The Understanding Brain Injury (UBI) Group, it could be argued, is the most important group of the programme at the Oliver Zangwill Centre (OZC) for Neuropsychological Rehabilitation. It is, perhaps, the main way of helping clients understand what has happened to them, how they have been affected by their brain injuries and what kind of recovery to expect. This information forms the basis of increasing awareness and self-esteem, and significantly contributes to the process of developing both a ‘shared understanding’ and a safe ‘therapeutic milieu’ as described in Chapter 4. Although the consequences of brain injury (e.g. memory, attention and emotional problems) are covered in more detail in other groups, without the knowledge and acceptance that we try to instil in the UBI Group, the other groups are thought to be less likely to succeed.
Central to the philosophy of the Centre is giving clients, where possible, the opportunity to develop good awareness of their strengths and weaknesses, and learn to self-advocate. Brain injury can be a bewildering experience, particularly in the context of cognitive impairments that make it more difficult to notice, understand or respond to problems. For the vast majority of clients, knowledge of brain injury and its consequences is limited to the client's own prior experience of it. One of the aims of the UBI Group is to normalize the consequences of brain injury; the educational, seminar-style format is used to describe how the brain works and how it may be affected by injury.
In order to illustrate our developing approach to interdisciplinary rehabilitation, we describe our work with Yusuf. He was one of the first clients with whom teamwork was organized across a range of impairments, activities and contexts, which in turn fed into increased social participation in one key goal area. The work also provides a good example of formulation-based rehabilitation, which provides a means of integrating assessment results, and developing a ‘shared understanding’ across the team and with the client. Since our work with this client we have sought to develop these principles further to become formalized aspects of the rehabilitation programme, as described in the ‘core components’ (Chapter 4), and in more detail in our work with Judith (Chapter 17). The case also highlights specific successful interdisciplinary interventions for pain and fatigue delivered as part of the integrated rehabilitation programme.
History of injury
Yusuf was involved in a car accident in May 1998. He was in coma for a week, and post-traumatic amnesia was reported to last for about a month, indicating a very severe head injury. Computerized tomography (CT) scans at the time of injury identified a left fronto-temporo-parietal subdural haematoma, which was causing some mass effect on the left cerebral hemisphere and left lateral ventricle.
Yusuf was a 35-year-old man (32 at time of injury) who lived with his wife and three young children.
The Oliver Zangwill Centre (OZC) for Neuropsychological Rehabilitation opened in 1996 and was modelled on the American holistic programmes developed by Yehuda Ben-Yishay and George Prigatano. It was named after Oliver Louis Zangwill, Professor of Psychology at Cambridge University between 1954 and 1984. He was also a pioneer of brain injury rehabilitation in Great Britain during the Second World War when he worked in Edinburgh with brain injured soldiers. The Centre follows many of the principles laid down by Ben-Yishay (1978), Prigatano et al. (1986) and Christensen and Teasdale (1995), and is also significantly influenced by the critical ‘scientist practitioner’ model of clinical psychology adopted in the United Kingdom.
A holistic approach to brain injury rehabilitation ‘… consists of well-integrated interventions that exceed in scope, as well as in kind, those highly specific and circumscribed interventions which are usually subsumed under the term “cognitive remediation”’ (Ben-Yishay and Prigatano, 1990; p. 40). The holistic approach recognizes that it does not make sense to separate the cognitive, emotional and social consequences of brain injury as how we feel and think affects how we behave. Ben-Yishay's (1978) model follows a hierarchy of stages through which the patient or client should work in rehabilitation. These stages are engagement, awareness, mastery, control, acceptance and identity. Individual and group sessions are provided to enable patients to work through these stages.
The origins of the OZC go back to 1993 when one of us (BAW) spent several weeks at Prigatano's unit in Phoenix Arizona.
Peter was one of the early clients at the Oliver Zangwill Centre for Neuropsychological Rehabilitation and this chapter gives a typical picture of the process of assessment and rehabilitation for our clients. We begin with a summary of the report from his preliminary (one-day) assessment as this details his major problems, his own and his wife's perceptions of his difficulties together with the staff's assessment of these.
Preliminary assessment report
History of injury
Peter was involved in a road traffic accident in July 1997 in which he sustained a severe traumatic head injury. At the time he was 33 years old. He was taken to the nearest hospital and then transferred to the Regional Neurointensive Critical Care Unit where he remained for one week, before being referred back to his local hospital. He stayed there for seven weeks. It is not clear how long he remained unconscious, but the notes from the Critical Care Unit say he had a head-on collision in a built-up area. His Glasgow Coma Score at the scene was 15 but by the following day had deteriorated to 11 and then to 7. It would appear that he had a post-traumatic amnesia of around 5–6 weeks. His retrograde amnesia, however, lasted only a few seconds. A CT scan of Peter's brain showed bilateral areas of attenuation in the temporo-parietal regions consistent with a cerebrovascular accident. This was subsequently found to be due to bilateral carotid artery dissection.
How should we plan and evaluate rehabilitation? We will argue here that the most appropriate way to plan, direct and measure the success of rehabilitation is through the process of goal setting. If neuropsychological rehabilitation is ultimately concerned with enabling people with brain injury to participate effectively in valued activities, then it follows that we should measure the outcome of an individual's rehabilitation programme in terms of whether or not the programme enables that individual to achieve his/her personal goals. If outcome is defined in terms of personal goals, then it makes sense that these goals should be the central focus when planning the specific components of a rehabilitation programme.
In relation to evaluation of outcome, if one is evaluating a specific treatment intervention that aims to improve a particular cognitive function, then it is useful to have an assessment of that cognitive function as an outcome measure. However, even when evaluating a specific treatment it is important to measure the extent to which the intervention improves the client's functioning in his/her everyday life. Some studies aiming to evaluate cognitive or neuropsychological rehabilitation programmes use standardized neuropsychological tests as their main, or only, outcome measure (see, for example, the studies reviewed by Carney et al., 1999). We would argue that use of such tests, on their own, either to plan or to evaluate rehabilitation programmes is wrong.
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