Psychotherapy following acquired brain injury: An integrative paradigm for facilitating psychological adjustment and psychosocial competence.

摘要

Despite evidence that acquired brain injury (ABI) causes enduring and debilitating psychological complications, psychotherapy as a means of treatment is not routinely provided. Historically, rehabilitative efforts for individuals with ABI have been principally aimed at the restoration of physical and sensory deficits. Considerably less attention has been paid to the prevention and/or remediation of pervasive psychological consequences. This traditional emphasis on "physical healing" and the tendency to underestimate the legitimacy of psychotherapeutic intervention for individuals with ABI has historical, philosophical, and economical origins. Early psychoanalytic theorists were among the first to question the value of psychotherapy for individuals with brain damage. Since that time, the perception that individuals with brain injury are inappropriate candidates for psychotherapy has been maintained by many in the field of mental health. The potential of psychotherapy as a viable addition to the rehabilitative process has been further limited by unsubstantiated doubt regarding its cost effectiveness. Despite accounts of credible gain via psychotherapy in individuals with brain dysfunction, organized efforts to address professional resistances and advance the practice of psychotherapy for this unique population have not been actualized. Considerable knowledge has accumulated from the fields of neuropsychology, rehabilitation, and psychology in recent decades. Such knowledge has not been maximized or sufficiently integrated for use as the basis of a new order of psychotherapy for individuals with ABI. In short, current literature does not reflect universal agreement regarding (a) the value of psychotherapy following ABI, (b) an acceptable model for providing psychotherapy to ABI individuals, (c) a theoretical context that integrates knowledge from the neurosciences, rehabilitation, and psychology, or (d) the use of neuropsychologically-sensitive strategies for modifying contemporary psychotherapeutic approaches. Clearly, an intentional approach to psychotherapy for individuals with ABI is currently lacking. In the interest of filling this void, and thereby promoting the use of psychotherapy with children and adults following ABI, this dissertation proposes an original paradigm for practitioners. An analysis, integration, and reformulation of existing knowledge has been undertaken. Primary sources of information have included neurorehabilitative research (controlled and single subject studies); applied research in psychotherapy; published expert opinion from the fields of rehabilitative medicine, neuropsychology, and psychology; and the clinical experiences of this writer. The proposed paradigm is sensitive to brain-behavioral relationships and the sudden, physiological damage that brain injury causes. It is theoretically pluralistic, that is, grounded in multiple theories of relevance. The paradigm endorses the systematic integration of various approaches to therapy and includes recommendations for circumventing common cognitive deficits that might otherwise inhibit client benefit and participation. The flexible format of the paradigm permits its use with different client types, problem hierarchies, and neuropsychosocial profiles, and at various stages of recovery. It is designed to promote functional outcomes and is sensitive to current trends in mental health. Goals and objectives for facilitating psychological adjustment and psychosocial competence are integral components of the paradigm. While various elements of the paradigm are supported by the literature, validation of the synergistic merger and reformulation of these elements is encouraged.