10

Neuropsychological Postacute
Rehabilitation
ANNE-LISE CHRISTENSEN

Introduction

On the grounds of a lifelong experience with and research into brain injury, its sequelae, and
restoration, it is the purpose of this chapter to present theoretical and practical tenets that have
given evidence of the validity of neuropsychological rehabilitation.
Originally, the goal of the Center for Rehabilitation of Brain Injury (CRBI), * estab-
lished in 1985 at the Department of Psychology, University of Copenhagen, was described
as follows: "The purpose of the institution is to undertake neuropsychological investigations
and treatment in the service of rehabilitating brain-injured persons, and at the same time per-
form research and teaching within the area." Through experiences and research in the years
that followed, gradual changes have occurred. Research and teaching are still main tasks, but
the rehabilitative goal has broadened, some aspects have been emphasized, and some addi-
tions made.
The goal today is to provide a rehabilitation program that ensures prospects for life af-
ter brain injury composed of elements that encourage personal growth, responsibility, at-
tachment to others and to work and enjoyment: to support brain-injured individuals in
gaining the ability to live their lives to the fullest and to master the constant changes that are
a part of human life. The focus of the chapter will be on the structure and content of a reha-
bilitation program working for this purpose. Research on outcome and cost-effectiveness are
also included.

*The author has been the director of the CRBI from its inception until February 1998. The current director is neu-
ropsychologist Mugge Pinner, a close collaborator during the center's early years.

ANNE-LISE CHRISTENSEN • Center for Rehabilitation of Brain Injury, University of Copenhagen, 2300
Copenhagen S, Denmark.
International Handbook ofNeuropsychological Rehabilitation, edited by Christensen and Uzzell.
Kluwer Academic/ Plenum Publishers, New York, 2000.

151
152 CHAPTER 10

Theoretical Premises for the CRBI

Rehabilitation after brain injury was originally, and still is in many countries, in the hands
of neurological medicine, supported by physical, occupational, and speech therapy. One of the
pioneers was Kurt Goldstein, the German neurologist who treated victims of brain injury dur-
ing and after World War I. In the framework of his organismic theory, Goldstein (1939) stated
that rehabilitation after brain injury was a psychological task (Goldstein, 1919). Goldstein's in-
sights into psychoanalysis were derived from the psychoanalytic milieu of Foulkes in Frankfurt
where he worked. His knowledge of psychological processes were obtained in his own psy-
chologicallaboratory, where he collaborated with among others A. Gelb (Goldstein & Gelb,
1918). Both were regarded by Goldstein as necessary additions to the practice ofneuro1ogy.
Goldstein opposed the stressing of the anatomical viewpoint in cerebral localization, stating
that a cerebral activity is a total one but with everchanging regional accents, in accordance
with the needed and variably activated structures, that is, an ever-changing play of figures and
backgrounds (Goldstein, 1959).
According to Goldstein, neurologists observe individuals suffering from disordered func-
tions; the essential characteristics first being disordered behavior, which makes the individual
unable to use his or her capacities and come to terms with the demands of the environment, and
second, anxiety. For Goldstein, disordered behavior and anxiety were objective and subjective
expressions of the situation of danger that the organism experiences when it is no longer able
to actualize its essential capacities, that is, to exist (Goldstein, 1952). It is for this "hindrance of
self-actualization" that intensive psychotherapy is needed. Goldstein's work (1942) as mani-
fested in Aftereffects ofBrain Injury during War, shows foresight and is remarkably "modem."
His impact on rehabilitation, however, did not occur until his student, Yehuda Ben-Yishay, prac-
ticed his model, first in Israel as a result of the Six-Days War, and later at the New York
University Medical School with Leonard Diller (Ben-Yishay & Diller, 1993).
Alexandre R. Luria's contribution during and after World War II introduced neuro-
psychology to brain injury rehabilitation. Luria's work was based on the principles of the
historicocultural school, which was developed with L. Vygotsky in the early 1930s (Vygotsky,
1962). This psychology was premised on the assumption of an intimate relationship between
culture and mental operations. Furthermore, Luria's medical studies and work at the
Bourdenko Neurosurgical University Institute in the late 1930s led to his theory about higher
cortical functions and the notion of functional systems. Luria's theories were in detail de-
scribed in Traumatic Aphasia (1970), Higher Cortical Functions in Man (1965), and The
Working Brain (1973). The investigatory method was developed with the main purpose of un-
derstanding what happens to the higher cortical functions in the presence of brain lesions. In
addition, the method was used to explain which syndrome of disturbed mental activity resulted
from the fundamental defect. Syndrome analysis was considered essential in the planning of
treatment for the patients.
Luria's investigative method leads to a qualitative analysis of the level of functioning of
the patient. The examiner has the task of identifying the disturbed functions. In addition, the
examiner is responsible for clarifying how a patient is trying to cope with the problems with
which he or she is presented. Proper use of this method further allows for very specific hy-
potheses about the fundamental defect by selecting different tasks in which the defect is an
essential component. The double dissociation principle suggested by Teuber and Weinstein
(1958) is in accordance with this method. The distinction between primary and secondary dis-
turbances is important for the planning of the rehabilitation process. In the case of primary dis-
turbances, major reorganization of the cortical processes is a necessity. According to Luria,
 POSTACUTE REHABILITATION 153

