The Rehabilitation of Children with
Post-Traumatic and Post-Operational Problems
with the de Bono Thinking Tools

By Peter de Bono

I have been training teachers and others involved in the care of children all over the world. A few days ago I received a report from Galina M. Bobrovina, a medical psychologist student of mine and a fully qualified trainer, who has been using the “de Bono Thinking” tools (the CoRT Thinking Programme and Six Thinking Hats by Edward de Bono) in her work for the rehabilitation of children in post-traumatic and post-operational circumstances.

Galina Bobrovina has requested that the identity of her patients remain anonymous but that any serious requests by practitioners should be addressed to her (email address: gdv_t@mail.ru, subject: 'rehabilitation'). Galina Bobrovina is member of the 'de Bono Thinking Centre' in Tomsk, Siberia, Russia. (http://debono.narod.ru - in Russian).

I believe that this report is of the utmost importance in the 'march' of the “de Bono Thinking Tools” on the world stage. In this particular circumstance, it shows how the tools in the hands of a highly skilled and motivated practitioner can, within a short time, alter the dire circumstances of a child into a positive person ready to accept their circumstances and indeed they themselves affect the speed of their recovery or rehabilitation. I do not know of any other theories or tools that could have such a profound effect. If the “de Bono Thinking Tools” can achieve such astonishing results in these circumstances I know that practitioners in any other field can achieve similar results. I would like to hear from them. I would be obliged if this 'article' could be brought to the attention of other psychologists who may be persuaded that the “de Bono Thinking Tools” work for the benefit of children and parents.

Along with the various psycho-diagnostical and psycho-correctional methods Galina Bobrovina uses the “de Bono Thinking Tools” extensively as a psycho-correctional means with children with post-traumatic and post-operational problems in the Tomsk Municipal Hospital No. 4.

Galina Bobrovina asserts that these thinking tools show the most systematic results. They allow others psychological aids to be more effective. They concentrate attention on every single case. They optimise the use of other psychological procedures. Use of the “de Bono Thinking Tools” has produced the following results:

• In the case of a 9-year-old girl with forth degree burns of her legs, who had to have the toes of her left foot amputated and skin grafts her fear of bandage replacement and movement was overcome, her sleep and appetite were restored. She started active communication with her family and other patients in the ward. She was motivated to be creative by drawing, dressing up and decorating. She was motivated to study and had her textbooks brought. Above all the girl was no longer frightened or frustrated by the sight of her severely damaged legs and asked her parents to bring her a new pair of trousers by the time of her discharge. The decision to discharge the girl was taken in a fortnight after reanimation while the prognosis to discharge had been 21-30 days; psycho-corrections lasted for two weeks.
• In the cases of the quick restoration of important physical functions. A 5-year-old girl with aphasia (post-operational 7 days speech loss) complete speech faculty restoration in 3 days of a psycho-correctional course. The case of a 7-year-old boy - aphasia was overcome in 4 days with simultaneous remission of frustration caused by medical manipulations.
• Partial or total prenatal CNS lesion remission, with quick psychical function restoration.
• Stress remission, adequate and constructive parental activity in tending an invalid child (parents’ consultation and involvement in the child's psychological rehabilitation) with the increased psycho-emotional protection of the invalid and its relatives in the course of treatment. A strong growth of a new high level trust and respect between child and parents are observed regularly.

General psycho-correctional effect could be defined as dominating perception patterns of health problems overcoming the perception of personal sickness; a stable positive aim at disease overcoming formation. Research has shown that positive psycho-dynamics of a patient conduces to the effectiveness of the treatment and earlier convalescence.

The results have been obtained in collaboration with the surgeons of the Tomsk Children's Hospital No. 4 - V.I. Tjutikov, I.A. Prokofjev (traumatic surgery), N.I. Trikhimchuk (war) and N.M. Morozov (head physician).

(see G.M. Bobrovina, D,V, Galkin "Patient's Psychodynamics, Sickness Perception and Effectiveness of Treatment" - Siberia Psychiatry and Nbarcology Herald - 2001 No 2 (20) pp 65-67.)

Case Studies

Inge, 5 years old

Cervical and dorsal spine operated (grave trauma), total immobility (paralyzed; the head, vision and speech faculty are safe), no voice (speech functions preserved); artificial lungs ventilation. Reanimation course completed.

