Slull reacquisition after acquired brain injury - villa martelli disability ...

NeuroRehabilitation 23 (2008) 1 15-126
10s Press
Slull reacquisition after acquired brain injury:
A holistic habit retraining model of
neurorehabilitation
Michael F. ~artelli"~~~~~*, Keith ~icholson~ and Nathan D. ~ asler"~~~~~~~g
aTree of Life Services, Inc., Glen Allen, VA, USA
b~epartments of Psychology and Psychiatry, Virginia Commonwealth University, Richmond, VA, USA
CDepartment of Physical Medicine and Rehabilitation, University of Virginia, Charlottesville, VA, USA
d~omprehensive Pain Program, The Toronto Western Hospital, Toronto, Ont., Canada
Concussion Care Centre of Virginia, Ltd.
f~epartment of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, USA
Wortheast Center for Special Care, Lake Katrine, NI: USA
Abstract. Persistent cognitive, emotional and behavioral dysfunction following brain injury present formidable challenges in
the area of neurorehabilitation. This paper reviews a model and practical methodology for community based neurorehabilitation
based upon:
1. Evidence from the "automatic learning" and "errorless learning" literature for skills relearning after brain injury;
2. A widely applicable task analytic approach to designing relevant skills retraining protocols;
3. Analysis of organic, reactive, developmental, and characterological obstacles to strategy utilization and relearning, and
generation of effective therapeutic interventions; and
4. Procedures for (a) promoting rehabilitative strategy use adapted to acute and chronic neurologic losses, (b) an individual's
inherent reinforcement preferences and coping style, (c) reliant on naturalistic reinforcers which highlight relationships to
functional goals, utilize social networks, and (d) employ a simple and appealing cognitive attitudinal system and set of
procedures.
This Holistic Habit Retraining Model and methodology integrates core psychotherapeutic and learning principles as rehabilitation
process ingredients necessary for optimal facilitation of skills retraining. It presents a model that generates practical, utilitarian
strategies for retraining adaptive cognitive, emotional, behavioral and social skills, as well as strategies for overcoming common
obstacles to utilizing methods that promote effective skills acquisition.
Keywords: Neurorehabilitation, holistic rehabilitation, cognitive rehabilitation, traumatic brain inju~y, habit retraining
1. Introduction formidable challenges in the field of neurorehabilitation.
Traditional treatments provided by clinical psy-
Persistent cognitive, emotional, behavioral and chology and psychiatry, special education, physical resocial
dysfunction following brain injury present habilitation, and related fields have proven inadequate
for addressing these persisting - sequelae and their as-
-
sociated disablement-~44,651. As a result, specialized
*Address for correspondence: Michael F. Martelli, Ph.D., Tree
cognitive rehabilitation services have been designed
of Life Services, Inc., 13458 North Gayton, Richmond, VA 23233,
USA. Tel,: +1 804 307 5293; F ~ +I ~ 775 : 305 4791; ~ - ~ ~ i l with : the goal of minimizing cognitive and behavioral
mfrnartelli@villamartelli.com; Wehpage: http://villamartelli.com. impairments and improving functional behaviors.
ISSN 1053-8135/08/$17.00 @ 2008 - IOS Press and the authors. All rights reserved
.

116 M.F: Marteffi et a/. /Skiff reacquisition after acquired brain injury
Schutz and Trainor [65] recently reviewed the status
of cognitive rehabilitation as a neurorehabilitation
treatment paradigm. They suggest that there has been
a shift from the original meaning as a paradigm of
complex, sophisticated, and integrated interventions,
to more recent poorly conceptualized, compartmentalized
and largely ineffectual service modalities. Based
on considerable empirical support for treatment efficacy
for the former "holistic" programs, they proposed a
new definition. Cognitive rehabilitation is defined as
a systematic, theory based program of "integrated di-
4. A procedure that (a) promotes rehabilitative strat-
egy use adapted to individual's neurobehavioral
losses, inherent reinforcement preferences, and
coping style, that is (b) reliant on naturalistic rein-
forcers which (c) highlight relationships to func-
tional goals, (d) utilize social networks, and (e)
employs a simple and appealing cognitive attitu-
dinal system and set of procedures that maximize
motivation.
&tic, experiential, procedural and psychosocial training
aimed at restoring -cognitively cornpromised
adaptation, including decrements in interpersonal
and vocational participation, self-awareness and selfdetermination."
ip. 546). They noted a central focus
on psychosocia~emotional aspects of recovery, recognizing
defective insight and consequent "dearth of adjustive
motivation" as major rehabilitation obstacles.
