dvorah Simon, and Bennett Hanig 167

10. Psychotherapeutic Issues in Treating Family

Members
Frank J. Padrone 191

11. Substance Abuse Interventions for People with

Brain Injury
Mary F. Schmidt and Allen W. Heinemann 211

Name Index 239

Subject Index 245

 Contributors

Robert W. Butler, Ph.D., ABPP, is Associate Professor, Depart¬

ment of Pediatrics, Oregon Health Sciences University;
Director, Pediatric Neuropsychology Clinic, Child Develop¬
ment and Rehabilitation Center, Oregon Health Sciences
University, Portland, Oregon.

Leonard Diller, Ph.D., ABPP, is Director, Psychology and Be¬

havioral Sciences, Rusk Institute of Rehabilitation Medi¬
cine, New York University Medical Center, Professor of
Rehabilitation Medicine, New York University School of
Medicine, New York City.

Robert M. Gordon, Psy.D., is Director, Intern Training, Rusk

Institute of Rehabilitation Medicine, New York University
Medical Center; Clinical Assistant Professor of Rehabilita¬
tion Medicine, New York University School of Medicine,
New York City.

Bennett Hanig, Ph.D., is a Consultant, RHR International, New

York City.

Allen W. Heinemann, Ph.D., is a Professor, Department of Phys¬

ical Medicine and Rehabilitation, Northwestern University
Medical School; Director of Rehabilitation Services Evalua¬
tion Unit, Rehabilitation Institute, Chicago; Associate Di¬
rector of Research, Rehabilitation Institute, Chicago.

Linda Laatsch, Ph.D., is Associate Professor of Psychology, De¬

partment of Rehabilitation Medicine and Restorative Medi¬
cal Sciences, University of Illinois College of Medicine,
Chicago.

Donna M. Langenbahn, Ph.D., is Supervisor, Adult Outpatient

Neuropsychology Service, Rusk Institute of Rehabilitation

vii
viii Contributors

Medicine, New York University Medical Center; Clinical As¬

sistant Professor of Rehabilitation Medicine, New York Uni¬
versity School of Medicine, New York City.

Karen G. Langer, Ph.D., ABMP, is Supervisor of Psychology,

Inpatient Services, Rusk Institute of Rehabilitation Medi¬
cine, New York University Medical Center; Clinical Assistant
Professor of Rehabilitation Medicine, New York University
School of Medicine, New York City.

Lisa Lewis, Ph.D., is Director of Psychology and Director of

Neuropsychological Services, Menninger Foundation, To¬
peka, Kansas.

Laurence Miller, Ph.D., is a licensed psychologist and brain/

behavior consultant, specializing in clinical and forensic
neuropsychology, psychotherapy and rehabilitation, crisis
intervention and trauma therapy, and workplace relations
and management training.

Frank J. Padrone, Ph.D., is Assistant Director of Psychology,

Director, Inpatient Services, Rusk Institute of Rehabilita¬
tion Medicine, New York University Medical Center; Clini¬
cal Associate Professor of Rehabilitation Medicine, New
York University School of Medicine, New York City.

Mary Sano, Ph.D., is a consultant, Physical Medicine Associates,

Jacksonville, Florida; Associate Professor of Clinical Neuro¬
psychology, Columbia University, College of Physicians and
Surgeons, New York City.

Paul Satz, Ph.D., ABPP, is Professor of Medical Psychology,

Department of Psychiatry and Biobehavioral Sciences,
UCLA Medical School; Director, Neuropsychology Pro¬
gram, Neuropsychiatric Institute, UCLA Medical School.

Mary F. Schmidt, Ph.D., is a Clinical Neuropsychologist, Reha¬

bilitation Center, Lutheran General Hospital, Park Ridge,
Illinois; Senior Clinical Research Associate, Rehabilitation
Institute of Chicago.
 Contributors IX

Rose Lynn Sherr, Ph.D., ABPP, is Director, Outpatient Psychol¬

ogy, Rusk Institute of Rehabilitation Medicine, New York
University Medical Center; Clinical Associate Professor of
Rehabilitation Medicine, New York University School of
Medicine, New York City.

Dvorah Simon, Ph.D., is Senior Psychologist, Adult Outpatient

Neuropsychology Service, Rusk Institute of Rehabilitation
Medicine, New York University Medical Center; Clinical As¬
sistant Professor of Rehabilitation Medicine, New York Uni¬
versity School of Medicine, New York City.

Robert W. Sury, M.D., is a partner in Physical Medicine Associ¬

ates, Jacksonville, Florida.

Joseph Weinberg, Ph.D., is Staff Psychologist, Rusk Institute

of Rehabilitation Medicine, New York University Medical
Center; Clinical Assistant Professor of Rehabilitation Medi¬
cine, New York University School of Medicine, New York
City.
 ,■

V
 Introduction

It is often helpful to view developments in a field within a

historical perspective. Until the mid-1980s, little had been writ¬
ten about conducting psychological treatment with patients
having traumatic brain injury (TBI), stroke, or other types of
acquired brain dysfunction, and much of what had been written
suggested that these patients’ cognitive deficits would prevent
them from taking a full part in the psychotherapeutic process.
“Organic Brain Dysfunction’’ was found on most lists of exclu¬
sionary criteria for various forms of individual and group psy¬
chotherapy. This attitude of therapeutic nihilism was
challenged in 1973 by Leonard Small in his book Neuropsychodi¬
agnosis in Psychotherapy, and was soon followed by an increasing
number of articles and books constructively addressing the psy¬
chological treatment needs of patients with brain injury or
stroke (e.g., Ball, 1988; Cicerone, 1989; Langer, 1992; Lewis,
1986; Miller, 1991; Prigatano et al., 1986). It is now commonly
recognized that attending to the patient’s psychological recov¬
ery and growth is as predictive of overall outcome as the reha¬
bilitation of cognitive and physical deficits. It is in the spirit of
this recognition that this book is written.
This volume is intended as a practical resource for clini¬
cians who treat brain injury and stroke patients whether in an
individual, family, or group psychotherapy format. Our goal is
to address the issues that face clinicians who work with these
patients. The challenge to the psychotherapist is to adapt tradi¬
tional approaches to the specific needs of patients with brain
injury. These needs are based on the neuropsychological defi¬
cits of the patient, as they disrupt linear learning, as well as on
the emotional effects that the brain injury has posed. These
emotional effects may include primary (i.e., direct) disruptions
(e.g., of personality or of affective control, etc., secondary to
the brain injury), or secondary effects (i.e., due to the losses
incurred by the brain injury and the subsequent need to adapt

XI
XII Introduction

to altered life circumstances, often in an abrupt and sometimes

wrenchingly painful way). These secondary emotional effects
may be very substantial and significant in their impact on the
person, in terms of former and current identity, sense of com¬
petence and mastery, and in short, on all of what makes up
one’s sense of self. All of these may be challenged by the brain
injury, sometimes altered in a fundamental way, and sometimes
merely reconsidered. The reconsideration itself, an integral
part of the psychotherapeutic process, can also be the founda¬
tion for mature review of personal assumptions, beliefs, and
values, and hence for personal growth.
We have concentrated entirely on acquired brain impair¬
ment, as opposed to congenital dysfunction, since the two pose
very different issues for patient and family. For purposes of
clarity, we restrict our discussion to the brain injury and stroke
patient populations, though we acknowledge that many of the
principles described will also be applicable to patients with neo¬
plastic or infectious diseases of the central nervous system, or
patients with organic brain syndromes secondary to substance
abuse or toxic exposure, and, to a lesser degree, patients with
primary degenerative dementias.
The reader will be able both to explore the challenges of
psychotherapy with the patient with stroke or brain injury in
general, and focus on recent developments in treatment appli¬
cations and clinical approaches. The topics covered in this vol¬
ume are by no means exhaustive of the array of diagnostic and
treatment considerations, but they are broad based and reflect
diversity in approach.
We have divided the book into sections based on concep¬
tual groupings. The first section includes the background, his¬
tory, and ethical issues involved in treating the patient with
brain injury or stroke. Key orienting and overview chapters are
written by Drs. Robert Sury and Mary Sano who provide an
accessible and clinically focused account of the range of deficits
and syndromes resulting from damage to the dominant and
nondominant cerebral hemispheres. Dr. Laurence Miller then
cogently describes the development of psychotherapeutic ap¬
proaches to the patient with brain injury/stroke, and Dr. Rob¬
ert Gordon discusses the crucial issues of what can be
 Introduction xiii

accomplished in treatment to help the patient in both ethical

and practical terms.
The next section deals with implications of emotional reac¬
tions, defensive functions, and countertransferential issues in
therapeutic treatment of these patients. The first two chapters
focus on the clinical phenomena which pose the biggest chal¬
lenge in the treatment of the patient with brain injury/stroke
and can, when successfully addressed, make the difference be¬
tween poor and favorable treatment outcomes: depression and
unawareness of deficit. Dr. Karen Langer addresses the multi¬
faceted problem of unawareness of deficit and the treatment
approaches that can lead patient and therapist to be mutually
allied in a shared understanding of the problems, their causes,
and their solutions. Drs. Robert Butler and Paul Satz provide
an excellent guide to navigating differential diagnostic dilem¬
mas and employing effective treatment strategies when working
with the patient manifesting depressive mood and affect. Dr.
Lisa Lewis, coming from a psychoanalytic perspective, describes
the common transference and countertransference paradigms
that emerge in therapy with the patient with brain injury/
stroke and how they can be put to therapeutic gain rather than
leading to derailment of the therapeutic enterprise.
A rapprochement between cognitive rehabilitation and
traditional psychotherapy is undertaken in the next set of chap¬
ters. Dr. Linda Laatsch addresses, in clinically relevant terms,
how cognitive retraining and psychotherapy can be blended
with synergistic effects on patient experience and treatment
outcome. Drs. Joseph Weinberg and Leonard Diller, two pio¬
neers in the field of rehabilitation, discuss and illustrate their
state-of-the-art clinical approach to treating patients with unilat¬
eral visual neglect, an approach which incorporates psychother¬
apeutic approaches to resistance and defense into an
integrated rehabilitative effort.
The final section of the book is devoted to treatment ap¬
proaches that are designed to meet unique or specialized pa¬
tient needs, or those of the family. Drs. Donna Langenbahn,
Rose Lynn Sherr, Dvorah Simon, and Bennett Hanig astutely
describe the power of group psychotherapy in which the pa¬
tient with brain injury/stroke can be lifted from painful isola¬
tion by a growing sense of deeply shared common experience
XIV Introduction

with other group members, and how this can serve as the cata¬
lyst for broader social and interpersonal reintegration. Dr.
Frank Padrone discusses how family dynamics can be destabi¬
lized by the shattering impact of brain injury/stroke and how
a restoration of meaning and cohesiveness can occur in a family
therapy process. Drs. Mary Schmidt and Allen Heinemann ad¬
dress a topic which has too long been neglected given that
it plays such a powerfully undermining role in recovery and
treatment outcome: substance abuse. Practical assessment
tools, means of establishing a multidisciplinary treatment pro¬
gram in the reader’s home community, and up-to-date psycho¬
therapeutic approaches are offered which address the unique
needs of the patient with brain injury/stroke who abuses alco¬
hol and other drugs.
It is hoped then that the reader will find this a rich and
useful text for reviewing the history and current considerations
in psychotherapy with the patient with brain injury/stroke and
in the diagnostic and conceptual challenges that pertain to
their treatment. It is the aim of the authors to collect and ex¬
pand our knowledge in this growing and important field of
practice.
Psychotherapy, at its essence, is about the creation and
discovery of meaning. For the patient with any form of brain
injury, the principles described in the following chapters will
allow for the discovery of meaning which can recreate a sense
of continuity to their lives, linking past (insight into the brain
injury/stroke), present (insight into current deficits, interper¬
sonal patterns, and adaptive capacities), and future (through
creation of realistic hope and increased self-efficacy which fos¬
ter goal attainment). As coeditors of this book, we would like
to express our appreciation to our patients, who have been the
driving force and inspiration behind this book, to our col¬
leagues whose insights have been powerfully educative, and to
our families and friends, who have been a constant source of
support, wisdom and encouragement.

K. G. Langer, L. L. Laatsch, and L. Lewis, Editors

 Introduction xv

REFERENCES

Ball, J. D. (1988). Psychotherapy with head-injured patients. Journal

of Medical Psychotherapy, 1, 15-22.
Cicerone, K D. (1989). Psychotherapeutic intervention with traumat-
ically brain-injured patients. Rehabilitation Psychology, 34,
105-114.
Langer, K. G. (1992). Psychotherapy with the neuropsychologically
impaired adult. American Journal of Psychotherapy, 46, 620-639.
Lewis, L. (1986). Individual psychotherapy with patients having com¬
bined psychological and neurological disorders. Bulletin of the
Menninger Clinic, 50, 75-87.
Miller, L. (1991). Psychotherapy of the brain-injured patient: Princi¬
ples and practices. Cognitive Rehabilitation, 9, 24—30.
Prigatano, G. P., Fordyce, D.J., Zeiner, H. K., Roueche,J. R., Pepping,
M., 8c Wood, B. C. (1986). Neuropsychological rehabilitation after
brain injury. Baltimore: Johns Hopkins University Press.
Small, L. (1973). Neuropsychodiagnosis in psychotherapy. New York:
Brunner/ Mazel.
\
 PART I

Background, History, and Ethical

Considerations
1.

Neuropsychological Impairment:
Challenges for Therapeutic
Intervention

Robert W. Sury, M.D. and Mary Sano, Ph.D.

Many patients in the rehabilitation setting have neurologic in¬

juries that result in both behavioral and physical impairments.
Neuropsychological deficits, affective disturbances, and behav¬
ioral problems can occur. To a great degree the pattern of
deficit is determined by the location of the injury. The organi¬
zation of the brain and the spinal cord is such that specific
injuries predict relatively specific patterns of deficit. The physi¬
cal challenges that are commonly associated with neuropsycho¬
logical impairment result from the paresis, plegia, and cranial
nerve injuries that can occur with serious brain injury. Physical
challenges for the patient with spinal cord injury, which in¬
clude paralysis and hemiplegia, are often accompanied by neu¬
ropsychological deficits which may result from minor head
injury (Davidoff, Roth, & Richards, 1992). These injuries may
initially go undetected because of the presence of severe physi¬
cal disability. Recent work had suggested that neuropsychologi¬
cal impairment from mild head injury is common and can
increase the challenge that the patient faces in dealing with his
physical limitations.

3
4 Robert W. Sury-Mary Sano

Neuropsychological impairment is also a common sequela

of stroke, and the accompanying challenges must often be con¬
sidered in the context of advanced age. The organization of
the brain determines the deficit, and therefore common pat¬
terns are seen regardless of the etiology of the deficit. This
chapter will discuss common patterns of neuropsychological
deficits and physical impairment which can be seen in the reha¬
bilitation setting. This work is not meant as a comprehensive
review of the consequences of neurologic injury. Rather, it rep¬
resents a selection of commonly observed patterns of deficits
which represent a challenge to psychotherapeutic interven¬
tions.

ORGANIZATION OF THE BRAIN AND SPINAL CORD

The brain may be divided into two hemispheres. The dominant

hemisphere refers to the half which controls language. In right-
handed individuals, this is the left hemisphere. The left hemi¬
sphere is also the dominant one for 60% of left-handed individ¬
uals. Motor control and sensation of one side of the body are
controlled by the opposite half of the brain. This contralateral
representation of motor control and sensation holds true for
the upper and lower extremities and for some facial muscles.
Other facial and upper body muscles are controlled by the
cranial nerves which have ipsilateral (same side) representation
in the brain. In addition to motor control, sensation, and lan¬
guage, other cognitive and behavioral functions have also been
associated with specific brain locations.
The brain is further divided into lobes which have associ¬
ated cognitive and physical functions. Motor control and sensa¬
tion for the entire body are represented on the cortical surface
of the brain in a highly organized fashion. The motor strip
refers to an area on the precentral gyrus of the frontal lobes,
which extends from the midline between the two hemispheres
and along the outside of each hemisphere. The sensory cortex
refers to the area along the postcentral gyrus of the parietal
lobes and is adjacent and posterior to the motor strip. Repre¬
sentations of motor control and sensation of a given area are
 Neuropsychological Impairment 5

adjacent to each other. The lower extremities are represented

in the midline between the cerebral hemispheres. Representa¬
tion of the upper extremities and head is lateral along the
surface of the frontal and parietal lobes. The amount of cortical
surface associated with a given body part is proportional to the
complexity of movement and sensation of that body part. For
example, there is a greater surface area on the motor cortex
representing the thumb than representing the leg or foot.
Damage to the these sites can result in sensory loss or motor
weakness.
The frontal lobes have been implicated in executive func¬
tions such as planning and initiation as well as inhibitory pro¬
cesses, which negate impulsive expression. Through this
mechanism the frontal lobes play an important role in emo¬
tional expression.
The temporal lobes are associated with memory abilities
with relative specialization for the verbal memory in the left
temporal lobe. The dominant temporal lobe is the center of
receptive language. Heschl’s gyrus, on the superior surface of
the left (dominant) temporal lobe, is the primary auditory in¬
put for language. There is cortical representation for attribut¬
ing meaning, source, and location of sounds. The ability to
make these associations is critical to the ability to comprehend
speech. The right temporal lobe is associated with learning of
visually presented material. Time perception has been associ¬
ated with either temporal lobe.
The parietal lobes are associated with visuospadal abilities
and awareness, including awareness of self. Recall that the sen¬
sory strip resides in the parietal lobe and is the source of infor¬
mation which allows one to know one’s physical position in
space. Through frontal connections, this lobe is an integrator
of sensory input and meaning. The parietal lobe also plays a
role in visual attention, and damage to this area is associated
with neglect of or inattention to the contralateral visual field
or to one’s space.
The occipital lobes are the location of the primary visual
cortex. This means that the occipital lobes are ultimately re¬
sponsible for sight. The representation of visual field is in the
contralateral side of the brain. For example, the left visual field,
6 Robert W. Sury-Mary Sano

which is captured by the right half of each eye, projects to the

right side of the occipital lobe of the brain. The upper portion
of the visual field is captured by the lower portion of the eye
and projects to the lower portion of the occipital lobe. The
lower visual field is captured by the upper portion of each eye
and projects to the upper portion of the occipital lobe. Lesions
in these areas are associated with loss of primary vision. How¬
ever, cortical blindness can occur in the absence of awareness
of vision loss.
Spinal cord injuries are a common source of physical dis¬
ability in patients in the rehabilitation setting. The spinal cord
is the pathway for all ascending and descending neural connec¬
tions. The ascending pathways relay sensory input from the
periphery to the brain while the descending pathways relay
motor instructions from the brain to the peripheral nervous
system. The spinal cord gives rise to 31 pairs of spinal nerves:
8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal. The
spinal cord is not of a single width; there are 2 enlargements.
The cervical enlargement carries innervation to and from the
upper extremities. The thoracic nerves innervate the intercos¬
tal muscles which expand the rib cage to assist in breathing.
The lumbar enlargement carries innervation to and from the
lower extremities, as well as the bladder, prostate, seminal vesi¬
cles, uterus, and external genitalia. Each spinal nerve of the
pair is directed to one side of the body with the ventral portion
of the nerve containing the descending fibers and the dorsal
containing the ascending ones.
Spinal cord injuries can be described as complete or in¬
complete (Frankel, 1969). In a complete injury, there is total
loss of motor control and sensation below the level of the le¬
sion. Several types of incomplete lesions have been described.
In sensory-only injuries, there is some sensation present below
the level of the lesion but there is complete motor paralysis
below that level. Motor-useless injuries are characterized by the
presence of some motor power below the level of the lesion,
but it is of no practical use to the patient. In motor-useful
injuries there is useful motor power below the level of the
lesion.
 Neuropsychological Impairment 7

CONDITIONS ASSOCIATED WITH DAMAGE TO THE

DOMINANT HEMISPHERE

Aphasia is a common disturbance of dominant hemisphere in¬

jury. Aphasia may be divided into expressive versus receptive,
which implies that language is both the production and the
comprehension of speech. However, while one type may be
prominent, individuals often have deficits in both. Expressive
aphasia may be described as nonfluent. It is characterized by
sparse output, requiring significant effort usually with observed
frustration, poor articulation, and disturbed prosody (i.e., ab¬
normal rhythm, inflection, timbre, and melody). Expressive
aphasia is usually associated with anterior brain lesions. Milder
forms of expressive aphasia may also occur. For example, ano-
mia (word-finding difficulty) may occur without other expres¬
sive problems.
Broca’s aphasia, an expressive aphasic syndrome, is charac¬
terized by nonfluent speech with relatively intact comprehen¬
sion and poor naming (which may be aided by contextual
cuing). Broca’s aphasia is usually associated with other physical
symptoms resulting from neurological damage in the dominant
hemisphere. These patients often have right hemiplegia, sen¬
sory loss, or visual field disturbance.
Receptive aphasia may be accompanied by “fluent”
speech. In this condition there is often sufficient, even an over¬
abundance of, word production, without articulation deficit
and intact prosody, but with an absence of meaning and the
presence of significant paraphasic errors (substitution of pho¬
nemes or words). This type of disturbance is associated with
more posterior damage, usually in the temporal lobe of the
dominant hemisphere. Wernicke’s aphasia is a receptive apha¬
sia with fluent speech interspersed with paraphasic errors and
neologisms. The cardinal features of this aphasia are loss of
comprehension and disturbances in repetition. With this apha¬
sia there may be a greater loss of comprehension of spoken or
written language. This condition may be accompanied by a
superior quadrantopsia, although this may go undetected be¬
cause of the language impairment. In general, these patients
8 Robert W. Sury-Mary Sano

have minimal neurologic findings and their presentation has

been mislabeled psychotic.
Unlike Wernicke’s aphasia, conduction aphasia is charac¬
terized by intact comprehension with a disruption of repetition
and fluent, paraphasic speech. Conduction aphasia is thought
to result from a disruption of the connections between frontal
expressive areas and more posterior receptive areas. This syn¬
drome is often accompanied by ideomotor apraxias of buccofa¬
cial and limb motions.
Aphasia can occur with damage to the supplementary mo¬
tor areas. Such lesions may produce an aphasia which is initially
characterized by mutism that resolves to slow, hypophonic,
nonfluent speech with echolalia. This condition may be accom¬
panied by weakness and/or sensory loss in the right lower ex¬
tremity and shoulder, but no deficit in the arm and face.
Damage in the adjacent extrasylvian sensory areas has been
associated with a fluent aphasia with jargon, echolalia, and poor
comprehension. The ability to repeat, coupled with fluent,
nonsensical speech, can lead these individuals to be mislabeled
schizophrenic.
Other language-based conditions including alexia and
agraphia are affected by dominant hemisphere lesions. Neglect
refers to the failure to respond to stimuli presented on one
side of the body. Right neglect associated with left hemisphere
lesions can lead to disturbance in a very basic level of visual
processing which gives meaning to the letters. This is important
to consider, because the inconsistency between visual abilities
and reading abilities may lead to the false interpretations that
the reading deficit is functional and not related to the injury.
Agraphia refers to the inability to write, which is not attrib¬
utable to a pure motor deficit. Agraphia with alexia, in the
absence of aphasia, is usually attributable to a left parietal lobe
lesion. Lesions of the right parietal lobe lead to a spatial
agraphia, which is characterized by duplicate stroke, writing on
the right side of the page, and insertion of blank spaces be¬
tween phonemes (Benson, 1979; Hecaen & Albert, 1978).
Agnosias are disturbances in body schema or body image.
They include the loss of recognition or perception of aspects
of self. Simultanagnosia refers to the inability to recognize the
 Neuropsychological Impairment 9

whole, even though the parts may be well recognized. Lesions

in the left occipitotemporal junction have been associated with
disturbances. These patients may negotiate their environment
without difficulty. However, when presented with a series of
stimuli, they may identify some but not all of the stimuli, unless
specifically directed to.

CONDITIONS ASSOCIATED WITH DAMAGE TO THE

NONDOMINANT HEMISPHERE

In general, visuospatial abilities are attributed to the nondomi¬

nant (usually right) hemisphere. Neglect may be observed in
space or in the person and can occur in many modalities. The
neglected side is contralateral to the lesion, but often patients
with unilateral neglect will demonstrate subtle deficits on the
opposite side. Neglect may occur with damage to either hemi¬
sphere. There are several conditions which are unique and
prominent with right-brain injuries. Right parietal lobe lesions
which may result in left neglect and inattention can sometimes
be associated with alexia. This visual deficit interferes with vi¬
sual processing of the written word. When patients with neglect
are asked to read words presented vertically, neglect is not seen
(Behrmann, Moskovitch, Black, & Mozer, 1990). However, all
patients who make neglect errors also produce orthographi-
cally related errors in both the neglected and nonneglected
direction, suggesting that the alexia is not merely a deficit in
attention, but also involves visual processing. However, the
alexia may be seen even when there is no demonstrable visual
field defect or visual neglect (Kinsbourne & Warrington, 1962).
It may be that reading disturbances reflect complex processing
that is sensitive to subtle visuospatial neglect which is not detect¬
able by routine clinical examination. Alexia can be highly disa¬
bling, and may occur with few other disturbances. This can
challenge the uninformed observer’s ability to appreciate the
full extent of the deficit.
Deficits in color perception are common with right hemi¬
sphere lesions, particularly when a field cut is present. Apper¬
ception of color can occur with left hemisphere lesions,
10 Robert W. Sury-Mary Sano

particularly when aphasia is present (De Renzi 8c Spinnler,

1967).
Deficits in the ability to locate an object in space have been
associated with lesions of both the left and right hemispheres,
depending on task demands. When patients are asked to point
to a location, lesions in the posterior portion of both left and
right hemispheres can result in deficits (Ratcliff, 1982). How¬
ever, deficits of location in space, when no motor response is
required, result from right hemisphere lesions (Warrington 8c
Rabin, 1970). Subsequent studies have also supported the no¬
tion that deficits in the location in space result from right hemi¬
sphere damage and are associated with visual field defect
(Hannay, Varney, 8c Benton, 1976).
Deficits in the direction of lines are associated with right
hemisphere damage (Benton, Hamsher, Varney, 8c Spreen,
1983). Other studies support the idea that deficits in pure spa¬
tial perception are associated with right hemisphere lesions
while deficits in tasks that require spatial rotation or orientation
may be seen in left as well as right hemisphere lesions (Mehta &
Newcombe, 1991).
Topographic disorientation is also more commonly associ¬
ated with right than left hemisphere lesions (Landis, Cum¬
mings, Benson, 8c Palmer, 1986), although some deficits have
been reported only in patients with bilateral parietal lobe le¬
sions.
Deficits of depth perception and stereopsis are most reli¬
ably associated with bilateral lesions in the visual cortex, al¬
though unilateral lesions on either side can result in reduction
of stereoacuity.
Visuoconstructional deficits are often referred to as con¬
structional apraxias. Most often tests which assess these deficits
require the integration of several abilities. For example, most
tests of visuoconstruction require visuoperception and grapho¬
motor abilities. As a result it is difficult to localize this ability.
Some form of constructional disability is frequently present in
patients with brain disease. While most studies report a slightly
higher rate in unilateral right hemisphere lesions than left, any
brain damaged group usually will have higher rates of construc¬
tional deficits than a control group (Benton, 1967).
 Neuropsychological Impairment 11

Visual imagery refers to the process of recalling visual stim¬

uli from memory stores. Some have suggested that this may be
of little clinical relevance. However, in a therapeutic setting it
may be important to recognize a limitation in this capacity.
While normative studies have suggested that the neural path¬
ways underlying visual imagery are similar to those that under¬
lie visual perception, studies in patients make it difficult to
determine which hemisphere is involved. Several reports indi¬
cate deficits in visual imagery in patients with left hemisphere
lesions (Farah, 1984, 1986), but reinterpretation of these re¬
sults suggests that both hemispheres may be involved, although
in different aspects of the process (Sergent, 1990).
Impairment in facial discrimination, a very specific visuo-
spatial ability, is twice as common with right hemisphere than
left hemisphere lesions (Hamsher, Levin, 8c Benton, 1979),
with poorest performance associated with damage to the more
posterior regions. However, patients with left hemisphere pos¬
terior lesions do more poorly than controls.
Aprosodia, occurring in the absence of other aphasic dis¬
turbances, may be associated with lesions in the nondominant
hemisphere. This refers to disturbances in tonal fluctuation,
which occur in normal speech, often conveying emotional con¬
tent through inflection. Patients with aprosodic speech may
find that others are either unable to interpret their affect or
misinterpret it altogether.

OTHER CONDITIONS ASSOCIATED WITH NEUROLOGICAL

DAMAGE

Amnesic disorders are commonly seen in rehabilitation pa¬

tients and can occur in the absence of other cognitive deficits
(Drachman 8c Arbit, 1966). Anterograde amnesia refers to the
inability to demonstrate new learning. This is sometimes re¬
ferred to as recent or long-term memory deficit. The key fea¬
ture is the inability to recall information that exceeds the
immediate memory span. For example, the patient may be able
to repeat a list of numbers or words immediately after they are
12 Robert W. Sury-Mary Sano

presented, but would not be able to recall the information after

a small delay. The inability to recall is often not improved even
when multiple choice or cuing is provided. Anterograde amne¬
sia inhibits the patient’s ability to establish new memories from
the time of injury and is very disabling. The memory deficit is
in stark contrast to the preserved conversational languages
skills, often leading the uninformed observer to have unrealis¬
tic expectations of the patient’s abilities.
Retrograde amnesia refers to the loss of memory for events
prior to the injury and includes loss of both factual and auto¬
biographical information. The most common pattern of forget¬
ting is in a temporal order with the greatest loss of those things
that happened closest to the injury. However, a nontemporal
loss has also been described and is usually associated with dis¬
eases such as herpes simplex encephalitis (Butters, Miliotis, Al¬
bert, & Sax, 1984; Damasio, Eslinger, Damasio, Van Hoesen, &
Cornell, 1985).
Typically, amnesic patients demonstrate memory deficits
across all modalities, probably because the deficit is a result of
bilateral damage, as with disease or with damage to a midline
structure. Modality-specific deficits have been reported in cases
of lateralized lesions, with greater impairment in the recall of
verbal than nonverbal material in left hemisphere lesions and
the opposite pattern in right hemisphere lesions.
Achromatopsia, a disturbance of hue discrimination or the
perception of grayness, can result from occipital lobe lesions.
It is usually associated with a visual field defect of the supe¬
rior quadrant.
Another condition seen with occipital lobe lesions is proso¬
pagnosia, which refers to the inability to recognize a familiar
face, either on a person or in a picture. This defect may extend
to the inability to interpret the meaning of facial expressions.
Visual field deficits are nearly always present in this condition.
Subtle sensory disturbances include extinction to double
simultaneous stimulation. The extinction occurs on the contra¬
lateral side of the lesion, even though unilateral stimulation
on the same side is recognized. Anosagnosia, which refers to
the lack of recognition of self, is also associated with inferior
parietal lobe lesions in the region of the supramarginal gyrus.
 Neuropsychological Impairment 13

This can be manifested by ignoring grooming to one side of

the body or denying somatic deficits. As some recovery occurs,
patients with these lesions have been known to demonstrate
catastrophic reactions, which are characterized by sudden
awareness of an aspect of deficit, with distress level out of pro¬
portion to the actual deficit. Patients with dominant parietal
lobe lesions without motor or sensory deficits have been found
to have ideomotor apraxia. They lose the ability to perform
learned motor skills on command or by imitation. For example,
they may be unable to demonstrate actions such as combing
hair or brushing teeth on command.

ISSUES OF NEUROPSYCHOLOGICAL ASSESSMENT

Neuropsychological assessment can play several roles for the

rehabilitation patient. First, it can characterize the nature of
the deficit. As illustrated above, small details of the specific
deficits can make significant differences in one’s ultimate dis¬
ability. Second, it can identify relative strengths and weaknesses
which can be used to direct the methods of rehabilitation. For
example, subde neglect can compromise one’s ability to read,
making reading a poor method for communicating new skills.
Third, it can provide indications of premorbid function. Aware¬
ness of premorbid function is critical in setting reasonable
goals for rehabilitation. Realistic expectations will permit the
patient to experience success, an important motivator for max¬
imizing the patient’s participation.
There are two primary approaches to neuropsychological
assessment, each with its own advantages. The first uses a stan¬
dard battery of tests to systematically assess each domain. The
Halstead Reitan Battery is an example of this technique. This
approach makes no assumptions that any function is intact.
The tests in the battery typically begin by formally assessing the
sensitivity to the stimulus and to the physical ability to produce
the response. Simple tasks are made more complex by adding
a single demand at a time. The advantage of this thorough
approach is that subtle deficits can be noted and all domains
are assessed. It is of particular value in a severe extensive injury.
14 Robert W. Sury-Mary Sano

Another approach is to begin the assessment with more

complex tasks and conduct in-depth testing of those areas
which are impaired. This approach assumes that there are
many different ways to accomplish a task and the focus should
be on those tasks which cannot be accomplished. In this ap¬
proach, the Wechsler Adult Intelligence Scale-Revised (WAIS-
R) may be administered initially to determine premorbid abili¬
ties and to identify deficits which need further assessment. One
can assess some levels of language comprehension and produc¬
tion, visuospatial abilities, and reasoning with the WAIS-R. If
deficits are suggested by the pattern of performance, more de¬
tailed and structured assessment of these domains is necessary.
Additional testing of domains not tapped by the WAIS-R must
also be included. The advantage of this approach is that it
evaluates cognition as a whole, identifying problems with ac¬
complishing tasks that may more closely approximate func¬
tional abilities. It may eliminate testing of unnecessary
domains.
The other areas which are important to assess include at¬
tention and concentration, memory and learning, concept for¬
mation and abstract reasoning, verbal and language functions
including reading and naming, and speed of information pro¬
cessing. These areas are particularly important in milder forms
of injury or after recovery from gross neurological and neuro¬
psychological deficits. There is a wide choice of tests for as¬
sessing each domain (for a review of tests, their application,
and available normative data see Lezak [1995]). It is important
to acknowledge that most neuropsychological tests are complex
and examine more than one function. For this reason, poor
performance in any test must be explored to isolate which func¬
tion is actually impaired. Selection may be based on the norma¬
tive data available for a given measure as well as the ability of
a test to meet the specific needs of a particular patient. For
example, assessment of visual memory or attention in a patient
with a hemiparesis would avoid tests which require construc¬
tions or other graphomotor responses.
The neuropsychological report will often attempt to attri¬
bute performance to injury or premorbid factors. While this
is never done with complete certainty, there are profiles of
 Neuropsychological Impairment 15

performance which are associated with noninjury factors.When

these factors are part of the clinical history, it is important to
weigh their impact on cognitive performance. For example, a
history of learning disability, alcohol use, or major depression
can be associated with cognitive deficits. In the case of stroke,
diseases of aging, including prior stroke or preexisting cogni¬
tive decline, may also be considered. In a conservative ap¬
proach to the assessment, deficits associated with the
premorbid condition would be acknowledged and only residual
deficits could be attributed to the injury. In some cases the
severity of a deficit may indicate contributions from several
factors.

AFFECTIVE DISTURBANCES AND

NEUROPSYCHOLOGICAL DEFICITS

Patients with brain injury often have changes in emotional ex¬

perience and behavior. The expression of an appropriate emo¬
tion may depend in part on the ability to comprehend
emotional stimuli. As mentioned above, many patients with
brain injury have difficulty comprehending the visual stimuli
which express emotions, with poorest performance from those
with right brain injury. In general, the deficits seen in right
brain injury are not valence dependent and are not emotion
specific (Borod, Koff, Perlman-Lorch, & Nicholas, 1986). Pa¬
tients with right brain damage also have trouble comprehend¬
ing some of the vocal nuances that convey emotion in speech
(Heilman, Bowers, Speedie, & Coslett, 1984). Some authors
have found that the facial expression of emotion is reduced in
patients with right hemisphere brain injury, although this is
not consistently reported. There is substantial evidence that
lesions of the frontal lobe are critical to the reduction of emo¬
tional facial expression, regardless of which side.
Another aspect of the effect of the lesion is the experience
of emotion. It has been reported that patients with right hemi¬
sphere disease appear to be euphoric or indifferent, while sev¬
eral studies have suggested that left hemisphere lesions are
16 Robert W. Sury-Mary Sano

associated with depression. The depressive syndrome is usually

seen in nonfluent aphasics with lesions in the anterior regions
of the frontal lobe. It can also be seen in patients with subcorti¬
cal injury. The severity of the depression seems to increase with
proximity to the frontal pole (Starkstein, Robinson, & Price,
1987) and is characterized by the presence of significant anxi¬
ety. More recent studies have suggested that right hemisphere
patients also experience a high level of depression, but it goes
undetected because of their difficulty with emotional expres¬
sion (House, Dennis, Warlow, Hawton, & Molyneux, 1990).
Other aberrations of emotional expression can be seen in
patients with limbic system involvement. Both animal lesion
studies and human observational studies lead to a complex
story of the role of the limbic system in emotion. However, it
is important to note that brain lesions can produce rage (Ze-
man & King, 1958), placidity (Poeck, 1969), aggression (Pin-
cus, 1980), fear and anxiety (Strauss, Risser, & Jones, 1982),
hyposexuality (Taylor, 1969), and increased libido (Cogen, An-
tunes, & Correll, 1979).

DEFICITS IN MILD HEAD INJURY

Patients with spinal cord injuries may also have mild traumatic
brain injury (MTBI), with estimates ranging from 40 to 50%
(Davidoff et al., 1992). Mild traumatic brain injury is defined
by the presence of a subtle cognitive disturbance consisting of
one of the following: (1) brief (less than 30 minutes) period
of loss of consciousness; (2) loss of memory for events before
or after the injury; (3) altered mental states (often reported
as “dazed, disoriented, or confused”); and (4) transient or
persistent focal neurological deficit. These deficits can occur
with a blow to the head or an acceleration-deceleration (e.g.,
whiplash) injury. In the face of serious spinal cord injury, the
possibility of MTBI may be overlooked. However, this entity
can be associated with symptoms which can impede rehabilita¬
tion efforts.
Three broad categories of symptoms are noted with MTBI.
The physical symptoms include nausea and vomiting, which
 Neuropsychological Impairment 17

are most common immediately after the injury. Other symp¬

toms which may persist include dizziness, blurred vision, sleep
disturbance, fatigue, and sensory disturbance. Cognitive diffi¬
culties include problems with attention, concentration, percep¬
tion, minor speech and language deficits, and executive (i.e.,
planning) deficits. These deficits may be so subtle that they
are difficult to capture in formal testing. Behavioral symptoms
include anger, irritability, changes in emotional respon¬
siveness, disinhibition, and emotional lability.
These symptoms and complaints may be particularly prob¬
lematic in a patient in the rehabilitation setting. They can inter¬
fere with ability to benefit from rehabilitation. It is usually
assumed that these symptoms are most prominent immediately
after the accident with significant recovery over time. It is esti¬
mated that 60 to 90% of patients with MTBI recover within a
year. However, there is persistence of these symptoms in the
first 3 to 6 months, which is usually the interval when patients
with acute injuries are participating in rehabilitation. The cog¬
nitive symptoms may not even become evident until rehabilita¬
tion begins, because this reflects the first challenge to these
skills. It may be difficult to determine the etiology of these
symptoms. In fact, multiple musculoskeletal injuries, which may
occur in serious accidents as well as in minor injuries, can pro¬
duce many of the same physical symptoms and complaints asso¬
ciated with MTBI. For example, in the absence of spinal cord
injury, soft tissue injury can cause disturbances of sensation,
including tingling or burning sensations. Chronic muscle pain
may be associated with fatigue and increased irritability. Muscu¬
loskeletal injuries of the neck and shoulders can be associated
with headache and complaints of blurred vision. It is therefore
important to carefully consider the range of possible etiologies
including brain injury when developing a plan for recovery.

OTHER PHYSICAL DISTURBANCES

Traumatic brain injury (TBI) can produce dysfunctional sensa¬

tions. These include visual field defects that can be compen¬
sated for by increased concentration and neck motion. There
18 Robert W. Sury-Mary Sano

can be alterations in sensation of vibration, temperature, posi¬

tion sense, light touch, and pain. These altered sensations pro¬
duce physical challenges by decreasing awareness of the
environment which can lead to falls, injuries, and skin break¬
down. Damage to the cranial nerves can cause diplopia, blurred
vision, nystagmus, dizziness, hearing impairment, facial paraly¬
sis, decreased taste and smell, and dysarthria. Visual field defi¬
cits can cause difficulties with the activities of daily living, the
patient’s driving, and employment.
Spasticity produces frequent physical challenges for pa¬
tients with spinal cord and traumatic brain injury. It is a diffi¬
cult problem to treat. Drugs that reduce spasticity frequently
produce fatigue and lack of coordination. Chronic spasticity
can progressively limit joint range of motion and produce
flexion contractures. The flexion contractures are painful and
further reduce the patient’s mobility and independence. Man¬
agement of spasticity involves active and passive exercises.
These help to decrease the spasticity for a period of time and
help preserve the range of motion. Bracing can help to prevent
spasticity and can also be useful to help correct joint deformi¬
ties. Surgery has also been used and has been most successful
in treating spasticity in the lower extremities.

PHYSICAL CHALLENGES AND ISSUES OF DISABILITY

Patients will have increased functional challenges the higher

the level of the spinal cord injury. Patients with lesions from
the C2 to C7 will require assistance with routine urinary cathe¬
terization and bowel routine. With lesions at the C2 to 3 level,
the patient will be totally dependent in activities of daily living
and be respirator dependent. A phrenic nerve pacemaker may
allow some patients to avoid respirator dependence. A patient
with a lesion at the C-4 level will still be dependent in activities
of daily living and transferring. However, they may have some
mobility by using a powered wheelchair with a chin control, or
a sip and puff control unit. Patients with lesions at the C-5 level
are able to self-feed and brush their teeth with assistive devices.
 Neuropsychological Impairment 19

They may also drive a powered wheelchair with a hand-control

unit. Patients with lesions at the C-6 level can push a manual
wheelchair with vertical tips on the hand rims. They have po¬
tential independence in self-care activities, and can be indepen¬
dent in transferring from bed to wheelchair using a sliding
board. They may be able to drive a van with hand controls and
power door lift. With the C-7 level lesion, self-care activities are
much easier and a manual wheelchair will be sufficient for
locomotion. Patients with C-8 to T-l level lesions can have full
independence although they will be wheelchair bound. In le¬
sions at the T-2 through Lr3 level, the paralyzed individual will
be completely independent and wheelchair bound, and have
better stamina because of minimal respiratory and upper ex¬
tremity limitations. L4 to 5 paraplegics are able to walk with
leg braces and crutches. S-l level paralysis will require braces
and crutches, and because of the neurogenic bladder and
bowel, require intermittent catheterization and a regular
bowel program.

PHYSICAL CHALLENGES ASSOCIATED WITH BRAIN

INJURY

Patients with brain injury often have unilateral impairment

which may permit them to compensate for physical limitations
with their unaffected side. However, they frequently have trou¬
ble with activities of daily living because of their unique neuro¬
logical impairment. Patients with brain injury can have
impairments in one or more physical functions which will im¬
pair their feeding skills. Dysphagia, difficulty swallowing, is
commonly seen in patients with brain injury and may result
in dietary restrictions. These patients are at a greater risk for
aspirating with thin liquids than thick liquids. Food consump¬
tion may be limited to pureed, soft, minced, or regular food.
Impairments in feeding may also result from hemiparesis, con¬
tractures, spasticity, sensory deficits, poor head control, and
impaired balance. These patients may need help with feeding
and/or assistive devices such as positioning aides, splints, or
20 Robert W. Sury-Mary Sano

adaptive utensils. Cognitive and perceptual deficits may impede

the progress of learning to incorporate assistive devices. For
example, patients with neglect may leave food in one side of
their mouth. This neglect can lead to aspiration.
The ability to dress and complete hygiene skills can be
compromised in the head injured patient. Hemiparesis or
hemiplegia may impede these activities. In addition, visual ne¬
glect, anasanosia, and apraxias can further limit the accom¬
plishment of these functional activities. Specific training with
adaptive aides and bathroom modifications such as bath bars,
raised toilet seats, and shower chairs may be helpful. These
patients may also need to have a routine set up for them, which
will organize the activity and require minimal initiation on
their part.
Communication skills may be severely impaired following
brain injury. Aphasia, alexia, agraphia all contribute to the pa¬
tient’s inability to write, type, or use the telephone. Adaptive
aides may be useful when neglect, weakness, visual field cut, or
incoordination are the source of the problems.
Homemaking skills present a series of physical challenges
to patients with brain injury. Physical limitations may reduce
independence in cooking and cleaning. Decreased sensation
or neglect can cause serious burns in patients because of lack
of awareness of potentially dangerous situations. Cognitive
problems, such as impulse control, difficulties with judgment
and problem solving abilities, can also increase the risk of un¬
safe behavior in homemaking activities. Both physical ability
and safety must be considered when determining one’s ability
to perform independently. In some cases, maximum indepen¬
dence will always require supervision to perform homemak¬
ing tasks.
There are many aspects to the challenge of mobility out¬
side the home for patients with brain injury. Driving can be
impaired by seizures, visual field defects, or neglect. Medica¬
tions can cause drowsiness. Poor judgment can make driving
unsafe. While adaptive devices can permit driving in the pres¬
ence of motor weakness, they do require intact perception
and judgment.
 Neuropsychological Impairment 21

Other independent living skills also offer physical chal¬

lenges, such as shopping and recreation. Shopping involves the
recognition of need, the organization of transportation for the
activity, selection of items, and management of money. Patients
with brain injury may have problems with all or any of these
areas. Because of physical limitations prohibiting driving, many
times these patients will need to use public transportation.
Strategies for these activities include getting on and off at the
same stop, and carrying fare in the same place, which help to
eliminate confusion. Patients will have difficulty with recre¬
ational activities, and may need to find new hobbies or activities
they can perform that are within their new limitations.

MEETING THE CHALLENGE IN THE FACE OF PREMORBID

FACTORS

Identification of premorbid conditions is an important step in

understanding how the patient will meet the physical chal¬
lenges facing them. Patients with a traumatic injury often have
a preexisting history of learning disability, substance abuse,
prior arrests and incarcerations, and psychological problems
including personality disorders (Fahy, Irving, & Millag, 1967;
Rosenthal & Bond, 1990). Alternately, brain injury may reflect
an event over which a patient had no control and premorbid
characteristics and self-perceptions may play a role in the ability
to rise to the challenges that occur. Patients with stroke may
have had a previous stroke, or other unaddressed risk factors
including uncontrolled hypertension or diabetes. A history of
all aspects of the patient’s life may be needed and many sources
may be called on to accomplish this, including family members,
employers, school records, teachers, and friends. Family mem¬
bers can often provide information, but it may be biased by
fear that negative information about the patient may alienate
the staff, inadvertently set a low expectation for recovery, or
jeopardize a legal claim. Consequently, it is important to get a
broad view of the patient’s premorbid status.
Since many patients will have increased dependence on
others after the injury, it is important to understand the dynam¬
ics of their interpersonal relationships. In the case of a patient
22 Robert W. Sury-Mary Sano

who will return to a home setting, preexisting tensions between

the patient and the family will interfere with their ability to
provide the appropriate level of supervision and indepen¬
dence.
Preexisting substance abuse, a not uncommon condition
in traumatic injury (Heinemann, Keen, Donohue, & Schnoll,
1988), is unlikely to resolve without intervention. This is true
of noncompliance with medical treatments for conditions such
as diabetes or hypertension, which increase the risk of stroke.
While these may be controlled in the rehabilitation setting, in
a less restrictive environment, these patterns are likely to re¬
turn. In the patient who faces physical challenges because of
their injury, the use of drugs or alcohol has a heightened likeli¬
hood of causing reckless behavior and reinjury.
Psychological factors often contribute to the behavior that
led a patient to the injury. These factors must be addressed to
maximize the patient’s new limitations and to avoid returning
to high-risk behavior.
The return to employment is part of a rehabilitation assess¬
ment. However, the work setting often provides a set of physical
challenges. If return to work is part of the goal, one must assess
premorbid employment history. Both the type of job and the
work habits need to be addressed. The simplest reentry to em¬
ployment would be to return to a preinjury job. This may re¬
quire adaptations to the workplace, assistive devices, and
flexible hours. It may not be possible to adapt some jobs, partic¬
ularly if they involve intense physical labor. Retraining for more
sedentary positions may be desirable, but premorbid educa¬
tional level and academic history may limit the potential for
retraining. The neuropsychological deficits of the present acci¬
dent must also be considered when retraining is being pro¬
posed.

CONCLUSIONS

There is a wide range of cognitive deficits and physical chal¬

lenges experienced by patients in the rehabilitation setting.
 Neuropsychological Impairment 23

Acknowledging the breadth of these problems permits one to

develop realistic goals for recovery. Injury usually impacts on
many aspects of the nervous system and many functions and
behaviors are controlled to a greater or lesser degree by several
different brain locations. Therefore, it is unlikely that a single
description will capture the nuances experienced by an individ¬
ual. However, understanding the most probable patterns of
deficit may provide a schema within which to approach the pa¬
tient.

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Rehabilitation of the adult and child with traumatic brain injury
(2nd ed.; pp. 179-192). Philadelphia: F. A. Davis.
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Taylor, D. C. (1969). Aggression and epilepsy, fournal of Psychiatric
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Warrington, E. K., & Rabin, P. (1970). Perceptual matching in pa¬
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2.

A History of Psychotherapy with

Patients with Brain Injury

Laurence Miller, Ph.D.

