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 Introduction to
Neuropsychotherapy
This groundbreaking volume provides a theoretical overview and
clinical guidelines for the application of neuropsychotherapy. It takes a
multidisciplinary approach, combining neuropsychological knowledge
with recent conceptualizations from neuroscience and psychotherapy,
with special emphasis on the role of working alliance.
The first part of the book focuses on the historical roots of neu-
ropsychotherapy, and a framework of interpersonal processes in
neuropsychotherapy and conceptualization for clinical purposes is
described. Resistance is examined from a historical perspective of
conceptualization through to the present-day demands of under-
standing this phenomenon in the practice of neuropsychotherapy. In
addition, the neuropsychology of emotions is presented through a
case intervention. The latter chapters of the book are concerned with
special interest interventions and psychotherapeutic working meth-
ods suited to neuropsychotherapy.
Representing a wide variety of theoretical, research-oriented, clin-
ical neuropsychological, and psychotherapeutic expertise, this book
will interest professionals in neuropsychological rehabilitation and
those working with patients with cognitive, emotional, and behav-
ioral disorders in inpatient and outpatient settings.
Ritva Laaksonen is a psychology graduate from the University of
Helsinki with a postgraduate degree of Licenciate of Psychology, and
a PsL specialization in clinical neuropsychology from the University
of Jyväskylä. She is an official supervisor registered by the Finnish
Neuropsychological Society. She has served as a clinician, adminis-
trator, educator, and researcher in public posts at the Helsinki Uni-
versity Hospital Department of Neurology, and has been the chief
psychologist there for 13 years. She is also a state registered psycho-
therapist trainer.
Mervi Ranta is a psychology graduate from the University of Jyväs-
kylä with a postgraduate degree of Licenciate of Psychology, and a
PsL specialization in clinical neuropsychology from the University
of Helsinki. She is a state registered psychotherapist, and she has
worked as a clinician and a supervisor in a public post at the Seinä-
joki Central Hospital Department of Neurology since 1986, where
she is presently serving as the chief psychologist.
 Introduction to
Neuropsychotherapy

Guidelines for Rehabilitation

of Neurological and
Neuropsychiatric Patients
Throughout the Lifespan

Edited by
Ritva Laaksonen and
Mervi Ranta

tp ~~~~~~~i?G~XP Press
NEW YORK AND LONDON
First published 2013
by Psychology Press
711 Third Avenue, New York, NY 10017

Simultaneously published in the UK

by Psychology Press
27 Church Road, Hove, East Sussex BN3 2FA

Psychology Press is an imprint of the Taylor & Francis Group, an informa business

© 2013 Taylor & Francis

The right of the editors to be identified as the authors of the editorial material,
and of the authors of their individual chapters, has been asserted in accordance
with sections 77 and 78 of the Copyright, Designs and Patents Act 1988.

All rights reserved. No part of this book may be reprinted or reproduced or

utilised in any form or by any electronic, mechanical, or other means, now
known or hereafter invented, including photocopying and recording, or in any
information storage or retrieval system, without permission in writing from the
publishers.

Trademark Notice: Product or corporate names may be trademarks

or registered trademarks, and are used only for identification and explanation
without intent to infringe.

Library of Congress Cataloging-in-Publication Data

Introduction to neuropsychotherapy : guidelines for rehabilitation of

neurological and neuropsychiatric patients throughout the lifespan / edited by
Ritva Laaksonen and Mervi Ranta.
pages. cm
ISBN 978-1-84872-622-2 (hardback) — ISBN 978-1-84872-623-9 (pbk.) —
ISBN (invalid) 978-0-203-07587-6 (e-book) 1. Neurobehavioral disorders—
Patients—Rehabilitation. 2. Clinical neuropsychology. 3. Psychotherapy.
I. Laaksonen, Ritva. II. Ranta, Mervi.
RC350.4.I58 2012
616.8914—dc23
2012032662
ISBN: 978-1-84872-622-2 (hbk)
ISBN: 978-1-84872-623-9 (pbk)
ISBN: 978-0-203-07587-6 (ebk)