They recommended that all mediational processes, including
wanting, feeling and thinking, are necessary
targets - of rehabilitation. They further elaborate that
well developed neurorehabilitation programs necessar-
The Holistic Habit Retraining (HHR) neurorehabilitation
mode1 represents a for continuing
neurorehabilitation that integrates psychotherapeutic
strategies with rehabilitation training as necessary
ingredients for the rehabilitation process. HHR aims
to reduce the complexity of conducting psychotherapy
with persons with acquired neurological disorders as
well as identifying and facilitating accomplishment of
meaningful individual rehabilitation goals through optimal
learning procedures. HHR accomplishes this by
simplifying and integrating the Processes and methods
of interdependent goal accomplishment in ps~chotherapy
& rehabilitation. At the heart of this model is the deily
do the following: (a) combine systematic treatment sign and presentation of practical, utilitarian strategies
of cognitivehehavioral deficiencies with psychothera- for retraining adaptive cognitive, emotional, behavioral
py and milieu therapy; (b) address many different im- and social skills. This includes strategies for overcompairments
and disabilities, and; (c) strive to supportpar- ing common obstacles to utilizing methods that proticipation,
independence and self managed adaptation
to all aspects of life through use of adaptive strategies
that represent durable adaptive systems that are used in
mote effective habit acquisition.
the real world.
2. Rehabilitation and the Holistic Habit Retraining
In the present paper, a model of holistic neurorehabilitation
that addresses persisting brain injury seque-
(HHR) model: Rehabilitation is relearning
lae and disablement is examined, along with illustrative Rehabilitation is the Systematic Process of Removing
methodology. This model conceptualizes many brain
injury sequelae in terms of disruption of previously
established hierarchical and interdependent habits that
underlie all efficient, adaptive living skills. The Holistic
Habit Retraining (HHR) model and methodology
of neurorehabilitation [32,35-37,39,40,42,44] is based
upon the following:
Obstacles to Independence & Accessing Opportunities
for Achievements of Desired Goals in the areas of love,
Work and Play! The Purpose of Rehabilitation is to
Change Fate!
- M.E Martelli, PhD & the Obstacle Busters ABI
Cope Group, circa 1994 -
1. The "automatic learning" and "errorless learning" Adaptive behavior is reliant on intact central nervous
literature and evidence supporting efficacy of this system (CNS) function. The ability to learn and store
methodology for skills relearning after brain in- information and execute tasks related to that behavior
jury [261;
is dependent on intact brain cells. Damage to brain
2. A task analytic examination of acquisition of rele- cells that occurs in acquired brain injury (ABI) can divant
behavioral habits as a model for constructing minish or delete the stored knowledge and adaptive beskills
retraining protocols;
havioral habits that sustain important human abilities.
3. Analysis of organic, reactive, developmental, and Despite the fact that damage to brain cells can impair
characterologic obstacles and facilitators of strat- adaptive behavior and habits, the ability to reorganize
egy utilization; and
and support re-learning is seldom erased 1161.

The highly evolved capacity of the human CNS to
support learning is the hallmark of our species. While
the behavior of many animals is controlled primari-
ly by instincts, human behavior is driven by complex
learning and a network of complex behavioral habits
that are established over the lifespan. From birth on,
human behavior is predominantly shaped by learning.
Through the construction of a sequence of hierarchical-
ly arranged habits with more complex learning built on
top of more basic learning, everyday functioning be-
comes an increasingly sophisticated network of habits.
The complex behaviors that make up the average per-
sons everyday behaviors are performed efficiently and
automatically because of the establishment of a hier-
archy of habits acquired through incremental learning.
In recognition of the critical role of behavioral habits
to human function, William James, the father of Amer-
ican Psychology, referred to them as the flywheel of
society [20].
Neural plasticity is the mechanism that underlies the
capacity of the human CNS to convert repeatedly per-
formed behaviors into habits. This enables the learn-
ing of complex behaviors that can be performed auto-
matically whereupon important adaptive functions like
concentration, energy and effort are freed up to ad-
dress other tasks. However, damage to neural tissue
can weaken, degrade, or erase some of the most basic
acquired habits of adaptive living. Everyday abilities
and routines can be seriously disrupted. and any sem-
blance of efficiency can be lost as some of the interde-
pendent components of automatic behavior disrupt be-
havioral routines. Previously automatic behavior that
had been performed easily or thoughtlessly can require
an enormous amount of effort and conscious control
subsequent to brain injury.
Although important prior learned habits may be se-
riously degraded or even erased, newly learned habits
can usually be developed as replacements. Importantly,
the primary requirements for both learning and relearn-
ing are becoming increasingly understood. Emotional
state, attitudes and expectancies constitute important
variables for learning and some of the moqt important
variables for relearning [44,77]. Emotions and atti-
tudes can both promote and guide re-establishment of
new habits, or interfere with their development. Nega-
tive expectancies regarding learning, including expec-
tations for only a relatively effortless return of previous
automaticity, or a belief that only childrencan or should
learn, will undermine relearning. Attitudes can facil-
itate or contaminate relearning and fertilize or poison
rehabilitation.
M.E Martelli er al. /Skill reacquisition after acquired brain injury 117
In the HHR model, three primary and essential in-
gredients for relearning and rehabilitation are empha-
sized. These three basic components, the 3 P's of reha-
bilitation, involve the Plan, Practice and a Promoting
attitude [44]:
- Plan: The plan component is a prescriptive reha-
bilitative strategy and design for stepwise progress
toward relearning a deficient behavioral skill.