Psychological deprivation is caused by difficulties of independent respiration.

Goal: stable positive aim at disease overcoming formation.

Work peculiarities: impossibility of verbal communication leads to game/role means of communication. The psychologist conducts the communication process, performing tasks together with the child and on it’s behalf. The “Six Thinking Hats” method corresponds to the requirements of the case. Balloons of the same colours to stimulate respiration and lungs training replace the coloured Hats. The method stimulates mental process (perceptive, cognitive, etc). The method was briefly explained to Inge and her parents.

1 hour daily practice

Hat Sequence (one day of the course example)

Red Hat (feelings and intuition) – “Blow the Red Balloon up!” “I feel better now. Mummy is near. I can see other children playing. I cannot speak, but whisper; I cannot move the arms and legs. I feel pain at the back of my head. I cannot feel my body. I want to be well again. And I want my voice first.”

White Hat (information) - “Blow the White Balloon up!” The most important thing to know is how to breathe by myself. Why is a special apparatus needed? It extracts mucus from the lungs. When the lungs are clean, we can start to learn to breathe through your nose and mouth. Mother would be permitted to hold Inge in her arms.

Yellow Hat (advantage, positive points, values) - “Blow the Yellow Balloon up!” Good lungs exercising – soon she will breath independently and could go for a stroll (carried by Mother). Good appetite – muscles grow stronger to move Inge’s arms and legs. Good behaviour – Inge is calm, she doesn’t cry, which means she is getting better.

Black Hat (difficulties, risks, what might go wrong) - “Blow the Black Balloon up!” There is a feeling of despair (confirmed by some prognosis). Mummy feels sad at her daughter’s condition. Other children cannot play with Inge or speak to her. The child is sensitive to negative emotions, and tires out quickly. Long recovery (“It heals up slowly”).

Green Hat (creativity; new ideas and alternatives) - “Blow the Green Balloon up!” The head might be placed more comfortably (to turn a little or to lift the head of the bed). It takes a doctor’s permission. It would be nice to decorate the ward and make it more cosy. Mother is worried, she needs support. Other people's attention is needed (they could encourage Inge, amuse her, especially during treatment); they could be taught the Six Hats method to communicate with Inge.

Blue Hat (what is the result? What is next? How to use Hats?) - “Blow the Blue Balloon up!” Effect is evaluated by the psychologist:

1. Kate learned to produce sounds (using her lips); she is more cheerful now, enjoys her mother’s reading; reacts well to music.
2. Kate enjoyed the “Six Balloons”. Every day by the time of the psychologist’s visit she had tried hard to have had a balloon indicating her mood blown up. The colours of the balloons indicated stable positive attitude to the situation (the Black Balloon was used only once after bandaging). The girl showed good humour and no fear of medical manipulations. (I made some suggestions to the psychologist and communicated with Inge through her).

The lungs ventilation devise was removed a week after the psychological work was started. A corset was put on to fix the support and locomotion system. According to the psychologist’s advise Inge’s mother took her for a stroll (fresh air is wholesome to the respiratory tract).

Martha, 9 years old

Diagnosis: forth-degree burn, 54% deep burn lesion of lower extremities. State: left toes amputated, skin grafts. Discharge Prognosis: 3-4 weeks after reanimation. Discharged in 2 weeks.

Psycho-diagnostics: Projective testing used - “House-Tree-Man”, “Non-existent Animal”, “My Family”, “My Fear” etc. Psychological state – great disquiet; fear of pain caused by bandage replacement, movements; shyness - confused by other patience presence in the ward.

Goal: stable positive aim at disease overcoming formation.

Psycho-correction Basic method – CoRT thinking lessons, Six Thinking Heats. Daily one hour in ward practice (depending on the child's condition). Personal tasks. Parents involved when wished.

Initially the psychologist takes an active part, while the gravely traumatised child has difficulties with speaking; this is needed to communicate on the child's behalf, stimulating non-verbal reactions. E.g.: in using “Six Hats” method verbal communication could be substituted by role play, in which the hats could be replaced by balloons, blocks, bow or other objects of a corresponding colour.