Typeset in Minion
by Apex CoVantage, LLC
 Contents

Contributors vii
Foreword ix
Introduction
Ritva Laaksonen and Mervi Ranta xi
1 Neuropsychotherapeutic Approaches in
the Rehabilitation Context 1
Ritva Laaksonen and Mervi Ranta
2 Neuropsychological Assessment in Adults: Integrating
Neuropsychological Knowledge for Treatment
and Therapeutic Purposes 29
Raija Ylikoski
3 Brain Development and the Everlasting Process
of Self-Regulation: Implications for the Development
of Perception, Attention, Language, and Memory 39
Nina Sajaniemi
4 Motivational Regulation and Its Effect on Mental
Processing in Neuropsychiatric Disorders: A
Rehabilitation Perspective 65
Liisa Paavola and Jukka Loukkola
5 Effects of Brain Injury on Emotional Reactions in
a Therapeutic Process 77
Arja Lindell
6 Resistance in Treating Neurological Patients 107
Paula Häkkinen
7 Process-Oriented Neuropsychological Outpatient
Rehabilitation: Practical Examples of Various Etiological
Groups at the Post-Acute Stages 127
Arja Lindell and Tarja Ketola

v
vi Contents

8 Helping Children with Acquired Brain Injury

to Engage in a Neuropsychotherapeutic Process 143
Hanna Kiiski-Mäki
9 Therapeutic Applications with Different Types
of Developmental Disabilities in Young Adults 171
Sari Haikonen
10 Challenge to Change in the Family Narrative 187
Tarja Ketola, Liisa Paavola, and Nina Sajaniemi
11 Neuropsychotherapeutic Elements as an Integrative
Part of Holistic Rehabilitation Programs 199
Sanna Koskinen and Jaana Sarajuuri
12 Summary of Applications of Psychotherapeutic Methods
in Neuropsychotherapy 215
Ritva Laaksonen and Mervi Ranta
Epilogue 245
Acknowledgments 247
Index 249
 Contributors

EDITORS Tarja Ketola

Specialized clinical
Ritva Laaksonen
neuropsychologist,
Lic. Psych. specialized clinical
Medical Center Mehiläinen,
neuropsychologist, reg-
Turku
istered psychotherapist,
advanced level trainer and
Hanna Kiiski-Mäki PhD
supervisor, director of
Specialized child neuropsychol-
training programs Vandark
ogist, developmental and
Ltd.:The Finnish Neuropsy-
educational psychologist,
chotherapy Institute/ KL-
psychotherapist CCSF
institute Ltd. Helsinki
coach, Department of Psy-
chology, Multiprofessional
Mervi Ranta
Teaching Clinic, University
Lic.Psych. specialized clinical
of Turku
neuropsychologist, regis-
tered psychotherapist, art
Sanna Koskinen PhD
psychotherapist, chief psy-
Specialized clinical neuropsy-
chologist, Psychology Ser-
chologist, chief psycholo-
vice Unit, Seinäjoki Central
gist, Käpylä Rehabilitation
Hospital
Center, Helsinki
CHAPTER AUTHORS Arja Lindell
Sari Haikonen Lic.Psych. specialized
Lic. Psych. specialized clinical clinical neuropsychologist,
neuropsychologist, private registered psychotherapist,
practice, Helsinki Medishare Ltd.,
Turku
Paula Häkkinen
Lic. Psych. specialized clinical Jukka Loukkola
neuropsychologist, Depart- Lic. Psych. specialized clinical
ment of Neurology, Helsinki neuropsychologist, Neural
University Hospital Ltd., Oulu

vii
viii Contributors

Liisa Paavola Jaana Sarajuuri

Lic. Psych. specialized Lic. Psych. specialized
clinical neuropsychologist, clinical neuropsychologist,
registered psychotherapist director of the INSURE
Neural Ltd., Oulu Program, Käpylä Rehabilita-
tion Center, Helsinki
Nina Sajaniemi PhD
Specialized clinical Raija Ylikoski PhD
neuropsychologist, Specialized clinical neuro-
adjunct professor, psychologist, Department
principal investigator, Uni- of Neurosciences, Faculty
versity of Helsinki, Depart- of Medicine, University of
ment of Teacher Education Helsinki
 Foreword

The role psychologists play in brain injury rehabilitation has greatly

expanded over the last 30 to 35 years. Early medically-oriented reha-
bilitation focused on the basic activities of regaining strength, avoid-
ing complications, feeding, toileting, walking, and talking. Functional
independence was the goal, to the degree to which it was possible.
Everyone recognized that cognitive and personality disorders
were present after significant brain injury, but their treatment was
often not the focus of rehabilitation. Little was known regarding what
to do for these problems. The exception to this rule was the work of
Kurt Goldstein, who in turn influenced the work of Ben-Yishay and
Diller. These clinicians targeted the patient’s cognitive and behavioral
disorders with the goal of trying to restore, or at least meaningfully
compensate for, residual cognitive deficits. Also, teaching patients
better ways of behaving in social interactions was clearly an area
of focus, with notable successes in some patients. Yet, the patient’s
personal feelings, their subjective sense of loss, their confusion, and
their frustrations were not specifically addressed until the need for
psychotherapy for the patient (and the family) began to become for-
mally recognized in the mid-1980s.
It is against this historical background that the importance of this
edited book by Ritva Laaksonen and Mervi Ranta should be appre-
ciated. This book emphasizes that psychological services provided
to patients with brain disorders, throughout the lifespan, should in-
clude efforts at improving cognitive functioning while also attend-
ing to the patient’s emotional and motivational needs. Reflecting on
and integrating the insightful observations of many clinicians from
several disciplines is the clear strength of this book. Insights from
neurology, neuropsychology, and neuropsychological rehabilitation
are interwoven with insights from psychoanalytic theory, attachment
theory, cognitive and behavioral therapies, social cognitive models

