collaborative therapeutic neuropsychological assessment

Collaborative Therapeutic Collaborative Therapeutic Neuropsychological Neuropsychological AssessmentAssessment

Presented at the Pennsylvania Psychological Presented at the Pennsylvania Psychological Association 75Association 75thth Anniversary Convention Anniversary Convention

Tad T. Gorske, Ph.D.Tad T. Gorske, Ph.D.

Assistant Professor of Physical Medicine and RehabilitationAssistant Professor of Physical Medicine and Rehabilitation

University of Pittsburgh School of MedicineUniversity of Pittsburgh School of Medicine

““The presentation of brain facts about The presentation of brain facts about specific damages is meaningless to specific damages is meaningless to patients unless they can begin to patients unless they can begin to understand how the changes in their understand how the changes in their brains are lived out in everyday brains are lived out in everyday experiences and situations”experiences and situations”

(Varella, 1991 as stated in McInerney and (Varella, 1991 as stated in McInerney and Walker, 2002)Walker, 2002)

This is about………This is about………Neuropsychological InterviewNeuropsychological Interview

Neuropsychological TestingNeuropsychological Testing

Interpersonal Feedback Interpersonal Feedback SessionSession

Neuropsychological Neuropsychological ReportReport

Challenges for Clinical Challenges for Clinical NeuropsychologyNeuropsychology

Case ExamplesCase Examples

The Role of Neuropsychological The Role of Neuropsychological Assessment: Historical PerspectiveAssessment: Historical Perspective

Period of Neuropsychological LocalizationPeriod of Neuropsychological Localization

Period of Neurocognitive EvaluationPeriod of Neurocognitive Evaluation

Current Period??Current Period??

Technician / ArtistTechnician / Artist

Neuropsychologists are challenged to Neuropsychologists are challenged to expand their roles from a purely technical expand their roles from a purely technical endeavor to a more holistic perspective. endeavor to a more holistic perspective.

Cognitive theorist, functional anatomistCognitive theorist, functional anatomist

Technician / ArtistTechnician / Artist

Neuropsychologists are challenged to Neuropsychologists are challenged to expand their roles from a purely technical expand their roles from a purely technical endeavor to a more holistic perspective. endeavor to a more holistic perspective.

Cognitive theorist, functional anatomist, Cognitive theorist, functional anatomist, psychotherapist, family therapist, psychotherapist, family therapist, emotional adjustment, viewing the person emotional adjustment, viewing the person from a holistic perspective. from a holistic perspective.

Holistic Neuropsychological PrinciplesHolistic Neuropsychological Principles

Empower patients and families to take an active role Empower patients and families to take an active role in the treatment process;in the treatment process;

Believe people with neurological disabilities are more Believe people with neurological disabilities are more

like people without neurological disabilities (ie. like people without neurological disabilities (ie. Go Go beyond the brainbeyond the brain) ;) ;

Convey honesty and caring in personal interactions Convey honesty and caring in personal interactions to form a foundation for a strong therapeutic to form a foundation for a strong therapeutic relationship;relationship;

Develop practical plans for rehabilitation; explain Develop practical plans for rehabilitation; explain rehabilitation techniques in understandable language;rehabilitation techniques in understandable language;

Holistic Neuropsychological PrinciplesHolistic Neuropsychological Principles

Help patients and families understand Help patients and families understand neurobehavioral sequelae of brain injury and neurobehavioral sequelae of brain injury and recovery;recovery;

Recognize change is inevitable and help families Recognize change is inevitable and help families cope with change;cope with change;

Every patient is important, treat with respect;Every patient is important, treat with respect; Remember that patients and families have Remember that patients and families have

different perspectives regarding treatment different perspectives regarding treatment approaches;approaches;

Be willing to refer if appropriate. Be willing to refer if appropriate.

Collaborative Therapeutic Neuropsychological Collaborative Therapeutic Neuropsychological Assessment (Gorske and Smith)Assessment (Gorske and Smith)

A collaborative method of interviewing and A collaborative method of interviewing and providing feedback from providing feedback from neuropsychological assessment;neuropsychological assessment;

Enlists the patient/family as an active Enlists the patient/family as an active collaborator;collaborator;

Empowers patients/families to be Empowers patients/families to be caretakers of their own cognitive health. caretakers of their own cognitive health.


1.1. Comprehensive Neuropsychological Comprehensive Neuropsychological AssessmentAssessment

2.2. Referral question, records review, Referral question, records review, behavioral observations, clinical behavioral observations, clinical interview, quantitative and qualitative interview, quantitative and qualitative assessment. assessment.