As recently as a week prior to this writing, a neurologist col¬

league, upon hearing that I was preparing a chapter on psycho¬
therapy with patients with brain injury, queried bluntly, ‘ ‘What
the hell can you do for those people?”
‘‘What we do for” our patients with organic brain syn¬
dromes is the subject of this volume, and to know where we’re
going, it’s useful to know where we’ve been. Most of the con¬
ceptual confusion and clinical public relations difficulties in
advocating psychotherapy as a legitimate, indeed vital, aspect
of brain injury rehabilitation comes from the entrenched, tra¬
ditional dichotomy of organic vs. psychological. Neuromedical
research is pinning down psychological symptoms to PET-en-
hanced cerebral structures, and physicians routinely take dou¬
ble board certification in neurology and psychiatry. But even
in the late 1990s there persists a clinical mindset that is appar¬
ently more willing to accept a biological component for depres¬
sion or psychosis, than a psychodynamic dimension to the
adaptive recovery from acquired brain injury.
The history in this chapter is a dual one, because neuropsy¬
chology and psychodynamics have always nourished one an¬
other—indeed, one could not exist without the other (Miller,

27
28 Laurence Miller

1991,1997, 1998b, in press). This chapter will provide a concep¬

tual history of psychotherapeutic approaches that have recog¬
nized this important link. The focus will be on one important
meeting ground between the two disciplines, namely cognition.
As human beings are thinking creatures, the vagaries of cogni¬
tion, along with its sister functions, emotion and action, lie at
the very core of the concept of selfhood. And it is this shattered
self that effective psychotherapy with patients who are neuro-
psychologically impaired must fundamentally address (Miller,
1993a, 1998a).

THE ORGANIC PERSONALITY

Neuropsychologists know that there are many individual varia¬

tions of the clinical picture seen after brain damage, depending
on the type and location of the injury, as well as the patient’s
preexisting and predisposing characteristics. However, certain
behavioral commonalities are typically found in brain injured
patients as a whole. Historically, one of the first and best com¬
prehensive descriptions of the organic personality as a unitary,
composite, clinical entity comes from the work of Kurt
Goldstein (1952). Goldstein (1952) conceived of brain damage
as impairing the person’s ability to make the necessary adapta¬
tions to his or her world in the service of discharging tensions
and satisfying needs—what psychoanalytic clinicians like Hart¬
mann (1939/1958) were calling adaptive ego functions.
Thus, observed Goldstein (1952), some organically im¬
paired patients are unable to bear even small changes in envi¬
ronment or routine. Others cannot sustain close relationships
because this usually involves tolerating some degree of frustra¬
tion of immediate needs. Such patients may appear overly de¬
manding, clingy, or “childish.” Still others can’t cope with the
disability caused by the brain damage, and its effect on their
lives.
Many such patients learn to achieve a kind of fragile equi¬
librium, wherein they constrain their range of activities in dif¬
ferent environments to a level that their altered cognitive
 History of Psychotherapy 29

capacities can handle. This, Goldstein (1952) pointed out, of¬

ten requires nothing less than a redefinition of the person’s
identity and self-image. This is difficult enough for a physically
disabled person with an otherwise intact brain, but a colossal
undertaking for someone who has sustained an injury to the
very organ of adaptation itself.
Aside from focal deficits such as aphasias, aprosodias,
apraxias, agnosias, and amnesias, much of the difficulties expe¬
rienced by the patient who has brain injury were attributed by
Goldstein (1952; Goldstein & Scheerer, 1941) to what he called
a loss of the abstract attitude. Although seen most often in pa¬
tients with frontal lobe damage, it also occurs frequently in
many other kinds of focal or generalized brain injury. This is
not surprising, as Goldstein pointed out, since the frontal lobes
constitute about one-third of the entire human brain volume,
so sufficient impact anywhere in the cranium is bound to affect
the frontal region to some degree.
It is this abstract attitude, said Goldstein (1952;
Goldstein & Scheerer, 1941), that enables a person to flexibly
detach their ego from the outer world or inner experience. It
enables us to assume a particular mental set, to account to
oneself for one’s own behavior and to verbalize that account.
It enables us to shift reflectively from one aspect of a situation
to another, to hold several aspects of a situation or problem in
mind simultaneously, and to grasp the essentials of a given
whole. We can break up a given whole into parts, and isolate
and synthesize these parts. We can abstract common properties
of a thing reflectively and form hierarchic concepts. We are
enabled to plan ahead ideationally, to assume an attitude to¬
ward the “mere possible,’’ and to think or perform symboli¬
cally.
Luria (1973, 1980), who cited Goldstein’s work extensively
(and, to a lesser extent, Freud’s), subsequently conducted his
now classic studies of the neuropsychology of cognition, and
outlined the stages ordinarily involved in what we regard as
mature, productive thought. First, there must exist a task or
problem for which there is no instinctual or automatically ha¬
bitual solution. Next, there must be some motivation for solv¬
ing that problem. Further, the person must be able to restrain
30 Laurence Miller

impulsive responding, and be capable of investigating and ana¬

lyzing the features of the problem. Out of many possible alter¬
native courses of action, the individual must select those few
that are judged to be most appropriate, sequence the action
appropriately, then put the plan into effect, and finally, evalu¬
ate the results against the original goal. This automatic cogni¬
tive cascade is what largely facilitates mature, adult, adaptive
thought and behavior.
When the adaptive capacity of the individual is strained to
the breaking point—which happens all too frequently for the
brain injured individual—the clinician may observe what
Goldstein (1952) characterized as the catastrophic reaction. Ex¬
pressions of this decompensation may range from the frankly
explosive—the patient screams, curses, lashes out, throws
things—to more subde and therefore more easily overlooked
manifestations, such as passive withdrawal, regression, smolder¬
ing hostility, sullen refusal to cooperate, or failure to partici¬
pate in self-care.
Over time, said Goldstein (1952), the patient with a brain
injury begins to develop protective mechanisms in order to fore¬
stall anxiety, frustration, and the catastrophic reaction. Exam¬
ples of this include denial of deficit and withdrawal from
demanding and frustrating activities. The latter frequently
plays havoc with rehabilitation staff, who may not understand
why the patient “doesn’t want to get better,’’ insufficiently ap¬
preciating what a blow to self-esteem and self-image each little
failure and struggle entails. Obsessive—compulsive behavior
may develop as the patient tries to achieve maximal control
over a delimited aspect of his or her environment.
An inability to fully comprehend the requirements of the
social milieu may lead to a variety of “immature” or “inappro¬
priate” behaviors. The need to discharge tension immediately
may be expressed in impulsive, angry, and “entitled” demands
for food, cigarettes, sex, privileges, and so on. The concreteness
associated with neurocognitive impairment may lead to a
“coarsening” of thought, feeling, and action, as well as a loss
of the patient’s sense of humor.
 History of Psychotherapy 31

More recently, Lewis and Rosenberg (1990), drawing on

their experience with patients who have traumatic head injur¬
ies, have presented a characterization of the “organic personal¬
ity” that comes close to the one offered earlier by Goldstein
(1952). Patients with brain injury, in this account, must strug¬
gle with high levels of anxiety at the same time that their capac¬
ity to tolerate painful emotions of any type has been reduced.
Heightened affective arousal, coupled with reduced tolerance
of affect, is a perfect set-up for the appearance of catastrophic
reactions and other forms of decompensation. By virtue of the
neurologic dysfunction and resultant cognitive deficits, the pa¬
tient is less adept at smoothly integrating raw feeling with re¬
fined perceptual apprehension and cognitive understanding.
The brain injury has thus created a condition that Lewis,
Allen, and Frieswyk (1983) call cortical vulnerability: These pa¬
tients tolerate emotion poorly because brain damage has de¬
prived them of the capacity to sufficiently titrate and modulate
emotion in a way that makes it comprehensible and manage¬
able. This may be exacerbated by a tendency to actively avoid
thinking about, or “dwelling on,” painful feelings, thereby pre¬
cluding the development of adaptive coping—an attitude often
abetted by well-meaning persons seeking to avoid “upsetting”
the patient.
Yet other patients, even without a history of acquired brain
injury, seem to encounter “upsetting” situations all too fre¬
quently, and to characteristically cope with them poorly. What
has neuropsychology and psychodynamic theory had to offer
these patients?

THE PRIMITIVE PERSONALITY

The psychodynamic side of this chapter’s history begins, appro¬

priately enough, with Freud. Freud (1900/1953, 1915/1957,
1923/1961) originally proposed that the transformation of
primitive instinctual impulses into consciously acceptable sub¬
stitutive drive derivatives utilizes the cognitive processes of sym¬
bolization and language. The purpose of thinking, said Freud,
32 Laurence Miller

is to permit the ego to achieve a delay of motor discharge, to

serve as a kind of “experimental action” which allows for the
exploration of behavioral alternatives with far less effort and
painful consequence than would be required for the real-world
testing of each different alternative.
But Freud failed to elaborate on the roles of these cogni¬
tive processes in the development of personality, preferring to
concentrate on the role of instinct. It became the task of the
later ego psychologists, exemplified by Heinz Hartmann
(1939/1958), to stress the importance of what they regarded
as constitutionally given mental endowments and apparatuses
for psychological development—such faculties as memory, per¬
ception, attention, and intelligence. According to Hartmann
(1939/1958), these basic human adaptive apparatuses com¬
prise a core of adaptive psychological functioning that is rela¬
tively independent of instinctual conflict, constituting the
conflict-free ego sphere. These apparatuses also influence the dif¬
ferent ways of handling conflict; that is, they are the underpin¬
nings of the classic psychological defenses.
Hartmann (1939/1958) proposed that evolution leads to
increasing independence of the organism from its environment
so that reactions which originally occurred in relation to the
external world are progressively displaced to the interior of the
organism, that is, to a mental domain. In order to achieve a
certain adaptation to and mastery of the world, a person need
not test every possible response and observe every possible re¬
action. Rather, he or she can think about consequences, antici¬
pate outcomes, and create contingency plans of alternative
means-end possibilities, which Hartmann collectively de¬
scribed as the process of internalization. Accordingly, Hartmann
spoke of ego autonomy as involving the relative freedom of the
ego or self from blind obediance to instinctual emotional and
motivational demands, as well as from a dependency on imme¬
diate environmental reinforcement for each action and plan.
The term cognitive style vrns introduced by George S. Klein
(1954, 1958) to refer to the arrangement of general regulatory
or control structures in each person’s psyche, having their basis
in the constitutional faculties suggested by Hartmann (1939/
 History of Psychotherapy 33

1958). An unfortunately little-known and underappreciated re¬

search project was carried out by Gardner, Holzman, Klein,
Linton, and Spence (1959) which explored the relationship
between psychodynamics, cognitive style, and psychopathology,
and served historically as the foundation of many of the “pro¬
jective tests” routinely used by psychoanalytically oriented clini¬
cians (Rapaport, Gill, & Schafer, 1968). David Shapiro (1965)
subsequently used the term style in his conceptualization of
neurotic styles; i.e., characteristic maladaptive modes of func¬
tioning that are built around each person’s characterological
style of perception, thought, and action.
Symptoms or prominent pathological traits, said Shapiro
(1965), regularly appear in the context of attitudes, interests,
intellectual inclinations and endowments, and even vocational
aptitudes and social affinities with which the given symptom or
trait seems to have a certain consistency. Accordingly, neurosis
is not simply the result of instinctually driven, intrapsychic con¬
flict superimposed on a tabula rasa personality. Rather, the
form that the neurotic expression of conflict takes is strongly
determined by how that person perceives the world, thinks
about it, reacts emotionally to it, and behaves in it; that is, by
how his or her own set of constitutional cognitive traits is ar¬
rayed in the psyche. Shapiro (1965) identified four main neu¬
rotic styles: the obsessive-compulsive, the paranoid, the
hysterical, and the impulsive, providing the foundation for a
later neuropsychodynamic conceptualization of personality by
Miller (1990, 1991).
More recently, Shapiro (1989) has asserted that the neu¬
rotic patient is “estranged from himself” to the extent that
his maladaptive or neurotic cognitive style contributes to the
obfuscation of his own motivations and interpretations of exter¬
nal reality. Shapiro’s (1989) neurotic personality is reminiscent
of Goldstein’s (1952) descriptions of the organic personality
and Luria’s (1973, 1980) studies of frontal lobe deficits in ver¬
bal self-regulation. Shapiro’s (1989) neurotic personality reacts
not deliberatively, proactively, and autonomously, but rather
quasireflexively to dispel or forestall external anxiety or inter¬
nal psychical discomfort produced by self-perceptions that
34 Laurence Miller

threaten the all too brittle and fragile stability of the personal¬
ity structure.
Robbins (1989) has provided a description of the primitive
personality, under which he subsumes the borderline, narcissis¬
tic, paranoid, and schizoid personality types. Other writers have
also included the impulsive and hysterical personalities in this
category (Begun, 1976; Masterson, 1988; Millon, 1981, 1990;
Shapiro, 1965). The key feature of primitive personalities is the
fundamentally compromised, non-self-aware, poorly self-regu¬
lated, and often self-destructive existences these individuals typ¬
ically lead.
Primitive personalities show deficient personality integra¬
tion, being characteristically dominated by self-contradictory
thinking. Their emotional life is typically undifferentiated from
raw perception and nonreflective action. Like children, or
some neuropsychologically impaired individuals, primitive per¬
sonalities tend to be concretely immersed in their immediate
interpersonal surroundings. They misconstrue their own cogni¬
tive-affective conceptualizations of others, and experience
strong urges to act impulsively toward these persons in a posses¬
sive, controlling, destructive, or distancing manner. Finally,
primitive personalities suffer from an inability to identify and
sustain core emotions, leading to affective lability and unstable
emotional attachments.
Thus, the synchronies between patients whose adaptive ca¬
pacities have been shattered by acquired brain injury—not to
mention those in which these capacities never fully developed
because of impaired neuropsychodevelopment—are therefore
obvious. Consequently, the treatment considerations may share
a similar correspondence.

COGNITIVE REHABILITATION AND PSYCHOTHERAPY

WITH THE ORGANIC PATIENT

Goldstein’s (1952; Goldstein & Scheerer, 1941) and Luria’s

(1973, 1980) neuropsychodynamic conceptualization of or¬
ganic brain syndromes have begun to find practical application
 History of Psychotherapy 35

in the neuropsychologically informed psychotherapeutic ap¬

proaches that are being developed in treatment centers
throughout the country, and that form the subject matter of
the present volume. Much of the impetus for developing more
refined and comprehensive psychotherapeutic approaches for
patients with brain injury has emerged from clinicians’ and
patients’ frustration with the oversimple, even puerile, quality
of some of the materials used in so-called “cognitive rehabilita¬
tion.” In addition there is the saturation effect of continued
and tedious practice of gamelike computer programs, with little
attention to emotional and psychosocial issues (Carberry &
Burd, 1985, 1986). Even “behavioral self-management,” with
its empowering-sounding connotations, often boils down to the
robotic repetition and arbitrary enforcement of behavioral
rules and routines. As some neurorehabilitation practitioners
(Ben-Yishay & Diller, 1983, 1993) have pointed out, rehabilita¬
tion efforts which emphasize cognition and behavior, to the
neglect of emotion and selfhood, omit the important function
of helping the patient in his attempt to redefine and integrate
a new identity.
Historically, the work of Leonard Small (1973, 1980)
marked a major turning point in moving neuropsychology from
its predominant focus on psychometric assessment and localiza¬
tion of function to an emphasis on psychodynamically in¬
formed diagnosis and in-depth psychotherapeutic treatment of
a variety of organic brain syndromes. Small (1980) pointed out
that brain damage often results in behavioral regression, due
in large part to the dissolution of higher integrative cognitive
skills necessary for complex adaptational tasks. Even as recov¬
ery and improvement in cognitive functioning occur, the pa¬
tient may cling to more regressed modes of functioning
because they have become predictable and manageable. Care¬
ful encouragement, support, and step-by-step training may be
necessary to enable such a patient to utilize his or her recov¬
ering capacities. Forcing a too early renunciation of “imma¬
ture” defenses and coping patterns may precipitate a
catastrophic reaction and instill massive resistance to further
therapeutic progress.
36 Laurence Miller

Denial, said Small (1980), especially when severe and per¬

vasive, is probably the most difficult of the defenses to deal
with, and organic denial is often refractory to any kind of psy¬
chotherapeutic approach. In other cases, denial serves a more
psychodynamically based, ego-protective function which, how¬
ever, may be maladaptive because it prevents the development
of a realistic self-concept and impedes efforts to focus on areas
where true progress can be made. The approach, then, should
be not so much a confrontation or challenge, but rather a
gradual focus on reality that continually monitors the patient’s
ego tolerance as it proceeds. Partial insights and interpretations
should take precedence over ultimate ones, so that sufficient
time is allowed for a reaction to the partial interpretation to
be elaborated and judged.
Another pioneer in the psychotherapy of patients with
brain injury has been George Prigatano (1991; Prigatano et al.,
1986) whose work clearly recognizes that cognitive and emo¬
tional issues are rarely separable in the real clinical world of
brain injury. Prigatano et al. (1986) point out that when pa¬
tients are cognitively confused, they are generally not clear
about what their feeling states are. When the confusion sub¬
sides, feelings of depression and deep sorrow often emerge.
Also, many of the interpersonal problems that a person with
brain injury experiences are related to faulty thinking and in¬
correct assumptions he or she may make about him- or herself
in certain situations. There is also a tendency for patients with
brain injury to deny and cover up deficits by increased rigidity
of thinking. Interpersonal dialogue is thus often characterized
by cognitive rigidity, loose associations, missing the main point,
tunnel vision, and egocentricity. Prigatano et al.’s (1986) devel¬
opment of group therapy approaches to foster self-reflective
psychosocial adaptation has become a model replicated around
the world.
More recent contributions to psychodynamically oriented
psychotherapy with patients who have a brain injury include
that of Lisa Lewis and her colleagues (Lewis & Rosenberg, 1990;
Lewis et al., 1983), who emphasize the effects of patients’ pre-
morbid personalities in determining whether therapy and the
therapist are seen as a benefit, or as a threat and a burden.
 History of Psychotherapy 37

Patients whose preexisting level of ego organization is in the

borderline range probably never fully developed the capacity
to use adaptive ideation and self-reflection in the first place.
In psychotherapy they are encouraged to reflect on their expe¬
riences, and therapy quickly becomes an onerous chore, as
their ability to use thinking in the service of self-understanding,
problem solving, and planning a course of adaptive behav¬
ior—vestigial at best, even before the brain injury—are chal¬
lenged.
Psychotherapy, with its thrust toward growth and auton¬
omy, may thus be viewed by such patients with considerable
ambivalence. Also, patients may be reluctant to make changes
that are genuinely within their capacity for fear that others will
perceive them as more competent, or less impaired, than they
actually are, and then abandon them. Further, patients with
brain injury are sometimes plagued by guilt, with the injury
perceived as just punishment. Psychotherapy, with its implicit
promise of a fuller and more productive life, may therefore
be viewed negatively, and the patient’s feelings of guilt and
“badness” must therefore be directly addressed. Many such
patients, therefore, show marked “resistance,” and the thera¬
pist must then continually tread the fine line between stimulat¬
ing the patient’s latent capacities for adaptive thought and
action, and pushing the patient beyond his or her limits,
thereby creating the set-up for a catastrophic reaction.
Similarly, the work of Karen Langer (1992) explicates the
diverse varieties of emotional syndromes, psychological reac¬
tions, and distortions of personality that may both follow and
underlie a patient’s response to brain injury. Her work teaches
us never to forget the individuality of each patient’s neuropsy¬
chodynamics in planning and implementing effective psycho¬
therapeutic and rehabilitative strategies.

PSYCHOTHERAPY, PERSONALITY, AND COGNITIVE

STYLE

But it works the other way, too. If the line between rehabilita¬
tion and psychotherapy is a fluid one in the case of brain in¬
jured patients, it is all the more so for patients with “primitive”
38 Laurence Miller

personalities, often overlapping with those described as having

neurotic cognitive styles (Shapiro, 1965). The term neurotic is
understood by some psychodynamic theorists to signify a some¬
what higher level of ego integration than “personality disor¬
der,” or “character pathology.”
According to Erickson and Burton (1986), the kind of cog¬
nitive impairment relevant to overall rehabilitation of psychiat¬
ric and other psychotherapy patients seldom consists of discrete
deficits specifically associated with brain damage, such as apha¬
sias, apraxias, or visual field defects. Rather, they typically repre¬
sent more general deficiencies in higher level complex
processes such as attention and concentration, learning and
memory, psychomotor speed, and problem solving. Such defi¬
ciencies are not only found among patients with brain injury
and chronic psychiatric patients, but may also occur with nor¬
mal aging, various personality disorders, and substance abuse.
Robbins (1989) speaks about the difficulty frequently en¬
countered by clinicians in forming a therapeutic working alli¬
ance with primitive personalities. This is because such
individuals lack the capacity for self and object constancy, are
unable to sustain a sense of pleasure in relationships, and tend
to form pathological symbiotic adaptations in which one party
is exploited as the “possession” of the other.
Work with primitive personalities often involves dealing
with what is termed pseudoinsight, repetitive sequences of ap¬
parent insight and understanding, followed by seemingly total
forgetting. Interactions which, at the time of their occurrence,
may have been viewed as meaningful and relevant seem to van¬
ish from the patient’s memory, as if they never took place.
This is similar, we may note, to the problems of therapeutic
continuity experienced by patients with organic memory dis¬
turbances and impaired conceptualization. What accounts for
these discouraging cycles in the case of primitive personalities
is their characteristic lack of integration, absence of self or
object constancy, global destructiveness, and the inability to
represent and sustain affective experiences. Again, all these
elements are reminiscent of the problems in adaptation experi¬
enced by patients with frontal lobe injury.
 History of Psychotherapy 39

Many clinicians, including Masterson (1988) and Robbins

(1989), have noted the overall refractoriness of primitive per¬
sonalities to accepting and utilizing interpretations in general.
If a patient has no internally experienced emotional referent
for the thoughts, feelings, and contradictions that emerge in
therapy, he or she may feel misunderstood or criticized, rather
than enlightened, by the therapist’s interpretive com¬
ments—similar to Lewis and Rosenberg’s (1990) characteriza¬
tion of psychotherapy as a “burden” to many brain injured
patients.
Robbins (1989) proposes a cognitively oriented psychoana¬
lytic technique to treat primitive personalities, the elements
of which may sound familiar to those clinicians applying the
modalities of brain injury psychotherapy discussed above. Rob¬
bins’ (1989) technique requires a process of clarification and
interpretation directed more toward these patients’ unusual
cognitive processes and affective deficits than toward their pu¬
tative unconscious conflicts and defenses. Such cognitively ori¬
ented psychodynamic psychotherapy first addresses the
question of how the patient constructs meaning from his or her
experience, and only secondarily explores what that meaning
might be. Rather than uncovering conflict, the emphasis of
psychotherapy with primitive personalities, says Robbins
(1989), should be an educative one—we might say a rehabilita¬
tive one. For these individuals, analysis of cognition and affect
occupies the central position that analysis of conflict and de¬
fense occupies in the treatment of other, more integrated pa¬
tients. Via the therapeutic relationship, the patient’s new self
is constructed out of the tangible, real-world, neuropsychody-
namically adaptive elements of thought, feeling, and action,
and thus serves as the scaffolding upon which a new, more
integrated personality structure can evolve.

CONCLUSIONS: CONTINUITY, NOT DICHOTOMY

Back to the question of “what we do for” our patients. Perhaps

the confusion of some of our colleagues as to the efficacy of the
kinds of historical and contemporary therapeutic approaches
40 Laurence Miller

discussed in this chapter derives from a conceptual misunder¬

standing of the “purposes” of psychotherapy as a whole.
Guze (1988) discusses two predominant contemporary
models of psychotherapy. The first of these, the etiological view,
is based on the premise that the psychotherapeutic process
provides a basis for exposing the complex psychodynamic driv¬
ing forces responsible for the patient’s symptoms and life dis¬
tress, and that such an approach is, indeed, the only legitimate
way of understanding and treating the disorder. Since the suc¬
cess of the treatment depends on the validity of the model,
to the extent that the etiological hypotheses are flawed, the
justification for the psychotherapy is undermined.
The second approach to psychotherapy described by Guze
(1988) is the rehabilitative view which approaches the patient’s
disorder without any obligatory assumptions about etiology,
although it may involve careful assessment of the patient’s psy¬
chological functioning. That is, the patient’s symptoms, per¬
sonality, attitudes, emotions, perceptions, strengths,
weaknesses, expectations, and relationships are all evaluated,
but without assuming any etiological hypothesis concerning the
presenting disorder. The aim is to help the patient understand
him- or herself better and, with the aid of the therapist, func¬
tion more effectively, with less discomfort and less disability,
even if there occurs little “insight” as to why the patient’s
problems began or how the patient’s personality developed.
A clinical analogy would be to physical therapy, or physical
rehabilitation, which is indicated for a wide variety of orthope¬
dic, neurologic, and other syndromes. This form of treatment
is nonspecific in that it does not necessarily deal with putative
causal conditions or pathogenetic factors. It takes into consid¬
eration age, strength, personality, previous skills, etc., in an
attempt to foster recovery or improvement in physical disabil¬
ity, but its practitioners need not accept any particular theory
of etiology to account for the syndromes they treat.
Undoubtedly, effective psychotherapy combines elements
of both the etiological and the rehabilitative approaches, in
different proportions for different types of patients and prob¬
lems (Miller, 1993b). Indeed, many of the psychotherapists
whose work has been reviewed here have attempted to tread a
 History of Psychotherapy 41

path between theoretical coherence and clinical practicality.

From the material reviewed in this chapter, we may conclude
that what psychotherapy with organic patients and those with
“functional” disorders of personality share in common is, first,
an emphasis on shoring up the fragile ego structure, the sense
of self—indeed, the patient’s core identity—before trying to
explicate and resolve dynamic-conflictual issues (Miller, 1993a,
1998a, 1998b, in press). In some cases, the self has been shat¬
tered by acquired brain injury; in others, it never fully devel¬
oped due partly to anomalous neurodevelopmental processes
which we are only beginning to understand. In both cases, how¬
ever, it requires our sharpest clinical skills to evaluate and treat
these challenging patients, and our efforts must begin with an
understanding of our history and a continuing search for
unities.

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3.

Ethical Challenges

Robert M. Gordon, Psy.D.

Ethics are the values, principles, and norms assumed in a given

cultural or professional setting and are utilized in determining
appropriate conduct. While literature in the field of bioethics
has proliferated, examples and models discussed therein pre¬
dominantly address emergency or acute medical care rather
than rehabilitation medical settings (Caplan, Callahan, &
Haas, 1987).
Acute care and rehabilitation medicine can be viewed as
two endpoints on a continuum of goals within health care.
The primary objective of acute medical care is immediate cure,
while the goals of rehabilitation are improvement in overall
functioning over an extended period of time. Rehabilitation
rarely involves the dramatic cure or the life-saving technology
found in acute care settings. Consequently, the moral and ethi¬
cal questions arising in rehabilitation tend to be different from
existing ethical models addressing issues of acute care (Caplan
et al., 1987).
In medical rehabilitation, professionals are more likely to
confront conditions that are chronic, irreversible, and relatively
stable (Caplan etal., 1987).Jennings (1993) described the over¬
all goal of rehabilitation as the revitalization of the patient’s
power to live a meaningful life. Rehabilitation professionals

45
46 Robert M. Gordon

attempt to reduce the impact of disability by enhancing com¬

pensatory functional abilities through skills retraining and
environmental modification (Haas, 1987). Through rehabilita¬
tion, patients are encouraged to strive toward the highest levels
of autonomy possible given the limitations and obstacles im¬
posed by the disability (Purtillo, 1988).

MODELS OF ETHICAL DECISION MAKING

Three ethical models of physician-patient decision making

dominate the field of medicine. These include the traditional
model of medical paternalism, as well as the contractual and
the educational models (Caplan et al., 1987). These models
parallel what Siegler (1993) described as the three phases of
medicine—the age of the doctor, the age of the patient, and
the age of the payer.
A fourth model particularly relevant to rehabilitation med¬
icine, the relational perspectivistic model, best represents the
psychological challenges and ethical complexities of working
with patients experiencing neurological impairment. This
model, which has not been applied to medical ethical decision
making, will be discussed at length later in this chapter.

The Traditional Model: Medical Paternalism

The “Age of the Doctor” characterized medical care from

about 500 bce to around 1965 (Siegler, 1993). In this model,
decisions are based principally on the physician’s ability to
prognosticate about the patient. Paternalism was the caregiv¬
er’s method of relating to patients. The physician believed that
he or she was entitled to act in the presumed best interest of
a patient without his or her consent. The paternalistic model
depicted the physician, given his or her specialized knowledge,
as an active patient advocate (Caplan et al., 1987). Historically,
 Ethical Challenges 47

many physicians in the United States and other Western na¬

tions did not perceive the patients’ best interest to involve in¬
forming them of the diagnosis or prognosis. As recently as the
1950s, physicians typically withheld information from seriously
or terminally ill patients. They rationalized withholding bad
news on the grounds that it would be harmful or that patients
preferred not to know negative truths (Caplan, 1988).

Contractual Model

Critics of the paternalistic model agreed that patients had mini¬

mal autonomy in contesting physicians’ recommendations.
These critics advocated for more egalitarian physician-patient
relationships and decision making (Caplan et al., 1987). By
1965, the spectrum of medical interventions began to change
rapidly with advances in kidney dialysis, transplantation surger¬
ies, chemotherapies and intensive care medicine. During this
phase of medicine involving complex choices regarding care,
patients and their families increasingly challenged the absolute
power of the physician and requested greater participation in
the decision-making process. The principles of informed con¬
sent and confidentiality thus became more prominent
(Siegler, 1993).
The opponents of medical paternalism advocated a more
democratic model of the physician—patient relationship based
on contract theory and reflecting the rapid social changes of
the 1960s. The doctrine of the patient’s informed consent was
a central feature of this model. The contractual model assumed
that the patient was competent to make rational choices and
was motivated to do so. From this perspective, physicians
should provide optimal medical care, but only that desired and
accepted by the patient. Patients had the right to refuse poten¬
tially beneficial care if their decisions were based on voluntary
informed choice (Caplan et al., 1987). As this model increas¬
ingly became a central component of all medical and ethical
decision making, a parallel shift in focus occurred in clinical
48 Robert M. Gordon

practice involving the increased sharing of information regard¬

ing diagnosis and prognosis (Caplan et al., 1987).

The Educational Model

The educational model emphasizes a flexible use of paternalis¬

tic and educational interventions depending on the phase of
rehabilitation. During the initial phases of rehabilitation, pa¬
tients with neurological impairments commonly experience
considerable distress, anxiety, and disorientation, rendering ra¬
tional choices difficult. Caplan (1988) has advocated that physi¬
cians and other health care professionals be allowed more
latitude during this initial phase of treatment than the contrac¬
tual model provides. The caregiver’s role in the educational
model could be paternalistic in the service of eventually restor¬
ing or enhancing the neurologically impaired patient’s long¬
term autonomy. In fact, patients psychologically capable of
making treatment decisions need time to adjust to new illnesses
or disabilities, as well as to process the information they are
given. In the view of Caplan et al. (1987), the onset of an unex¬
pected neurological impairment warrants great sensitivity by
health care providers regarding the patient’s readiness to hear
and retain important information. The educational model also
requires, however, that the rehabilitation team strive to restore
patient autonomy as quickly as possible by providing detailed
information regarding the course of treatment and risks and
benefits of alternative approaches, as well as involving the pa¬
tient and family actively in goal-setting.

The Relational-Perspectivistic Model

An alternative approach to physician-patient interaction and

ethical decision making is based on the relational—perspectivis-
tic model described in the recent psychoanalytic literature
(Aron, 1996). This paradigm of ethical decision making consid¬
ers the importance of the following components: (1) values;
 Ethical Challenges 49

(2) patients’ and their families’ transference reactions; (3) staff

countertransference feelings; (4) institutional, social, and cul¬
tural context (including the impact of insurance and managed
care companies); and (5) the importance of ongoing negoti¬
ation.
This model takes into consideration a new development
in medical care: the impact of financial and insurance concerns
on the patient and health care providers in the current “Age
of the Payer” (Siegler, 1993), and it runs parallel with the third
phase of medicine—the age of the payer (Siegler, 1993). The
national attempt to control escalating costs, which emerged in
1983 when the concept of diagnostic related groups (DRGs)
came into being, metamorphized the traditional dyadic physi¬
cian-patient relationship to a triadic relationship, with consid¬
erable power and influence over all aspects of decision making
being held by managed care organizations (Kirschner, 1995).
The relational-perspectivistic model is strongly influenced
by Hoffman’s writings on social constructivism (1991, 1992).
This paradigm emphasizes the critical role of the observer in
shaping, constructing, and organizing the patient’s reality.
This constructivistic perspective maintains that “objective real¬
ity” varies considerably among different cultures (Malec,
1993). Thus, the relational-perspectivistic approach stresses
the ambiguity of reality: Each individual involved in making
ethical decisions has his or her plausible view of the situation.
Knowledge is perspectival and other beliefs, value systems, and
centers of subjectivity are acknowledged (Aron, 1996). This
does not imply that every construction of the patient’s experi¬
ence is equally valid or accurate. The patient’s experience, de¬
spite its highly ambiguous nature, consists of particular
constraints of interpretation analogous to form level on the
Rorschach (Mitchell, 1997). By highlighting the importance of
meaning and values, ethical decisions are arrived at through
an ongoing dialogue between the patient, family, and interdis¬
ciplinary staff.
Understanding the critical role that values play in the rela¬
tional perspective sheds light on this fourth model of decision
making. Impairments in speech, ambulation, perception, read¬
ing, memory, and activities of daily living have different mean¬
ings for different patients, family members, and health care
50 Robert M. Gordon

providers (Caplan et al., 1987). Patients entering a rehabilita¬

tion setting encounter a novel situation with differing expecta¬
tions and demands reflecting underlying values (Wegener,
1996). Rehabilitation settings promote values such as indepen¬
dence, maximum effort without complaining, and accepting
pain at the expense of comfort and nurturance (Wegener,
1996) . Gunther (1987) stated that there is a strong emphasis
in rehabilitation settings on performance-oriented goal attain¬
ment. The complexity of quality of life concerns tend to be
minimized as focus is placed on treatment outcomes, efficiency,
accountability, and compliance (Wegener, 1996). Holmes
(1996) believed that values tend to have a powerful uncon¬
scious influence on attitudes and behaviors. Consciously held
values, however, may be defensive efforts to minimize the im¬
pact of unconscious feelings of hatred, envy, guilt and frustra¬
tion. Holmes advocated that therapists carefully explore and
monitor how their values affect their work, a process described
as gaining awareness of ethical countertransference.
Transference and countertransference reactions are also
critical features of the relational-perspectivistic model. Trans¬
ference and countertransference define the global, interactive
experience of the patient and the therapist. Each is assumed
to respond to the real participation of the other, shaped by
internal conflicts, character, values, and past experiences. Nei¬
ther transference nor countertransference are assumed to be
distortions. The patient’s transference reactions are patterned
attempts by the patient to relate to others, protect the self,
and regulate levels of closeness and privacy. Conversely, the
therapist’s countertransference is an effort to relate to the pa¬
tient, protect the self, and regulate his or her level of intimacy
or distance from the patient (Gordon with Aron, Mitchell, &
Davies, 1998). Transference and countertransference reactions
are extremely common events and should be examined as ac¬
tions within a specific context, with specific aims (Mitchell,
1997) . In addition, both the therapist and patient are seen as
the initiators of transference-countertransference conflicts
and impasses (Aron, 1996).
From a relational perspectivistic model, transference and
countertransference are mutual creations by patient and ana¬
lyst. Patients evoke specific feelings, thoughts, and memories in
 Ethical Challenges 51

the therapist, while the therapist’s own defenses, coping styles,

values, and unconscious motivations ultimately determine the
countertransference response (Gabbard, 1995). Transference
can be described as a selectivity in awareness or rigidity in
perception (Fiscalini, 1995). Hoffman (1983) believed that
transference operates like a “Geiger counter,’’ with past experi¬
ences causing patients to selectively perceive meaning in situa¬
tions or notice qualities and motivations in others that might
be insignificant to someone else.
Psychologists working with adults who are neurologically
impaired are confronted with intensive and ongoing patient
transferences, events that are increased by several factors in a
rehabilitation setting: the traumatic and sudden disorganiza¬
tion of the adult patient’s personality structure and defensive
system, the inevitable psychological regression, and the pro¬
longed state of physical dependency (Gunther, 1987). Promi¬
nent countertransference reactions in staff members include
rage and hatred toward patients who may consistently frustrate
their best therapeutic efforts, as well as the caregiver’s own
feelings of helplessness, hopelessness, and fears of their own
mortality and limitations (Gans, 1983; Gunther, 1987).

ETHICAL CHALLENGES IN PSYCHOTHERAPY WITH BRAIN-

INJURED ADULTS

The major ethical challenges in psychotherapy with adults ex¬

periencing a neurological impairment encompass clinical di¬
lemmas regarding: (1) decision making; (2) refusal of
treatment; (3) potential dangerousness; (4) patient and staff
conflict; and (5) broader philosophical issues regarding the
overall goals of rehabilitation (Jennings, 1993). This popula¬
tion particularly challenges the therapist’s ideals of autonomy,
self-determination, and independence (Jennings, 1993).
Ethical considerations must shape the therapist’s ap¬
proach to the obstacles and daily realities confronting individu¬
als adjusting to neurological impairment. Unrealistic notions
52 Robert M. Gordon

of ideal autonomy may lead the patient to experience disap¬

pointment and conflict, rather than empowerment and self-
respect. Concrete and contextual descriptions of potential inde¬
pendence are needed to deal with the patient’s daily concerns
after experiencing a sudden and unexpected neurological im¬
pairment.
Three ethical issues provide the foundation for any poten¬
tial psychotherapeutic encounter: quality of life, the nature of
autonomy, and decision making. The complexity and depth of
ethical challenges in psychotherapy are demonstrated by care¬
fully exploring these concepts.

Quality of Life

Quality of life is a multidimensional and interactive concept

that consists of the overall level of personal satisfaction with
objective life conditions such as physical, material, social, and
emotional well-being (Felce & Perry, 1996). Values such as self-
determination, autonomy, and personal choice are critical
components in determining life satisfaction (Hughes & Hwang,
1996). An individual’s subjective sense of well-being is highly
related to that which is most meaningful in life (Dresser &
Whitehouse, 1994). One of the central features of our demo¬
cratic society is a respect for pluralism. We expect and encour¬
age individuals to express diverse perspectives of the meaning
and ultimate purpose of human life. Pluralism posits that no
one standard exists measuring “good” for a patient experienc¬
ing a neurological impairment. Psychotherapeutic interven¬
tions and decision making depend on highly specific
conceptions of the meaning of human life (Emanuel, 1987).
Common emotional themes for individuals experiencing
a neurological impairment include: (1) loss of a sense of self¬
cohesion and integrity; (2) feelings of helplessness and vulnera¬
bility; (3) fears of an uncertain future; and (4) existential issues
of loss of control over events and one’s mortality (Langer,
1992). These themes all relate to the patient’s and caregiver’s
conception of what constitutes a qualitatively meaningful life.
 Ethical Challenges 53

Emanuel (1987) described five perspectives on a purpose¬

ful existence for patients who are experiencing significant neu¬
rological impairment: (1) vitalism; (2) hedonism; (3)
interpersonal orientation; (4) autonomous emphasis; and (5)
utilitarianism. The physical or vitalism view advocates that life
alone, whatever the degree of suffering, is meaningful and pur¬
poseful. A consequence of this perspective is that any interven¬
tion that maintains or improves physical existence, regardless
of issues of pain, is beneficial to the patient. In contrast, the
hedonistic perspective stresses that pleasure, and the avoidance
of significant pain and suffering, is the most critical component
in defining an acceptable life. The interpersonal orientation
highlights the meaning and satisfaction derived from the love
and care of interpersonal relationships. The autonomy para¬
digm, on the other hand, stresses the importance of self-deter¬
mination and freedom from the coercive control of others. In
this view, when an individual is not capable of making inten¬
tional and informed decisions (Romano, 1989), medical inter¬
ventions cease to be useful. The fifth, or utilitarian, perspective
stresses the collective total of pain and pleasure experienced by
all individuals involved in the decision process as the ultimate
criteria of determining “an acceptable existence.’’ Medical in¬
terventions are beneficial only if collective pleasure is greater
than the pain experienced by the entire family system (Eman¬
uel, 1987). These five perspectives justify different types and
intensities of treatment, and can be considered components
of the therapist’s ethical countertransference (Holmes, 1996).
Different diagnoses, issues in treatment, and the patients per¬
sonality traits and family dynamics may evoke varying ethical
countertransference reactions in the therapist.

Autonomy

A frequently unexamined and unconscious aspect of the thera¬

pist’s ethical countertransference system involves different per¬
spectives on the patient’s autonomy. As described in the
democratic tradition, the ideal of autonomy depicts the individ¬
ual as possessing a maximum of independent action and
54 Robert M. Gordon

thought, self-determination, and ability to identify desires and

interests (Agich, 1990). While this definition is useful in politi¬
cal and legal discussions, it does not fully address the pressing
real-life issues arising during psychotherapy with adults experi¬
encing brain injury. A more concrete and contextual definition
is needed (Agich, 1990).
Autonomous choices need to be consistent with one’s val¬
ues, beliefs, and life plans. The concept implies that choices,
even those that consist of depending on others for physical and
emotional care, are reflective of one’s basic character. From
a relational-perspectivistic viewpoint, autonomy results from
contextually situated options that are personally meaningful
for those involved (Agich, 1990; Childress, 1990). The choices
offered to an individual experiencing a neurological impair¬
ment must be personally meaningful, worth making, and re¬
flective of one’s unique personality (Agich, 1990), while at the
same time taking into consideration the realities posed by the
neurological deficit.
A more clinically relevant description of patient autonomy
in this context must recognize the influence of professionals
and the power of managed care companies and institutional
politics and values. This perspective advocates an increased
awareness of these underlying forces. Autonomy is not some¬
thing that precedes interactions with patients and families, but
is “an emergent property of the interactive process, not some¬
thing that can be sheltered from influence, but something that
grows through influence” (Mitchell, 1997, p. 21). The caregiv¬
er’s most constructive protection of patient autonomy is accom¬
plished by acknowledging the interactive and perspectivistic
nature of the rehabilitation process (Mitchell, 1997).

Ethical Decision Making

Competency involves the capacity to make decisions for which

the individual is accountable and responsible. Individuals need
to adequately appreciate the long-term positive and negative
 Ethical Challenges 55

implications of decisions, rather than focus exclusively on

short-term factual aspects of decisions (Elliott, 1997). Freed¬
man, Stuss, 8c Gordon (1991) stated that decision-making ca¬
pacity depends on an ability to retain, process, and understand
information, develop and analyze alternative plans, as well as
an ability to communicate one’s choices. Thus, competency is
not a unitary concept. The reality of multiple competencies
means that a central question is the patient’s ability to perform
a specific skill in a particular context (Marson, Schmitt, In¬
gram, 8c Harrell, 1994). Professionals’judgments regarding the
patient’s competency to make decisions should be based on
the highest observed level of performance under optimal con¬
ditions (Haffey, 1989).
Ethical decision making is complicated by common per¬
sonality changes that may result from neurological impairment,
including poor social judgment and impulsivity, egocentricity,
emotional lability, and disinhibition. Typical reactive emo¬
tional problems include increased anxiety, depression, irritabil¬
ity, withdrawal, and mistrust of others (Cicerone, 1989).
Neurological impairment tends to exacerbate preexisting per¬
sonality traits and to interfere with coping strategies. These
regressions are attributable to a decrease in problem-solving
abilities and cognitive flexibility and the stress and anxiety of
living with a disability (Langer, 1992).
Among the most ethically challenging tasks in psychother¬
apy with brain injured adults is decision making. This covers a
wide spectrum of dilemmas including managing finances, con¬
senting to medical treatment, giving power of attorney, making
a will, choosing a place to live, resuming a job, driving a car,
managing a medication schedule, and choosing a level of care¬
giver assistance (Freedman et al., 1991; Gass & Brown, 1992).
When a psychologist must determine a patient’s compe¬
tence to make decisions, he or she will need to evaluate four
different dimensions: (1) the risk-benefit ratio of the decision;
(2) patient neuropsychological functioning; (3) patient emo¬
tional and motivational factors; and (4) patient understanding
of the specific decision that needs to be made.
56 Robert M. Gordon

Consent to Medical Interventions

When dealing with decision-making choices in psychotherapy,

the psychologist needs to consider such factors as the risk-be¬
nefit ratio (i.e., how much do the potential benefits of the
decision outweigh the possible risks?). A lower level of reason¬
ing and understanding is required when a patient gives in¬
formed consent to a medical intervention with a beneficial
risk-benefit ratio or refuses a treatment with an uncertain
chance of success. On the other hand, a higher degree of rea¬
soning and understanding is needed when a patient refuses a
medical intervention with a highly beneficial risk-benefit ratio
or if the decision poses a significant medical threat to the per¬
son (Roth, Meisel, & Lidz, 1977).
When evaluating a neurologically impaired individual’s
level of competence to consent to medical interventions or
other major decisions, a number of neuropsychological vari¬
ables need to be considered including attentional, memory,
language, visuospatial and executive skills, as well as emotional
functioning. Alexander (1988, cited in Callahan & Hagglund,
1995) cites a number of risk factors and test scores that can
be utilized in making competency determinations, including
patient’s ability to state fewer than five digits forward, decrease
in mental control when performing serial subtraction, inability
to encode and recall a list of four words, disorientation, con¬
crete, tangential, or autistic thinking and the presence of such
conditions as receptive aprosodia and anosognosia.
Motivational and emotional factors may significantly im¬
pact an individual’s ability to make responsible decisions (Cal¬
lahan & Hagglund, 1995). Severe depression will impact the
neurologically impaired individual’s ability to care about medi¬
cal decisions, to appreciate the long-term consequences of the
decision, and to carefully consider the risks and benefits of the
decision (Elliott, 1997). Many studies have found that severely
depressed patients have cognitive deficits in reasoning and in¬
formation processing (Appelbaum, 1997).
A fourth component in evaluating competency to consent
to medical interventions involves the patient’s understanding
of specific aspects of the actual intervention. Venesy (1994)
 Ethical Challenges 57

described a number of questions that can be explored in psy¬

chotherapy with a neurologically impaired adult faced with a
difficult decision regarding a specific medical intervention.
The patient should confront his or her level of awareness of
medical needs, the imminence of the decision, the patient and
his or her physicians’ thoughts on the implications of accepting
or rejecting treatment, alternative interventions, and the po¬
tential benefits and limitations of each choice. Venesy (1994)
observed that since competence for decision making may vary
among patients, two or three assessments are often necessary.
Moreover, the manner in which treatment choices are pre¬
sented can have a significant impact on assessment of compe¬
tency (Callahan & Hagglund, 1995). The patient’s level of
understanding and recall of information can be affected by the
mode of presentation (i.e., visual, auditory), rate of presenta¬
tion, open-ended versus forced or multiple choice, linguistic
or conceptual complexity, degree of extraneous stimulation in
the environment, and time of day (Haffey, 1989).

Refusal of Treatment

Refusal of treatment is a multidetermined behavior and has

different meanings for each patient as the treatment evolves.
Reidy, Crozier, Caplan, Kutys, and Sinnott (1992) used a con¬
sultative model to describe a number of steps a psychologist
can employ when a patient refuses to participate in aspects of
the rehabilitation process. Using strategies from both a behav¬
ioral and psychodynamic orientation, the specificity of the re¬
fusal should be explored, particularly with respect to whether
the refusal is ongoing, sporadic, or acute in nature. The ante¬
cedents and the consequences of the behavior should be con¬
sidered as well as the underlying causes and stated reasons for
the refusal. In addition, the patient’s significant others should
be consulted on whether the reasons for the refusal are consis¬
tent with the patient’s premorbid character and values. These
detailed areas of inquiry will often resolve the dilemma.
Another potential reason for refusal of treatment is projec¬
tive identification, or an unconscious attempt on the part of
58 Robert M. Gordon

the patient to communicate intense feelings. Projective identi¬

fication differs from pure projection in that it not only expels
uncomfortable aspects of the self, but also induces the object
of the projection to experience the projection. Individuals who
engage in projective identification are reluctant to experience
or notice within themselves qualities and traits that are recog¬
nized critically in others (Mitchell, 1997). Ogden (1979) trans¬
formed the concept into an interpersonal construct by
describing projective identification as a process in which a
group of fantasies and accompanying self representations are
deposited into the therapist and are later returned in a modi¬
fied and less threatening version. The patient unconsciously
attempts to induce in the therapist a particular role or feeling
in order to protect against overwhelming anxiety (Knapp,
1989). Often, refusals of treatment are simply the patient’s at¬
tempt at communicating feelings of helplessness, fear, and
rage. The positive aspects of projective identification, including
its adaptive function as a form of communicating feelings that
cannot be put into words, needs to be balanced with its disrup¬
tive aspects. Refusal of treatment can also be viewed as an at¬
tempt at assertiveness and control, or a sign of ineffective
communication patterns between patient and staff.
Venesy (1994) also noted that a patient’s refusal of treat¬
ment may be affected by the fear and intense anxiety evoked
by the potential intervention stimulated by unconscious associ¬
ations concerning loss of control, issues involving body integ¬
rity, fear of total dependency, and mortality. Other factors that
need to be considered are the accuracy and comprehensiveness
of the information presented to the patient, the consistency or
fluctuation in the patient’s mental status and level of orienta¬
tion, metabolic status, level and tolerance of pain, and the im¬
pact of various medications (Venesy, 1994). A case example
will be used to illustrate these concepts.

