Episode 60: The Art and Science of Unlocking the Brain That Relearns

Rick Parente is an Emeritus Professor at Towson Univeristy in Baltimore.  He teaches courses on Neuropsychological Assessment and NeuroRehabilitation.  He has published over 75 journal articles and three books on NeuroRehabilitation. He is a Licensed Psychologist and Certified Cognitive Rehabilitation Therapist.

Books

• Retraining Cognition: Techniques and Applications

Todd:  Alright. Welcome back to Full PreFrontal, where we are exposing the mysteries of executive function. I am here, as always, with our host, Sucheta Kamath. Sucheta, you’re going to lead us off and help us understand why Oliver Sacks is relevant to today’s conversation and also introduce our guest. Good morning, my friend, always good to be with you.

Sucheta Kamath:  Great to be with you, Todd. I’m so excited to have a conversation with our guest today. I will tell everybody who that is but let me start with Dr. Oliver Sacks. When I went on a maternity leave, I won’t name the year, but a girl friend of mine gifted me a book titled ‘An Anthropologist on Mars: Seven Paradoxical Tales’ by renowned neurologist, Oliver Sacks. It had fascinating stories of seven patients with varied neurological conditions.

A year or so earlier, I had heard Dr. Sacks speak at Harvard and I was fascinated by his book then it was kind of – he had written that a decade ago, I think, which was ‘The Man Who Mistook His Wife for a Hat.’

Sacks had a knack of brining stories of impairment and disorders into the lives of ordinary people who probably had no exposure to anything such as a brain injury or any anomalies to the brain. He, in fact, was known to not just limit to understand the patient’s story by interacting with them in the clinical setting. Sometimes he would travel long distance to go and visit the patient in their homes and see how they behave and function.

One of the quotes comes to mind is that he has said that defects, disorders, disease can play a paradoxical role by bringing out latent powers, developments, evolutions, forms of life that might never be seen or even be imaginable in their absence. The most important thing I wanted to talk about today is the topic of rehabilitation. Until I read Oliver Sacks, I had never known anyone speak so eloquently about neurological diseases, neurological changes, and its profound impact on one’s life. Or particularly, nobody had spoken so clearly about the work that I do.

My career is peppered with experiences where I have seen individuals who had skills once, lost them, they had to work on gaining them back. In the process, they have somehow discovered inner transformation and even function at a level when they had never been before or have found a new path.

The question comes to mind is what’s the goal of life after brain injury? Does one return to original state or does really work on bouncing back to newer states and whatever they may be? An injury or insult to the brain affects attention, memory, and executive function. One needs some skills to learn to compensate for the lack of skills and to work with people and work on one’s self after the brain injury to remove the obstacles that the brain injury brings.

Today, our expert has dedicated his career to studying this process of cognitive retraining. I am very delighted to introduce Rick Parente. He is an emeritus professor at Towson University in Baltimore. He is a licensed psychologist and a certified cognitive rehabilitation therapist. Dr. Parente teaches courses on neuropsychological assessment and neurorehabilitation. He has published over 75 journal articles and 3 books on neurorehabilitation. His first book that he wrote, he co-authored in 1991, that’s called ‘Retraining Memory Techniques and Applications.’ In 1995, he co-authored a second a book which is one of my favorite books. It is sitting in the shelf behind me, that’s called ‘Retraining Cognition Techniques and Applications.’ It summarizes the techniques developed over two decades prior and how to help people restore their mental processes and help them become functional. His latest book which he co-authored in 2017 which is called ‘Behavioral Statistics.’ With great pleasure, I am delighted to have Dr. Rick Parente with me. Welcome.

Rick Parente:  Thank you.

Sucheta:  Let me get started with this question: how would you describe your own executive function? As a psychologist who works on cognitive retraining, have you benefited from your insights into improving skills and managing self and have you applied them to your own life?

Rick:  I would describe my executive skills as constantly getting better. I say that because I had probably a low start point. I’ve noticed over the years, for example, that when I look at my student evaluations in my courses, one of the lowest ones is always organization which is a —

Sucheta:  Really?

