Abstract

Psychosocial Rehabilitation

A process that facilitates the opportunity for individuals - who are impaired, disabled or handicapped by any disorder or trauma- to reach their optimal level of independent functioning in the community.This type of intervention focuses on the functioning of persons, improving their personal and social skills and providing support to the different roles undertaken in their social and community lives.

Neuropsychological rehabilitation 

Neuropsychological rehabilitation is concerned with the amelioration of cognitive, emotional, psychosocial, and behavioral deficits caused by an insult to the brain

Comparison of psychosocial rehabilitation with the traditional medical models of care

Aspect of Care	Psychosocial rehabilitation	Traditional medical rehabilitation
Focus	Focus on wellness and health not symptoms	Focus on disease, illness and symptoms
Basis	Person’s abilities and functional behavior	Based on person’s disabilities and intrapsychic functioning
Setting	Care giving in natural settings	Treatment in institutional settings
Relationship	Adult to adult relationship	Expert to patient relationship
Decision making	Case management in partnership with patient	Physician makes decision and prescribes treatment
Emphasis	Emphasis on strengths and interdependence	Emphasis on dependence and compliance

Psychosocial Rehabilitation Team

It is a multidisciplinary team comprising all the members of the health care team in order to give holistic care to the patients.

Principles of Psychosocial Rehabilitation

Based on the belief that all people have the capacity to learn and grow.

• Hope is a crucial and necessary ingredient of the rehabilitation process.
• All people should be treated with respect and dignity.
• The person, not the illness is the focus of Psychosocial Rehabilitation.
• Self-determination and Empowerment- The person with acquired brain injury should be an active partner in the rehabilitation process, for making the decisions of everyday life

Neuropsychological (NP) Deficits in TBI

• Acute (or time limited) NP difficulties
  • Arousal, alertness, orientation
  • Post-traumatic amnesia
  • Aphasia and neglect
• Chronic (long-term) Impairments
  • Attention
  • Memory
  • Executive functioning, concept formation, planning, information processing speed

Common Cognitive Deficits

• Executive Functions
  • Reasoning
  • Problem solving
  • Self-monitoring
  • Emotional and behavioral control
  • Insight and judgment
• Memory
  • Working memory
  • Short-term and long-term memory
• Related to “Deficit Syndromes”
  • Isolation, withdrawal, apathy, low motivation
• Related to Cognitive Changes
  • Poor judgment, inability to comprehend consequences, poor decision making, perseveration, impaired memory and concentration, difficulty adjusting to the unexpected

Interventions for Behavioral Problems after Brain Injury

• Take Proactive Measures
  • Developing Trusting Relationships
  • Understanding the Behavior
  • Recognizing and Responding to Precursors
• Insight Oriented Psychotherapy

A process to gain more awareness and insight into our thoughts, feelings, and behaviors (Pologe, 2001). This type of therapy requires the individual to attend to task, maintain thought process, recall what is occurring (or occurred) during therapy, use reason, and develop insight.

• Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) is a type of psychotherapeutic treatment that helps people learn how to identify and change destructive or disturbing thought patterns that have a negative influence on behavior and emotions. Cognitive behavioral therapy focuses on changing the automatic negative thoughts that can contribute to and worsen emotional difficulties, depression, and anxiety. These spontaneous negative thoughts have a detrimental influence on mood.Through CBT; these thoughts are identified, challenged, and replaced with more objective, realistic thoughts.

Types of Cognitive Behavioral Therapy

CBT encompasses a range of techniques and approaches that address thoughts, emotions, and behaviors. These can range from structured psychotherapies to self-help materials. There are a number of specific types of therapeutic approaches that involve CBT, including:

• Cognitive therapy centers on identifying and changing inaccurate or Distorted thinking patterns, emotional responses, and behaviors.2

• Dialectical behavior therapy (DBT): addresses thoughts and behaviors while incorporating strategies such as emotional regulation and mindfulness.

• Multimodal therapy suggests that psychological issues must be treated by addressing seven different but interconnected modalities: behavior, affect, sensation, imagery, cognition, interpersonal factors, and drug/biological considerations.3

• Rational emotive behavior therapy (REBT): Involves identifying irrational beliefs, actively challenging these beliefs, and finally learning to recognize and change these thought patterns.

While each type of cognitive-behavioral therapy takes a different approach, all work to address the underlying thought patterns that contribute to psychological distress.

CBT Techniques

CBT is about more than identifying thought patterns; it is focused on using a wide range of strategies to help people overcome these thoughts. Techniques may include journaling, role-playing, relaxation techniques, and mental distractions.4

Identifying Negative Thoughts

It is important to learn how thoughts, feelings, and situations can contribute to maladaptive behaviors.5 The process can be difficult, especially for people who struggle with introspection, but it can ultimately lead to self-discovery and insights that are an essential part of the treatment process.

Practicing New Skills

It is important to start practicing new skills that can then be put in to use in real-world situations. For example, a person with a substance use disorder might start practicing new coping skills and rehearsing ways to avoid or deal with social situations that could potentially trigger a relapse.

Goal-Setting

Goal setting can an important step in recovery from mental illness and helping you make changes to improve your health and life. During CBT, a therapist can help with goal-setting skills by teaching you how to identify your goal, distinguish between short- and long-term goals, set SMART (specific, measurable, attainable, relevant, time-based) goals, and focus on the process as much as the end outcome.

Problem-Solving

Learning problem solving skills can help you identify and solve problems that arise from life stressors, both big and small, and reduce the negative impact of psychological and physical illness.

