The Brain Injury Rehabilitation Workbook
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Memory Rehabilitation:
Integrating Theory and Practice
Barbara A. Wilson
The Brain Injury
Rehabilitation
Workbook
Edited by
Rachel Winson
Barbara A. Wilson
Andrew Bateman
THE GUILFORD PRESS
New York London
Copyright © 2017 The Guilford Press
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Library of Congress Cataloging-in-Publication Data
Names: Walpole, Sharon, author. | McKenna, Michael C., author.
Title: How to plan differentiated reading instruction : resources for grades
K–3 / Sharon Walpole, Michael C. McKenna.
Description: Second edition. | New York : Guilford Press, [2017] | Includes
bibliographical references and index.
Identifiers: LCCN 2016054228 | ISBN 9781462531516 (pbk.)
Subjects: LCSH: Reading (Primary) | Individualized instruction.
Classification: LCC LB1525 .W175 2017 | DDC 372.4—dc23
LC record available at https://lccn.loc.gov/2016054228
About the Editors
Rachel Winson, MA, MSc, an advanced occupational therapist, is currently working as
part of a community neurorehabilitation team at the University of East Anglia, in Norwich,
Norfolk, United Kingdom. Previously, she worked at The Oliver Zangwill Centre for Neu-
ropsychological Rehabilitation, in Ely, Cambridgeshire, United Kingdom, which provides
high-quality evidence-based neuropsychological assessment and rehabilitation to patients
with acquired brain injury. Ms. Winson has also worked in an acute inpatient stroke reha-
bilitation setting and in dementia research.
Barbara A. Wilson, OBE, PhD, a clinical neuropsychologist, is founder of The Oliver
Zangwill Centre for Neuropsychological Rehabilitation. She has worked in brain injury
rehabilitation since the 1970s. Dr. Wilson has published 23 books, 280 journal articles and
book chapters, and 8 neuropsychological tests, and is editor of the journal Neuropsycho-
logical Rehabilitation. She has won many honors for her work, including three lifetime
achievement awards, the Ramón y Cajal Award from the International Neuropsychiatric
Association, and the M. B. Shapiro Award from the British Psychological Society. She is past
president of the British Neuropsychological Society and the International Neuropsychologi-
cal Society, and is currently president of the Encephalitis Society and on the management
committee of the World Federation for NeuroRehabilitation. Dr. Wilson is a Fellow of the
British Psychological Society, the Academy of Medical Sciences, and the Academy of Social
Sciences. She is an honorary professor at the University of Hong Kong, the University of
Sydney, and the University of East Anglia.
Andrew Bateman, PhD, a chartered physiotherapist, has been Clinical Manager at The
Oliver Zangwill Centre since 2002. He has worked in research and clinical rehabilitation
since 1990. Dr. Bateman has been involved in a range of research studies investigating
patient-reported outcomes, executive functions, assistive technology, dyspraxia, and Rasch
analysis.
v
Contributors
Andrew Bateman, PhD, The Oliver Zangwill Centre for Neuropsychological Rehabilitation,
Ely, Cambridgeshire, United Kingdom
Susan Brentnall, DipCOT, The Oliver Zangwill Centre for Neuropsychological Rehabilitation,
Ely, Cambridgeshire, United Kingdom
Jessica Fish, DClinPsy, The Oliver Zangwill Centre for Neuropsychological Rehabilitation,
Ely, Cambridgeshire, United Kingdom
Catherine Longworth Ford, PhD, The Oliver Zangwill Centre for Neuropsychological
Rehabilitation, Ely, Cambridgeshire, United Kingdom; Cambridgeshire Community Services
National Health Service (NHS) Trust, St. Ives, Cambridgeshire, United Kingdom; Community
Neuro-Rehabilitation, Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge,
Cambridgeshire, United Kingdom; and Health Education England, Leeds, West Yorkshire,
United Kingdom
Fergus Gracey, DClinPsy, University of East Anglia, Norwich, Norfolk, United Kingdom;
and Cambridgeshire Community Services NHS Trust, St. Ives, Cambridgeshire, United Kingdom
Emily Grader, BA, The Oliver Zangwill Centre for Neuropsychological Rehabilitation,
Ely, Cambridgeshire, United Kingdom
Kathrin Hicks, DClinPsy, Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge,