Rick:  Yeah. No matter how hard I try, it gets a little bit better but it never seems to get to the point where I really want it to be. I think my biggest problem today is organization. But then again, I think that there’s lots of different kinds of organization. There is a classic definition of a person who is organized, has a clean desktop and place for everything and everything in his place. There’s other definitions as well but one that I subscribe to myself is, the measure of organization is how quickly you can find something when you need it. That applies not only to —

Sucheta:  I love that.

Rick:  — your desktop, but also how well you can dredge things out of your mind. I think that’s one of the things that people with brain injuries lose noticeably. Personally, every one of them loses it, ability to organize and the ability to retrieve information from memory rapidly or as rapidly as they used to.

I think I found ways around that and one of the ways around it, I think, is creating systems. That came from working with people with brain injuries. By systems, I mean, for example, something as simple as putting everything that you commonly need every day in a bowl next to the front door so you know where it is. The system of doing that, make sure that you don’t lose things. You can find them when you need them. Also, systems for explaining things to people when you talk to them. We have a mnemonic, one of the mnemonics that we use is called the ‘BOMBS’ pneumonic which is explain or say what you want to say right upfront and then omit the details and then mention it again at the end so that you end up talking about the information at the beginning and also at the end of the conversation to capitalize on what the cognitive psychologists call primacy and recency.

There’s different ways of improving organization certainly. I think I learned most of those from simply trying them out on people that I’ve worked with and seeing which ones worked and which ones didn’t.

Sucheta:  Well, thank you for sharing your own personal journey. I think one of the most fascinating executive function that you have and probably you’re extremely skilled at is your insight and your self-awareness. Particularly somebody who is highly published and has co-authored so many books, you wouldn’t do that because that inherently requires organization too. It’s such a message of hope that you don’t need to have excellent skills because that’s a myth anyway.

That brings me to this first question regarding the actual work that you do which is: are all injuries to the brain made equal? For example, is concussion and mild traumatic brain injury and traumatic brain injury, do they fall in the same category even though I know the answer but I would love for you to explain this a little bit. And what are the most common problems encountered after brain injury?

Rick:  The answer to the first question is no, they’re not the same at all. I worked at what used to be the Maryland Rehabilitation Center for many, many years. I still do work there, actually. We dealt with any number of different injuries, typically the ones you see most commonly are automobile accidents and there’s also motorcycle accidents. There’s gunshot wounds. There’s assaults and beatings. There is drug overdoses.

I think the only consistency that you see pretty much across all of those injuries is poor memory. I always tell people that memory is the first to go and probably the last thing to come back. But depending upon the nature of the injury, then different techniques for improving memory are going to be warranted. For example, I deal to some extent with dementia patients. One of the things I learned years ago from a speech and language therapist whose practice was devoted to dealing with Alzheimer’s patients in Florida told me about what I call personal fact repetition tapes where she would simply get the client and their family to provide 100 facts about the person’s life like what was their name, where did they live, what high school did they go to, what was their first job. Things like that. And she would make a tape – this was back in the days when tapes were used. I realized that they’re not — but she would make a tape of the 100 facts and she would have the person listen to them every day. And then whenever she saw them, she would have the facts listed 1 through 100 and she would simply go through and say, “What is your name? Where do you live? What high school did you go to? What’s your wife’s name?” etc. And she would check them off and they would listen to the facts again and again and again until they could finally recall all 100 facts without any errors. Then she’d get another 100 facts.

The reason she did that was because with that population on Alzheimer’s patients, a lot of the problems they have are simply resolved from the fact they were embarrassed because they can’t remember things that anyone should be able to remember like their name, for example, or where they live. I’ve used that technique again and again and again with Alzheimer’s patients and it works really quite well.

With other people, with other injuries, you have very different techniques. If I’m dealing with a college student, for example, who’s going to go back to school or make an attempt to go back to school again, then what I’ll do is I’ll try to teach them mnemonics so that they can memorize the information in their textbooks and have an easy way of recalling it and retrieving it. But generally, what happens with people with respect to any type of memory disorder is that they don’t lose access to the information. What they lose is the ability to recall the cue that is necessary to retrieve it and the focus of the therapy resides with teaching the people to formulate reliable and effective cues. It’s very similar to what everybody experiences these days when they put a file on their computer. The file is there and assuming you can get at it, you can retrieve the information and it’ll come right back to you on the screen. But you’re not going to be able to retrieve it unless you have the file name.

