Conference “Complex neurorehabilitation as the basis for reintegration into society and the labor market” „NEUROPSYCHOLOGY and SENSORS“ Praha, 27. - 28.9.2013 Clinical Neuropsychology An Overview of the Field in Germany Tobias Gräßer Clinical Neuropsychologist (GNP) Systemic Therapist (IGST) Bonn, Germany Clinical Neuropsychology in Germany Contents: Definition of Neuropsychology Domains of intervention according to ICF Working fields of Neuropsychologists in Germany Topics adressed in clinical settings Benefits (and side effects) of NP for patients Benefits (and side effects) of NP for teams in rehabilitation What is Neuropsychology? Definition Wikipedia: „Neuropsychology adresses the structure and function of the brain as they relate to psychological processes and behavior.“ Functional changes / deficits in cognition Emotional and psychological symptoms or consequences Consequences on behavior, activities and participation C:\Users\Tobias\Job\Workshop Int. Classification of Functioning, Disability and Health (WHO, 2001) Definition of Health in ICF (WHO, 2001) A person in considered healthy if a) his/her bodily and mental structures and functions are intact according to statistical norms b) he/she is able to perform all kinds of activities as a person without a health problem would c) he/she is able to fulfill social roles and partake in society as a person without a health problem would (participation) Working fields of Neuropsychologists in Germany Assessment and therapy in clinical (diagnostics and treatment) settings Acute clinics and early rehabilitation Stationary rehabilitation Ambulatory rehabilitation Neuropsychological Practice Diagnostics and assessment to verify claims against insurances, pensions, forensic questions Working fields of Neuropsychologists in Germany Rehabilitation in the workplace Case management University and research settings Topics adressed in clinical settings Functional status Attention Memory Visuo-spatial functions Visual field and Neglect Executive functions Awareness of symptoms Psychological status (e.g. Depression, Anxiety) Topics adressed in clinical settings Consequences of functional deficits in everyday life Basic activities of daily living Mobility (including Driving) Work Social Roles Relationship and Family Topics adressed in clinical settings Therapy Functional Training (e.g. attention, visual defects) Adaption and Compensation (e.g. memory, executive Functions) Coping with consequences of illness (individually, family coping) Topics adressed in clinical settings Therapy II Support of rehabilitation in the workplace Support in finding alternative work settings if return to former one is not possible Support in finding activities and life content if work is not possible at all Essential views on NP-Therapy In Neuropsychological Therapy a clear distinction between cognitive therapy and psychotherapy is impossible. Changes in one field always lead to changes in the other. Coping with neuropsychological deficits always challenges former ideas of how life is. Diagnostics are part of the therapy process. What can Neuropsychologists do for patients? Assessment of function and explanation about the meaning of the result for the life of the person can help clarify unknown / strange / irritating sensations and experiences Development of a therapeutic strategy that comprises functional improvements as well as aspects of dealing with the symptoms and coping can help patients to regain a sense of control What can Neuropsychologists do for patients? Actual improvements in functional status can lead to improvements in activities of everyday life and, ideally, lead to „healing“, reinstatement of former ways of living Neuropsychologists can take a useful role as „translator“ or counselor for patients in relation to partners/families, and if return to work is an option, towards employers and collegues What can Neuropsychologists do for patients? Neuropsychological Diagnostics can give clear recommendations for otherwise unclear questions, i.e. can I drive, go back to work, take care of my finances etc. Psychotherapeutic interventions can enhance coping and dealing with the illness Side Effects and Limitations of Neuropsychological Therapy Not every assessable symptom is treatable Improvements might not go far enough to fullfil the goals a patient has Relatively extensive diagnostic options are not matched with clear-cut strategies for treatment Diagnostic results can lead to restrictions and negative consequences Side Effects and Limitations of Neuropsychological Therapy Frequently, neuropsychological diagnostic and therapy is „prescribed“ by doctors and not something a patient voluntary seeks after This can lead to the fact that the neuropsychologist has the role of control agent more than the role of a therapist Confrontation with deficits can lead to frustration, anxiety or depression Interview with Patient FL Horse-Riding Accident in 2007 Traumatic brain injury Beginning: hemiparesis, wheelchair, speech disorder, intense aggressiveness, severe neuropsychological disorders Ressources: excellent family support, probably high intelligence before accident, good verbal skills Today: bodily functions and speech about normal, remaining neuropsychological deficits in attention, memory and executive functions Interview with Patient FL Living in her own apartment in mother´s house Not successful in trying to find a job perspective in office / administration At the moment “supported work” as volunteer in daily care for elderly people Videos 2, 4, 5, 6 about Neuropsychology 8 about Rehabilitation Clinic 9, 10 about Aggression 14, 13 about NP Therapy 15, 17, 18 about Situation today 20, 21 about Outcome of Therapy Use of NP for other occupations in the rehabilitation team? Provide information that is relevant for the planning of rehabilitation Help explain problems experienced in other therapies Attention deficits might be interpreted as insufficient motivation Visuospatial deficits might lead to the impression of inappropriate contact behavior A lack of awareness or drive might seem as motivational problems Use of NP for other occupations in the rehabilitation team? Neuropsychologists can take the role of contact person for partners or relatives of the patient Neuropsychologists can make contact with employers in order to plan and advance return to work Case management “Side effects” and problems in interdisciplinary team settings Different occupational backgrounds lead to different views and interpretations about symptoms and ways to treat them Different languages and „codes“ In neurorehabilitation there are wide overlaps of possible responsibilities (neuropsychologist – occupational therapist; neuropsychologist – doctors). This can lead to a lack of clarity about who is responsible for what “Side effects” and problems in interdisciplinary team settings Hierarchical differences between occupations (in Germany Doctor – Npsych – other therapeutic occupations) Ways to deal with problems in interdisciplinary team settings Clarity about the hierarchical structure Clarity about individual fields of responsibility Defined ways to deal with conflicts Well defined processes of team meetings Clear definition of goals of rehabilitation and the therapist or occupation that is mainly responsible Therapy goals should be described as concrete and practical as possible Evaluation of goal attainment on a regular basis Ways to deal with problems in interdisciplinary team settings Differing views of patient problems and needs and resulting ideas for treatment are the most important strength of interdisciplinary teams. Thank you for your attention!