Application of neuropsychology and imaging to brain injury and use of the integrative cognitive rehabilitation psychotherapy model

1 Background

Historically, cognitive rehabilitation therapy (CRT) has primarily focused on cognitive remediation or compensatory strategy approaches in brain injury rehabilitation, with minimal or no emphasis on the role of psychological, social, or environmental factors involved in the recovery process. CRT has traditionally addressed cognitive deficits to maximize safety, independence, and daily functioning in order to enhance life satisfaction and quality of life. Generally, CRT is thought to involve both retraining and compensatory approaches. Retraining of specific cognitive skills (e.g., attention training) is used to optimize functioning of essential cognitive skills. Compensatory approaches typically involve teaching and incorporate skills and strategies to assist with reducing the impact of cognitive deficits (e.g., use of calendars or notebooks) (Harley JP, 1992).

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Fig. 1

Stages of recovery.

During the 1930’s, Alexander Luria developed a theory and practice of neuropsychological rehabilitation that promoted the use of preserved cognitive skills, supplementing them with external strategies and aids to reconstruct cognitive abilities using a new functional system (Glozman, 2007). Luria used a comprehensive neuropsychological evaluation to identify mental activities affected by the brain injury and identify factors explaining the symptoms (Glozman, 2007). He created a dynamic and systematic theory of cerebral organization of which resulted in the definition of different brain systems (Luria, 1973). This hierarchical structure of brain functioning was comprised of three interdependent cortical zones: Unit I, regulating tone, waking, and mental states; Unit II, obtaining, storing, and processing information; and Unit III, programing, regulating, and verifying activities (Kostyanaya, 2013). Luria’s three-unit approach describing brain functioning was employed to create cognitive rehabilitation treatment goals and objectives following a neuropsychological evaluation in the Developmental Metacognitive Approach (Laatsch et al., 2020; Laatsch, Thulborn, Krisky, Shobat, & Sweeney, 2004).

Neuropsychological evaluation remains the foundation for neurocognitive assessment after brain injury and serves as an important component in cognitive rehabilitation treatment planning. Traditional reports provide assessment results across several cognitive domains, describing performance on objective standardized tests. This testing approach, generally focused on identification of cognitive strengths and weaknesses, lacked sufficient assessment of emotional functioning and substance use. Developmental Metacognitive Approach (DMA), a more comprehensive assessment strategy, incorporated psychological assessment with the neuropsychological testing (Laatsch & Stress, 2000). Later, DMA expanded to include motivational interviewing, more psychological interventions, and stages of recovery to describe a process of rehabilitation with increased specificity regarding treatment goals. This system is called the Integrative Cognitive Rehabilitation Psychotherapy (ICRP) model (Pedrotty, 2016). Mood, anxiety, and substance use history evaluations are included in the comprehensive evaluation to create a more cohesive rehabilitation treatment plan. In the ICRP, assessment of academic skills and communication are also incorporated.

In this paper, we propose the use of ICRP to establish goals for rehabilitation therapy in clients with brain injury. We describe tools for evaluating neuropsychological status, psychological needs, and substance abuse treatment. Additionally, we detail client goal development, readiness to change approach, and a range of treatment approaches. Application of current and future imaging techniques in relation to efforts in CRT are briefly described.

The Integrative Cognitive Rehabilitation Psychotherapy (ICRP) model is an extension of the Developmental Metacognitive Approach (DMA) model (Laatsch & Stress, 2000). This model provides a framework for neuropsychologists to integrate issues that commonly co-occur in clients living with brain injury into a unified treatment plan. ICRP provides best practices and latest research on the complexity of brain injury in order to guide assessment and recommendations. Neuropsychologists can apply the ICRP model throughout the assessment process by inquiring about awareness, insight, readiness to change, availability and appropriateness of multiple interventions through a cultural perspective. Following this assessment, through the lens of developmental theory, stage of recovery, and empirical support, they may determine appropriate treatment recommendations.

The ICRP model uses a biopsychosocial approach, expanding to include cognitive and spiritual components, and posits that interactions exist between biological, cognitive, psychological, social, and substance use issues. This model supports the idea that people living with brain injury would benefit from the adaptation of traditional care for psychological and substance use issues by accommodating the unique challenges of learning, developing awareness, and insight that often accompany a brain injury (Gros, Lancaster, Horner, Szafranski, & Back, 2017; McHugo et al., 2017).

3 Neuropsychological testing

Since the 1970s, neuropsychological testing has been generally used with clients with brain injury to determine cognitive issues and disability and to develop appropriate treatment goals (Bergquist, 2005). Table 1 lists neuropsychological tools for adults with brain injury, Table 2 reflects many commonly used self-report measures of substance use and mood/anxiety in the ICPR model. It is important to complete a comprehensive evaluation within a few months of beginning comprehensive rehabilitation. Some clients will have already completed a brief, acute neuropsychological evaluation; however, a comprehensive evaluation is essential for the development of appropriate treatment goals. It is crucial to review all past evaluations and obtain childhood neuropsychological or psychological evaluations if they have been performed. A neuropsychological test in each one of the domains in Table 1 should be included so a broad picture of the client’s cognitive status can be applied to the development of ICRP goals and to determine the status of the client’s cognitive network (Pedrotty, 2016).

