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Running head: TBI, NEURO-PLASTICITY, AND SFBT

Traumatic Brain Injury, Neuro-Plasticity, and Solution Focused Brief Therapy Gina Wilson Adams State College

Abstract

This literature review highlights studies attempting to produce reliable results indicating that Solution Focused Brief Therapy (SFBT) is a safe, effective and cost saving treatment for clients suffering from Traumatic Brain Injury (TBI) and sequelae to it. In addition, the cultural and ethical concerns of the TBI population are discussed. A brief historical review of SFBT revealing that the foundation of the approach can be found in Milton Ericksons use of metacognition within Indirect Hypnosis is also included. The SFBT approach is based on the assumption that clients attitudes, perceptions and beliefs are crucial components in treatment outcomes. Findings include research on neuro-plasticity issues in the TBI client. In addition, the impact SFBT can have on neuro-plasticity and brain repair in this client population is discussed as an important component of this treatment approach. Also addressed are limitations in methodology and creating standardized protocols that could greatly expand the use clinical applications of SFBT for TBI clients. Keywords: Hypnosis, neuro-plasticity, Solution Focused Brief Therapy, traumatic brain injury

TBI, NEURO-PLASTICITY, AND SFBT Traumatic Brain Injury, Neuro-Plasticity, and Solution Focused Brief Therapy

According to the Center for Disease Control (2010), the number one cause of Traumatic Brain Injury (TBI) in America is falls. TBI is considered an acquired brain injury (not from organic sources, such as; birth defect, Alzheimers disease, tumors, etc.) resulting from internal or external physical forces, hypoxia (lack of sufficient oxygen), or stroke. TBI may also be described as an insult to the brain caused by an external physical force that may produce a diminished or altered state of consciousness resulting in impairment of cognitive abilities, emotional control, or functioning. Regardless of the originating cause, parts of the brain are no longer functioning normally. TBI often results in cognitive, emotional, behavioral, or physical impairment, and can cause either partial or total functional disability. Sequelae of traumatic braininjuryincludeheadacheanddizziness, anxiety, apathy, depression, aggression, cognitive impairments, personality changes, mania, psychosis, sleep disturbances, and any other changes caused by neurological trauma (McAllister, 2008). Communications between the body and the brain are diminished with TBI, presenting in memory loss, difficulty multi-tasking, and with information processing, seizures, difficulty sustaining concentration, speech impairment (aphasia), paralysis, headaches, and increased need for sleep, depression, mood-swings, and impulsivity. However, there is solid evidence of growth of new neurons in the adult brain, especially in environments of stimulation and activity. This research has profound implications psychological rehabilitation, and enhanced mind-body communications. Growing neurons and actually changing the brains architecture via psychosocial experiences is called neuro- plasticity (Burke, 2009).

Neuro-plasticity

Neuro-plasticity is defined as the capacity of nerve cells in the brain to modify their activity in response to environmental stimulation. In the last 10 years, neuro-plasticity research highlights the impact psychosocial experiences have on neurobiological processes. These processes point to the ability to actually change the structure of the adult brain. These structural changes include: increased arborizations of neurons, enhanced synaptic connectivity, and even the genesis of new neural tissue. Guiding these changes, and enhancing neuro-plasticity and brain repair in TBI, using novel treatment protocols such as SFBT, are supported in the literature(Montgomery, et.al, 2009). Following a brain injury, the plasticity involves negative components: Long-term potentiation is reduced; long-term depression is increased; membrane excitability is reduced; and anatomical changes including axon terminal damage, and the reduction of synapses. Recent research highlights the use of neuromarkers as a scientific measure, helping with diagnosis. This is an important step in designing specific treatments to actually guide neural plasticity away from the negative aspects after injury, to positive, healing aspects (De Fina, 2009). Current research on the management for symptoms of chronic sequelae of war-related TBI indicates neuro-plasticity as a critical component of healing and re-learning. For example, studies indicate aphasia responds positively to brain training, as well as the brains ability to recover function through neuroplastic processes (Halbauer, et. al., 2009).Another important process contributing to neuroplasticity is a deep, restful sleep. Good sleep hygiene promotes synaptic homeostasis, which enhances the brains ability to heal and learn after a traumatic injury (Gironda, et. al., 2009).

