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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.
In Chapter 1 we presented a model of rehabilitation that highlights the range of theories that may be drawn upon to support the identification and development of interventions for the many consequences of brain injury or illness. The case presented here highlights in practice how cognitive neuropsychological intervention (as defined by Coltheart (2005)) can be integrated into neuropsychological rehabilitation, with a specific emphasis on communication and numeracy. The importance of learning method is also raised both in terms of learning specific skills or information as well as functional generalization.
We describe our work with Lorna as a further example of our interdisciplinary approach, in which team members worked in an integrated way with the client towards shared functional goals. Significantly, Lorna's level of communication was initially considered a potential barrier to her ability to benefit from the groups and participate fully in the therapeutic milieu process. Subsequently these concerns appeared largely unfounded.
Once again a formulation-based approach provided a means of integrating assessment results, developing a collaborative understanding regarding the client's needs and building a basis upon which to address these across the team. The case highlights specific and successful interventions for naming and numeracy difficulties, as well as development of compensatory strategies, together applied to increase participation in meaningful activities as part of the integrated rehabilitation programme.
History of injury
Lorna suffered a brain injury in May 1999 whilst living and working abroad.
Previous chapters have described the principles of neuro psychological rehabilitation and outlined the Oliver Zangwill Centre (OZC) for Neuropsychological Rehabilitation programme providing descriptions of groups developed to address specific types of difficulties experienced by many individuals following acquired brain injury. In addition, within a holistic neuropsychological rehabilitation setting, other groups may be run according to shared needs of the individuals undertaking the programme at any one time. This chapter aims to identify some of the types of groups that have been utilized and discusses the format, content and ways in which such group work can be integrated within individual rehabilitation programmes. Group attendance is discussed and agreed as plans of action towards individualized client goals, which help to co-ordinate the activities of the clinical team.
Within society, people are members of one group or another, within the home, at work or in recreational and social interests. Groups provide us with a shared identity and roles, in addition to peer support, and we know that many people experience a loss of role and purpose and a sense of isolation after brain injury. Klinger (2005), summarizing the results of a qualitative study with traumatic brain injury participants, notes: ‘participants had to learn a new way of “being” in order to move on to a new way of “doing”’ (p. 14). A similar finding is reported by Gracey et al. (2008). Group activity is thus of central importance to the programme especially the ‘therapeutic milieu’ core component.
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