Currently, a majority of neuropsychologists do not use a fixed test battery with clients who have a history of brain injury. The use of a fixed battery is less useful in the phase of goal development, as it might not include tests that are related to the client’s rehabilitation aims and discharge goals. Additionally, if the client had an inpatient evaluation, the evaluator must be cautious when repeating the same tests due to practice effects. The evaluator will need to prepare for the evaluation by reviewing the client’s emergency department report, neuroimaging studies, neurological reports, acute mental status evaluations, and notes concerning progress during inpatient rehabilitation. Neuroimaging emphasizes the identification of focal areas of injury that may impact function, prognosis or treatment planning, and may also elucidate changes that contribute to rehabilitation success. It is a driving force in the application of network theory to neurorehabilitation (Bigler & Allder, in print) and is emerging as an essential component of a comprehensive evaluation and precision-based neurorehabilitation treatment plan. When records of early testing and details concerning the client’s acute brain injury are unavailable it is useful to have an informant available who knows the individual well to assist in providing missing information.

During the initial meeting with the client, a comprehensive interview should include the following components: birth history, social status, legal issues around the brain injury, preinjury educational and occupational history, and careful review of past hospitalizations for medical and psychiatric issues prior to the index brain injury. Understanding the client’s history of brain damage is important, as current injury recovery will be dependent on the status of brain at the time of injury. For example, an early childhood brain tumor or multiple concussions may influence the client’s ability to recover. Educational and occupational history will allow the evaluator to roughly gauge the client’s level of pre-injury functioning. Additionally, a measure of pre-morbid functioning is recommended given the tendency to exaggerate personal history. As seen in Table 1, the use of one of the two measures of premorbid functioning is suggested: the Test of Premorbid Functioning or the National Adult Reading Test; both oral reading tests include a range of atypically pronounced words. These measures can be confidently used if the client’s primary language is English, there is no history of a learning disability, and there are sufficient visual skills for reading (Shura, Ord, Martindale, Miskey, & Taber, 2020). If these issues pertaining to the client being evaluated are present, then Lezak et al. suggest the use of confirmed information about the client’s education and career, and the average of a cluster of highest scores on the intelligence test as an estimate of premorbid functioning (Lezak, 2012).

Additionally, during the interview, information concerning the client’s goals for comprehensive rehabilitation treatment should be obtained. For example, if the client is planning to return to college or a prior occupation, tests should be selected to help determine the client’s readiness for return to prior responsibilities. If the client is a student, a range of academic tests should be administered as part of the evaluation. In general, at least one test in each domain in Table 1 should be included in the test battery.

During the evaluation, close observation of the client’s level of alertness and fatigue will assist in producing the most reliable results. While some insight about the client can be obtained during the initial interview, direct observations during the client’s neuropsychological evaluation is invaluable. At times, during the evaluation, limit testing can be useful and completed with any standardized test (Lezak, 2012). Testing the limits is most useful when there is a suspicion that some other ability, rather than one emphasized on the test, is interfering with the client’s ability to demonstrate optimal performance (Lezak, 2012). Some of the modifications, like asking what mental strategy was used on a test, can demonstrate metacognitive skills, an essential component of the ICRP model, and should be noted in the neuropsychological testing report.

To determine readiness for discharge from treatment, the initial battery of neuropsychological testing is often repeated. The results of the post-CRT testing can be used in discharge planning or vocational placement. Unfortunately, most of the tests listed in Table 1 do not have alternative versions, so test-retest improvements may be partially due to a practice effect (Lezak, 2012). In adult control groups, improvement on retesting is quite common, but has been found to vary across elements of the specific test (Dikmen, 1995). Learning on repeated material is common in most clients, with the exception of those with severe memory impairments. This consistent finding needs to be considered when evaluating the client’s improvement following comprehensive rehabilitation treatment. If there is a surprising improvement in the post-testing, the evaluator might consider asking the client what approach was used during the specific test that may be related to rehabilitation tools taught. One approach in looking at re-test results is to use a stricter level of significance in determining improvement, or the use of the Dikmen reliable change index score (Dikmen, 1995) to understand changes in post-CRT test scores (Laatsch & Stress, 2000). In addition to a practice effect, improvements on neuropsychological tests can be due to multiple factors, including the client’s increased confidence when approaching cognitive challenges and the direct application of compensation strategies taught during rehabilitation. During the treatment period, the client may also experience improvement in medical issues, changes in medication, or a reduction of substance use.