Solution Focused Brief Therapy (SFBT) Solution focused brief therapy (SFBT) combines the metacognition techniques of Milton

TBI, NEURO-PLASTICITY, AND SFBT Ericksonss Indirect Hypnosis with some attributes of cognitive therapy, and some components in goal orientation of behavior therapy. Originating with Ericksons applications of Indirect Hypnosis, the Miracle Question is the most popular piece of SFBT (Visser, 2008). For the purposes within, hypnosis shall be, at times, used interchangeably with SFBT with careful consideration to maintaining the SFBT model. Furthermore, hypnosis, within the scope of this paper, is viewed from the cognitive behavioral perspective and not the traditional hypnotic state theory. For the purposes of this paper, the scientific definition of hypnosis will be used, a state of focal attention and heightened concentration (Vimhans, 2011), as well as, hypnosis as a neural trance.

When in a neural trance, the synchronization of synaptic circuits is activated enhancing the clients abilities to control imagination and to increase focused attention (Spiegel, 2007). Clinical Hypnosis is highlighted in multiple lines of research focusing on the efficacy of application to many of the symptoms found in the sequelae to TBI. For example; headaches, fatigue, sleep disturbance, body image issues, pain management, addiction, and others are all supported as effectively treated with hypnosis (SFBT). Some of the positive changes that have been properly researched and documented include; biofeedback changes, immunological changes, neurotransmitter changes, EEG changes, event related potentials changes, and brain imaging changes (Vimhans, 2011). Studies indicate this type of brain training is critical to guiding the positive components of neuro-plasticity. There is increasing understanding of the underlying neural circuitry that is activated with SFBT models. The more a neuron or assembly of neurons is used during specific exercise, those neurons responses will become more rapid and even more responsive, when performing that exercise in the future. The therapeutic application of SFBT techniques lead to long term changes in synaptic connectivity (Spiegel, 2007). When a practitioner

speaks to a client and the client listens, the practitioner is not only making eye contact and voice contact, but the action of neuronal machinery in the counselors brain is having an indirect, and, potentially, long-lasting effect on the neuronal machinery in the clients brain. Many like words produce changes in client's minds; these psychotherapeutic interventions produce changes in the client's brain (McAllister, 2008). The SFBT approach assumes that attitudes, expectations and beliefs play an enormous role in determining treatment outcomes. These components are viewed as extremely important, particularly the concept of expectation in enhancing clinical outcomes. Furthermore, a critical component to TBI rehabilitation is for the clients to have a grasp of their own deficits regarding the TBI. SFBT can be effective with clients who are unaware, or in denial about these deficits. .In addition, studies show individuals dealing with high levels of anxiety after automobile accidents are also likely to benefit from this approach (Guckien, 2010). Interestingly, the CDC reports automobile accidents as the second highest cause of TBI in America. In contrast to anecdotal claims of extreme benefits by clinicians of the superiority of Indirect Hypnosis (SFBT), there is not much empirical support in research literature (Chavez, 1999).Exploring and defining expectations of self efficacy, focusing on positive predictions of the clients own performance capabilities, and collaborating with the client to explore discrepancies between perceived and actual abilities, are all included in the counselors role. Using the evocative, and reflective questioning techniques of SFBT, the practitioner can effectively reframe the clients frame of reference to a more positive one, establish treatment goals, and initiate client change. The SFBT model is known for using three types of questions used to gain positive change in the client; 1) the exception questions; 2) the outcome questions; 3) the coping and/or externalization questions, in addition to the Miracle Question, and scaling questions (Johnson & Miller, 1994). Other research includes the core components of a search for pre-session change, a search for