Cambridgeshire, United Kingdom; Cambridge University Hospital NHS Trust, Cambridge,
Cambridgeshire, United Kingdom
Clare Keohane, MRes, The Oliver Zangwill Centre for Neuropsychological Rehabilitation,
Ely, Cambridgeshire, United Kingdom
Donna Malley, MSc, The Oliver Zangwill Centre for Neuropsychological Rehabilitation,
Ely, Cambridgeshire, United Kingdom
vii
viii Contributors
Leyla Prince, MSc, The Oliver Zangwill Centre for Neuropsychological Rehabilitation,
Ely, Cambridgeshire, United Kingdom
Barbara A. Wilson, OBE, PhD, The Oliver Zangwill Centre for Neuropsychological
Rehabilitation, Ely, Cambridgeshire, United Kingdom; and The Raphael Medical Centre,
Tonbridge, Kent, United Kingdom
Jill Winegardner, PhD, The Oliver Zangwill Centre for Neuropsychological Rehabilitation,
Ely, Cambridgeshire, United Kingdom
Rachel Winson, MA, MSc, Cambridgeshire and Peterborough NHS Foundation Trust,
Cambridge, Cambridgeshire, United Kingdom
Contents
List of Handouts xi
CHAPTER 1 General Introduction 1
Barbara A. Wilson
CHAPTER 2 Introduction to Brain Anatomy and Mechanisms of Injury 15
Emily Grader and Andrew Bateman
CHAPTER 3 Attention 36
Jessica Fish, Kathrin Hicks, and Susan Brentnall
CHAPTER 4 Memory 68
Jessica Fish and Susan Brentnall
CHAPTER 5 Executive Functions 106
Jill Winegardner
CHAPTER 6 Communication 139
Clare Keohane and Leyla Prince
CHAPTER 7 Fatigue 167
Donna Malley
ix
x Contents
CHAPTER 8 Mood 204
Catherine Longworth Ford
CHAPTER 9 Working with Identity Change after Brain Injury 235
Fergus Gracey, Leyla Prince, and Rachel Winson
CHAPTER 10 Working with Families after Brain Injury 263
Leyla Prince
Index 277
Purchasers of this book can download and print the handouts
at www.guilford.com/winson-forms for personal use
or use with individual clients.
List of Handouts
HANDOUT 1.1 Formulation Template 14
HANDOUT 2.1 Understanding Brain Injury: Group Questionnaire 29
HANDOUT 2.2 Neurons 30
HANDOUT 2.3 Protection for the Brain 31
HANDOUT 2.4 Brain Regions 32
HANDOUT 2.5 The Brain’s Blood Supply 33
HANDOUT 2.6 Understanding Brain Injury: Starting a Portfolio 34
HANDOUT 3.1 Brain Areas Involved in Attention: The Alerting System 52
HANDOUT 3.2 Brain Areas Involved in Attention: The Orienting System 53
HANDOUT 3.3 Brain Areas Involved in Attention: The Executive System 54
HANDOUT 3.4 Attention Monitoring 55
HANDOUT 3.5 Sustained versus Selective Attention 56
HANDOUT 3.6 Switching Attention versus Divided Attention 57
HANDOUT 3.7 How Does It Feel? 58
HANDOUT 3.8 Environmental Distractions 59
HANDOUT 3.9 Selective Visual Attention (1) 60
HANDOUT 3.10 Selective Visual Attention (2) 61
HANDOUT 3.11 Visuospatial Attention 62
HANDOUT 3.12 My Attention Profile 67
xi
xii List of Handouts
HANDOUT 4.1 Brain Areas Involved in Memory 86
HANDOUT 4.2 How Do I Remember Things? 87
HANDOUT 4.3 Memory Diary 89
HANDOUT 4.4 What Is Memory? 92
HANDOUT 4.5 Do You Ever Have . . . ? 94
HANDOUT 4.6 Making the Links 95
HANDOUT 4.7 Chunking 96
HANDOUT 4.8 The Mind’s Eye 98
HANDOUT 4.9 Mental Blackboard 99
HANDOUT 4.10 Memory Palace 100
HANDOUT 4.11 Mnemonics 101
HANDOUT 4.12 The PQRST Strategy 102
HANDOUT 4.13 Making Your Memory System Work 103
HANDOUT 4.14 My Memory Profile 104
HANDOUT 4.15 My Memory System 105
HANDOUT 5.1 Brain Areas Involved in Executive Functions 123
HANDOUT 5.2 More Brain Areas Involved in Executive Functions 124
HANDOUT 5.3 What Are Executive Functions? 125
HANDOUT 5.4 Who Needs Good Executive Functions? 127
HANDOUT 5.5 How Does It Feel? 128
HANDOUT 5.6 How Does It Feel? (Continued) 130
HANDOUT 5.7 Christmas at JFK Airport 132
HANDOUT 5.8 Monitoring My Use of Stop/Think 133
HANDOUT 5.9 Using the Goal Management Framework (GMF) 134
HANDOUT 5.10 Cue Cards 135
HANDOUT 5.11 Emotion Thermometer 136
HANDOUT 5.12 Behavioral Experiment 137
HANDOUT 5.13 My Executive Functioning Profile 138
HANDOUT 6.1 Communication Skills: Strengths and Challenges 156
HANDOUT 6.2 Communication Behaviors Checklist 157
HANDOUT 6.3 Communication Behaviors Observations Sheet 158
HANDOUT 6.4 Paraphrasing 159
HANDOUT 6.5 Clarifying and Summarizing 160
List of Handouts xiii
HANDOUT 6.6 Starting Conversations 161