reorganization can be either intrasystemic or intersystemic. The intrasystemic reorganization

can take place in either of two basic ways: in one the same functional system is transferred to
a new level of organization, that is, transferred to a level either more automatic or to a higher
level, that is, by employing speech to support the performance. In the intersystemic reorgani-
zation, different functional systems have to be organized anew. An example is in the case of af-
ferent motor aphasia or apraxic aphasia, where destroyed kinesthetic pathways can be replaced
by afferent visual input.
The task analysis performed during the investigation can teach the therapist how to struc-
ture a task in order to make the patient use intact functions in the service of reorganization, or
in other words, how to compensate in the most effective way. Close collaboration between the
patient and the therapist in this process will strengthen the effectiveness of the cognitive train-
ing. Four major rules for planning a patient's cognitive rehabilitation have been deducted: ( 1)
Diagnostic qualification is essential and the patient needs to be given exact and complete in-
formation at a level that the patient is currently able to integrate. This is accomplished in or-
der to ensure the patient's awareness of the deficits and their implications for functioning. (2)
Intact functions should be utilized. (3) Integration of intact automatic functions in the learning
process. (4) Systematization and repetition are required (Christensen, 1989).
Luria's theory of brain function has been accepted in the Western world, but his tech-
niques for investigation as yet have not been widely used. Luria's theory defines the processes
being examined rather than viewing them as a preconceived classification of "functions" that
are in accordance with contemporary psychological ideas, which by no means always reflect
the disturbances of mental processes actually resulting from brain lesions. The advantages of
a procedure like Luria's neuropsychological investigation (LNI) (Christensen, 1975) has spe-
cial significance in neurosurgery and neurology due to the comparability of the LNI results
with (1) the neurological examination, (2) the objective neuroradiological techniques [regional
cerebral blood flow (rCBF), functional magnetic resonance imaging (tMRI), and positron
emission tomography (PET)], and (3) the neurosurgical operation techniques. Very early re-
search relating the findings from the LNI with these methods seemed promising (Christensen
& Caetano, in press) but has until recently only resulted in limited collaboration (Christensen,
Jensen, & Risberg, 1990). However, growing interest and appreciation of the benefits of col-
laboration between medical and psychological specialities are becoming increasingly
accepted. In a recent article on functional systems, Castro-Caldas, Petersson, Reis, Stone-
Blander, and Ingvar (1998) presented a brain activation study using PET and statistical para-
metric mapping confirming behavioral evidence of different phonological processing in
illiterate subjects compared to literate. The results indicated that learning to read and write dur-
ing childhood influences the functional organization of the adult human brain.
The process of investigating and analyzing the psychological functioning of a specific
person by using the LNI demands a phenomenological approach where the basic assumptions
of the historicocultural school-that the higher psychological processes are social in origin,
are structured through the mediation of speech, and function consciously in a self-regulated
manner-are incorporated. The approach corresponds well to the phenomenological tradition
that through many years has characterized psychology at the University of Copenhagen
(Rubin, 1949). The need in rehabilitation to consider the individual differences not only in ac-
cordance with the patient's brain injury but also with his or her social situation matches the
general approach of Danish psychology. In structuring the CRBI's rehabilitation program, is
the notion that complex forms of mediated activity, which arise in society and history and con-
stitute the essential components of complex human mental activity, develop as a result of peo-
ple's social experiences is incorporated.
154 CHAPTER 10