TBI, NEURO-PLASTICITY, AND SFBT exceptions, a consulting break, and a message including compliments and task assignment as identifying components of this approach (Gingerich &Eisengart, 2004).The use of vivid imagery and multi-sensory metaphors within SFBT helps to catch the sensory and affective dimensions of the pain and suffering associated with TBI. With this approach, usually with brief instruction within the first meeting, a client can quickly, develop voluntary control of levels of awareness, internal positive resources, and controlled disassociated states, which can become a source of comfort for the TBI client. Many practitioners approve of the SFBT approach and find it particularly useful for soldiers returning home from war, and for treating PTSD (Gingrich & Eisengart, 2000). SFTB relies on the processes of metacognition to enact positive change. Metacognition is a critical component of mental function, and may be defined as the capacity to think about thinking, or the minds creation of mental perceptions about itself. Metacognition involves the idea of pointing out discrepancies in how things appear-and how they really are. Clients with TBI score poorly on the self-awareness questionnaires, and decreased metacognitive

self-awareness is correlated with increased problems in some components of the executive system (Halbauer, et al., 2009). Negative Self Hypnosis In working with TBI clients and their families, research revealed that hospital and procedural settings can induce a spontaneous trance state, creating susceptibility to negative Comments, such as; this is really going to hurt, or you will never have full range of motion again. These types of statements can have a focused impact on the clients attention towards negative outcomes. Using a powerful healing language that the unconscious can understand to reduce the pain and suffering components around the sequelae of TBI, is a particular strength of SFBT. This approach focuses attention on healing opportunities with statements that enhance a

clients strengths, such as, everything you need for your recovery is here for you, and these are soft plastic tubes made to fit your body, bringing you everything you need for your comfort and healing (Eimer, 2000). When facing procedures related to their injuries, clients can learn to manage physiological responses and psychosocial issues with this approach. The premise being that attitude, moral perception, and mental focus make a critical difference in coping, healing and recovery, enhancing the potential of positive treatment outcomes for TBI clients (Greenleaf, 2006). Methods In this review of literature some of the reporting methods encountered included; self reports, scaling questions, inventories, questionnaires, biofeedback, neuromarkers, gene assays, and PET scans. Early studies show a reliance on self reporting, anecdotal reports, and questioning. While compelling for the practical applications of the SFBT approach, this is not strong enough for an emerging application. Future methods for empirical research methods may begin to rely on more current technology for measure, such as gene assays, neuromarkers, and PET scans as they becomes more accessible, affordable and mainstream. Results The majority of the research indicates that SFBT is an applicable treatment to TBI, particularly for addressing the sequelae to it. In addition, the research reveals that neuroPlasticity is an important component of brain healing and rehabilitation. In the future, I would research the most affordable, current technology base measure, such as gene assay, neural markers, or PET scans, and look for ways to provision these services in safe, affordable, user-friendly ways. I am confident this would greatly enhance SFBT treatment outcomes for the TBI client population. Discussion This review of literature has highlighted several areas of importance; cultural and ethical concerns

TBI, NEURO-PLASTICITY, AND SFBT

in working with the TBI population within the SFBT modalities, the usefulness of this approach to the counseling profession and the direction(s) future research might take, as well as a cost savings component. In addition, the limitations and weaknesses of available literature are an important part of the discussion, as well as needs and ideas for future research in this field. Cultural and Ethical Concerns Counter-transference of a counselors fear of TBI, pain, or any of the other sequelae surrounding TBI is a serious consideration. Complex bio-psychosocial issues exist within this population, such as; reduced employment, impaired social relationships, etc. (Halbauer, 2009).A counselor understanding assumptions about healing and the affect on the client are important. As well as, how the clients experience of power in the family and in society influence the disposition to experience chronic pain, and other sequelae. In addition, the religious and spiritual components influence the resiliency to face the challenges associated with the conditions experienced around TBI, and are an important consideration. Understanding the influence of family and society on the clients sense of power and control, and the potential of negative influence causing a negative impact on rehabilitative outcomes is also an important concern (Burns, 2010). The American Pain Society strongly suggests that medicine alone is rarely successful for many of the symptoms associated with TBI. However, in this collaborative approach, pharmacology will be encountered in this population. As many of the medications prescribed are potentially addicting, counselors can be aware of this and add drug and drug mis-use screening to the treatment plan. Usefulness to the Counseling Profession and Future Direction The usefulness of the SFBT approach to the counseling profession can be found in the efficacy of the approach, as well as, its cost effectiveness. In managed care settings, therapeutic

