Integrating the Head Injury Team

By Steven E. Rothke, PhD, and Elizabeth Michael, PhD

Neuropsychology and rehabilitation psychology are important players on the case management and rehab teams.

Approximately 1,000,000 visits are made each year to hospital emergency departments in the United States for head injury, and there are another 400,000 hospital admissions for brain injury.1 The most common causes are motor vehicle accidents, sports injuries, assaults, and falls. A majority of these visits are mild injuries that do not require inpatient hospitalization. However, some of these injuries are accompanied by changes in cognitive thinking, emotional and/or behavioral functioning, and head or neck pain that can last indefinitely. These changes can negatively impact patients’ ability to return to work.

Neuropsychology

Neuropsychology is a scientific discipline that studies the relationship between brain functioning and behavior. In the clinical setting, neuropsychologists focus on the thinking, emotional, and behavioral changes that occur because of neurological conditions like brain injury. They perform detailed evaluations, design treatment interventions for cognitive and neurobehavioral disturbances, and ultimately perform a critical role in establishing job modifications or reassignments to enable an employee to successfully return to work and productive living.

A neuropsychological evaluation consists of a comprehensive interview and a battery of tests that examine the following functional abilities: alertness and orientation; attention, concentration, and working memory; speech and language; memory and new learning capacity; sensorimotor and psychomotor functioning; visuospatial reasoning; abstract thinking and mental flexibility; self-monitoring capacity and error awareness; insight, judgement, and decision-making; appropriateness of emotional reaction; impulse and behavioral self-control; and motivation for treatment and improvement.

The deficits that most often interfere with treatment, family functioning, and job retention or acquisition after brain injury are:

Concentration and working memory. Sustaining attention and keeping track of more than one thing simultaneously.

New learning ability. Acquisition of new knowledge and skills whether on the job or in the rehabilitation clinic.

Flexibility of thinking. The capability of taking a different approach to a problem or changing a belief when presented with evidence that the strategy or belief is incorrect.

Emotional/personality changes. Reduced control over emotional expression or the ability to inhibit impulses.

Neuropsychologists work with the rehab team, family members, and case managers to design treatment approaches and strategies to assist in recovery or compensation for these deficits. All those involved with the patient need to know what to do and what not to do when relating to the brain-injured individual, in order to prevent the behavioral and emotional problems from becoming exacerbated and possibly increasing the potential for self-harm or violence.

A common issue that neuropsychologists are asked to address, especially in the case of mild brain injury, is the question of malingering or exaggeration of disability. Although the evaluation of malingering disability is not an exact science, neuropsychological interviewing and testing approaches exist that greatly assist the treatment team and insurance carrier in determining whether a patient is actually trying to get well, is displaying signs and symptoms uncharacteristic of a genuine injury, or is capable of much better functioning than is being displayed. Aspects of malingering that a neuropsychologist will attend to are whether the patient is completely fabricating a condition, exaggerating deficits, or misattributing difficulties to a work-related injury that are actually due to some other etiology like learning disability, depression, marital stress, or substance abuse.

Early identification of malingering or exaggerated cognitive or emotional injury will save considerable insurance expense and case manager time, frustration, and embarrassment. The most common approaches to malingering assessment are standardized tests of memory and personality, and a qualitative analysis of the patient’s test performances, ie, looking for signs that do not make neurological sense such as a response style where a patient gets easy items wrong and difficult questions correct.

Cost savings ensue from setting realistic treatment and return-to-work plans and by eliminating unnecessary therapies that are unlikely to enhance patient functioning and may even reduce compliance (ie, if the patient had a preexisting limitation in reading level or lack of interest in academics, this limitation will remain even after the formal cognitive therapies are completed).

Designing treatment plans that address how to best facilitate patient learning or cooperation, or how to work around other neurobehavioral disturbances, will enable the patient to return to work and other responsibilities sooner. Techniques for working with brain-injured patients include: sandwiching critical feedback between two favorable observations, conveying new information in different ways (spoken, written, and demonstrated directions), and minimizing external distractions during task performances.²

Rehabilitation Psychology This clinical discipline provides psychological care to patients and their families to help them address their emotional reactions to physically and cognitively disabling conditions. Some degree of emotional adjustment and coping is necessary in order for patients to fully participate in their rehabilitation and return-to-work programs. Rehabilitation psychologists may serve as individual therapists to patients and family members, and as consultants to the treatment team, the case manager, and eventually the employer.