Rehabilitation within the above-mentioned theoretical framework expands the premises

of cognitive neuropsychology as it has been practiced mainly in the United States and in
Britain. It goes beyond psychology into physiology, sociology, linguistics, and even anthro-
pology, into what has in the later years been termed cultural psychology. In this context, the
ideas presented by Jerome Bruner in his books, A Study of Thinking (Bruner, Goodnow, &
Austin, 1956) and Studies in Cognitive Growth (Bruner, Oliver, & Greenfield, 1966) initially
influenced the cognitive retraining at the CRBI. In one of Bruner's (1996) latest books, The
Culture ofEducation, the framework for the pedagogical attitude characteristic of a phenome-
nological, cultural approach is clearly expressed:
Acquired knowledge is most useful to a learner when it is "discovered" through the learner's own cog-
nitive efforts, for it is then related to and used in reference to what one has known before. Such acts of
discovery are enormously facilitated by the structure of knowledge itself, for however complicated any
domain of knowledge may be, it can be represented in ways that make it accessible through less com-
plex elaborated processes. (Bruner, 1996, p. XII)

A learning principle particularly suited to purposes of cognitive training in rehabilitation is fur-

ther expressed by Bruner:
The object of instruction [is] not coverage but depth: to teach or instantiate general principles
that renders self-evident as many particulars as possible. The teacher in this version of peda-
gogy, is a guide to understanding, someone who helps you discover on your own. ( 1996, p. XII)

Bruner's approach matches exceedingly well the approach inherent in the LNI. The task
of the examiner is to disclose how patients orient themselves in the world and how they try to
find meaning in the presence of a brain injury. It is a demand of the LNI that the examiner pro-
vide continuous feedback as part of the investigation method. This not only assists the neu-
ropsychologist in dealing with what neuropsychological processes are at work, but also helps
the patient become aware of the problems of performance of tasks. This is the basis on which
to initiate an individualized program. In order to understand the variations in the problem-solv-
ing approaches of different patients, ascertaining their specific social and cultural background
becomes particularly relevant. A patient's specific "state of mind" contains his or her specific
experiences and background as well as motivational and cognitive characteristics. Recognition
of the patient's individuality and the importance of that individuality for the planning of reha-
bilitation for the specific person in recent years has been generally accepted in most rehabili-
tation programs. The extent to which rehabilitation can profit from deeper insight into social
and cultural factors is a new approach that needs further interest and study. One example re-
garding the latter is a case study, where specific musical skills supported a remarkable recov-
ery (Christensen, 1998).
The issues described above have been building blocks for the construction of the rehabil-
itation day program at CRBI. Support for this structure has been found in the research of
Donald G. Stein (Stein, Brailowsky, & Will, 1995), whose contributions have influenced and
promoted the notion that neurorecovery mechanisms are at work in the service of a positive re-
habilitation outcome. Research on the importance of treatment for the central nervous system
(CNS) recovery after injury has given evidence of the complexities involved when the CNS is
viewed as an integrated and dynamic system. A host of agents including complex proteins,
peptides, and hormones are capable of directly stimulating the repair of damaged neurons or
blocking some of the degenerative processes caused by the injury cascade. Because the in-
jury-recovery cycle takes place overtime, it has been ascertained that individual variables (i.e.,
such as environmental situations, health status, individual learning, and emotional history) will
affect the outcome of any kind of medical or psychological therapy.
 POSTACUTE REHABILITATION 155

In their visions for the future Stein et al. (1995) state that we have learned more about
neural recovery mechanisms in the last 10 years that in the last I 0 centuries. It is no longer
questioned that the rate and extent of recovery from traumatic injury can be enhanced by prop-
erties inherent in the CNS, but this seems to happen only with ''priming." They consider that a
combination of therapies or what has been termed a holistic view is necessary for appropriate
treatment. The recommendations these three researchers present deal with the following: (I)
early treatment, (2) combined pharmacological and psychological intervention, (3) careful at-
tention to the individual's past history, health status, age and experience, (4) a supportive en-
vironment, and as a very new and interesting suggestion that is based on gender differences,
that (5) particular schedules are advised for men and women.