These are derived from thorough functional task
analyses. Functional task analyses are the most re-
lied upon building block of relearning in the HHR
model. This involves breaking seemingly com-
plex tasks down into simple component steps, and
putting them into a checklist that can be followed
in a list wise fashion. More specific, concrete, and
conspicuous plans or prescriptions for successful
task completion are more likely to be effectively
utilized [22].
- Practice: The practice or repetition component
is the habit manufacturing process stage. It in-
volves structured, consistent and repeated trials of
practice. conducted over many weeks to months.
It is the cement for learning that makes complex,
challenging and cumbersome or boring tasks more
automatic and effortless. With practice and repe-
tition, even complex tasks become automatic and
habitual. That is, a habit, or our automatic robots,
can perform many tasks for us without special ef-
fort, energy, concentration, memory, or other cog-
nitive demands.
- Promoting attitude: The promoting or facilitat-
ing attitude component represents the fuel for mo-
bilization and persistence of effort that is prerequi-
site for sustaining the repeated practice necessary
for establishing reliable skills learning. Sustaining
motivated practice over numerous repetitions and
aprogressive series of increasingly challenging se-
quences is required to achieve automaticity in per-
formance of adaptive task sequences and behav-
ioral habits. This is especially true in more chal-
lenging situations and where skills require longer
training periods. This promotional attitude build-
ing component fosters continued practice through;
(a) shaping of incremental expectancies; (b) re-
inforcement for incremental gains; and (c) adap-
tive reinterpretation and redirection of any sig-
nificant residual negative emotion. Anger, frus-
tration, depression, fear, pessimism, feelings of
victimization, self pity, hopelessness and/or low
grade chronic despair may be left over from the
early post-injury experience of being confronted
by overwhelming deficits [44].

118 M.E Martelli et al. /Skill real cquisition after acquired brain injury
The HHR model posits that the greatest obstacle to
learning or relearning is the diversion of energy away
from sustained, adaptive goal directed activity and to-
ward inactivity or debilitating activity. Some of the
most potent habit relearning "poisons", or rehabilita-
tion debilitating attitudes, are depression, anger and re-
sentment, feelings of victimization, fear, and inertia.
These obstacles both direct energy away from relearn-
ing and inhibit it. These common catastrophic emo-
tional reactions following brain injuries represent sig-
nificant internal obstacles that must be removed as bar-
riers before the very challenging process of relearning
can be optimally engaged [32,35-37,39,40,42,44,49,
501.
3. The catastrophic reaction
Three central postulates of the HHR model are: 1)
significant emotional reactions frequently follow neu-
rological injuries; 2) These reactions often exert per-
sistent negative influences on post injury adaptation;
3) Formal treatment of these reactions is frequently re-
quired in order to optimize rehabilitation. Early post
injury, an individual's discovery of traumatic loss of
functional abilities and accustomed aspects of the self
can be overwhelmingly devastating. The sudden loss
of limb function, the inability to stand or control one's
bowels, difficulty expressing a need or understanding
another's speech or intentions, or inability to remember
previous events can produce a powerful reaction char-
acterized by acutely intense despair and distress. This
response, which has been observed and described most
clearly after left hemisphere cerebrovascular accidents
(CVA) or other neurologic insults, has been referred
to as the "catastrophic reaction" [15]. Kurt Goldstein
observed that in patients with left-hehisphere CVA's,
when faced with "unsolvable tasks", states of ordered
behavior could "decompensate into catastrophic reac-
tions" showing all the characteristics of "acute anxi-
ety". Goldstein interpreted this reaction as the individu-
al struggling to cope with the challenges of the environ-
ment and hisher own changed body. Goldstein argued
that an individual could not be divided into "organs" or
"mind" and "body". Rather than tissue damage, he de-
fined disease as a changed state of adaptation with the
environment. This early biopsychosocial conceptual-
ization posited that "healing" came from adaptation to
conditions causing the new state of person-environment
interaction, and not through "repair".
Importantly, catastrophic or related reactions do not
occur only in the context of left hemispheric lesions
but may reflect a host of situational, personological, or
other biomedical factors. Many post injury syndromes
reflect problems in adaptation and coping with persist-
ing injury sequelae. Miller [49,50] has described "neu-
rosensitization syndromes" to summarize empirical and
theoretical work in the area of post traumatic disabili-
ty syndromes characterized by long-term demoralizing
disability. Persistent postconcussion syndrome, chron-
ic pain, posttraumatic stress disorder, depression, and
other syndromes share many common pathophysiolog-
ical mechanisms and are hypothesized to develop as
the result of progressively enhanced sensitivity or re-
activity of the central nervous system (CNS). A prima-
ry mechanism in the perpetuation of disability in these
disorders is an avoidance of stimuli that evoke anxiety
and emotional distress. Because these syndromes are
frequently comorbid, they can create vicious cycles of
impairment and reduced quality of life.