Case Example 1

Mrs. L, a 68-year-old retiree with a left cerebrovascular accident,

mild expressive aphasia, short-term memory deficits, and a pre-
morbid history of anorexia, refused to participate in any of
 Ethical Challenges 59

her inpatient therapies. She felt that certain members of the

treatment team hated her and treated her unjustly. After at¬
tending her therapies for the first 2 weeks of her hospitaliza¬
tion, she abruptly refused treatment and subsequently lost a
significant amount of weight. The entire rehabilitation team
became highly anxious and preoccupied with the case. Mrs. L
played staff members against one another. Her primary physi¬
cian tried to avoid her frequent and frantic pleas for constant
and undivided attention. This situation escalated over a 2-week
period, and a series of team meetings were held. Staff members
contributed to this difficult situation in part by providing incon¬
sistent information regarding her diagnosis and treatment
goals. In addition, the patient and her family had an idealized
view of the physician. Failing to meet their unrealistically in¬
flated expectations, the physician became the target of uncon¬
scious feelings of rage and disappointment (i.e., projective
identification). The physician experienced his own hateful re¬
actions, but felt guilty and responded in an overprotective, but
unassertive manner. At the team meeting, the physician was
given permission to experience his hateful feelings, which were
shared by a number of members of the treatment team.
Other members of the interdisciplinary team were more
positively disposed toward Mrs. L. They perceived that, under¬
neath a demanding, aggressive facade, she was, in fact, quite
needy and attention-seeking. The psychologist, acting as a con¬
sultant, maintained that each staff member was playing out a
different aspect of Mrs. L’s personality and that the patient was
inducing the staff to experience her unmanageable feelings.
The staff subsequently agreed to refer all questions concerning
her diagnosis and treatment program to the physician. It was
also decided that an alternative rehabilitation program focus¬
ing on her anorexia would be more suitable at the present time.
This case illustrates the difficulties in distinguishing neuro¬
psychological symptoms from premorbid psychiatric problems.
The staff increased its awareness of the powerful unconscious
forces that impact on their daily work by considering psychoan¬
alytic concepts such as countertransference and projective
identification at the team meeting. As Mitchell (1997) has
stated, “Projective identification is one way to think about the
60 Robert M. Gordon

unconscious processes through which the conflictual richness

of experience, too varied to be containable in one mind at any
time, becomes distributed in dyads and groups” (pp. 264—265).

Case Example 2

Mr. R, a 50-year-old male accountant, suffered a right cerebro¬

vascular accident. During a 2-month inpatient rehabilitation
process, he had no contact with his accounting firm. A compre¬
hensive neuropsychological evaluation indicated significant
deficits in visuomotor planning and inattention to small visual
details. Mr. R adamantly stated that all information regarding
his medical condition remain confidential since he intended
to return to work upon discharge from the hospital. The psy¬
chologist was quite concerned about Mr. R’s ability to success¬
fully perform his job, given the necessity for close attention to
detail and the potentially serious ramifications in the case of
errors. Mr. R threatened to sue the psychologist if the medical
condition was revealed to business partners. After consulting
with his own supervisor, the psychologist scheduled a meeting
with Mr. R, his wife, and physician to focus on the risks and
benefits inherent in resuming full-time employment. Daily
problems that Mr. R had noted and expressed during his psy¬
chotherapy sessions, as well as the confirmation of these prob¬
lems disclosed in neuropsychological testing, were discussed.
Mr. R and his wife expressed their fears regarding finances,
the threatened loss of role identities, and the impact of these
changes. A compromise was reached, and Mr. R agreed to at¬
tend cognitive remediation for a 4-month period and subse¬
quently worked on a part-time basis under close supervision.
Mr. R was able to share some of his deficits with his partners,
who responded in a flexible and supportive manner.
This case highlights the need to protect the patient and
potential third parties. By involving significant others at the
team meeting, a helpful transition phase was made feasible.
Alerting Mr. R’s firm was viewed as a last resort. Even then, it
would have occurred only with the approval of the patient and
 Ethical Challenges 61

his wife in order to safeguard confidentiality and the patient’s

sense of integrity. If Mr. R had been in a position in which the
health of others was in danger (i.e., a surgeon), then the need
to protect third parties would have been considered even
more rigorously.

Dangerousness

The clinical challenges posed by an adult who is neurologically

impaired who decides to resume driving involve ethical issues
concerning caregiver’s duty to protect third parties and patient
confidentiality. The Tarasoff ruling of a mandated duty to pro¬
tect has been extended to unspecified victims of impaired driv¬
ers and their physicians (Brittain, Frances, & Barth, 1995). If a
patient who is neurologically impaired injures another person
while driving, the victim can sue the physician working with
the patient. The victim must prove, however, that the physician
knew that the patient was driving, failed to notify law enforce¬
ment or licensing authorities (i.e., Department of Motor Vehi¬
cles), did not confront the patient or the patient’s legal
representative about the fact that driving was dangerous and
forbidden, and that the harm to the victim was a direct conse¬
quence of a foreseeable cognitive mistake by the patient (Beres-
ford, 1996).

Case Example 3

Mr. S, 48 years old, suffered a traumatic brain injury as a result

of a motor vehicle accident. Computed tomography (CT) of
the brain revealed bilateral frontal hematomas. During his in¬
patient hospitalization course, Mr. S exhibited poor judgment,
impulsivity, and a general lack of awareness of his deficits and
the implications of these problems on activities of daily living. A
serious ethical dilemma arose when Mr. S told the psychologist
during a session that he wished to resume driving upon his
discharge. Mr. S became enraged when the psychologist ex¬
pressed her concerns over his stated intention. Feedback from
62 Robert M. Gordon

neuropsychological testing and discussions with his occupa¬

tional therapist regarding his impulsivity and poor planning
skills had minimal impact, except to increase his sense of rigid¬
ity and determination to drive.
A team meeting was held with Mr. S’s wife, eldest son,
psychologist, occupational therapist, and physician. At this
meeting, Mr. S was able to express his rage over his lack of
independence and his perception of his family’s overprotective
and infantilizing response to his disability. The psychologist
posed the question to the patient and family as to how they
would feel if the patient’s grandson was seriously injured by an
impaired driver. This question and the emotionally cathartic
discussion resulted in a mutual decision by the entire family to
have a comprehensive driver evaluation.
The ethical obligation to protect neurologically impaired
adults and potential victims does not imply that all those with
neurological injuries are dangerous drivers. Some patients with
more focal lesions are capable drivers. The assessment of driv¬
ing capacity needs to be carefully evaluated on an ongoing
basis by a specialist.

Conflicts Between Patients, Families, and Staff

Among the most complex and anxiety-provoking challenges

confronting health care professionals are the conflicts between
patients, their families, and the treatment team on treatment
and financial decisions. These conflicts often involve issues of
hope, denial, and awareness. Family members may perceive
denial as the other face of hope, and there may be some bene¬
fits derived from this “optimism,” but professionals may, with
good reason, experience the denial as the other face of disaster.
Hope is comprised of both cognitive and affective compo¬
nents. When hope is experienced as an expectation regarding
the high attainability of a goal or anticipated future, its cogni¬
tive aspect is emphasized (Buechler, 1995). Buechler differenti¬
ated a passive longing for a more satisfying future, which
consists of the wishful expectation that a person, event, spiritual
 Ethical Challenges 63

faith or time itself, will bring fulfillment and healing and hope
as an active affect. As an active motivating force, change occurs
as a result of effort and taking personal responsibility. Hope
can be understood only in the context of other emotions such
as joy, curiosity, dread, and fear (Mitchell, 1993; Buechler,
1995).
Hope is a concept that crystallizes when contrasted with
denial, awareness, and dissociation. Langer and Padrone
(1992) proposed a tripartite model of understanding and work¬
ing clinically with denial and awareness. The individual may:
(1) lack the required information regarding their own neuro¬
logical condition; (2) have the necessary factual information
about their condition, but minimize the implication of this
knowledge; or (3) utilize the coping strategy of denial. In this
frequently encountered and normal reaction to trauma, the
individual possesses the knowledge and has the cognitive and
emotional capacity to comprehend the implication of this in¬
formation, but behaves in a manner that indicates a belief that
the information is not accurate. The individual perceives the
information as too painful and anxiety provoking.
Langer and Padrone (1992) stated that, in the beginning
phase of acute rehabilitation, incomplete awareness of deficits
is frequently observed because patients have not had the oppor¬
tunity to discover their limitations on their own. With the grad¬
ual and difficult process of attempting activities of daily living,
memory, visuospatial and attentional, gross and fine motor
tasks in the hospital and at home, the adult with brain injury
is more likely to gain awareness of his or her own problems. In
some cases, patients should be permitted to maintain some
degree of denial if it does not significantly interfere with their
rehabilitation and daily functioning. Denial is an appropriate
and adaptive coping strategy in the earlier stages of adjustment
to brain injury. It provides a transitional period of time to adapt
to an overwhelming situation.
The defensive use of denial, however, needs to be differen¬
tiated from dissociation. According to Bromberg (1994) and
Davies (1996), trauma creates affects and thoughts that cannot
be integrated by the individual. Bromberg stated that dissocia¬
tion is a protection against overwhelming anxiety that can re¬
sult in self-fragmentation. The individual’s inability to reflect
64 Robert M. Gordon

on experience occurs out of necessity (Stern, 1997). Stern

(1997) contrasted dissociation in response to trauma with ex¬
pectable dissociation, which he delineates as an unconscious
decision not to interpret and linguistically encode experience.
To dissociate means to constrict the range and depth of inter¬
pretations one makes of experience. Bromberg (1994), Davies
and Frawley (1994), and Stern (1996) emphasized that dissoci¬
ated self-states cannot be put directly into words and can be
discovered only through the impact on the patient—therapist in¬
teraction.

Case Example 4

Mr. H, 21 years old, was admitted to an inpatient rehabilitation

program with a mild traumatic brain injury and a fractured
ankle and femur. Mr. H was the driver of a car in which his
older brother died. Mr. H came from a strong patriarchal fam¬
ily that promoted values such as perseverance, stoicism, and
achievement. During the initial phase of rehabilitation, Mr. H
was highly anxious and disoriented as to time and place. He
had dissociated the accident and was experiencing nightmares.
During the second week of hospitalization, Mr. H’s ability to
focus and his level of orientation improved. A neuropsychologi¬
cal evaluation was conducted at this time. Mr. H was quite con¬
cerned with his performance and frequently asked for
immediate feedback. He had extremely high expectations for
himself, which was also an important feature of his premorbid
personality. His neuropsychological deficits included reduced
information processing speed, and difficulties with complex
attentional tasks and visuomotor skills when timed.
A number of staff and family conflicts emerged during the
second week of rehabilitation. Mr. H’s father attended all his
physical, occupational, and speech therapy sessions, and
wanted to be present during the neuropsychological evalua¬
tion. He firmly stated that he did not want his son to be told
that his older brother died in the accident, believing that this
knowledge would significantly interfere with his surviving son’s
 Ethical Challenges 65

ability to remain strong and focused. During physical therapy

sessions, Mr. H’s father commanded and pressured his son to
work harder and faster. It appeared that Mr. H’s family held
the unconscious fantasy that, if Mr. H worked hard and fast
enough, his complete recovery would miraculously bring back
his deceased brother. Mr. H’s father’s constant and manic pres¬
ence provoked a high degree of anxiety in the staff, who felt
that Mr. H needed more time and independence to discover
his own limitations and mourn his losses. The father denied
that there were any changes in Mr. H’s status except for his
broken leg and ankle. While Mr. H had some awareness of
changes in his neurological status, he tended to minimize the
implications or severity. He also used humor and externalized
blame as primary defenses. Mr. H and his parents believed that
he could return to college on a full-time basis upon his dis¬
charge.
The staff became quite concerned over the father’s intru¬
sive involvement and desire to keep his son from learning about
his brother’s death. A family meeting was held with Mr. H’s
physician, psychologist, social worker, and physical and occupa¬
tional therapist. Mr. H’s father’s goals appeared to be a combi¬
nation of denial of his son’s limitations and an unrealistic hope
that more activity and effort would lead to a complete cure.
The staff strongly recommended that Mr. H be told of his
brother’s death because he was beginning to ask questions
about his brother. They expressed concern about how Mr. H
would react if he accidentally found out. The psychologist sup¬
ported the father’s values of perseverance and achievement
and his dedication to his son’s rehabilitation. In addition, the
father’s hopeful feelings were validated, but it was recom¬
mended that a more patient and gradual attitude toward his
son’s progress be taken. Staff also recommended that the father
not attend therapy sessions due to his son’s growing anxiety
and self-criticism if he failed to reach goals immediately. Be¬
reavement counseling for the family as well as Mr. H’s return
to college on a part-time basis were suggested.
Mr. H’s father agreed not to attend his son’s therapy ses¬
sion, but refused the suggestion of family counseling or his
son’s returning to college on a part-time basis. He did agree,
66 Robert M. Gordon

after considerable discussion, that the psychologist could con¬

tact Mr. H’s college advisor regarding ancillary interventions
that would increase his chances of succeeding at school. The
psychologist informed the advisor of specific remediation strat¬
egies that would increase the student’s chances of success.
Therefore, someone at the school needed to take an active role
in providing these interventions.
This case illustrates the complex family and staff conflicts
that emerge when issues of hope, denial, dissociation, and indi¬
vidual and family personality traits and values collide. Clinical
interventions to handle denial and unrealistic hope should be
carefully considered at team meetings. In this case, staff felt
that the withholding of information about Mr. H’s brother and
his father’s constant pressure interfered with Mr. H’s rehabilita¬
tion and emotional functioning, while returning to school on
a full-time basis posed a lower degree of risk.

Case Example 5

Mr. C, 55 years old, sustained a moderate traumatic brain injury

as a result of a motor vehicle accident. He was observed spend¬
ing and giving away money at an alarming rate. The large fi¬
nancial settlement that he had been awarded had dwindled to
half its original amount. Mr. C’s wife and two children became
extremely distressed when they were notified by Mr. C that he
had revised his will and was leaving most of his money to his
closest friend and younger brother. Both had visited Mr. C
on a regular basis during his extended inpatient rehabilitation
program. Mr. C’s wife and children became outraged and de¬
cided to take legal steps to declare Mr. C incompetent. Mr. C
became highly anxious about this possibility. He agreed to at¬
tend an outpatient brain injury program where he completed
an extensive neuropsychological evaluation.
The results of the testing indicated that Mr. C had signifi¬
cant left frontal and temporal impairment, including short¬
term auditory memory deficits, and difficulty shifting sets and
evaluating the effectiveness of problem-solving strategies. Al¬
though Mr. C was able to perform simple calculations and use
 Ethical Challenges 67

a calculator, he was unable to balance a checkbook and to

budget a monthly expense task. He was able, however, to ex¬
press his disappointment and hurt feelings toward his wife and
children. He felt they were not sufficiently involved during his
rehabilitation program and generally showed an apathetic atti¬
tude toward him and his neurological condition. He was also
able to state the reasons why he wanted to leave his money to
his closest friend and brother. The case eventually went to court
and the judge ruled that Mr. C’s brother would be appointed
guardian of his financial affairs. The judge also decided that
Mr. C’s revised will was valid because Mr. C was able to reliably
express whom he was leaving the money to and the reasons for
this decision.
This case describes the complexities of differentiating le¬
gal and neuropsychological aspects of competency. Cognitive
impairment may cause inattention to financial responsibilities,
managing bank accounts, and impulsive spending, which can
have a significant impact on the family (Beresford, 1996). Cur¬
rent legal decisions usually restrict a guardian’s powers to those
areas affected by the individual’s limitations and allow for au¬
tonomous functioning in areas that are likely to pose minimal
risk (Beresford, 1996). In this case, Mr. C’s reckless and impul¬
sive spending was found to pose a greater threat to his own
and to his family’s security than his decision to revise his will.
In addition, his decision to revise his will could be explored
in greater detail during individual and family therapy sessions
during the upcoming years and could be considered a revers¬
ible decision.

CONCLUDING REMARKS

The use of a relational-perspectivistic model of ethical decision

making provides a rich foundation of practical concepts such
as quality of life, autonomy, hope, projective identification, eth¬
ical countertransference, and the importance of meaning and
context. These philosophical principles and psychoanalytic
ideas add depth and complexity to discussions of ethical dilem¬
mas regarding adults with neurological impairment. It provides
68 Robert M. Gordon

a framework that is most consistent with the difficult, day-to-

day challenges posed in psychotherapy and rehabilitation. This
model stresses that autonomy and quality of life are achieve¬
ments that are mutually discovered and created by the patient,
family, and health care professional. These goals are not con¬
cepts that are applied identically to each patient, but are
unique accomplishments that are consistent with the individual
patient’s character, values, and culture.
In order to arrive at optimal ethical decisions in rehabilita¬
tion, it is advisable to organize family and team meetings at
which all parties can express their different perspectives and
concerns, and where each member of the rehabilitation team
and each family member may contribute their unique view¬
points. The process of ethical decision making provides an op¬
portunity to learn other disciplines’ perspectives. Ultimately,
the most significant teacher may well be the patient.

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■
 PART II

Emotional Factors and Defensive

Functioning: Diagnostic and Conceptual
Issues in Treatment
4.

Awareness and Denial in Psychotherapy

Karen G. Langer, Ph.D.

The phenomenon of unawareness in brain dysfunction is intrig¬

uing at a theoretical level, and challenging at a clinical level.
The finding that a patient after brain injury or stroke may
actually be, at some level, unaware of some or all of the physical
or neuropsychological changes, let alone of their implications,
is often startling to the clinician who witnesses this.
Of course, in standard psychiatric and psychotherapy prac¬
tice, it is not unusual to view the phenomenon of emotional
denial among the defense mechanisms, and to attempt to un¬
derstand its role in shaping personality and in influencing be¬
havior.
Emotional denial may cloud conscious awareness of as¬
pects of reality, certainly at the level of affect, so that the person
is not aware of the underlying psychic processes that are op¬
erating or guiding his or her activity (including thoughts and
feelings). Of course, these processes are inferred or indirectly
observed.
In this chapter, we consider the operations of emotional
denial along with those of disruptions of brain functioning
after brain injury or stroke, in order to understand better the
diagnostic and psychotherapeutic challenges of these opera¬
tions. What is striking about unawareness of disability in brain

75
76 Karen G. Langer

injury is the sharp and dramatic contrast of the patient’s inter¬

pretations (of what is wrong) with the quite visible physical
losses and notable limitations. In extreme form, a patient with
right hemisphere dysfunction on an inpatient unit may actually
“deny” or disavow that the paralyzed left arm is his or hers,
and state that it is someone else’s. One of our patients actually
asked her husband to get his hand off her bed, and struggled
with her unimpaired hand to push her own paralyzed arm off
the bed, to her husband’s horror. Patients with hemianopsia
may state that they “see just fine” or simply need new glasses.
One patient read a hallway sign advertising a spring raffle, and
asked with puzzlement, “What is a ring affle”; another patient,
equally puzzled, inquired about “feteria” (cafeteria), but with¬
out a sense that there was something wrong with his visual
perception. Unawareness of disability in different patient sam¬
ples with brain impairment including traumatic brain injury
and stroke is amply reviewed (Blonder & Ranseen, 1994; Lev¬
ine, 1990; McGlynn 8c Schacter, 1989; Prigatano & Schacter,
1991). This paper focuses on the psychodiagnostic and psycho¬
therapeutic implications of unawareness and denial in patients
with brain injury and stroke.
The question we naturally ask ourselves when witnessing a
graphic display of unawareness, with the patient behaving as if
there is no problem, is how can the person not know about this,
how can she or he not realize? And the word realize is a key to
beginning the exploration of the nature of unawareness.
Some fundamental questions become apparent to anyone
studying the phenomena of unawareness and denial, with im¬
plications for studies of brain function, psychic functioning,
psychopathology, cognitive processing, and consciousness;
these include:
1. What is the source or etiology of unawareness? This
question is basically diagnostic in nature, and is fundamental
to our scientific method of inquiry and treatment, since there
may be differential treatment efficacy depending on the eti¬
ology.
2. What is the content of awareness being considered, that
is, awareness of what? This question may often be clouded when
terms such as awareness of disability, of condition or illness, of
 Awareness and Denial 77

prognosis, or of affect, among others, are used interchange¬

ably, or without any distinction at all. Patients may often know
about the diagnosis of stroke or head injury and even the symp¬
toms, but not of the implications or prognosis. This lack of
knowledge may be due to naivete and/or lack of medical so¬
phistication, or to defensive denial, so the assumption that
awareness of prognosis is a natural corollary of the awareness
of condition may be inaccurate.
3. How much awareness does the patient have: full, partial,
or none? Some patients may be fully aware, but others may
have only partial or implicit knowledge of deficits so that they
may verbally deny the deficit, but their behavior or other com¬
munication suggests that they do have implicit knowledge (Kihl-
strom & Tobias, 1991; Schacter 8c Prigatano, 1991).
One may also wonder whether awareness after brain dys¬
function is any different from denial of disability after other
medical illnesses-disabilities, which we know is not uncommon
(for discussion, see reviews in Caplan 8c Schechter, 1987;
Langer, 1994; Lewis, 1991). The relationship between depres¬
sion and awareness or denial is also of interest (Folks, Freeman,
Sokol, 8c Thurstin, 1988; Havik 8c Maeland, 1986). These issues
are also being addressed in clinical studies at the Rusk Institute.
The work of writers including Gazzaniga (Gazzaniga, 1970;
Gazzaniga 8c LeDoux, 1978), Kihlstrom (Kihlstrom 8c Tobias,
1991), and Hilgard (1977), among others, offer fascinating in¬
sights into mechanisms of conscious awareness, for those inter¬
ested in exploring the subject in greater depth.

DEFENSE MECHANISMS AND AWARENESS IN BRAIN

DYSFUNCTION

The need of the psyche to protect itself from threat is the key
to the deployment of the defenses. In her influential work on
the ego and defense mechanisms, Anna Freud (1936/1966)
distinguishes repression as a defense against instinctual drives
(i.e., the ego defending against itself) from the defense of de¬
nial against an external reality or knowledge. She suggests that
78 Karen G. Langer

without the protection of the defense-in-place, anxiety can

overwhelm the ego, and symptoms may overtake adjustment.
This model of defense mechanisms, which helps to explain
emotional contributants to unawareness, presupposes that the
psyche recognizes at some fundamental level that the informa¬
tion is noxious or threatening to its own integrity. The defense
is employed purposefully, then, although the threat itself may
be only vaguely perceived, or even unconscious.
Useful conceptualizations of unawareness and denial have
focused on the adaptiveness of defense and the degree of dis¬
tortion of reality. Breznitz (1983) has defined awareness in
terms of levels of increasing distortion, including denial of in¬
formation, threat, personal relevance, urgency, vulnerability,
responsibility, affect, and affect relevance. Janis (1983) differ¬
entiates adaptive and pathological denial, along with an inter¬
mediate “pathogenic denial” that involves minimization of
threat, but without a break with reality.
Classic psychologic defense mechanisms may mimic in
content the neurologic forms of unawareness or anosagnosia
(meaning unawareness of deficit), and vice versa. Each of the
statements below could be made in the defense of the ego, by
preventing conscious awareness of painful loss or diminish-
ment. Alternatively, they might not have ego-defensive purpose,
but reflect a cognitively based inability to understand or ap¬
preciate what has happened. For example, the statement, “I
have no problem” could be emotional denial; “At my age, we
all forget,” could be projection (and not just a faulty interpreta¬
tion); “I am just too tired to read because it is late in the
day,” could be rationalization; “It’s difficulty with vision (visual
acuity), not my concentration-memory that’s the problem,”
could be displacement; or “My memory is better now than it
was before,” could be reaction formation. In other words, the
same statement may reflect either faulty interpretation due to
cognitive dysfunction (in the case of unawareness), or the ac¬
tions of the defense mechanisms.
We should remember that denial, when operating as a
defense mechanism, is indeed always nonconscious. The pur¬
posefulness of the defense is in contradistinction with its non¬
conscious, nonvolitional operation. People are not conscious
 Awareness and Denial 79

of using the defense of denial themselves when they do, but

others around them may readily recognize the operation of this
defense. Of course, this can be very frustrating for the observer.
With regard to the emotional-defensive source of un¬
awareness, reasons the psyche gives for the existence of the
problem are designed to protect the person from threat and
anxiety associated with conscious attention to the underlying
problem.
On the other hand, in brain dysfunction, neuropsycho¬
logic deficits may themselves interfere with a patient’s ability
to become aware of limitations, disability, loss, or implications.
The deficits may also disrupt the self-appraisal and self-monitor¬
ing skills needed to be sensitive to the impact on others of
speech, behavior, or disability. Neuropsychologic functions
that may have significant impact on awareness include: (1)
arousal; (2) mental status; (3) thought quality (coherence,
logic, concreteness, flexibility-rigidity, conceptual judgment,
ability to prioritize and categorize); (4) attention and distracti-
bility; (5) memory (all forms); (6) ability to learn, plan, and
anticipate consequences; (7) ability to process emotions (of
self and others); and (8) egocentricity and ability to take anoth¬
er’s point of view.
Prigatano (1996) has provided one of the most helpful
distinctions between the phenomena of unawareness and de¬
nial in brain impairment. He explains that denial “represents
an attempt to cope; in contrast, impaired self-awareness simply
reflects a failure to recognize a need to cope” (p. 200).

MODELS OF UNAWARENESS

Historically, the phenomenon of unawareness of deficit accom¬

panying brain dysfunction has been approached from a num¬
ber of vantage points. Traditionally, unawareness has been
considered a neurologic feature or actual symptom of certain
cerebral lesions, particularly of the nondominant hemisphere.
Anosagnosia was the term first used by the neurologist Babinski
in 1914 to describe unawareness of deficit after neurologic in¬
sult. Motivational factors and emotional implications were later
80 Karen G. Langer

introduced as explanations of the phenomenon (Weinstein &

Kahn, 1955), such that denial of the deficit was considered to
be related to premorbid high expectations of the self, which
would no longer be viable and would therefore be intolerable.
Weinstein has revised the neuropsychiatric approach to denial
and unawareness, adding to the motivational and adaptive
components the importance of networks involving cortical, lim¬
bic, and paralimbic connections and interhemispheric rela¬
tions (Weinstein, 1991), as well as of personality factors and
even cultural influences (citing the work of Gainotti in 1975).
Weinstein states that “the existence and form of denial/an o-
sagnosia are determined by the location and rate of develop¬
ment of the brain lesion, the situation in which the denial is
elicited, the type of disability, and the way the patient perceives
its meaning on the basis of his past experience” (p. 254).
Recent literature describes the development of several so¬
phisticated neurogenic models to explain the phenomenon of
unawareness; these point to disrupted neuropsychologic func¬
tioning as a cause of unawareness of deficit. Bisiach and col¬
leagues (Bisiach, Valler, Perani, Papagno, Sc Berti, 1986)
propose a modality-specific unawareness, related to particular
lesion sites, with each sensory modality (such as hearing, vision,
etc.) having its own self-contained, individual awareness. In this
model, awareness of one deficit may exist without awareness of
the other. In contrast, McGlynn and Schacter (1989) posit that
unawareness is independent, and has its own systemic mecha¬
nism (the conscious awareness system), which is intercon¬
nected to all specific modalities, so that either the system itself
or the interconnections may be disrupted. In fact, a book has
been devoted entirely to various theoretical and clinical expla¬
nations of awareness of deficit after brain injury, with contribu¬
tions by a number of prominent writers (edited by Prigatano 8c
Schacter, 1991).
Levine (1990) has proposed that unawareness is the imme¬
diate fundamental result of sensory deficits at any level, and
that there is “no immediate sensory experience that uniquely
specifies the deficit. . . sensory loss must be discovered by a pro¬
cess of self-observation and inference ... no information . . .
 Awareness and Denial 81

specifies the absence of a sensory stimulus” (p. 233). He sug¬

gests that cognitive impairment is a necessary condition for
unawareness, but only for certain easily discovered deficits such
as acquired blindness, and not for the harder to discover defi¬
cits such as left visual inattention.
Our model at New York University represented an attempt
to integrate the psychological and dynamic factors that may
play a role in certain patients who display unawareness, with
the neuropsychologic or cognitive ingredients of conscious
awareness.
The tripartite model, as we call it, has three components,
called information, implication, and integration (Langer & Pa¬
drone, 1992). The first source of not knowing, or not being
aware, may simply involve not having the information or data.
(Levine has discussed the neurologic perspective on dis¬
covering information.) The patient may lack the information,
or lack the technical expertise or medical sophistication to un¬
derstand the meaning of the information, and/or may have
anosagnosia as a neurologic symptom. The second source of
not knowing involves implication, where someone has the infor¬
mation but may not be able to glean the implications. At the
level of unawareness, the patient cannot take “self-as-object”
(and may have difficulty with an abstract attitude of self-reflec¬
tion) , or cannot understand the information (whether linguis¬
tically or cognitively), or cannot retain or recall the
information, or has insufficient arousal for awareness. At the
level of minimization, the patient has the information but can¬
not understand or abstract from the information its conse¬
quences and implications (impaired “if/then” processing), so
these are minimized. The third source of not knowing involves
emotional integration. The person has the information and
knows the problem, but cannot tolerate the full impact of the
information emotionally, so she or he “makes light” of it, at
the level of minimization. At the level of denial, the person
cannot believe the information because it is too stressful, pain¬
ful, shocking, or overwhelming; the information is held at bay
from conscious experience, or the person’s words or actions
suggest that she or he does not or cannot believe it and does
82 Karen G. Langer

not integrate it. This denial is typical when the truth is really
shocking or when the news is catastrophic.

NEUROGENIC VERSUS EMOTIONAL SOURCES OF

UNAWARENESS

In our clinical practice, we are often faced with the question

of the complex interplay between contributions of neurogenic
causes of unawareness versus those of emotional factors. Care¬
ful assessment of the causes of unawareness, or consideration
of the possible interaction of causes, is crucial in maximizing
the effectiveness of treatment and in enhancing the patient’s
response. Just as treating a neuropsychological deficit as emo¬
tionally based may be destructive to the patient’s psyche, aside
from being ineffective (Langer, 1992; Lewis 8c Rosenberg,
1990; Prigatano et al., 1986; Prigatano, 1991), so is the con¬
verse, that is, treating denial as a neurologically based un¬
awareness. To make matters more difficult, a patient can be
found to “know” about a deficit at one moment, and to seem¬
ingly ‘ ‘not know” the next, and we are left to figure out whether
this means that the patient had only a transient cognitive ap¬
preciation to begin with (Langer 8c Padrone, 1992), or whether
she or he is showing a form of the natural variability in denial
(Horowitz, 1983). We realize that our challenge is com¬
pounded because we know that sources of not knowing may
coexist, with both the neuropsychological and the emotional
features operating at the same time, so we have recommended
the consideration of multiple meanings of not knowing in a
given patient, which is similar to the psychoanalytic concept of
“multiple determination” (Hartmann, 1939/1958).
Signs and symptoms of emotional denial that will help the
clinician to identify it include: the avoidance of associational
connections or continuity of meaning; a reduced level of ex¬
pected emotional responsiveness and emotional numbness or
constriction; disavowal of meanings of stimuli; and loss of ap¬
propriate reality or fantasies that counteract reality (Horowitz,
1983, p. 134).
 Awareness and Denial 83

But there are also some other clues that may help us to
distinguish emotional denial from cognitive unawareness:

1. By definition, denial as a defense serves a need; it pro¬

tects from psychic threat. Can one detect a need or a
threat that would potentially foster the defensive use
of denial?
2. What are the cognitive or neuropsychological limita¬
tions of the patient? Could these compromise
awareness?
3. What happens when the patient is:
a. Given information?
b. Confronted about the deficit?
c. Offered strategies to compensate for the cognitive
difficulties that impede awareness?

We would expect that emotional denial, when provided

with information, would show no resolution. In fact, cognitive
remediation and review of neuropsychological deficits might
result in resistance or even, potentially, decompensation. In¬
deed, if the patient responds best to treating the resistance
first, or the threat, it is probably an emotional denial. On the
other hand, for a neuropsychologically based deficit, the pa¬
tient may show response to education and cognitive remedi¬
ation.
Certain predictions regarding denial and unawareness
have been generated from our clinical conceptualizations
(Langer Sc Padrone, 1992). First, the more acute the onset (i.e.,
recent), the more likely there will be unawareness (due at least
in part to the information issue). Second, the worse the cogni¬
tive deficit, the more likely that there may be some unawareness
(due to a neuropsychological difficulty). Third, the greater the
premorbid tendency to use denial or repression as defenses,
especially with greater subjective loss, the more likely we would
be to predict unawareness, although there may be much inter¬
individual variability. (This may also help explain why some
patients deny and others do not.) Fourth, the greater the emo¬
tional denial, the less the manifest depression, although this is
not absolute (and it is not necessarily true that the less the
84 Karen G. Langer

denial, the greater the depression); there may also be selec¬

tive denial.

CASE EXAMPLES

With these clues in mind to help us, we present the examples

below to illustrate our attempt to distinguish between emo¬
tional denial and neuropsychologically based unawareness.

Case 1

The following is a transcript from an initial evaluation of a

74-year-old woman with posterior left hemisphere brain injury after
hitting head in a fall on the ice (with surgical evacuation of left
temporoparietal subdural hematoma).

In this transcript we will see the minor role of cognitive

factors relative to what begins to emerge as the very strong
impact of emotional denial on her awareness of disability.
There were clear historical roots of the defense of denial that
emerged in later psychotherapy.

E: What happened to bring you here?

P: I don’t know.
E: So you have no idea why you are here?
P: No, not at all, I don’t know why I’m here.
E: Well, tell me what the problem was in the first place.
P: My kids seem to think that when I want to say a word,
another word comes out, close to what I mean, I think,
in talking.
E: You look sort of sad right now.
P: Because they think I talk wrong.
E: And you don’t?
P: I don’t.
E: Well, why is it that you are sitting in a wheelchair?
P: I don’t know, maybe because they, the nurses, say you
have to use it in rehabilitation, and because they said I
 Awareness and Denial 85

once came to class without it and they said I have to

use it.
E: Well, are your legs weak at all?
P: No. Maybe they said it because they think I walked to
the left, and then another time, to the right.
E: How about your arms, is either arm weak?
P: The left. Because of my surgery on my brain. {Patient
has right hemiparesis}.
E: You know, you just said the left.
P: I did? Well, see [what I mean].
E: Yes. So is it the left or the right?
P: I meant the right.
E: You said surgery. Why did you need it?
P: I had bleeding in my head.
E: How did you know you had it?
P: I fell.
E: When was this?
P: November, no, October 1994.
E: How were the symptoms then?
P: Well, first not too much, just a headache; but 2 years,
no, 2 weeks later, they did an MRI; then they did see
something, and they sent me to a neurosurgeon.
E: Where did he operate?
P: Over here (patient points correctly to the left side of
head). That’s why I have no hair there. That’s it.
E: So why are you here now?
P: For occupational therapy, and other, whatever it’s
called.
E: Well, what’s the purpose of being here?
P: To get on my feet more, to start to not walk to one side.
E: I’m curious, before you said you had no idea why you
were here, and now you give very clear reasons for be¬
ing here.
P: I look at it as nothing, but it [really] is something.
E: So it sounds like you make light of it?
P: I do [smile].

In this vignette, we observe the patient’s tendency to de¬

fensively deny, avoid, or minimize her disability. What was com¬
pelling in the psychotherapy treatment, and added to the data
86 Karen G. Langer

in favor of the denial hypothesis, were the obvious historical

roots of the patient’s denial that emerged as a premorbid style
of response to stress. The patient noted in therapy, once her
tendency to make light of disability was illustrated to her, that
this had been a lifelong coping technique, one that she be¬
lieved she needed to employ to deal with her husband’s infidel¬
ity for many years. She quite literally drew her attention away
from its significance as she stewed in a repressed, quiet rage
and hurt.
Our second example illustrates the prominence of un¬
awareness secondary to significant cognitive dysfunction, in¬
cluding short-term memory difficulties and confusion, in a man
of superior intellect and achievement.

Case 2

The following is a transcript of an interview with a 77-year-

old man with closed head injury due to motor vehicle accident sus¬
tained while suffering a heart attack.

E: What happened to bring you here?

P: I’m just here for entertainment; I have no real problem.
E: I’m not sure I know what you mean.
P: I thought all these programs were designed for patients
at the hospital so that they could learn something to
stimulate their minds; somehow I forgot for the mo¬
ment that it’s a hospital and I considered it like a hotel,
like the Concord, like the psychologist has a forum at
2 p.m., and then I remembered that it’s a hospital.
E: Well, what was the problem that brought you here first?
P: I had a heart attack a couple of weeks ago, in a car crash.
E: Do you remember it?
P: My wife remembers it better; she’s the observer.
E: How is your memory now?
P: I feel like Keats said, {patient quotes accurately from
Ode to a Nightingale}; we read it repetitively in college,
then I got a C.P.A., from there to the army in World
War II.
 Awareness and Denial 87

E: I see; tell me, what was your rank?

P: I went from a private to a corporal, to DOD (sic), to the
army; I don’t know if you understand. After the corpo¬
ral, my case, in Detroit, it was Louisiana at the begin¬
ning, the army. . . the Atomic Bomb, I’ll tell you
quickly. . . .
E: Let’s return to more recent times. Can you tell me what
exactly is the purpose of being a patient here now?
P: I said before, I had nothing to do. What time is it?

The patient’s confusion and fluctuating attention are glar¬

ingly apparent in this case, although certainly emotional factors
may also have shaped his interactional style.
Other examples of cognitively based unawareness that
have some obvious bases in neuropsychological impairment,
with relatively little apparent role of emotional denial, follow.

Case 3

The following is a transcript of an interview with a 60-year-

old-man, with a doctorate in biophysics, with stroke due to left fron¬
tal hemorrhage.

E: What happened to bring you here?

P: I thought about it. I looked around but it didn’t make
sense. Something happened between my wife and me;
there was some CIA work; I would go into government,
but I am too old for starting a new job. My wife suddenly
took ill. My science teeters in and out and I have to rely
on what other people tell me. I put in an application
to the CIA and they asked both of us to come see them.
I am not sure if it was that occasion that the vehicle we
were driving had an accident with another vehicle, a
CIA truck.
E: Why are you in the hospital now?
P: Well, I am in the hospital because my wife in that acci¬
dent had a severe sprain of the right ankle and hand
88 Karen G. Langer

that worsened and needed a continuous therapy

process . . .
E: And you are here because?
P: Because the sprain won’t heal and the atomic (sic) is
very slow in healing.

In the next vignette, a patient with a right hemisphere

stroke who was aware of physical but not cognitive limitations,
who was disoriented to time, and only grossly oriented to place,
tried to make sense out of her disability in the face of some
memory loss and confusion. She had a left visual field defect
and hemisensory loss in addition to the hemiplegia. (She had
been informed that she had sustained a stroke.) There was no
denial of affect, as the patient readily discussed her depression
and emotional reactions to loss and limitation.

Case 4

The following is a transcript of an interview with a 50-year-

old, woman with right hemisphere stroke.

E: What happened to bring you to the hospital?

P: I broke my arm and leg.
E: Did someone tell you that?
P: No, no one told me. I think I remember falling. My
husband drove me to the hospital, I think. I really
don’t remember.
E: Have you noticed any trouble with your memory lately?
P: Oh no, clear as a bell as they say.
E: What have the doctors told you about your arm and leg?
P: That they are broken and it will take about a year for
them to heal; for me a year feels like forever.
E: That is certainly understandable. It’s hard to just wait.
P: It feels awful for me. My son is a doctor here you know.
E: What kind of doctor?
P: I can’t really remember. His name is John. I have two
other sons; Bill and Tom (sic; there are really four sons).
Anyway my son says I will be better soon.
 Awareness and Denial 89

E: So why are you here with us now?

P: I’m here so my bones can heal. I broke my foot once
before, or was it my arm? Well, I broke something once
before and couldn’t use it for a while. It’s just so frustrat¬
ing. I also hate being so dependent. Do you see that
piece of trash on the floor? Normally I would just pick
it up myself. I hate being so dependent. . . . And to boot
they are having me see a psychologist this morning.
E: That’s me.
P: Oh, well you’re very nice, so that’s O.K. (She laughed).

Our next vignette illustrates the dual and simultaneous

contributions of unawareness (due to informational and cogni¬
tive factors) with a defensive style that fostered denial.

Case 5

The following is a transcript of a psychotherapy session with

a 48-year-old woman with stroke due to a right frontal subarachnoid
hemorrhage and clipping of anterior communicating artery an¬
eurysm.

P: You know, I slept at home last night in my own bed

(Note: this is inaccurate; patient was a hospital inpa¬
tient) .
E: Tell me what you need to gain from being back here in
the rehabilitation center then today.
P: Nothing. I always use a shopping cart, and I only cook
for one so I have no heavy oven trays to carry. So what
do I need? A cleaning girl (smiles).
E: Well, do you have any goals in being here?
P: To find a husband (smiling). I don’t know. I’m here to
get better. I want to walk, to get better, and to lead a
normal life.
E: What exactly is disrupted at this time?
P: The hospital controls the situation; I’m don’t act on
my own.
90 Karen G. Langer

E: If you left today, is there anything that would be hard

for you to do?
P: To find a salad for dinner (smiling). Really, the ordinary
routines of life, it’s all done for you, they wash and
dress you.
E: Is there anything difficult since the aneurysm for which
you need help?
P: No.
E: Are there any physical changes now?
P: Yes, I have to get the sphincter muscle in order; I get
wet.
E: Oh, that can be difficult and pretty embarrassing. Well,
it seems that there is a goal that you can work on improv¬
ing while you are here. I notice that you sit in a wheel¬
chair. Why is that?
P: They [the nurses] put you there.
E: Why is that?
P: They don’t want you to move about; they’re worried
that you might fall and break your back and sue.
E: Why would they be more worried about that now?
P: You don’t have the balance.
E: So you’re aware of the balance.
P: I guess so. It’s a genuine fear. Do you sway and act
drunk and waver when you walk?
E: Well, was that ever a problem before the aneurysm?
P: It may have been. I have a short memory; that’s a lit¬
tle problem.
E: Isn’t that something you would like then to work on im¬
proving?
P: It’s a goal; so you’ve given me a goal (smiling).
E: How is the strength in your legs; any weaker recently?
P: No, it was all prior, from arthritis.
E: How about concentration and memory; are they
harder?
P: No, nothing since the aneurysm has changed, I had
ADD—you know, attention deficit disorder; I always had
trouble concentrating.
E: But the balance?
P: I never really had balance.
 Awareness and Denial 91

E: You’re saying there are no changes since the aneurysm?

P: Well, there are some changes that I have to work on.
E: What are they?
P: Balance, concentration.
E: So you feel that you should be here?
P: Absolutely. I need therapy for walking; there are no side
effects of the stroke, but I guess I forget this and that.
E: So your goals are walking, balance, concentration, and
memory. How come, though, at the beginning you
didn’t mention these?
P: Maybe I’m more resilient now, or more trusting of you.
Maybe I was protecting myself.

The interaction of emotional denial and cognitively based

unawareness are readily apparent here.

ASSESSMENT ISSUES

In order to treat a patient most effectively, we need to accu¬

rately assess a broad range of aspects of life-functioning and
psychologic adaptation.
There are formal questionnaires that can be used to assess
awareness of disability after brain dysfunction (Prigatano et al.,
1986; Simon, Riley, Egelko, Kaplan, Newman, & Diller, 1991).
For the patient with questionable awareness, one may inquire,
with increasing structure and specificity, about circumstances
of onset, name, and nature of the condition, other health prob¬
lems, the nature of the disability (both physical and cognitive),
the degree of dependence and assistance needed, expectations
of self and others, and goals for treatment, with examples of
queries contained in the vignettes presented above.

TREATMENT IMPLICATIONS

There are some treatment implications that emerge. If a neuro¬

psychological (implication) difficulty is what obscures knowl¬
edge and awareness, the clinician should work on building
92 Karen G. Langer

cognitive structures that would support the knowledge. If, on the

other hand, emotional denial predominates, then the thera¬
peutic effort would instead best focus on strengthening the ego
functions that could support the knowledge. (The two possibili¬
ties are of course not mutually exclusive, and if the stress pro¬
duces regression in ego functioning, structure, support, and
reeducation may be needed until psychic equilibrium is re¬
stored.)
There are some other therapeutic considerations in treat¬
ing either unawareness or denial. We need to balance the risk
of despair, versus the need to maintain hope; the risk of shame,
versus the need to maintain self-esteem and self-respect; the
risk of psychic decompensation were the denial to be punc¬
tured; and the nature and level of distress and the patient’s
ability to tolerate it. The risks involved in maintaining denial
or unawareness, though, may include real physical danger to
self or others if the patient ignores the physical reality (and
tries to climb out of bed or drive a car, for example), or may
be emotional if the patient risks failure and humiliation that
could have been otherwise averted. Of course, the positive side
to denial is that, certainly in the acute phases, it may permit
adaptive coping with catastrophic loss. It may also fuel creative
endeavor that would be impossible if the patient became fully
resigned to a sense of limitation as opposed to one of challenge.
In psychotherapeutic treatment of awareness (whether
cognitively based or emotionally driven), the therapeutic alli¬
ance is paramount for the patient to feel secure and trusting.
There may be a tendency to get to the point quickly and un¬
cover all the difficulties, but prioritization and hierarchy must
take precedence if the patient is to feel a sense that she or he
can tackle the problem. Lewis (1991) cautions wisely that denial
“is not an obstacle to treatment to be overcome as quickly as
possible but rather, as a motivated process that has adaptive
value and meaning’’ (p. 235), and although adaptive, it is not
maintained without a price.
Clinical strategies with which we are all familiar include
dosing or titration of the painful information at a pace that can
be tolerated, effectiveness and sensitivity of timing, and empathic
tone and wording. The use of humor can make a real difference
 Awareness and Denial 93

in lightening the tone of difficult topics, and can help the pa¬
tient consolidate the new awareness with an emotional frame,
one that decreases the dread of isolation and shares what is
fundamentally human in the therapist as well. Another key fac¬
tor in addressing awareness is the patient’s perception of the
direct relevance to him or her, as well as the premorbid context
and meaning of the loss. This involves considerations of the
normal narcissistic aspects of the patient’s self-image. Cicerone
(1998) sensitively discusses the importance of consideration of
the patient’s assumptions and beliefs about his or her own
world, calling for real therapeutic neutrality and a nonjudg-
mental stance. The therapist needs to continuously monitor
current and potential sources of distress to titrate these, and
to provide support for the shame, hurt, and pain.
To summarize, the psychotherapeutic challenge involves
monitoring the dynamic fluctuations in a patient’s readiness
to become aware of losses, considering the interaction of neu¬
rogenic and emotional factors, and sensitivity to and therapeu¬
tic treatment of the emotional reactions, such as shame,
depression, anger, and/or despair, that may accompany grow¬
ing awareness of loss. We as therapists ought also to consider
the importance of maintaining (realistic) optimism and hope
(Janis & Mann, 1977) that change is possible and that patients
can find ways to live with loss and to overcome certain obstacles.
This determination is not akin to denial, for in it the person
recognizes the limitation, but is motivated to find ways to adapt
and live with it. Lastly, we remind ourselves of our own human¬
ity, particularly when dealing with patients with brain dysfunc¬
tion when we work on awareness, since we realize that many of
us have pockets of diminished awareness of our being, or of
our own strengths and weaknesses, undesirable in certain in¬
stances but adaptive in others. But building conscious aware¬
ness is after all a hallmark of the challenge that we all face as
individuals in our own continued development.

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5.

Depression and Its Diagnosis and

Treatment

Robert W. Butler, Ph.D. and

Paul Satz, Ph.D.