Of note, computerized cognitive evaluation tools have been developed. The NIH Toolbox© is a set of neuro-behavioral measurements that can quickly assess cognitive, emotional, sensory, and motor functions on an iPad (Weintraub et al., 2013) with normative data from a large age range and many populations (Shields et al., 2020). The toolbox can be useful in the acute setting as well as at the start or middle of cognitive rehabilitation for determining a place to start or progress in cognitive rehabilitation while waiting for more in-depth and time intensive testing. In addition to the NIH Toolbox© Cognition Battery (Tulsky et al., 2017), Cambridge Neuropsychological Test Automated Battery (CANTAB) (Smith, Need, Cirulli, Chiba-Falek, & Attix, 2013) and CNS Vitals (CNSVS) (Gualtieri & Johnson, 2006) have been widely researched for general and specific populations such as TBI. For head injuries and sports concussions, the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), CogSport battery, and Automated Neuropsychological Assessment Metrics (ANAM) have been widely used by neuropsychologists (Arrieux, Cole, & Ahrens, 2017). These tools are easy to administer and can be especially useful with clients who have had repeated sports concussions.

The DMA posits a developmental approach to cognitive skills (Laatsch & Stress, 2000) which can be utilized as building blocks or a hierarchy of cognitive skills. This developmental approach is incorporated into the ICRP model. Lower order skills include alertness, stamina, attention, processing speed, and working memory. Higher order skills include memory, executive functioning, and communication. The capacity of an individual’s ability to engage in cognitive tasks are dependent on alertness and stamina. Attention and processing speed are the next steps in building more complex cognitive skills. Elements of attention include selective, divided, and alternating attention. Processing speed is comprised of simple and complex reaction times and information processing reaction times (Chiaravalloti, Christodoulou, Demaree, & DeLuca, 2003; Chiou, Sandry, & Chiaravalloti, 2015). Executive functioning includes five areas: social cognition, response selection, meta-tasking, executive cognitive functions, and initiation and maintenance (Suchy, 2015). Adding fluency and communication skills to the assessment rounds out the cognitive skills needed to be independent and successful in recovering from a brain injury. Memory and executive functioning are multidimensional, complex, and require knowledge of how the lower order skills affect them (Suchy, 2015). Mental fatigue, processing speed, and working memory have been found to affect learning, memory, and executive functioning and are shown to require remediation before addressing the higher order functions (Chiaravalloti et al., 2003; Chiaravalloti, Sandry, Moore, & DeLuca, 2016; Chiaravalloti, Stojanovic-Radic, & DeLuca, 2013; Chiou et al., 2015; Sandry, Chiou, DeLuca, & Chiaravalloti, 2016). See Fig. 3 for a list of the cognitive skills, and Table 1 for a list of tests that can be used to assess cognitive skills.

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Fig. 3

The Integrative Cognitive Rehabilitation Psychotherapy model.

In recent decades, the focus of brain injury rehabilitation has shifted to recognize the influence of contextual variables and co-occurring issues in the recovery process. The biopsychosocial approach in brain injury rehabilitation is a conceptual framework that integrates the biological and psychosocial components into cognitive rehabilitation (Williams & Evans, 2003). Research studies have consistently documented the importance of incorporating personal, social, and environmental variables into treatment planning and brain injury rehabilitation. For example, Ben-Yishay and Leonard Diller (2011) emphasized the role of neurologic, cognitive, and personality factors that are involved in the rehabilitation process within the context of the environment using a holistic framework of brain injury rehabilitation (Ben-Yishay, 2011).

Incorporating psychosocial functioning in the assessment and treatment of brain injury is crucial. First, psychological factors need to be taken into consideration in the neuropsychological evaluation, given that these may impact cognitive functioning and consequently, influence optimal cognitive rehabilitation. Personal factors after brain injury, including one’s development of a personal narrative (i.e., sharing one’s story) and process of redefining and reconstructing self after brain injury, may be critical in addressing one’s loss of personal identity (D’Cruz, Douglas, & Serry, 2019). Similarly, other constructs such as self-awareness and insight, personal identity and self-image, grief process and ambiguous loss, premorbid functioning, and post-injury adjustment for the client and the family after brain injury may also impact the engagement, recovery process, and rehabilitation outcomes (Belchev et al., 2017; Halligan, 2006; Kortte, 2003; Prigatano, 2005). Studies have shown that perceived changes in identity resulted in greater depression, grief, poor self-esteem, and awareness (Carroll & Coetzer, 2011).

Lack of awareness is associated with poor rehabilitation outcomes (Prigatano, 2005), and must be clarified as to etiology to make appropriate recommendations (Haskins, 2014). Biologically-based impairment of awareness and insight requires different interventions than educational or psychological-based impairments. To assess awareness and insight, the most common assessment tools are the Awareness Questionnaire (Sherer, 2004) and the Patient Competency Rating Scale (Prigatano, 1996), although there is no consensus on the preferred instrument to use after brain injury (Brown et al., 2019). In addition, the Mayo-Portland Adaptation Inventory (MPAI-4) measures awareness and provides three indices that are pertinent to assessing functioning (Malec, 2005). Further, obtaining collateral information from someone who knows the person well is imperative to corroborate the person’s self-report. Taken together, a comprehensive and functional assessment that includes biopsychosocial factors and awareness and insight is essential in determining the stage of recovery and appropriate interventions within the ICRP model.