Treatment at the CRBI

A few comments concerning the transfer from the acute care to postacute rehabilitation
are needed. The importance of the treatment in the acute phase after an injury for the course of
recovery has become increasingly manifest. The conviction that neuropsychological knowl-
edge should be available and affect treatment in the very first stages after brain injury in the
later years has been shared by nurses and doctors in the acute care. There is a growing accep-
tance that rehabilitation specialists should be .available in the neurosurgical department to ad-
vise (doctors and nurses) regarding patients' behavioral manifestations and to evaluate baseline
functioning. Furthermore, contact with the relatives should be considered not only as a thera-
peutic means, but also with the aim of obtaining necessary information for the process of the
evaluation. In the acute phase of treatment the nursing staff can benefit from collaboration
with clinical neuropsychologists for preventing or ameliorating behavioral problems. In addi-
tion, interpretation of behavioral patterns, comparisons with neuroradiological findings, and
assistance in prognostic evaluations are appropriate tasks for a neuropsychologist. A neu-
ropsychologist on the staff in a neurosurgical department could further evaluate and follow up
on the progress of patients and could assist in assessing when the right time for entering a re-
habilitation program has come. Close collaboration between hospital staff and rehabilitation
center could make the change of environment and the new situation easier for both the brain-
injured person and his or her family, and in this way ensure a smooth continuation of the re-
covery process.
In Denmark, the above-described situation is as yet only taking place at a few hospitals,
and thus only for a minority of brain-injured persons. A gap between the acute treatment
phase and the starting of a rehabilitation program such as the CRBI is more common.
Initially, when a patient was referred to the CRBI, the primary criteria for acceptance was the
presence of verified brain injury, with loss of consciousness and objective, neuroradiologi-
cal findings. This is still the main inclusion criteria. At the start of the program our medical
advisors and the paying parties (at that time a group of municipalities in the Copenhagen
area) demanded that patients not be accepted until2 years after an injury because of the ex-
pected spontaneous recovery period. However, at the First International Conference held at
the CRBI in 1987, an important subject for discussion was the optimal time for the initiation
of rehabilitation. Stein (1988) argued
that various physiological events occurring after injury have a specific time course and may be
responsible for the limited "spontaneous recovery" that one often sees. We now know that re-
covery is not "spontaneous" nor is it time itself that mediates the necessary events. The out-
come of brain injury is not a constant. Posttraumatic recovery and/or impairment is rather a
156 CHAPTER 10

complex series of environmental events whose outcome depend on the specific context in
which the injury occurs. (p. 6).

Stein further argued that these posttraumatic events could be altered by various kinds of ther-
apies most effectively if provided in specific intervals during the time course. Five years later
at the Second International Conference at the CRBI, Stein, Glasier, and Hoffman (1994)
stated:
If we have learned anything about treating brain injury over these last years it is that therapy to
promote functional recovery must begin as soon as possible after the initial trauma. Delaying
the course of treatment to observe how much "spontaneous recovery" is likely to occur, will in
most cases result in permanent impairment. For example, inflammatory reactions, edema, pro-
duction of free radicals, and excess excitatory amino acids must be eliminated before growth
promoting and regenerating factors can take effect. (p. 33)

The CRBI criteria for admission were changed, and it was accepted that psychological and
social rehabilitation should begin as soon as the patient can tolerate this type of environmental
stimulation. A natural limit to very early admission is another criterion, that is, that the person
must be self-sufficient, a demand caused by the CRBI's university location. A criterion that is
not medically or psychologically defined but determined by public payers is that brain-injured
persons accepted to the program should have the potential for work or education. Due to this
group of criteria, the CRBI program is tailored to persons with medium to severe brain injury
who have recovered enough to be self-sufficient in daily activities. In addition, they must be
functioning in the average intellectual range, have had a job or started an education, and want to
work or regain the capacity to take care of their own lives. The disturbances they have can be
physical or cognitive (including aphasia). Typically, they also have emotional difficulties and
show loss of self-esteem, and their social situations are frequently drastically changed. (For a
detailed overview of the CRBI selection criteria, see Appendix A Chapter 17, this volume.)
Even within these criteria, the diversity of abilities among the patients is great. The crite-
ria provide a framework that ensures the establishment of a feeling of communality, which is