HANDOUT 6.7 Maintaining Conversations and Taking Turns 162
HANDOUT 6.8 Ending Conversations 163
HANDOUT 6.9 Social Communication Skills Questionnaire 164
HANDOUT 6.10 Communication Styles 166
HANDOUT 7.1 Model of Fatigue after Brain Injury 189
HANDOUT 7.2 What Is Fatigue? 190
HANDOUT 7.3 Fatigue Management Questionnaire 191
HANDOUT 7.4 Fatigue Formulation 192
HANDOUT 7.5 Screening Tool 193
HANDOUT 7.6 Fatigue Triggers 196
HANDOUT 7.7 Fatigue Diary 198
HANDOUT 7.8 How Does It Feel? 199
HANDOUT 7.9 My Fatigue Traffic Light 200
HANDOUT 7.10 The Art of Delegation 201
HANDOUT 7.11 Weekly Timetable 202
HANDOUT 7.12 Recharging Different Types of Energy 203
HANDOUT 8.1 The Cognitive-Behavioral Therapy (CBT) Cycle 220
HANDOUT 8.2 Thinking, Feeling, Doing 221
HANDOUT 8.3 Three Emotion Systems 222
HANDOUT 8.4 Brain Anatomy and Emotion 223
HANDOUT 8.5 Understanding Emotions: New Brain/Old Brain 224
HANDOUT 8.6 Do You Ever . . . ? 225
HANDOUT 8.7 Mood Diary 227
HANDOUT 8.8 How Do You Cope? 228
HANDOUT 8.9 Mindfulness 229
HANDOUT 8.10 Calming Breaths 230
HANDOUT 8.11 Compassionate Imagery 231
HANDOUT 8.12 Progressive Muscle Relaxation 232
HANDOUT 8.13 What’s the Evidence? 233
HANDOUT 8.14 My Mood Profile 234
HANDOUT 9.1 The Y-Shaped Model of Identity Change in Rehabilitation 253
HANDOUT 9.2 The “Vicious Daisy” Cycle 254
xiv List of Handouts
HANDOUT 9.3 Personal Values 255
HANDOUT 9.4 Family Roles 256
HANDOUT 9.5 My Motivation: Why Do I Do What I Do? 257
HANDOUT 9.6 Predictions 258
HANDOUT 9.7 Occupational Experiment 259
HANDOUT 9.8 Questions and Observations for an Occupational Experiment 260
HANDOUT 9.9 Comfort Zones 261
HANDOUT 9.10 How Do I See Myself? 262
CHAPTER 1
General Introduction
Barbara A. Wilson
“Neuropsychological rehabilitation” is a process whereby people who have sustained insults
to the brain are helped to achieve their optimum physical, emotional, psychological, and
vocational well-being (McLellan, 1991). The main purposes of such rehabilitation are to
support people with disabilities resulting from brain insults in achieving their optimum
level of well-being, to reduce the impact of their problems in everyday life, and to help them
return to their own most appropriate environments. Rehabilitation is not about teaching cli-
ents to score better on tests, to learn lists of words, or to be faster at detecting stimuli. The
focus of treatment is on improving aspects of everyday life; rehabilitation therefore needs
to involve personally meaningful themes, activities, settings, and interactions (Ylvisaker &
Feeney, 2000).
PRINCIPLES OF REHABILITATION
This workbook has grown out of the psychoeducation groups run for clients with acquired
brain injury (ABI) who attend The Oliver Zangwill Centre (OZC) for Neuropsychologi-
cal Rehabilitation in Ely, Cambridgeshire, United Kingdom. The rehabilitation program at
OZC is based on six core components that the staff members believe illustrate the principles
of good clinical practice, and that underpin the material offered in this book:
1. Therapeutic milieu. A concept derived from the work of Ben-Yishay (1996), the
“therapeutic milieu” in holistic rehabilitation refers to the organization of all aspects of the
environment to provide maximum support in the process of adjustment and increased social
participation. The milieu embodies a strong sense of mutual cooperation and trust—a sense
that underpins the working alliances between clients and clinicians.
1
2 T H E B R A I N I N J U RY R EH A B I L I TAT I O N WO R K B O O K
2. Meaningful goals. Care is taken to make the goals set with clients meaningful and
functionally relevant. By “meaningful functional activity,” we are referring to all daily activ-
ities that form the basis for social participation. These can be categorized into vocational,
educational, recreational, social, and independent living activities. It is through participa-
tion in these areas that we all gain a sense of purpose and meaning in our lives. Although
we may not think about this consciously in everyday life, these types of activities enable us
to achieve certain aims or ambitions that are personally significant to us and thereby con-
tribute to our sense of identity.