And what people lose generally in their mind is not the information itself but actually the retrieval cue or the file name. Teaching them to focus on generating those and keeping those available even if it amounts to writing them down is really probably one of the most effective techniques for improving their memory.

You asked about more than just memory, though. You asked about executive skills and I think other things as well.

Sucheta:  And attention too.

Rick:  Well, attention is, as you might guess, a very complex process. We talk about attention and concentration. We hear those words thrown around quite a lot but we don’t find a lot of people who can distinguish them that easily. Mental control is another aspect of attention. Regardless of the neuropsychological characteristics that determine it, I think in terms of function, attention is best thought of as essentially your ability to train your senses on something and to apprehend or process what you’re seeing. Whereas concentration on the other hand is more an issue of ability to work with information and memory to, for example, formulate or answers to mathematical problems in your head. That takes concentration. But when somebody walks into a room and you simply turn your eyes and your ears towards that person, that’s more of what we call attention.

Attention is usually diminished after head injury. Typically, if you give a person an attention task, you’ll find that they perform quite poorly after a head injury. The question always becomes, how much of their memory problem is due to their attention problem and how much of their attention problem dictates other problems like inability to process, for example. What do you do about it? It’s a really tough road to hoe because again, every person is different and they all have different attention problems. I think the only out-of-the-box type of attention process training that I’ve ever seen right now that’s available is one by [inaudible 00:13:32]. That has some proven efficacy to it. If a person wanted to improve their attention, then probably that type of computerized activity would be the way to go.

I think though that one other aspect of attention that is usually either overlooked or ignored is the issue of how interested you are in something. When I test kids, for example, their mothers always tell me that, “They can’t pay attention. They can’t pay attention. They can’t pay attention.” But then again, you give that kid a cellphone and they will pay attention to that manual for the cellphone to the point where they can learn to operate it much better than I can. That takes attention.

I think probably one of the major aspects with dealing with an attention problem is asking the person, “What are you interested in? What turns you on? What do you like to do?” And you’ll find that they can easily pay attention much, much better if you can isolate some of those activities. Ideally, if it’s a school-related activity, then that works out quite well.

The other avenue of approach is medication. There is a lot of different medications out there that are designed specifically for improving attention. Sometimes, all it takes is a medication like Ritalin or [inaudible 00:14:44] or Adderall or Focalin or Concerta or something like that to make a big difference in the person’s attention span. If the stimulant ones, like the ones that is mentioned don’t work very well, then probably some of the non-stimulant ones like [inaudible 00:14:59] or Strattera will do the job.

I think whenever I’m working with someone with attention problems, my first approach is to say, “First of all, what are you interested in?” And secondly, “Have you tried any medication for this?” If they haven’t tried any medication for it and if they are not – they’ll tell me anything that they’re particularly interested in and we go to some other activity. What are some of those other activities?

Sucheta:  Can I ask you something?

Rick:  Yeah. Go ahead.

Sucheta:  Yeah. One question that comes to mind is – this is where I get quite often I see pushback from parents which I’m not really sure if it’s something that they fully understand but particularly if it’s not a brain injury or those with brain injury and a pre-existing diagnosis such as ADHD, there’s a strong kind of personal beliefs that medication – I don’t believe in medication or I don’t want my child to be dependent on medication. There are lots of things that people bring in to that whole decision that there’s a genuine tool available that can have a positive impact on attention but there are a lot of reservations people have. What would you say to those parents as well as individuals who are very hesitant to intervene with medication particularly if it’s not a brain injury?

Rick:  Well, I think the parents are afraid that their children are going to get hooked on it somehow but what I tell them is that with medication, the advantage of a medication trial is that you know relatively immediately whether or not it’s going to work. Medications for attention deficit have a paradoxical effect. For most people, stimulant medications make you hyper. For a person with an attention deficit, it calms you down.