Recent research on constraint induced movement
therapy (CIMT) [28,70-721 offers evidence indicating
that a significant portion of disability is explained by
"learned non-use" [71]. This concept is similar to
Seligman's learned helplessness model of depression
and coping [67]. Failure and punishment for use at-
tempts early post injury can permanently suppress fu-
ture efforts after acute organic damage resolution and
return of potential for cerebral reorganization and re-
training and regrowth for body part use. CIMT and
other emerging research [16] provide empirical sup-
port that neurologic disability is an adaptational phe-
nomenon and that learning following injury can sup-
press rehabilitation. Moreover, this suppression can be
reversed through relearning to produce significant im-
provements in human function even many years after
injury.
The HHR model recognizes that the initially expe-
rienced acute distress and catastrophic reactions fol-
lowing injury usually become less conspicuous over
time and often reach some level of resolution. How-
ever, residual effects can also persist and become more
subtle or concealed. Catastrophic emotional reactions
can be maintained or recapitulated through continued
confrontation of injury related deficits and continued
requirement for compensatory efforts that are difficult,
unsuccessful or result in chronic anxiety, frustration
andlor resignation [18,35,37,44,59,60]. These emo-
tions can easily subvert goal directed activity, energetic
efforts and progress leading to feelings of powerless-
ness, helplessness and being overwhelmed by the chal-

*
lenge of coping. That is, the remnants of early catas-
trophic emotional reactions are seen as negative, en-
ergy consuming emotions. They can deplete adaptive
energy, hope and persistent goal directed effort neces-
sary for relearning and rebuilding functional abilities
and optimizing post injury adaptation.
The HHR model postulates, as its most critical tenet,
that persisting catastrophic emotional reactions are a
frequent impediment to adaptation that must be re-
solved in order to optimize rehabilitation. Further, con-
siderable anecdotal and observational data and unpub-
lished case reports collected by the authors, along with
emerging research reports in related areas [63,70-721
indicate that the gains that can follow resolution of
the catastrophic reaction, when combined with potent
retraining strategies, can convert into impressive im-
provements in functional status and adaptation even
many years post injury.
The proposal that persistent emotional distress must
be reduced in order to improve functional adaptation is
a common theme in post traumatic disorder treatment.
Miller [49,50] observed that the same classes of psy-
chotropic medications are usually the first treatments
for most of these disorders, while psychotherapy is usu-
ally the treatment of choice. Dubovsky [7] described
that the post injury psychotherapy relationship "splints"
neurophysiological regulatory mechanisms and pro-
vides a repeated corrective stabilization that eventually
allows normal functioning. In the system of holistic
"neuropsychotherapy" developed by Ben Yishay [4],
psychotherapy is central to the rehabilitation process.
Prigatano [59,60] also strongly articulated the impor-
tance of psychotherapy for facilitating post injury adap-
tation. In the HHR model, resolving the persistent
catastrophic emotional reaction is posited as an inte-
gral and necessary part of the rehabilitation training
process.
The rationale and method for resolving the persis-
tent catastrophic reaction in the HHR model is derived
largely from the research literature on learning [64],
cognitive-behavioral psychotherapy, and coping with
anxiety, especially procedures involving graduated ex-
posure and cognitive restructuring [461. Resolving per-
sistent catastrophic emotionarreactions involves three
integrated HHR components:
1) Confronting deficits in an incremental manner in
order to prevent being overwhelmed by distressful
emotion, through graduated exposure.
2) A supportive conceptual framework and rehabilitation
methodology that fosters hope and includes
self-instruction to reinforce graduated successes
M.E Martelli et al. /Skill real ~quisition ajier acquired brain injury 119
in very incremental stages that progress toward
desired goals
3) A rehabilitation methodology that emphasizes er-
rorless learning and task analyses, as described
below. This simultaneously simplifies reacquisi-
tion and habitualization of many basic adaptation-
a1 skills while minimizing anxiety and distressful
emotions that are associated with hopelessness
and failure.
In the HHR methodology, Graduated Exposure (GE)
is an important behavioral anxiety reduction procedure
that involves slowly and incrementally increasing a pa-
tient's exposure to a feared or distressful situation (46,
62,681. It has been applied by the first author for suc-
cessfully reducing disruptive levels of specific post in-
jury anxieties across a wide range of persistent symp-
toms [3,33-40,43,73,78,79].
Critical to the HHR methodology is the intention
to promote learning through calming the CNS and de-
creasing the significant anxiety and negative emotional
states which are consistently shown to be highly disrup-
tive to performance and learning [53]. The envisioning
of a progressively more desirable future is a guiding
principle and "psychoemotional magnet" in HHR that
pulls persons toward their goals. Incremental move-
ment toward desired goals is accomplished to the extent
that a person focuses on the vision of a desirable future,
breaks expectancies and goals into small, progressive
steps, and develops habits that facilitate persistent and
stepwise, goal directed efforts. Patterns of interpreting
events and expectancies of rehabilitation progress rep-
resent predictions of the future. Habitual patterns of ex-
pecting failure or dissatisfaction, or mistreatment, and
habitual patterns of becoming depressed, angry, fearful
andfor resigned are energy depleting debilitative habits
that reinforce disability and failure.