ix
x Foreword

of psychological intervention, brain development, cognitive develop-

ment, and the biology of temperamental differences in children. Col-
lectively, this book argues, in a convincing manner, that a thorough
understanding of how a brain disorder in a given patient directly or
indirectly affects their pre-existing cognitive and personality func-
tioning must guide both scientifically driven research and the provi-
sion of clinically sensitive services.
The term used by these authors to emphasize the importance of
this approach to treatment is neuropsychotherapy. Kiiski-Mäki, in her
chapter on helping children with brain disorders, makes the point
that neuropsychotherapy does not refer to “using exotic methods
outside the range of traditional psychotherapies. Rather, it is thera-
peutic work that combines methods eclectically from other fields of
psychotherapy and, at the same time, modifies them according to the
ABI child’s [or adult’s] special needs” who has suffered brain injury.
Thus, the neuropsychotherapist is acutely aware of how various neu-
ropsychological disturbances have to be kept in mind when plan-
ning psychotherapeutic interventions and when conducting those
interventions.
This book will help those clinicians who attempt psychother-
apy and cognitive rehabilitation with brain dysfunctional patients
throughout the lifespan. It is an important addition to our under-
standing of how to deal with the various problems that clinicians face
when doing this work.
It is refreshing to see competent clinical neuropsychologists in
Finland embrace the importance of psychotherapy in their work as
clinical neuropsychologists. This book adds to the long tradition of
meaningful clinical contributions that have been the hallmark of the
work of neuropsychologists and neuropsychiatrists from Finland
over many years.

George P. Prigatano, PhD

Barrow Neurological Institute
Phoenix, Arizona
 Introduction

This book was brought about by the collaboration of a group of

specialized neuropsychologists sharing common interests in neu-
ropsychological rehabilitation from a holistic perspective in brain–
mind relations. We wanted to write this book in order to share our
interests and expertise with colleagues and other professionals work-
ing with neurological and neuropsychiatric patients in rehabilitation
settings.
Neuropsychological rehabilitation has a long tradition in Fin-
land, starting in the 1920s to 1940s, mainly for war veterans, and the
later 1960s for civilian patient groups at university hospitals. In our
professional work, the frame of reference has included personality
and emotional, as well as social, contexts with the goal to treat “real
people in the real world,” as expressed in the writings of respected
pioneers, such as Dr. Leonard Diller and A. R. Luria. Dr. George
Prigatano had also expanded our awareness to the needs of ABI and
TBI-patients’ treatment procedures, together with professor Anne-
Lise Christensen’s crystallized views. However, there seems to have
been a misunderstanding in treatment settings for decades, with
explicit concentration mostly on cognitive exercises. Some neuro-
psychologists have achieved holistic training for neuropsychological
treatment, while others have mainly focused on treating cognition in
post-illness situations.
Our main goal is to emphasize the importance of seeing and un-
derstanding the person suffering from the sequelae of illness as a
whole human being, not just the neuropsychological disturbances.
Recent research in the fields of neuroscience has given us a firm basis
together with the “Zeit Geist” for a more integrative approach.
Our project had its impulse in a postgraduate training program in
neuropsychotherapy. It had been in the air for a long period of time.
However, when Dr. Barbara Uzzel came to me at the INS meeting in

xi
xii Introduction

Baltimore, Maryland, and asked, “Ritva, do you have any books you’re
working on?” that was it: Why not a book on neuropsychotherapy?
We had many experienced experts in the first 3-year neuropsycho-
therapy training program, all trying to integrate neuropsychological
rehabilitation in a multidisciplinary fashion. The idea was there. We
decided to go to Tuscany, Italy, to a retreat in 2007, in order to have
peace and inspiration in our collaboration of the book project. That
worked out fine. We all got to know each other better, and our indi-
vidual special interests were well suited to make this book of guide-
lines and theoretical background for clinicians interested in a more
holistic and therapeutic approach in treating different neurological
and neuropsychiatric groups. Three years of collaboration in a cre-
ative spirit brought this book into life.