I face the same thing with my granddaughter. Her mother and father did not want her to try any medication so I said, “Okay. Fine.” So I went out and I got her a cup of coffee and I said, “Drink this.” She drank it down, a world of difference in her within 15 minutes. That’s a stimulant medication effect. The parents, if they’re concerned about that, then they should go and be with their physician and say, “Can we have a trial with this?” They can sit there in the doctor’s office if they want because it’s not going to take that long to know whether or not it works. But there will be such a dramatic difference in the person if it does work that is going to be hard for them to continue making that argument.

Sucheta:  Got it. Got it. Now, let’s talk a little bit about what is cognitive rehabilitation?

Rick:  The thing that you mentioned before, what about the person taking medication, they all want their kids to start using medication as a crutch or anything like that. I tell those parents that they better not have their kids wear their glasses either because they don’t want them to become a crutch or they better stop using that microwave, they better stop driving that car, using that washing machine because they’re all crutches in that sense.

Sucheta:  Yeah. I’m glad that it’s coming from you. In addition, coming from me, I think I often find it fascinating that I think – in fact, I just received an email from a colleague of mine who herself is a speech and language pathologist. She wrote to me that, “I felt so guilty by using medication and I felt that I was receiving unfair advantage over my peers. And so I have stopped taking it but my life has fallen into a disarray.” I just assured her that please, I mean, it’s like punishing yourself, as you mentioned, for using a dishwasher. So, I have decided to now wash all my clothes by hand. There’s no need to do that.

Rick:  Sure.

Sucheta:  Yeah. I think there’s certainly some cultural barriers there.

Rick:  Sure, sure.

Sucheta:  Let’s talk about cognitive rehabilitation or cognitive retraining. How would you define that and how does that play a role in managing or treating people with brain injury?

Rick:  There’s a lot of different definitions of those terms. Rehabilitation versus retraining is a subtle distinction. Rehabilitation usually involves the use of stimulation type exercises to improve the functioning of the overall cognitive system. Now, there’s a lot of contention there concerning whether or not these things actually work. I am personally of the notion that those particular types of stimulation therapy exercises really do not have much of a beneficial effect. With retraining on the other hand, the idea there is that you’re teaching a person different ways of doing what they used to do before. You’re teaching them, for example, rather than try to remember something, to write it down and keep a written notebook with you so that you can refer to it.

What they used to do, they no longer do it that way. You taught them a different way of doing it. Those techniques do definitely have an impact and they work pretty quickly. What is it used for? It’s used in any number of different ways with any number of different types of people. Speech and language therapists, I think, are the ones who deserve most of the credit for this type of therapy because they’ve been doing it the longest. For speech and language therapists, the cognitive rehabilitation is usually referred to as teaching a person to communicate better. For the psychiatrists or the psychologists, you’re usually dealing with teaching the person skills or getting along with other people and controlling their emotions. For the psychiatrists, you’re usually talking about some type of medication management. For the occupational therapist, you’re talking about teaching a person functional skills of independent living. And usually for the neuropsychologists, you’re dealing with simply testing the person and seeing what their current levels of function are whether or not there’s been any changes in their functioning.

It really is a very different definition, depending upon the discipline that is being addressed. For me, cognitive rehabilitation is simply getting the person back to the point where they can do much of what they used to do before. That can be done in any number of different ways and it varies from person to person and person and there is no one conveyor belt type of therapy that can be used with every single person.

I will usually try at the beginning of the process to simply ask the person, “What’s your biggest problem?” And ask the family members also, “What is this person’s biggest problem?” And then with the family, I will sit down and say, “What can we do in order to eliminate this problem?” It may be something, for example, that the person and their family will say, “I can’t remember where I put things around the home” or one that I commonly hear, “I go into one room and I can’t remember why I went into that room.”

Well, one of the simplest things you can do for the first example is again to simply get a large bowl and put it in some place where the person comes and goes and says, when you come home, the first thing you do is put everything in that bowl and keep it there and you’ll know where it is. And if it’s not put in that bowl, you’re probably going to forget where it is.