The "Five Commandments of Rehabilitation" [32,
35,39,40,42,44] were developed through examination
of the successful adaptive attitudes of rehabilitation pa-
tients who despite poor prognoses made remarkable
progress. These serve as a primary prescription for
countering the catastrophic emotional reactions that
block optimal rehabilitation achievement. They in-
clude (1) making accurate comparisons, (2) learning
new ways to do old things, (3) building one self up,
(4) employing positive self-coaching, and (5) viewing
rehabilitation as a series of small steps each requiring
celebration. These commandments, and some illustra-
tive explanations that are typically given to patients, are
included in Table 1.

120 M.E Martelli et al. /Skill reacquisition afier acquired brain ir~jury
Table 1
Five commandments of rehabilitation
Commandment 1: Thou Shall Make Only Accurate Comparisons. Thou shall not make false comparisons.
That is, it is only fair (and adaptive) to compare oneself to persons with similar injuries, illnesses, disabilities and stress, as this comparison
allows us to accurately measure ourselves. It is unfair to compare ourselves to others without similar challenges, or to ourselves before we
were challenged, as this makes us look poor by comparison.
Commandment 2: Thou Shall Learn New Ways to Do Old Things.
Learning new ways, or finding another way to do desired tasks, vs. giving up & feeling hopeless because the old way doesn't work, is the
key to Challenging obstacles and overcoming them.
. . . Overcome thinking that the old way is the best way (i.e., Stinking Thinking)
Commandment 3: Thou Shall Not Beat Thyself Up . . . Instead, Thou Shall Build Thyself Up!
We clearly understand that when we have a physical injury, such as a broken leg, getting mad, yelling at, or hitting (i.e., beating up) the leg
only delays recovery, increases symptoms and pain, and makes us and the leg function worse. We know that pampering the leg, massaging it
and coaxing it along gently & patiently will help it recover. Unfortunately, we too often forget that our brains are similar. An injured brain
will perform poorly when we get mad with it, or get frustrated. Instead, understanding it, pampering it, being patient, using pacing & coaxing
it along in a supportive way will help us function our best, and help our recovery and rehabilitation. Talking to ourselves in supportive and
understanding ways (vs. getting mad at ourselves for being injured or having difficulty) and coaxing things out gently is a good way of
building ourselves up in order to face the challenges of rehabilitation. Rewarding ourselves for efforts and each small step of progress, despite
tremendous obstacles & challenges, is the best way to build ourselves up!
. . . Child & Spouse Abuse are recognized as illegal and intntoral . . . Sey'Abuse is just as bad!
Commandment 4: Thou Shall View Progress as a Series of Small Steps.
Rehabilitation is appropriately viewed One Step At a Time - by focusing on the gains over where we were when we were one step behind
where we are now, we can focus on the Graduated Successes and feelings of accomplishment (despite giant obstacles) which will leave us
feeling proud and hopeful and enable us to focus and reach the next small step ahead, and make progress through the many small steps
necessary to make substantial progress. Focusing on our current gains and small steps of progress (compared to where we were earlier in
rehab and when we were at our worst) will build hope and a sense of challenge and growing victories (versus comparing ourselves to before
the injury, which only makes us feel sad & depressed.
. . . Inch by Inch & It's a Cinch. Meter by Meter; Lifi. is Sweeter:
Commandment 5: Thou Shall Expect Challenge & Strive to Beat It.
By Converting Complaint (I don't want) To Challenge (I want), We Can Shape Our Future Through Our Vision and Driving Thoughts. We
will actively shape our future by focusing on a vision of hope, challenge, control & satisfaction. By changing our focus from complaint
and feelings of victimization & helplessness & pessimism, we can avoid giving up and giving in to a pessimistic prophecy of dissatisfaction
and doom. (cf. "Thou Shall not Pretend to Have a Contract Guaranteeing Freedom from Injury, Disease, Illness or Unfair circumstances or
Significant Stress!")
M.E Martelli, Ph.D: @ 1995
The prescribed attitude "antidotes" captured in
the "Five Commandments of Rehabilitation" are the
essence of the "medicines" that interrupt the rehabilitation
"poison" cycles. Energy tends to be selfpropagating
in a cyclical fashion. Given negative expectancies
and hopelessness, more energy is expended
nonproductively. This depletes and redirects limited
energy and resources away from allocation toward
adaptive relearning and rehabilitation accomplishments.
A habitual depressive response to physical
losses can reduce activity, prevent adaptive relearning,
and lead to increased depression by depletion of
brain chemicals associated with positive mood and energy
[46,50]. Ongoing depression, in turn, leads to
poorer progress, more negative expectancy and confirmation
of reasons to be depressed.
The "Five Commandments" represent a cognitive
behavioral prescription for a more positive vision of a
gradually improved future necessary for planning and
successfully practicing compensatory cognitive and be-
persons against depression, anger, and other destructive
emotion. This ensures that energy and motivation will
be available for the persistent pursuit of desired goals,
with each step of progress adding momentum for con-
tinued hope, self-efficacy, energy, and continued effort.