TABLE 1. Pro me of the Students Accepted into the CRBI 1985-1998

Characteristics Number Percentage

Injury type
Cerebrovascular accident 131 42%
Traumatic brain injury 137 44%
Other 41 13%
Total 309 100%
Sex
Male 184 59%
Female 125 40%

Years

Age at injury
Median 32.7
Quartile range 22.8-42.8
Time since injury
Median 2.5
Quartile range 1.1-2.7
 POSTACUTE REHABILITATION 157

necessary for socialization, with reference to the theoretical premises and the goals of the pro-
gram. In addition to these intake restrictions, further criteria have been developed and proved
useful. Up until June 1997, the CRBI has treated 25 day program groups and 10 additional
groups where the treatment provided has been less intensive. The allocation to these groups
has been decided on the basis of the general conditions of the patients, both physical and psy-
chological. Furthermore, in a number of cases, individual treatment programs have been de-
veloped based on the initial evaluations, where these patients did not yet show adequate ability
and motivation to take advantage of the intensive day program. Where appropriate, inclusion
has taken place at a later stage. For patients with specific and minor problems the possibility
for individual treatment exists. The demographic data for the patients accepted to the day pro-
gram can be seen in Table 1.

Application of Theoretical Premises

The postacute day program at the CRBI has been described in various publications, the
latest of which are Christensen and Teasdale (1993), Christensen and Caetano (1999), and
Chapter 17, this volume, where the program is illustrated through a case history. In this con-
text, the program elements will be discussed with reference to the theoretical foundations. It is
also on the grounds of previously described theories that the goal of the CRBI program has
been defined, namely, to promote growth, responsibility, attachment, and enjoyment in life.
Once a person is admitted into the program, he or she will receive a letter of admittance
in which the conditions for acceptance are stated. The person is asked to make a commitment
to collaborate to the fullest of his or her ability. However, to secure the brain-injured persons
interest, motivation, and energy, the first requirement of the program is to ensure a social mi-
lieu, where possibilities are available for the person to feel respected as an individual, where
trust can be developed, and where anxiety, insecurity, and loss of self-value are met with em-
pathy. The aim is to provide a common working background for the group of 15 brain-injured
persons who enter the program at the same time, such that a process of individual growth can
occur physically, cognitively, emotionally, and socially. Since it is considered the first and main
task of the entire staff to provide this milieu, the rehabilitative work at hand becomes a shared
interactive enterprise. The primary task is to support and encourage the brain-injured person's
responsibility in the rehabilitative process. The person is no longer a patient in a hospital but a
student in an educational situation. Part of the role of the therapist is one of a teacher rather
than one of a doctor. Furthermore, as a consequence of the CRBI's location at the university,
the program is described as a course that runs for one semester, and the patients taking the
course are "students." Taking part in a course requires responsibility, it is socially valued, and
it includes the hope that graduation signifies an improved status. At the New York University
Medical School, the participants from the start have been termed "trainees," a name with cor-
responding implications.
After inclusion into the social milieu, the task of developing attachment to the group and
its work begins. The goal is to provide content in the daily program activities that captures as
much of the complexity ofbrain injury and its sequelae as possible. To serve this task, the staff
at the CRBI is composed of professionals from medicine, psychology, and various therapy ar-
eas (physical, speech, voice, educational), working as an interdisciplinary team. To ensure ef-
fectivity, the present therapist-student ratio in the program is one to two. Close to half the staff
are neuropsychologists-clinical psychologists due to the predominant needs for psychological
knowledge and insight. Each student is allocated a psychologist, who serves as the student's
158 CHAPTER 10