Ritva Laaksonen and Mervi Ranta

La Poggiarella, Tuscany,
September 24, 2009
1
Neuropsychotherapeutic Approaches in the
Rehabilitation Context

Ritva Laaksonen and Mervi Ranta

Introduction

Neuropsychotherapy is a form of treatment based on recent advances

in the domains of neuroscience, neuropsychological rehabilitation,
and models of psychotherapy. It can be considered an alliance be-
tween scientific, theoretical and clinical knowledge in these areas
(Laaksonen, 2007).
The term neuropsychotherapy has been used in different conceptu-
alizations. In the context of this book, we follow the contextualization
indicating that neuropsychotherapy is a name for interventions, which
we need for people who suffer from emotional, behavioral, or person-
ality disorders after neurological dysfunction or syndromes. Remedia-
tion of cognitive disturbances will also be included in the treatment
process. The term neuropsychotherapy has also been used when neuro-
scientific knowledge has been integrated into psychotherapy (Grawe,
2007), or neuropsychoanalysis (Kaplan-Solms & Solms, 2000).
The concept and procedures are multidisciplinary in nature. The pa-
tient groups concerned vary within different types of central nervous
system (CNS) involvement. The metatheory for guideline information
in the therapeutic remediation procedure needs to be multifarious
and must cover several domains of knowledge to serve as a guideline
for rehabilitation in practical and ecologically valid settings.

1
2 Introduction to Neuropsychotherapy

Neuropsychotherapy is the use of

neuropsychological knowledge in the psychotherapy
of persons with brain disorders

Neuropsychotherapy

Cognitive
rehabilitation

Psychotherapy

Rehabilitation

Figure 1.1 What Is Neuropsychotherapy?

Even though psychotherapy is now, according to Coetzer (2007),

an approach used within several models of neurorehabilitation, a
core theoretical model to guide psychotherapeutic practice is lack-
ing. The aim of this chapter is to open a scope of applicable concep-
tualizations for further developments in the field of comprehensive,
integrated rehabilitation procedures. Judd (1999) has conceptualized
the overlap of various forms of rehabilitation of people with brain
injuries. His illustration is seen in Figure 1.1.
The overlapping use of knowledge from different cases of people
with brain injuries has proved necessary if suitable and efficient treat-
ment procedures are to be designed.

Neuropsychological Rehabilitation and Psychotherapy:

Historical Perspectives

Fractured minds (Ogden, 2005), shattered worlds, and grief reactions

are not unfamiliar to clinical psychologists, nor to neuropsycholo-
gists. Historically, however, psychotherapy has not been consid-
ered useful in the rehabilitation of brain-dysfunctional patients
 Neuropsychotherapeutic Approaches in the Rehabilitation Context 3

(Prigatano, 1991). It has been viewed as having little application in

a brain-injured population in the past (Coetzer, 2007), despite the
phenomenological necessity.
It should be kept in mind that this doesn’t mean that the clinical
professionals working in the field would have neglected the injured
person’s emotions or personality as a whole. What it means is that
the writings and explicit ways of describing the interventions have
often focused on remediation of cognitive functions. In the tacit level,
the importance of social adjustment, individuality, and interpersonal
problems have been acknowledged and worked at in real life situa-
tions by experienced professionals. There are published examples of
this line of thinking, for instance, in treating cerebrovascular patients,
as early as the 1970s. A historical example of treating post-stroke
depression with psychological management is given by Horenstein
(1970). His suggestion is a stepwise psychological approach involving
structured teamwork and family participation rather than medica-
tion. Horenstein points out that depression of mood frequently ac-
companies isolated and multifocal cerebral vascular lesions as grief
which resembles that observed after other major illness. He associ-
ates the occurrence and severity of depression also with the person’s
previous ability for adaptation and other premorbid factors (i.e., per-
sonality, self-esteem, intelligence, and experience). The life situation
and family support are likewise important in psychosocial recovery.
Since family members will also have to go through a process of grief
and adaptation, it is important to include them in the comprehensive
treatment procedure. Neuropsychological recognition of the deficit
and appreciation of its significance in the altered state and life situa-
tion are present in depressive reactions of the patient. Knowledge of
the patient’s premorbid ways of reacting to illness, injury, or bereave-
ment, as well as personality traits, may help in predicting the type
and length of depression and adjustment to changes after illness. As
one example of slow adjustment, Horenstein mentions premorbid
obsessive–compulsive traits, which make the person apt to hostility
and blaming others for his anger and disappointment in recovery
(Horenstein, 1970).
In Finnish neuropsychology, the pioneer Niilo Mäki (1902–1968)
treated war veterans using a holistic orientation. He was well ac-
quainted with the work of Ahhemar Gelb and Kurt Goldstein (Laak-
sonen, 1987). For Niilo Maki, the whole person was important. This
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