The occurrence of a mood and affective disorder following an

injury to the brain is extremely common. The incidence of
major depressive disorder following traumatic brain injury
(TBI) has been reported to be in the range of 25 to 50% of
all patients (Gualtieri Sc Cox, 1991; Kinsella, Moran, Ford, Sc
Ponsella, 1988; McKinlay, Brooks, Bond, Martinage, Sc Mar¬
shall, 1981). It has also been reported that the severity of the
trauma is positively correlated with increased depressed mood
following TBI (Satz et al., in press). Similar estimates of fre¬
quency have been reported in the stroke population (Rob¬
inson Sc Price, 1982).
Neuropsychologically, the comorbidity of brain impair¬
ment and depression can create diagnostic confusion, and
make psychological treatment extremely complex. The reasons
for this are that many types of brain dysfunction can cause
depression symptoms which may exist in the absence of de¬
pressed mood. For example, Blumer and Benson (1975) de¬
scribed a syndrome of “pseudodepression” in patients who
had suffered damage to the medial and orbital frontal lobes.
This syndrome is characterized by apathy, unconcern, a lack of

97
98 Robert W. Butler—Paul Satz

drive, decreased emotionality, and difficulties in the initiation

of behaviors. Thus, the patient may present with many of the
symptoms of major depressive disorder but not actually mani¬
fest the underlying psychiatric disorder. Conversely, major de¬
pressive disorder can be characterized by neuropsychological
impairment. Patients with major depressive disorder but no
discernable central nervous system (CNS) damage have been
reported to manifest impairment in attention-concentration,
memory (retrieval in particular), and on cognitive tests that
require effort (Caine, 1986). Pseudodementia, a descriptive term
for the presentation of depression with associated cognitive
impairment in the elderly, is recognized as a common form of
treatable “dementia” (Benson, 1982). Finally, a recent study
has suggested the possibility of an interactive relationship be¬
tween CNS status and the emergence of major depressive disor¬
der. It has been reported that while depression episodes can
be characterized by nonverbal intelligence deficits, the pattern
of reduced performance IQ, when compared to verbal IQ and
with accounting for the timed nature of nonverbal tests, was
present in these patients even after the affective disorder remit¬
ted (Sackeim et al., 1992).
It is our position that the assessment and treatment of
depression in the neurologically impaired patient is not a sim¬
ple technical process. There is considerable overlap between
the symptoms of major depressive disorder without accompa¬
nying CNS impairment and the neuropsychological sequelae
of a brain injury. Further, depression can be a natural psycho¬
logical reaction to a neurological disease. Treatment ap¬
proaches to depression with a neuropsychologically impaired
patient will have to take into account additional variables, is¬
sues, and factors. In this chapter we will: (1) describe those
aspects of depression that are commonly apparent in patients
with a primary CNS disorder; (2) offer specific approaches de¬
signed to effectively formulate a diagnostic schema for depres¬
sion in this population; and (3) address important
psychotherapeutic issues in the treatment of brain-impaired
patients who have a diagnosis of affective disorder.
 Depression: Diagnosis and Treatment 99

SYMPTOMS OF DEPRESSION ASSOCIATED WITH

NEUROPSYCHOLOGICAL IMPAIRMENT

One of the most common referrals to the clinical neuropsychol¬

ogist in an adult practice involves a diagnostic question regard¬
ing the presence of “pseudodementia.” Specifically, the
neuropsychologist is asked, “Does this patient suffer from de¬
pression, or is a dementing process present?” We believe that
this is a specious question, not only in the aged population
but also in all differential brain injury/depression diagnostic
dilemmas. Rather than asking, “Is the patient depressed or
does the individual have a neurological disorder?” one needs
to consider, “Is there evidence of depression and has the pa¬
tient suffered a neuropsychological impairment?” The two
probabilities are not mutually exclusive. One can be demented
and depressed, depressed and not demented, or demented and
not depressed. Thus, the diagnostic query is not simple and
needs to be multifactorial in nature. In an assessment of depres¬
sion in the CNS-impaired population the following factors
should be entertained.

Mood-Affect

Internal perceptions of emotion can be altered following a

brain injury, particularly if the nondominant hemisphere is
involved. The ability to perceive emotion in others is associated
with posterior nondominant cortical functioning, while the ex¬
pression of emotionality is more anteriorly located in the non¬
dominant hemisphere (Bryden 8c Ley, 1983; Heilman,
Watson, & Bowers, 1983; Ross, 1981). Behaviorally, the patient
with a brain injury can present with incongruent mood and
affect due to a defect in the ability to perceive and/or express
emotionality. Thus, decreased prosody, absence of gesturing,
and a lack of appropriate facial expression secondary to right¬
sided brain impairment may give the illusion of depression in
a patient whose subjective mood is euthymic. The integrity of
these and other nondominant hemispheric functions should
100 Robert W. Butler—Paul Satz

be directly assessed in a brain-impaired patient who is suspected

of having major depressive disorder.
One should also be aware of research evidence which indi¬
cates that the presence of depression in a patient with brain
impairment can be associated with increased severity of neuro¬
psychological deficits, particularly those of a nondominant na¬
ture (Fogel & Sparadeo, 1985). Thus, it is critical that an
accurate diagnosis of depression is made and confirmed in a
timely manner. Treatment should be instituted rapidly, and
neuropsychological functions need to be reevaluated after suc¬
cessful resolution of the affective illness. The neuropsychologi¬
cal evaluation can be an invaluable blueprint for planning
rehabilitation efforts, vocational screening, social-marital ad¬
justment counseling, and helping the patient, in general, max¬
imize his or her resources following CNS illness or injury.
Misleading neuropsychological results may be present in the
patient who is also suffering from a major depressive disorder.
Damage to the frontal lobes and the limbic system can
alter emotionality and the expression of affect. This area of the
brain is especially prone to contusions following closed head
injuries (Gurdjian & Gurdjian, 1976). Thus, a detailed history
of past head injuries needs to be obtained on all patients. Fron¬
tal damage following a head injury can result in difficulties
with initiating behavior, flat affect, impairment in modulating
emotion, and excessive lability (Levin, Benton, & Grossman,
1982). These behavioral symptoms can also be expressed by
the patient with depression, and it is necessary to identify the
underlying causality in order to develop an effective treat¬
ment plan.

Neurovegetative Signs

While all of the symptoms of major depressive disorder identi¬

fied in the Diagnostic and Statistical Manual (DSM-IV; APA,
1994) are relevant for a diagnosis, some have decreased sensitiv¬
ity and specificity in the brain-impaired population. Neuroveg¬
etative symptoms, in particular, are less useful for a diagnosis
 Depression: Diagnosis and Treatment 101

of depression because brain dysfunction can cause alterations

in these areas independent of depressed mood. For example,
changes in sleep patterns, appetite, energy, memory, arousal,
and sex drive can be due to diencephalic and limbic damage
secondary to a CNS insult and have reduced diagnostic efficacy
(Butler & Satz, 1988; Jorge, Robinson, & Arndt, 1993). A care¬
ful review of the time course of symptom emergence will assist
the clinician in making a judgment in this area. Neurovegeta-
tive symptoms which emerge relatively soon after the brain in¬
jury or damage are likely to be less reflective of major
depression, particularly if they are not associated with a signifi¬
cant change in mood.

Social/Occupational Functioning

A necessary criterion for the diagnosis of major depressive dis¬

order or another mood disorder is that a significant impair¬
ment in social and/or occupational functioning has occurred
(APA, 1994). Deficient functioning in these areas is assumed
to be secondary to symptoms of depression. Within the brain-
impaired population, however, alterations in social and occupa¬
tional adjustment are very common, even following very subtle
cognitive impairment. Denial of illness when combined with
neuropsychological impairment can result in decreased voca¬
tional performance. Familial and marital relationships often¬
times undergo stressful upheaval, and the patient may suffer
from disabling initiation deficits resulting in social isolation
(Butler & Satz, 1988; Lezak, 1978; Prigatano, 1987). Thus, the
diagnostic discrimination of these criteria in major depressive
disorder with a neuropsychologically dysfunctional patient is
reduced.

ASSESSING DEPRESSION IN PATIENTS WITH

NEUROPSYCHOLOGICAL IMPAIRMENT

Prior to a clinical assessment for depression with the brain-

impaired patient, one will first want to have a detailed history
102 Robert W. Butler—Paul Satz

of the neurological insult, review pertinent neurological and

neurodiagnostic reports, and obtain a neuropsychological eval¬
uation. This information will provide the clinician with the nec¬
essary information required to make an effective diagnosis of
mood alterations independent of or associated with CNS im¬
pairment. Neurological and neurodiagnostic evaluations will
provide evidence of the location, nature, and extent of struc¬
tural and functional brain damage. A history will allow the
clinician to make judgments regarding possible causative rela¬
tionships between mood, brain dysfunction, and the psycholog¬
ical reaction to CNS illness. The neuropsychological evaluation
is an invaluable tool for determining the extent to which occu¬
pational and/ or social dysfunction is associated with brain im¬
pairment, depression, or a combination of both. The
importance of this evaluation cannot be overemphasized. A
comprehensive neuropsychological evaluation is the only neu¬
rodiagnostic procedure that quantifies the end product of
brain function: thought and behavior. Quite simply, it is the
brain’s responsibility to provide the substrate for one’s effective
and successful adaptation to a complex and demanding world.
The neuropsychological evaluation is designed to measure the
degree of this role efficacy, which the brain mediates under
our conscious activation.
After the neurodiagnostic evaluations have been reviewed
and incorporated, the clinician should then determine if a ma¬
jor depressive disorder or dysthymia is present. As noted above,
the differential diagnosis of brain impairment versus depres¬
sion or a “pseudodementia” is somewhat specious. A more
clinically relevant and, in our minds, practical approach is to
ask first: (1) whether there is evidence of brain dysfunction
and (2) whether there is depression present. The assessment
of subjective mood is especially critical for a diagnosis of depres¬
sion in the brain-impaired population. This is because, as iden¬
tified earlier, the behavioral, affective, and neurocognitive
symptoms of depression overlap with many neurobehavioral
consequences of brain insults. We strongly recommend using
the Beck Scales for Depression as an aide in quantifying mood.
The Beck Depression Inventory has been revised (BDI-II: Beck,
 Depression: Diagnosis and Treatment 103

Steer, & Brown, 1996) and remains a brief but excellent quanti¬
fication of depressive mood and ideation. The clinician is also
encouraged to supplement the BDI-II with Beck’s hopelessness,
anxiety, and suicidal ideation scales. These are all very well
constructed psychometric measures that provide excellent in¬
formation on the patient’s internal, subjective psychological
state. An excellent illustrative example of how these scales can
be used clinically with brain-impaired individuals is presented
by Hibbard and coworkers (Hibbard, Gordon, Egelko, &
Langer, 1987).
While self-report measures of mood are invaluable for
identifying dysphoria, they can provide misleading results and
should be used with appropriate caution. Most depression in¬
ventories have been developed using non-brain-impaired pa¬
tients, and there may be unknown normative discrepancies for
this reason. Different rating scales for depression have been
demonstrated to have poor concordance for classifying individ¬
ual “cases” of depression, even though the scales may have
very high correlation coefficients with each other (Harker,
Satz, D’Elia, Miller, &Jin, 1997). One possible explanation for
this discrepancy is that while all self-report measures may be
validly assessing depression, some may be more heavily
weighted toward the cognitive and neurovegetative aspects of
mood disorders (e.g., concentration, memory, fatigue). As
noted earlier, these scales can result in increased false positives
with neuropsychologically impaired patients. Impaired patients
may also have significant perceptual and attentional cognitive
deficits that can increase the likelihood of reading errors. Le¬
sions to the parietal-occipital cortex, and to a lesser extent the
temporal lobe, can cause acquired dyslexia (Luria, 1980) which
can also reduce the validity of self-report measures with brain-
impaired adults and children. Given these caveats, what is
needed is a good, thorough clinical assessment using a scien¬
tific, hypothesis testing approach. The self-report inventory
should be closely inspected for each individual item response,
in addition to using the summated score for classification. Item
responses should be evaluated in light of the clinical interview
and verified with the patient if necessary. Any discrepancies
between self and family member reporting should also be
104 Robert W. Butler—Paul Satz

closely investigated. It is the clinician’s responsibility to follow

all these steps in order to make an accurate diagnosis.
While the primary focus of this chapter is directed toward
the clinician who is treating adults, there are some very im¬
portant issues specific to the pediatric and adolescent brain-
impaired population that should be briefly discussed. The diag¬
nostic criteria for depression in children and adolescents are
identical to adults. This should not fool the clinician into think¬
ing that the diagnostic considerations are entirely the same for
these two populations. The importance of a comprehensive
neuropsychological evaluation, history, and other neurodiag¬
nostic assessments is equally pertinent to the diagnosis of possi¬
ble depression in brain-impaired children. There are, however,
some very critical caveats to differentiating neuropsychological
impairment from depressive symptoms in children versus
adults. The clinician needs to take into account the status of
the child in terms of brain and behavior development. For
example, the frontal lobes do not complete myelination and
maturation until the second decade of life (Passler, Isaac, &
Hynd, 1985). Thus, initiation and self-control difficulties are
relatively common in normal children and not necessarily re¬
flective of an actual insult to the frontal brain structures. Fur¬
ther, the status of the child’s language development is often a
critical factor in assessing mood and in mediating self-control.
The child may be unable to accurately label a mood state, or
to use internal dialogue in an effective manner.
Child neuropsychology has been emerging as a subdisci¬
pline with its own advanced training requirements. In the case
of a brain-impaired child who is suspected of having a mood
disorder, the clinician should seek consultation from a profes¬
sional specifically trained in pediatric neuropsychology. There
is a child’s version of a self-report depression inventory, The
Child Depression Inventory (CDI: Kovacs, 1992). This is a use¬
ful measure and should be administered to the patient. While
we do not have data to support this impression, in our clinical
experience mild elevations on the CDI (T score between 60 or
70) can be suggestive of significant dysphoric mood, especially
in a child who is not verbal facile, or who is somewhat delayed
 Depression: Diagnosis and Treatment 105

or compromised in communication skills. Information on the

child’s psychological status will also need to be obtained from
the caregivers. They can provide critical information on the
child’s mood and affect, particularly with a patient who is cogni¬
tively impaired as well. A clinical interview with the child’s care¬
givers will be illuminating, but this should be supplemented
with an other-report psychometric inventory specifically de¬
signed to evaluate the presence and severity of a mood distur¬
bance. The two most widely used questionnaires for children
and adolescents are the Child Behavior Checklist (CBC: Achen-
bach, 1991) and the Personality Inventory for Children-Revised
(PIC-R: Lachar, 1984). There are advantages to each measure.
The CBC is relatively brief but may be somewhat insensitive to
mild or moderate dysphoria. This is due, in part, to its brevity,
but also because it was constructed to identify clinically signifi¬
cant depression rather than more mild mood dysphorias, such
as what would be characteristic of an adjustment disorder. We
prefer the PIC-R because of its greater sensitivity and use of
validity scales (Butler, Rizzi, 8c Bandilla, in press). Completing
the PIC-R, however, is much more time consuming and re¬
quires a cooperative caregiver.
It is very important to note that children, because of brain
and language development, often lack the abilities for self-re¬
flection and/or verbal expression of mood alterations. When
queried they may fail to endorse corresponding symptoms of
depression. Thus, inconsistencies between self-report mood, af¬
fect, and behavior are likely to be more prominent in child¬
hood depression. Our clinical experience supports this
likelihood, and we believe there are even greater diagnostic
problems with neuropsychologically impaired children because
language can suffer considerable disruption following a pediat¬
ric brain insult. As was noted above, the diagnosis of depression
in the neuropsychologically impaired patient necessitates the
consideration of additional nuances that will effect the validity
and reliability of clinical diagnostic tools. When the patient is
a child, even more additional factors must be weighed and ana¬
lyzed.
106 Robert W. Butler—Paul Satz

PSYCHOTHERAPY OF DEPRESSION WITH

NEUROPSYCHOLOGICALLY IMPAIRED PATIENTS

Over 10 years ago we stated that psychotherapy is just as im¬

portant of a consideration with the brain-impaired population
as it is with cognitively intact individuals (Butler & Satz, 1988).
We continue to believe that this is true, and the emergence of
this text is a strong indication that others also value the impor¬
tance of psychotherapy with the patient who has suffered neu¬
rological impairment. The traditional belief that these patients
could not benefit from insight-oriented, self-exploratory, and/
or cognitively based treatments has not held up over time.
Brain-impaired individuals can clearly benefit from these ap¬
proaches. Psychotherapy with a neuropsychologically impaired
person, however, does require special considerations. We will
address what we believe to be the most important characteris¬
tics of the psychotherapy of depression in brain-impaired pa¬
tients.
Our primary approach to therapy with both adults and
children is cognitive-behavioral. In using this therapeutic ap¬
proach for depression, the clinician is typically working in two
major areas. First, the patient’s own self-statements and style
of thinking about events in their life, or schemata, are exam¬
ined. The theoretical assumption is that depressive mood is
associated with underlying errors in judgment, and inaccurate
or ineffective thought patterns. While the complexity of the
internal dialogue will increase with adults as opposed to chil¬
dren, the errors in thinking can be quite similar. Second, the
patient’s specific behaviors are examined in order to ensure
that there is an adequate supply of reinforcers in his or her
environment, and that the individual is successfully obtaining
rewards in life. Typically, the depressed individual withdraws
socially, reduces their access to secondary reinforcers, and will
even decrease use of primary reinforcers such as food, and with
adults, sexual activity. The patient is given specific homework
assignments which are expected to be completed in between
psychotherapy sessions. Additionally, the patient is typically re¬
quired to keep a diary or record of both internal thoughts and
behavioral events. The above approaches can be supplemented
 Depression: Diagnosis and Treatment 107

with direct instruction in coping strategies that are designed

to control depressive symptoms, and also social skills training
to increase life-style reinforcers, particularly with children and
adolescents (Stark, Rouse, & Livingston, 1991).
The reader has probably already identified the neurocog-
nitive deficits that would directly impact on this type of psycho¬
therapy. Cognitive-behavioral therapy for depression requires
some degree of initiation, the ability to learn new verbal mate¬
rial, language comprehension and expression skills, memory
and attention-concentration. While these neuropsychological
functions can suffer some degree of impairment following a
brain injury, rarely do they all become profoundly impaired.
Even children with severe neuropsychological involvement typi¬
cally have rudimentary language systems and basic learning
abilities. Thus, it is the rare patient who has undergone a seri¬
ous global or specific neuropsychological deterioration to the
degree that they are inappropriate candidates for cognitive-be¬
havioral therapy for depression. To the extent that some degree
of impairment is present, however, the clinician will have to
make some allowances and treatment adjustments in order to
maximize the potential effectiveness of psychotherapy.
If memory is defective, the patient should be instructed
in the use of compensatory devices. Treatment sessions should
be tape recorded, and the patient should be taught how to use
an organizing system, electronic or script-based. The organiz¬
ing system is recommended because it can serve as both an
appointment schedule and a record-keeping diary for the psy¬
chotherapy assignments. If memory is severely impaired, the
therapist may want to have an assistant provide periodic re¬
minders to the patient about completing homework assign¬
ments. If the patient has a friend, partner, or available family
member willing to provide memory reminders this can also
be instituted. This “personal assistance” is also necessary for
patients who have significant initiation difficulties following a
frontal brain injury. In addition to compensatory devices, the
patient can be taught mnemonic strategies designed to improve
memory functioning. For higher functioning individuals, this
can be done in the form of bibliotherapy. There are numerous
108 Robert W. Butler—Paul Satz

memory improvement books readily available in all large book¬

stores. With more impaired patients, consultation with a thera¬
pist skilled in cognitive remediation and rehabilitation will be
helpful.
All neuropsychologically impaired patients who begin psy¬
chotherapy for depression should be evaluated by a psychiatrist
for possible medication treatment. In addition to consideration
for antidepressant therapy, the physician should weigh the po¬
tential benefits of stimulants such as Ritalin, Dexedrine, and
Cylert. These approaches can be beneficial with brain-impaired
patients in two ways. First, they can be useful in improving
attentional deficits associated with CNS dysfunction. Second,
stimulants may help counter initiation difficulties that the pa¬
tient may be suffering (Kraus, 1995).
If the patient has not fully adjusted to the life changes
associated with the brain impairment, then this should become
a treatment goal, in addition to the more traditional cogni¬
tive-behavioral procedures. As we have written before (But¬
ler Sc Satz, 1988), brain injuries can result in a very unique
sense of loss. Specifically, the patient is forced to cope with a
loss of the psychological self. If one loses sight or an arm or
leg, this is a traumatic event that can lead to depression, but
the person still possesses their cognitive abilities and basic per¬
sonality structure. Social, family, and marital relationships may
show some initial strain, but generally remain intact. In our
experience, the loss of self that can result from neuropsycholog¬
ical impairment is a much more devastating event, and can be
extremely destructive to social and familial support systems.
Others have also made these observations (Lewis, Athey, Ey-
man, Sc Saeks, 1992; Lezak, 1978). A willingness to briefly de¬
tour, at times, from the goals of therapy for symptoms of major
depression is essential. The patient may be in need of empathy,
understanding, and support for issues more reactive to the
brain impairment and his or her losses. If the patient is suffer¬
ing from highly significant complications in this area, a referral
is necessary. The referral network for the clinician treating a
brain-impaired patient for depression needs to include a neu¬
rologist, neuropsychologist (preferably one skilled in psycho¬
therapy and cognitive remediation with brain-impaired
 Depression: Diagnosis and Treatment 109

patients), family therapist, psychiatrist, marital therapist,

speech pathologist, occupational therapist, and vocational spe¬
cialist.
The neuropsychological evaluation will provide important
data on the manner in which psychotherapy should proceed.
If the patient has a decelerated learning curve and/or reduced
information processing efficacy, then the therapeutic process
will require greater time. The amount of information imparted
in any single treatment session will need to be reduced and
tailored to the patient’s learning ability. If the patient has an
aphasia, a speech pathologist needs to be consulted and ther¬
apy altered as appropriate. The degree of neuropsychological
impairment will give the clinician a good basis for the initial
formulation of appropriate treatment goals.
Denial of symptoms, or anosognosia, is very common fol¬
lowing a brain injury (Benson, 1994; Prigatano & Schacter,
1991), and presents an obvious set of hurdles for the psycho¬
therapist. The patient, most often an adult, may deny even
the most profound cognitive impairment, including deficits in
memory, speech, planning, judgment, and attention-concen¬
tration. Personality and mood changes may also be steadfastly
ignored and disclaimed. Our experience suggests that direct
confrontation for anosognosia is rarely helpful and can be dam¬
aging to the therapeutic alliance. We prefer to expose the pa¬
tient to situations which will force him or her to undergo a
self-confrontation process. It is the therapist’s role to provide
a supportive, but insightful environment so that the patient
learns from and accepts the self-confrontation. Related to the
issue of symptom denial, the therapist will need to carefully
weigh psychodynamic interpretations of resistance with pa¬
tients who have suffered brain impairment. As described pre¬
viously, a patient may fail to complete homework repeatedly
because they have impaired memory. Similarly, an anosognosia
neglect syndrome associated with right hemispheric damage
may be present, and the patient may deny and refuse to ac¬
knowledge cognitive or mood impairment because of the brain
injury not because of “unconscious” psychological processes.
Finally, specific attention will likely have to be directed at
familial relationships. For the adult this may involve the marital
110 Robert W. Butler—Paul Satz

or other partner, and with children the parents will be involved.

Family members may react to the patient with feelings of frus¬
tration, guilt, depression, resentment, and/or anger (Cooper,
1976; Lezak, 1978). Overinvolvement and intrusive caretaking
may begin to occur, or conversely, partners or caretakers may
deny the patient’s illness and attempt to continue their rela¬
tionship as if nothing has changed. Delicate role balances in
the family relationships that have been established can become
extremely disrupted. While the therapist may have recom¬
mended, and begun treating the neuropsychologically im¬
paired patient for individual psychotherapy of depression, it is
quite probable that family therapy issues will become promi¬
nent, especially if a family member has been enlisted as a thera¬
peutic assistant. Referral and treatment by a competent family
and/or marital therapist is necessary should these issues arise.

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6.

Transference and Countertransference

in Psychotherapy with Adults
Having Traumatic Brain Injury

Lisa Lewis, Ph.D.

Leonard Diller (1994) notes that one of the trends in neuropsy¬

chological rehabilitation over the past 5 years has been a reem¬
phasis of ego psychological constructs such as the self and self-
efficacy as well as ego mechanisms of defense, including denial.
He and others (Christensen, Henry, Ross, Kostasek, & Rosen¬
thal, 1994) further note that primarily psychological factors
such as strength of alliance formed with the rehabilitation team
and degree of depression are better predictors of rehabilitation
outcome than measures of neurological damage. It was over 50
years ago that Sir Charles Symonds (1937) said, “It is not only
the kind of injury that matters but the kind of head” (p. 1087).
So it is not that we are only now recognizing the role of psycho¬
logical factors in determining the extent and rate of recovery
following brain injury. It is only fairly recently, however, that
we have begun to integrate an appreciation of psychological
factors into our way of thinking and working.
We are aiming for an attitude in which the therapist and
patient recognize the disability and deficits and also see more,
see past them to the totality of the person and a vision of what

113
114 Lisa Lewis

that person might become. This implies an openness in the

therapist to an empathic identification with the patient and an
emotional reverberation with the patient’s subjective experi¬
ence. Out of this process frequently emerges an idealizing trans¬
ference on the part of the patient to the therapist and a
mirroring response from the therapist, processes described by
Kohut (1977; Wolf, 1988) in general, and in particular by Klo-
noff and Lage (1991) in therapy with patients having traumatic
brain injury. Some therapies never get to this point while others
remain at this point until termination, but many evolve further.
The Humpty Dumpty syndrome, true and complete restoration
of the mind and self following brain injury, is the exception
rather than the rule. Disillusionment and disappointment and
working through of despair must also be a part of what we are
open to experiencing with our patients (Lewis, Athey, Ey-
man, & Saeks, 1992)
Before talking about countertransference and transfer¬
ence in greater detail, it will be useful to briefly give an overview
of the psychotherapy process so that transference and counter¬
transference can be viewed in context (see Table 6.1). There
TABLE 6.1 '
Curative Factors in Psychotherapy
Technique Relationship

Education Real Alliance Transference & Countertransference

Skills Training
Clarification Tx Frame Hopefulness
Confrontation Respect Shared goals
Interpretation Caring Shared procedures
Advice Dependability
Praise Objective CT

are two broad spheres of curative activity in psychotherapy.

One sphere is the practical realm of therapeutic technique em¬
ployed, such as education, skills training (e.g., relaxation, as¬
sertiveness, cognitive retraining), confrontation, clarification,
interpretation, advice, praise, and so on. The other realm con¬
stitutes the intimate edge of the treatment relationship where
existential meanings are discovered and created. The relation¬
ship consists of several components: The real relationship in¬
cludes what Langs (1982) calls the treatment frame as well as
 Transference and Countertransference 115

the realistically expectable qualities of respect, caring, and de¬

pendability. The real relationship also includes what Ferenczi
(1919) and Winnicott (1949) call the objective countertransfer¬
ence, meaning the kinds of responses the patient’s behavior
would elicit in nearly anyone. A second important ingredient
of the therapeutic relationship is the alliance. The alliance is
comprised of three factors: a sense of mutual trust and hope¬
fulness in the effectiveness of treatment, an agreement on the
problems and goals which will be the focus of therapy, and an
agreement on the therapeutic techniques which will be em¬
ployed. A last component of the therapeutic relationship, and
one which will be the focus of the remainder of this chapter,
is the transference and countertransference.
Transference and countertransference are ubiquitous.
They happen not only in therapy but also in all relationships.
They simply mean that current day relationships are perceived
and experienced through the lens of our past significant rela¬
tionships as they have affected our personality development.
Our past is transferred or displaced onto our present. De¬
pending upon how troubled our past relationships were and
depending upon the extent to which we have individuated from
our families of origin, transference and countertransference
can be subtle and muted, a backdrop adding texture and nu¬
ance to our current relationships, or they can be in the fore¬
ground leading to maladaptive repetition of the same basic
relational paradigms over and over again. In the latter case,
transference and countertransference demand attention in the
therapy process and can be powerful vehicles for change.
Transference and countertransference are two sides of the
same coin. There are two models that are particularly helpful
(see Table 6.2). They are simple enough to be remembered

TABLE 6.2
Transference and Countertransference

Complementary: Feel as other person did

Racker. Concordant: Feel what patient feels

Idealizing: Therapist as omnipotent, soothing presence

Kohut:
Mirroring: Response validating self worth
116 Lisa Lewis

and used during the nitty gritty of clinical hours and are also
true to the clinical process. One model is formulated by Hein¬
rich Racker (1968), an Argentinian analyst who trained with
Melanie Klein and D. W. Winnicott. He speaks of complemen¬
tary and concordant countertransference. In complementary
countertransference, we feel what significant people in the pa¬
tient’s past, usually parents, felt in response to the patient’s
behavior. In concordant countertransference, we feel what the
patient is feeling, or, perhaps more accurately, what the patient
is defensively struggling not to feel. A second, and overlapping
model, is provided by Kohut (1977). Nearly all patients, espe¬
cially those who have experienced neuropsychological impair¬
ment, come to therapy with a large measure of narcissistic
injury which needs to be addressed (Lewis & Rosenberg, 1990).
Kohut describes the development of a self/object or idealizing
transference in which the patient perceives the therapist as an
omnipotent figure with whom the patient can merge and whose
very presence is soothing and healing. The patient hungers for
a mirroring response from the therapist, a confirming, validat¬
ing response that Kohut likens to “the gleam in the mother’s
eye’’ and which provides the patient with a sense of self-worth.
An example will illustrate. Sarah, a 32-year-old single
woman, sought treatment at Menninger 5 years after a signifi¬
cant traumatic brain injury (coma for 11 days, bilateral frontal
lobe contusions, contusion of right temporal lobe, petechial
cerebellar hemorrhage, brainstem contusion). Tragically, the
injury was sustained in a car accident as Sarah was driving to
visit her sister in the hospital who herself had been in a car
accident 2 months before and rendered quadriplegic. Sarah
had spent four of the last five years in medical hospitals and
rehabilitation centers. In one rehabilitation center, she was be¬
friended by her physical therapist who continued a social rela¬
tionship with her after her discharge, eventually proposing
marriage, which she accepted. The relationship was likely
doomed from the start. Her fiancee was homosexual, he related
to her more as if he were an omnipotent treater than a lover
or friend, and he was financially dependent on her—she paid
for everything out of the settlement from her accident. It
seemed to be a Pygmalion sort of relationship where each of
 Transference and Countertransference 117

them tried to ignore the other’s negative traits and transform

the other into the person of their dreams. The negative traits
could not be ignored and anger and resentment increasingly
crept in.
At her concerned family’s insistence, Sarah presented her
fiancee with a prenuptial agreement designed to protect her
finances. He did not sign it and two weeks later put her on a
plane back to her mother. Her mother and father had divorced
some 10 years ago. Sarah viewed her mother as a critical, de¬
meaning, depressed woman who had been rejected by her fa¬
ther. She in turn idealized her father, a judge, whom she viewed
as a knight in shining armor despite the fact that he was emo¬
tionally distant with her. After the breakup with her finacee,
Sarah collapsed into deep, suicidal depression which failed to
improve with outpatient psychotherapy and pharmacotherapy
in her hometown. It was for this reason she came to Menninger.
In therapy with me, Sarah came to each session with writ¬
ten questions about herself, her life experiences, and her disor¬
ders, which included an ataxic gait, dysconjugate gaze,
numerous cognitive deficits, and a preexisting narcissistic per¬
sonality disorder with borderline features. She seemed to love
to hear me talk, and the questions were designed to get me
talking at length, to explain her to herself. For most of each
session, she sobbed heavily about how badly life had treated
her. Several times she told me I was the best, the very tip of
the Ivory Tower, the best of the best. I found myself admiring
her courage, her flashes of insight, her humor, and her pluck.
Clearly, we had developed an idealizing and mirroring relation¬
ship. I also found myself quite taken with being the tip of the
Ivory Tower. I suspected, and exploration with Sarah con¬
firmed, that I was being idealized as her father was and financee
had been, and that one of the bases of that idealization was
splitting. She confirmed that she felt good about herself simply
basking in the attention she got from me.
Predictably, the negative feelings being split off from our
relationship began to intrude. I learned that Sarah was alie¬
nating a number of her peers and other staff by, for example,
marching into a group session being led by her nurse and de¬
manding immediate attention for her headache or telling pa¬
tients in her group psychotherapy that she couldn’t relate to
118 Lisa Lewis

their depression because no one had suffered anywhere near

as much as she had. I found myself embarrassed by these re¬
ports and realized I was feeling a complementary countertrans¬
ference of a parent for a child who went around the
neighborhood acting entitled. I realized the danger of needing
to change Sarah to make myself feel like a good therapist, and
I suspected her mother had frequently felt the same way. In
response to my question, Sarah indicated that she had indeed
felt such expectations from her mother and often deliberately
misbehaved to defeat her mother. Sarah began to act entitled
with me; for example, insisting that I answer the same questions
over and over or telling me, when I greeted her in the waiting
room, “Pick that up, hon,” referring to her backpack, and
treating me like her servant. My embarrassment turned to irri¬
tation, again a complementary reaction I suspected I shared
with her parents and fiancee. When I confronted her with how
she irritated and demeaned others with her behavior she ex¬
ploded, “How dare you!” and with hurt and angry glares laid
into me for my inability to judge her in any way since I’d never
had a head injury and I’d never suffered one tenth what she
had. \
It became clear to both of us that she waved the banner
of her suffering proudly and was not going to give it up, despite
her conscious wish to change. To her credit, she was able to
reestablish an alliance and to explore the shift in her transfer¬
ence reaction to me. She recognized that by believing no one
had suffered as she had she had reestablished her narcissistic
equilibrium; now at last she was special, she was better than
others. We came to call this her Queen for a Day complex. For
those of you too young to remember, Queen for a Day was a
TV program where women came on and told tales of woe to
the audience who then applauded for the one who elicited the
most sympathy. An applause meter was used to determine
which woman had suffered the most and should be awarded a
prize, such as a Maytag washer and dryer.
There then followed in the therapy with Sarah a very pro¬
ductive 4 months of therapy where the nuances of her narcissis¬
tic attachment to her injury and suffering were explored with
all its ramifications. This led to a resolution of her depression,
 Transference and Countertransference 119

investment of her energy in pursuits more worthwhile than

being Queen for a Day—such as getting her driver’s license and
entering vocational rehabilitation—an increase in her empathy
with others, and significant improvement in her relationships
with others.
In addition to illustrating complementary and concor¬
dant, idealizing and mirroring transference and countertrans¬
ference reactions, the above case description also reveals a few

TABLE 6.3
Transference and Level of Ego Organization
Ego Strength: A product of endowment, experience, neurological in¬
tegrity
Ego functions: Plan and execute action, regulate emotion and drive, rea¬
son, perceive, remember

Least Coherent: Orbitofrontal Damage

Most Coherent: Posterior Damage
Mediators: Gender & Lifestage

additional important points (see Table 6.3). First, the intensity

and coherence of the patient’s transference is very much a
product of their level of ego organization. Ego organization is
in turn a product of experiential and developmental factors. It
is also a product of neurological factors. A short list of primary
autonomous ego functions described by Hartmann (1939/
1958), Anna Freud (1936-1967), Rapaport, Gill, and Schafer
(1968) and others, will sound familiar to the reader: planning
and execution of purposeful behavior, regulation of emotion
and drive, logical reasoning, perception, memory. These are
neurologically mediated higher cognitive functions, especially
executive functions associated principally with the frontal
lobes. In clinical experience, it is patients who have had frontal
lobe injury, especially orbitofrontal injury, who tend to have
the most chaotically shifting transferences. Orbitofrontal injury
is associated with disinhibition over lower brain regions, re¬
sulting in what John Hughlings Jackson (1931) termed regres¬
sion or the emergence of positive symptoms. The resulting
abrupt, reactive, and labile emergence of limbic emotion and
drive can produce quickly shifting and intense transference
120 Lisa Lewis

states (Lewis, 1992). The content of the transference is in part

determined by the individual’s life experiences as they have
shaped enduring character (e.g., dependent, erotic, aggressive
transferences). Conversely, patients with posterior injury seem
to have the least intense and most stable transferences.
Gender also influences transference reactions. Traumatic
brain injuries are most commonly sustained by males in their
late teens and early 20’s. The injury occurs at a time when
they need all of their resources to negotiate age-appropriate
developmental tasks of forging and consolidating a cohesive
adult identity. Complex themes of sexuality, emancipation
from family of origin, selecting a life’s work and mate must all
be synthesized into an identity. The brain injury shatters this
process and the patient regresses to an enforced state of depen¬
dence.
Usually it is the mother who takes the primary caretaking
role (Solomon & Scherzer, 1991). She needs to function as
an auxiliary ego-cortex for her adult son, exercising all of the
protective and adaptive ego functions that have been dimin¬
ished or lost due to brain dysfunction. Her son, often in a state
of reduced self-awareness due to denial, impaired cognitive fac¬
ulties for realistic self-appraisal, and/or anosognosia, can view
her efforts as unwanted and unneeded intrusions. He resists
her and goes his own way, only to encounter a crushing experi¬
ence of failure or humiliation. He alternately clings and rebels,
with neither position being adaptive. With a female therapist,
as with the mother, these young men usually express a chaotic
dependency attachment, alternately being clingy and then re¬
bellious.
By way of additional illustration of the effects of gender
and lesion locus on transference, two patients are both strug¬
gling with dependent transference longings. One is a 26-year-
old man with diffuse but primarily bifrontal damage sustained
in a motorcycle accident 7 years ago. He expresses his depen¬
dency by showing up at my office at any time, whether he has an
appointment or not, but then often not keeping his scheduled
appointments. During sessions, he alternately pleads for help
and guidance then can be standoffish and haughty. Like many
young men, he experienced his dependency longings with
 Transference and Countertransference 121

great ambivalence. Just as he was individuating and forming an

adult male identity, the brain injury threw him back into a state
of realistic dependence.
A second patient is a 52-year-old woman who sustained
diffuse but primarily right parietal damage two years ago. She
also struggled with dependent transference toward me but it
was expressed in subtle ways of trying to make me happy and
trying to make as few demands on me as possible, yet letting
me know that she viewed me as a special person and the only
one who could recreate a sense of wholeness and meaning in
her life. Thus, in ways we are beginning to learn about, lesion
locus, gender, and dynamic conflict interact to alter the form
and content of transference reactions.
The case of Sarah also illustrates that we as therapists can
have countertransference to multiple aspects of the patient and
that countertransferences of opposite emotional valence can
coexist or succeed one another (Laatsch, Rothke, & Burke,
1993; see Figure 6.1) Our perception of the patient’s deficits
can elicit countertransference. Typical reactions include a view
of the patient as someone who has been cruelly and unfairly
damaged, evoking great sympathy within us and an intense
longing to restore them to wholeness. Conversely, we can feel
overwhelmed by the enormity of their suffering and need, lead¬
ing us to withdraw (Ball, 1988; Lewis, 1991). Second, counter¬
transference can be elicited by how the patient perceives his
or her own deficits. A patient’s denial of deficit or a patient’s
sense that the injury entides them to special treatment, or a
patient’s magnification of deficit, all can elicit varied counter¬
transference reactions, depending on the therapist, but typi¬
cally elicit irritation and anger (Langer, 1994). The
countertransference anger can then find expression in overly
zealous confrontation of the patient’s perception of deficit. At
times, the anger can be defended against, leading the therapist
to collude with the patient’s misperception of deficit.
Last, the patient’s transference toward us can elicit coun¬
tertransference. Just as the content of the patient’s transfer¬
ence is determined by their unique conflicts and characters, so
too are therapists’ countertransference reactions. In response
to being idealized, most therapists feel pride and an increased
 122 Lisa Lewis

— Rescue fantasy

To patient’s deficits —

—Afraid/helpless

t— Cottusive denial

To patient’s attitude toward deficits -

Irritation, overzealous confrontation

—Pride, mirroring

rtdealtzation

To patient’s transference - —Uneasiness

“Anger

-Devaluation

—Submission

Figure 6.1 Countertransference

sense of liking and warmth for the patient. At other times or

for other therapists, being idealized elicits uneasiness and in¬
creased distance. Being placed on a pedestal can leave the ther¬
apists uneasy about there being nowhere to go but down, and
uneasy about the inevitable disappointment to come when the
illusion of perfection is not sustained. In response to being
devalued (ignored, deskilled, belittled, competed with), most
therapists feel anger. However, others, either fearful of con¬
frontation-conflict or as a result of employing reaction forma¬
tion against their anger, can become submissive or overly
conciliatory in the face of devaluation. Though it may feel
more comfortable to be the very tip of the Ivory Tower than
to be relegated to the role of applauder in the audience of
Queen for a Day, both countertransference reactions can be
explored with benefit to the patient. The goal for the therapist
is to recognize, reflect on, and understand the meanings of
countertransference so as to foster insight in the patient.
 Transference and Countertransference 123

While it is commonly accepted that transference and coun¬

tertransference can be vehicles of change when recognized and
understood, the process of attaining insight is not formulaic.
As Gunther (1994) states, the price an effective team pays for
significant therapeutic involvement with patients having severe
brain damage is periodic subjective distress and less than opti¬
mal professional functioning. The solutions he cites are to bet¬
ter understand the patient’s subjective experience, have a firm
grounding in the essentials of modern psychoanalytically based
depth psychology, attain awareness of one’s inner world ac¬
quired through self-reflection and psychoanalysis, and schedule
regular and candid staff meetings with a consultant. The gain
is that by listening more fully to ourselves, we learn what is
going on in the minds of our patients.
Pepping (1993) provides a number of helpful suggestions
about how to make productive use of transference and counter-
transference. A psychoeducational approach to teaching pa¬
tients about transference, especially self-defeating or
masochistic styles of relating, can be taken. For example, pa¬
tients can be given the mnemonic of the 3 Ps: pick, provoke,
perceive. That is, patients can be helped to understand that
conflictual and painful ways of relating, forged in childhood,
can lead them to find someone who will mistreat them (pick),
aggravate someone into treating them unfairly (provoke), or
distort their view of reality into seeing themselves as injured by
others to a greater degree than is actually true (perceive).
Then, when events in treatment or daily life contain strong
transferential elements, the patient can be reminded of this
mnemonic as encouragement to reflect on the meaning of the
maladaptive interchange.
Often, when a therapist is trying to help a patient recog¬
nize and reflect on transference, the patient’s anxiety increases
with a proportional increase in defensiveness. A strong dose of
support can be helpful in decreasing anxiety and sustaining
that alliance. Pepping (1993) refers to this as the sandwich
technique. Confrontation (the act of drawing the patient’s at¬
tention to the transference behaviors) and interpretation (of¬
fering a way of understanding the meaning of the behavior) are
preceded and followed by praise for accomplishments made,
124 Lisa Lewis

positive traits and talents, and for persevering with the hard
work of treatment.
In addition to the sandwich technique, Pine’s (1986) sug¬
gestion of “striking when the iron is cold” is useful. This is a
way of doing expressive work in a supportive fashion. One waits
until the patient has recovered his or her composure before
embarking on efforts at reflection and insight. In other words,
interpretations are made deliberately late, after the moment of
emotional intensity has past and the patient can think more
clearly and with some appropriate distance.
The work with the countertransference follows the same
general principles of awareness (confrontation) and insight
(interpretation). The therapist sorts out the part of the coun¬
tertransference having to do with his or her own issues from
those having to do with the patient’s inner world. The latter is
then introduced into the work as either a confrontation or
interpretation. For example, the therapist, based on his or her
own countertransference anger, might say, “I wonder if you
have been feeling some anger towards me” (confrontation),
or “I wonder whether your irritability towards me has to do
with feeling I expect too much of you” (complimentary coun¬
tertransference), or “Perhaps you are being irritable with me
as a way of making me feel the anger you have felt over your
situation” (concordant countertransference).

CONCLUSION

To sum up, as in psychotherapy with neurologically intact indi¬

viduals, transference and countertransference in psychother¬
apy with adults having brain injury or stroke are potentially
powerful vehicles for change as well as powerful sources of
resistance. The form of a patient’s transference, its coherence
and intensity, is determined by structural factors, primarily the
level of ego organization. Level of ego organization is the prod¬
uct of constitutional endowment, character, and locus and ex¬
tent of neurological injury. The content of the transference,
especially its dynamic themes, is determined by historical and
 Transference and Countertransference 125

current life experiences, including the phenomenology and

psychological meaning of being brain injured. The patient’s
experience and expression of being impaired in turn elicits
countertransference in the therapist, with gender playing a
prominent mediating role.
Karl Menninger (1958) said that the countertransference
is dangerous only when it is forgotten about. One of the values
of working with an interdisciplinary team in a milieu oriented
program is that the potential for recognizing and therapeuti¬
cally processing transference and countertransference reac¬
tions is multiplied (Prigatano, 1989, 1994). When working as
a solo psychotherapist, it is very useful for the therapist to have
adequate time to reflect on sessions so as to be able to recognize
countertransference and engage in self-analysis to learn what
it means for the self and the patient. Yet, as Freud said, the
problem with self-analysis is the countertransference. In some
instances of stalemates, the opportunity to consult with a col¬
league or to seek focused therapy of our own can be invaluable.

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thal, M. (1994). The role of depression in rehabilitation outcome
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Diller, L. (1994). Finding the right treatment combinations: Changes
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126 Lisa Lewis

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 Transference and Countertransference 127

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%
 PART III

Interplay of Psychotherapy and Cognitive

Remediation in Individual Treatment
7.

Application of Cognitive Rehabilitation

Techniques in Psychotherapy

Linda Laatsch, Ph.D.

INTRODUCTION

The central goal of psychotherapy is to effect a beneficial

change in a client through verbal or symbolic interaction
(Langer, 1992). To do this, therapists frequently ask their cli¬
ents to reflect on their current emotional experiences, discuss
long-standing conflicts, and expand on their knowledge about
themselves. Unfortunately, common consequences following
brain dysfunction include significant cognitive impairments
such as memory deficits, limited concentration, impaired per¬
ception and communication, and difficulties with reading, writ¬
ing, math, planning, self-awareness, and judgment (National
Head Injury Foundation, 1989). These impairments can have
a significant impact on the client’s ability to communicate
needs and conflicts in therapy, effectively perceive their own
and other’s emotional state, and reliably recall therapeutic in¬
terventions during and after therapy.
For almost 40 years, cognitive deficits following a brain
dysfunction have been treated with what can now be identified
as cognitive rehabilitation therapy (CRT). Cognitive rehabilita¬
tion therapy is broadly defined as those activities that improve

131
132 Linda Laatsch

a patient with brain injury’s “higher cerebral functioning or

help the patient to better understand the nature of those diffi¬
culties while teaching him or her methods of compensation”
(Klonoff, O’Brien, Prigatano, Chiapello, & Cunningham, 1989,
p. 37). Experts frequently comment on the rapid growth of
cognitive rehabilitation as a treatment modality in the past 15
years (Gianutsos, 1991; Lehr, 1990). Parents and loved ones
of individuals with brain dysfunction are demanding cognitive
rehabilitation services. Therefore, most brain dysfunction facil¬
ities offer cognitive rehabilitation as part of their treatment.
Mazmanian and collaborators (Mazmanian, Martin, & Kreut-
zer, 1991) in their comprehensive survey found that 91% of
“brain injury programs” offered in-house cognitive rehabilita¬
tion. Bach-y-Rita (1992), well known in the field of brain reha¬
bilitation, stated, although following brain dysfunction there is
generally some early recovery, specific rehabilitation programs
are usually required to obtain later gains. He also stated that
“if recovery is not expected or strived for with active participa¬
tion of the disabled person, little recovery is obtained” (Mat¬
thews, Harley, & Malec, 1987, p. 191). Systematic studies of
individuals 5 to 7 years post brain damage havfe revealed that
without treatment many individuals do not continue to prog¬
ress and may even get worse (Gianutsos, 1991).
The recent rapid growth of the field of CRT has lead to
the development of a variety of models of cognitive rehabilita¬
tion and a variety of names for the many types of treatment.
Popular names include neuropsychological rehabilitation, cog¬
nitive retraining, behavioral rehabilitation, and cognitive reme¬
diation. In addition, related therapeutic approaches that focus
on a specific cognitive problem include memory rehabilitation
and perceptual rehabilitation. Currently, there is uncertainty
in defining extent of cognitive rehabilitation therapy as a result,
professional standards are currently being developed (Maz¬
manian et al., 1991), and guidelines for the field have been
published (Matthews et al., 1987).
As defined broadly above, CRT is very similar to a defini¬
tion of psychotherapy. Both techniques involve facilitation of
change and both involve interventions that impact the emo¬
tional and cognitive status of the client receiving treatment.
 Cognitive Rehabilitation Techniques 133

Stern, a psychiatrist providing guidelines for psychotherapy

with the neuropsychologically impaired, states that psychother¬
apy is designed “to ‘assist’ nature in arriving at higher func¬
tional levels by integrating the components of the various
clinical syndromes” (Stern, 1985, p. 84).
Within the last 10 years numerous papers have been writ¬
ten describing psychotherapy with individuals who have neuro¬
psychological impairments (Cicerone, 1989; Langer, 1992;
Langer & Padrone, 1992; Lewis, 1992; Lewis, Athey, Eyman, &
Saeks, 1992; Morris & Bleiberg, 1986; Prigatano & Klonoff,
1988; Laatsch, 1996). Application of standard theoretical psy¬
chotherapeutic approaches are described, and the impact of
the neuropsychological deficits on the therapeutic process are
described in detail. Individuals with neuropsychological impair¬
ments frequently exhibit lack of insight, decreased awareness
of their current abilities and deficits, and a general loss of their
sense of self (Prigatano, 1995). Cicerone (1989) also suggests
that rigidity and defensiveness may also hinder a client’s ability
to benefit from psychotherapeutic interventions. Neuropsycho¬
logically impaired clients may focus on the “old self” (whom
they were before their injury) and almost perseverate on things
they recall from the past and who they might have become
without the injury. Since some or even all of these factors may
influence a client’s self-awareness and mental flexibility, psy¬
chotherapists may find it difficult to develop and sustain an
effective therapeutic relationship with a client who has neuro¬
psychological deficits.
Even though neuropsychological impairments can hinder
the client’s ability to make therapeutic changes in their emo¬
tional status, some clients, as a result of their trauma, are more
open to change than they were prior to their injury. The
trauma and the realization of previous health-threatening be¬
haviors, may provide for some clients an opportunity for reeval¬
uation. All clients who have experienced a brain dysfunction
need to “establish meaning in their life in the face of (not
despite) their impairments” (Prigatano, 1995, p. 87). Some
brain injured individuals stop abusing drugs and alcohol
thereby having a beneficial effect on their life-style. Clients will
generally seek to answer a question concerning, “Why did this
134 Linda Laatsch

happen to me?” (Prigatano, 1995, p. 88). A change in how the

client views his life and how he defines his priorities may result.
Therefore, although psychotherapists working with individuals
who have experienced a brain dysfunction may be faced with
many obstacles in therapy, some clients may be more ready for
change because of the trauma they have experienced.