primary therapist, who provides overall planning in- and outside the program. The main pur-
pose, however, is the development of a therapeutic relationship, where feedback based on trust
is the essential element. The initiation of this trust is most often based on the interaction dur-
ing the LNI, performed early in the process. The primary therapist is also the student's indi-
vidual therapist in cognitive training and psychotherapy and he or she also has the primary
contact to relatives, friends, and eventually the workplace. An important part of the primary
therapist's work is to ensure and promote the student's attachment to the training, but also to
the social activities in- and outside the program.
The reason for the introduction of the concept of the primary therapist has been to prevent
what Goldstein termed "protective mechanisms," (Goldstein, 1952) and to strengthen motiva-
tion and interest, first, through the development of a close relationship, and second, to ensure
comprehensive planning, for the specific needs of the individual to be taken care of.
Individualizing the daily program content for all students within the common program sched-
ule is of utmost significance and takes place continuously from program start to program com-
pletion. In addition, general questions, that is, pedagogical attitude, introduction of new ideas
or various suggestions, can be considered and discussed at these meetings. Regarding the de-
velopment of specific premorbid interests and skills among the students, smaller groups of
staff collaborate with the students to create projects to meet these needs. This is done by in-
cluding as much knowledge about each student as can be obtained by daily observations and
interactions and by contact with relatives, friends, and colleagues.
The elements in the program focus interchangeably on working with more general prob-
lems and on the losses of specific abilities. This means that some part of the program sched-
ule are the same for everybody, but others vary, as can be seen in the case history (see
Appendix B, Chapter 17, this volume). Training in cognition can take place both individu-
ally and in groups of various sizes and purposes according to the specific problem or the
strategy planned for remediation. Likewise, the psychotherapy is directed toward the psycho-
logical changes caused by the brain injury and its consequences. Therapy is viewed within
this frame of reference.
A group element containing many different aspects of the theoretical premises directed
toward a variety of skills of a general and social character comprises our morning meeting. The
15 students are present with two therapists consistently present, and the primary therapists of
individual students occasionally attend according to a student's need for their presence. The
meeting has an agenda, including tasks related to everyday life, such as in workplaces or edu-
cational contexts. The general purpose is to stimulate activity, interaction, and discussions.
Students take turns fulfilling different roles during the meeting. One student is responsible for
the agenda and for running the discussion, three for bringing in news, one for leading a light
gymnastics program, one for clarifying of a specific problem that previously was raised, and
one taking the minutes. The meeting ends with general feedback being provided by all partic-
ipants. The structure is clear, the sequence of tasks is the same from day to day, and the roles
are defined. The meeting is highly accepted by the students and most often fulfills its various
purposes; it adds greatly to a feeling of participation and engagement, often leading to new in-
sight for both students and staff. Luria's four rules of rehabilitation are present in this program
element, as well as in the cognitive training in general.
A component of the CRBI's rehabilitation program that most clearly adheres to the moti-
vational aspect is the physiotherapeutic program partly based on Luria's rehabilitation theory
as described in Chapter 3 in The Restoration of Motor Functions after Brain Injury (Luria,
1963). The development of a physical, neurological examination and a cognitive approach to
physical treatment was partly inspired by the American physiatrist, Sheldon Berrol, and his
 POSTACUTE REHABILITATION 159