The Information Gathering / The Information Gathering / Medical Model Medical Model Clinician knows best;Clinician knows best; Fragile patients;Fragile patients; Knowledge is dangerousKnowledge is dangerous

Collaborative ModelCollaborative Model

Clinician is an expert Clinician is an expert in neuropsychology; in neuropsychology; the patient/family is the patient/family is the expert on the expert on themselvesthemselves

Patients are resilientPatients are resilient Knowledge is powerKnowledge is power


1)1) The patient does not understand the nature of a The patient does not understand the nature of a neuropsychological examination and are confused as neuropsychological examination and are confused as to the purpose, methods, and potential outcomes; to the purpose, methods, and potential outcomes;

2) Patients are often not informed of the results except for 2) Patients are often not informed of the results except for final conclusions. This leads to even more confusion final conclusions. This leads to even more confusion because the rationale for the conclusions is unclear; because the rationale for the conclusions is unclear;

3) There is an aura of secrecy around the whole process. 3) There is an aura of secrecy around the whole process.


The Information Gathering / Medical The Information Gathering / Medical Model of Neuropsychological Model of Neuropsychological Assessment.Assessment.

Clinician knows best;Clinician knows best; Fragile patients;Fragile patients; Knowledge is dangerousKnowledge is dangerous


Technological AdvancesTechnological Advances

Managed CareManaged Care

Patient Centered TrendPatient Centered Trend


Developing a patient-centered Developing a patient-centered neuropsychological assessment neuropsychological assessment process. process.


Psychologists are giving Psychologists are giving feedback………but what are they feedback………but what are they doing? doing?

Survey of Feedback PracticesSurvey of Feedback Practices

719 Participants from NAN, SPA, INS in an 719 Participants from NAN, SPA, INS in an online survey. online survey.

Over 70% provide feedback, nearly half the Over 70% provide feedback, nearly half the time consisting of a “therapy hour.” time consisting of a “therapy hour.”

Clinicians providing feedback Clinicians providing feedback overwhelmingly perceived it as having a overwhelmingly perceived it as having a positive impact on patients. positive impact on patients.

(Source) Smith, S., Wiggins, C., & Gorske, T. (2007). A survey of psychological (Source) Smith, S., Wiggins, C., & Gorske, T. (2007). A survey of psychological assessment feedback practices. assessment feedback practices. AssessmentAssessment, 14(3), 310 – 319. , 14(3), 310 – 319.

A Brief HistoryA Brief History

Neuropsychological Test FeedbackNeuropsychological Test FeedbackPsychological Testing as a Therapeutic Psychological Testing as a Therapeutic

InterventionInterventionCollaborative Individualized Psychological Collaborative Individualized Psychological

Assessment Assessment Therapeutic Psychological AssessmentTherapeutic Psychological Assessment

CTNA Conceptual BasisCTNA Conceptual Basis

Collaborative Individualized Assessment Collaborative Individualized Assessment (Dr. Constance Fischer)(Dr. Constance Fischer)

Therapeutic Individualized Assessment Therapeutic Individualized Assessment (Dr. Stephen Finn)(Dr. Stephen Finn)

Recommendations in the Literature Recommendations in the Literature (Gass and Brown, 1992)(Gass and Brown, 1992)

Motivational Interviewing (MI) Motivational Interviewing (MI) (Miller and Rollnick, 2002)(Miller and Rollnick, 2002)

CTNACTNA

The spirit of the CTNA lies in Collaborative The spirit of the CTNA lies in Collaborative and Therapeutic Assessment Modelsand Therapeutic Assessment ModelsOpen sharing; explore results contextually; Open sharing; explore results contextually;

use results to facilitate empathic use results to facilitate empathic understandingunderstanding

The framework for conducting the CTNA is The framework for conducting the CTNA is drawn from MI.drawn from MI.

The CTNA adopts and adapts the MI The CTNA adopts and adapts the MI Personalized Feedback ReportPersonalized Feedback Report

CTNA Feedback SessionCTNA Feedback Session

Two primary componentsTwo primary components

1.1. Provide information from Provide information from neuropsychological test resultsneuropsychological test results

2.2. Interact with clients in a collaborative Interact with clients in a collaborative manner consistent with TA and MI.manner consistent with TA and MI.