Research has identified the importance of screening for depression, anxiety, and suicidal ideation post TBI (Awan et al., 2020; Campbell-Sills et al., 2020; Fann et al., 2005; Fisher et al., 2016; Hart et al., 2016). Psychiatric manifestations prior and after brain injury such as depression, anxiety, post-traumatic stress disorder (PTSD), and suicidal risk have also been found to negatively impact cognitive functioning and recovery (Bryant et al., 2010; Teasdale & Engberg, 2001). In one study, individuals who reported higher depressive symptoms also reported more injury-related problems, suggesting an association between depression and psychosocial functioning (Hibbard et al., 2004). Awan et al., (2020) found typical associations between depression, unemployment, and substance use with suicidal ideation within the first and second year post TBI (Awan et al., 2020). However, they also found an independent association between severity of injury (extracranial injury or ECI) and suicidal ideation within the first year that is similar to findings in general trauma populations. They suggested that focusing treatment on optimizing vocational goals and screening for substance misuse and ECI within the first year might reduce the risk of suicidal ideation and depression. Brief measures of depression, suicide, and anxiety such as the PHQ-9 and GAD-7 can be used as a screening tool in the neuropsychological evaluation (Fann et al., 2005; Teymoori et al., 2020). When screening for PTSD, the PTSD Checklist 5 (PCL-5) may be useful to assess the 20 DSM-5 symptoms of PTSD and to make provisional diagnosis (Weathers, 2013). Screening for suicidal, homicidal, and psychotic experiences should also be done during the clinical interview (Sharp, 2013). Assessment of psychiatric symptoms is crucial in providing individual-tailored recommendations for cognitive rehabilitation after brain injury.

In addition, the prevalence of substance use problems is high, and these problems may also serve as a major complicating factor in the recovery process for individuals with brain injury (Bombardier, Temkin, Machamer, & Dikmen, 2003; Corrigan, 1995; Niemeier et al., 2016). Brain injury may result in cognitive, psychosocial, or affective problems that result in impaired decision-making and leads to substance misuse (Wood & McHugh, 2013). Further, alcohol misuse and/or dependence can inhibit neuronal regrowth and result in impaired executive functioning and poor vocational outcomes (Jorge et al., 1993). Screening for substance misuse with measures such as Alcohol Use Disorders Identification Test (AUDIT) (Ponsford, Whelan-Goodinson, & Bahar-Fuchs, 2007; Saunders, Aasland, Babor, de la Fuente, & Grant, 1993), Drug Abuse Screening Test (DAST) (Ponsford et al., 2007; Skinner, 1982), and Two Item Alcohol and Drug Screening Questions (TICS) (Brown, Leonard, Saunders, & Papasouliotis, 2001) may undercover underlying risks of cognitive recovery. Bryce et al. suggest using a cutoff score of 11 on the AUDIT to indicate alcohol use issues, and a cutoff score of 6 on the DAST to indicate substance use issues for individuals with traumatic brain injury (Bryce, Spitz, & Ponsford, 2015). Assessing and treating substance use problems must be prioritized and integrated into treatment planning for optimal cognitive rehabilitation. Table 2 lists self-report measures to screen for mental health problems that are common among individuals with brain injury.

Personality characteristics must also be considered in neuropsychological treatment planning as studies suggest these traits may impact treatment, engagement, and recovery (McCrae & John, 1992; McIntyre et al., 2020). Personal factors including adaptation, resiliency, coping, hope, and life satisfaction after brain injury may contribute to optimal recovery outcomes across the life span. Psychological assessments such as the MMPI-2-RF or the Personality Assessment Inventory (PAI), both psychometrically sound personality assessments used in brain injury, may be used to determine psychopathology or behavioral manifestations of premorbid conditions and/or post-TBI sequelae (Goldsworthy & Donders, 2019; Till, Christensen, & Green, 2009). In addition, family functioning has been found to play a role in maximizing recovery (Haskins, 2014; Testa, Malec, Moessner, & Brown, 2006). The healthier and more supportive the family is, the greater the opportunity to maximize recovery.

Given these considerations, psychosocial factors and substance use should be formally assessed in neuropsychological evaluations and incorporated into the formulation of treatment recommendations. Often, in traditional neuropsychological assessment, psychosocial background and substance use history are obtained through a clinical interview and are not further assessed and incorporated in the context of providing integrated, individualized cognitive rehabilitation, and treatment recommendations. It is important to assess these issues to identify current psychological status and educate the client and/or their caregivers on the need to be vigilant for changes in mood and substance use over the course of recovery. Assessment of these factors is crucial in developing holistic and precision rehabilitation that is individually tailored to maximize brain injury recovery across a lifespan.

6 Psychotherapeutic interventions after brain injury

Psychotherapy that addresses awareness and insight, personal loss and adjustment, hopelessness, suicidal intervention, managing medical issues, and/or psychosocial or substance use problems may be a primary target of intervention or used in conjunction with cognitive rehabilitation based on the ICRP model. These co-existing problems often undermine the effectiveness of cognitive rehabilitation and a holistic and optimal recovery. For individuals with brain injury, a number of theoretical approaches have been utilized to help clients work through cognitive, psychosocial, and emotional barriers to maximizing recovery and independence, quality of life, and life satisfaction. Building a strong therapeutic alliance and understanding the individual’s phenomenological field and experience of brain injury, as well as level of insight and awareness into associated impairments, is often viewed as the first step in determining appropriate psychotherapy (Prigatano, 1999).

