Psychological Approaches to Rehabilitation After Traumatic Brain Injury. Andy Tyerman and Nigel S. King, eds. London, UK: Wiley Blackwell, 2008. 528 pages, $174.95, hardcover: ISBN: 1405111674.
Since the explosion that ripped through our lives on January 29, 2006, my family and I have experienced many powerful changes. We've all endured a crisis. And we've survived to feel the miraculous force of recovery at work."1(p277)
The sentiment expressed by Bob Woodruff is likely shared by many survivors of traumatic brain injury (TBI) and their families. Traumatic brain injury is considered to be the leading cause of death and disability worldwide.2 In the United Kingdom, around 1 million people are estimated to seek medical treatment for a head injury and in the United States, the incidence is about 1.4 million annually.3 Not all TBI survivors receive state-of-the-art care in large metropolitan medical centers, whether in the United States or in the United Kingdom. Specialized services are typically located in urban centers of care, creating a care challenge for those in settings outside the urban core. In an effort to educate clinicians about psychological issues and treatment of TBI, Dr Andy Tyerman and Dr Nigel King have edited a textbook that aims to be a practical resource for rehabilitation professionals and other clinicians treating patients with TBI.
The book is smartly organized into 5 overarching topics with 3 to 4 chapters/subtopics devoted to each: service provision, cognitive rehabilitation, behavioral and emotional interventions, vocational rehabilitation, and family interventions. Chapter authors, including Barbara A. Wilson, Andrew D. Worthington, and Joanna C. McGrath, who are practitioners from the United Kingdom provide their insights about such subtopics as rehabilitation of memory problems and visual-perceptual and spatiomotor disorders, postacute inpatient rehabilitation and residential services, and fear, anxiety, and depression. I particularly appreciated that service provision-spanned psychology involvement from acute hospitalization through to community rehabilitation and residential services. Also, in describing the role of the team psychologist, the authors emphasized flexible and thorough assessment, use of behavioral management techniques, and a patient-centered and goal-oriented approach. Consistent with this approach, example questionnaires to assess life goals and expectations and wishes were provided in the appendix. The chapters on outpatient rehabilitation describe a community rehabilitation service that meets the United Kingdom's national service framework for long-term conditions, as well as residential services and long-term supported living as recommended by the British Psychological Society's working party report (British Psychological Society, 1989). This is both a review for most psychologists intimately involved in these areas and an excellent overview for novice mental health professionals unfamiliar with psychological issues after TBI. It is also well suited for practitioners who specialize in certain areas of TBI rehabilitation, such as inpatient acute settings, to understand other settings and challenges with which they may be less familiar.
In the second portion of the text, cognitive rehabilitation in the areas of communication difficulties, memory problems, visual-spatial disorders, and executive and attentional problems is explicated. I was excited to see neuropsychologists describing multidisciplinary responsibility to assessment and treatment of language and pragmatic deficits, as well as emotional aspects of memory functioning. I agree with the authors that rehabilitation of these areas should not be restricted to 1 group of specialists and instead should be shared by the neuropsychologists, speech and language therapists, occupational therapists, and clinical psychologists, among other specialties. Rehabilitation for visual-spatial and spatiomotor disorders, an often-misunderstood and neglected area, is explained with an emphasis on the importance of observation in addition to use of traditional neuropsychological measures to evaluate perceptual difficulties as well as interventions that incorporate both restorative and compensatory methods. Assessment and treatment of executive functioning and attention, areas that are frequently affected in brain injury, but typically some of the most challenging to treat, are offered in the final chapter in this section. The proposed treatments provided in this section can easily be added to anyone's repertoire to lend variety. With the interdisciplinary nature of the chapters, even experienced clinicians may find some novelty in the practical if not theoretical explanations of the treatments described.
Psychological interventions for behavior problems; fear, anxiety, and depression; posttraumatic stress disorder; and adjustment are elucidated in the third section. Leading the section is an overview of the biologic bases of behavior after TBI, along with a description of behavioral management and cognitive-behavioral techniques that include consideration of pharmacologic management and environmental controls. Differentiation of fear, anxiety, and depression from each other and from pathology, as well as a copy of the Rivermead Fear Questionnaire in the chapter appendix, is provided in this section. I was pleased to read a discussion of posttraumatic stress disorder in relation to TBI and the complication of dual diagnosis of posttraumatic stress disorder and TBI. This chapter also included an interesting section on interpreting amnesia and fugue-states and trauma because of the event that caused the TBI versus the aftermath of the TBI (referring to hospitalization and treatment). Understanding these emotions and disorders in the context of TBI should supply the reader with an adequate understanding to best treat their clients in the outlying communities.