UTILIZATION OF CRT TECHNIQUES IN PSYCHOTHERAPY

WITH CLIENTS WHO HAVE NEUROPSYCHOLOGICAL
IMPAIRMENTS

There are many reasons why the integration of cognitive reha¬

bilitation techniques into a psychotherapy environment with
brain injured clients would assist treatment. The integration of
treatment is natural, a detailed examination of psychotherapy
with neuropsychologically impaired clients reveals that many
CRT techniques are embedded in psychotherapy. For example,
if at the end of the therapy session, important topics are re¬
viewed for the client, the therapist has facilitated rehearsal of
material and assisted in encoding. In addition, the integration
is supported by extensive research that has demonstrated the
effectiveness of CRT with brain injured clients. Gianutsos
(1991) feels that, given the current research describing the
efficacy of CRT following brain dysfunction, a no-treatment
group is not ethical. Very recently, CRT was related to signifi¬
cant changes in SPECT imaging (Single Photon Emission Com¬
puted Tomography) in a longitudinal study with patients with
diverse brain injuries. A significant increase in blood flow redis¬
tribution was seen in areas adjacent to the brain dysfunction
and also in areas of the brain associated with the specific CRT
strategies utilized. It is theorized that CRT serves to “turn on
plasticity’ ’ even in patients many years post brain dysfunction
(Laatsch, 1996; Laatsch, Jobe, Synchra, Lin, & Blend, 1997).
Since there is much research suggesting the effectiveness of
CRT, it is expected that the use of CRT techniques would most
likely serve to enhance the psychotherapeutic endeavor.
Finally, because of the similarity of the treatment tech¬
niques and goals, the inclusion of CRT techniques can only
 Cognitive Rehabilitation Techniques 135

serve to facilitate treatment effectiveness. The level of integra¬

tion of CRT techniques into the psychotherapeutic session can
be varied according to specific patient needs and goals. Below,
three levels of integration of CRT techniques, casual, moderate,
and an alternating approach, are described. Examples of each
specific technique are described at each level and client illustra¬
tions have been provided to facilitate understanding of each
of the specific applications. This chapter does not attempt to
describe the broad range of CRT techniques available, but in¬
stead how some CRT techniques can be easily integrated into
psychotherapy with neuropsychologically impaired clients.
CRT techniques are described in detail in recent issues of the
Journal of Cognitive Rehabilitation and in many books, such as
Parente and Herrmann (1996).

CASUAL INTEGRATION OF CRT TECHNIQUES IN

PSYCHOTHERAPY

A casual or occasional integration of CRT techniques into psy¬

chotherapy with neuropsychologically impaired clients will de¬
pend on the specific neuropsychological and emotional
limitations of the client. As is true in psychotherapy, the client
will have to be open to application of the techniques and be
able to trust their therapist sufficiently to believe that the tech¬
nique might be effective. A central goal in CRT is to facilitate
the client’s ability to think about their own thinking. This tech¬
nique is very familiar to educators and is defined by educators
as “metacognition.” The use of SPECT in CRT cases has dem¬
onstrated that effective CRT, which results in neuropsychologi¬
cal improvements and the successful return to a functional
occupation or school, generally involves a significant increase
in resting blood flow in the frontal and prefrontal regions of
the brain (Laatsch et al., 1997). Self-awareness, initiation, and
motivation are known to be mediated by these areas of the
brain. Therefore, even the casual introduction of CRT tech¬
niques should include an effort to involve the client’s thinking
about their own cognitive limitations and effective compensa¬
tion strategies. Casual introduction of CRT techniques will be
136 Linda Laatsch

described for individuals with neuropsychological impairments

in attention and memory, communication, and executive pro¬
cessing.
Deficits in attention and memory are known to be one of
the most common neuropsychological deficits following brain
dysfunction. Although clients with severe memory deficits
sometimes are unable to remember that they have a memory
problem, many clients with mild to moderate memory diffi¬
culties are aware of their memory problems. Since getting the
client to the therapy session is the first essential step in promot¬
ing therapeutic changes, all clients need a mechanism that will
allow this to regularly occur. Clients who do not use an appoint¬
ment or date book should be provided with one (even Freud,
on occasion, is known to have provided his psychoanalytic cli¬
ents with food!). A date book facilitates organization and pro¬
vides a mechanism for rehearsal. Most clients respond well to
the use of a date book which can facilitate pride and indepen¬
dence. In addition to recording the next scheduled appoint¬
ment, clients can be taught to use it to maintain their own
medication schedule. One client who was completely depen¬
dent on his spouse for his medication schedule was taught to
list the times he took his medication on each day in the date
book and cross that time off once he took his medication. This
client was taught to have his date book open on the kitchen
table and learned to use the book continuously. This client,
who was also being seen in couple therapy, revealed that the
simple use of the date book helped to restore a more indepen¬
dent relationship with his wife.
A date book, with enough space, can be used to provide a
way for the client to practice therapeutic techniques promoted
in therapy. Therapeutic goals can be written in the date book
at the end of each session. A client who needs to practice relax¬
ation techniques prior to the next session but states that he or
she ‘ ‘forgot to do it ” can be provided with reminders in their
date book. In addition, the client can use it to record the use
of therapeutic techniques outside of therapy.
Patients with memory disorders will need numerous repe¬
titions during sessions to help recall suggestions and goals in
 Cognitive Rehabilitation Techniques 137

therapy. Visual elaboration or simple rehearsal of the sugges¬

tion will usually assist recall. Symbolism, as described by Lewis
and Langer (1994), especially if utilizing a visual image, can
provide the visual stimuli needed to assist recall. For example,
a patient with a storage deficit (unable to regularly store new
information for effective recall) was provided with the image
“in one ear and out the other.” This image was used repeatedly
in therapy sessions to assist the client’s recall of her neuropsy¬
chological impairments and increase her self-awareness. Al¬
though it is most beneficial if clients are able to spontaneously
develop their own “symbol” to illustrate a concept, clients with
communication or initiation deficits might need to be supplied
with a symbol to illustrate a concept.
It is well known by neuropsychologists that communication
deficits can result from damage to both left and right cerebral
hemispheres. Communication deficits resulting from damage
from the dominant hemisphere (usually left hemisphere) are
generally more obvious and may involve both receptive and
expressive language skills. Many clients following brain dysfunc¬
tion have difficulty with double negatives or statements which
involve inverted commands, such as “before pressing the letter
‘Q’ press the letter ‘M’ ” (Bracy, 1994). Unfortunately, abstract
speech patterns are frequent in therapy sessions because the
issues being addressed are often complex. Therapeutic ap¬
proaches may be ineffective because the client did not under¬
stand the complexities of the communication. Clients with
communication deficits will need to be asked to restate the
issue in their own words. Clients can be asked to “tell me what
we have talked about” or asked to recall what they were going
to work on prior to the next session.
Clients with communication deficits that involve expres¬
sion might benefit from rehabilitation techniques typically em¬
ployed in speech therapy. When the therapist is able to assist
in word-finding by suggesting alternate choices or providing an
initial sound, the client’s sense of trust and connection with
their therapist is reaffirmed. Just as speech therapists utilize
exaggerated speech to assist in articulation deficits, a client
with expressive speech deficits can be asked to use exaggerated
emotional expression to facilitate communication. Again, to
138 Linda Laatsch

facilitate self-awareness, the client should be made aware that

a specific approach is being used because of existing neuropsy¬
chological deficits. The use of techniques designed to facilitate
communication should be promoted at home and modeled for
family members if possible. The use of exaggeration or model¬
ing helps to facilitate immediate communication with a client,
but these techniques are also compensation techniques that
can be taught to assist communication outside the therapeutic
environment.
Clients who have extensive executive processing deficits,
such as difficulties in motivation, insight, problem solving, and
initiation, generally require the most creativity and patience
on the part of the therapist. A client, 20 years post severe brain
dysfunction that required the removal of his right frontal lobe,
began every session for 2 months with the statement, “If I had
a gun I’d shoot myself.” After checking carefully for suicidal
ideation, it was determined that this statement was part of a
perservative thought pattern that involved a focus on his past
self and who he “could have become.” There was a sense that
this patient found himself “stuck” in a depressive cycle of
thoughts and was calling for help in restructuring his thinking
about himself. As needed with patients who have deficits in
executive processing, a directive, cognitive behavioral ap¬
proach was taken. This client developed self-statements, called
“behavior resolutions,” such as, “I am the most important part
of my recovery and I will think about the here-and-now.” These
statements were written by the client in his daily recorder and
repeated every evening. He was made aware that he was
“stuck” on thoughts about how “bad” his life is, and an at¬
tempt was made to break the cycle with new self-statements.
The depressive, suicidal thoughts were found to quickly decease
using this technique.
Clients with impulsivity, impaired insight, and poor self-
control in therapy can be asked to establish a contract, signed
by both client and therapist, to define appropriate behavior in
therapy. The rules listed in the contract (such as, “I will not
ask my therapist personal questions”) need to be closely fol¬
lowed by both client and therapist to facilitate self-control. It is
hoped that the “rules” would be internalized so that, following
 Cognitive Rehabilitation Techniques 139

excessive practice and modeling, the client would be able to

use the established rules to guide behavior outside therapy,
such as on a job interview. Occasional or casual use of CRT
techniques, which include facilitation of self-awareness through
modeling of correct behavior and the establishment of rules
to guide behavior, helps the client to compensate for existing
neuropsychological deficits.

MODERATE INTEGRATION OF CRT TECHNIQUES

Moderate application of CRT techniques is loosely defined as

application of CRT as part of every therapy session. It can pro¬
vide a challenging but safe, artificial environment for both pa¬
tient and therapist. It provides a vehicle for increasing the
therapist’s understanding of the patient’s cognitive and emo¬
tional state by providing examples of current functioning and
behavior. The psychotherapist too can benefit in numerous
ways when CRT is integrated into every therapy session. On a
basic level, with clients unable to describe or recall details of
daily activities, cognitive rehabilitation tasks serve to provide
concrete examples of behavior such as the client’s ability to
cope with challenges or frustrations. Because the behavior oc¬
curs during the session, it is readily available for discussion
between client and psychotherapist. Furthermore, cognitive re¬
habilitation therapy can reveal subtle cognitive changes in a
client’s neuropsychological functioning that may imply that a
change in psychotherapeutic focus is now possible. Finally,
since there is a similarity in themes addressed in cognitive reha¬
bilitation and psychotherapy, joint treatment can serve to en¬
hance progress in treatment. For example, both CRT and
psychotherapy require the client to think about their own inter¬
nal state, cognitive and emotional, and thereby facilitate self-
awareness.
Assisting the client with brain dysfunction to use a date
book or appointment calendar at the beginning of therapy,
and instructing the client to bring the date book in for every
session, provides a connection with the client’s outside world.
140 Linda Laatsch

Because of their brain dysfunction, clients are often unable to

recall details of recent significant events. Clients can be in¬
structed to use the date book to record significant events oc¬
curring each day (a date book with sufficient room for daily
recording is essential here). One client who was shot through
the left side of his head and sustained extensive damage in
both frontal lobes, was asked to write daily sentences in his date
book describing one thing he did independently. He was able
to write a unique sentence every day but, within each sentence,
verbal perservation was evident. In reviewing the date book in
session, it was possible to talk about his achievements like,
“How was it to make your own sandwich for lunch?” Looking
at the date book at the beginning of each session provides
topics for discussion and allows for the exploration significant
relationships and events. The date book can be used as a diary
to record emotions or difficult situations faced by clients, and
it can be used to record achievement. The date book can also
be used for homework assignments. A date book/appointment
calendar is typically called an “external memory device” by
CRT specialists but also can function as a therapeutic aide in
psychotherapy.
When CRT is included in each therapy session the clini¬
cian needs to decide how and when to include CRT in the
sessions. For some clients it is important to address emotional
issues early in the session. The emotional needs may hinder
the client’s ability to work on their cognitive impairments in
CRT. If the cognitive tasks used to illustrate current cognitive
status and develop compensation strategies are standardized
and scores are regularly recorded (such as done on computer¬
ized cognitive rehabilitation tasks), the impact of emotional
issues can often be seen. Therefore it might be necessary to
return to overriding emotional issues after attempting CRT.
Alternately, some clients, especially those with reduced self-
awareness, can benefit from CRT in the first part of the session,
rather than the final part of the session. This is illustrated in
the following case.
A highly educated, young professional woman who devel¬
oped anoxic encephalitis following an asthma attack that re¬
sulted in a respiratory arrest, was found to have great
 Cognitive Rehabilitation Techniques 141

difficulties expressing her emotions except in a very superficial

manner. She tended to prefer to minimize her emotional re¬
sponse to her losses and drastic changes in her life. Providing
both CRT and psychotherapy in her sessions was thought to
facilitate her ability to understand the impact of her deficits in
everyday life. The cognitive rehabilitation tasks selected at this
point in her recovery revealed that the client tended to focus
and perseverate on inessential details rather than develop an
effective overall plan in simple problem-solving tasks. Following
CRT addressing this difficulty, this client reported, laughing,
that she had learned that her professional license had been
used to bill for treatment that she could no longer perform
following her brain dysfunction. When her unusual emotional
reaction was explored further it was striking that she was unable
to identify the serious implications of the use of her license by
other professionals. She was focused on, “I’ve been working so
hard to go back to work again and here I’ve been ‘working’
and I didn’t know it.” The insight she was able to derive from
the situation was limited to an immediate, personal implica¬
tion, but she was unable to express an understanding of the
larger implications of the situation. Her performance on the
cognitive rehabilitation tasks was used to help her understand
her difficulties in conceptualizing the larger implications of the
situation. Just as she was unable to see the forest for the trees
on the problem-solving tasks earlier in the session, she could
not identify the larger implications of the situation. The use of
CRT and psychotherapy in the same session also allowed the
therapist to develop more insight into how the client’s current
cognitive impairments might impact her understanding of inci¬
dents that occurred in her everyday life.
Including CRT in sessions with clients who have neuropsy¬
chological deficits can be uncomfortable for both client and
therapist. Therapists early in their training in cognitive rehabili¬
tation may find themselves more comfortable with “talk” ther¬
apy and find themselves tending to emphasize psychotherapy
in sessions. One student, in his second CRT session, asked his
supervisor if he could just do psychotherapy with the client he
was assigned because “she needs that too.” He was able to
142 Linda Laatsch

demonstrate good insight into his own reaction. He could iden¬

tify that watching the client struggle with the cognitive rehabili¬
tation tasks made him feel uncomfortable, and therefore,
because of his discomfort, he felt he would prefer to do only
psychotherapy.
In a well-designed cognitive rehabilitation program, the
specific neuropsychological deficits of the clients are identified
and emphasized and therefore the client is often made acutely
aware of his or her limitations. This can be minimized by care¬
ful selection of cognitive rehabilitation activities and the use
of a developmental model of CRT (Bolger, 1980; Christensen,
1987; Laatsch, 1983). In this approach, cognitive rehabilitation
tasks designed to improve attention, processing speed, and con¬
centration are presented before tasks involving higher cogni¬
tive operations (such as memory and visual perception). While
problem-solving skills are addressed in the final stages of CRT,
throughout the therapy there is an emphasis on the patient’s
ability to think about their own thinking (metacognition).
Moderate integration of CRT into individual sessions with
clients requires flexibility. There is a need to integrate the treat¬
ment in a way that is most beneficial for the client given his or
her current cognitive and emotional status. Clients in treat¬
ment right after the acute phase of brain dysfunction experi¬
ence relatively rapid changes, and therefore the client’s
cognitive and emotional needs will most likely change during
treatment. Although early in treatment a client may benefit
from beginning each therapy session with CRT, later in treat¬
ment the same client might require that the therapist begin the
session with psychotherapy. An increased self-awareness and a
prevalence of emotional issues often occurs as treatment prog¬
resses. The client described above with anoxic encephalitis was
able to benefit from 3 months of psychotherapy following dis¬
charge from CRT because, as her insight increased, she experi¬
enced periodic depressions related to her difficulty obtaining
employment within her vocation.

ALTERNATING CRT AND PSYCHOTHERAPY

For some clients it may be helpful to overtly structure the treat¬

ment by alternating between CRT sessions and psychotherapy
 Cognitive Rehabilitation Techniques 143

sessions. This is only effective if the client can meet for treat¬
ment more than one time per week. In these cases, the patient
should be informed that the focus of sessions will be alternated
and that reminders be provided, “Today we will do cognitive
rehabilitation.’’ A different area of the treatment room might
be selected for each type of treatment. In this way, the physical
setting will be a reminder of the type of treatment scheduled.
If the same therapist participates in each treatment, the CRT
can provide an opportunity to observe the patient’s ability to
tolerate a limited amount of frustration and the patient’s abil¬
ity to self-evaluate current abilities. Again, observation of the
client while doing CRT provides insight into what it might be
like for the client to be challenged by his environment (such
as on a job or at home) given his or her current status. This
insight can be utilized in the next psychotherapy session sched¬
uled and helps the psychotherapist develop more empathy for
the client’s emotional struggles.
A client who had a motor vehicle accident that resulted in
a diffuse brain dysfunction began alternating CRT-psychother-
apy treatment 9 months after his brain injury. During the initial
interview he expressed frustration that he was still “having
trouble going to college’’ and that he wanted to complete col¬
lege so that he could train to be a commercial airline pilot.
Initial CRT sessions revealed that this client tended to focus on
and become very frustrated with the errors he made during
the tasks. Even when performance was adequate, he would fre¬
quently be unable to continue the task following a minor error.
Further exploration revealed that this individual had main¬
tained unrealistic high expectations that hindered both his
ability to work effectively with his existing mild deficits and to
use compensation strategies when needed. The psychotherapy
allowed this client to express his prior beliefs about being “all-
powerful,’’ perfect, and infallible, and slowly helped him incor¬
porate knowledge about his new self. As he continued to work
on the cognitive rehabilitation tasks, overt frustration dimin¬
ished as the patient began to employ effective strategies to the
presented tasks. At the conclusion of treatment, this client en¬
tered the Air Force hoping to become involved in airplane
maintenance.
144 Linda Laatsch

If the same therapist alternates CRT and psychotherapy in

treatment he or she has the benefit of detailed knowledge
about both the client’s current emotional struggles and cogni¬
tive abilities. This can serve to facilitate integration of treat¬
ment and allow for the transfer of cognitive strategies to assist
emotional adjustment. Conceptually, the therapist who inte¬
grates both types of treatment is helping the client separate
“soul” from “mind.” The therapist also provides guidance in
the integration of the two components of self in the most bene¬
ficial way.

SUMMARY

Integrating CRT into psychotherapy with neuropsychologically

impaired clients can be accomplished many ways; three tech¬
niques are suggested in this chapter. The benefits of integrating
treatment are thought to be substantial but unfortunately there
are disadvantages associated with this type of treatment. First,
the treatment personnel need to have specific and well-devel¬
oped clinical skills. The emotional investment that the therapist
needs to be able to make at least doubles when both types of
treatment are done by one therapist. Although the therapist
can certainly improve his or her empathic stance through the
painful reminders provided by the cognitive tasks, the activities
may also be an uncomfortable reminder of the vulnerable na¬
ture of human existence and the significant impact that cogni¬
tive deficits have on everyday living. The therapist needs to
effectively process and understand his or her countertransfer¬
ence response to the increased intensity of the relationship.
The client, in turn, may become more dependent on the thera¬
pist because of the comprehensive nature of joint CRT-psy-
chotherapy treatment.
It is felt that the benefit of combining CRT and psychother¬
apy is substantial. From the client’s point of view, there is often
no clear distinction between the cognitive and emotional di¬
mensions. This is clearly and beautifully described by Rob Tay¬
lor in “From the Patient’s Point of View” (Taylor, 1996). He
 Cognitive Rehabilitation Techniques 145

describes his loss as a “fierce severance, as of sword, came the

cognitive leaving of my accumulated world” while his emo¬
tional response is described as “despairing months of deepen¬
ing frustration.” The poem describes the joy of getting help
from an individual with “keys to all the locks” (see p. 146).
Integrated treatment, including both CRT and psychother¬
apy, can facilitate change because a deeper, more personal ap¬
proach is taken with the client. The similarity between the
intentions of both CRT and psychotherapy suggests that integ¬
rating the two treatments is quite possible. Typically, a therapist
needs to act as an auxiliary ego in supportive psychotherapy
(Lewis & Rosenberg, 1990). In treatment with neuropsychologi-
cally impaired clients the therapist must also act as an auxiliary
“cortex,” helping the client structure and learn to compensate
for cognitive limitations (Lewis & Rosenberg, 1990). It is be¬
lieved that by incorporating CRT techniques, the therapist’s
ability to empathize with the client is enhanced and thereby
facilitating change in clients with neuropsychological impair¬
ments.
146 Linda Laatsch

APPENDIX A

Walking Tall And helped me let him go.

With skill you planted just two seeds
As quickly as a blink of eye, Inside my ravaged mind.
Fierce severance, as of sword, Compassionately you nurtured them
Came the cognitive leaving of With dedication of rare kind.
My accumulated world. For endless hours, you worked with me
Comprehending that disaster, With caring I’d not seen,
It’s scope, it’s devastation, Until again inside me grew
Setded slowly, through despairing months My hope and self-esteem.
Of deepening frustration. Gendy then you led the way
The curtain fell; sickly gray, not black, Over pebbles, stones, then rocks.
The fog of living while not here. And firmly pushed me up the hills
The world alleged I wasn’t me. With keys for all the locks.
I denied, in total fear. Finally the wind of new
I longed to be where “I” had gone, Refreshing on my face,
Could not discern the way. You pointed to the mountain tops
Unable to perceive my plight, Where I should find my place.
Depression deepened every day. As I stride toward that goal
Since I could not go to me I often pause in fear,
Soon I’d return again! Cast, tentative, a backward glance,
That surely thus it had to be Praying you’re still near.
I clung to through the pain! Looking o’er my shoulder
Enveloped in the blanket of Again I see your wave,
Despair and weary fight, Hear silendy you telling me
While losing all, so futilely . . . You want me to be brave.
Suddenly appeared a light. I know that I will make it.
Light can be heard I know, because Will build my life anew,
When I first heard your voice, Attain at last that pinnacle,
Somehow instandy I knew Triumphant, thanks to you.
You were sent to help, God’s choice. This new me has a purpose.
The old me was a person The care bestowed by you
That you didn’t choose to know. I’ll now dispense to others.
You wrapped support around me Then they can share it too!

A. Taylor, (1996), Reprinted with permission from: The Journal of Cognitive Rehabilita¬
tion, Vol. 14, Issue 5, p. 4.
 Cognitive Rehabilitation Techniques 147

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8.

Dealing with Rationalization and

Unawareness in the Treatment of
Visual Inattention

Joseph Weinberg, Ph.D. and

Leonard Diller, Ph.D.

INTRODUCTION

Unilateral spatial neglect is a disorder characterized by the pa¬

tient’s diminished response to stimuli on the side contralateral
to the hemisphere lesion. It occurs more often in patients with
right hemispheric damage than those with left hemispheric
damage (Kinsbourne, 1993). A loss of visual field is often suf¬
fered but the person continues as if no loss has occurred.
The behavior of the patient with spatial neglect has been
the subject of study and speculation over the past century. The
disorder may be expressed in a variety of confusing ways from
a failure to identify a limb as paralyzed to a lame excuse for
difficulty in engaging in a normal activity such as reading a
newspaper (Weinberg & Diller, 1968). Attempts have been
made to identify the disturbance in association with locus of
lesion (McGlinchey-Berroth et al., 1996); sensory diminish-
ment (Battersby, Bender, Pollack, & Kahn, 1956; Gianutsos &

149
150 Joseph Weinberg—Leonard Diller

Mathesson, 1987); cerebral imbalance in processing informa¬

tion (Birch, Belmont, & Karp, 1967; Kinsbourne, 1993); a pre-
morbid tendency to deny, minimize, or repress unpleasant
events (Weinstein & Kahn, 1955); and a disturbance in dealing
with informational complexity wherein individuals must infer
information which is not experienced directly (Levine, 1990).
Some have postulated a specific system of awareness which is
impaired following brain injury (McGlynn 8c Schachter, 1989).
Many tests have been developed over the past 50 years to cap¬
ture and measure the patient’s diminishment of space. The
bulk of this literature aims to identify the nature and anteced¬
ents of this condition in order to increase our understanding.
Such accounts may be useful in attempting to understand ne¬
glect, but leave open the question of how to approach the pa¬
tient if one wishes to ameliorate the problem. Attempting to
engage a person in a problem which is not acknowledged poses
an active clinical issue for workers in a rehabilitation setting.
In this paper we pursue an important clinical issue in un¬
awareness, common in cases of visual neglect, which must be
considered from the perspective of the remediator. In order
to engage the subject in problem solving or remediation, there
must be a plausible reason for such engagement from the sub¬
ject’s perspective. The remediator’s treatment scheme asks:
How does the individual who is unaware interpret the situation?
Is there a problem? If there is a problem what might be the
reason for it? If the individual is unaware of a problem when
it is pointed out, to what can he or she attribute deviant perfor¬
mance?
In psychiatric disorders and in everyday life, distorted attri¬
butions have been related to helplessness and depression and
influence emotional and behavioral responses. In people with¬
out brain injury, distorted impressions due to misperceptions
or faulty reasoning, excess drive may be driven by defense
mechanisms. These serve as critical barriers to be removed in
insight therapies ranging from psychoanalysis to cognitive be¬
havioral therapies. The diminished awareness associated with
neurologic disturbance calls forth defensive maneuvers which
must be addressed before and during therapy. The defensive
 Treatment of Visual Inattention 151

maneuvers which act to cover up feelings of shame when cogni¬

tive slippage appears, result in lack of engagement in rehabilita¬
tion therapies from perceptual retraining to ambulation
retraining to participation in social groups. Clinically the most
common presenting feature of a perceptual problem, there¬
fore, is not the denial of a problem, but the defensive maneuver
offered as a rationalization or excuse for failure. An example
of such a maneuver would be the person who does not read a
newspaper due to a perceptual problem who may say, “I can
read, but I am not reading today because I forgot my glasses”;
or “I am tired.” In dealing with the problem the therapist
must move rapidly to deal with the unawareness by rearranging
situations and/or facts which will capture the patient’s immedi¬
ate attention. In a series of papers we outlined a number of
strategies to facilitate remediation of the difficulty. The earlier
papers include a set of training modules using principles and
illustrations of anchoring, pacing, feedback, information load,
and stimulus density (Weinberg et al., 1977, 1979; Weinberg,
Piasetsky, Diller, 8c Gordon, 1982) to improve performance.
More recently, we addressed the issue of resistant patients who
pose problems in remediation. We argued that resistance, re¬
sponse style, and unawareness shared common features related
to severity of cognitive impairment (Diller & Weinberg, 1993).
Individuals who are unaware of a problem “resist” engagement
in a therapeutic alliance. We suggested that unawareness is not
a unitary all or nothing phenomenon, but exists in different
degrees. The training situation could be greatly facilitated by
taking into account the individual’s response style. Response
styles may be identified at four levels, ranging from active resis¬
tance to admit the presence of a stimulus, to indifferent passive
denial when an error is pointed out, to passive denial accompa¬
nied by complexity when confronted by error, to ready ac¬
knowledgment of a problem without the necessary action to
correct it. Knowledge of response style is a key to an individual’s
level of unawareness and provides the remediator with clues
regarding stimuli and strategies for treatment, as well as guides
for duration and outcome. Briefly, the more unaware the indi¬
vidual, the more simple the program, the more modest the
152 Joseph Weinberg—Leonard Diller

goals, and the longer the expected duration of treatment will

be.
Our experiences are based on therapeutic contacts, gener¬
ally on a weekly basis, with over 100 patients over the past 20
years. We noted patient accounts of their problems and their
treatment. In this paper we present case studies which may
serve as useful paradigms for clinical interventions. We selected
two patients with markedly restricted awareness of their failures
or at least limited willingness to admit failure, to illustrate how
resistant patients can be engaged in treatment. These patients
had completed a course of physical and occupational therapy
and had reached a plateau in these areas. Their percep¬
tual-cognitive problems alarmed their families and caused
them to seek further help.

CASE 1

Mr. A, a successful 68-year-old professional, sustained a right

parietal embolic infarct. Initial psychological evaluation re¬
vealed perceptual problems manifested by a left neglect and
impulsiveness, a left-sided facial weakness, and a left-sided
numbness. As an inpatient in a rehabilitation program it was
noted that Mr. A was aware of what had happened to him, but
unaware of residual cognitive impairments. The report read:
“He remains unaware of cognitive changes and the implica¬
tions of his condition. He plans to return to work, with no
insight into the potential changes caused by his disability.” A
summary of the neuropsychological examination at 4 months
postonset, when he was transferred to an outpatient program,
found problems in attention and concentration and in visuo-
motor functioning. While verbal scores were above average,
perceptual performance was significantly impaired (Verbal IQ
= Performance IQ = 74). Attention to details in the visual
environment, sequential visuomotor activities, activities requir¬
ing organization of information into meaningful or abstract
wholes, and visual scanning accuracy, were markedly reduced,
particularly as materials become more difficult.
 Treatment of Visual Inattention 153

When first seen for perceptual cognitive retraining, Mr.

A avoided looking to his left when asked a question by the
interviewer. He asserted that his only problems were residual
physical difficulties and memory failure in recalling names. He
had been told that he had a short-term memory problem based
on his performance on the neuropsychological examination.
He also complained of “being tired.” When pressed about his
cognitive problem, he remarked that he first had such prob¬
lems immediately after his stroke, but they cleared after a cou¬
ple of weeks ‘ ‘just as my speech came back and my right side
came back.” He felt that his attention and concentration were
no different than before the stroke. The main problems were
memory and fatigue (see Table 8.1).
In the first working session he was instructed to ask the
therapist as to the purpose of any task which was to be given
to him. He was told that periodically he would be questioned
about his problems and the rationale for any exercises that
were assigned. He was told that he should know about and be
able to explain the exercises. Because he was not fully aware
of the nature of his perceptual problems, by verbalizing the
reasons for the exercises, his awareness and understanding of
his problems would be enhanced and this would help him en¬
gage in ways to deal with them.
He received a task involving simple multiplications (see
Figure 8.1). As the figure illustrates, he failed to deal with the
number “5” in the first problem and the number “9” in the
second problem. He was told that the difficulty was not in mul¬
tiplication, since he multiplied numbers correctly, but rather
in the neglect of the left side of space. He was surprised that
he omitted the numbers 5 in the first problem and 9 in the
second problem. “How much space do the numbers take up?”
he remarked. He also received a visual cancellation task and the
Weinberg “and, the, but” task (Diller and Weinberg, 1993).
Difficulties in scanning to the left and attention and concentra¬
tion were pointed out (for a description of the problem and
the remedial strategies see Table 8.1).
In one hour a week training sessions and 15 minutes a day
of home exercises, he improved in visual scanning. As treat¬
ment progressed, exercises were increased to 30 to 45 minutes
154 Joseph Weinberg—Leonard Diller

TABLE 8.1
Description of Problems and Remedial Techniques

Description of Problems Remedial Techniques

A. Patient Unaware that He Has a Given arithmetical calculation such

Problem as 543 X 345. Task can’t be
rationalized

B. Patient Does Not Look to the 1. Explain to patient the importance

Left, Head Tilted to the Right of looking at faces while
communicating with others (e.g.,
“Look at me”)
2. Practice moving head to the
center, then to the left

C. Patient Has Difficulty Scanning 1. Following finger moving from left

to the Left of Side of Sphere to right.0
2. Looking at index cards attached
on a wall (left to right side).
3. Crossing out letter/letters.
4. Copying first and last word.

D. Increasing Patient’s Attention 1. Canceling words: and, the, but, in

editorials.
2. Serial numerical task to increase
attention over time and increase
attentional load.4

E. Reading 1. Summarizing short articles

(written).
2. Reading popular magazine
articles and summarizing: oral
and written.

F. Arithmetic Practice arithmetical subtraction &

multiplications 2 X 2, 3 X 2, 4 X
2, etc.

a Instructions: “Move finger L to R, if patient fails, repeat. If fails again, discontinue.

If pass, use index fingers of both hands moving parallel.
b Written serial numerical task—modifying information load; e.g., add serial 3’s_3,
6, 9; serial 5’s—5, 10, 15; 3 & 5’s, 3 + 5 = 8, + 3 = 11, + 15 = 26, etc. A similar
principle is used for serial subtraction. From 700 - subtract 3’s, then subtract 7’s,
then combine alternating 3’s and 7’s.
 Treatment of Visual Inattention 155

Figure 8.1. Arithmetic performance: Mr. A & Mr. Z.

Mr. A

7^^
3H 5T
x SLI 3 9 ? 7

5/^3

V 7~~ ?

Mr. Z

H S£
/ S 3S
I 4 z
il t &
TTo

per day. After 12 sessions, Mr. A returned to his office on a

part-time basis, and after 24 sessions he returned on a full-time
basis. He continued the exercises for 3 months. He is now
actively involved in his work, travels, and participates in his
social life. Below is an account of how Mr A summarized his
training.

First I could not understand why I could not resume my work

and drive a car. Although I was told that I sustained a neglect
of visual space and had cognitive problems, I could not relate
these problems to daily activities. I was also told that I was im¬
proving and yet I was told that I had cognitive problems. I was
156 Joseph Weinberg—Leonard Diller

confused and so was my family. ... In the training sessions, my

problems and the ways they were affecting my thinking and
organization, were pointed out to me. When I left out numbers
in multiplication or when asked to cancel the words and, the,
but in an editorial column and saw the number of my omissions,
the neglect problem became clearer to me. I could not dismiss
or fail to see the impact on my daily activities. My attention and
concentration improved, and I was able to stay with a task for
longer periods of time without getting tired. I was able to accept
an explanation for my difficulties in reading newspapers and
watching television. Avoiding movies, which I excused as “I am
tired,” was related to attention and concentration and not lack
of interest.
I was told (and this was reinforced by my family) that I was
depressed and not motivated. This was difficult for me to accept.
Before the stroke I was active in projects and was too busy to
be depressed. During rehabilitation, I was deprived of normal
activities which reenforced the impression that I was depressed.

CASE 2

Mr. Z is a 52-year-old, right-handed social scientist who sus¬

tained a right CVA. On neurological evaluation he manifested
a left hemianopsia and a left hemipegia. A CT scan revealed
an edema and a mass involving the right temporal and pari¬
etal lobes.
Five months postonset he was admitted to the outpatient
department of the Rusk Institute of Rehabilitation Medicine.
Neuropsychological evaluation showed a significant loss of in¬
telligence from a pretraumatic level. Deficits in visual pro¬
cessing, visual memory, planning, and cognitive flexibility
appeared, as well as problems in attention, concentration, read¬
ing, arithmetic skills (Verbal IQ = 138; Performance IQ = 65).
When presented with a newspaper, he read headlines only on
the right side of the page. He skipped lines and had difficulty
in making sense of what he read. Similarly, in copying, he cop¬
ied only the right side of the page, omitting the left. Attention
to visual details was profoundly impaired.
When first seen for cognitive retraining, Mr. Z was asked
a sequence of questions: whether he had a problem in visual
 Treatment of Visual Inattention 157

perception, whether he was omitting objects on the left, how

he was perceiving his problem, why he was referred for therapy.
His main concerns were with physical motor skills such as walk¬
ing, lack of independence, and inability to drive (Table 8.2).

TABLE 8.2
Perceived Problems of Patients

Mr. A Mr. Z

What is your problem? 1. Difficulty Can’t Walk

Walking
2. Lacks Lacks Independence
Independence
3. Can’t Drive Can’t Drive
4. Can’t Travel Can’t Travel

Did you read paper Yes Yes

before?

Do you read paper now? No. Why? Hard to hold. Not like before stroke; I
Not interested in news have no patience

Do you have a reading No No

problem?

Reading or under- No No
standing what is read?

Do you watch TV? Yes Yes

Understand TV? No problem No problem

Do you have problems No M.D. says I have problems

with vision or seeing No (hasn’t seen eye doctor
things? in 2 years)

Do you have a problem Memory . . . can’t Short-term memory . . .

with attention or remember “tend to forget now &
concentration? then, so I’m told”

During the brief interview, he did not look at the examiner,

who was seated to his left. He looked to the right or at the
floor. On command he looked at the interviewer. During a 50-
minute session, 22 times he was told to look to the left. Ac¬
cording to the patient, he had no problem in reading profes¬
sional journals, despite the fact that he omitted half of the
158 Joseph Weinberg—Leonard Diller

newspaper headlines. The reason he was referred to cognitive

retraining was to improve his ambulation and driving.
Before engaging in retraining it was necessary to confront
Mr. Z with the presence of his visual perceptual problem and
his neglect, and how these problems pervaded his academic
activities and interfered with his judgments and social contacts.
As in the case of Mr. A, previously cited, arithmetic calculation
served as a primary therapeutic vehicle, with similar results
(Figure 8.1). When omission of digits in performing calcula¬
tions was pointed out, Mr. Z stated that he had not performed
simple calculations in a long time and, indeed, in the following
session he brought a calculator to prove his point. When it was
noted that the purpose of the exercise was not to illustrate
an arithmetic difficulty but a visual perceptual problem, he
suggested that he could set up a formula to make it easier to
multiply 3X3 and 3X4. While it was possible that he ne¬
glected stimuli on the left side of space, he argued that this
did not affect his profession and his general behavior. Although
he improved and learned to compensate for his neglect, as did
Mr. A, he continued to rationalize all failures, offering reasons
for his difficulties. For example, he brought a paper that he
was reviewing for a scientific journal. When asked to read the
summary, he left out words on the left side and skipped lines.
When these errors were pointed out, he commented that the
omitted words and the skipped lines were unimportant. He
remarked that when he had difficulty with a task and saw the
reason why he failed, he committed himself and needed to
have a reason for the failure even if it did not make sense
to others.
Mr. Z improved and learned to compensate for the neglect
and difficulties in scanning. On the Weinberg “and, the, but”
test he omitted 41 of 48 targets initially. On retest, after 2
months of training, he omitted only three targets, placing him
within the normal range. He continued training for 3 months,
feeling comfortable with his progress, before he discontinued
treatment.
 Treatment of Visual Inattention 159

DISCUSSION

In our earlier studies we developed methods, principles, and

evidence for an approach to perceptual remediation for visual
neglect. These efforts parallel developments in psychotherapy
research which culminated in manuals used in clinical trials to
demonstrate efficacy of treatment (Garfield, 1997). Such an
approach is congruent with requests of third-party payers for
evidence before treatment is reimbursed. However, psychother¬
apy researchers who note limitations in this approach, when
describing experiences in applying the manuals in clinical tri¬
als, ascribe such limitations to individual differences in the use
of these manuals by training therapists (Beutler, 1997). That
is, for a given clinician a manual may be quite effective for one
patient but not for another (Strupp 8c Anderson, 1997). In a
sense, in this paper we have taken a step back from previous
writings. We have shown the interplay between what is generally
considered as clinical sensitivity to patient response through
examples of situations that are generally not reported in formal
studies. We report the clinical fine tuning that goes along with
formal procedures.
In presenting materials to deal with unawareness in Table
8.1, we note that depending on the clinical situation, it is often
useful to start with naturalistic situations or common stimuli
which are part of conventional surroundings. For example, ask
a patient to describe a picture on a wall and note omissions in
the description. Note whether or not the patient looks at the
examiner during an interview or conversation, or point out
discrepancies in grooming or appearance. This is also useful
in the presence of a significant other. The examiner calls the
patient’s attention to these problems with gentle probes: “Why
do you think you omitted this or why do you think I gave you
this task in the first place or how do you think you appear
to others?” The remediator’s feedback is very specific to the
patient’s response to the given task to ensure that the reason
for the failure is not falsely generalized (“I’m dumb!”) or
falsely attributed (“I have a memory problem or I am not wear¬
ing my glasses!”). The remediator might say, “You may have
160 Joseph Weinberg—Leonard Diller

failed to notice the details in the picture not because you are
dumb or careless or mentally incompetent or nearsighted, but
because since your stroke you find it easier to pay attention to
one space over the other. You are simply following your old
prestroke habits. Let me show you a way around the problem.”
The remediator illustrates or models ways in which percep¬
tual habits can be altered to overcome the problems, and offers
ways in which retraining can be helpful. Casting the response
so specifically, followed by corrective action which is equally
specific, gives the patient the feeling of working with someone
who understands and accepts his problem and can deal with it
in an open way without the patient feeling diminished. One of
the obstacles in treatment is the patient’s feelings of shame as
a result of failure or fear of failure on seemingly simple tasks.
The strategy helps restore a patient’s sense of mastery and
reduces feelings of shame. It is common for patients to give
priority to this treatment over other forms of therapies, even
though in rehabilitation it is more typical for patients to prefer
building functional motor skills. Thus patients may request this
treatment after being discharged from the remainder of reha¬
bilitation therapies.
In a previous paper (Diller 8c Weinberg, 1993) we noted
that patients with low levels of awareness resist acknowledging
problems even on direct confrontation and in the face of over¬
whelming evidence. We argued that acknowledgment and en¬
gagement can be facilitated by presenting the patient with
samples of behavior which were difficult to deny (e.g., having
to read one’s own handwriting, or reviewing omissions in an
important overlearned task such as making change with coins
which are spread on the table). In the cases of Mr. A and Mr.
Z, we illustrate the same effect by the use of simple arithmetic
as a sample of behavior to enhance awareness of difficulties, in
that arithmetic is a necessary overlearned skill which is mean¬
ingful. Unlike reading, where the person can fill in the mean¬
ing of omitted words, the consequences of failure are readily
apparent. An important step is to show the patient strategies
for overcoming the failures on the spot. The key element is
that the failure does not have to result in a loss of personal
control. Much of the attempt to cover up or deny a problem
 Treatment of Visual Inattention 161

is to hide embarrassment over failure in ordinary events. Often

the embarrassment is not presented on initial contact and ap¬
pears only with more close contact and trust. Mr. A’s case illus¬
trates the feeling of regaining mastery. Mr. Z’s case illustrates
the struggle to retain mastery. He attempts to retain mastery
over each situation anew.
In this paper, we also illustrate the rationalizations of both
patients, steps taken to correct the rationalizations by system¬
atic verbalization of the presence of the problem, explanation
of steps taken to overcome it, and concrete success in finding
the correct solution. The rationalizations are illustrated in Ta¬
ble 8.2 and the sequence of tasks used to bring out the problem
and correct it in Table 8.1. The rationalizations present only a
sample of situations. For example, a patient may avoid social
engagements because of embarrassment in not recognizing
people, while insisting that he doesn’t go out because he is
not interested. In rationalizations it is important that one deal
directly, yet tactfully with the stated reason and correct it. For
example, when Mr. A said that he had a memory problem but
not a perceptual problem, he was asked what he had eaten the
night before. Upon answering correctly, he was told that there
was evidence of good working memory, but the problem was
perceptual. Memory difficulties, a common reason offered for
failure, serve as an excuse for not addressing a treatable
problem.
Although the unawareness had its roots in visual dysfunc¬
tion, unawareness occurs in a variety of situations with brain
injured individuals, which are not due to stroke and are not
associated with visual difficulties. Rationalizations for failure
may involve similar defensive maneuvers and would call into
play similar therapeutic strategies. The syndromes described
here are more striking and the strategies can be explicated
more clearly.
It is also apparent that awareness and success in perceptual
retraining does not occur suddenly or by leaps and bounds.
Because perceptual problems are pervasive and recur in unex¬
pected as well as expected situations, rationalizations are fre¬
quently invoked until the person learns to identify the reasons
for failure.
162 Joseph Weinberg—Leonard Diller

One note. Mr. A stated how unhappy he was because of

his initial confusion. Both family and staff attributed this to
depression as a more pervasive condition. While Mr. A may
have been depressed, it is useful to distinguish and treat the
elements which enter into depression rather than considering
it as a blanket affective state. While some have attributed de¬
pression to biological factors (Robinson et al., 1981), we have
noted that limitations of normal activity patterns are highly
correlated with depression (Gordon et al., 1985). The reasons
for the depression and different patterns of treatment are be¬
yond the scope of this chapter.

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psychotherapy: An illustration by reference to the role of the
therapist experience and training. Clinical Psychology, 4, 44-53.
Birch, H. G., Belmont, I., & Karp, E. (1967). Delayed information
processing and extinction following cerebral damage. Brain,
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Diller, L., & Weinberg, J. (1993). Response styles in perceptual re¬
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(pp. 162-182). Andover, MD: Andover Press.
Garfield, S. L. (1997). The therapist as a neglected variable in psycho¬
therapy research. Clinical Psychology, 4, 40-43.
Gianutsos, R., & Mathesson, P. (1987). The rehabilitation of visual
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 PART IV

Specialized Treatment Applications for

Specific Population Needs
9.

Group Psychotherapy

Donna M. Langenbahn, Ph.D.,

Rose Lynn Sherr, Ph.D.,
Dvorah Simon, Ph.D.,
and Bennett Hanig, Ph.D.

OVERVIEW

This chapter is based upon our experiences working with adults

with brain injury in a large outpatient neuropsychology pro¬
gram. The Neuropsychology Service (NPS) of the Psychology
Department of the Rusk Institute of Rehabilitation Medicine
annually provides cognitive and psychotherapeutic services to
approximately 250 adult outpatients with acquired neuropsy¬
chological impairment (Sherr 8c Langenbahn, 1992). Both cog¬
nitive and psychosocial group treatment are integral to the NPS
treatment approach. Our clinical experiences and those of oth¬
ers have indicated the value of group treatment with this popu¬
lation, used both alone and integrated with individual
treatment (e.g., Ben-Yishay 8c Diller, 1981; Deaton, 1991; Priga-
tano et al., 1986).
Group treatment can both intensify and extend the bene¬
fits obtained from individual treatment for brain injured indi¬
viduals. Groups provide the opportunity for peer support and

167
168 Langenbahn et al.

feedback, the sharing of effective ideas and compensatory strat¬

egies, the sense of feeling helpful, the easing of isolation, and
repeated comparisons of one’s abilities and limitations with
those of others with the same or a similar diagnosis.
The potential benefits of group treatment address one of
the general goals of psychotherapy with individuals with brain
injury, i.e., to assist with the emotional and social changes that
make their lives so difficult following the injury. However, the
brain injury also results in cognitive, emotional, and social
changes that may render traditional approaches to psychother¬
apy ineffective. Skills such as attention and concentration, ver¬
bal expression and comprehension, memory, cognitive
flexibility, generalization, empathy, and abstract thinking are
thought to be essential for effective psychological treatment;
yet these capabilities can be impaired by brain injury (e.g.,
Miller, 1993, pp. 54-67). Further, brain injury can cause re¬
duced ability to be aware of, observe, and monitor one’s feel¬
ings, thoughts, and actions (Prigatano & Schacter, 1991), also
essential capacities for effective psychotherapy. The resulting
array of limitations often engenders a new and confusing sense
of “self.” Concurrently, one’s capacity to stabilize oneself with
what Weiner (1966) referred to as consistent and organized
patterns of dealing with people, affects, and life situations is
often drastically reduced.

MODIFICATIONS IN PSYCHOTHERAPY AFTER BRAIN

INJURY

In general, psychotherapy is adapted to meet the needs and

abilities of the individual (s) being treated. To treat the brain
injured individual in a group setting, two other critical adapta¬
tions of traditional psychotherapy need to be considered: (1)
the ways in which psychotherapy must be altered to provide
comfort and to make change possible for the brain injured
individual; (2) the methods that allow individuals with brain
injury to participate meaningfully in group psychotherapeutic
treatment. Successful realization of both adaptations involve a
 Group Psychotherapy 169

knowledge of brain injury based difficulties as they impact on

the individual’s ability to benefit from psychotherapeutic inter¬
ventions.
With regard to the first consideration, rehabilitation litera¬
ture now reflects the commonly accepted viewpoint that indi¬
vidual psychotherapy must be modified for brain injured
individuals (Langer, 1992; Lewis & Rosenberg, 1990; Prigatano
et al., 1986). Miller (1993) enlarges the scope of modifications
considerably:

Psychotherapy, in the broadest sense, may include remedial in¬

struction, specialized training, manipulation and structuring of
the environment, medication where appropriate, and support¬
ive, behavioral, cognitive, and psychodynamic approaches to
psychotherapy, (p. 48)

Our experience suggests that many approaches and tech¬

niques used in cognitive remediation also must be incorporated
into the practice of psychotherapy, both individual and group,
in order for persons with brain injury to benefit optimally (Ben-
Yishay & Diller, 1981; Sherr & Langenbahn, 1992).
Specific modifications include a set of procedures and
techniques that transform the psychotherapy in line with an
overall approach with this population: repetition; checking the
patient’s comprehension of what has been said; the consider¬
ation of cognitive hypotheses for behaviors commonly interpret¬
ed as dynamically based “resistance” (e.g., poor eye contact,
lateness, moments of forgetting). Written notes are used either
by, or, if necessary, for the patient within sessions along with
reviewing within sessions and journal-keeping outside of ses¬
sions. The therapist utilizes diagrams, drawings, checklists,
graphs, and other methods of concretizing information and
ideas. The pace of treatment is slowed. Scaling or rating tech¬
niques are used for anchoring experience of difficulties, view¬
ing difficulties on a continuum, and measuring change.
Normalizing frames of reference are used for both injury and
noninjury related experience. Therapeutic interventions are
altered based upon the understanding that cognitive/percep¬
tual difficulties can trigger defensive reactions (e.g., difficulties
170 Langenbahn et al.

in auditory comprehension may evoke symptoms of regression,

obsessiveness, or denial), and, conversely, defensive reactions
can exacerbate cognitive or perceptual difficulties (e.g., obses¬
siveness can reduce attentional focus).
In order for individuals with brain injury to benefit from
group treatment, the approach mentioned above must be
adapted further. Yalom (1985) notes that group psychotherapy
is a guided encounter in which the therapist sets up the environ¬
ment and format of the group to promote certain “therapeutic
factors’’ (e.g., cohesiveness, universality, and interpersonal rela¬
tionship). These therapeutic factors are not easily attainable
with a brain injured population due to cognitive compromise
and the impairment of more basic social and emotional abilities.
Thus, the initial focus of group psychotherapy with this popula¬
tion often must entail the rebuilding of basic underlying social
skills as much as possible, and then, practice in the management
of emotional reactions within the context of varying reductions
in ego defensive and cognitive capacities. Structuring tech¬
niques of group interaction (i.e., instructions, cues, modeling,
and other explicit information) may also be used to guide group
members so they can participate successfully in group interac¬
tion and generalize the benefits gained to their everyday lives.