For the second common one, when you go into a room and you can’t remember why you went into that room, the easiest and quickest fix for that is to go back to the room that you just came from because something in that room will again formulate the cue to remind you why you went into the other room. That works every time.

Another, people will tell me, “I can’t remember phone numbers.” I tell them, go to the touchtone phone and key in the phone number 50 times. Don’t even bother to pick up the phone and listen to it but just key in the phone number 50 times. When you can’t remember the phone number, walk up to the phone and soon as your finger gets next to the dial because it’s now on number code, it will bring back the phone number into your memory.

There’s lots of things like that, very simple fixes that people have and have used effectively but which ones you use? Very, very different for each person. What I have in my book at the end of the book in the appendix comes from 27 years of dealing with brain-injured people at the Maryland Rehab Center. We would ask them every time we met, what’s your biggest problem? They would tell us what was their biggest problem.

Over the 27 years, we took all of those things and we reduced them down to 50 of the ones that were repeatedly mentioned by more or less everybody. They were also asked, what did you do about the problem? What solved the problem for you? And so we took all those suggestions for each of those 50 problems and we came up with one page that listed all the different things that the clients, not us, but the clients said works for them. And then we formulated them into a little book of 50 therapeutic exercises and the 50 questions we made into the form of a questionnaire that we give to the family members and to the client.

And when we look at which of those items both the family member and the client endorse as being problematic, then we go to those pages and that’s where we begin. We find those exercises that are key to those items. We say, “These are things we’re going to try first.” We come up with literally a little book that’s unique to them and all of those things in that little book are things that are uniquely suited to their individual problems.

Sucheta:  I think that’s brilliant. I think that’s why I found your book so valuable because it not only provides for a clinician like me, provides a framework but also as you mentioned, there’s a point of intersection, where do you begin?

I’ll quickly tell you a story of a client of mine many, many years ago. This was in 1994, I think. The first session he came and he brought all his phone bills and he says, “My phone is about to be cut off. I desperately need you to help me pay the bills. I just don’t know how to organize. I don’t know what I owe them.” Of course, people may not have the imagination to know what it feels like to not be able to look things up on the internet. And then I would come up with some system, feel very relieved and anxious about his success. And then next week, he would come and say, “You know what, can you please, please talk to my wife? I think she wants a divorce.” And then you’re like, “What happened to the phone bill?” There was no trace of anything that – whether he had followed up, whether his phone got cut off, what about the water bill? And so from that, I learned a lot about not really focusing on the patient’s description of that particular day’s problem but really taking some global inventory as you just mentioned.

Biggest takeaway I’m hearing from you which is so valuable for all the listeners is, I think there are three ways to conceptualize cognitive retraining, if I’m right. That (1) health patients develop that self-awareness; (2) to help them built a repertoire of compensatory strategies like you mentioned. If you can’t find your keys, then have a bowl. Bowl doesn’t improve your memory but actually has a place which houses a key and it doesn’t move and that brings that stability. And the last part of the cognitive retraining rehabilitation, so to speak, is the skill-building process. Am I fair to say that?

Rick:  Sure, it is. I can’t emphasize strongly enough that the issue of prosthetic devices, those things really work and they work right away. That and medication are the two things that work the quickest. By prosthetic devices, I mean things that take over the function for the person. Like you were mentioning bills. With every person I work with, I insist that they set up an automatic bill payment system with the bank to get the bills paid automatically every week without them having to do anything.

Also, electronic devices around the home that turn the lights on in the room when you walk into the room and turn them off after a minute that’s not being in the room. Things like that save enormous amounts of money with respect to electricity bills. Anything at all that you can do like that.

The other thing that I tried to work with all the time with memory is I try to get the people to carry with them a small digital recorder that they can get at the office supply store for about $20. As you can talk 11 times faster than you can write, you can simply make notes to yourself rather than writing them down on a pad and you can review them every minute or every 15-20 minutes, every hour even, and then delete the ones that are no longer relevant. But that also made a big, big impact in their ability to remember things throughout the day.

