In 2012, MossRehab established the Neuro Mental Health Clinic in collaboration with Einstein Healthcare Network’s Behavioral Health Department. It is the first clinic in our region to specifically address patients experiencing cognitive difficulties—such as those involving memory, attention, language comprehension and executive function—who are also struggling with depression, anxiety, stress or other emotional concerns. Sheryl Berardinelli, PsyD, a neuropsychologist at the Neuro Mental Health Outpatient Clinic, recently discussed this unique service for patients undergoing rehabilitation.
Could you talk a little bit about why this clinic was originally established? What unmet needs did it address?
Dr. Berardinelli: We know that mental health problems in patients with neurological impairments, such as those caused by stroke or traumatic brain injury (TBI), often continue indefinitely and frequently result in increased disability and mortality, greater caregiver burden and greater medical costs. In addition to reducing quality of life, these impairments also can significantly interfere with progress during physical rehabilitation. Prior to the development of the clinic, we did not have a formal way of addressing the special needs of patients with these problems. Our Neuro Mental Health Clinic, which was developed with the support of an Albert Einstein Society Innovative Program grant, was the result of planning by John Whyte, MD, PhD, the director of the Moss Rehabilitation Research Institute, and William Shapiro, PsyD, the director of outpatient psychiatry services at Einstein Healthcare Network.
What kinds of patients benefit from the clinic?
Dr. Berardinelli: Patients with neurological impairments who are having difficulty adjusting to changes in their life, level of functioning, or personal relationships following a neurological injury are the best candidates. While we accept a wide range of patients, we also do have exclusion criteria, including individuals with psychosis, long-standing personality disorders or major substance issues, all of whom will require longer-term therapy than we provide. Those with profound cognitive limitations that cannot be compensated for are also not appropriate, nor are those whose primary need is for case management.
How does a patient begin to receive services through the clinic?
Dr. Berardinelli: The initial appointment is an intake where a clinician meets with the patient to obtain clinical information. For patients who are appropriate for the clinic, they will be asked to undergo a brief neuropsychological evaluation to identify specific cognitive limitations that must be taken into consideration when planning their treatment. Modifications to the psychotherapy sessions will be made to facilitate their learning and retention of strategies. The number to call for a referral is 215-456- 9850 or fax to 215-456-9442, and specify that you are referring to the Neuro Mental Health Clinic.
Why can’t these patients benefit from traditional therapy?
Dr. Berardinelli: Depression and anxiety are common and persistent after many neurologic injuries and diseases. However, these same conditions may result in cognitive impairments that interfere with participation in psychotherapy. Patients may forget the content of their last session by the time they arrive at the next one; they may have difficulty following through on therapy homework; and problems with language comprehension or expression may interfere with making notes or keeping a diary. For example, patients with aphasia can have a particularly difficult time expressing themselves, and many psychotherapists do not have the training necessary to address the unique problems associated with this disorder. Patients with severe memory problems may not be able to benefit from standard talk therapy because they may not be able to comprehend or retain what is discussed in therapy; frequently they can’t move forward because therapy amounts to rehashing the same issues week after week. At our clinic, we tailor treatment to address the cognitive deficits that may interfere with the patient’s ability to effectively engage in psychotherapy. Our individualized treatment involves strategies that aren’t typically used or may not be necessary in traditional treatment.
Could you give an example?
Dr. Berardinelli: One of my patients experienced a severe traumatic brain injury that left her in a coma, and her condition was so critical that initially no one thought she would survive. Amazingly, she did survive, and during the early stages of her recovery she began to see a psychiatrist, who referred her to me because of her severe cognitive impairment and depression.
When we first began to work together, the patient would not remember me at all from week to week, or any of the things that we did or talked about. We used a number of strategies to address her severe memory impairment. For example, she and I started by taking a “selfie” of the two of us, in which I was holding a sign that identified me by name. The sign said “I’m Dr. Berardinelli and I’m your psychologist” and she was able to take this photo with her and look at it prior to our next appointment. Next I worked closely with her family, and together we created a memory book for her, which provided her with useful information that she could understand. The patient eventually took selfies with each of her doctors, and all of the therapists with whom she was working, and we included these photos in the memory book. The memory book was helpful in reducing her agitation and anxiety about her medical appointments.
Her memory impairment also interfered with her ability to recognize her own progress. To address this issue, we used videos to help her understand where she had been when we first started and to help her see how far along she had progressed. When she was experiencing low moods, she also would have trouble recalling more positive times, and sometimes a video would help her remember that just the other day she had enjoyed a pleasant visit to a book store or a similar outing.
She also took pictures of coping cards that we generated during our psychotherapy sessions. She would look at these pictures during the week to help her with her depressing thoughts. As her family members have noted, her progress has been truly remarkable. Now she is in the habit of writing notes for herself, which is a good sign.
Do you frequently involve family members in therapy?
Dr. Berardinelli: Yes, as with most of our clinical programs, we encourage family and caregivers to participate in treatment whenever possible. With our patients’ consent we do like to involve at least one family member, whom we consider a partner in therapy. We share various strategies with family members so that exercises can be practiced at home. The more exposure a person has, when it comes to practicing a particular skill, the better his or her retention will be.
Do you meet with other therapists who are involved with a patient’s rehabilitation?
Dr. Berardinelli: Absolutely. We do our best to work with all of the other providers on a patient’s treatment team. I communicate with physiatrists at MossRehab’s Drucker Brain Injury Center, and with speech therapists, physical therapists and occupational therapists to make sure that the treatment goals for each patient are carefully aligned. This gives us an opportunity to learn whether behavioral or emotional issues may be getting in the way of other rehabilitation therapies–whether a patient is too depressed or tearful, for example, to fully engage in speech therapy exercises. We work as a team to refine treatment strategies.
How long do you typically work with a particular patient?
Dr. Berardinelli: The length of treatment is variable. The clinic is designed to provide short-term treatment but the needs of each patient can vary considerably.
Does the clinic have plans to expand the services it provides?
Dr. Berardinelli: Yes, we do plan to expand, and eventually we hope to offer services beyond MossRehab patients to individuals throughout the Philadelphia region. We already are responding to referrals from a local multiple sclerosis clinic. We are proud to be the only clinic in Philadelphia specifically dedicated to providing psychological and psychiatric treatment for patients with cognitive impairments due to neurologic conditions, and our hope is that we will soon be available for more patients who are in need of our services and to train others.