With the addition of potent learning strategies like task
analyses, errorless learning strategies, and scheduling
to help promote routines, energy is increasingly pro-
tected and positively allocated through adaptive inter-
pretations and expectancies. In a cyclic fashion, energy
fueling consistent repeated practice turns these rehabil-
itation promoting strategies into incremental success-
es and increasingly automatic habits. These produce
continued achievements and energy that strengthen the
adaptive interpretations and expectancies that strength-
ens adaptive energy.
To summarize, any behavior that is structured and
consistently repeated will eventually become a habit.
The HHR model promotes both the activity and attitude
routines that will mobilize energy for practicing potent
learning strategies that will help shape patient efforts
havioral strategies. Simultaneously, they help inoculate toward their important goals.

4. Functional task analyses
A task analytic examination of relevant behavioral
habits is the model for constructing slulls retraining
protocols in HHR. Task Analysis is a learning proce-
dure based upon brealung any task, chore. or complex
procedure into single, simple, and logically sequenced
steps. It typically includes recording the steps in a
Checklist [221. The checklist guides task performance
by checlung off each sequential step as it is completed.
Task analyses simplify and optimize task initiation, se-
quencing, completion and follow-up, and make previ-
ously formidable or impossible tasks much easier. Per-
forming a Task Analysis and generating a checklist to
guide behavior assists in errorless learning in persons
with a wide range of neurocognitive difficulties [32,
35-37,4042,441.
A growing body of research is consistently demon-
strating the effectiveness of errorless training methods
across a range of disorders [I, 17,2 1,23-261. This evi-
dence further demonstrates its relative superiority ver-
sus traditional training procedures for persons with sig-
nificant memory problems following brain injury and
disease [6,8,14,24,26,29,47.64,65,69,74], and for per-
sons with executive impairments [23,57,45].
Task analysis checklists are also especially useful in
countering performance and learning difficulties asso-
ciated with fatigue [41,48,54]. The disruptive effects
of fatigue can be mitigated by reducing the demand
for, and energy consumed by, reasoning, problem solv-
ing and effort associated with planning, organizing and
having to recall, make decisions, sequence and priori-
tize appropriate steps for a task. They provide an er-
rorless learning format, especially when supplemented
with any needed direct instruction or supervision. The
checklist represents the support that ensures: (a) a sim-
plified learning process; (b) successful task comple-
tion; (c) learning of only correct and successful learning
procedures; (d) a reduced number of competing mem-
ory traces and elimination of frustration and distressful
emotional reactions; these can be especially inhibitory
to memory and learning performance in persons with
brain injury, disease andlor dysfunction.
Task analyses can be beneficial for both basic and
complex behaviors. Most importantly, Task Analy-
ses facilitate re-establishing the efficient routines that
make up normal everyday human behavior and activ-
ity. When the procedures assisted by Task Analyses
are repeated consistently, they eventually become auto-
matic and habitualized. Samples of task Analyses are
included in Table 2.
M.F: Martelli et al. /Skill reacquisition afler acquired brain injuq 121
To reiterate, in the HHR model, the ingredients for
rebuilding automatic habits are the 3 P's: Plan, Practice,
and Promotional attitude. These components of reha-
bilitation represent a formula for removing obstacles
to continually increasing independence while achiev-
ing incremental progress toward recovery of important
functional life skills.
5. Application of HHR principles and strategies
A case study that illustrates an early application of
the HHR model is that of JF. JF was a 39 year old wom-
an who was seen 2.5 years status post craniotomy for
resection of a very large pituitary adenoma. The tumor
and surgery produced complete blindness, an amnestic
syndrome and numerous vegetative-metabolic distur-
bances. This former architect showed especially severe
memory problems. She was unable to recall the route
out of the bathroom in the house in which she grew up
havingreturned home to be taken care of by her parents
(even after living there for 2 years post surgery), and
was only able to conduct over learned activities of daily
living with assistance. She had just been discharged
from the state school for rehabilitation of the visually
impaired due to inability to show any benefit from train-
ing. She had been deemed incapable of new learning
by virtually all health and rehabilitation professionals,
who recommended that her elderly parents institution-
alize her. JF was admitted for assessment of capacity to
benefit from rehabilitation in a transitional living pro-
gram for persons with brain injury. This was offered
as a last resort in the hopes of altering permanent dis-
ability and avoiding need for institutional care. While
admitted, she was seen for a more focal and supportive
approach to memory rehabilitation screening. Previ-
ously unable to demonstrate recall of any new informa-
tion after 10 to 20 seconds, her memory was assessed
in a relaxed atmosphere, in a non confronting manner
during a birthday party and discussion invoking her
more intact remote memory. Numerous repetitions of
the examiner's name were conducted while recall was
subsequently prompted after one minute with calming
self talk, humor and the following repeated phrases:
"Patience, persistence, coax it out gently, build yourself
up, don't beat yourself up . . . if it comes it will come
in calmness and that will be okay, and if it doesn't,
that's very, very good too, because you persisted with-
out quitting and you have the best persistence I've ever
seen,'' along with lots of support, encouragement and
instruction in calming, paced breathing.