Sucheta:  One of the things that I exclusively focus on executive function, I have now my practice where we work with people who are underachieving and their memory functions are not that impaired, their attention skills are not that impaired but their ability to manage the goals of life and one of the problems I run into with them is they have these prosthetic devices, they just don’t have that consistency and processes built into their life or they don’t adhere to those processes which goes back to that motivational component too.

But like you mentioned, if you have a digital recorder, you make notes to self and then you need to have a regular time in your day particularly chocked off for reviewing the notes that you have made. That’s where the barrier happens for these people where they don’t review them or they actually did not held the record button carefully enough that they were speaking into the recorder but they’ve never recorded.

I see lots of those types of glitches as well. How about those clients or patients who don’t have the highest level of awareness about their self-efficacy? How effective am I? What do I need? How well am I using all the tools and strategies that I’ve been given?

Rick:  That’s the multimillion-dollar question. I’d like to pretend that I have the answer to that. I can [inaudible 00:29:05] of it certainly specifically with respect to the voice recorder. I find that I have to train the person to use it and it takes a while sometimes to get the person to the point where they do use it. What I do as far as doing it is I give them a cheap Casio watch, costs about $12 at Target. I set it to beep on the hour so that every time the watch beeps, then they listen to all the messages on the recorder. So their cue to listen to the messages is that watch beeping.

With respect to them actually using it themselves or being aware of their deficits, that’s a tougher one. Because a lot of times, about all you can really do when you talk to the person is to point out the mistakes that they’ve made this week and look for consistencies in the errors that they’ve made. And then also, you have to make some judgement as to how important the error is to them. Sometimes they just don’t care. They don’t care because it doesn’t have as much of an immediate impact on them as it should.

In the back of my book, there is another appendix, appendix A, I think. It is called the ‘Self-Motivation Treatment Planner.’ What we did with the people at the rehab center is we asked them again over the course of many, many years, what were the reasons why they didn’t do the things that they know that they should do. We got lots and lots and lots of answers to that. We reduced it down to I think somewhere about 7 or 8 categories.

One of the most common ones was dealing with what was called comfort zone. They don’t want to do something because they’re comfortable doing it some other way. They don’t want to use a voice recorder because they’re comfortable writing things down on a pad. Another one that they have that they said quite frequently was inability – rebelling against someone else. Sometimes they are actually rebelling against a family member or they’re rebelling against someone in their family because they feel somehow that that’s the only way to make their point that they’re an independent person and no one respects them anymore.

We give them the questionnaire, it’s about I think about 20 questions on the questionnaire. We begin by trying to figure out what it is that’s making them not do the things that they should be doing and then try to plan the strategy from there. But above and beyond that treatment planner, I don’t know that there is a lot more specifics I can actually say because if I have the answer to that question, like I say, I would really be in high demand.

Sucheta:  Well, I’ll share with you some of the things I have done in the last 10-12 years with metacognition. I do a lot of video recording. In my practice, one of the ways at the end of the – I do something called “glitch analysis.” I have a specialized planner that I have developed. In the planner, there is a section where they write down three glitches that have happened that day. And then what we do is at the end of the week, I collect all the glitches and the I categorize them into five categories. And then predominantly, wherever the glitches tend to be, then we take that category and then doing that meta analysis of what is the mistake, why does this mistake happen, why does this mistake matter, what are the consequences and what are the unseen consequences? And so the unseen consequences are mostly how did it impact a relationship that you have and how did it impact your future goals. Once we have this kind of thing, then they read this summary and I video record them. This video recording, they see the next time.

Sorry. You were saying something?

Rick:  Yeah. That’s brilliant. It reminds me a lot of what [inaudible 00:32:59] did. [inaudible 00:33:00] believes in the notion of lack of awareness as the underlying cause of executive dysfunction. A lot of times, you can make something perfectly obvious to a brain injury survivor but they’re not going to see it. They’re not going to be aware of it. What your technique is doing actually is literally creating awareness.

Sucheta:  Yeah. I’m so excited to share with you and everybody else that I have a – I’m about to launch a software which is called EXQ. One of the primary premise of this is how do we develop self-awareness and what are the tools and processes that go into developing awareness of self, awareness of strengths and weaknesses, and awareness of strategic thinking by your capacity to evaluate mistakes. In the training process, one of the tools that I have created for every individual, that they make a video addressing the future self.

