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Guidelines for Early Psychotherapy Sessions and General Treatment Considerations

Chapter 2

This chapter offers detailed guidelines for the initial consultation and the early psychotherapy sessions. It then describes some important general treatment parameters and techniques for effecting meaningful change with brain-injured patients. A few comments on care coordination and the reimbursement process, together with a brief case study, conclude the chapter.

The Initial Consultation

The initial consultation emanates from Phase 3 of the PEM (see Chapter 1, Figure 1.2). A key determinant for referral of a brain-injured patient to psychotherapy is that the patient has struggled and often failed to achieve independence in the home and community, and/or has been unable to reintegrate successfully to work or school. Alternatively, patients may be referred by their physicians immediately after discharge from an inpatient rehabilitation setting, so as to avoid potential posthospitalization adjustment problems. Of note, patients themselves are often not the ones seeking psychotherapy; distressed and overwhelmed family members or astute health care professionals are usually the ones who recognize that the patients need psychotherapy, with an emphasis on psychoeducation, coping,and adjustment to their deficits. Therefore, a psychotherapist should not assume that a patient is motivated (at least initially) for psychotherapy.

Typically, a patient being considered for psychotherapy will need a physician’s referral. This facilitates the acquisition of relevant medical records, which are necessary for determining the patient’s appropriateness for therapy and anticipating possible psychotherapeutic needs and challenges. Records should be obtained and reviewed in advance of the initial consultation. Helpful medical records should include the background neurological findings and associated medical history; radiographic reports; neurosurgical reports; consultations by neurologists and neuro-ophthalmologists; and summary reports from other rehabilitation settings (both inpatient and outpatient). If available, prior neuropsychological reports are very informative—especially when they contain pertinent preinjury social history, including drug and alcohol use, employment history, and the psychosocial adjustment of the patient and family members. For a student, prior grades and standardized test scores are very beneficial in establishing the individual’s academic and behavioral history.

This volume does not address how to do a neuropsychological evaluation (see Lezak, Howieson, Loring, Hannay, & Fischer, 2004; Strauss, Sherman, & Spreen, 2006; Snyder, Nussbaum, & Robins, 2006; Uomoto, 2004). However, an up-to-date neuropsychological evaluation will provide essential quantitative and qualitative data about the patient’s neuropsychological and emotional status, and will delineate specific cognitive strengths and difficulties; therefore, it will guide the consultation (and treatment) process (Erickson, 1995; Prigatano & Klonoff, 1988). For example, the intake interview approach will need to be modified to fit the patient’s memory capacity, abstract reasoning skills, language abilities, and speed of information processing. In some situations, the psychotherapist may also be the neuropsychologist who performs the neuropsychological examination. This can be useful, as clinical observations and other data obtained by the neuropsychologist/psychotherapist during the evaluation process typically provide an excellent starting point for the psychotherapeutic and alliance-building process. Table 2.1 lists assessment domains and sample neuropsychological tests for each domain. This list is not exhaustive and can be modified according to the preferences of the examiner, the requirements of the treatment setting, and the nature and extent of the patient’s neurological injury. Note that symptom validity testing should be included, in order to be sure that the patient has the necessary motivation to embrace the psychotherapeutic process, with a goal of improving independence and functionality.

The purpose of an initial 1-hour consultation is to make a formal determination of the patient’s “fit” for a psychotherapeutic relationship, as well as the potential for meaningful change. It is recommended that family members be included for at least a portion of the consultation. This gives the clinician the opportunity to preview not only the family members’ unique emotional resources and psychodynamics, but also the dynamics, interaction styles, and behavior patterns between family members and the patient. All parties are asked in advance for permission (and the patient is asked to sign a release form) to discuss the patient’s and family members’ perceptions about the patient’s deficits. Also, when the first appointment is set, the patient and attending support system members are told that the consultation precedes formal initiation of psychotherapy services, and that as part of the appointment, all parties will be asked about their willingness to proceed with treatment sessions.

The initial consultation provides a critical opportunity to assess the patient’s neuropsychological and emotional status in order to make cogent recommendations, including possible goals of the psychotherapy process. If psychotherapy is to occur in the context of other treatment modalities, this consultation often provides valuable input regarding the patient’s potential to benefit from other therapies.

Table 2.2 lists the relevant domains for inquiry during the initial consultation. These include demographics, social and medical history, injury-related data, subjective report of present status, and current medical treatment. Other key areas to assess are the patient’s overall psychological/psychiatric status and the family’s involvement.