In psychodynamic interventions the focus is on ego development, interpersonal dynamics, unconscious processes, and when appropriate, transference issues. As a result of brain injury, individuals are faced with many changes in cognition, behavior, mood, interpersonal relationships, and bodily functioning; consequently, they experience increased emotional distress and poor adjustment to injury (Jureidini, 1988). The goal in insight-oriented psychotherapy is to help individuals process and understand the nature of these changes, partially through empathic understanding by the therapist, and develop an improved understanding of how these fit with past relationships and abilities to optimize coping, functioning, and the reconfiguration of self or identity.

From the first encounter, insight-oriented psychotherapy relies on the exploration of feelings and thoughts within the session, connection to past and future events and relationships, and preconscious and unconscious material. Quality and quantity of emotions are explored to flesh out the range of human experience and begin to integrate more painful or distressing emotions and thoughts with those that are initially expressed or on the surface. Defense mechanisms are addressed to guide the psychodynamic process within the therapy session to explore and uncover the complexity of emotions and thoughts that evolve over time throughout the stages of recovery. Material from nighttime dreams are incorporated into sessions to enhance the exploration of unconscious feelings. Through the development of the therapeutic alliance and examination of feelings and thoughts within the session the client is able to practice new ways to manage thoughts and feelings, reconstruct their identity to pursue their new set of values, manage cognitive strengths and impairments, and develop meaningful relationships. The uncovering of depressive, anxious, suicidal, and distressing thoughts and feelings allows for the application of other specific psychotherapeutic interventions, emergently and long-term. Exploring how the client is coping with the stress and demands of rehabilitation allows for direct, individualized, and ongoing adjustment of setting goals and objectives in the cognitive rehabilitation across stages of recovery and application of interventions. Over the long-term insight-oriented psychotherapy creates a therapeutic relationship that guides the client from the depth of despair and loss to the jubilation and pride of having the courage and resiliency to find new meaning and purpose and re-establish meaningful relationships and activities.

In self psychology, a type of insight-oriented psychotherapy, the focus is on the reaction of self after brain injury- this may lead to narcissistic injury or catastrophic reactions that manifest in significant emotional turmoil (Klonoff, & Lage 1991). The focus is to help clients understand and accept the changes after brain injury, improve self-esteem, and learn to carry out adaptive and productive lives (Klonoff, Lage, & Chiapello, 1993).

Behavioral problems after brain injury such as poor impulse control, disinhibition, aggression, perseveration, anxiety or depression, to name a few, often are maladaptive and disruptive to daily functioning. Consequently, behavior therapy aims at reducing these behavioral problems while increasing positive, adaptive behaviors through use of behavioral analysis, teaching adaptive behaviors, positive reinforcement, contingency management, and problem solving (Giles, Scott, & Manchester, 2013; Persel, 2004). Often, a well-formed, behavioral plan that takes into account personal, social, and environmental factors is created and implemented to redirect, shape, and maximize adaptive behaviors for daily living.

In cognitive therapy, the target of intervention relies on the individual’s processing of information after brain injury. The perception and interpretation of one’s experience often impacts, shapes, and drives behaviors (Beck, 1976). Having an increase in cognitive distortions, maladaptive thoughts and cognitive inflexibility may be a common sequelae of brain injury. In treatment, the goal is to help individuals link how these thoughts are associated with negative feelings and behavior and in turn, create a therapeutic environment to help individuals challenge how they view oneself, environment and the future after brain injury.

Of the psychotherapeutic approaches used to for brain injury, cognitive-behavioral therapy (CBT) is by far, the most utilized and widely accepted psychotherapeutic approach, especially in TBI (Gomez-de-Regil, Estrella-Castillo, & Vega-Cauich, 2019). CBT integrates cognitive and behavioral mechanisms to treat behavioral and emotional disturbances after brain injury. CBT targets cognitive schemas (i.e., individual’s thoughts on view of self, others, and the world) and helps the client to understand how these are associated with one’s feelings, behaviors and actions. After brain injury, self-perception or thoughts may be negatively impacted and lead to catastrophic thinking, all-or-nothing thinking, or emotional reasoning, to name a few. The goal in CBT is to teach the individual how to be aware of these thoughts, identify maladaptive, distorted, or dysfunctional thoughts, and confront and challenge them using a thought record (Beck, 1976). Behavioral techniques are also incorporated to facilitate engagement of effective strategies (i.e., controlled breathing, mindfulness, socialization, and physical activity) to improve mood and promote positive experiences, proactive life goals and adaptive behaviors for optimal brain injury recovery (Anson & Ponsford, 2006).

CBT as well as the above-mentioned psychotherapeutic approaches have also been incorporated and adapted in various clinical settings for the treatment of other associated problems such sleep (Ouellet & Morin, 2007), PTSD (Sripada et al., 2013), and headache after brain injury (Minen, Jinich, & Vallespir Ellett, 2019). Modified prolonged exposure and modified cognitive processing therapy (SMART-CPT) have been shown to be effective in treating PTSD and TBI in Veterans (Rosen & Ayers, 2020).