The chapters covering vocational rehabilitation explain specific programs in the United Kingdom that support return to employment, whether it is the person's previous job or a new job. The emphasis in these chapters is on a supportive work environment, timing of the return to work, and the use of job coaches. The working out program, run by the Community Head Injury Service at Buckinghamshire Primary Care Trust, is explained as an example of a comprehensive specialist brain injury vocational rehabilitation program that meets national guidelines. However, funding for such programs is a problematic issue, as it is in the United States. This is the only section of the book that may be difficult to translate for those practicing in the US. Articles regarding these programs in the United States are referred to, but these sections are primarily for those readers practicing in the United Kingdom.
Perhaps the most important portion of this book in terms of its utility and impact is in the final 3 chapters covering family interventions. A community service program is described, specifically, the Community Head Injury Service in Aylesbury, that was considered an "example of good practice" in the United Kingdom and was summarized briefly in the Web-based good practice guide (http://www.dh.gov.uk/longtermnsf). In addition, the challenges to family from the standpoint of spouses, parents, and children are considered. The effect of TBI on the children of the injured adult is an infrequently covered topic in brain injury literature, as Drs Daisley and Webster acknowledge in their chapter. The authors provide an excellent review of the existing literature and suggest areas in need of further examination.
There are several strengths to this text that benefit professionals from the United Kingdom and around the world. First, the editors recognize that some readers may be unfamiliar with TBI, and, therefore, they devoted the first chapter to a thorough introduction to the topic, including the medical definition, definition of severity levels, psychological effects and psychological rehabilitation, and a brief overview of services. Many individuals who sustain TBI are located in areas with scant psychological resources or comprehensive programs to assist the individual with chronic issues related to TBI. Much like a family physician, mental health professionals are frequently not trained to treat individuals who have psychological, cognitive, and physical complications that occur with TBI. This volume can assist them in treating the long-term aspects of TBI.
A second strength is that most chapters provide at least 1 case example to illustrate the concepts discussed. The case examples include information on the interview and assessment portions as well as treatment examples. The interventions, while heavily based on cognitive-behavioral techniques such as graded exposure, also include psychoeducation for both the individual and the family. Many of these case examples explain psychotherapy that occurred over a year or more, illustrating the long-term nature of the rehabilitation process. Comprehensive brain injury programs are also described.
Third, the approach to care is patient-centered. Assessment tools incorporating patients' goals and desires are listed in appendices in some chapters for the practitioner to use in his or her practice. Adjustment of family and children is considered, as are cultural issues including racial and ethnic considerations, and concern for the least restrictive environment of care. These concerns are equally applicable for clients in the United States.
Finally, the chapters include recommended readings and useful resources for those wishing to explore further. For example, a 2002 article by Kreutzer and colleagues4(p471) is listed as recommended reading for a "summary of family intervention service and curriculum-16 topics in four areas." Useful resources from that same chapter included a Web site, http://www.headway.org.uk, with the explanation "Headway, the brain injury association (United Kingdom) Web site provides information on TBI, access to local Headway groups and branches which provide support to carers." While the resources may be more specific to the United Kingdom, the recommended readings appear to be more universal.
The reader should be cautioned that the interventions are not all evidence-based. The editors chose to use case examples and provide outcome data "only when it enhances the practical emphasis of the book" (page 11). There appear to be limited outcome data related to the programs that are described. The national service framework for long-term conditions5 and a proposed acquired brain injury service network6 establish a foundation for the development of outcome data.
I recommend this text for mental health professionals unfamiliar with treating people who have sustained a TBI, as a training tool for students in rehabilitation disciplines, and for experienced rehabilitation practitioners. Particularly now that soldiers from many countries are returning from the Afghanistan and Iraq wars with brain injuries, this book is necessary reading for professionals across the globe and especially in the United Kingdom.
-Monica Kurylo, PhD, ABPP
Department of Rehabilitation Medicine
Kansas University Medical Center
Kansas
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