TA Samples: Single Tasks
'Making A Bed' "Cheatlist"
1. Strip sheets, blankets and pillow cases
2. Put blankets and pillows on table
3. Take break
4. Get sheets and pillow cases from closet
5. Put on fitted sheet
6. Put on top sheet, evening it out
7. Put on blankets and tuck in comers
8. Put pillow cases on pillow
9. Put comforter on bed
M.E Martelli et al. /Skill reacquisition after acquired brain injury
TA Sample: Daily Habits & Routines
AT'S Initiative~Energy Retrainer
MORNING
- Wash Face
- Shave
- Apply medication to face if needed
- Brush Teeth
- Comb Hair
- Dress before "morning" nap
- Check finger nails & toe nails; trim when needed
-Check hair length and get a haircut as needed
- Shower and wash hair
-Perform an ActivitylChore (Choose from Menu)
-Check Schedule (e.g., M,W,F = Y; Tues = RedX)
-Check your appearance before leaving the house
AFTERNOON
-Fill Out Chart (Behavioral Activity Monitor & Points)
- . . . etc.
EVENING
- Eat Dinner
- PRN (PowerRelaxationNap; Use Tape)
-Engage in Evening Activity
- . . . etc.
-Prep for Bed (PJ'S, Brush Teeth, etc.)
- BedTime
On this occasion, after approximately 5 minutes of
supportively coached persistence of effort, JF demon-
strated her first documented successful recall of new in-
formation. Her second documented recall was that her
memory had actually functioned and that she had been
able to eventually recall something, even though she
couldn't recall what it was. Despite these promising
accomplishments, JF's overall progress was judged in-
sufficient to justify continued residential rehabilitation
treatment. Nonetheless, her elderly parents refused to
institutionalize her and continued to care for her in their
home. Over the next two years, she was seen twice
Table 2
Task analysis samples
TA Samples: Daily Activity Trainers
DH's Daily Plan Checklist
MORNING
-Wake 6:00 AM to the Alarm Clock
- Take Medication
- Make Bed
- Shower
- Get Dressed
- Comb Hair
- Make and eat breakfast
- Clear, rinse, stack breakfast dishes (for pm wash)
-Wipe counter, table stovetop if needed
- Feed animals
- Brush teeth
- Gather items to take for the day
- Leave house at 7:OO; go to Grandma's
REHAB CENTER
-Arrive between 7:3&8:00Am by van
- Follow Morning Schedule (In Rehab SchedBook)
- Lunch at 11:30, Take medication
- Follow Afternoon schedule
- Leave for Grandma's between 3:3@4:00
LATE AFTERNOON
- Dinner at Grandma's & take medication
- Home between 6:0&7:00PM
- Get mail, read & sort; put bills on microwave
WENING: PREPARE FOR THE NEXT DAY
Loundry if needed (clothes, sheets,batb/'kit towels)
- separate colors and whites
- set water level
- . . . etc.
Kitchen
-wash dishes
- . . . etc.
Bathroom if needed
-clean sink, tub, countertop
- . . . etc.
ReladFree Time
Prepare for Bed
- Floss/Brush Teeth
-Wash Face
- Shave
-Put away clothes (in hamper or drawerlcloset)
Pick & lay out clothes to wear for the next day
Set Alarm for 6:00 AM
weekly in an outpatient neurobehavioral "Cope" group,
and once to twice a week for tutoring from a humorous
and friendly ex-patient volunteer. Her mother and vol-
unteer were instructed in use of repetition (e.g., "Three-
Peat" - a timely term in the early 90's when the Chicago
Bulls had won three consecutive NBA championships)
and association as memory enhancement strategies, and
"tiny step" expectations with positive shaping and lib-
eral praise, as reinforcers of continued hope and efforts.
With this scant treatment, JF slowly showed increasing
recall for more and more information. Increasing social
activities were especially facilitative as they seemed to

eawaken this previously very gregarious woman and
fuel slow but incremental gains in new memory. No-
tably, JF contributed to the development of the "Five
Commandments of Rehabilitation" by offering inspira-
tional one liners, coined or borrowed from Sunday tele-
vision preachers, during outpatient group attendance.
At four years post injury, despite strenuous resistance
to even stronger advocacy, she was re-accepted at the
state school for the visually impaired for a one week
evaluation for ability to benefit from a typing recording
device. She amazed the staff with her ability to learn
the basics of Braille and the use of a Braille typewrit-
er that also served as a compensatory memory device.
Two years later, she was typing 60 words a minute and
had learned to use adaptive text-voice equipment and
was working a volunteer job and applying for more
competitive jobs with the support of a job coach.
Per the HHR model, JF's case is conceptualized in
terms of the suppression of memory by the underly-
ing catastrophic emotion experienced every time shc
attempted to recall information. JF was undoubtedly
sensitized to distressful emotion by her blindness, her
repeated confrontations with it due to arnnestic syn-
drome, and her punishing failures with every memory
effort. JF could not be expected to endure the contin-
ued distress that accompanied repeated failed recollec-
tion efforts without hope for success. However, when
recollection efforts were incremented for a single, sim-
ple piece of socially relevant information and persis-
tent recollection effort was strongly supported through
emotionally calming talk, a discovery occurred. It was
learned that she did retain at least some memory stor-
age ability - that is, she demonstrated slow but intact
storage and retrieval capacity only after five minutes.