In recent decades, insight psychotherapy, group, and family therapy have been found to be useful in treating problems after brain injury (Corrigan, 1995). Specific approaches have also been effective in treating TBI such as mindfulness-based stress reduction and cognitive behavioral therapy (Azulay, Smart, Mott, & Cicerone, 2013). Studies have shown that group intervention using modified CBT with booster sessions helped lower levels of depression and anxiety, and emotional distress or acute stress disorder following TBI (Bradbury et al., 2008; Ponsford et al., 2016; Soo & Tate, 2007). Group interventions using CBT to target hopelessness has also shown preliminary evidence of decreasing hopelessness after TBI (Brenner et al., 2018).

There is growing research to support the utility of CBT after brain injury. In a recent paper, Vanderploeg and colleagues (Vanderploeg, Belanger, Curtiss, Bowles, & Cooper, 2019) conducted a literature review and urged providers to shift the focus of treatment from cognitive rehabilitation to incorporating and using CBT interventions to effectively address comorbid psychiatric problems among individuals with mild TBI. Fann et al. (2005) noted that although CBT has the best preliminary evident for treating depression, there are simpler interventions such as behavioral activation that are at least as effective (Fann et al., 2005). They concluded that holistic treatment programs may be more effective than CBT alone and more research is needed. Often therapy modifications are necessary to tailor psychotherapy to the individual’s cognitive level and ability to process information and understand session content (Gallagher, McLeod, & McMillan, 2019). Insight-oriented psychotherapy is contraindicated for cognitive impairments that include executive functioning and memory and result in lack of awareness and insight. In those cases, behavioral therapy, family therapy, and a focus on environmental accommodations are indicated.

Other psychotherapeutic applications with less research evidence, but show promise, are positive psychology which emphasizes personal strengths, coping, and resiliency after brain injury (Andrewes, Walker, & O’Neill, 2014) and existential and acceptance-based therapies (Myles, 2007). Ruff introduced the existentially-oriented approach in helping individuals with TBI identify pre-injury life expectations, examine how these expectations have changed post-injury, and facilitate a process of grief and loss with the goal of living out a meaningful life as the outcome (Ruff, 2013). Other interventions like behavioral activation target increasing rewarding activities through environmental reinforcement to improve psychological functioning and prosocial behaviors, or social skills training to improve social functioning and relationships (Driscoll, Dal Monte, & Grafman, 2011; Hart et al., 2016; Hawley & Newman, 2010; Martell, 2010). Hart et al. found that behavioral activation-based interventions may be effective in the treatment of anxiety and/or depression and increasing productive activity in chronic, moderate to severe TBI (Hart et al., 2016).

At this time, psychotherapy after brain injury remains understudied given the complexity of establishing research designs that effectively targets the active ingredients that promote acute and long-term recovery (Prigatano, 2013). In fact, recent papers have called for a paradigm shift in how to understand and treat brain injury. These conceptual models highlight the need to understand brain injury and recovery in a more complex and dynamic process where biological, psychological, and cognitive symptoms do not exist independently, rather that these work simultaneously in amplifying and reinforcing one another in direct or indirect pathways (Iverson, 2019; Kenzie et al., 2017). More studies using a network analysis paradigm may help clarify and point to targeted areas for individualized treatment planning and intervention in neuropsychological assessment and recommendations (Iverson, 2019; Raizman et al., 2020). Psychotherapy remains a core component of the complex rehabilitation process as highlighted in the ICRP model. Recently there has been a call to accommodate traditional psychotherapies for co-occurring issues (mood, substance use, and brain injury) to improve outcomes (Gros et al., 2017; McHugo et al., 2017).

In the ICRP model, psychosocial and substance use problems must be addressed along with the cognitive rehabilitation issues as they arise. Rather than recommend separate therapies, the neuropsychologist can identify the specific issues and suggest a variety of ways to treat them simultaneously within several interventions and modalities. The treating therapist can determine how best to adapt the recommendations to the individual needs of the client and apply the interventions at the right time over the course of therapy and within each session to manage ongoing and emergent issues to maximize outcome and maintain continuity of care over time.

7 Treatment recommendations and goal development in the ICRP model

Treatment recommendations in cognitive rehabilitation are based on the following elements: where a person is in the process of recovery, awareness, insight, cognitive strengths and weaknesses, premorbid level of functioning, severity of injury, readiness to change, accessibility and availability of resources, and support. ICRP promotes the integration of treatment of co-occurring issues and applies a heuristic approach to identify stages of recovery in order to assist in the creation of tailored treatment recommendations and setting culturally sensitive goals across these elements. Creation of goals includes discussion of which of the eight interventions are appropriate and the client’s willingness to use specific interventions. See Table 3 for list of interventions, and discussion below to clarify the interventions. The use of errorless learning, graduated exercises, and multimodal interventions to manage cognitive, psychosocial, and substance use issues provides integrative care and allows for deepening of the therapeutic alliance across the stages of recovery. The four stages of recovery are surviving, healing, thriving, and maintaining/ending. These stages are somewhat similar to those proposed by (Sohlberg, 2001): acquisition, application, and adaptation as described in the ACRM Cognitive Rehabilitation Manual (Haskins, 2014). See Fig. 2 for list of stages.