CTNA Personalized FeedbackCTNA Personalized Feedback

1.1. IntroductionIntroduction• Provide feedback report; explain session purpose; Provide feedback report; explain session purpose;

facilitate collaboration and empathic understandingfacilitate collaboration and empathic understanding

2.2. Develop QuestionsDevelop Questions• Develop 2 or 3 well defined questions the client Develop 2 or 3 well defined questions the client

hopes the results can answerhopes the results can answer

3.3. Explain how strengths and weaknesses are Explain how strengths and weaknesses are determineddetermined

• Percentiles, determine criteria for strength or Percentiles, determine criteria for strength or weaknessweakness


4.4. Feedback about strengths and Feedback about strengths and weaknessesweaknesses

• ElicitElicit: What skills did the client : What skills did the client use to complete the test.use to complete the test.

• ProvideProvide: Therapist provides : Therapist provides information on the cognitive skill information on the cognitive skill test(s) examine.test(s) examine.

• ElicitElicit: Therapist elicits reactions : Therapist elicits reactions from the clients and applies results from the clients and applies results to their real life. to their real life.


5.5. Summarize results and provide Summarize results and provide recommendationsrecommendations

Summary and key questionSummary and key question Ask permission to provide recommendationsAsk permission to provide recommendations Make recommendationsMake recommendations

Pilot Study ResultsPilot Study Results

NAFITAU

S1

71%

48%

0102030405060708090

100

Adherence Ratesp = .042, cohen's d = .78 (.02-1.55)

NAFI (n = 14); TAU (n = 14)

Pilot Study Results: D&A UsePilot Study Results: D&A UseNAFI = 6; TAU = 5NAFI = 6; TAU = 5

30 Day Alcohol Use

0

3.4

5.46

7.13

0

12

34

5

67

89

10

Baseline 30 Day

NAFI

TAU

Pilot Study Results: D&A UsePilot Study Results: D&A Use

30 Day Drug Use

0.66

3.43

0.40

4.73

0

1

2

3

4

5

6

7

Baseline 30 Day

NAFI

TAU

Pilot Study Results: DepressionPilot Study Results: DepressionNAFI = 7; TAU = 5NAFI = 7; TAU = 5

30 Day DepressionHRSD-25

20.21

11.4

22.221.2

0

5

10

15

20

25

Baseline 30 Day

NAFI

TAU

Patient ResponsesPatient Responses ““The assessment was helpful to me. I learned a lot about myself…I The assessment was helpful to me. I learned a lot about myself…I

would have done it without being paid.”would have done it without being paid.”

““Allowed me to see why I may be reluctant to participate in groups.”Allowed me to see why I may be reluctant to participate in groups.”

““Helped me narrow in on specific steps I need to take with my Helped me narrow in on specific steps I need to take with my therapist re: depression and addiction. Identified couple things we therapist re: depression and addiction. Identified couple things we can work on.”can work on.”

““I am so pleased that I participated in the study. It was right on. M- I am so pleased that I participated in the study. It was right on. M- allowed me to share during the process, which really assisted with allowed me to share during the process, which really assisted with my overall understanding of the feedback.” my overall understanding of the feedback.”

Future ImplicationsFuture Implications

ClinicalClinical:: A high degree of utility for consultation, A high degree of utility for consultation, initiating therapy, working with “sticking points” in initiating therapy, working with “sticking points” in therapy, rehabilitation planning. therapy, rehabilitation planning.

TeachingTeaching:: Developing students into “human-Developing students into “human-science” practitioners, researchers, and teachers. science” practitioners, researchers, and teachers.

ResearchResearch:: Study at U of Pitt, Collaborative Study at U of Pitt, Collaborative Neuropsychological Assessment at UC Santa Neuropsychological Assessment at UC Santa Barbara, many other possibilities. Learn Barbara, many other possibilities. Learn outcomes, factors influencing effectiveness, outcomes, factors influencing effectiveness, manual development.manual development.

CTNA was developed through:CTNA was developed through:

Funding from the National Institute on Drug Abuse Funding from the National Institute on Drug Abuse and research in Addiction Medicine Services at and research in Addiction Medicine Services at Western Psychiatric Institute and Clinic at the Western Psychiatric Institute and Clinic at the University of Pittsburgh. University of Pittsburgh.

Clinical experience at Cognitive Dynamic Therapy Clinical experience at Cognitive Dynamic Therapy Associates (CDTA) in Pittsburgh, Pennsylvania – Associates (CDTA) in Pittsburgh, Pennsylvania – www.cogdyn.comwww.cogdyn.com

Clinical experience at the Department of Physical Clinical experience at the Department of Physical Medicine and Rehabilitation, University of Medicine and Rehabilitation, University of Pittsburgh, Division of Neuropsychology and Pittsburgh, Division of Neuropsychology and Rehabilitation PsychologyRehabilitation Psychology

collaborative therapeutic neuropsychological assessment

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