Perhaps the most rewarding part of my work is helping post-traumatic brain injury clients to regain mastery of skills they thought were lost forever. Many of you may be familiar with this aspect of my work from Clark Elliott’s book, The Ghost in My Brain, about his nearly decade-long journey to recover from a concussion suffered in a minor traffic accident.

Elliott is a professor of artificial intelligence and cognitive science, so his understanding of the brain’s inner workings is extensive. However, he was unprepared for how this seemingly minor accident wiped away his ability to physically and mentally accomplish even the most minor task without a huge effort. In his book, Elliott describes his difficulties, such as taking nearly seven hours on a frigid and snowy Chicago evening to walk five blocks, figure out how to get into his car, drive a few miles to his home, and get into his house. That minor accident destroyed his ability to control his mind and thoughts as well as the motor skills required to complete simple tasks such as getting into his car or putting a key into a lock. Worse still was how it affected his cognitive ability to put two and two together such as not understanding that a needle in his arm was causing him pain.

Rehabilitation after brain trauma may include physical therapy, speech therapy, cognitive therapy, and occupational therapy, and while these are crucial therapies post-injury, they paint with a broad brush. What I mean by that is that they don’t address some finer points in cognitive therapy. If a patient scores within normal ranges on a standard cognitive test, they are mostly told that they should learn to live with the remaining dysfunction. Their symptoms are medically unverifiable and therefore untreatable. This answer is frustrating to most patients, especially high-functioning, successful adults who want to return to work and function as they always have.

Recovering these abilities requires using the brain’s plasticity to rewire itself. The part of the brain that tends to suffer the greatest loss in brain injuries is the part that controls thinking, planning, dreaming, language, math, etc. These finer points require the brain to forge new connections, and the key to this process is the same as any other form of learning: Attention, Intention, and Rehearsal.

Attention is first and foremost. The appropriate parts of the brain must be focused on, both by the client and therapist, in order to rewire the circuits.

The intention may seem obvious, but in many cases, patients don’t understand the goals of their therapies. It is crucial that patients understand what they are doing and why. If they think the exercise is a waste of time, irrelevant, or has no real payoff, then they won’t buy into the work.

Finally, we have a rehearsal, which helps create “muscle memory.” By repeating the types of exercises, clients train particular neurons to fire and strengthen their use for particular tasks. Rehearsal allows the brain’s plasticity to take over and allow new connections to be made so that cognitive behavior can become habitual.

Cognitive Rehabilitation with Designs for Strong Minds (DSM)

The DSM program is based on a neurocognitive model that uses attention, intention, and rehearsal to implement learning and behavioral change. What differentiates DSM from other cognitive-based programs is its use of mediation and its large variety of increasingly complex visual puzzles that are organized by logical structures. Mediated learning helps clients transfer learning because it makes them consciously aware of the inherent structure of problems, the intended goal, and the relevant information.

DSM uses “content-free exercises” that all the client to think, explore, and isolate known from unknown without making them explicitly use prior knowledge (e.g., writing, calculating, or organizational skills). The content-free nature of the exercises makes them non-threatening and less anxiety-producing.

DSM also takes into account the client’s skills pre-injury. We all know the old joke:

Doctor, will I be able to play the violin after the operation?

Of course!

Great! I was never able to play it before!

We can expect that skills or situations that were difficult pre-injury will still be at least as or even more difficult post-injury. Many patients marvel at their ability to develop skills after treatment that were difficult or impossible before their injury such as math, logic puzzles, reading comprehension.

DSM’s mediated learning uses a large variety of visual puzzles organized by logical structures to enhance conscious recognition of logical structures such as conditional reasoning, bi-conditional reasoning, analytic perception, and classification. DSM helps the client redevelop alternative ways of thinking. The puzzles make the client visualize what makes some answers logical and others illogical. In this way, the learner experiences both the depth and breadth of neurocognitive restructuring. The organization of materials and the rehearsal present opportunities to create new neural networks the brain needs for permanent change. DSM mediators encourage learners to engage in an internal dialog that transforms the lesson into a meaningful experience.

Understanding when, where, why, and how new learning can be applied creates usable knowledge that enables learners to:

Recognize similarities in diverse situations

Assess the ways in which situations are similar and different

Formulate a plan of action in accordance with the assessment

Analyze the degree to which the actions succeed or fail

Gain insight into their own preferences and expectations

Mediation offers the learner the opportunity to explore the structure or examine the premise on which the exercise is based. DSM requires the learner to use bottom-up thinking to solve the exercises. DSM mediators guide learners through their own subconscious thought processes, allowing them to objectively think about how they think and structure information. This awareness of their own organizational behaviors allows them to:

Verbalize their rationale for doing something in a particular way

Monitor their current level of understanding

Determine when additional information is required

Evaluate new information based on its consistency with what they already know and its relevance for achieving their intended goal

Create analogies that help them and other people advance their understanding ·of the situation

Unlike most learners who are conditioned to looking for correct formulas and single solutions, DSM learners develop ‘‘Expert Minds’’ that:

Seek to understand the goal

Organize the available information based on the goal

Structure the problem so that the goal can be achieved

Evaluate the solution’s success at satisfying the goal

Strategize more effective ways of achieving similar goals

Over my next several blog posts, I will show how DSM works specifically with post-traumatic brain injury clients like Elliott. As his book shows, there was nothing easy or magical about the process. It required determination and hard work, but in the end, DSM combined with neuro-optometric rehabilitation gave Elliott his life back.