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Fig. 2

Stages of readiness to change.

Individuals who are in the initial or acute stage of recovery, surviving, are typically engaged in intensive outpatient therapies that can occur for several hours a day, over several days each week, focusing on the development of significant environmental support to help with Activities of Daily Living (ADL). The stress of intensive interdisciplinary interventions, the need to encourage rest, and pacing the amount of daily exerted effort puts specific limitations on what can reasonably be accomplished. Understanding and acknowledging what each of the different rehabilitation therapies are accomplishing is essential to effective planning. In the surviving stage, treatment recommendations for cognitive rehabilitation are typically focused on learning external and internal compensatory strategies and making environmental accommodations to ensure a safe return to the community and establish as much independence as possible. The literature suggests that it is also important to focus on maximizing vocational goals and treating medical issues that are burdensome beyond the brain injury, psychosocial issues, suicidal ideation, and substance use that may co- occur (Cernich, Kurtz, Mordecai, & Ryan, 2010; Stergiou-Kita, Rappolt, & Dawson, 2012). Integrating the multitude of interventions in treating any existent co-occurring issues across the different rehabilitation therapies increases the potential to maximize outcome. The neuropsychologist can create treatment recommendations that allow for the rehabilitation therapist to integrate the management of these important issues within the cognitive rehabilitation.

With the reduction in intensity of services and passage of time the individual transitions from the surviving stage to healing. The individual has now settled into a new routine and has more time to focus on the acquisition of specific goals. Multiple rehabilitation services may or may not be present at this time. The cognitive rehabilitation therapist can increase focus on developing internal compensatory strategies and remediating lost or damaged cognitive skills. The expectation in this stage is that the individual will have more time, interest, and motivation to practice cognitive skills outside of therapy sessions in order to improve the performance of the skill and begin to reduce the need for environmental and external compensatory strategies. The presence of psychosocial, suicidal ideation, and substance use issues are important to identify and integrate into the cognitive rehabilitation therapy.

Rehabilitating or creating new cognitive skills follows evidence-based research and clinical acumen. Creating goals that include a myriad of appropriate interventions and a focus on targeting skills using a developmental model provides ongoing safety and cultural sensitivity to encourage progress. This stage can take up to several years to move through with the focus on mastery of skills (retraining and internal compensation) within therapies and therapeutic settings that are relevant to improving independence, creating and maintaining relationships, returning to work or school, and developing a healthy lifestyle.

As skill acquisition increases in internal compensatory strategies and remediation of impaired or development of new cognitive skills, the client is moving towards the critical stage of cognitive rehabilitation: generalization of skills to the environment, or thriving. In the thriving stage, the objectives are focused on maintaining gains, practicing those skills in the environment, and accommodating the skills to be functional in the environment. Thus, it is essential to include a functional assessment within the neuropsychological evaluation to determine the client’s place or stage in their rehabilitation and how the objective scores translate into meaningful, functional, and client-centered treatment recommendations. Cultural sensitivity becomes paramount in this phase given the generalization of skills into the client’s environment and making specific accommodations that are most effective and relevant to the client and their family.

When clients are nearing the end or have already ended their rehabilitation, the neuropsychological evaluation can provide data to affirm the progress made and make suggestions for transition to the environment for support over the lifetime as needed. This is referred to as the ending stage. Goals of this stage may include activities to maintain gains, adjusting interventions as appropriate to manage stress, and use of booster sessions in the future. The hope at this stage of recovery is that the psychosocial, suicidal ideation, and substance use issues have been identified and resolved. However, it is important to provide an adequate screen for these issues and create treatment recommendations that identify immediate or long-term issues.

A neuropsychological evaluation can be requested by individuals who are several years post brain injury and have or have not received cognitive rehabilitation. Some individuals may have struggled for years with or without any previous rehabilitation; others may have recently worsened after successful rehabilitation, but both are interested in engaging in rehabilitation. In setting up treatment recommendations it may be helpful to consider this the surviving stage. The client might benefit from as much environmental support as possible to allow them to begin to engage in treatment and transition to the healing stage. Treatment recommendations may initially focus on external compensations and environmental accommodations. Any other compensations and interventions will be helpful to prepare for the more focused work on developing internal compensation and retraining cognitive skills that are the focus of the healing stage. Recent or long-term psychosocial, suicidal, and substance use issues may be present and need to be addressed appropriately.

8 Imaging to enhance the ICRP model

Neuroimaging is an essential component of the ICRP model and will become more so as the science matures and the techniques become affordable, available and promulgated. Common clinical brain neuroimaging including CT and MRI, can be helpful in identifying large injuries, abnormalities and bleeds in specific regions of the brain. This information provides basic confirmation of gross injuries that can be translated into measurable treatment goals. However, the sensitivity of these techniques is limited and is not used to rule out a brain injury or to create very specific treatment goals. Bigler and Allder (in press; this issue) describe methods to maximize information from CT and MRI to help in development of treatment goals over time.