At the beginning of the training, they make a recording and the script is a shell and they fell in the script and the software fills in their own weaknesses and strengths. But the script says, “Hey, dear future me, these are the things I’m going to do for you.” And then during the training on every other week or so, whatever the rhythm is, they are asked to see this video. One of the processes to let them see this video where they have made a promise to their future self.

And then the third part about that self-awareness is they are categorically exposed to some game-based training but then they have something called error analysis that they review with a virtual coach. In that, the coach is showing the user or the client a mistake made by somebody else.

The game that they played based on their performance, they are shown there are 12 types of mistakes and all that stuff. But the idea there, what I was thinking about is, how can I develop understanding of a performance evaluation but how can I take the emotions out of it? Instead of me critiquing me which is very difficult for a lot of our patients as you know, I’m very willing and eager to critique somebody else. They are shown the mistakes of others and those strategies then are brought into their conscious awareness, that these are the strategies you recommended. “Hannah, how about you using those strategies too?” That kind of idea.

Rick:  That’s great. When that comes out, let me know because I really want to buy that because I sounds like a great program. And that’s what this field needs, really more than anything else is programs and training options that are generally available to the therapist.

Sucheta:  Yeah. And I think your book was so transformational for me. I think you are probably one of the very few psychologists – again, your work that I came across 20 years ago. So imagine your work that in your book captured work that you had done prior to that. But I feel that the psychologists who study are very focused on evaluation part and then the clinicians who are working are very focused on the treatment part. That continuum, I think there are very few researchers like you who actually connect that two. Because I think it’s really important to talk about not just the deficits but the plan.

As you mentioned, there are some myths that float around when it comes to injury and the plans that work or don’t work. It’s really, really important to understand the functional aspect of treatment plans and not use those things that feel like that may use – do you mind telling us a little bit about what are the things that don’t work when it comes to therapy?

Rick:  Well, one of the things that I think doesn’t work is perhaps the most commonly used therapeutic treatment which is stimulation therapy, where people sit in front of a computer and they try to remember lists of words or number strings or try to match things on the screen. I guess there’s some value to it but there’s really no evidence whatsoever that it actually has any carryover to the real world. You can talk about carryover globally but there’s actually a dichotomy of carryover, one of which is generalization, meaning that what you’re learning is actually you’re able to apply it in any number of different novel situations. And the other one is transfer, meaning that what you are learning carries over to the real world in exactly the same way that you learned it when you were training.

There’s lots of evidence for transfer even with brain-injured people. There’s no shortage of that. But there’s very little evidence of generalization. That’s not just with people with brain injuries, that’s with people in general. There’s a book by Singley and Anderson called ‘The Transfer of Cognitive Skill’ that was devoted to that entire issue of if you’d look at different ways of measuring transfer and generalization and real-world context, you’ll be hard-pressed to find people who can generalize quite people but you’ll have no difficulty finding people who can transfer.

If the goal is to teach generalization, you’re probably wasting your time. If the goal is to teach transfer, you’re probably doing something right. Those techniques, things like Lumosity, for example, or the computerized software that you buy that gives you stimulation drill and practice exercises. There’s very little evidence that they carry over into any aspect of the person’s everyday life. What happens is that the person gets better on the exercises but they don’t get better in real life. I think as far as those things go, you’re probably better off playing video games which would be fun and mentally more interesting.

Another thing that doesn’t really seem to work very well is Freudian psychotherapy, teaching or trying to get the person to understand their relationship with their mother when they were 3 years old probably is not going to have much of an effect on their life right now because they don’t have the executive functioning, the metacognitive skills to see how those things relate at all.

And there’s other things but I think the two are areas that I think are the squeakiest wheels, put it that way, what does work well, one thing I found myself is that with the mildly brain-injured people, if they simply go back to a community college and take a non-credit course, where you don’t have to take tests or get grades, I see much more improvement in them in one semester than I see incomparable people going through all these very expensive therapies. There’s just something about being in that environment where you have to interact with other people. You have to sit and listen. You have to take notes. You have to talk every now and then. That seems to make a very rapid improvement in their overall cognitive status.