Conditions like brain injury, spinal cord injury, and pain syndromes may result in deep psychological wounds that leave patients feeling devastated. These emotional wounds include fears that the patients’ life goals will now be unachievable and the shattering of beliefs of physical indestructibility. Other common fears experienced by the injured patient are: no longer being attractive, loveable, and desirable; loss of dignity; being a burden to others; further bodily deterioration and future physical and emotional pain; loss of identity; and fear of the unknown. Injured workers may be particularly distressed by the potential loss of sense of identity and role in life (eg, being the breadwinner), which largely depends on their employment in American culture.

Because of the significant psychological issues that accompany conditions like brain injury, patients will respond in ways that may be difficult for the therapist or case manager to understand or accept. For example, injured patients may employ coping strategies like the use of excessive denial, exaggeration of degree of pain and suffering, refusal to do what is asked of them, and manipulation (getting others to do for them what they are actually capable of doing for themselves). This often leads to labeling the injured patient as unrealistic, ungrateful, uncooperative, or unmotivated.

Many of these difficulties can be minimized or prevented by including a rehabilitation psychologist from the onset of the program. They can give the staff an understanding of what healthy denial (or denial in the interest of survival) is as opposed to pathological denial; ways to give patients more control over their care so the need to be uncooperative (in order to assert some sense of life control after injury) is lessened, and approaches for setting realistic goals for patients.

Patients may have physical limitations because of age, fatigue, and loss of function, which therapists need to accept. This is a more common problem than team members may realize. Most therapists are young, energetic, and highly enthused—many patients do not share these qualities. As a result, therapists experience frustration, anger, and burnout, and/or may be left feeling incompetent because of patients’ lack of progress.

In some cases, therapists may equate patient progress with their own clinical competence or mistake lack of patient gratitude with lack of recognition for their professional efforts. This puts an extra burden on the patient (ie, supporting the provider’s self-esteem), can greatly interfere with rehabilitation progress, and can lead to therapist/caregiver stress.

Rehabilitation psychologists are well prepared to serve as consultants or coaches to case managers and care providers to help them balance how they meet self-esteem and professional recognition needs, develop more characteristics of stress-resistant individuals, and learn to work with challenging patients more effectively.

Reimbursement

An important concern for case managers is how they are going to persuade insurance companies to include neuropsychological and rehabilitation psychology services in the rehabilitation and return-to-work process. The two largest cost savings resulting from these clinical services are: reduction in the length of the rehabilitation program (because the patient has obtained more benefit from their care than one who is uncooperative, or unrealistic, or creates negative reactions in providers), and prevention of future complications that result from poor emotional adjustment (eg, poor self-care that leads to increased utilization of medical services, and failure to return to work or loss of job due to behavioral dyscontrol or failure to accommodate cognitive difficulties).

Similar savings have been noted in patients with other medical conditions such as those undergoing surgical procedures who utilize fewer medical services afterward when psychological services are made part of their treatment protocols.3 The emergence of the field of behavioral disability management is in large part because of a recognition of these cost savings. The inclusion of neuropsychology and rehabilitation psychology is essential to the patient’s maximum recovery and return to work after brain injury and they are key tools for the case manager of these challenging patients.

Steven E. Rothke, PhD, ABPP, holds board certification in clinical neuropsychology and rehabilitation psychology and is the co-owner of the NeuroBehavior and Rehabilitation Network, a network of rehab psychologists in Northbrook, Ill. Elizabeth Michael, PhD, is a postdoctoral fellow in clinical health psychology with the network. They can be reached at (847) 480-5744.

References

1. Sosin DM, Sniezek JE, Thurman DJ. Incidence of mild and moderate brain injury in the United States, 1991. Brain Injury. 1996;10:47-54.
2. Rothke SE, Bergquist TB, Schmidt M, Landre NA, Speizman R. Behavior Management Strategies for Working with Persons with Brain Injury: A Practical Manual. Chicago: Rehabilitation Institute of Chicago; 1998.
3. Kiecolt-Glaser JK, Page GG, Marucha PT, MacCallum RC, Glaser R. Psychological influences on surgical recovery. American Psychologist. 1998;53:1209-1218.