PSYCHOSOCIAL IMPACT OF NEUROPSYCHOLOGICAL

IMPAIRMENT

Neuropsychological impairment after brain injury reduces psy¬

chosocial functioning in very basic ways. For instance, signifi¬
cant deficits in cognitive areas such as the ability to think
abstractly may create problems in taking another’s perspective,
in seeing oneself accurately in interpersonal situations, and in
understanding social context, boundaries, timing, and dis¬
tance. Often observed, also, is a certain “narcissism,’’ not nec¬
essarily based on psychodynamic etiology, but related to the
above-mentioned difficulties.
For those with severe cognitive impairments, a loss of
friends and social contacts might be noted, but the causes are
 Group Psychotherapy 171

often attributed to others’ lack of understanding. Feelings of

anger (often compounded due to emotional disinhibition),
anxiety, and depression, as well as further social withdrawal,
often worsen rather than rectify the situation. Severe impair¬
ments in initiation can reduce access to constructive preinjury
behaviors, including those necessary in developing and main¬
taining social relationships and activities.
Individuals with only moderate impairment of such cogni¬
tive abilities as abstract reasoning show social-emotional func¬
tioning characterized by relatively greater flexibility of thought
and reason. Greater perspective, capacity for self-assessment,
and ability to acknowledge personal contributions to emotional
and social well-being may still be present. Most importantly,
there is more ability to acknowledge the need to change one’s
own behavior to improve social and emotional dysfunction.
With those having moderate cognitive impairment, while there
may be an awareness of and discomfort with social isolation
and dysfunction, the degree of cognitive limitation often still
interferes with spontaneous remediative behaviors that are
predicated upon social facility, initiation, and planning and
organizational abilities.
Individuals with relatively minor changes in cognitive abil¬
ity (presuming good premorbid social, emotional, and intellec¬
tual resources) usually have greater residual emotional and
social capacity. They can acknowledge and label emotional ex¬
perience, shift their perspective, hear feedback about the im¬
pact of their behavior upon others, and express empathy for
and concern about others’ experiences. While social function¬
ing is commonly reduced from preinjury levels, the capacity to
plan and implement social and recreational activities usually is
retained. With increased cognitive capacity, there is greater
general concern about emotional and interpersonal changes.
Personal responsibility in the maintenance of friends and
friendships is acknowledged. If the person is married or in a
sustained intimate relationship, the preservation of that rela¬
tionship, as well as the understanding of and adjustment to
new roles and the resolution of conflict within the relationship,
are central concerns.
172 Langenbahn et al.

GROUP TREATMENT OF PSYCHOLOGICAL AND

PSYCHOSOCIAL PROBLEMS

General Rationale for Group Structure

The Neuropsychology Service has developed different types of

groups addressing several aspects of psychological and psy¬
chosocial functioning. They include Psychosocial Groups, fo¬
cusing on issues of social interaction and presentation of self;
Self-Regulation Groups, dealing with emotional disruption of
the process of logical thinking; and Anger Management
Groups, for those whose loss of anger control has been identi¬
fied as a significant problem by themselves, family members,
friends, or staff.
Different protocols of treatment have been developed
within each type of group to accommodate differences in the
level of preinjury life experience, developmental level and in¬
telligence, and extent of cognitive impairment. Modifications
are designed also to circumvent the effects of the brain injury
so that maximum benefit can be derived from the treatment.
Structuring techniques in psychotherapy groups include ex¬
plicit determination and ongoing review of short- and long¬
term goals, the use of notetaking, following a prepared agenda,
and reviewing of the previous session. Such techniques provide
organization, memory compensation, and focus to the groups’
activities. Based on the degree of impairment of group mem¬
bers, topics are made more or less limited or concrete, pace of
group activities and discussions is slowed or quickened, repeti¬
tion of key points is frequent or rare, and generalization exer¬
cises are emphasized or not. In addition to the group culture¬
building techniques described by Yalom (1985), responsibility
for the group process is encouraged by group members taking
charge of timekeeping, leading selected sections or exercises
within groups, reviewing the previous session, and summarizing
individual progress toward goals within sessions.
In the following sections, we will discuss the format and
content of Psychosocial, Self-Regulation, and Anger Manage¬
ment Groups. Within each section, we will describe member
 Group Psychotherapy 173

selection issues, group format, and the details of treatment in¬

terventions.

Psychosocial Groups

Within the NPS program, Psychosocial Groups (PSs) are a sub¬

set of the Basic Skill Groups (BSGs) that comprise a large com¬
ponent of outpatient treatment (Sherr 8c Langenbahn, 1992).
Training within BSGs emphasizes competence in five basic
skills: awareness of current strengths and limitations; ability to
pay attention to and concentrate on a task; effective use of
notetaking for organizing and remembering information; the
ability to give, accept, and use feedback as a means of self-
evaluation; and emotional-social interaction skills. Individuals
are assigned to BSGs by virtue of their level of competence in
the five skill areas, as well as their overall residual intellect,
speed of language and information processing, motivation,
stamina, and tolerance for group interaction. Consideration is
also given to factors of group cohesion (Yalom, 1985), such
as age, education, and cultural background. However, group
members are not necessarily separated by etiology of the brain
injury. By use of neuropsychological data, clinical interview,
and input from the brain injured individual, family, and treat¬
ing staff, these factors are combined to result in “low,” “moder¬
ate,” and “high” level BSGs. These divisions are clinically
useful to patients, who often have limited tolerance for seeing
themselves as similar to more impaired individuals, or alterna¬
tively, experience anxiety in the face of group exercises that
are too challenging, or other group members who have notably
stronger cognitive abilities.
Psychosocial Groups, although a subset of BSGs in the NPS
program, may be developed in any brain injury program in
which the treatment of emotional and social interaction diffi¬
culties is essential. Despite the emotional and social interactive
emphasis, PGs are introduced to members as distinct from tra¬
ditional “psychotherapy” groups, in part to prevent the groups
from being seen as open forums for complaints and “express¬
ing feelings.” Because individuals with brain injury often lack
174 Langenbahn et al.

control over emotional expression and have difficulty recogniz¬

ing suitable contexts and the social consequences of unbridled
expression of thoughts and emotion, interactions in PGs first
highlight the educative and rational components in emotional
management and social exchange.
The initial focus in PGs is on the establishment of individu¬
alized goals, and groups emphasize achievement of these goals
throughout subsequent sessions. Although complaints and ex¬
pression of feelings occur, group leaders seek to guide and
channel these, and other group phenomena, into reasoned
and effective communication and behavior. Psychosocial
Groups emphasize three of the five BSG skills noted above:
awareness of current strengths and limitations (especially in
emotional and social areas); ability to give, accept, and use
feedback as a means of self-evaluation; and improvement of
social interaction skills and management of emotional reac¬
tions.

Levels of Psychosocial Groups

\

We have found it useful to divide Psychosocial Groups into

three levels, depending upon individuals’ cognitive and social
skill capabilities. The first, level 1, is designed to accommodate
the most psychosocially and cognitively impaired individuals.
Level 1 employs a highly structured approach (borrowed from
BSG cognitive remediation groups) in which sheets listing
group members’ individual psychosocial goals are used, note¬
taking is stressed, and repetition is the norm. Level 1 PGs are
designed to focus on the basic building blocks of social skills
and awareness of social skill strengths and difficulties. These
building blocks include initiation of interpersonal interaction,
listening to others, modulation of voice volume and rate of
speech, speaking with animation and inflection, making appro¬
priate eye contact, understanding body language, and planning
recreational (although not necessarily “social”) outings.
Level 1 members also work on developing awareness of
their social skill limitations, giving and accepting feedback in
social skill areas, and developing means of judging their own
 Group Psychotherapy 175

behavior in social situations. Interaction between and among

group members is guided by highly structured exercises and is
accompanied by monitoring and coaching from the group
leader. Role playing and structured presentations frequently
are used in level 1 groups, with goals and feedback centering
around the skills mentioned above.
Level 2 groups are characterized by a moderate to high
degree of structure that allows for a greater degree of interper¬
sonal interaction among group members. While participants
continue to work on the basic social skills mentioned above,
more emphasis is placed on the development of social rapport,
as well as on the sharpening of social judgment and problem
solving. More emotionally-based goals are included in goal¬
setting in level 2 groups (e.g., self-acceptance, heightening of
self-confidence, and reduction of social anxiety). After exhib¬
iting competence in level 1 skills, patients in level 2 focus on
the awareness of context and timing that heightens success in
social interactions. Role-playing and structured presentations
are also used in level 2 groups, with the goal of learning and
practicing effective behavior in a variety of social situations.
Level 3 groups are for those functioning at the highest
level of premorbid and current abilities. These individuals are
generally reasonably aware of some of the implications of their
cognitive deficits. They can interact socially with a moderate
level of effectiveness, and they have the capacity to explore,
acknowledge, and use feedback about their emotional reac¬
tions and social interactions.
Level 3 PGs are conducted with a low to moderate degree
of structure. Typical goals include improving interpersonal
skills, facilitating closer relationships within the group, height¬
ening self-confidence, reducing social impulsivity, stabilizing
mood, reducing social anxiety, developing greater insight into
personality and interaction style, compensating for ineffective
social behaviors, and working toward self-acceptance. Group
goals can be achieved with less structured interaction among
members, as well as more member input, as feedback from
level 3 group participants often has a meaning and accuracy
surpassing that in lower level groups. In level 3 PGs, the leader
often acts more as a facilitator, but during certain exercises,
176 Langenbahn et al.

still may give explicit and detailed instructions and feedback

to assist in effective and emotionally safe group interactions.
Treatment tools include role-play and semistructured discus¬
sions and presentations within topic areas selected by the lead¬
ers or by the group members.

Format of Psychosocial Groups

All Psychosocial Groups have the following format: (1) an¬

nouncements; (2) review of previous session; (3) psychosocial
exercise/discussion; and (4) summary of today’s learning/
progress. All groups use individualized goal sheets to record
each member’s personal goals. Videotaping is used to demon¬
strate successes and persistent problems, and to monitor im¬
provement.
In all levels of PGs, isolation and repeated practice of the
basic components of a task are accomplished before attempting
the entire task. Suitable amounts of instruction, cuing, and
feedback are provided depending upon the competence level
of the group. This structured approach allows limited degrees
of freedom for “errors,” and thus promotes greater opportu¬
nity for success in performing exercises (Ben-Yishay, Diller,
Gerstman, & Garden, 1970). With increased competence of
group members, structure and cuing can be gradually reduced.
Increased structure is often reintroduced for new goal areas,
or when the task is made more complex by adding greater
cognitive or interpersonal demands.
Announcements are brief; they include an account of who
is present or absent, a reminder to refer to personal goals,
mention of any planned absences for the following week, and
examples of any successes or problems encountered in goal
areas during the past week. In level 1 and 2 groups, group
members often need structured guidelines in order to provide
an example of a psychosocial success or a problem. Guidelines
may be such as the following:

An example gives enough information to paint a “mind pic¬

ture,” in an example you mention: (1) the goal for which you’re
giving the example; (2) where you were; (3) who was there; (4)
 Group Psychotherapy 177

what happened; and (5) what body language and words you
used to meet your goal.

Reviews in PGs focus on updating group members on the

topics and principles learned in the previous session. Members
are expected to have notes that assist them in presenting an
informative overview of the previous session, and feedback is
given primarily upon style of presentation, while also noting
any major errors or omissions. The group leader adds com¬
ments, as needed.
In the psychosocial exercise/discussion section, the topic
or exercise of the day is introduced. In level 1 and 2 groups,
the exercise is highly or moderately structured, with clear in¬
structions. In level 3 groups, the section may either be an exer¬
cise with moderate to low structure, or a guided discussion of
a topic area. In the latter groups, while instructions may give
more latitude for spontaneous responses, they are still designed
to provide clarity about the group task.
In the final section of PGs, a brief summary of the session
is given by a group member or group leader. Each member
then evaluates the degree of personal learning and objective
progress made toward individual goals in that day’s session.
Methods of assessing progress include use of rating scales to
anchor observations from self, other group members, and
group leader (s), listing of “principles” that can be practiced
in everyday settings, and assistance in setting the next more
challenging goal as progress is shown.

Exercises and Approaches

Initial sessions of all levels of Psychosocial Groups include dis¬

cussions of the group and its purpose. The format for the orien¬
tation discussion varies according to the level of the group, but
always involves concrete examples of the psychosocial problems
that the therapy will address. In the higher level PGs, members
are encouraged to bring in examples from their recent expe¬
rience.

Levels 1 and 2. As noted earlier, goals addressed in level 1

PGs include many of the fundamental verbal, vocal, and body
178 Langenbahn et al.

language skills of communication, such as speaking at a reason¬

able rate of speed, making eye contact with the entire group,
and speaking with animation. Initial group exercises, however,
may address only one of these skills; more complex interaction
exercises often are deferred to later sessions after preliminary
competence is demonstrated. An example of a level 1 or 2
Psychosocial Group exercise could be one to train suitable
voice volume. The exercise would involve members taking turns
giving brief presentations on topics such as: “Who is my favorite
actor and why?” or “How do I get from home to here and how
long does it take?” while attempting to raise or lower voice
level.
After each presentation, other group members give feed¬
back to the presenter, with the group leader providing addi¬
tional structure in the form of prompts, modeling, examples,
and feedback, as necessary. In later sessions of level 1 groups
or early sessions of level 2 groups, depending upon the compe¬
tence and potential of the members, more recreational goals
(such as planning an outing for oneself) or interactive goals
(e.g., initiating conversation, listening to and summarizing con¬
versation, giving feedback) are attempted.
Level 1 and 2 groups also have curricula that address the
important social skill of being able to give and receive positive
feedback and suggestions for improvement. Treatment inter¬
ventions in groups of individuals with greater impairment are
very concrete. For instance, when training on giving admiring
or appreciative feedback to others, this skill area is practiced
across several sessions. The initial exercise may be to generate
a list of admiring or appreciative statements (e.g., “Wow, you
cooked a great dinner tonight”; “I appreciate you helping me
with my knapsack; it was really heavy for me.”), and a list of
vocal styles and body language that convey sincerity and enthu¬
siasm (e.g., eye contact, smiling, emphasis). Group members
then spend several sessions participating in structured two-per¬
son role plays in which parts are described (or even scripted)
for participants and the goal is to express appreciation or admi¬
ration. Following each role play, other group members give
feedback regarding the words and phrases used, the vocal style,
 Group Psychotherapy 179

and the body language of the role play participants. Finally,

group members begin structured exercises to express admira¬
tion or appreciation of a quality or action in each other (e.g.,
“I really appreciated it when you smiled at me and said ‘Hi’
when I joined the group; it made me feel welcome.”), with
feedback provided by the group and leader.

Level 3. Initial exercises in level 3 Psychosocial Groups in¬

clude presentations on the following topics: ‘‘How am I the
same now as I was before my injury (stroke, etc.), and how am
I different?” “How has my social life changed since my injury
(stroke, etc.), and how is it the same?” Topics are deliberately
designed to emphasize both continuity and change in group
members, in order to enhance their awareness of how they are
the same as or different from the way they used to be. They
also help the person combat catastrophic reactions and assist
in verbalizing regrets and complaints that will help them formu¬
late individual goals within the group.
Later level 3 group exercises typically use role plays con¬
structed with two or three members as participants. Each mem¬
ber is assigned a role designed to address an individual social
skills goal. For example, one member (goal = being inquisitive
and keeping conversation flowing) interviews another member
(goal = disclosing personal likes/dislikes with greater specific¬
ity and confidence) about an interest in jazz. A third group
member (goal = giving opinions with less sarcasm) is ap¬
pointed the role of “feedback-giver.” Following the role play
this group member evaluates each role player’s success in work¬
ing on his or her goal. Then the feedback-giver is given feed¬
back by other group members and the group leader (s).
Discussion topics in the psychosocial exercise/discussion
section are either preplanned and introduced by the leader(s)
(e.g., “How do I cope with a rehabilitation therapist I do not
like?”), or are developed from a topic brought up by a group
member during “Announcements” into a role play situation
or discussion. Even in using this more “unstructured” type of
180 Langenbahn et al.

exercise, the emphasis is upon participants practicing behav¬

iors to meet individual goals as group members discuss and in¬
teract.

SELF-REGULATION GROUPS

Problems in Self-Regulation

The NPS Self-Regulation Groups (SRGs) were initially devel¬

oped as part of a federally funded grant addressing problem
solving in persons with brain injury.1 For participants in these
groups, problems in affective and behavioral regulation are
conceptualized as a stumbling block to effective problem solv¬
ing in that unmodulated emotional responses preclude careful
consideration of options or effective implementation of solu¬
tions. Unchecked emotional reactions include both “external”
loss of control, such as shouting or physical violence, and “in¬
ternal” reactions, such as a feeling of flooding or mental paraly¬
sis, described by one patient as, “My mind goes into a Fifth
Avenue traffic jam.” Difficulty with affective and behavioral
regulation is common in persons with brain injury as a result
of a confluence of factors including cognitive deficits (e.g., dif¬
ficulty processing complex environmental stimuli, difficulty
keeping in mind a larger perspective or taking the perspective
of another person, all-or-nothing thinking), loss of emotional
control (e.g., “short fuse,” lability, disproportionate reactions,
disinhibition), psychological effects of trauma (e.g., depres¬
sion, anxiety, increased startle response, poor sleep), and physi¬
ological effects of brain injury such as increased fatigue and
increased vulnerability and reactivity to environmental stimu¬
lation.
These factors interact in a variety of ways, both with each
other and with premorbid personality disposition. For exam¬
ple, persons with a preinjury tendency toward a depressive cog¬
nitive style may be particularly vulnerable to “all-or-nothing”

1 The development of these groups was supported in part by NIH grant # 1 ROl
HD 32943-01Al, Leonard Diller, Principal Investigator.
 Group Psychotherapy 181

comparisons with premorbid functioning, leading to an in¬

creased propensity for disparaging self-statements and cata¬
strophic emotional reactions.
The SRGs are designed to assist individuals with brain in¬
jury to become aware of their patterns of difficulties with self¬
regulation, and to develop ways to recover from and compen¬
sate for these difficulties by developing distance and perspec¬
tive from emotional reactions and increasing the ability to
maintain cognitive control over reactions and behaviors.

Structure of Self-Regulation Groups

Selection for SRGs is predicated upon a moderate degree of

competence in attention-concentration, awareness of assets
and deficits, notetaking, ability to give and receive feedback,
and social—emotional skill. However, despite a relatively high
level of social and cognitive competence, a structured format
is employed that includes the use of a prepared agenda, in¬
session notetaking, and methods of tracking progress, all cru¬
cial to contain and focus discussion and facilitate retention and
integration of learned material.
The SRGs are conducted in either a 2-hour session once
weekly, or two 1-hour weekly sessions for an 8- to 12-week pe¬
riod, and to follow a protocol of topic-focused modules. The
objectives of the modules are: (1) to increase awareness of
breakdowns in emotional self-regulation; (2) to analyze each
person’s pattern of self-regulation difficulties in terms of the
relative contributions of (a) processes of disinhibition and loss
of emotional control; (b) environmental and physiological fac¬
tors that increase vulnerability to the above; and (c) disparag¬
ing self-talk resulting from unfavorable comparisons with
premorbid functioning; (3) to increase awareness and effective¬
ness of existing strategies for regulating emotions and manag¬
ing the effects of the three processes listed above; (4) to learn
new regulation strategies; (5) to increase awareness of condi¬
tions under which breakdowns in emotional self-regulation are
likely to occur, anticipate potentially problematic situations,
and plan accordingly; and (6) to increase confidence in the
capacity for emotional self-management.
182 Langenbahn et al.

Modules and Exercises

Exercises during the course of SRGs have been divided into

modules. In the first module, the concept of self-regulation
is introduced and defined. Examples of breakdowns in self¬
regulation are then elicited from group members. The group
leaders use one of the situations provided by members to intro¬
duce the method of analyzing the breakdowns. A structured
worksheet is employed, on which group members record spe¬
cific elements of the process by which breakdowns in self-regu¬
lation occur, including probable situations, people, and
internal stressors (illness, lack of sleep, etc.) that trigger the
overly emotional reaction; the initial reaction of the group
member (feelings, thoughts, behaviors, and physical sensa¬
tions); and the earliest physical, behavioral, and emotional
signs of the reaction sequence occurring. In later sessions of
module 1, group members are taught to analyze their own
breakdowns on the worksheets. Eventually they are given home¬
work involving continued use of the worksheet between ses¬
sions to refine awareness of patterns of vulnerability and
response, as well as to begin to become aware of times when the
resolution of the self-regulation situation is more successful.
Successful strategies become the focus of the second mod¬
ule, as each group member participates in a “solution focused”
interview (de Shazer, 1985; de Shazer et al., 1986) about im¬
provements in functioning that already have occurred, strate¬
gies or conditions which have contributed to those
improvements, and coping strategies for problems that have
not shown improvement. As a result of this interview, group
members learn that not all of their methods of managing emo¬
tional expression are failures, thus counteracting the “all-or-
nothing” mental set. In addition, participants learn to distin¬
guish and appreciate their existing strategies that are successful
or partially successful and to utilize such successes as a basis
for developing a more consistent and deliberate approach to
difficulties with self-regulation.
Once group members have both a general sense of their
pattern of difficulties with self-regulation and some beginning
ideas of strategies that may be helpful, role-play exercises are
 Group Psychotherapy 183

introduced in module 3. Role plays use both hypothetical situa¬

tions generated by the group leader (s) and personal examples
of loss of self-regulation brought in by group members as part
of an ongoing “homework” assignment. One group member
enacts the problem situation, using other members as the “sup¬
porting cast.” After the initial depiction of the situation, all
group members brainstorm alternative ways of responding to
and managing the situation. These alternatives are then en¬
acted by the “actors,” with breaks in the action to evaluate
effectiveness and assess the impact of behavioral changes on
internal experience. The beginnings of a list of coping strate¬
gies is generated by the group in module 3. Group members
use it to suggest alternate behaviors to the actors in the role
plays. By processing the action in the role play and postulating
other options from the list, members become more competent
at analyzing their own behaviors. The competence is reinforced
by requiring that group members use between session work¬
sheets to track their self-regulation patterns and the successful
implementation of new strategies.
The sequence described above (increase awareness of
problems and helpful strategies, brainstorm and role play alter¬
native strategies, implement strategies, and report back) is re¬
peated with a more refined focus on specific problems with:
(1) emotional disinhibition (module 4); (2) vulnerability to
the effects of environmental and physiological conditions (such
as overscheduling combined with excessive fatigue) (module
5); and (3) disparaging self-talk resulting from unfavorable
comparisons with premorbid functioning that results in cata¬
strophic reactions or emotional shut-down (module 6).
In the final module of the group (module 7), lists of strate¬
gies addressing problems in each of the three focus areas are
further detailed and then distributed to each group member.
Problems of emotional disinhibition are addressed by a variety
of strategies. The early “signals” of reaction patterns are identi¬
fied (e.g., internal cues or reactions from others indicative of
overstepping interpersonal bounds). Members learn to inter¬
rupt the pattern by calling for or taking a break in the action
(e.g., using calming self-talk, taking deep breaths, counting to
10, tabling the discussion of a provocative situation by politely
184 Langenbahn et al.

leaving the scene). These techniques allow the individual to

shut down emotional processing temporarily in order to stop
escalation of emotional reactivity (e.g., “This is a very im¬
portant topic, but I just can’t think about it clearly right
now—let’s pick this up later’’).
Problems related to increased vulnerability to environmen¬
tal and physiological conditions are addressed by first identi¬
fying problematic conditions (e.g., too much activity scheduled
for one day; overstimulating environments such crowds or
noise; touchy topics of discussion among family members or
friends; challenges to one’s performance in a work context in
light of disability; injury-related symptoms such as fatigue,
headaches, and dizziness). Strategies for coping with such vul¬
nerabilities include altering expectations about one’s capacity
to manage energy and time demands (e.g., reducing frequency
of visits with difficult family members, learning to shop for gro¬
ceries during quiet hours to avoid overstimulation). In addi¬
tion, such methods are employed as letting others know about
limitations, and asking for alterations in conditions which
might make the environment more conducive to effective func¬
tioning. For example, an important meeting might be sched¬
uled to allow for breaks to accommodate reduced endurance.
Finally, strategies for addressing disparaging self-talk in¬
clude noticing, analyzing, and replacing negative and self-
defeating internal dialogue or self-statements (Burns, 1980).
Disparaging self-statements are supplanted with positive, self¬
enhancing self-statements; “all-or-nothing’’ thinking with
“shades of gray,” and comparisons between now and “how I
was before the injury” to comparisons between now and “how
I was just after I was injured.” For example, a person who tells
herself that “I can’t think as quickly as I used to, so I’m really
worthless and useless” practices telling herself instead that,
“Even though I can’t do things like I used to, I still have some¬
thing to contribute.”
Group members leave the SRG with a printed copy of their
group’s “Group-Generated Strategies for Self-Regulation.” As
nearly all the strategies in the list are generated in discussion
with group members, the use of a written “official” document
 Group Psychotherapy 185

serves as a powerful boost to confidence in one’s ongoing abil¬

ity to notice, analyze, and address continuing problems that
may emerge. The list also provides the brain injured individual
with a tangible reminder of the newly learned skills and a
bridge between the group and everyday life.

ANGER MANAGEMENT GROUPS2

Problems in Anger Management

Anger Management Groups (AMGs) were designed in response

to family and staff reports of marked difficulties with temper
control exhibited by some individuals treated on the NPS, e.g.,
episodes of intense emotionality, shouting, or verbal or physi¬
cal aggression. The AMGs address specific problems of anger
management that are more severe than those targeted in the
Self-Regulation Groups. Such difficulties are frequent in the
clinical experience of therapists treating patients with acquired
brain injury, especially those with underlying cognitive prob¬
lems associated with injury to the frontal lobes (Mateer & Wil¬
liams, 1991).
The AMGs are similar to Self-Regulation Groups in that
their purpose is to increase cognitive control over emotional
processes, but differ in that they are open to persons with a
lower level of basic skill and cognitive competence, and have a
more specialized focus on emotional and behavioral control of
anger. Episodes of loss of anger control are related to the same
brain injury-related factors as those interfering with emotional
self-regulation (e.g., emotional disinhibition, cognitive impair¬
ments such as reduced tolerance for environmental stimula¬
tion, loss of ability to maintain a larger perspective or take the
perspective of another person, reduced stamina). Such epi¬
sodes are compounded by other factors including reduced cog¬
nitive ability (either postinjury or premorbid) and lower
premorbid self-regulation skills related to personality or envi¬
ronmental learning.
2 Anger Management Groups were developed and conducted by Dvorah Simon,
Ph.D., Leo J. Shea, III, Ph.D., & Edward Barnowski, Ph.D.
186 Langenbahn et al.

Structure and Content of Anger Management

Groups

The AMGs are similar in content to Self-Regulation Groups

with some modifications based upon differences in the popula¬
tions, as described above. The basic format of the Anger Man¬
agement Group is the same as for all NPS groups, using
agendas, structured exercises, notetaking, and homework.
Change is implemented by means of discussion, solution-
focused interviewing, role plays, and structured worksheets to
elicit greater awareness and utilization of effective coping strat¬
egies. To accommodate the lower levels of cognitive compe¬
tence of members of the AMG, the group proceeds at a slower
pace, with more concrete discussions, more repetition, and em¬
phasis on careful notetaking. Key points are written on a black¬
board by the group leader, and the group leader (s)
distribute (s) printed copies of notes from the previous session.
In addition to differences in cognitive competence, many
AMG members differ from members of a typical Self-Regula¬
tion Group (for whom learning emotional self-regulation often
entails recovery of previous social skills) in that they report a
greater premorbid tolerance for their own aggressive behaviors.
For example, some members, coming from a “street” culture,
have argued that unless they can demonstrate the ability to
“defend oneself” when insulted, they will be vulnerable to
abuse. Others in this group display what appears to be a lifelong
personality style of “not taking bulls-1” from anyone. De¬
spite an outwardly tough stance, however, AMG members are
often quite sensitive about perceived insults to their self-worth.
Issues of self-worth are compounded by deficits in abstract rea¬
soning that lead to an all-or-nothing, black-or-white thinking
style, e.g., “If I have a deficit, then I am totally defective.”
To address these concerns, the structure of the group is
modified somewhat from the SRG to include a preliminary
component in which the philosophy of response to insult is
examined. To the polarity of passivity versus aggression in the
face of insult or frustration is added the option of healthy asser¬
tion. Thus the AMG is more psychoeducational in tone than is
 Group Psychotherapy 187

the SRG. In addition, consequences of uncontrolled anger-

based behaviors are explored in a nonjudgmental manner. For
example, in answer to the question, “Why is hitting someone
not always the best idea?” group members might respond, not
with an abstract concept about sublimation being preferable to
actions that might harm others, but with the idea that, if
caught, such behaviors could lead to undesirable conse¬
quences. Group leaders model a respectful tone by accepting
such reasoning with gentle suggestions of alternative ways of
looking at things, but offer no argument or judgment.
Once the concept of the advisability of alternatives to ag¬
gression is established, solution-focused interviewing, work¬
sheets, and role plays are used with a special focus on eliciting
strategies of self-calming. Each group member develops a per¬
sonal list of effective strategies, such as “listening to music
when upset” or “thinking about my goals and how what I do
might get me there.” Issues of self-worth are addressed by pay¬
ing even more attention than usual to acknowledging group
members’ contributions and to structuring opportunities for
group members to give each other statements of appreciation
and support. Group members’ self-calming strategies lists are
repeatedly reviewed and praised.
The final segment of the group involves review and discus¬
sion of anger incidents in the group members’ lives. As in the
SRG, group members brainstorm and role play alternative strat¬
egies for handling the described event, relying on their per¬
sonal lists for suggestions. Group members reporting successful
application of strategies receive positive feedback and support.

SUMMARY/CONCLUSIONS

We have discussed the use of group psychotherapeutic treat¬

ment with a brain injured population. The three types of
groups described do not exhaust the possibilities for use of this
treatment format. Other groups can be conceptualized dealing
with specific psychosocial problem areas, e.g., social problems
at home or in the work setting, difficulties with social project
188 Langenbahn et al.

planning, role changes in the family, and philosophical or spiri¬

tual questions about self-concept following the injury.
The many well-known benefits of group treatment apply
as well to this population. The important principle in planning
such groups is that due to the neuropsychological effects associ¬
ated with the brain injury, and the consequent problems with
psychological adaptation and social skills, these benefits do not
occur without explicit planning of group content and format
and guidance from the group leader. Groups for individuals
with brain injury must be designed to elicit successful group
participation and generalization of group gains. With such
structure, the therapeutic process for individuals with brain
injury can take useful and meaningful form.

REFERENCES

Ben-Yishay, Y., & Diller, L. (1981). Rehabilitation of cognitive and

perceptual deficits in people with traumatic brain damage. Inter¬
national Journal of Rehabilitation Research, 4, 2Q8-210.
Ben-Yishay, Y., Diller, L., Gerstman, L., & Garden, W. (1970). Rela¬
tionship between initial competence and ability to profit from
cues in brain damaged individuals. Journal of Abnormal Psychology,
78, 17-25.
Burns, D. D. (1980). Feeling good: The new mood therapy. New York:
Morrow.
Deaton, A. V. (1991). Group interventions for cognitive rehabilita¬
tion: Increasing the challenges. In J. S. Kreutzer & P. H. Wehman
(Eds.), Cognitive rehabilitation for persons with traumatic brain in¬
jury: A functional approach (pp. 201-214). Baltimore: Paul
Brooks.
de Shazer, S. (1985). Keys to solution in brief therapy. New York:
Norton.
de Shazer, S., Berg, I. K., Lipchik, E., Nunnaly, E., Molnar, A., Gin¬
grich, W., & Weiner-Davis, M. (1986). Brief therapy: Focused
solution development. Family Process, 25, 207-222.
Langer, K. G. (1992). Psychotherapy with the neuropsychologically-
impaired adult. American Journal of Psychotherapy, 46, 620-639.
Lewis, L., 8c Rosenberg, S. J. (1990). Psychoanalytic psychotherapy
with brain-injured adult psychiatric patients. Journal of Nervous
and Mental Disease, 178, 69-77.
 Group Psychotherapy 189

Mateer, C. A., & Williams, D. (1991). Management of psychosocial

and behavior problems in cognitive rehabilitation. In J. S. Kreut-
zer 8c P. H. Wehman (Eds.), Cognitive rehabilitation for persons
with traumatic brain injury: A functional approach (pp. 117-126).
Baltimore: Paul Brooks.
Miller, L. (1993). Psychotherapy of the brain-injured patient: Reclaiming
the shattered self New York: Norton.
Prigatano, G. P., Fordyce, D. J., Zeiner, H. K., Roueche, F. R., Pep¬
ping, M., & Wood, B. C. (Eds.). (1986). Neuropsychological rehabil¬
itation after brain injury. Baltimore: Johns Hopkins University
Press.
Prigatano, G. P., 8c Schacter, D. L. (1991). Awareness of deficit after
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Sherr, R. L., & Langenbahn, D. M. (1992). An approach to large-scale
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417-426.
Weiner, I. B. (1966). Psychodiagnosis in schizophrenia. New York:
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Yalom, I. D. (1985). The theory and practice of group psychotherapy (3rd
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 '

>
10.

Psychotherapeutic Issues in Treating

Family Members

Frank J. Padrone, Ph.D.

Advances in medical technology have led to increased survival

from brain injury due either to traumatic brain injury (TBI),
cerebral vascular accident (stroke), or surgical interventions,
such as those for brain tumor.
Rehabilitation services for people with neuropsychological
disabilities have been steadily increasing over the past few de¬
cades. Sophisticated neuropsychological diagnosis and treat¬
ment are now commonplace in rehabilitation (Diller, 1987).
The process of psychological adjustment to physical disability
has been well described by Janis and Leventhal (1965), Langer
(1994), and McDaniel (1976), as have the approaches to family
therapy directed at the adjustment process of the family group
with a member who has a physical disability (Parry & Young,
1978; Whiting, Terry, & Strom-Henrikson, 1984).
The increased survival rate amongst the TBI/stroke popu¬
lation has led to an escalation in the number of family members
who suffer stress as a result. Many rehabilitation professionals
feel that psychological intervention with family members is es¬
sential (Prigatano, 1987). Since this need is not often fulfilled,

191
192 Frank J. Padrone

many family members are referred increasingly outside the re¬

habilitation system for individual psychotherapy to help them
cope with the situation.
The stress experienced by the family in response to physi¬
cal disability with neuropsychological impairment may be
somewhat different from that experienced in response to a
disability without a neuropsychological component. Although
stress subsequent to loss, family disruption, dependence, and
practical concerns are similar, the challenge to cope with conse¬
quences of neuropsychological impairment presents relatively
unique considerations. The possibility of altered personality
and impaired cognitive skills is not so readily understood by
most people as are the physical changes that pose a challenge
to adjustment. Such characteristics need to be addressed in any
comprehensive treatment regimen.

DISABILITY AND THE FAMILY

Family members struggle with issues at once similar to and

different from those of the person with the disability. The focus
here is on issues to be considered when a relative of a person
with a neuropsychological impairment is seen in psychotherapy
with the goal of helping them to cope better with the stress.
The age of the person with the disability most probably assumes
a bimodal distribution, since the disabilities represented form
two major groups: Traumatic brain injury occurs primarily be¬
low age 35 (Williamson, Scott, & Adams, 1996), and stroke
(CVA) occurs primarily over age 65, although 20% are below
age 65 (Binder, Howieson, & Coull, 1987).
The family member as patient may present for treatment
with feelings of confusion, depression, anxiety, guilt, and/or
desperation. If the onset of the disability has been recent, he
or she may be feeling overwhelmed and may be in crisis. Family
members in need of treatment may not have had the opportu¬
nity or necessary support to deal with their own reactions, since
the focus of attention has been primarily on the person who
suffered the disability. By necessity the family members have
 Treating Family Members 193

been the responsible ones. Often having been encouraged to

become a member of the rehabilitation team, the family mem¬
ber has shouldered a disproportionate share of the burden.
The natural reaction of denial may foster this state in which
the family member has not yet processed the event emotionally.
The adjustment process for those who suffer traumatic dis¬
abilities includes familiar stages (McDaniel, 1976). Reactions
to major losses, such as those occurring with disability, are simi¬
lar to those posited by Ktibler-Ross (1970) in her work on the
knowledge of one’s own impending death. Denial, anger, de¬
pression, and adjustment are the reactions that are now famil¬
iar in the field. It may be said that family members experience
a similar loss process, the intensity of which is commensurate
with the relative meaning of the disability for them and the
relationship to the person with the disability (Padrone, 1994).
Whether the therapeutic intervention targets the individ¬
ual family member, the entire family, or some subunit, familiar¬
ity with family therapy concepts will be useful in the work with
family members of those with disabilities. In family systems ther¬
apy the focus of treatment is the family unit rather than the
individual. It is necessary for this unit to accommodate to major
changes in the life cycle for optimal functioning (Minuchin,
1974). When changes, such as a birth, a death, or a disability
occur, adaptation within the family unit is required. The bal¬
ance within the family system has been altered by a tragedy
with which the family and its individual members must contend.
The structural analytic approach to family therapy utilizes
an individual and systems perspective (Kantor, 1983) that fo¬
cuses on perceptions held by individuals and the family group
in the present and past. This approach advocates that members
have developed views of inner and outer reality that comprise
their anticipations and expectations of others, and enhance
communication. These views provide the foundation for inti¬
macy, since through them the members can share a common
view of reality. Such views when applied to the self in connec¬
tion to others are the ones we hold about relationships. If some
event leads to conflict between the views of any two people, an
impediment to family growth develops, so that the family may
become blocked in the adaptation process (Munro, 1985). The
194 Frank J. Padrone

process of adjustment may be blocked by a number of consider¬

ations, such as personality characteristics or situational factors.
For example, those who tend to cope by blaming others, or
even themselves, may become stuck in the process, while issues
such as quality of the premorbid relationship, the extent of
dependence, or frustrations with helping organizations in the
community also may be an impediment. In some instances the
disability may serve as a scapegoat, when other problems exist
in the relationship which would produce significant anxiety if
they were to be addressed.
Using a systems perspective Turnbull and Turnbull (1990)
examine the impact of disability on the family by considering
(1) the family; (2) the disability; (3) individuals within the fam¬
ily; and (4) the network of relationships (subsystems) that exist
within the family. For example, the extent of disability and the
coping styles of family members influence both the experience
of the disability and the adjustment process. All of the relation¬
ships within the family will be impacted by the disability. The
integration of this change will be influenced by the extent to
which the family does not become chaotic in i,ts function, but
is flexible, and does not rigidly hold on to former ways of man¬
aging. If the family can remain cohesive and not become en¬
meshed in the details of the disability, while trying to support
the person with the disability, the probability of a satisfactory
adjustment is enhanced. Family values and cultures are also
seen to influence adjustment. For example, cultural differences
in attitude toward disability, changing family roles, or issues
regarding dependence have significant impact on adjustment.
The general conceptualizations regarding disability, family
systems, and interventions can be useful only when considering
the specific context of the sequelae of brain injury. Neuropsy¬
chological impairments present challenges to adjustment, not
only because they are often major losses with which the family
must cope, but also by their very nature. The losses are not so
easily understood as are physical losses. For example, it takes a
relatively short time for a family member to realize many of
the physical limitations consequent to a T10 paraplegia or
hemiplegia with the aid of brief instruction and imagination.
The same cannot be said for the consequences of a moderate
 Treating Family Members 195

attention deficit or a significant visual field neglect. In addition,

cognitive and personality changes are experienced as yielding
a different person, which is not the case in a T10 paraplegia.
Just as adjustment to physical changes is influenced by different
cultural systems and personal psychological issues, so too is
adjustment to neuropsychological changes.

THE PATIENT

Since psychotherapy in some form is increasingly recom¬

mended for relatives of people with disability secondary to
brain injury, especially following TBI (Prigatano, 1987), and
also after stroke (Binder et al., 1987), the identification of the
patient and the locus of treatment is less predictable. Regard¬
less, many of the ongoing processes described above are
brought into treatment. The patient may be struggling to cope
with the realization of such significant impairments in their
loved one that he or she is overwhelmed, especially if there is
a lack of understanding of the neuropsychological elements.
He or she may be attempting to deal with the disruptive impact
of the disability on the relationship, current family functioning,
issues regarding extended family, lack of resources, and inte¬
gration with extended family, friends, and the community. If
the patient is also the caregiver, there are additional sources
of stress.
Given the enormity of the above stressors, the patient’s
emotional reactions nonetheless can be easily overlooked until
they have become quite intense. If the patient is referred for
treatment while in the initial throes of distress, the therapeutic
management of reactions to such trauma is not an unusual task
for the therapist. The patient may be intensely experiencing
some stage of the coping process, e.g., denial, anger, or griev¬
ing. Although there is a danger in becoming absorbed in the
practical aspects of the disability and its consequences, knowl¬
edge of the neuropsychological impairment is necessary for
therapist and patient. In the process of psychotherapy it is not
unusual for a patient to educate the therapist about some area
196 Frank J. Padrone

of experience with which the therapist has little familiarity. In

this situation, however, the patient is in the process of learning
the information not only for practical reasons, but also to aid in
emotional adjustment. The realization that a spouse no longer
remembers key events shared in the past, or is having difficulty
concentrating sufficiently to carry on more than a brief conver¬
sation, is a major loss to be processed. Within the context of
the patient’s ability to cope, the therapist may need to advocate
for education, since resistance to such information may often
represent denial of painful realities. Since the possibility exists
that the patient’s more intense feelings may have been labeled
as inappropriate in quality or degree by others, support for
such feelings may be indicated. For example, there may have
been open or subtle disapproval of the patient’s angry feelings,
so that support for such a reaction while monitoring its inten¬
sity may be necessary. In time, however, the use of anger as a
defense against the more painful feelings of grieving may also
need to be explored.
In the early phase of treatment the patient may experience
considerable guilt. It may be difficult to tolerate the not uncom¬
mon wish to flee from stress, responsibilities, and the feelings
of anger or disgust over major physical changes. The experi¬
ence of such repressed feelings can produce considerable anxi¬
ety or conflict, which may be relieved only when the patient
has been able to make a distinction between the disability per
se and the person with it. For example, one may be angry about
another’s behavior and the injury that has caused it, without
being angry at the person with the disability. In like manner,
one may wish to be free of the responsibilities, but not necessar¬
ily the person associated with them.
Although “acceptance” of the disability (Kubler-Ross,
1970) is often seen as an important goal of treatment (Vargo,
1979), the connotation that the person somehow has agreed
to this terrible state of affairs leads to resentment and resistance
in many. The advice to “accept reality” during the struggle for
adjustment may have an unfortunate connotation (Padrone,
1994). In order to deal with such resistance it may be helpful
to indicate that painful realities can be acknowledged. They
 Treating Family Members 197

can be integrated into the psyche and permitted to take their

place in reality without one having to like them.
Feelings of shame may develop in reaction to having a
family member who is disabled and different. Such feelings,
when coupled with the inability of the person with the disability
to fully participate socially, may lead to isolation. The restric¬
tion or elimination of many family social events and activities
(Lezak, 1988) can lead to resentment and alienation.

THE TREATMENT

Treatment interventions with such patients should be multidi¬

mensional. Rosenthal (1984) has recommended a four-part
program with families of those with brain injury that includes
education, counseling, therapy, and support groups. Extent of
family involvement is dependent on variations in disability and
in family function. It has been our experience that a similar
four-layered approach is often indicated: education, family in¬
tervention, direct psychotherapy for a family member(s), and
referral to community resources, such as a support group.
The educational layer evolves from the fact that in addition
to the physical and emotional components of the disability,
neuropsychological changes are not easily comprehended.
Families may benefit from information provided by publica¬
tions such as Stroke: Why Do They Behave That Way ? (Fowler 8c
Fordyce, 1974).
Without information regarding the consequences of brain
injury the family may attempt to explain their loved one s be¬
havior in terms with which they are familiar that can be primar¬
ily physical, psychological, or even moralistic. In addition to
the conflict that usually arises from such misinterpretations,
the patient is deprived of the opportunity for the use of better
management strategies, but also of the necessary emotional
processing of a loss. Brief outlines of the possible changes fol¬
lowing brain injury may be presented to the family member(s)
with some discussion of the factors that are relevant for them.
When necessary education is not provided, family mem¬
bers can fall victim to misinterpretations similar to those that
follow:
198 Frank J. Padrone

Impairment in arousal may be seen as depression or lack of moti¬

vation.
Impairment of attention may be labeled as disinterest, inconsider¬
ateness, or willfulness.
Memory impairments may be misinterpreted as resistance, denial,
or confusion.
Impulsivity may be seen as merely being “in a hurry” or stub¬
bornly doing it their way.
Diminished ability to initiate may be seen as depression, depen¬
dence, or laziness.

Family members often believe that those with aphasia un¬

derstand more than they actually do, and when the impairment
is misinterpreted, they are thought to be confused, disoriented,
or uncooperative and hostile.
The misreading of an impaired ability to abstract may be
seen as stubbornness, rather than rigidity of thought, or pro¬
crastination rather than the inability to plan ahead.
Problems due to perceptual losses may be interpreted as
poor motivation or confusion and disorientation.
A change in the ability to express and control affect may be
misinterpreted as solely depression or willfulness.
A lack of awareness of disability may be misinterpreted as
solely due to emotionally based denial, when in fact neurologi¬
cal and neuropsychological factors may be at work.

Family Intervention

Lezak (1986) suggests that discussions should be held with fam¬

ily members concerning the following:

1. Feelings of anger, frustration, and sorrow should be identi¬

fied as natural and to be expected.
2. Caretakers must not minimize their own needs.
3. Caretakers should rely on their own conscience and judg¬
ment to deal with conflicts.
4. Role changes that occur may be distressing to everyone.
 Treating Family Members 199

5. Family members should avoid the use of a guilt model for

not doing more, but rather weigh all aspects of the situation,
including the eventual price to be paid if other decisions
are made.
6. When the welfare of dependent children is at stake, the
conflict arising from divided loyalties should be acknowl¬
edged and responsibilities should be prioritized.

Family intervention can utilize an educational and coun¬

seling approach, or include active family therapy.
A number of factors need to be considered in the third
layer, psychotherapy with these patients including initiation of
therapy; severity of disability; onset issues; stage of rehabilita¬
tion; relationship to the disabled; life stage; meaning of disabil¬
ity; preexisting relationship; dynamics of relationship; and
countertransference.

