In neuropsychological & neuro-rehabilitation there are times when we meet clients who profoundly disagree with our analysis (which I accept is only ever a hypothesis). Sometimes the nature of the disagreement might be about expected outcomes. For example "when will my hand start moving again?" might be met with a therapist's view - this is a profound paralysis explained by extent of lesion and it might not voluntarily move again - that contrasts with the patient's view "if I keep seeking opinions, keep striving, someone might be able to help restore the lost function"). There are times when it is very difficult to shift from this narrative that seems to head into persisting disagreement&disappointment, preventing adjustment & acceptance. Playing into this context is a marketplace of people with their latest gadget or therapy approach. IN my view, this can perpetuate distress. I think there are some interesting therapeutic implications but not aware of much literature on this (?). I'd be fascinated to know if this is of interest to others in this forum. What therapeutic strategies would you try?
I feel that your question can be addressed from a 'working alliance building' point of view [a disagreement of goals]. This is a problem that clinicians face not only with ABI, but also with other neurological conditions, such as spinal cord injury. In my opinion, what is at stake here is very delicate, because such 'impasses' can break a working alliance. I have not read anything related to this either, perhaps Rudi Coetzer has mentioned some of this in his recent paper: psychotherapy after acquired brain injury: is less more. The main point here is whether we should force our hypothesis in order that the patient gains some awareness and acceptance, or whether we have to wait until reality does this work. If we push to hard and to quick, the emotional bond can suffer and later, when reality finally shows the patient that the hand will not move, we could not support him dealing with the suffering that such realization entails. So where do we want to sand? I do believe that the adequate management of countertransferential feelings by the therapist here is key [the capacity to tolerate internally the anxiety of knowing that the hand or legs will not move, but not doing anything about it]. I also believe that rehabilitation settings with very restricted time frames may sometimes demand from therapists to intervene perhaps too much, in order to generate change [this versus long term processes]. Now I remember that Ylvisaker proposed similar ideas, unfortunately, on a paper written in spanish
really great points Christian, thanks. I agree therapeutic alliance literature will be a good domain to investigate. I also have a sense that sometimes therapists in working to create an alliance can be complicit in building expectations.
Now you've mentioned the topic of countertransference (which is valuable to reflect on...('why am I stressed by this?") that makes me think about the interventions such as sharing our own distress at the situation. It's a good observation about limited timeframes.
This is a really interesting discussion. I have often wondered about arm rehabilitation post ABI, it seemed when I qualified that we blamed the patient ( I.e. they didn't comply with Bobath). Now we name funding ( more sessions, more expensive equipment ), but maybe we should triage in some way and accept there will never be recovery for some?
I agree with Catherine on the need to work on acceptance in many cases. The problem [and this is my main point] is that acceptance is not as simple as it sounds. On the contrary it is an emotionally dynamic process, highly complex, for the patient [his family] and the therapists as well. I believe that more training [and the development of models] on this matter is needed. So professionals can facilitate this process and avoid interventions that are iatrogenic.
With the level of detail now available to us in brain imaging, I think judging the likelihood of recovery should be possible. Isn't this is the approach that the PLORAS study is taking to language.
I really agree that the development of models is needed. The Y shaped 'model' Gracey et al wrote about is relatively simple proposal - that a starting point we have is that there is discrepancy (either intra-personally, or between clinician and patient) from present and desired self.
For sure there are layers of complexity to this!