care interventions may be limited because of the high cost of ongoing physical, cognitive and behavioral rehabilitation. This approach is effective, evoking and relatively affordable. The SFBT approach offers, in about 6 sessions, an effective, non-pharmacological alternative treatment plan for difficult to treat disorders such as TBI and sequelae. Perhaps the most exciting component of SFBT, is contributing to positive neuro-plasticity in the healing brain of the TBI client. A new direction in this field is new technology, such as brain imaging, neuromarkers, and gene assays that show SFBT can invoke neuro-plasticity in the TBI client, enhancing brain healing. Further studies on the neuro-cognitive effects of TBI, and SFBT as an effective treatment approaches are also needed. Evidence on which to base diagnostic and management recommendations, and formal studies of specific sequelae of TBI are needed and research into the efficacy of SFTB treatment modalities is strongly indicated. SFBT has been shown to be an effective treatment approach, worthy of future research focus. The long established use of clinical hypnosis (SFBT) in modulating pain, emotion, and stress, are cause for brain imaging research to further the clinical applications of SFBT. In addition, future studies should include; detailed manuals of procedures; standard assessment tools, and two year follow ups to determine therapeutic effects. Last, but not least is the need for specification and proceduralization of SFBT itself, and the consistent use of detailed treatment manuals and measures. The justification for these ideas lies in providing standards of care, and generalizability of the treatment protocol from case to case, enhancing provisioning of services in a reliable, cost-effective manner. Cost Savings Every 21 seconds in America somebody sustains a Traumatic Brain Injury. It is estimated that the total cost of TBI in America is about 60 billion dollars annually (Burke, 2009). An important feature of SFBT and other non-pharmacological techniques is cost savings. These

TBI, NEURO-PLASTICITY, AND SFBT techniques are fairly easy to teach practitioners, as well as the clients themselves (Askay, et.al, 2007). Cost savings has been substantiated, even in the operating room, with hypnotic (SFBT) procedures. Increased trend of interest in hypnosis (SFBT) based, cost saving therapies has grown, and is likely to continue. As this approach is relatively brief, it is relatively

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inexpensive. Recent evidence suggests that for reduced recovery time, and enhanced healing, this approach is a useful and cost effective measure in medicine (Patterson & Jensen, 2003). Limitations and Weaknesses A prevailing theme limiting these studies is the reliance on anecdotal reports of success from both practitioners and clients. Case reports, and follow up studies, as well as, self reporting and scaling questions are heavily relied on. Future research might focus on promoting standard assessment tools. However, research reveals that classic open ended statements often found in SFBT may create cognitive disorganization in this population (Cicerone, 1989). The literature has inconsistencies regarding the concept of awareness. A comprehensive model of awareness is needed to guide the development of measurement tools and interventions (Halbauer, et al., 2009).Another limiting pattern is low study groups. There is a need for more randomized, clinical trials, with larger samples and standardized SFBT procedures, particularly in the area of TBI and the sequelae of that injury. In addition, hypnosis/SFBT treatment conditions vary from study to study, and the experiential portions of the study vary in interventions. Small study group size and cognitive impairment were not indexed, which could be an influence on treatment efficacy during brain injury. In general, the problems were with lack of controlled studies and inferring causation in correlation research, as well as non random convenience samples, limited generalizability of findings, reliance on self report. Conclusion

Despite research limitations, the available published literature produce findings indicating SFBT as a viable, cost-effective, non-pharmacological intervention for clients suffering fromTBI and sequelae to it. The additional benefit of enhancing neuro-plasticity and brain healing provide additional support for the use of SFBT in the field of TBI treatment. Finally, the benefit of no adverse effects, and its relative affordability, make applications of SFBT a promising opportunity to bridge the gap between research and clinical application. The components of neuro-plasticity and the effects of psychosocial experience and brain-training on cognitive, emotional, and behavioral functions are definitely an area deserving of development. Thinking in open-minded, creative ways we can create collaborations that collect knowledge and expertise, culminating in the maximum potential for TBI clients, using SFBT models. By better understanding the mechanisms and parameters of brain function, and gathering good data to guide evidence-based treatment, we will be better able to predict positive outcomes for the TBI client.

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Centers

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