Problem solving in CBT often involves five steps:

• Identifying a problem
• Generating a list of possible solutions
• Evaluating the strengths and weaknesses of each possible solution
• Choosing a solution to implement
• Implementing the solution6

Self-Monitoring

Also known as diary work, self-monitoring is an important part of CBT that involves tracking behaviors, symptoms, or experiences over time and sharing them with your therapist. Self-monitoring can help provide your therapist with the information needed to provide the best treatment. For example, for people coping

Behavior Therapy
This form of therapy seeks to identify and help change potentially self-destructive or unhealthy behaviors. It functions on the idea that all behaviors are learned and that unhealthy behavior can be changed.

Concepts in Behavior Therapy

Positive reinforcement

Positive reinforcement occurs when a desirable event or stimulus is presented as a consequence of a behavior and the chance that this behavior will manifest in similar environments increases.[13]:?253?

• Example: Whenever a rat presses a button, it gets a treat. If the rat starts pressing the button more often, the treat serves to positively reinforce this behavior.
• Example: A father gives candy to his daughter when she tidies up her toys. If the frequency of picking up the toys increases, the candy is a positive reinforcer (to reinforce the behavior of cleaning up).

Negative reinforcement

Negative reinforcement occurs when the rate of behavior increases because anaversive event or stimulus is removed or prevented from happening.[13]:?253?

• Example: A child cleans their room, and this behavior is followed by the parent stopping "nagging" or asking the child repeatedly to do so. Here, the nagging serves to negatively reinforce the behavior of cleaning because the child wants to remove that aversive stimulus of nagging.

Differential reinforcement

Differential Reinforcement is the implementation of reinforcing only the appropriate response (or behavior you wish to increase) and applying extinction to all other responses. Extinction is the discontinuing of a reinforcement of a previously reinforced behaviour.  A basic principle of differential reinforcement is the concept of discrimination. Discrimination is developed through differential reinforcement by determining when reinforcement is and is not received.  An example of differential reinforcement is rewarding a child for brushing their teeth before bedtime and withholding the reward when the child does not brush their teeth before bedtime. Differential Reinforcement of Other Behaviors (DRO) – Also known as omission training procedures – an instrumental conditioning procedure in which a positive reinforcement is periodically delivered only if the participant does something other than the target response.

• Example: Reinforcing any hand action other than nose picking.

Differential Reinforcement of Alternate Behaviors (DRA) – is the reinforcement of behaviors which serve as alternatives to problem or inappropriate behavior, especially alternative means of communication.

• Example:A child could be taught to present his teacher with a PECS icon for a break from work instead of using tantrums to escape his undesired activity.

Differential Reinforcement of Incompatible Behaviors (DRI) – is the reinforcement of behaviors which are incompatible with problem or inappropriate behaviors that are behaviors which the child cannot be doing simultaneously.

• Example:If a child is constantly touching his neighbors during play time, he could be encouraged by reinforcements for keeping his hands in his lap or sitting on them.

Differential Reinforcement of Lesser Rates of Behavior (DRL) – is the reinforcing of periods of time in which the child exhibits the behavior at a predetermined lesser rate.

• Example:When a child stands up in class ten times in an hour, he can be reinforced by standing only five times in an hour.

Social rehabilitation services

the achievement of a higher level of independent functioning and social participation by individuals with physical impairments or disabilities through assistance with their activities of daily living as well as with employment, transportation, and appropriate housing. It helps with the basic social skills, interpersonal skills, problem solving skills and recrearion activities. Problem-solving techniques allow the individual to develop conflict resolution skills. For individuals with TBI, this type of training can be especially useful as many individuals have difficulty expressing themselves, which often results in frustration and maladaptive responses. Denmark and Gemeinhardt (2002) suggest that role modeling the problem situations in a safe environment is the most beneficial. The role-playing allows the individual to learn appropriate responses or strategies at his/her own rate. It also provides opportunities for repetition and rehearsal of skills.

Cognitive Rehabilitation- interventions

• Recall Strategies
  • Mneumonics
  • Chunking
  • Cueing
• Specific interventions
  • Face Name Recall
  • Number Recall
  • Story Recall
  • List/object recall
  • Procedural Memory
• Additional Support
  • Memory aids
  • Environmental adaptation
  • Relaxation

Vocational Rehabilitation

Vocational rehabilitation provides the person with neurotrauma to become productive and contributing member of the community. It includes pre-vocational training, vocational training, career counselling, job placement, and ongoing job support. Pre-vocational work provides an opportunity for the person to improve work tolerance and improve self-image. Activities develop confidence in: Following instructions, Being accurate, Learning to correct oneself, Accepting criticism, Getting along with co-workers and supervisors and Taking initiative.

Role of family

Psychosocial disorders are distressing to families, disruptive to therapy and can jeopardise patient safety. The family has to cope with these disorders. It is therefore important to address the needs of these clients and their families to minimize distress and problems as well as to facilitate and maximize the coping resources and skills of these individuals. The family also plays an important role in both the sustenance of problem behaviors' and the development of adaptive functioning.

Technological advancements in psychosocial rehabilitation

• Computer Assisted Cognitive Retraining (CACR)
• Current programs target specific deficit areas such as

  attention	visual tracking/scanning
  concentration	planning/organization
  impulsivity	sequencing
  distractibility	inattention/neglect
  eye-hand coordination	reasoning/abstraction
  thinking	problem solving
  performance speed	Quality control/self
  cognitive endurance	monitoring
  learning/memory	spatial analysis/synthesis

  Summary

  Many types of challenging behaviors can result from TBI. Different types of problems require different types of interventions. It should be driven by the needs/wants of the individual AND their capabilities. Creative thinking, knowing and listening to the person, and being willing to modify strategies lead to greatest successes

Keywords

Psychosocial Neuropsychological Nursing medical