Historically, conventional (qualitative) imaging has not played a significant role in assessing readiness for, or response to rehabilitation intervention; however, advances in quantification and sequence development have increased interest in the use of imaging within an integrative model of rehabilitation. In particular, imaging may be useful as a predictor of outcome following rehabilitation therapy (Ressel et al., 2020) and in rehabilitation treatment planning and prognostication regarding independent ambulation (Maeshima, Okamoto, Mizuno, Okazaki, & Sonoda, 2020; Soulard et al., 2020) and language recovery (Keser, Sebastian, Hasan, & Hillis, 2020) following stroke.

Additional advanced imaging modalities including diffusion tensor imaging, functional MRI, positron emission tomography and single photon emission computed tomography are quickly becoming useful in describing the impact of injury and to guide treatment and measure progress. The application of network theory in neuroimaging and neurorehabilitation is evolving rapidly and will become an essential element of the ICRP model (Bigler & Allder in print). In particular, advanced imaging techniques may be useful as a predictor of outcome following rehabilitation therapy (Ressel et al., 2020) and in rehabilitation treatment planning and prognostication regarding independent ambulation (Maeshima et al., 2020; Soulard et al., 2020) and language recovery (Keser et al., 2020) following stroke.

Current literature includes a growing number of articles that examine the effects of treatment on the function and structure of the brain after TBI (Galetto & Sacco, 2017; Krawczyk et al., 2019; Moore et al., 2020), stroke (Faul, Knight, Espay, Depue, & LaFaver, 2020; Jaywant, DelPonte, Kanellopoulos, O’Dell, & Gunning, 2020; Wu et al., 2020), and multiple sclerosis (Feinstein et al., 2020; Sandroff, Jones, Baird, & Motl, 2020). These studies show changes in imaging findings associated with cognitive improvement of other treatment effects, and reflect a degree of post-injury neuroplastic capacity, even in chronic recovery intervals (Han, Davis, Chapman, & Krawczyk, 2017) (Chiaravalloti et al., 2016) (Galetto & Sacco, 2017; Krawczyk et al., 2019) (Chen et al., 2011). Though additional research is necessary to fully appreciate the effects of rehabilitation following TBI, some studies appear to validate the principle of using quantitative imaging in understanding of the biological effects and general efficacy of various rehabilitation techniques.

In addition to measurement of cognitive rehabilitation interventions, others have examined the potential benefits of other therapeutic treatments, including exercise and physical therapies (Yuan et al., 2017). Others have explored how functional magnetic resonance imaging (fMRI) may be used to identify how activation patterns change and restructuring occurs after virtual reality therapy training (Ansado, Chasen, Bouchard, & Northoff, 2020). Finally, neuroimaging has been applied to guide and tailor rehabilitation strategies in persons with chronic TBI and to select clients that might benefit most from particular therapies. (Strangman et al., 2008). Eventually, neuroimaging may also play an important role in enhancing our understanding of complex brain networks which may be critical in the development and evolution of more sophisticated brain-computer interfaces in the use of exoskeleton control and neurofeedback rehabilitation (Gonzalez-Astudillo, Cattai, Bassignana, Corsi, & De Vico Fallani, 2020; Pillette et al., 2020).

9 Conclusion

Neuropsychology continues to play a prominent role in cognitive rehabilitation. It has gone from relying on objective tests to describe brain injury and create treatment goals to integrating advances in imaging, understanding of brain injury, and optimization of rehabilitation. Bigler has spoken of the need for neuropsychology to prepare for these advances over the past 15 years at numerous presentations. Integrative cognitive rehabilitation models have been a peripheral part of the discussion for decades but not fully embraced. The current state of research into brain injury allows for a more robust and evidenced based practice of integrative rehabilitation. The ICRP model builds on the work of others to provide a structure for neuropsychologists to apply the most current knowledge in creating a comprehensive, inclusive, and holistic evaluation that individualizes treatment of brain injury across the life span. It applies the current state of knowledge and provides a structure to update methods and suggest questions that still need to be answered to better treat brain injury and improve outcome. In treating the whole person, ICRP applies a humanistic, phenomenological and dynamic approach to applying techniques and technology that identify goals within and between co-occurring issues to improve recovery over time. The model is expected to be adapted and/or changed as our knowledge increases in brain injury and recovery. It is designed to be applied in parts, for professionals to use whatever parts apply to and work for them, and as a whole, to provide a format for clinicians to apply holistic and complex integrative care within a session and across time to address the complexity of co-occurring conditions that frequently are a part of brain injury. In the integrative therapy the therapist and client can struggle together and in whatever amount of time is needed to develop a new way of being without having to ignore important experiences and struggles. It is hoped that this type of therapy, albeit more complex and challenging than traditional therapy, will be very satisfying and helpful to all involved in the arduous work of recovery. There is great excitement in and expectation for what is yet to come in maximizing recovery from brain injury and restoring people’s lives.