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Brain Injury
state of anxiety, [so they react] without hesitation [without being aware of the deficits and their functional consequences) as much as possible in all of its
fact] that the solution is not correct.” details”
9
without precipitating a catastrophic reaction. While planning what to
tackle, remedially and therapeutically, in brain-injured persons, “we have to
The authors have frequently observed ‘novices’ in neuropsychological decide… which symptoms can be eliminated and which should remain
assessment arriving at faulty neurodiagnostic conclusions in persons with undisturbed” (i.e. which should be left alone and not treated).
9
Finally, it will be
pronounced frontal lobe dysinhibition syndromes. In one case, the person’s necessary “to evaluate and to choose from among the different therapeutic
rash, poorly modulated, and inadequately self-monitored statements led the approaches [those techniques that are particularly suited to the needs and
examiner to conclude that the patient was “unable to empathize” with others. capacities of brain-injured persons, which will have to be different from the
In another case, on the basis of written statements containing grammatical and practices of other schools of psychotherapy particularly that of psychoanalysis].
syntactic errors, the examiner diagnosed “the presence of aphasic problems.” Therapy will be successful only if the patient and the therapist interact in a kind
In a third case, failure to adequately perform the Wechsler Adult Intelligence of communion between them.”
9
Scale III block design tests led to the conclusion that the patient’s
“constructional praxis” was impaired. An early study
17
demonstrated that Although typical programs focus on the development of sets of skills, in a
failure in performing a task in brain-damaged people is not qualitatively holistic program the development of skills is seen as part of a larger process.
different from failure in non-brain-damaged people. The failure is related to the In this process, the teaching style and the calibration (for level of complexity)
continuum of the level of complexity of the task. A brain-damaged person may of the tasks that will have to be performed as part of the remedial training
experience complexity at a simpler level of task demand than a non-brain- are adjusted to induce a feeling of safety and to avoid precipitating anxiety
damaged person. Goldstein also postulated: “In the interpretation of and defensive behaviors. The therapeutic milieu therefore makes possible an
symptoms, it is of the greatest importance to be aware that the [patient], like educational process that draws upon the realization of strengths and an
normal [individuals], is driven by the [inherent nature of human beings] to awareness of one’s limitations. The emphasis is on minimizing as much as
realize his capacities as much as possible.”
10
possible potentially demoralizing factors while enhancing the acquisition of
skills that will enable the brain-injured individual to become productive
Considerations for Treatment commensurate with his or her current abilities. The holistic approach is
A basic assumption by Goldstein is that when it is impossible to restore an therefore a balancing act between the areas that are singled out for
organism to its full (pre-injury) integrity, a state of ‘health’ can be established if treatment, the nature of the tasks presented to the patient, and the judicious
the patient’s environment is so organized and structured by others that the clinical management of the patient who may be hovering between
patient can cope with the situational demands that confront him or her. Under depression and denial. In this context, it is crucial to deal with limitation in
such conditions, the likelihood of catastrophic reactions will be significantly the patient’s attention, memory, and reasoning functions and to take into
reduced. Thus, an ordered (and structured) environment will enable the patient account the dynamics of the patient’s family roles and the concrete
to cope. The ability to cope (based on an inherent characteristic of human vocational choices that the patient could realistically pursue.
nature) “will lead the patient to feel healthy.”
9
However, “becoming healthy
demands a transformation of the individual’s personality” to enable the person The structural, organizational, and programmatic details of the ‘therapeutic
to bear restrictions that will inevitably result from having to live in an community’ type of day program that makes possible the effective
environment that is organized and structured by others. Therefore, only by application of Goldstein’s ideas were published by Daniels-Zide and Ben-
accepting such restrictions can the person feel that “life remains worth living Yishay.
18
Evidence concerning the most effective treatment mix,
19
as well as
in spite of restrictions.”
9
“The central aim of therapy” in a rehabilitation context showing that this type of program yields superior outcomes to conventional
is to help the brain-injured person to accept restrictions, i.e. limitations, with approaches, in terms of returning brain-injured individuals to work
20
and in
equanimity and “to make the right choices,” since only this will help the reconstituting their shattered sense of identity
21
has been published
patient “feel that life is worth living.”
10
It is therefore “our task in therapy to elsewhere. Although much has been learned, more is required to address the
help the patient to realize the necessity of [accepting] restrictions [in order to full range of questions concerning the efficacy and empirical validity of the
become] healthy.”
9
Because both the cognitive and emotional functions of the approach. Although there is a need for more adequate research, at this stage
brain-injured person are impaired, “a particular [task of the rehabilitation of our knowledge the holistic approach is cited as part of best practices in
process] consists of making the patient understand the problem (i.e. his/her recent reviews of the literature.
22,23
■
1. Ben-Yishay Y, An outline of a theoretical frame work for the 7. Bach-y-Rita P, Recovery of function: Theoretical consideration for head injured adult, Philadelphia: FA Davis, 1983;367–80.
rehabilitation of persons with severe head trauma, Keynote brain injury rehabilitation, Baltimore: University Park Press, 14. Ben-Yishay Y, et al., Semin Neurol, 1985;5:252–77.
address, Sixth annual Rehabilitation Symposium, Sheba Medical 1980;225–68. 15. Ben-Yishay Y, Neuropsychol Rehabil, 1996;6:327–43.
Center, Tel Hashomer, Israel, 1975. 8. Goldstein K, The effects of brain damage on personality, Presented 16. Christenson AL, Uzzell BP (eds), International Handbook of
2. Ben-Yishay Y, Diller L, A multi-impact clinical experiment in the at the annual meeting of the American Psychoanalytic Association, Rehabilitation, New York: Kluwer Academic/Plenum Publishers,
rehabilitation of problematic brain injured Israeli war veterans, Atlantic City, 1952. 2000.
Presented at the 13th World Congress of Rehabilitation, Tel Aviv, 9. Goldstein K, J Individ Psychol, 1959;151:5–14. 17. Ben-Yishay Y, et al., Cortex, 1974;10:121–32.
Israel, 1976. 10. Goldstein K, The relationship between rehabilitation and 18. Daniels-Zide E, Ben-Yisha Y, International Handbook of
3. Goldstein K, The Organism, New York: American Book, 1939. psychology, Proceeding of the Clark University Conference, Neuropsychological Rehabilitation, New York: Kluwer
4. Goldstein K, Human nature in the light of psychopathology, 1959:36–51. Academic/Plenum Publishers, 2000;183–93.
Cambridge: Harvard University Press, 1951. 11. Ben-Yishay Y, et al., NYU Medical Center Rehabilitation 19. Rattok J, et al., Neuropsychology, 1992;6:375–415.
5. Goldstein K, After effects of brain injuries in war: their evaluation Monograph No. 59, 1977:1–6. 20. Ben-Yishay Y, et al., J Head Trauma Rehabil, 1987;2(1):35–48.
and treatment, New York: Grune and Straton, 1942. 12. Ben-Yishay Y, Diller L, Cognitive deficits. Rehabilitation of the 21. Ben-Yishay Y, Daniels-Zide E, Rehabil Psychol, 2000;452:112–19.
6. Moore, Recovery of function: Theoretical consideration for brain adult, Philadelphia: FA Davis, 1983;167–84. 22. Cicerone KD, et al., Arch Phys Med Rehab, 2000;81:1596–1615.
injury rehabilitation, Baltimore: University Park Press, 1980;9–90. 13. Ben-Yishay Y, Diller L, Cognitive remediation. Rehabilitation of the 23. Cicerone KD, et al., Arch Phys Med Rehab, 2005;86:1685–92.
80 US NEUROLOGY
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