wife, Cynthia Berro!, the dance movement therapist, and partly by the American physical ther-
apist Joan Roush, Mediplex, Philadelphia, who all visited CRBI in its early days for a longer
period of time. The main concern in the physical training and education is the improvement of
the individual's physical condition and well-being driven by personal interests and ecological
values (Rasmussen, 1994). The tasks consist of doing various exercises and training strength
and endurance in a social environment, that is, a health center at a nearby hotel. Parts of the
training include sports, bicycling (with two or three wheels), sailing, dancing, and other phys-
ical activities. The sessions have strong cognitive elements owing to self-monitoring of
progress in the exercise series. The main goal is a feeling of well-being through physical ac-
tivity. The results of the physical training were significant improvement during the 4-month
period of the intensive program.
As emphasis is placed on the student's cooperation in treatment, the hopes and wishes he
or she may have for the future are the focus of the therapeutic relationship. Weighing reality
against hope, but still encouraging hope in the service of energy and effort, is of special im-
portance. Lazarus (1998) stresses that hope more often than not stems from a situation in
which we must prepare for the worst while hoping for better. In this sense, hope can be re-
garded as a form of coping and can be of support in avoiding depression.
The phenomenological approach that governs the process strengthens attempts to under-
stand and guide the systematization and control of the entire rehabilitation. The constant in-
teraction between and within the staff and student groups is indicative of the dynamics in the
recovery process and emphasizes the ongoing evaluation of both process and content. The em-
pathy that Prigatano (1997) refers to as "entering the patients' phenomenological space" is im-
portant for knowing the right time for introducing changes that can lead to further
development. Shifts in attachment to new endeavors have to be encouraged and followed
through both during the course but mainly at the end, where learned patterns can be used in
new contexts. Gradual decrease in contact to the program has to be replaced by investment in
the social world, through continuing development and maintaining activation. Four months of
rehabilitation determined by the practical circumstance of being located at a university may
not be the optimal amount of time for everybody, but the sense of group feeling and common
experiences strengthen the efforts each individual shows in adapting to the next stage: attach-
ment to ordinary social life. While the fixed time schedule may cause problems, these can be
dealt with by the availability of a variable follow-up period, dependent on the individual stu-
dent's needs.
The need and wish to fulfill the goals of rehabilitation are also supported by the possi-
bility to go back to an education or again find one's place in the labor market. Discussing
these possibilities and working out realistic plans take place in the last part of the program
and continues in the follow-up period under the guidance of the primary therapist, collabo-
rating with the workplace (often the original work place) and a social worker from the brain-
injured persons municipality. A special research project initiated by the Ministry for Social
Affairs, a county (Frederiksborg), and the CRBI has operated for 4 years. The aim is to es-
tablish optimal conditions for work reentry by involving a colleague at the workplace, who is
interested and willing to spend time in supporting a brain-injured person in relearning and
readapting during an introduction period. The workplace is paid for the hours the colleague
spends on the project. Both the colleague and the brain-injured person receive advice and
guidance from the neuropsychologist in the project (who is the brain-injured person's per-
sonal adviser). The department or firm is also provided with information of a more general
nature by the neuropsychologist. A cost-benefit analysis is presently being performed by an
independent research group and will be published shortly.
160 CHAPTER 10

Another important aspect of the entire process of rehabilitation is the collaboration with
families. The family constitutes the emotional and social universe of the brain-injured person,
which is dramatically influenced by the brain injury. The bonds are still there, but the family
roles change dynamically in ways that can be difficult to appreciate, accept, and respond to.
The entire process of recognizing the impact of the disturbances, understanding the compen-
satory reactions of the brain-injured person to diminish anxiety, and finding new means to
function can be as difficult for family members as for the brain-injured persons. This is mainly
because it is looked on from different perspectives, but also because brain injury is a frighten-
ing and unknown subject. The role of the therapist as a "knowing mediator" in these relation-
ships is difficult but essential for a positive emotional outcome. At the CRBI, relatives are
collaborators invited to participate in a process where the student is the key person, who has to
regain his or her place in the family. In support of the relatives, group meetings are available
every 2 weeks for groups of spouses, parents, and siblings and close friends, and when needed,
children of the brain-injured persons.
The European Brain Injury Questionnaire (EBIQ) (Teasdale et al., 1997; Deloche et al.,
1992) is a tool used at the CRBI that clinically serves to eliminate misunderstandings and dif-
ferences between brain-injured persons and their close relatives. Psychotherapeutic treatment
is provided by the primary therapist both individually and occasionally with a close relative
(most often the husband or wife).

Research and Outcome

In the first years of the CRBI the demand was to provide results showing the usefulness
of rehabilitation. In the first study (Christensen et al., 1992), data from 46 patients were col-
lected concerning the following: living conditions, work situation, and leisure activities. The
data showed the four points in time: pretrauma, prerehabilitation, postrehabilitation, and 1 year
after graduation from the program. Half the patients were traumatic brain injury, 30% had en-
dured cerebral vascular insults, and the remainder, included tumours, hypoxic and metabolic
damages. The results were socially convincing: Living conditions were normalized, depen-
dence reduced (more students lived alone), more than 70% returned to education and work,
and leisilre activities reached the preinjury level. The general improvement was present at the
one year follow-up, a fact that was attributed to the intensive half year follow-up at the CRBI
of the brain-injured persons.
The results were supported by a study carried out by an independent research institute
sponsored by the Association of Counties and Municipalities in Denmark (Larsen, Mehlbye,
& Gmtz, 1991 ). The time period covered by the study was 31/ 2 years and results showed that af-
ter treatment the student's quality of life had improved and the public costs were reduced. The
distribution of gain (reduced expenditures) differed among public authorities. The conclusion
was that the economic indications supported rehabilitation. Later studies within the area of
outcome have been performed with larger numbers of patients and a follow-up period of 3
years (Teasdale & Christensen, 1994). Gains confirmed previous results and appeared either
in the time following completion of the day program or at the 1-year follow-up. At the 3-year
follow-up, gains were substantially sustained.
A later study performed with 96 students who completed the CRBI program during the
period 1993 to 1996 was based on a follow-up interview conducted during autumn 1996
through January 1997. Interviews were obtained with 74 students (77%), and the EBIQ was
completed. Results were obtained regarding employment and partner relationships. In all, 69%
 POSTACUTE REHABILITATION 161

