Prof Rudi Coetzer, clinical director at Brainkind – the UK’s largest brain injury charity – spoke to NR Times about the neuro-behavioural approach to treatment.
He explained how it addresses patients’ social behaviour and their ability to adapt to changing situations through the use of repetition, practice, feedback, and compensation as well as its benefits at all stages post-injury.
What is the neuro-behavioural approach?
The model originates from the days of Rodger Llewellyn Wood – he was the first clinical director [who pioneered the neuro-behavioural approach within the organisation] and has been further refined over the years.
He acknowledged that a lot of what might happen in the clinician’s room doesn’t translate well into the world out there.
From science, we know that repetition is really important to ensure the best outcomes during rehabilitation.
To use a simple example, we don’t learn to play pool in an afternoon, we have to practice many times before we’re good at a new skill.
We need to play pool in different hotels, to learn to play on slightly different tables, and to really cement that skill.
So that’s where one of his seminal insights come from – in that every interaction is an opportunity for rehab.
That provides the opportunity for frontline staff to constantly reinforce or praise desirable behaviours and to not reinforce behaviours that might trip people up.
When is the approach most useful?
We find that the difficulties that people with an acquired brain injury face longer term after the hospital, is the social behaviours, the reintegration.
Faling to reintegrate results in loneliness, social isolation, and not being part of a community.
Let’s now turn to how to work around lost skills to find an alternative way to do things. The clinician’s assessment of someone [may have, for example] identified poor memory, and we want them to use their mobile phone app.
In the first instance, if you follow a very clinical approach, they’re going to forget about the mobile phone anyway.
So, you need to tell ‘John’ repeatedly, every time in the dining room where he is, and ask ‘what are you doing next?’
[Follow that with] ‘look at your phone’ until that repetition settles the behaviour down, and then praise it to reinforce it.You can reinforce behaviours. If you win a race then the medal reinforces you, if somebody tells you, you have done something well, that reinforces you, also known as social reinforcement, which is very powerful.
How does that relate to neuroplasticity?
That’s the first part of that journey, where a high number of repetitions, capitalises or makes the best use of something called neuroplasticity.
We still have some of that after a brain injury. For anybody who’s had, or observed kids, it takes a long time before your child can say papa or mama or nana for banana.
You have to smile and reinforce that many times, which is one of the ways language starts to develop.
Then with repetitions those pathways in the brain, which are called neurons, they cement down, become habits, and become well-overlearned behaviours or skills.
Neurons that fire together, wire together – and so it’s almost like a muscle building approach.
So that’s in the beginning, shortly after the injury, and that makes the best of neuroplasticity and spontaneous recovery as well.
Then that runs out at some point and we have to find a better way.
What is the compensatory approach?
To again use a metaphor, if you can’t get across town with a car, you find something to work around – you might get an Uber or you might walk.
Similarly, if you’ve lost the lower part of your limb, you can have a prosthesis to help you walk again. You can work around lost abilities, there can be a compensation to find another way to do something.
What that means is, you find something, to do something that you’ve lost in a better way.
If you can’t use your left hand, but you would love to cook a meal to be able to be part of the whole social aspect of cooking and eating [you could use a tool instead].
You could compensate for poor memory and for lack of planning, by having, say, a programme or an app.
Again, for that to become habit, you need consistent praise, reinforcement, reward.
That’s the middle part, when spontaneous recovery has run its course, but there’s still gains to be made by finding a way around obstacles.
When else can the neuro-behavioural approach be used?
The last part is for those people who despite our best efforts do not make a good recovery or do not have a good outcome.
The evidence shows us if those people are just left, they can over time deteriorate and decline.
For example, if somebody’s got a lack of drive, they don’t exercise, they’ve got muscle wastage, they’ve developed all sorts of other problems.
They become socially isolated, their health including for example cardiovascular status becomes poor and they develop other health problems as well.
For those people, we provide… a ‘home for life’, but with relapse prevention to make sure that the outcome that they did achieve or the gains they’ve made during early rehabilitation and recovery are maintained.
That fits in with some of the longer-term neurological conditions, for example, with the Sue Ryder services coming on board with us, that part of our model fits that very well.
And also, within the broader health landscape of the UK, there are hundreds of thousands of people out there who [for them] recovery has run its course, or rehab has run its course, or the nature of the condition is that they might decline.
And again, even with declining neurological conditions, if you can build that in, you make the rate of decline slower.
Where we are not able to ‘cure’ anything, we can you make its rate of decline slower, and ensure a better quality of life.
Everything that drives our model in Brainkind is really about informed and guided by research, our clinical expertise, and the management side of things.
Our drive is to make the lives and the quality of life of the people in our care better after brain injury in the long term, not only in the hospital, not only immediately after the hospital, but over the whole journey after a neurological condition or brain injury.
Prof Rudi Coetzer is clinical director at Brainkind, an honorary professor at Bangor University, and an honorary professor at Swansea University. His main clinical and academic interests are neuropsychological assessment and rehabilitation of persons with acquired brain injury, clinical leadership, and service development. Dr Coetzer’s book ‘Working with brain injury’, that he co-authored with Ross Balchin in 2014, was awarded Practitioner Book of the Year 2016 by the British Psychological Society. His most recent book published with Oliver Turnbull and Christian Salas during 2023 is ‘Mistakes in Clinical Neuropsychology – Learning from a case-based Approach. He is on the specialist register of the British Psychological Society Division of Neuropsychology.