And if you take away the evaluation component of it, they’re usually not so wary about doing it. And also, work is a good therapeutic modality. The person can go back to some aspect of their job that may not be what they did before, maybe some lesser version of what they did before. There’s again, something about being in that social environment, something about being in that context where they have to think all the time and make decisions that makes a big improvement in their cognition in a very short period of time. It has direct carryover and transfer to the real world.

There’s also, I think, the whole idea of socialization training, teaching a person how to behave in certain situations. What to say. What not to say. At the rehab center, when we did a five-year follow up which people got jobs and which people stayed employed the longest, the single best predictor of those two variables was whether or not they had psychosocial group training. We emphasize that quite a lot. How do you make friends and influence people, so to speak? Get them a [inaudible 00:40:53] or something like that. No, I wouldn’t do that. But I would certainly give them that type of training because socialization is terribly important in their ability to get along with other people and to reintegrate themselves into a social environment and not end up in their home watching cartoons and afraid to go out into the real world.

Sucheta:  Well, I think you nailed it that socializing is literally having to adapt and adjust to the presentations of others as well as having to pay attention to the non-verbal as well as verbal content having to read minds of others, having to consider context and recognize social relevance of information. So many components go into that socializing.

In my practice, for those clients who don’t have the skills ready, I worked, for example, with a gentleman who worked at CNN in a very high position and he was in a motorbike accident and he was not able to go back. There were 12 people who reported to him and he produced the actual live show. He was one of the important key persons. We just did some mock – we created mock situations where he would have that opportunity through volunteer work. We had created some artificial group settings where he would be taking decisions at the rapid-fire settings. We would hold fake meetings, so to speak. We did a lot of simulations.

Yeah, you’re right. I think all the points that you have tapped are so meaningful and tremendously valuable. And as I mentioned, you’re probably the first person on the show who has actually outlined the treatment process. As we close our discussion, are there any thoughts that you have regarding this concept that I think I read about many, many years ago called ‘Shaken Sense of Self’? A lot of times, the barrier is not just cognitive barrier but it is also some of the social psychological barrier where the person who’s endured the brain injury has a tremendous shock regarding poor skills and sometimes those barriers are greater than the actual impairment that comes about because of the cognitive changes. Do you have any thoughts about that?

Rick:  Yeah. It’s usually with the higher functioning people I see that quite a lot. The thing that I try to impress upon them is that even though they can’t do the job they used to do or they can’t do what they used to do – and again, these are the fairly high functioning people who were in good jobs or had families and pretty much a normal life. What they tell me is that they just want to get back to the way they were before. But the problem with that is that how do you know what you were before? Unless you have some type of benchmark there. Without identifying the benchmark, you’ll never know if you’re going to get back there.

They end up in this cyclical loop where they’re always trying to achieve something that they thought they were before but there’s really no way of knowing how accurate their impression of what they were like before is. So consequently, they can never really get back to that state. I try to teach them that we have to establish concrete benchmarks, not so much look in the past and see what you were before but look to the future and say, “Where do you want to be? What do you want to – this is going to take some time. Where do you want to be in six months? Where do you want to be in one year? Where do you want to be in five years? Where do you want to be with your relationship with your wife or your husband? Where do you want to be with your relationship with your children? Not so much what it was before but where do you want to be in the future?” When you start writing these things down and making them concrete goals, then they’re achievable. But unless you do that, then probably, you’re not going to have a lot of success and never achieving them.

Sucheta:  Well, this is fantastic. Thank you, Rick, for coming on the show today. Our conversation was extremely meaningful to me. I bet it will be extremely valuable to all the listeners. Once again, thank you for finding time for us and have a great evening.

Rick:  Sure. Thank you very much.

Todd:  Alright. That’s all the time we have for today. On behalf of our host Sucheta Kamath, today’s guest Rick Parente and all of us at Cerebral Matters, thanks for listening today. We look forward to seeing you again right here next week on Full PreFrontal.