3. Shared understanding. In a rehabilitation context, this term refers to mutual under-
standing among clients, families, and staff. The notion comes from the use of “formulation”
in clinical practice (Butler, 1998). As explained in more detail below, a formulation is a map
or guide to intervention that combines a model derived from established theories and best
evidence from the client’s and family’s own personal views, experiences, and stories. This
concept should be applied to all individual clinical work, and should influence the way the
rehabilitation experience is organized as a whole. It includes a team philosophy that incor-
porates a shared team vision, explicit values, and goals. Additional characteristics of shared
understanding include assimilation of research and theory; participation in knowledge and
experience with other professionals and families; peer audit of the services provided; and
absorption of the views and contributions of past clients.
4. Psychological interventions. These are based upon certain ways of understanding
feelings and behavior. Specific psychological models are applied to guide work, depending
upon each individual’s specific needs. Approaches from these models provide ways for team
members to engage clients in positive change and to tackle specific problems.
5. Compensatory strategies and retraining. These are the two principal approaches to
managing cognitive impairments. “Compensatory strategies” are alternative ways to enable
individuals to achieve a desired objective when an underlying function of the brain is not
operating effectively; many of these are outlined in this workbook. “Retraining” is under-
taken to improve performance of a specific brain function or to improve performance on
a particular task or activity. Retraining also helps to address skills lost through lack of use
(e.g., through not being at work since an injury occurred).
6. Families and caregivers. Rehabilitation involves working closely with families
and caregivers, who sometimes report that they feel like “afterthoughts” in rehabilitation.
Recent government policies within the United Kingdom highlight the fact that families and
caregivers experience significant burden following ABI, and provision of support for them
is recommended.
At OZC, we follow a holistic approach to brain injury rehabilitation, pioneered by
Diller (1976), Ben-Yishay (1978), and Prigatano (1986). Such an approach “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 reme-
diation’ ” (Ben-Yishay & Prigatano, 1990, p. 400). Perhaps the main philosophy of the holis-
tic approach is the insistence that it is futile to separate the cognitive, social, emotional, and
General Introduction 3
functional aspects of brain injury. Given that emotions affect human behavior, including
how people think, remember, communicate, and solve problems, we need to acknowledge
that these functions are interconnected and often hard to separate; all of them need to be
dealt with in rehabilitation.
Ben-Yishay and Prigatano (1990) provide a model of hierarchical stages in the holistic
approach through which a client must work (either implicitly or explicitly) in rehabilitation:
• Engagement: Increasing the individual’s awareness of what has happened to him or
her.
• Awareness: Increasing the person’s understanding of what has happened.
• Mastery: The provision of strategies or techniques to reduce cognitive problems.
• Control: The development of compensatory skills.
• Acceptance.
• Identity: Provision of vocational and other counseling.
It can be argued that the holistic approach is less of a model and more of a series of beliefs
or principles (Prigatano, 1999). Nevertheless, the holistic model makes clinical sense—and
in the long term it is probably cost-effective, despite its apparent expense (Cope, Cole, Hali,
& Barkan, 1991; Mehlbye & Larsen, 1994; Wilson, 1997; Wilson & Evans, 2002).
In fact, there is mounting evidence that rehabilitation reduces the effects of cogni-
tive, psychosocial, and emotional problems, leading to greater independence and eventual
employability for many persons with brain injuries, as well as reductions in family stress
(Cicerone et al., 2005; Wilson, Gracey, Evans, & Bateman, 2009). Cicerone, Mott, Azulay,
Sharlow-Galella, Ellmo, et al. (2008) and Cicerone, Langenbahn, Braden, Malec, Berquist,
et al. (2011) endorse the effectiveness of holistic approaches for traumatic brain injury (TBI):
“Comprehensive holistic neuropsychological rehabilitation is recommended to improve
post-acute participation and quality of life after moderate or severe TBI” (2011, p. 526).
Although the holistic approach is possibly best for the majority of people with brain
injury, it is probably true to say that holistic programs can be improved through the incor-
poration of ideas and applications from learning theory, including task analysis, baseline
recording, and monitoring. Other improvements can come from the implementation of
single-case experimental designs within individual treatment programs. Further refine-
ments can be encouraged by the use of cognitive neuropsychological models; such models
enable us to identify cognitive strengths and weaknesses in more detail, to explain observed
phenomena, and to make predictions about cognitive functioning.
THIS BOOK’S INTENDED AUDIENCE
While the myriad difficulties faced by survivors of brain injury—which can range from
word-finding difficulties to memory problems to anger outbursts—require support from
an experienced interdisciplinary team of speech and language therapists, occupational
therapists, and clinical psychologists, few clients have such a team at their disposal. Many
