The relationship of cognitive retraining to neurological patients' driving status: the role of process variables and compensation training.

PRIMARY OBJECTIVE: To explore the relationship of cognitive retraining performance to discharge driving status. METHODS AND PROCEDURES: One hundred and three brain-injured patients from a holistic milieu-oriented work/school re-entry programme. EXPERIMENTAL INTERVENTIONS: Initial, last, mean, and best cognitive retraining scores; Behavioural Checklist ratings; Working Alliance (WA) scores. MAIN OUTCOMES AND RESULTS: At the time of discharge, 50.5% of the sample were cleared to drive. Better performance on a cognitive retraining task addressing information processing and motor speed, focused attention, visual scanning and memory was associated with clearance to drive. Patients' behavioural approach to cognitive retraining tasks (use of compensations, organizational and procedural skills) and higher mean and discharge WA scores with staff were associated with driving clearance. Higher mean WA scores were also related to an enhanced behavioural approach to cognitive retraining tasks, including timeliness to sessions, compensation use, better communication pragmatics, decreased distractibility and the ability to apply the 'big picture' benefits of cognitive retraining to the 'real world'. CONCLUSIONS: Cognitive retraining exercises that incorporate skill remediation, 'process' variables and metacognitive skills, as well as a better WA with patients, positively related to clearance to drive at the time of discharge from a holistic milieu-oriented programme.

A family experiential model of recovery after brain injury.

The Family Experiential Model (FEM) described in this article is a therapeutic "navigation tool" for families traversing the recovery process with their loved one after brain injury. Its conception furnishes a personal voice and the pragmatic "stoplight model" depicts how the family's myriad of powerful emotions affects the chosen path in the rehabilitation and recovery process. As an example of mentalizing, the FEM is a healing tool that instills mutual insight and empathy among the family, psychotherapist, and patient. The application of the FEM to individual and group treatment in a holistic treatment milieu is also described.

The relationship of cognitive retraining to neurological patients' work and school status.

PRIMARY OBJECTIVE: To explore the relationship of cognitive retraining performance to discharge productivity status. METHODS AND PROCEDURES: One hundred and one brain-injured patients from a holistic milieu-oriented work/school re-entry programme. EXPERIMENTAL INTERVENTIONS: Initial, last, mean and best cognitive retraining scores; cognitive retraining behavioural checklist ratings; and working alliance scores. MAIN OUTCOMES AND RESULTS: Most (82.2%) of the sample returned to paid work or school. Better performance on two cognitive retraining tasks addressing information processing speed, visual scanning, visuospatial skills and memory were associated with return to the same level of work/school with and without modifications. Selected process variables related to the patients' behavioural approach to cognitive retraining tasks (e.g. their use of compensations, organizational and abstraction skills, procedural skills and unassisted task recall) were associated with better work/school outcomes. Patients' positive working alliance ratings related to their behavioural approach to cognitive retraining tasks. This highlights the importance of combining interventions targeting both the therapeutic interactive process and skill remediation to maximize work/school reintegration. CONCLUSIONS: Cognitive Retraining exercises that incorporate both process variables and metacognitive skills, as well as a better working alliance with patients, positively related to return to work and school at the time of discharge from a holistic milieu-oriented programme.

Psychosocial outcomes 1-7 years after comprehensive milieu-oriented neurorehabilitation: the role of pre-injury status.

PRIMARY OBJECTIVE: To explore pre-injury variables related to post-discharge psychosocial status and identify factors related to work and driving outcomes. METHODS AND PROCEDURES: Ninety-three brain-injured patients attended a holistic milieu-oriented neurorehabilitation program and were contacted 1-7 years post-discharge. EXPERIMENTAL INTERVENTIONS: Questionnaire data addressing pre-injury and post-injury work, driving, income, marital status and living situation. MAIN OUTCOMES AND RESULTS: 74.3% were involved in competitive work and/or school with 86.0% productive at follow-up. Post-injury income decreased significantly compared with pre-injury levels. Pre-injury relationship status did not differ significantly from post-injury; 81.1% remaining in a stable relationship or married at follow-up. Pre-injury and post-injury accident rates were related; 73.1% drove at follow-up. Higher education, non-right hemispheric injury, shorter treatment length and return to work related to driving. Younger age, higher education, non-right hemispheric injury and driving post-injury related to positive work status. CONCLUSIONS: Pre-injury psychosocial data provide an important context for understanding post-discharge outcome after brain injury. Holistic milieu-oriented rehabilitation facilitates long-term successful work, driving and relationship stability.