were engaged in some form of work. Stable partnerships before the inquiry characterized 78%,
while 22% had not been cohabiting or otherwise. Among the 78% in stable partnerships, over
half (45%) were still in that relationship, 9% had engaged in a new relationship, and 25 %lived
alone. Those who were still in a relationship were slightly older at the time of injury. An inter-
esting finding was that a strong association existed in the EBIQ profiles between those not in
a stable relationship and those not working.

Conclusion

The goal has been to create a postacute program based on evidence obtained in previous
studies combined with new research, but also based on experiences gained in work with brain-
injured persons, nationally and internationally. In this context, an editorial on the effectiveness
of postacute rehabilitation by Neil Brooks (1991) is illuminating. The point made is that de-
spite a tremendous growth in the field, "figures for late outcome often make a rather gloomy
reading" (p. 103). Evaluating change due to rehabilitation is difficult, and Brooks argues that
the outcome literature suggests that change should be demonstrated in terms of real life out-
come. Four papers in the issue of the journal Brain Injury ( 1991) are referred to as examples
of important research in this respect. The papers are written by two groups: two papers by
Cope and colleagues in California and two by Johnston and Lewis based in Community
Reentry Services, Ann Arbor and Kessler Institute of Rehabilitation in Philadelphia. The stud-
ies are well conducted and include population samples, demographic data, and etiologic fac-
tors, and severity of initial injury are described, outcome defined, and duration of follow up,
treatment effectiveness, and cost effectiveness are described. The overall impression stated by
Brooks (1991) is: " The short answer is that rehabilitation works" (p. 106).
The reader, however, is left with only sparse information regarding the theoretical
premises of the treatment provided, the content of the programs, the professionals involved, the
therapeutic attitude of the staff, the collaboration with families, and how motivation was se-
cured. These issues are addressed with the aim of identifying salient characteristics by Trexler
and Helmke (1996), who describe a group of holistic programs in detail, for example, hours of
treatment in various therapies, the professionals working in the program, and the kind of ther-
apeutic interventions made.
To become truly convincing and didactic, combining both measurable components of
programs and the psychological contents and atmosphere, future research regarding the ef-
fectiveness of rehabilitation is necessary. The fact that research becomes more complicated
due to measurement difficulties is an aspect that will need close attention, including a hu-
manistic approach.
The value of comprehensive and valid rehabilitation has been difficult to obtain. The old
statement, that dead brain cells cannot regenerate, has been long-lived and difficult to defeat.
Current neuroscience supports psychologically based rehabilitation, and outcome results from
comprehensive programs have proved that economic gains can be achieved. Brain-injured per-
sons should be offered the kind of treatment that corresponds to the complexity of the brain and
to our present scientific knowledge. It is time for the treatment offered in Goldstein's rehabili-
tation center, almost 100 years ago, to be surpassed by the best possible standards of today.

AcKNOWLEDGMENTS The inspiration for the writing of this chapter stems from collab-
oration with a dedicated and engaged staff and eager and motivated students and families.
For this I want to thank everyone. For commenting on the chapter, I want to thank David W.
162 CHAPTER 10

Ellis, PhD, who worked at the CRBI during the center's first year, and Bjarne Pedersen, PhD,
a present collaborator. I especially want to express my gratitude to Tom W. Teasdale,
Associate Professor, and Carla Caetano, PhD, for their contribution to the center's research
and publications.

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