JF's ability to recall that her memory could work,
given patient persistence and supportive coaching from
a caring and empathic professional whom she liked,
ushered in a hopeful expectancy that undoubtedly trans-
formed her. The content for shaping this expectancy is
now transcribed in the "5 Commandments". The for-
mula for delivery within the HHR model format is one
that borrows from the knowledge of psychotherapy and
personality change. In what is arguably the best scien-
tific analysis of psychotherapy to date, Wampold [75]
demonstrates that specific therapy techniques are not
active in and of themselves, and are active only be-
cause they are a component of the healing context.
The overwhelming conclusion of all major reviews of
psychotherapy data [5,9-13,19,56,75] show that ther-
apist relationship factors play a much more important
role in influencing outcome than treatment approach-
M.E Martelli et al. /Skill reacquisition after acquired brain injury 123
es. Wampold [75] and many others recommend defin-
ing therapist competence by the quahty of their out-
comes. The HHR model adopts this same recommen-
dation with regard to rehabilitationists, prescribes spe-
cific strategies for facilitating strong therapeutic rela-
tionships, and offers a model of rehabilitation delivery
that can be summarized by the u s : Belationship, &-
tionale and &tual [40]. That is, a strong, positive and
trusting therapeutic Relationship is required to facilitate
emotional trust while calming anxieties and emotion-
al distress, and inspiring hope and collaborative effort.
A credible Rationale is required to offer a believable
treatment model and procedure that is logically con-
vincing and sets positive expectancies. Finally, a cred-
ible Ritual or methodology and procedural intemen-
tions that produces measurable successes and confirm
expectations, hope and continued efforts is required.
Since the HHR model and methodology have been
developed, refined and consistently applied in our clin-
ical treatment, numerous other illustrative HHR case
studies have been catalogued and are being written up.
Some are included on the villamartelli.com disability
resources webpage [3 1 1, including an interesting one
involving rehabilitation of severe dorsolateral frontal
lobe injury related initiation problems [41]. Although
space limitations do not allow review or discussion of
other case studies, or even many other specific HHR
strategies, an instructive introduction to building reha-
bilitation protocols using the "3 P's" approach is includ-
ed on the villamartelli.com resources website [3 1.1. The
online protocol segments illustrate samples of applica-
tion of task analytic derived, errorless learning based
slulls building protocols (the Plan), individually adapt-
ed reinforcement via a palatable cognitive attitudinal
approach for countering inherent resistances to strate-
gy utilization and practice, and promoting increment-
ed goal achievement and reinforcement from graduated
successes (the Practice and Promotional attitude com-
ponents). Complete protocols and a larger sample of
illustrative adapted strategies can be downloaded from
this website [3 I].
6. Conclusion
The HHR model of neurorehabilitation is a skills
re-aquisition paradigm which postulates that a primary
learning function of the human CNS involves "habit"
manufacturing - that is, converting repeated behav-
iors that are functionally adaptive into efficient and
automatic habits. For example, it is adaptive to re-

124 M.F: Martelli et a[. /Skill reacquisition after acquired brain injury
member how to walk, so the sequences involved in
walking are chained together in a task analysis that
makes it automatic so that performance requires min-
imal thought and energy. The same conversion oc-
curs when such habits as attentional focusing, memory,
and multi-tasking are acquired and automated through
chaining of the component steps. Through learning,
internally incorporating the tasks that are involved in
getting dressed, or remembering what to take with us
when we leave the house, etc. are acquired as habits
through natural task analysis that sequences behaviors
as if we were learning automatic task inventories. The
same is true for self control habits ranging from ini-
tiation and awareness to inhibition, which involve the
very complex chaining of multiple tasks to produce the
highest level executive shlls habits.
Although HHR shares many features with other
holistic neurorehabilitation models, it also provides a
distinctive and unique approach. HHR is a parsimo-
nious model that is relatively simple to understand and
apply. It offers an uncomplicated and intuitively ap-
pealing model and methodology for devising and indi-
vidualizing specific retraining protocols. Protocol tem-
plates have been developed for a broad range of relevant
skills areas. Most importantly, HHR recognizes the
powerful importance of psychotherapy, or neuropsy-
chotherapy, synchronizing it with potent and compati-
ble learning methods. It integrates psychotherapy as an
inseparable part of the rehabilitation process. HHR em-
powers therapists and family members as agents armed
with highly potent neurorehabilitation-specific learn-
ing and psychotherapeutic strategies. Finally, and ul-
timately, HHR aims to expand "neuropsychotherapeu-
tic" rehabilitation beyond enhancing emotional adjust-
ment and functional compensation to include promo-
tion of neuroplastic based rehabilitation of cognitive,
behavioral and physical capabilities.
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