Initiation of Therapy

Although some rehabilitation programs provide routine inter¬

vention for all families of both head injury and stroke patients,
a significant portion do not. In the former group families may
be seen for education and some counseling, and in the latter
group such interventions are provided only when family mem¬
bers are referred for psychotherapy after significant distress is
perceived. Even where education and counseling may be rou¬
tine, the focus appears to be on the person with the disability,
and not on the difficulties of the family member, as is usually
the context for individual psychotherapy. In this regard the
patient may perceive the atmosphere to be one in which the
person with the disability should be the “real patient,” and he
or she is not the focus of treatment. Such a perception may
contribute to an experience in which the therapist is perceived
as having split loyalties or “an agenda,” as in our experience
many family members have commented.
Although unfortunately at times this perception may be
accurate, it also can reflect feelings of guilt or resistance in the
family member, when he or she experiences their own treat¬
ment as a shift in focus of attention from the person with the
200 Frank J. Padrone

disability. The patient can feel undeserving of such attention,

especially since he or she remains unscathed.
Attention to the ordeal of the family member also can lead
to feelings of anxiety. Such anxiety can stem from a growing
awareness of suppressed, ambivalent feelings regarding the situ¬
ation, the disability, and the person with the disability. For
example, the disability may have resulted from a life-threaten¬
ing situation, leading to thoughts as to whether the person with
the disability might have been better off if he or she had not
survived. Such thoughts are not uncommon, as are the concom¬
itant feelings of guilt and anger that often underlie them.
The severity of disability both physically and neuropsycho-
logically is directly proportionate to the extent of loss and
change in the life of the family member. Physical dependence
and cognitive dependence clearly produce different effects
which are not identical for different families or even family
members. In the domain of everyday labor, who takes out the
trash, does the cooking and shopping, balances the checkbook,
provides child care, and produces the bulk of family income
may be differentially impacted contingent on the preexisting
distribution of these responsibilities.
Lezak (1988) suggests that there is a direct correlation
between the extent of neuropsychological deficits and the im¬
pact on family members, which can be crushing to a relation¬
ship. The stress from changes in roles, finances, and social
status are exacerbated by the common social isolation and loss
of emotional supports to these families.
It has been suggested that the presence of any of the fol¬
lowing three factors places families at high risk in terms of
eventual adjustment: (1) premorbid history of significant fam¬
ily problems, such as marital conflict or alcoholism; (2) an inor¬
dinately long period of denial; or (3) persistent, severe
cognitive or physical impairments (Rosenthal, 1984).
Contingent on severity of disability the effect on social
lives can range from totally destroyed to minimally changed.
Levels of companionship, partnership, and intimacy can also
be impacted in varying degrees. Once again premorbid life¬
styles and values must be taken into account when considering
the degree of loss.
 Treating Family Members 201

There can be a sudden increase in the workload, leading

to fatigue and resentment. Family members may become care¬
takers and experience themselves in a parental role, while the
person with the disability becomes infantilized. Significant
physical or cognitive dependence can lead patients to consider
the person with the disability as inferior. Such a perception is
supported by a comparative value system in societies (Dembo,
Leviton, & Wright, 1956), rather than a system that values peo¬
ple’s assets, regardless of how they measure up to others.
As noted earlier, if the family has not been educated re¬
garding neuropsychological changes, they can misinterpret
such changes or their consequences, leading to conflict and
interminable frustration. Personality changes are common with
significant brain injury, especially in TBI, so that the patient
can now experience the family member with the disability as
no longer the same person. Not only are aspects of the person
with the disability lost, leaving patients feeling isolated and
abandoned, but they can be replaced by irritability, impulsivity,
socially inappropriate behavior, diminished sensitivity to oth¬
ers, and affective disturbances in varying degrees (Prigatano,
1987). Exacerbating the situation is the fact that the person
with the disability may not be aware of many of these diffi¬
culties.
Issues associated with the onset of the disability can influ¬
ence significantly the adjustment process for the patient. Does
the patient hold the person responsible for the disability due
to some imprudent action, or does he or she in some way hold
him- or herself responsible for the disability? For example, it
may have followed a heated argument or the patient may have
been driving the car in which the person with the disability was
injured. Clearly such issues can influence the patient’s feelings
and adjustment.

In the early stage of rehabilitation the family member may

be struggling to cope with the initial crisis, the acute symptoms
of neuropsychological impairment, and adjustment reactions
to loss, in addition to the distress of the person with the disabil¬
ity. After transition to the outpatient phase of rehabilitation
202 Frank J. Padrone

family members may be struggling openly with their own de¬

pression and anxiety, while hoping that specific abilities will be
recovered. As rehabilitation comes to an end, treatment of the
disability is no longer the focus, but the need to live with it is
at hand. “The family and the person with the disability are now
more on their own dealing with the day-to-day problems of the
disability, its chronicity, and its impact on all aspects of life”
(Padrone, 1994, p. 201).
Clearly during this period the patient, the person with the
disability, and the entire family unit are progressing through a
mourning process. It has been suggested by Leber and Jenkins
(1996) that since the person with the disability has survived as
a new and different individual, the ritual is incomplete. The
people involved are mourning abilities and qualities of a per¬
son, while adjusting to a person who behaves differently.
The relationship to the disabled defines many of the
changes with which the patient will contend. A spouse, child,
parent, or sibling vn\\ be coping with different issues.
The spouse of the person with the disability has lost much
of the partner whom he or she knew. Role changes, with their
concomitant threats to ego and value systems are common.
Changes in sex lives are also common, including matters of
intimacy and privacy, especially if attendant help in the home
is required.
A significant percentage of couples report that their sexual
activity had ceased following a stroke (Ducharme, 1987). In
addition, in TBI there also may be major sexual changes rang¬
es from disinhibition to loss of interest. There are many anec¬
dotal reports and some surveys on sexual activity following
neuropsychological changes, but as Lezak suggests (as cited in
Leber and Jenkins, 1996) the cognitive and behavioral sequelae
of brain injury explain most of the difficulties, even weighing
the limitations from the physical changes.
Sexuality is certainly one of the central components in a
couple s relationship, and should be a significant part of the
treatment. It has been observed in Western cultures that there
may be an undue emphasis on the role of sexual intercourse
in sexual intimacy and satisfaction (Glass and Padrone, 1978).
 Treating Family Members 203

Approaches to preserving these aspects of the relationship with¬

out sexual intercourse should be explored where indicated. In
order to accomplish such goals, the treatment will probably
need to include elements of the grieving process to address
this important issue. When such issues are openly addressed in
the therapy, the patient may be obliged to deal with his or her
own sexuality. Ignoring such issues increases the probability of
long-term frustrations and a lack of intimacy. It should be
noted that there may be a tendency by therapists who are not
experienced in this area to omit this important topic.
The patient who is the parent may be truly ambivalent in
the face of enormous responsibility. There may be resentment
regarding the loss of an expected future, and anger if there is
a question of imprudent actions contributing to the disability.
The reawakening of conflicts from the earlier relationship leads
to feelings that are commonly laced with guilt.
The patient who is a child of someone with a disability can
be affected even more by the previous relationship, including
unresolved needs, past grievances, conflicts over role reversals,
and the keen awareness of issues of mortality.
The patient who is a sibling may be distressed during
younger years due to an awakening of issues of vulnerability
and possibly survivor guilt. The history of the relationship be¬
tween siblings can be fertile ground for conflicted feelings,
including anger over this family disruption and anxiety regard¬
ing future responsibilities.
Although a disability strikes at a specific period of life, it
does not remain static but is dynamic, since the life stages con¬
tinue to change (Williams & Kay, 1991). Although the stage of
onset may carry with it its own tasks with which it may interact
(Turnbull & Turnbull, 1990), there also will be an interaction
with all of the remaining stages for each of the family members
and the entire family unit.
The meaning of the disability significantly influences the
effect it has on the patient from two perspectives: (1) the appar¬
ent meaning which derives from the obvious practical conse¬
quences, e.g., physical dependence, workload, or loss of a
companion whom one knew; and (2) the inner or psychologi¬
cal meaning which derives from its psychodynamic influences.
204 Frank J. Padrone

Does the change in the person with the disability present a

threat to the patient in ego terms? Are well-developed coping
skills or defensive strategies that were used to negotiate life
rendered useless, thereby disrupting psychic equilibrium? Very
often these are the issues that need to be addressed when treat¬
ing the patient.
In addition, the disability of the loved one may lead the
patient to experience certain inner conflicts, such as exposing
repressed personality characteristics, e.g., unresolved depen¬
dency issues or exposing personality difficulties, which compro¬
mise functioning when challenged by the presence of the
disability.
The preexisting relationship includes elements that are
generally considered assets as well as those considered liabili¬
ties. Preexisting conflicts in the relationship can be exacer¬
bated by the new demands and stress imposed by the disability.
“Each family . . . has weaknesses that, given a particular trig¬
gering event or circumstance, can lead to serious family dys¬
function” (Parry and Young, 1978, p. 64). Grievances or
dissatisfactions that had been dormant or tolerated can limit
the patient’s capacity to extend him- or herself during this
period, or additional demands can disrupt a previous delicate
balance. It may be said that the quality of the relationship be¬
tween any two people contributes to its ability to withstand
stress. Conversely the poorer the relationship the more vulnera¬
ble it may be. It is equally important to note the impact that
the stress of disability has on the dynamic balance of the rela¬
tionship.
The balance of the respective psychodynamics of the per¬
sons involved, and how that balance is altered by the disability,
significantly influences the impact it will have on the relation¬
ship (Padrone, 1994). The disability may negate the primary
supports of the relationship or it may result in some intolerable
conflict either within one of the parties or between them.
Clearly if the positive supports of a relationship are removed,
the stress of the disability may be more difficult to tolerate.
If certain critical ego “needs” that had been supplied in the
relationship are now absent, even a relatively mild disability
 Treating Family Members 205

can be disastrous to the relationship, especially if issues of self¬

esteem are at stake. For example, when characteristics of a
partner that have maintained the self-esteem of the other are
eliminated by even a mild neuropsychological impairment, the
relationship may be in jeopardy.
Although the loss of any ability, such as earning a living
or being socially active, is stressful, it appears to be the meaning
of that loss at multiple levels that is critical. Not only the practi¬
cal and emotional consequences need to be examined with the
patient, but also the interpersonal, intrapsychic, and system
(family) influences may need consideration. The following ex¬
ample may demonstrate more clearly this multidimensional
perspective:

[I] f a member of a couple is more dependent as a result of a

(neuropsychological) disability. . . for the able-bodied person
(patient) there is probably more work at a practical level, which
(can be) . . . disruptive and require burdensome responsibility.
Personally, (the patient) will need to experience the griev¬
ing process regarding all areas of living impacted by this loss,
e.g., the patient’s image of the partner with the disability and
what he or she had been able to do, the inability to attend
certain functions together (inaccessibility), the inability to
dance or make love. . . .
Interpersonally, role reversals . . . can be burdensome,
stressful, (and) produce conflict due to a clash with personal
values or cultural beliefs. . . . Within the family unit changes in
responsibilities and style of managing, e.g., disciplining young
children will have ripple effects. . . .
Intrapsychically if a concealed dependence on the part of
the patient can no longer be satisfied . . . not only is the frustra¬
tion and . . . angry depression a problem, but the experi¬
ence ... of the repressed need, (can) result in anxiety and
defensive irritability. (Padrone, 1994, p. 203)

The topic of countertransference is addressed in detail in

another chapter, so that the following comments are limited
to those issues that are relevant to the treatment of family mem¬
bers of those with neuropsychological impairment. Although
countertransference in psychotherapy is commonly addressed
206 Frank J. Padrone

in the training of dynamic psychotherapists, the effect on the

therapist of the emotionally laden issues of mortality, physical
and neuropsychological disability, and sexuality and disability
are not commonly considered. Furthermore, given the value
that is probably placed on cognitive function by those who have
pursued graduate education, the area of neuropsychological
impairment can be especially vulnerable to unexplored count-
ertransferential reactions.
When treating a family member within the rehabilitation
system, there is the possibility of identification by the therapist
with the needs of the person with the disability, who may be
seen as the “primary patient” in that setting. Such identifica¬
tion limits choices for the family member, and often limits a
full exploration of the problems. Conversely, when a family
member is treated outside of the rehabilitation system, the un¬
recognized countertransference to neuropsychological disabil¬
ity may have the opposite effect, causing the psychotherapist
to align with the patient’s anxiety, and limit the exploration
of the dynamic roots of the problem within the patient. Regard¬
less of the setting and source of these often subtle countertrans-
ferential reactions, both the patient and the person with the
disability are underserved.
The very fact that the patient is struggling to cope with
reality-based changes and losses that appear so evident is what
makes them vulnerable to easy identification and unrecognized
countertransference by the therapist. Lastly, as a more subtle
indication of countertransference there may be a tendency to
focus on concrete solutions or strategies for the patient, since
the “causes” of the problem are seen as physical.
The fourth layer of the approach, referral to community
resources, can be very useful during and after the outpatient
phase of treatment. Groups sponsored by the National Head
Injury Association and local Stroke Clubs can offer education,
insight, and considerable support.

RECOMMENDATIONS

Since there is an increasing need for treatment of family mem¬

bers of those with neuropsychological disabilities, there is a
 Treating Family Members 207

need for specific training in these areas for those who deliver
psychotherapeutic services (Kemp & Mallinckrodt, 1996).
Some of the stress-producing content for therapists is quite
specific, and produces a high probability for unrecognized
countertransference. Hornby and Seligman (1991) point out
that even though there has been some effort to provide coun¬
seling skills to those working in these areas, access to such train¬
ing is not readily available. Just as many doctoral level programs
in psychology are now providing training in neuropsychology,
benefit would derive from more specific training in providing
psychotherapeutic services to persons with physical and neuro¬
psychological impairment and their family members.

SUMMARY

The need for individual psychotherapy for family members of

persons with neuropsychological disabilities is growing as medi¬
cal interventions improve and survival rates increase. The fam¬
ily members’ grief reactions are one part of the adjustment
process. Psychological difficulties that develop are influenced
by a number of considerations.
The family member who is the psychotherapy patient is
part of a family unit whose balance, functioning, and develop¬
ment have been disrupted. Factors relevant to physical disabil¬
ity, family systems approaches, and psychodynamic theory are
influential in the treatment. The severity and type of a relative’s
disability determine the practical and personal impact for the
patient, as does the relationship of the patient to the person
with the disability. A spouse, parent, child or sibling will each
experience different practical and emotional consequences
within the context of his or her stage of life and culture. The
circumstances of the onset of the disability, the quality of the
relationship, and the psychodynamic balance within each per¬
son and within the relationship are important issues to con¬
sider.
All of the above affects the meaning of the disability for
each family member personally, interpersonally, intrapsychi-
cally, and within the family unit. Because of limited experience
208 Frank J. Padrone

with these emotionally loaded issues, possibilities for unrecog¬

nized countertransference are significant. Recommendation is
made for increased exposure to the area of neuropsychological
disability in the training of psychotherapists.

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■

'
11.

Substance Abuse Interventions for

People with Brain Injury

Mary F. Schmidt, Ph.D. and

Allen W. Heinemann, Ph.D.

Each year an estimated 1.9 million people experience trau¬

matic brain injury (Collins, 1990); approximately 80,000 expe¬
rience continuing, significant disability (National Foundation
for Brain Research, 1994). Alcohol and other drug (AOD)
abuse is a major risk factor for acquired brain injury. Although
alcohol is the primary drug associated with acquired brain in¬
jury, the use of other drugs such as benzodiazepines, mari¬
juana, opiates, barbiturates, and amphetamine has also been
linked with acquired brain injury (Kreutzer, Wehman, Harris,
Burns, & Young, 1991; Boyle, Vella, & Maloney, 1991). Alcohol

Acknowledgments. This work was funded in part by the National Institute of Disabil¬
ity and Rehabilitation Research Demonstration Project (84-133a): H133A10014-93
and the Rehabilitation Services Administration Contract #H128A00002 (Midwest Re¬
gional Head Injury Center for Rehabilitation and Prevention) to the Rehabilitation
Institute of Chicago. The authors wish to acknowledge the significant contributions
of the following coinvestigators of the NIDRR project: Miles Cox, Ph.D., S. Vincent
Miranti, Ph.D., Eric Klinger, Ph.D., and Joseph Blount, Ph.D., who adapted Systematic
Motivational Counseling at Schwab Rehabilitation Center; Mary Ridgely, C.R.C. and
Mervin Langley, Ph.D., who applied Skills-Based Substance Abuse Prevention Counsel¬
ing within the Wisconsin Vocational Rehabilitation system; and all the people who
participated in this project.

211
212 Mary F. Schmidt—Allen W. Heinemann

use is implicated in 48% of all fatal motor vehicle crashes and

upward to 72% of all brain injuries (Kreutzer, Doherty, Har¬
ris, 8c Zasler, 1990; Sparadeo, Strauss, 8c Barth, 1990; Kreutzer,
Wehman et al., 1991). Moreover, alcohol abusers are more
likely to be involved in repeat motor vehicle crashes (McLellan
et al., 1993) and other traumatic injury-producing events such
as falls.
The connection between AOD use and the occurrence of
traumatic brain injury has been well established. Corrigan and
colleagues (Corrigan, Rust, 8c Lamb-Hart, 1995) noted that ap¬
proximately two-thirds of patients admitted to brain injury re¬
habilitation programs have a history of alcohol or other drug
use that can be described as abusive. Among a sample of people
interviewed one year after discharge from inpatient rehabilita¬
tion for brain injury, at least one half reported resumption of
alcohol use (Schmidt 8c Garvin, 1994). Kreutzer, Witol, and
Marwitz (1996) have found that 2 years after injury, alcohol
use patterns often return to preinjury levels.
A personal history of alcohol or other drug use has been
associated with deterioration of functioning after brain injury
(Dunlop, Udvarhelyi, Stedem, & O’Connor, 1991). This may
be explained by a number of factors. For example, intoxication
may interact with the brain injury itself to increase the resulting
cognitive or motor impairments (Kreutzer et al., 1991). People
with a history of AOD abuse, especially chronic abuse, may
have fewer financial, social, and medical resources including
social supports, to facilitate their continued recovery. In addi¬
tion, the use of substances following acquired brain injury is
potentially dangerous when combined with prescription medi¬
cations and may increase the likelihood of seizures (Murray,
1987). Resumption of substance use following brain injury is
associated with continued significant cognitive deficits (Par¬
sons, 1987). Other negative sequelae of substance use after
brain injury include increased balance problems, depression,
and increased suicide risk (as cited by Langley 8c Kiley, 1992).
Complicating the picture is the fact that alcohol and other
drug use or abuse can cause transient or permanent brain dys¬
function. A perusal of the American Psychiatric Association’s
 Substance Abuse Interventions 213

Diagnostic and Statistical Manual (4th ed., DSM-IV, 1994) under¬

scores this point. Alcohol and other drug effects can run the
behavioral gamut from delirium to dementia. However, there
is no reliable way to accurately predict the effect alcohol or
other drugs can or will have on a person’s cognitive or behav¬
ioral functioning; complex biopsychosocial factors are involved
in determining the effect that substances have on a person’s
functioning. In fact, some people acquire neuropsychological
dysfunction (e.g., alcoholic dementia) solely through the direct
action of substances that can be neurotoxic, rather than
through indirect or secondary effects, such as increased risk of
traumatic brain injury or nutritional deficits.
Prudence suggests that identification, prevention, and
treatment of substance problems should be integral compo¬
nents of rehabilitation, especially given the increasing focus on
increasing rehabilitation efficacy and improving outcomes. If
approximately two of three participants in brain injury rehabili¬
tation programs are potentially at risk for less than optimal
outcome and quality of life secondary to AOD use, brain injury
rehabilitation professionals would be wise to incorporate sub¬
stance use intervention strategies in their rehabilitation pro¬
grams. However, rehabilitation professionals often lack basic
information regarding the identification, assessment, and in¬
tervention of substance use problems among clientele (Kiley,
Heinemann et al., 1992; Moore, 1992), and few specialized in¬
tervention programs are available (Corrigan, Lamb-Hart, &
Rust, 1995; Jones, 1992; Schmidt & Garvin, 1994).
Research has shown that substance abuse treatment among
the general population has variable outcomes. Relapses among
patients who have received formal substance abuse treatment
continue at a high rate (Donovan 8c Chaney, 1985; Marlatt &
Gordon, 1985), but is minimized when treatment components
meet client expectations. Components of successful treatment
include the development of positive alternatives to substance
use (Valliant, 1983; Tucker, Vuchinich, 8c Harris, 1985) and
feelings of satisfaction with life (Polich, Armor, & Braiker,
1981). Marlatt and Gordon (1985) and Sanchez-Craig and col¬
leagues (Sanchez-Craig, Wilkinson, & Walker, 1987) reported
that frustration in goal-directed activities (as well as the manner
214 Mary F. Schmidt—Allen W. Heinemann

in which people deal with these frustrations) is the most com¬

mon determinant of relapses. The choice between using a drug
or not using it, moreover, has been shown to vary as a function
of alternative enjoyable activities that are available to a person
and barriers to these activities (Vuchinich & Tucker, 1988). In
short, the ability to find emotional satisfaction nonchemically
is a critical determinant of abstinence from substance abuse.
Treatment that specifically helps patients develop enduring
sources of emotional satisfaction as alternatives to substance
use would appear to be highly promising. However, for many
people with brain injury, the perceived value of using alcohol
outweighs the negative consequences. Social situations become
easier to handle, and lowered functional abilities can be attrib¬
uted to intoxication (Langley, 1995).
This chapter presents information on the risks of devel¬
oping substance abuse among people with neurologic dysfunc¬
tion, and identification, prevention, and intervention strategies
that can be implemented as part of rehabilitation and psycho¬
therapy. Two treatment models shown to be effective with
people with brain injury will be presented. The greatest oppor¬
tunity for successful intervention comes when the clinician is
able to artfully combine cognitive skill-based techniques with
motivational approaches to provide the “how” and “why” for
clients to change substance use patterns.
This chapter is organized around a public health preven¬
tion model that targets people at risk for a particular health
problem, namely substance abuse, and intervenes at several
levels. Typically in this prevention model, primary prevention
refers to stopping a problem before it even begins. For most
people with acquired brain injury, especially those who were
under the influence of alcohol or other drugs at the time of
injury, prevention begins at the level of secondary prevention,
that is, the identification of the problem and implementation
of strategies to limit its spread. Treatment is considered tertiary
prevention; limiting the harm that is caused by an existing
problem. The prevalence of substance abuse among people
with acquired brain dysfunction demands the use of secondary
and tertiary prevention strategies.
 Substance Abuse Interventions 215

SECONDARY PREVENTION: SCREENING FOR RISK AND

SYMPTOMS OF SUBSTANCE ABUSE

Screening Techniques: A Few Pointers

In general, use open-ended questions when asking about sub¬

stance use. Ask questions that require more of an answer than a
simple yes or no. Convey an open and nonjudgmental attitude;
avoid confrontation and allow the person to save face when
possible. Provide empathic responses that convey your goal of
understanding so that you can best be of help to the person.
Paraphrase a person’s concerns to improve understanding and
facilitate the exchange of information.
This information might be best obtained once you have
established a working alliance or relationship with the client.
Moreover, this information does not need to be garnered in
one brief interview. Ask about the use of prescription medica¬
tions as well as other drugs such as caffeine, nicotine, alcohol,
and illicit drugs. Corroborate information with data from multi¬
ple sources, including background and collateral information,
observations, physical examinations, and information from
family and significant others. There is a high degree of concor¬
dance, typically greater than 90%, between self-report and fam¬
ily reports of substance use, yet in our clinical experiences,
families often have a different perspective from clients on how
use affects day-to-day functioning. To minimize resistance and
defensiveness in the screening interview, it may be helpful to
focus on historical questions and perspectives rather than
query the person about current use and practices.

Screening for Risk Factors

The unique cognitive, emotional, behavioral, and physical im¬

pairments associated with brain injury create particular risks
for alcohol and other drug use. Therapists and other rehabilita¬
tion professionals should be sensitive to these risks. Clientele
and their families should be assessed for the presence of such
216 Mary F. Schmidt—Allen W. Heinemann

risks. This can be done in interview format, or through the

use of a thorough interdisciplinary evaluation that looks at all
aspects of the person’s functioning, including community and
social climate. If preferred, a number of commercially available
standardized questionnaires and assessment instruments are
available for examining specific areas of risk, such as the Alco¬
hol Expectancy Questionnaire (Brown, Christiansen, & Gold¬
man, 1987) or the brief Michigan Alcohol Screening Test
(Pokorney, Miller, & Kaplan, 1972). Following assessment, re¬
habilitation professionals should provide information and edu¬
cation to minimize risk and thus minimize AOD use.
Both pre- and postinjury risk factors need to be consid¬
ered. Preinjury risk factors include premorbid AOD abuse, a
life-style associated with the recreational use of AOD, limited
knowledge of the potential dangers of substance use or an un¬
willingness to acknowledge these dangers, a family history or
addiction or abuse, and a history of arrests or conviction of
substance abuse related crimes, such as assault and battery, or
driving while intoxicated.
Postinjury risks include both personal and environmental
factors. Perhaps the most germane personal factor is the sense
of social dislocation that occurs following acquired brain dys¬
function and its rehabilitation. At its core, brain injury is pro¬
foundly isolating (Pollack, 1989). Weeks of acute care followed
by extended rehabilitation result in a prolonged absence from
the “real world” as one survivor of brain injury described it.
“It was like I got caught out on an island, surrounded by rush¬
ing water. All my friends and family were in boats, sailing down
the river away from me. I was stuck by myself. That’s how lonely
I felt,” reported this 33-year-old man who was in coma for 3
months following a motorcycle crash. Loneliness and a desire
to return to former social patterns can lead to increased risk
of use, especially if the former life-style included activities that
center around drinking or drug use (e.g., hanging out in a bar
or tavern).
Reduced physical and cognitive abilities following ac¬
quired brain injury create unique stress and risk for substance
use. One’s ability to tolerate stress, frustration, and boredom
is decreased following brain injury. There may be heightened
 Substance Abuse Interventions 217

sensitivity to stimulation and fatigue. Problem solving, mem¬

ory, attention, and the ability to engage in constructive activity
or interpersonal relationships may be impaired. These may all
increase the risk of substance use. Diminished ability to accu¬
rately assess cause-and-effect relationships (which may occur in
acquired brain injury) alone may contribute to the risk of mak¬
ing poor judgments about using alcohol or other drugs.
Many people with brain injury show limited social skills
and limited coping skills. Some of these skill deficits may have
existed preinjury, but cognitive and neurobehavioral sequelae
of brain injury also may limit coping and social behavior. In
general, people who are unable to engage in effective or adap¬
tive problem solving or who have a limited repertoire of social
skills are at risk for substance abuse. They may use alcohol or
other drugs as a means of coping or relieving social anxiety.
There are a number of coping instruments, including the Ways
of Coping Questionnaire (Folkman 8c Lazarus, 1980) that can
be used to formally assess coping skills.
Acquired brain injury often brings with it the burdens of
loss and change. There may be a sudden reduction in abilities
that may have been sources of pride and self-confidence. Ele¬
ments of preinjury personality may be lost, leaving the person
a stranger to self and loved ones. Brain injury can threaten or
destroy vocational, romantic, athletic, artistic, social, familial
and financial abilities.
Family stress may contribute to the increased substance
use following brain injury. If the person with brain injury had
been living with his or her family, separation during acute care
and rehabilitation can be hard on family relationships. Com¬
munication can become difficult if the shared experience is
disrupted. Role changes may occur. A person may go overnight
from primary wage earner to dependent. The noninjured fam¬
ily members often need to assume additional family responsibil¬
ities, plus fit in time to visit and learn about the injured
person’s needs. Support once found within the family may be¬
come a scarce resource as the family system works to adapt to
the changes.
Expectations and beliefs about the benefits of alcohol and
other drug use may increase the chances that a person with
218 Mary F. Schmidt—Allen W. Heinemann

brain injury will develop alcohol or other drug abuse. For ex¬
ample, if a person feels that alcohol can help her relax, then
when she is stressed, she is more likely to use alcohol to excess.
Some people believe that alcohol or other drugs help them
“think clearer,” feel “sexy,” or “feel comfortable around peo¬
ple.” These AOD expectancies motivate substance use and ap¬
pear to be pervasive in our society. Research suggests that these
beliefs may be deeply engrained. The stronger the expectation
that alcohol or other drug use has positive benefits, the more at
risk the person is for developing problems (Goldman, Brown, 8c
Christiansen, 1987). The Alcohol Expectancy Questionnaire
(Brown et al., 1987) can be used to formally assess a person’s
beliefs about alcohol use.
Social or environmental factors may also heighten a per¬
son’s risk for developing substance problems. For example, so¬
cietal misconceptions about people with disabilities in general
(such as thinking that people with brain injury have pitiful
lives and thus “deserve” to feel good in whatever way possible,
including the use of alcohol or other drugs) add to the stress
a person may feel following brain injury and may increase use.
Conversely, the misconception that people with cognitive defi¬
cits have an inherent weakness, or can’t be expected to cope
well, may foster the notion that it is expected, in fact, seen as
accepted, that people with brain injury can’t handle stress and
will turn to the quick fix. Lastly, many people believe that a
person with brain dysfunction, particularly someone who was
injured while intoxicated “must surely have learned his lesson”
and “wouldn’t do that again.” For example, a neurologist who
was working with a young, financially successful commodities
trader did not want to refer this patient for substance abuse
services, despite the fact that the patient had bilateral stroke
in the frontal lobe secondary to cocaine use. The neurologist’s
reasoning was, “Surely he has learned his lesson and we don’t
want to stigmatize him—he’s a young guy.” The patient’s rea¬
soning for requesting treatment was, “I’ll be sitting at home
with nothing to do—except cocaine!” The nexus of these atti¬
tudes and misconceptions results in limited attention to the
problem and consequently, limited accessibility to appropriate
treatment, which in turn had the potential to intensify ex¬
isting problems.
 Substance Abuse Interventions 219

Closer to home, the tendency of family, friends, and even

rehabilitation professionals, to ignore evidence of substance
problems among people with brain dysfunction may stem from
more than misinformation about these issues. Instead, this ten¬
dency may be “enabling” behavior. Enabling behaviors are
words and actions that keep others from experiencing the full
consequences of their alcohol and drug use, abuse, or depen¬
dence. Such enabling behaviors intensify the risk of substance
abuse following brain injury. For example, one person with
brain injury reported he did not see a problem with drinking
beer at home—his mother bought it for him! When asked
about the situation, mother reported that she indeed did buy
beer for her son. This way, he was less likely to go out “looking
for trouble,” and “besides that, he tends to fall asleep early
rather than complaining about how bored and depressed he

Screening for Symptoms

In addition to assessing a person’s risk for developing alcohol

problems, the therapist should evaluate the person’s behavior
for symptoms of substance abuse. The following symptom
checklist was developed for the Resource Center for Substance
Abuse Prevention and Disability by the Substance Abuse Re¬
sources and Disability (SARDI) Project (Moore, 1992) and in¬
cludes substance abuse-related behaviors shown by people with
disabilities. The presence of one or more of these symptoms is
not necessarily indicative of substance abuse; however, if several
of these symptoms are present, it suggests that issues related to
alcohol and other drug use should be thoroughly explored and
a full substance abuse assessment should be done.

Substance Abuse Checklist

• Frequent intoxication: Important information within this cate¬

gory includes the frequency of use or intoxication as well as
the frequency of recreational activities which focus on drink¬
ing or drug use. For example, a client of day rehabilitation
220 Mary F. Schmidt—Allen W. Heinemann

services for TBI reported that he “partied” four or five times

per week. His family verified that he indeed hung out with
the same group of friends he partied with prior to his injury.
Although the client denied drinking to intoxication each
time he met with his friends, he did admit to smoking dope
on almost every occasion.
• Use of atypical social settings: Assessment of the settings in
which substance use occurs includes asking about the per¬
son’s immediate peer group, whether or not the person uses
in isolation, and whether or not the person engages in social
activities that do not include alcohol or other drugs. For ex¬
ample, the previously mentioned client did not have any
other social contacts outside of “partying.” If he was not
hanging out, he was at home watching television alone in
his room.
• Intentional heavy use: Inquiries under this category include
information on whether the person drinks deliberately to get
drunk, his or her tolerance level, and whether alcohol or
other drug use is combined with prescription medications.
• Symptomatic drinking: Are there predictable patterns of use
that are well known to others? Does the person rely on alcohol
and other drugs to cope with stress? Does substance use re¬
main constant across social contexts and during life-style
changes?
• Psychological dependence: Information about the motivations
for substance use can help identify psychological dependence
on substance use. For example, one client reported that since
her injury, she could not manage to attend school without
taking extra codeine pain tablets to “not feel so jittery if the
teacher calls on me and I can’t remember the answer.”
• Health problems: Does the person experience recurring physi¬
cal conditions that may be associated with substance abuse?
Did the person become disabled as a result of injury sustained
under the influence of alcohol or other drugs? Does the per¬
son use substances despite taking anticonvulsant medication?
• Job problems: Often the presence of job-related problems can
be indicative of ongoing substance abuse problems. Informa¬
tion about attendance, punctuality, and employment history
can provide clues about substance abuse.
• Problems with significant others: Have important relationships
been lost or damaged due to alcohol or other drug use? Have
 Substance Abuse Interventions 221

family members or significant others expressed concern re¬

garding the person’s use?
• Problems with the law or authority: Although problems with
the law or authorities around substance-related offenses (e.g.,
driving under the influence or disorderly conduct) can be
direct indicators of substance use problems, other more sub¬
tle signs of substance abuse may be discerned in the person’s
attitude toward authority in general.
• Financial problems: Can the person account for spending
money? Are payments made on time? Does the person fre¬
quently attempt to borrow money from peers, family, and
staff?
• Anger or belligerence: Does the person act angry or defensive
when asked about alcohol or other drug use?
• Isolation: Has the person become increasingly isolated from
social contacts? Has there been a change in participation in
social and family activities?
• Handicappism: Does the person blame all of his or her prob¬
lems in life on the disability? Does the person focus on the
disability to the exclusion of other personal aspects?

Brief Screening Tools

Two brief screening devices that are appropriate for use among
people with neurologic dysfunction, and which can be easily
incorporated during the information gathering process, are the
RAFFT (Riggs & Alario, 1992) and the CAGE (Ewing, 1984),
(see appendix A). Positive responses to any of these questions
should be seen as a red flag, and further assessment of sub¬
stance use patterns, beliefs, and expectations should be done.

TERTIARY PREVENTION: IDEAL INTERVENTION

STRATEGIES FOR REDUCING SUBSTANCE ABUSE
AMONG PEOPLE WITH BRAIN INJURY

As noted above, few specialized treatment programs for people

with brain injury are available, and traditional treatment mod¬
els are often insufficient to meet the needs of this population.
222 Mary F. Schmidt—Allen W. Heinemann

Cognitive and behavioral problems associated with brain dys¬

function, such as memory problems, limited awareness, and
communication difficulties, may interfere with traditional mod¬
els of treatment delivery which often rely on verbal, insight
oriented, group treatment modalities. For example, because of
new learning difficulties, information may need to be pre¬
sented several times and the timeframe for learning length¬
ened. The traditional 30-day program may be too short for
learning and generalization to novel situations to take place,
as individuals with brain dysfunction often fail to generalize
learned behaviors to novel situations (Vogenthaler, 1987). Of¬
ten, materials and methods may need to be concretized rather
than being solely verbal or insight oriented. Methods that rely
on self-awareness, including traditional psychotherapy and sup¬
port group methods, may fail due to the person’s inability to
self-reflect or to perceive the effects of his or her behavior.
Denial of deficits caused by brain dysfunction and those associ¬
ated with substance abuse itself may be present but are often
secondary to organic insightlessness rather than “denial” per
se (Deaton, 1986; Fleming, Strong, 8c Ashton, 1996). “Denial”
is a voluntary defense mechanism; people “choose” to ignore
reality (Valliant, 1993). Substance abuse counselors who are
unfamiliar with brain injury issues may not recognize the im¬
pact of cognitive issues on treatment participation and may see
the person as noncompliant and unwilling to change.
The interplay between cognitive deficits and emotional de¬
nial may be seen in the following clinical vignette. A rehabilita¬
tion patient was admitted following frontal lobe injury
sustained when the patient fell 30 feet at his workplace and
fractured his skull. At the time of admission, his blood alcohol
level was .15, well over the state’s legal limit for intoxication.
Throughout the course of the patient’s inpatient rehabilitation
stay, he denied “having trouble” or “having a problem” with
alcohol, but was ready and willing to participate in an inpatient
alcohol treatment because he felt he “needed help.” However,
he steadfasdy denied “using” alcohol the day of his injury. The
substance abuse counselor reported that he could not autho¬
rize treatment for the patient since the patient denied and
 Substance Abuse Interventions 223

refused to admit that he had a problem with alcohol. The pa¬

tient’s wife reported that she was reluctant to bring the patient
home without substance abuse treatment because she felt that
he might start up drinking again. She reported that the patient
had been in substance abuse treatment about 12 years earlier,
and occasionally “slipped” at home but it wasn’t “much of a
problem, not like he had before.” Nevertheless, despite the
staff’s and family’s concerns, the substance abuse counselor
insisted that unless that patient admitted that he had a prob¬
lem, treatment could not be authorized because “patients who
deny they have problems do not succeed in our program.”
Rehabilitation staff intervened, and in a joint session with the
substance abuse treatment provider and the patient, shifted the
discussion from asking the patient to admit he had a problem
to asking “if (he) had slipped” that day. The patient readily
agreed that he had slipped but “wasn’t using again, just had a
few drinks with a friend for the holidays.” The substance abuse
counselor heard the patient’s admission, and the patient began
substance abuse treatment the next day. The patient’s concrete
reasoning and limited insight (secondary to frontal lobe in¬
jury), together with his self-belief that he was “not using,” but
only “having a few drinks, a slip,” resulted in perceived “denial
of alcohol problems.” This case example stresses the impor¬
tance not only of being aware of cognitive deficits that may
interfere with intervention approaches, but also the need for
collaboration between rehabilitation and substance abuse treat¬
ment professionals.
Ideal substance abuse interventions for people with brain
dysfunction should be highly individualized. While experience
working with people with brain injury is helpful, it is not always
necessary. Jones (1992) noted that counselors who succeed
with this population share two primary characteristics: creativ¬
ity and client-centeredness. Creativity can be found in the ther¬
apist’s willingness to be open to change in the means or route
used to reach the client’s stated goal, to let go of preconcep¬
tions, and to adapt conventional techniques to any particular
client. Client-centeredness involves the capacity and willingness
to meet the client at his or her level and to empower him or
her to formulate goals to improve quality of life.
224 Mary F. Schmidt—Allen W. Heinemann

Other components and strategies which effective sub¬

stance abuse interventions share with this population are: (1)
Interdisciplinary services wherein a team of professionals with
varied backgrounds and specialties work collaboratively to eval¬
uate and treat the client’s multiple, complex needs and facili¬
tate growth in skills needed to achieve personal goals. (2)
Concrete, goal-directed (versus psychodynamic) strategies.
Many people with brain injury have limited insight or self-
awareness. Effective strategies focus on the concrete here-and-
now and focus on achievable goals that may lead to bigger
goals. There is an emphasis on the development of specific
skills relevant to the individual’s day-to-day life. (3) Emphasis on
the impact of substance use on functional-independent living
skills. Most people with brain injury desire to live in the most
independent manner possible and may benefit from education
on how alcohol or other drug use interferes with indepen¬
dence. (4) Comprehensive and multidimensional programs ad¬
dress client needs on several levels including health,
independent living skills, social and interpersonal skills, voca¬
tional needs, leisure and recreational skills, housing, financial
needs, and family issues.
An exemplary program that offers specialized substance
abuse intervention for people with disabilities, the Anixter Cen¬
ter in Chicago, has found that day-to-day concerns such as the
need for reliable transportation or mentoring to attend com¬
munity self-help groups create real obstacles to successful par¬
ticipation in treatment. To minimize external barriers, the
Anixter Center uses case managers to coordinate auxiliary ser¬
vices such as transportation and eligibility for entitlements. Pro¬
graming includes groups for improving social skills, academic
skills, work adjustment skills, and communication in addition
to individual and group substance abuse treatment. Partici¬
pants have access to a health clinic that administers to the
health needs of people with disabilities. Ongoing evaluation of
this program suggested that the use of interdisciplinary services
that support basic needs for daily living (e.g., health, housing,
etc) allowed people with disabilities enough security and safety
to actively engage in substance reduction protocols (Lorber,
 Substance Abuse Interventions 225

personal communication, May 24, 1996). The treatment pro¬

gram at the Anixter Center thus views substance abuse counsel¬
ing as only one facet of the comprehensive program needed
to help ameliorate substance abuse by people with brain dys¬
function.

COLLABORATING WITH EXISTING TREATMENT

PROGRAMS

In the absence of specific treatment programs for people with

brain dysfunction, networking with existing community sub¬
stance abuse programs is necessary. Collaboration and cross¬
agency cooperation is recommended to create resources to
serve the unique needs of this group. Cross-training among
agencies can increase the number of experts in the field. The
brain injury rehabilitation professional can educate substance
abuse professionals about the needs of people with brain in¬
jury. The substance abuse counselor can help the brain injury
professional learn about prevention, intervention, and re¬
lated issues.
This cross-training may be especially helpful in developing
self-help and support groups for people with coexisting sut>
stance abuse and brain injury. These specialized groups may
be necessary to adjust to the cognitive needs of people with
cognitive dysfunction. Often, these people have difficulty with
fatigue, complex attention, demands for rapid processing, and
handling external distractions (Montgomery, 1995). According
to the anecdotal reports of several clients who have brain in¬
jury, participation in nonadapted support group meetings can
be frustrating, overwhelming, and shame-producing because
they often feel as if they “can’t keep up.’’ For this reason, we
try to link people to substance abuse support groups that are
adapted to address cognitive dysfunction. In an effort to de¬
velop a larger number of socially accessible Alcoholics Anony¬
mous groups in Chicago, we worked together with some of the
volunteers who facilitate introductory Twelve Step groups at a
major medical center. The introductory groups, entitled “How
226 Mary F. Schmidt—Allen W. Heinemann

It Works,” provide an overview of Twelve Step meetings and

the principles of Alcoholics Anonymous. By providing informa¬
tion and consultation about brain injury and other disability
issues to the volunteers, we increased the opportunity that a
person with brain injury would be able to attend an introduc¬
tory group that could be adapted to his or her needs. Qualita¬
tive analysis of this collaboration showed that volunteer
substance abuse meeting leaders were receptive and welcomed
the opportunity to learn skills that would help them to be more
effective in individualizing programs.
Participation in self-help support groups for people in re¬
covery can be very helpful. Most brain injury rehabilitation
programs have support groups for recovery from brain injury
issues. People in recovery for both brain injury and chemical
dependence generally should be linked to as many community
support services as available.
Corrigan, Lamb-Hart, and Rust (1995) described a pilot
program initiated in 1991 to increase collaboration among re¬
habilitation and substance abuse professionals to improve the
treatment efficacy for people who had experienced TBI. Called
the TBI Network, the model of treatment is community-based,
it uses an interdisciplinary staff with specialized knowledge of
brain injury to facilitate treatment by local substance abuse
professionals. Upon referral, clients are screened for their
likely eligibility (incurred a TBI with current sequelae and have
a history of substance abuse or are risk of same), and a small
amount of demographic information is recorded. Those who
are willing to participate and are appropriate for services re¬
ceive a comprehensive assessment, which includes an indepen¬
dent interview of a family member when willing and available.
The primary method of subsequent intervention is resource
and service coordination to make linkages with existing sub¬
stance abuse providers and sustain those linkages over the pro¬
longed course of community integration. The TBI Network
uses case consultation to assist substance abuse program staff
to understand the unique strengths and weaknesses of an indi¬
vidual, adapt services and treatment plans to the individual’s
abilities, trouble-shoot problems as they arise, and assist in
 Substance Abuse Interventions 227

‘wrapping around” other resources and services that individu¬

als require to stabilize their health, financial, and vocational
status. The large number of referrals to the program has indi¬
cated a marked need for the service, and initial evaluation data
have shown positive behavior changes resulting from treat¬
ment. Because service provision is not facility-based, the pro¬
gram can be replicated with a minimum of start-up costs and
can serve a large geographic region. Intervention of this type
allows for maximal use of limited resources.
Within this type of collaboration, the TBI professional pro¬
vides consultation to the substance abuse professional to adapt
intervention to fit the specialized needs of the person with
brain injury. The TBI professional can suggest different treat¬
ment modalities and can provide information about the indi¬
vidual’s learning needs.
Two treatment protocols that have been field tested with
people with brain injury will be described in the next section.

SPECIALIZED INTERVENTION PROTOCOLS FOR PEOPLE

WITH BRAIN INJURY

Heinemann and colleagues (1995) field tested two models of

substance abuse treatment (Skills Based Substance Abuse Pre¬
vention Counseling and Systematic Motivational Counseling),
that had not been previously studied among people with brain
injury, by applying interventions in a variety of treatment set¬
tings (e.g., outpatient rehabilitation, vocational training pro¬
grams, residential services) to patients in different stages of
recovery. Counseling techniques were designed to meet the
unique needs of people with brain injury, including accommo¬
dations for cognitive impairments, motivational difficulties,
and behavioral impairments. Often, such persons are not ad¬
mitted to traditional treatment programs. The substance abuse
interventions were incorporated into persons’ existing brain
injury rehabilitation programs, and various members of the
team were instrumental in its delivery. Information about each
intervention follows.
228 Mary F. Schmidt—Allen W. Heinemann

SKILLS BASED SUBSTANCE ABUSE PREVENTION

COUNSELING

Mervin Langley described Skills Based Substance Abuse Preven¬

tion Counseling (SBSAPC) in 1991 and 1995 publications on
prevention of alcohol-related problems after traumatic brain
injury. Dr. Langley’s method involves four stages of treatment:
comprehensive evaluation, motivational enhancement, coping
skill training, and structured generalization. All techniques uti¬
lized in this approach are based on strategies already found
effective among non-brain-injured persons. The basic premise
of the model is that the risk of abusing substances as a coping
mechanism is heightened for people with brain injury, and
techniques target areas that contribute to this problem.
As reviewed above, several neuropsychological deficits,
such as impaired learning and generalization, and impaired
insight and awareness, may lessen the utility of conventional
treatment approaches. Langley’s SBSAPC is expressly directed
toward circumventing these aspects of neuropsychological im¬
pairment. Clients learn by rehearsing cognitive and coping
skills rather than obtaining information through traditional ed¬
ucation. Awareness deficits are addressed by systematically in¬
creasing problem recognition, by retraining self-monitoring
abilities, and by selecting techniques that do not rely on aware¬
ness for their success. Impulse control deficits are dealt with by
extinguishing or counterconditioning reactivity to substance
cues and by increasing self-control under protected stimulus
conditions.
Interventions progress through four overlapping stages. In
the first stage, comprehensive evaluation, measures are com¬
pleted which guide the selection of treatment targets and pro¬
vide baseline data for determining the effectiveness of the
strategies. Homework is introduced which facilitates self-moni¬
toring abilities. In stage 2, motivational enhancement, the fo¬
cus is on strengthening decision-making abilities. Stage 3,
coping skill training, provides training in neurocognitive and
coping skills for making changes happen. Finally, in stage 4, or
 Substance Abuse Interventions 229

generalization, newly learned behaviors are transferred to real-

world settings. Each component has highly structured tech¬
niques that occur within a collaborative client-therapist rela¬
tionship.
Within the collaboration of client and therapist, personal
feedback about the interaction of substance use and neurocog-
nitive and motor impairments offers the best hope for behavior
change. The challenge for the clinician is to provide informa¬
tion that relates to deficits the client acknowledges as legiti¬
mate. For example, a person with balance problems may be
given information about the effects of alcohol on cerebellar
function for coordinated movement. The goal in this process
of “motivational interviewing” is to establish dissonance be¬
tween the person’s substance use behavior and important per¬
sonal goals (Miller, 1985). The clinician must thoroughly
understand the client’s actual and perceived deficits as well as
goals. Identifying and formulating achievable short- and long¬
term goals is a prerequisite to success and provides a rationale
for modifying substance use.
Techniques used in SBSAPC include establishing a work¬
ing relationship, providing highly personalized feedback that
creates a discrepancy between important goals and substance
use behaviors, and managing positive outcome expectancies. In
addition, SBSAPC techniques help clients recognize that beliefs
mediate substance use, develop counters to positive substance
use beliefs, practice countering skills, identify personal high-
risk situations, determine strengths and weaknesses in high-risk
situations, and practice coping responses in high-risk situa¬
tions. Teaching clients to cope with cue exposures requires
caution. There is a fine line between allowing a client to re¬
hearse skills in cue situations and allowing the client to indulge
in substance use fantasies. Several procedural safeguards are
suggested, including revising the abstinence contract, ending
cue sessions with successful use of skills which facilitates a re¬
duction in subjective desire to use, and using cues which the
client is likely to experience within the course of a normal week.
Powerful cues, such as the direct use of substances, should be
avoided in favor of symbolic presentations such as pictures or
imagery.
230 Mary F. Schmidt—Allen W. Heinemann

Evaluation of the effectiveness of this program showed that

participants whose alcohol coping skills increased from base¬
line to reassessment were more likely to have become abstinent
over time than those who did not show a change. Analysis of the
treatment components showed that preparatory interventions,
such as conceptualization, goal-setting, discussion of costs and
benefits of substance use, instructions, modeling, and feedback
were represented to a greater extent than skill rehearsal. The
benefits obtained from coping skill training were the result of
personally relevant information, instruction, and demonstra¬
tion rather than the clients’ actual performance of the skills
during sessions. By making information about substance use
effects relevant to the person in his or her personal life situa¬
tion, treatment appeared more effective than when informa¬
tion is provided generally. Cognitive deficits that are associated
with the failure of traditional information giving, such as ab¬
straction, attention, and memory deficits are circumvented by
the addition of interventions that link information with day-to-
day functional skills.

Systematic Motivational Counseling

Several current theories of substance abuse (Cox & Klinger,

1988; Marlatt, 1985; Miller, 1985), hinge on the concept of
“motivation.” Motivation refers to the balance between the
satisfaction that a person expects to obtain by using substances
and the emotional satisfaction that he or she expects to find
from nonchemical sources. A motivational intervention is one
that shifts this balance by increasing the person’s “probability
of entering, continuing, and complying with an active change
strategy” (Miller, 1985, p. 88). Systematic Motivational Coun¬
seling (SMC) specifically targets persons’ motivation for recov¬
ery. Miranti, Cox, Klinger, and colleagues adapted this
technique for use with people with brain injury as part of the
federally funded field test coordinated by Heinemann et al.
 Substance Abuse Interventions 231

(1995). They found that SMC techniques can be used success¬

fully with people with brain injury by focusing jointly on indi¬
viduals’ motivation for recovery from brain injury and
substance abuse alike.
Systematic motivational counseling is based on Cox and
Klinger’s (1988) motivational model of substance use. Defini¬
tions of basic motivational principles will facilitate understand-
ing of this model. First, affect is the experiential or psychological
component of an emotional response. Motivational theorists
think of affect being either positive or negative. Positive affect
means pleasurable engagement with the environment whereas
negative affect is unpleasurable. Affective change is a change in
affect from its present state, and most people are motivated to
change negative affect to positive affect. Substances often are
used to achieve affective change. An incentive is any object or
event that a person expects will bring about an affective change.
Incentives can be positive (things the person wants to obtain)
or negative (things the person wishes to avoid). Every goal is
an incentive, but not every incentive is a goal. For example, a
woman with brain injury might expect that having a million
dollars would increase her positive affect, but will not be com¬
mitted to having a million dollars because that may be un¬
achievable. A current concern is a person’s motivational state
between the time a decision is made to pursue an incentive
and the time the goal is reached or relinquished. During this
time, people appear vigilant to cues that have an impact on
obtaining their goals. Many current concerns may be operative
at the same time.
This motivational model illuminates the principles by
which substances or other nonchemical events can be incen¬
tives for people. Motivations to pursue nonchemical incentives
to bring about affective change may also govern substance use.
The relative balance between chemical and nonchemical incen¬
tives is a critical determinant of the motivation to use alcohol.
Systematic motivational counseling operates on the idea that
it is possible to empower people to increase their nonchemical
sources of emotional satisfaction that are incompatible with
232 Mary F. Schmidt—Allen W. Heinemann

substance use, thereby shifting the balance in favor of decisions

not to use.

Getting Started

The therapist who intends to use SMC will spend some time
initially becoming acquainted with the client, establishing rap¬
port, and beginning to establish a therapeutic bond. For clients
with brain injuries, this process may be lower than with persons
without cognitive impairments. The therapist also introduces
SMC by explaining its rationale and eliciting the client’s reac¬
tions to determine if he or she wants to proceed. Assuming
that there is a desire to go forward, the therapist then begins
to understand the client’s motivations for substance use and
how this relates to other areas in life. Some areas to be explored
include the circumstances surrounding the beginning of coun¬
seling, the person’s history of substance use, the client’s view
of the problem and his or her goals for counseling.
Systematic motivational counseling is initiated by assessing
people’s motivational patterns through the use of the Motiva¬
tional Structure Questionnaire (Cox, Klinger, 8c Blount, 1996).
The technique is an individualized one that, does not use a
session-by-session agenda that is identical for all clients. Al¬
though certain components are used with all clients, others
may or may not be used with specific clients, depending on
their motivational characteristics.
Preliminary counseling components include reviewing the
individual’s MSQ to review goals and analyzing the interrela¬
tionships among goals. Goal-setting is the next component, and
treatment goals are established. Goal ladders, with short-term,
session-to-session goals determined to achieve major long-term
goals, are constructed. Subsequent sessions focus on improving
the client’s ability to meet goals and resolving the conflicts
among goals. There is also focus on empowering clients to dis¬
engage from inappropriate goals and identifying new incen¬
tives.
In SMC, the therapist also works with the client to move
to achieve more positive goals than to avoid negative goals, as
 Substance Abuse Interventions 233

this kind of appetitive life-style is seen as psychologically satis¬

fying. For some clients, this may be accomplished by cognitive
reframing to help them focus on positive aspects of their goals
rather than negative aspects. In other cases, more success might
be gained by helping clients reduce the number of negative
concerns in their lives. Associated with this is an effort to help
people reexamine their sources of self-esteem. Low self-esteem
is a pervasive problem for people with substance abuse as well
as people with brain injury. Some people tend to hold high
standards for themselves and are unduly harsh on themselves
when they are unable to achieve them (Klinger, 1977). This
may be especially true for people with brain injury who cling
to the image of themselves before the injury, and who because
of neurocognitive and motor impairments, are no longer able
to perform activities that they once did with ease. This self-
condemnation, of not being satisfied with current achieve¬
ments because they do not seem commensurate with previous
achievements, is often seen among people with brain injury
who continue to abuse substances and presents a major barrier
to adjustment. Thus, counselors try to assist clients find new
ways of feeling good about themselves, to become less self-con¬
demning and to develop self-forgiveness for goals they have
not attained.
Field evaluation of this model with people with brain in¬
jury showed that approximately 20% of people became absti¬
nent and 41% maintained abstinence during treatment.
Participants showed significantly fewer concerns and greater
movement toward an appetitive life-style than did the no-treat-
ment control group.

CONCLUSIONS

People with brain injury are at particular risk for resuming

or starting substance abuse. Providing skills and counseling to
reduce risks is but one approach. Such abuse may be main¬
tained as a coping mechanism or means of achieving positive
affect. Successful substance abuse treatment for people with
234 Mary F. Schmidt—Allen W. Heinemann

brain injury requires accommodation of neurocognitive and

other neuropsychological impairments, but can be achieved,
especially when treatment is part of a multidisciplinary ap¬
proach to brain injury rehabilitation. Two models of treatment,
a skills based substance abuse prevention model, and a model
of motivational counseling, have been field tested and shown
to be useful in this population. An ideal treatment modality
would target both skill deficits and motivational concerns.
Therapists who work with people with brain injury recog¬
nize the need for specialized services. However, because few
specialized services are available, brain injury rehabilitation
professionals will find it prudent to learn as much as possible
about the subject. Such knowledge enables the professional to
consult effectively with substance abuse professionals to cus¬
tomize available interventions to meet the needs of any particu¬
lar client. A collaboration between brain injury and substance
abuse professionals was described as one means of delivering
services to people with brain injury. Skillful blending of cogni¬
tive and motivational treatments and judicious application of
substance abuse interventions, offer great promise in helping
people with brain injury adjust and improve their quality of life.

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238 Mary F. Schmidt—Allen W. Heinemann

APPENDIX A: SCREENING INSTRUMENTS

The RAFFT (Riggs Sc Alano, 1992) includes these questions:

• Have you ever drank or used drugs to Relax, feel better about
yourself, or fit in?
• Have you ever drank or used drugs while you were by your¬
self, Alone?
• Do any of your closest Friends drink or use drugs?
• Does a close Family member have a problem with alcohol or
drug use?
• Have you ever gotten into Trouble from drinking or drug use?

The CAGE (Ewing, 1988) is named for the first letters of the
boldface words in the following questions:

• Have you ever decided to Cut down your drinking (or drug
use)?
• Have you ever felt Annoyed because of criticism of your drink¬
ing (or use)?
• Have you ever felt Guilty about your use of alcohol (or
other drugs)?
• Have you ever had an Eye-opener in the morning (morning
drinking or use)?
 Name Index

Achenbach, T. M., 105 Berti, A., 80

Adams, R. L., 192 Beutler, L., 159
Agich, G., 53-54 Binder, L. M., 192, 195
Alano, M., 238 Birch, H. G., 150
Alario, M., 221 Bisiach, E., 80
Albert, M. D„ 12 Black, S. E., 9
Albert, M. L., 8 Bleiberg, J., 133
Alexander, M., 56, 149 Blend, M., 134, 135
Allen, J. G„ 31, 36 Blonder, L. X., 76
Anderson, T., 159 Blount, J., 21 In, 227, 230-231, 232
Antunes, J. L., 16 Blumer, D., 97
Appelbaum, P. S., 56 Bolger, J. F„ 142
Arbit, J., 11 Bond, M., 21
Armor, D. J., 213 Bond, M. R., 97
Arndt, S., 101 Borod, J., 15
Aron, L., 48, 49, 50 Bowers, D., 15, 99
Asarnow, R. F., 97 Boyle, M.J., 211
Ashton, R., 222 Bracy, O., 137
Athey, G. I., 100, 108, 114, 133 Braiker, H. B., 213
Breznitz, S., 78
Babinski, J., 79-80 Brittain, J. L., 61
Bach-y-Rita, P., 132 Bromberg, P., 63-64
Ball, J. D„ xi, 121 Brooks, D. N., 97
Bandilla, E. B., 105 Brown, G. K., 102-103
Barnowski, E., 185n Brown, M. C., 55
Barth, J. T„ 61, 212 Brown, S. A., 216, 218
Battersby, W. J., 149 Bryden, M. P., 99
Beck, A. T., 102-103 Buechler, S., 62-63
Becker, D., 97 Bullis, D. P., 149
Begun, J. H., 34 Bui ter, R. W., 101
Behrmann, M., 9 Burd, B., 35
Belmont, I., 150 Burke, W. F., 121
Bender, M. B., 149 Burns, C. T„ 211, 212
Benson, D. F., 8, 10, 97-98, 109 Bums, D. D., 184
Benton, A. L., 10, 11 Burton, M., 38
Ben-Yishay, Y„ 35, 167, 169, 176 Buder, R. W„ xiii, 101, 105, 106, 108
Beresford, H. R., 61, 67 Butters, N., 12
Berg, I. K, 182
Bergsneider, M., 97 Caine, D., 98

239
240 Name Index

Callahan, C. D„ 56, 57 Donovan, D. M., 213

Callahan, D„ 45, 46, 47-48, 49-50 Drachman, D. A., 11
Caplan, A. L„ 45, 46, 47-48, 49-50 Dresser, R., 52
Caplan, B., 57, 77 Ducharme, S., 202
Car berry, H., 35 Dunlop, T. W., 212
Chaney, E. F., 213
Chiapello, P. A., 132 Egelko, S„ 91, 103, 162
Childress, J., 54 Elliott, C., 54-55, 56
Christensen, A.-L., 142 Emanuel, E. J., 52, 53
Christensen, B. K., 113 Erickson, R., 38
Christiansen, B. A., 216, 218 Eslinger, P. J., 12
Cicerone, K. D., xi, 55, 93, 133 Ewing, J. A., 221, 238
Cogen, P. H., 16 Eyman.J., 100, 108, 114, 133
Coleman, E., 98 Ezrachi, O., 151
Collins, J. F„ 211
Cooper, I. S., 110
Fahy, T.J., 21
Cornell, S., 12
Farah, M. J., 11
Correll, J. W„ 16
Felce, D., 52
Corrigan, J. D., 212, 213, 226
Ferenczi, S., 115
Coslett, B., 15
Filgate, M., 212
Coull, B. M„ 192, 195
Fiscalini, J., 51
Cox, D. R., 97
Fleming, J. M., 222
Cox, M„ 21 In, 227
Fogel, B. S., 100
Cox, W. M., 230-231, 232
Folkman, S., 217
Crozier, K. S., 57
Folks, D. G„ 77
Cummings, J. L., 10
Ford, B., 97 \
Cunningham, M., 132
Fordyce, D. J., xi, 36, 82, 91, 167
Fordyce, W. E., 197
Damasio, A. R., 12
Forney, D. L., 97
Damasio, H., 12
Fowler, S. R., 197
Davidoff, G. N., 3, 16
Frances, J. P., 61
Davies, J. M., 50, 63-64
Frankel, H. L., 6
De Renzi, E., 9-10
Frawley, M., 64
de Shazer, S., 182
Freedman, M., 55
Deaton, A. V., 167, 222
D’Elia, L. F., 103 Freeman, A. M. Ill, 77

Dembo, T., 201 Freeman, J., 98

Dennis, M., 16 Freud, A., 77-78, 119

D’Esposito, M., 149 Freud, S., 29, 31-32, 125, 136

Devanand, D. P., 98 Frieswyk, S., 31, 36
Diller, L., xiii, 35, 91, 113, 149, 151,
153, 160-161, 167, 169, 176, Gabbard, G. O., 51
180n, 191 Gainotti, G., 80
Doherty, K. R., 212 Gans, J. S., 51
Doll, M„ 213 Garden, W., 176
Donohue, R., 22 Gardner, R. W., 33
 Name Index 241

Garfield, S. L„ 159 Hornby, G., 207

Garvin, L. J., 212, 213 Horowitz, M. J., 82
Gass, C., 55 House, A., 16
Gazzaniga, M. S., 77 Hovda, D., 97
Gerstman, L. J., 151, 176 Howieson, D., 192, 195
Gianutsos, R„ 132, 134, 149-150 Hynd, G. W., 104
Gill, M. M., 33, 119
Gingrich, W., 182 Ingram, K. KL, 55
Glass, D. D., 202 Irving, M. H., 21
Goldman, M. S„ 216, 218 Isaac, W., 104
Goldstein, K., 28-29, 30, 31, 33, 34-35
Gordon, J. R., 213
Jackson, J. H., 119
Gordon, M., 55
Janis, F. L., 191
Gordon, R. M., xii-xiii, 50
Janis, I. L., 78, 93
Gordon, W. A., 103, 151, 162
Jenkins, M. R., 202
Gualtieri, C. T., 97
Jennings, B., 45, 51
Gunther, M. S., 50, 51, 123
Jin, S., 103
Gurdjian, E. S., 100
Jobe, T., 134, 135
Guze, S. B., 40
Jones, G. A., 213, 223
Jones, M. W., 16
Haas, J., 45, 46, 47-48, 49-50
Jorge, R. E., 101
Haffey, W. J., 55, 57
Hagglund, K. J., 56, 57
Kahn, R. L„ 79-80, 149, 150
Hamsher, K., 10, 11
Kanto, D., 193
Hanig, B., xiii
Kaplan, E., 91
Hannay, H. J., 10
Kaplan, H. B„ 216
Harker, J. O., 103
Karp, E., 150
Harley, J., 132
Kay, T„ 203
Harrell, L. E„ 55
Keen, M., 22
Harris, C. V., 213
Kelly, D„ 97
Harris, J. A., 211, 212
Kemp, N. T., 207
Hartmann, H., 32-33, 82, 119
Kihlstrom, J. F., 77
Havik, O. E„ 77
Kiley, D., 212, 213
Hawton, K., 16
King, F. A., 16
Hecaen, H., 8
Kinsbourne, M., 9, 149, 150
Heilman, K. M„ 15, 99
Heinemann, A. W., xiv, 22, 213, 227, Kinsella, G., 97

230-231 Kirschner, K. L., 49

Henry, R. R„ 113 Klein, G. S., 32, 33

Herrmann, D., 135 Klein, M., 116

Hibbard, M. R„ 103, 162 Klinger, E., 21 In, 227, 230-231, 232,

Hilgard, E. R., 77 233

Hodges, G., 151 Klonoff, P. S., 114, 132, 133
Hoffman, I. Z., 49, 51 Knapp, H. D., 58
Holmes, J., 50, 53 Koff, E., 15
Holzman, P. S., 33 Kohut, H., 114, 115t, 116
242 Name Index

Kostasek, R. S., 113 Maeland, J. G., 77

Kovacs, M., 104 Malec, J. F., 49, 132
Krause, M. F., 108 Mallinckrodt, B., 207
Kreutzer.J. S„ 132, 211, 212 Mann, L., 93
Kiibler-Ross, E., 193, 196 Marlatt, G. A., 213, 230
Kubos, K. L„ 162 Marshall, M. M., 97
Kutys, M., 57 Marson, D. C., 55
Martin, K. O., 132
Laatsch, L.,xiii, 121,133, 134, 135, 142 Martin, N., 97
Lachar, D., 105 Martinage, D. P., 97
Lage, G. A., 114 Marwitz, J. H., 212
Lakin, P., 151 Masterson.J. F., 34, 39
Lamb-Hart, G. L., 212, 213, 226 Mateer, C. A., 185
Landis, T., 10 Mathesson, P., 149-150
Langenbahn, D. M., xiii, 167, 169, 173 Matthews, C., 132
Langer, K. G., xi, xiii, 37, 52, 55, 63, Mazmanian, P. E., 132
77, 81, 82, 83, 103, 121, 131, McCleary, C., 97
133, 137, 169, 191 McDaniel, J. W., 191, 193
Langley, M. J„ 21 In, 212, 214, 227, McElhiney, M., 98
228, 230-231 McGlinchey-Berroth, R., 149
Langs, R., 114—115 McGlynn, S. M., 76, 80, 150
Larkin, E., 212 McKinlay, W. W., 97
Lazarus, R. S., 217 McLellan, B. A., 212
Mehta, Z., 10
Leber, W. R., 202
Meisel, A., 56
LeDoux,J. F., 77
Menninger, K., 125
Leiberman, A., 151, 162
Milberg, W. P., 149
Leventhal, H., 191
Miliotis, P., 12
Levin, H., 97
Millag, P., 21
Levin, H. S., 11, 100
Miller, B. A., 216
Levine, D. N., 76, 80-81, 150
Miller, E. N., 103
Leviton, G. L., 201
Miller, L„ xi, xii, 27-28, 33, 40-41,
Lewis, L., xi, xiii, 31, 36, 39, 77, 82, 92,
168, 169
108, 114, 116, 119-120, 121, Miller, W. R., 229, 230
133, 137, 145, 169 Millon, T., 34
Ley, R. G., 99
Minuchin, S., 193
Lezak, M. D., 14, 101, 108, 110, Miranti, S. V., 21 In, 227, 230-231
198-199, 200 Mitchell, S. A., 49, 50, 54, 58, 59-60, 63
Lidz, C., 56 Molnar, S., 182
Light, R., 97 Moloney, E., 211
Lin, Q., 134, 135 Molyneux, A., 16
Linton, H. B., 33 Montgomery, G. K., 225
Lipchik, E., 182 Moore, D., 213, 219
Livingston, R., 107 Moran, C., 97
Lorber, 224—225 Morris, J., 133
Luria, A. R., 29-30, 33, 34-35, 103 Moskovitch, M., 9
 Name Index 243

Mozer, M., 9 Ranseen,J. D., 76

Munro,J. D., 193 Rao, K., 162
Murray, P. K., 212 Rapaport, D., 33, 119
Ratcliff, G., 10
Namerow, N., 97 Reidy, K., 57
Newcombe, F., 10 Richards, S., 3, 16
Newman, B., 91 Ridgely, M„ 21 In, 227, 230-231
Nicholas, M., 15 Riggs, A., 221, 238
Nunnaly, E., 182 Riley, E., 91
Risser, A., 16
Rizzi, L. P., 105
O’Brien, K. P., 132
Robbins, M., 34, 38, 39
O’Connor, J. M„ 212
Robinson, R. G., 16, 97, 101, 162
Ogden, T., 58
Romano, M. D., 53
Rosenberg, S. J., 31, 36, 39, 82, 116,
Padrone, F. J., xiv, 63, 81, 82, 83, 133,
145, 169
193, 196, 202, 204, 205
Rosenthal, M., 21, 113, 197, 200
Palmer, E. P., 10
Ross, E., 99
Papagno, C., 80
Ross, T. P„ 113
Parente, R., 135 Roth, E„ 213
Parry, J. K, 191, 204 Roth, E. J., 3, 16
Parsons, O. A., 212 Roth, L., 56
Passler, M. A., 104 Rothke, S., 121
Pepping, M., xi, 36, 82, 91, 123, 167 Roueche, J. R., xi, 36, 82, 91, 167
Perani, D., 80 Rouse, L. W., 107
Perlman-Lorch, J., 15 Rust, E., 212, 213, 226
Perry, J., 52
Piasetsky, E., 151 Sackeim, H. A., 98
Pincus, J. H., 16 Saeks, S„ 100, 108, 114, 133
Pine, F., 124 Sanchez-Craig, M., 213
Poeck, K., 16 Sano, M., xii
Pokorney, A. D., 216 Satz, P„ xiii, 97, 101, 103, 106, 108
Polich, J. M., 213 Sax,D. S„ 12
Pollack, I. W., 216 Schacter, D. L„ 76, 77, 80, 109, 150,
Pollack, M., 149 168
Ponsella,J., 97 Schafer, R., 33, 119
Price, T. R., 16, 97, 162 Schechter, J., 77
Prigatano, G. P., xi, 36, 76, 77, 79, 80, Scheerer, M., 29, 34-35
82, 91, 101, 109, 125, 132, 133, Scherzer, B. P., 120
134, 167, 168, 191, 195, 201 Schmidt, M. F„ xiv, 212, 213, 227,
Prudic, J., 98 230-231
Purtillo, R., 46 Schmitt, F. A., 55
Schnoll, S., 22
Rabin, P., 10 Scott, J. G., 192
Racker, H., 115<, 116 Seligman, M., 207
Ragnarsson, K., 162 Sergent, J., 11
244 Name Index

Shade-Zeldow, Y., 213 Valler, G„ 80

Shapiro, D., 33-34, 37-38 Valliant, G. E., 213, 222
Sharkey, P. W., 212 Van Hoesen, G. W., 12
Shaver, M. S., 162 Vargo, J. W., 196
Shea, L. J. Ill, 185n Varney, N. R., 10
Sherr, R. L., xiii, 167, 169, 173 Vella, L„ 211
Siegler, M., 46, 47, 49 Venesy, B. A., 56-57, 58
Simon, D., xiii, 91, 185n Verfaellie, M., 149
Sinnott, M. C., 57 Vingilis, E., 212
Small, L., xi, 35-36
Vogenthaler, D. R., 222
Sokol, R. S., 77
Vuchinich, R. E„ 213, 214
Solomon, C. R., 120
Sparadeo, F. R., 100, 212
Walker, K., 213
Speedie, L., 15
Spence, D. P., 33 Warlow, C., 16
Spinnler, H., 9-10 Warrington, E. K., 9, 10
Spreen, O., 10 Watson, R. T., 99
Stark, K. D., 107 Wegener, S. T., 50
Starkstein, S. E., 16 Wehman, P. H„ 211, 212
Starr, L. K., 162 Weinberg, J., xiii, 149, 151, 153, 158,
Stedem, A. F., 212 160-161
Steer, R. A., 102-103 Weiner, I. B., 168
Stern, D. B., 63-64 Weiner-Davis, M., 182
Stern, J. M., 133 Weinstein, E. A., 79-80, 150
Stoduto, G., 212 Whitehouse, P.J., 52
Strauss, D., 212 Whiting, R. A., 191
Strauss, E., 16 Wilkinson, D. A., 213
Strom-Henrikson, H., 191 Williams, D., 185
Strong, J., 222 Williams, J. M., 203
Strupp, H. H„ 159
Williamson, D. J., 192
Stuss, D. T., 55
Winnicott, D. W., 115, 116
Sury, R., xii
Witol, A. D., 212
Symonds, C., 113
Wolf, E. S., 114
Synchra, J., 134, 135
Wood, B. C„ xi, 36, 82, 91, 167
Wright, B. A., 201
Taylor, A., 146
Taylor, D. C., 16
Taylor, R., 144-145 Yalom, I. D., 170, 172, 173
Terry, L. L., 191 Yarkony, G., 213
Thurstin, A. H., 77 Young, A. FL, 191, 204
Tobias, B. A., 77 Young, H. F., 211, 212
Tucker, J. A., 213, 214
Turnbull, A. P„ 194, 203 Zasler, N. D., 212
Turnbull, H. R., 194, 203 Zaucha, K., 97
Zeiner, H. K_, xi, 36, 82, 91, 167
Udvarhelyi, G. B., 212 Zeman, W., 16
 Subject Index

Abstract attitude, loss of, 29 Amnesia, modality-specific deficits of,

Abstract reasoning, assessment of, 14 12
Abstract speech patterns, difficulty Amnesic disorders, 11-12
with, 137 Amphetamine, 211
Acceptance, of disability, 196-197 Anasanosia, 20
Achromatopsia, 12 Anger
Acute care medicine, 45 with brain impairment, 171
Adaptive apparatuses, 32 management problems of, 185
Adaptive capacity Anger management groups, 172
disturbed, 34 Anixter Center, 224—225
strained, 29-30 Anosognosia, 12-13, 78, 79-80
Adaptive ego functions, 28 with brain injury, 109
Adjustment Anosognosia neglect syndrome, 109
of family members, 193 Anterograde amnesia, 11-12
to neuropsychological impairment, Anxiety
194-195 with brain injury, 16
Affect in family members, 200
with brain injury, 99-100 AOD abuse. See Alcohol abuse;
change in, 231 Substance abuse
disturbances in, with brain injury, Aphasia, 7-8
with brain injury, 20
15-16
Appointment calendar. See Date book
Aggression
Apraxia
brain injury-related, 16
with brain injury, 20
premorbid, 186
constructional, with right
Agnosia, 8—9
hemisphere injury, 10
Agraphia, 8
with parietal lobe lesions, 13
Alcohol
Aprosodia, without aphasic
in brain injury risk, 211-212
disturbances, 11
expectations about, 217-218
Arithemetic performance, 153, 155
Alcohol abuse Arousal, 79
in brain dysfunction, 212-213 Articulation deficits, 137-138
personal history of, 212 Attention
Alcohol Expectancy Questionnaire, assessment of, 14
216, 218 awareness and, 79
Alcoholics Anonymous, 225-226 deficits of, rehabilitation of, 136
Alexia, 8, 9 Auditory control, 5
All-or-nothing mental state, 180-181 Autonomy, 53-54
anger management problems and, in neurologically impaired patient,
186 53

245
246 Subject Index

Awareness. See also Attention; neurovegetative signs with, 100-101

Unawareness physical challenges associated with,
content of, 76-77 19-21
defense mechanisms and, 77-79 physical disturbances of, 16-18
emotional denial and, 75-93 premorbid conditions in, 21-22
substance abuse interventions and,

Barbiturates, 211 211-234

Basic Skill Groups, 173. See also unawareness of disability in, 75-76

Psychosocial groups Brain-injured patients

Beck Depression Inventory, 102-103 clinical phenomena of, xiii

Beck Scales for Depression, 102-103 ethical challenges in psychotherapy

Behavioral regression, 35 with, 51-67

Behavioral self-management, 35 ethical issues of treating, xii

history of psychotherapy for, 27—41
Benzodiazepines, 211
neuropsychological deficits of,
Bibliotherapy, 107-108
xi-xii
Blurred vision, 18
organic vs. psychological, 27
Body image disturbances, 8-9
Brainstorming, for self-regulation
Body schema disturbances, 8-9
strategies, 183
Borderline personality, 34
Broca’s aphasia, 7
premorbid, 37
Bracing, for spasticity, 18
CAGE, 221, 238
Brain
Caretakers, overinvolved, 110
cortical surface of, 5
Catastrophic reaction, 30
hemispheres of, 4
Central nervous system impairment,
lobes of, 4—5
98
organization of, 4-6
Cerebral hemispheres, 4
Brain dysfunction
deficits with damage to, xii
acquired versus congenital, xii
dominant injury conditions, 7-9
assessing disability with, 91
midline between, 5
awareness and defense mechanisms
nondominant injury conditions,
in, 77-79
9-11
cognitive rehabilitation therapy
Cerebrovascular accident (CVA)
for, 131-132
confidentiality of information
historic perspective on, xi
about, 60-61
substance abuse in, 212-213
refusal of treatment for, 58-60
Brain injury. See also Traumatic brain
rehabilitation after, 156-158
injury
Cervical enlargement, 6
behavioral regression in, 35 Character pathology, 38
cognitive rehabilitation programs Child Behavior Checklist, 105
for, 132 Child Depression Inventory, 104-105
in family dynamics, xiv Childish behavior, 28-29
location of, and deficit patterns, 3 Children
mild traumatic, 16-17 diagnosing depression in, 104-105
modifications in psychotherapy of disabled patient, 203
after, 168-170 Client-centeredness, 223
 Subject Index 247

Client-therapist collaboration, 229 complexities of, 67

Clinical issues, xiii for consent to medical
Cognition, 28 interventions, 56-57
neuropsychology of, 29-30 Comprehension, loss of, 7-8
processes of, in personality Comprehensive evaluation, 228
development, 31-32 Concentration, assessment of, 14
Cognitive capacity Concept formation, 14
altered, 28-29 Concretization, 169
minor impairment of, 171 Conduction aphasia, 8
Cognitive deficits Confidentiality, 60-61
with brain injury, 20 Conflict, patient-family-staff, 62-67
denial and, 222-223 Conflict-free ego sphere, 32
rehabilitation and, 38 Confrontation
treatments problems with, 222 of countertransference, 124
Cognitive rehabilitation, xiii of transference, 123-124
alternating with psychotherapy, Consciousness, loss of, 16
142-144 Consent, 56-57
definition of, 131-132 Constructional apraxia, 10
discomfort with use of, in Constructivism, 49
psychotherapy, 141-142 Contracting, for impulsivity and
integration of, into psychotherapy, impaired self-control, 138-139
135-142 Contractual decision making model,
with organic brain syndromes, 47-48
3^-37 Control, loss of, 52
in psychotherapy, 131-146 Coping skill training, 228
psychotherapy and, 132-133 Cortical vulnerability, 31
in psychotherapy with Cost controls, 49
neuropsychologically Counseling
impaired clients, 134—135 getting started with, 232-233
Cognitive retraining, 156-158 skills based substance abuse
Cognitive rigidity, 36 prevention, 227, 228-230
Cognitive structures, building, 91-92 systematic motivational, 227,
Cognitive style, 32-33 230-233
neurotic, 33—34, 38 Countertransference
in psychotherapy for organic brain complementary and concordant,
syndromes, 37-39 115-116
Cognitive-behavioral therapy, 106—107 concordant and complimentary,
Color, apperception of, 9-10 124
Color perception deficits, 9-10 in family members, 205-206
Communication deficits issues of, xiii
cognitive rehabilitation techniques models of, 115—116
with, 137-138 to multiple aspects of patient,
treatments problems with, 222 121-122
Communication skills, 20 paradigms of, in brain injury/
Community resources, referral to, 206 stroke patient therapy, xiii
Competency, 54-55 processing, 125
248 Subject Index

in relational-perspectivistic model, assessment of, 101-105

50-51 with brain impairment, 171
with traumatic brain injury with brain injury, 15-16
patients, 115-125 in brain injury/stroke patients, xiii
Couples, coping with disability, in children, 104-105
202-203 differential diagnosis and treatment
Cranial nerve injury of, xiii
physical challenges of, 3 emotional denial and, 83-84
physical symptoms of, 18 narcissistic attachment to source
Cross-agency cooperation, 225-226 of, 118-119
Cylert, 108 neuropsychological impairment
symptoms of, 99-101
Dangerousness, 61 prevalence of, 97
case example of, 61-62 psychotherapy for, 106-110
Date book, 136, 139-140 severity of neuropsychological
Decision making, competence for, deficits and, 100
54-55 symptoms of, 97-98
Defenses treatment of, 98
in brain dysfunction, 77-79 Depth perception deficits, 10
against diminished awareness, Dexedrine, 108
150-151 Diagnostic related groups, 49
Defensive functions, xiii Diary-keeping
Deficits of internal thoughts, 106-107
denial of, 36, 63-64 for memory loss, 107
determinants of patterns of, 3 Diencephalic damage,
incomplete awareness of, 63 neurovegetative signs with, 101
unawareness of, xiii. See also Differential diagnosis, depression, xiii
Unawareness Diplopia, 18
Delirium, drug-related, 213 Disability
Dementia acceptance of, 196-197
depression with, 98 awareness of, 76-93
substance abuse in, 213 emotional stress of coping with,
Denial. See also Emotional denial; 195-196
Unawareness family impact of, 192-195
awareness and, 75-93 guilt about, 196
cognitive deficits and, 222-223 meaning of, 203-204
as defense, 77-79 misunderstandings about, 198
defensive, 89-91 onset of, 201
ego-protective function of, 36 period of life of, 203
emotional, 82-84 preexisting relationships and,
emphasis on, 113 204-205
of neurological deficit, 63-64 severity of, 200-201
pathogenic, 78 with spinal cord injury, 18-19
treatment implications of, 91-93 unawareness of, 75-76
of visual inattention, 160-161 Disinhibition, 119
Depression Dissociation, 63-64
 Subject Index 249

Distorted attributions, 150-151 Emotional stress, 195-196

Distractibility, 79 Emotional syndromes, 37
Dizziness, 18 Emotions
Dominant hemisphere injuries, ability to process, 79
conditions associated with, 7-9 difficulty expressing, 140-141
Double simultaneous stimulation impact of, 140
extinction, 12 integration of, 81-82
Driving, 20 Empathy, 92-93
Drug abuse. See Alcohol abuse; Enabling behaviors, 219
Substance abuse Environmental conditions
Dysarthria, 18 in substance abuse risk, 218
Dyslexia, acquired, 103 vulnerability to, 183, 184
Dysphagia, 19 Ethical decision making, 46, 54-55
Dysphoria, 105 case examples of, 58-62
contractual model of, 47-48
Echolalia, 8 educational model of, 48
Education, for family of disabled relational-perspectivistic model of,
patient, 197-198 48-51
Educational decision making model, traditional model of, 46-47
48 Ethics, xii, 45-68
Ego Etiological view, 40
autonomy of, 32 Euphoria, 15
organizational levels of, and Exaggerated speech, 137-138
transference, 119-120 Executive processing deficits, 138
psychological constructs of, 113 Expressive aphasia, 7
Ego defenses, 113 Expressive communication deficits,
need for, 77-78 137-138
resistance to psychotherapeutic Extrasylvian sensory area injury, 8
approach of, 36
Ego functions Facial discrimination impairment, 11
adaptive, 28 Facial muscles, control of, 4
strengthening, 92 Facial paralysis, 18
Egocentricity, 79 Family
Emotional denial. See also Denial; adjustment process for, 193
Unawareness conflict with, 62-67
versus cognitive unawareness, 83 of depressed brain-injured patient,
depression and, 83-84 109-110
signs and symptoms of, 82 destabilizing dynamics of, xiv
Emotional disinhibition, 183-184 disability and, 192-195
anger and, 185 education about disability, 197-198
Emotional experience, 15-16 psychotherapeutic issues in
Emotional expression treating, 191-208
with brain injury, 15-16 relationship of members to disabled
control of, 5 patients, 202
lack of control over, 173-174 stress experienced by, 192
Emotional reactions, xiii as substance abuse risk factor, 217
250 Subject Index

team meetings with, 68 Halstead Reitan Battery, 13

Family intervention, 198-199 Handicappism, 221
initiation of therapy, 199-206 Head injury
recommendations for, 206-207 closed, 86-87
Fear mild deficits of, 16-17
with brain injury, 16 unawareness and denial following,
with neurological impairment, 52 84-86
in refusing treatment, 58 Hearing impairment, traumatic, 18
Feedback, psychosocial group, Hedonism, 53
178-179 Helplessness, 52
Feeding problems Hemiparesis, 20
with brain injury, 19 Hemiplegia
with spinal cord injury, 18 with brain injury, 20
Feeling states, confusion over, 36 neuropsychological deficits with, 3
Financial concerns, 49 Hemisensory loss, 88-89
Fluent speech problems, 7-8 Heschl’s gyrus, 5
Focal neurological deficit, 16 Homemaking skills, 20
Friendships, loss of, 170-171 Hope, compromised, 62-63
Frontal hematomas, bilateral, 61-62 Hue discrimination disturbance, 12
Frontal lobe, 4-5 Humpty Dumpty syndrome, 114
affective change with injury to, 100 Hygiene skills, 19-20

executive functions of, 5

Frustration, 216-217 Ideomotor apraxia, 8
with parietal lobe lesions, 13

Generalization, 228-229 Immature behavior, 30

Immature defenses, 35
Goal-directed strategies, 224
Implication, 81
Goal-setting, in systematic
Impulsive response, ability to
motivational counseling, 232
restrain, 29-30
Group interaction techniques, 170
Impulsivity, 138-139
Group psychotherapy, xiii-xiv,
Incentives, in substance abuse
187-188
counseling, 231
adaptations to brain-injured
Independent living skills, 20-21
patients, 168-170
Inhibitory processes, 5
for anger management, 185-187
Injury, narcissistic attachment to,
overview of, 167-168
118-119
for psychological and psychosocial
Insight
problems, 172-180
cognitive rehabilitation techniques
self-reflective psychosocial
with impairment of, 138-139
adaptation in, 36
into emotional responses, 141-142
for self-regulation, 180-185
process of attaining, 123
Group structure, rationale for,
into transference, 123-124
172-173
Insurance, health care, 49
Guilt
Interdisciplinary services, 224
about disability, 196 Interdisciplinary team, 125
in family members, 199-200 Internalization, 32
 Subject Index 251

Interpersonal orientation, 53 compensatory devices for, 107-108

Interpersonal skills building, 175 with mild traumatic brain injury, 16
Intoxication, frequent, 219-220 temporal vs. nontemporal, 12
treatments problems with, 222
Judgment deficit, 20 Mental state, altered, 16
Mental status, awareness and, 79

Language center, 5 Metacognition, 135, 142

Language function, assessment of, 14 Michigan Alcohol Screening Test, 216

Mirroring response, 116
Language-based conditions, 7—8
Mobility, 20
Learning
Mood
assessment of, 14
change in, with brain injury,
awareness and, 79
99-100, 109
Left hemianopsia, 156-158
self-report measures of, 103-104
Left hemiplegia, 156-158
Motivational counseling, systematic,
Left hemisphere brain injury
227, 230-233
communication deficits with, 137
Motivational enhancement, 228
depression with, 15-16
Motivational model, 231-232
unawareness and denial following,
Motivational Structure Questionnaire
84-86
(MSQ), 232
Libido, 16
Motor area injury, 8
Life satisfaction, factors determining,
Motor control, 4-5
52
Motor strip, 4
Limbic system
Motor vehicle accidents, 86-87
affective change with damage to,
substance abuse in, 212
100 Motor-useful injuries, 6
in emotion, 16
Motor-useless injuries, 6
neurovegetative signs with damage MTBI. See Brain injury, mild traumatic
to, 101 Multidimensional programs, 224
Location in space deficits, 10
Loose associations, 36
Narcissism, 170
Lumbar enlargement, 6 Narcissistic personality, 34
National Head Injury Association, 206
Marijuana abuse, 211 Neglect. See also Spatial neglect;
Medical interventions Unawareness; Visual
consent to, 56-57 inattention
refusal of, 57-61 with nondominant hemisphere
Medical paternalism, 46-47 injury, 9
Memory right, 8
assessment of, 14 Neural connections, ascending and
awareness and, 79 descending pathways of, 6
Memory devices, external, 139—140 Neurodiagnostic evaluation, 102
Memory loss Neurological impairment
with brain injury, 11-12 conditions associated with, 11-13
cognitive rehabilitation techniques emotions associated with, 52-53
with, 136-137 perspectives on purposeful
252 Subject Index

existence with, 53 Organic personality, 28-31

Neuromedical research, 27 Orthographic errors, 9
Neuropsychodiagnosis in Psychotherapy
(Small), xi Paralysis
Neuropsychological assessment neuropsychological deficits with, 3
approaches to, 13-14 with spinal cord injury, 19
issues of, 13-15 Paranoid personality, 34
Neuropsychological functions, 79 Parent, of disabled patient, 203
Neuropsychological impairment Paresis, 3
adjustment challenges of, 194—195 Parietal embolic infarct, 152-156
affective disturbances and, 15-16 Parietal lobes, 4—5
assessing depression with, 101-105 conditions associated with lesions
depression and severity of, 100 of, 12-13
depressive symptoms associated functions of, 5
with, 99-101 Parietal-occipital cortex lesions, 103
identifying, 140-142 Paternalism, 46-47
impact on therapeutic process, 133 Pathological traits, 33
openness to change with, 133—134 Perceptual remediation
psychosocial impact of, 170-171 case examples of, 152-158
psychotherapy for depression with, modeling in, 160
106-110 for visual neglect, 152-162
therapeutic intervention for, 3-23 Personality
Neurosis, 33, 38 brain injury-related change in, 109
Neurotic cognitive style, 33-34 functional disorders of, 41
with primitive personality, 37-38 organic, 28-31
Neurovegetative signs, 100-101 premorbid, 56-37
Nondominant hemisphere injuries, primitive, 31-34
conditions associated with, in psychotherapy for organic brain
9-11 syndromes, 37-39
Nystagmus, 18 as substance abuse risk factor, 217
Personality disorder, 38
Objective reality, 49 Personality Inventory for Children-
Obsessive-compulsive behavior, 30 Revised, 105
Occipital lobes Phrenic nerve pacemaker, 18
conditions associated with lesions Physical disability
of, 12 with neuropsychological
functions of, 5-6 impairment, 3
Occupational functioning, 101 psychological adjustment to, 191
Opiates, 211 with spinal cord injury, 18-19
Orbitofrontal injury, 119-120 Placidity, 16
Organic brain dysfunction, xi Plasticity, turning on, 134
Organic brain syndromes, xii Plegia, 3
cognitive rehabilitation and Pluralism, 52
psychotherapy with, 34-37 Premorbid personality, 36-37
neuropsychodynamic conceptu¬ Primitive personality, 31-34
alization of, 34—35 in organic brain syndromes, 37-38
 Subject Index 253

psychotherapy with, 38-39 ethical challenges in, 51-67

refractoriness of, 39 for family of disabled patient,
Problem-solving skills, 142 192-208
Projective identification, 57-58, 59-60 group,167-188
Prosopagnosia, 12 history of, with brain injury
Protective mechanisms, 30 patients, 27-41
Pseudodementia, 98 integrating cognitive rehabilitation
differential diagnosis of, 102 techniques into, 135-142
Pseudodepression, 97-98 modification of, after brain injury,
Pseudoinsight, 38 168-170
Psychiatric problems, premorbid, 59 with organic brain syndromes,
Psychological factors, 22 34-37
Psychological problems, 172-180 personality and cognitive style in,
Psychological self, loss of, 108
37-39
Psychosocial groups, 173-174
process of, 114-115
exercises and approaches in,
purpose of, xiv
177-180
special training in, 206-207
format of, 176-177
for unawareness, 92-93
individualized goals in, 174
levels of, 174-176
Quadrantopsia, superior, 7
rationale for, 172-173
Quality of life
Psychosocial problems
complexity of, 50
group psychotherapy for, 172-180
ethical challenge of, 52-53
with neuropsychological
impairment, 170-171
RAFFT screening instrument, 221, 238
Psychotherapy
Rage, 16
alternating with cognitive
Rationalization
rehabilitation techniques,
of failure, 150-152
142-144
of visual inattention, 149, 161
awareness and denial in, 75-93
for brain dysfunction, xi Receptive aphasia, 7-8

central goal of, 131 Referral network, 108-109

cognitive rehabilitation and, xiii, Regression, 119-120

132-133 Rehabilitation. See also Cognitive

cognitive rehabilitation techniques rehabilitation

in, 131-146 versus acute care medicine, 45
cognitively oriented cognitive techniques in, 131-146
psychodynamic, 39 ethical challenges of, 45-68
contemporary models of, 40 for left hemianopsia and left
curative factors in, 114 hemiplegia, 156-158
for depression with neuropsychological assessment for,
neuropsychological 13-15
impairment, 106-110 psychotherapeutic techniques in,
development of therapeutic xiii
approaches in, xii-xiii stages of, 201-202
efficacy of, 39-41 values in, 49-50
254 Subject Index

Rehabilitative view, 40 modules and exercises for, 182-185

Rehearsal, 137 structure of, 181

Relation-perspectivistic model, 48—51 Self-regulation problems, 180-181
Remedial techniques, 153-154 anger and, 185
Remediator feedback, 159-160 Self-reporting, in children, 105
Repetition, 136-137 Self-statements, 138
disruption of, 7, 8 Self-talk, disparaging, 183, 184
in level 1 psychosocial groups, 174 Sensations
Resistance control of, 4-5
cognitive based, 169 dysfunctional, 17-18
in family members, 199-200 Sensory cortex, 4
Respirators, 18 Sensory deficits, 80-81
Response style, 151-152 Sensory disturbances, subtle, 12-13
Retraining, post-brain injury, 22 Sensory strip, 4, 5
Retrograde amnesia, 12 Sensory-only injuries, 6
Right hemisphere lesions, 15 Sexual intercourse, loss of, 202-203
Ritalin, 108 Sexuality, 202-203
Role playing Shame, about disability, 197
for anger management, 186, 187 Sibling, of disabled patient, 203
in psychosocial groups, 175, Simultanagnosia, 8-9
178-179 Skills based substance abuse
for self-regulation problems, prevention counseling, 227,
182-183 228-230
Rusk Institute of Rehabilitation Social constructivism, 49
Medicine, Neuropsychology Social contacts, loss of, 170-171
Service of Psychology Social dislocation, 216
Department, 167 Social functioning
with brain impairment, 171
Schizoid personality, 34 in depression, 101
Self, 113 Social interactions, psychosocial
Self-care activities, 19 group, 175
Self-cohesion, loss of, 52 Social isolation, 221
Self-control deficit, 138-139 Social risk factors, 218
Self-efficacy, 113 Social skills
Self-esteem, 204-205 awareness of limitations of, 174-175
Self-feeding abilities, 18-19 exercises for, 177-178
Self-help groups, cross-training with, in psychosocial groups, 174-175
225-226 Social withdrawal, 171
Selfhood concept, 28 Solution-focused interviewing, 182
Self-integration, 143-144 for anger management, 186, 187
Self-management, behavioral, 35 Spasticity, 18
Self-reflective psychosocial Spatial neglect, 149-150. See also
adaptation, 36 Visual inattention
Self-regulation, defining breakdowns SPECT imaging, 134
in, 182 Speech, nonfluent, 8
Self-regulation groups, 172, 180-181 Speech therapy, 137-138
 Subject Index 255

staff-family conflicts over, 64-65 personal history of, 212

Spinal cord, organization of, 6 prevention of, 214-234
Spinal cord injury relapses in, 213-214
C2 to C7 lesions, 18-19 screening for risk factors in,
C-8 to T-l lesions, 19 215-219
complete vs. incomplete, 6 screening for symptoms of, 219-221
disability issues of, 18-19 screening techniques for, 215
mild traumatic brain injury with, 16 skills based prevention counseling,
physical challenges and 228-233
neuropsychological deficits specialized intervention protocols
of, 3 for brain injury with, 227
Spinal nerves, 6 symptom checklist for, 219-221
Spouse, of disabled patient, 202-203 Substance abuse interventions,
Staff-family/patient conflict, 62-67 211-234
case example of, 64-67 effective strategies in, 223-224
Stereopsis, 10 individualized, 223
Stroke strategies for, 221-225
denial following, 89-91 Substance Abuse Resources and
in family dynamics, xiv Disability (SARDI) Project,
neuropsychological deficits with, 4 symptom checklist of, 219-221
right hemisphere, 88-89 Support groups
survival rate with, 191 for family members, 197
treatment of, xi in substance abuse treatment,
unawareness following, 87-88 225-226
Stroke: Why Do They Behave That Way ? Supramarginal gyrus lesions,
(Fowler, Fordyce), 197 conditions with, 12-13
Stroke Clubs, 206 Symbolism, 137
Stroke patients Systematic motivational counseling,
clinical phenomena of, xiii 227, 230-232
ethical issues of treating, xii getting started with, 232-233
Structural analysis, family, 193-194 Systems approach, 193-194
Structured group presentations, 175
Structured worksheets T-2 to L-3 lesions, 19
for anger management, 186 TBI Network, 226-227
for self-regulation, 182 Temporal lobes, 5
Substance abuse, xiv lesions of, 103
in brain dysfunction, 212-213 Temporoparietal subdural
before brain injury, 22 hematoma, 84—86
in brain injury risk, 211-212 Tension discharge capacity, 28-31
brief screening tools for, 221 Therapeutic alliance, 115
collaborating with existing in treating awareness problems, 92
treatment programs for, Therapeutic relationship, 114-115
225-227 in case illustration, 116-118
denial of, 222-223 negative feelings in, 117-118
functional-independent living skills Thoracic nerves, 6
and, 224 Thought quality, 79
256 Subject Index

Tonal fluctuation disturbance, 11 etiology of, 76

Topographic disorientation, 10 following closed head injury, 86-87
Transference models of, 79-82
content of, 119-120 neurogenic sources of, 80
ego organization level and, 119-120 neurogenic versus emotional
gender and, 120-121 sources of, 82-84
lesion locus and, 119-121 neuropsychological source of, 79
models of, 115-116
resistance to knowledge of, 160-161
paradigms for, in brain injury/
treatment implications of, 91-93
stroke patient therapy, xiii
treatment problems with, 222
processing, 125
tripartite model of, 81-82
in relational-perspectivistic model,
50-51 in visual inattention treatment,
teaching patients about, 123-124 149-162
with traumatic brain injury Utilitarianism, 53
patients, 115-125
Trauma, dissociation in response to, Values, 49-50
63-64 in quality of life, 52
Traumatic brain injury. See also Brain Verbal assessment, 14
injury Visual cortex, 5-6
incidence of, 211 Visual elaboration, 137
mild, 16-17
Visual field, 5—6
staff-family conflicts after, 64—67
Visual field defects, 9
survival rate with, 191
with location in space deficits, 10
symptoms of, 16-18
with traumatic brain injury, 17-18,
transference and
18 '
countertransference in
psychotherapy for, 113-125 Visual imagery deficit, 11
treatment of, xi Visual inattention. See Visual neglect
Treatment Visual memory assessment, 14
refusal of, 57-61 Visual neglect, 9, 149-162- See also
specialized approaches in, xiii-xiv Neglect
Treatment frame, 114—115 with brain injury, 20
Twelve Step groups, 225-226 Visuoconstructional deficits, 10
Visuospatial abilities, 5
Unawareness. See also Awareness; Visuospatial deficits
Denial with dominant hemisphere injury,
assessment issues for, 91
10
with brain injury, 75-76
with nondominant hemisphere
case examples of, 84—91
injury, 9-11
as defense, 78-79
Vitalism, 53
with defensive denial, 89-91
degrees of, 151-152 Vulnerability, 52
due to sensory deficits, 80-81
versus emotional denial, 83 WAIS-R. See Wechsler Adult
emotional-defensive source of, Intelligence Scale-Revised
78-79 “Walking Tall” (Taylor), 146
 Subject Index 257

Wechsler Adult Intelligence Scale- Word-finding

Revised, 14 assistance with, 137
Wernicke’s aphasia, 7-8 difficulty with, 7
Wheelchair, 18-19 Worksheets, anger management, 187
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