Day 1

PMI (Plus-Minus-Interesting) was presented as a means to an “unprecedented magic recovery”; 3 minutes for each point.

Plus Points (It would be better, if…) Minus points Interesting Points 1. eat and sleep well 1. fear of bandaging and pain 1. find a “good nurse” to put bandages 2. follow doctors advise 2. fear of body movements, position changing 2. let Mummy will be near while bandaging 3. listen to Mummy and Grandma 3. fear of not being able to stand on feet 3. enough time to play and read (when possible) 4. have favourite toys and other things handy (drawing-book, books, Walkman, etc.) 4. home burnt down – there will no where to go back to 4. more time to think of good and nice things 5. meet a younger brother (aged 1)

Effect: The girl become cheerful, communicative and more active.

Day 2

CAF (“What factors are involved?”) is applied to the idea of an “unprecedented magic recovery”.

Factors affecting Martha

1. Isolation from children of the same age
2. Mother’s dictate (demanding tone)
3. Matha is kept from school

Factors Affecting Others

1. It would be better not to be sad, but to cheer up
2. Mother is kept from work

Factors Affecting Society in General

1. Teachers and classmates worry about Martha
2. Doctors worry too and will be glad at her convalescence

Day 3-4 PMI+CAF, introduction of AGO (Aims-Goals-Objectives)

Day 5 Effect: depression, disquiet and fear of bandaging removed (the girl is more cheerful, had her hair done, decorated it with ribbons, put her bracelets on; she is not afraid to sit in her bed, sleeps well; she tries to work with textbooks; she is more affable now, less irritable and communicating with her parents).

Day 6 APC (“Alternatives”). Task: generate variants of escape from movement limitation cased by burn. Fear of movement removed. Martha can bend one leg and moving aside the leg, which was operated on, turn over.

Day 7-9 “Six Thinking Hats” in sequence; steady psychological effect. The girl calmly (without crying) stood the sight of amputated toes, which she saw for the first time. She is more communicative and active; can stand on one foot with support. Sitting in a wheelchair Martha goes out of the ward (moves along the corridor).

In the Green (creative) Hat Martha thought of motivation to start walking.

In working with sick children a particular Hat sequence was noticed to be more effective – Red, White, Yellow, Green, Black, Blue, Red, which accentuates the Yellow Hat to emphasize positive points (convalescence; getting stronger; being able to move, read, draw, etc; surroundings atmosphere alteration – disease perception widening). The Green Hat reinforces the positive points of the Yellow Hat – Martha decided to alter the atmosphere of the hospital ward by means of decorations and nice dresses.

Hilda, 12 years old

Grave cerebral trauma (traffic accident). Three months in a coma. Frontal bone partly extracted. Rehabilitation 6 months after discharge. Psychological problems: partial social adaptation (the girl is kept from school), coeval communication problems (ignored by former friends, not invited to parties). Disquiet increased; fear of the future (disablement); family problems caused by overprotection. Doctors and the psychologist had the misgiving that psycho-emotional condition could affect injured cerebral tissues and lead to complications.

Psycho-diagnostics: Projective testing - “House-Tree-Man”, “Non-existent Animal”, “My Family”, “My Fear” etc.

Psycho-correction: CoRT1 Thinking Tools are practised by the patient using a pen to improve handwriting.

Goal: stable positive aim at disease overcoming formation. The same scheme of work (as in the previous case). The psychologist explains the meaning of projective testing to clarify the problems, which positively affect task performance.

PMI (Plus-Minus-Interesting). The ides of an “unprecedented magic recovery”.

Plus Points

I can attend school, study and communicate with classmates

I can go for a walk, to the movies, cafes

I can do a lot myself – there is no need for other’s help

I can pay visits to relatives and acquaintances

Minus points

It is difficult to keep the regimen

Possible negative points in relationship with classmates

Possibly reduce relatives’ attention and care

Participation in housekeeping fuss

Interesting Points

To learn to work with the computer; find new friends through the Internet

To learn knitting and sewing (to dress better), cooking

To join a study group at school

CAF (Factors involved)

Factors affecting Hilda Limited physical abilities (No abrupt movements! No dances!)

Regimen keeping. Attention to the head!

Coercive obedience to mother

Complete convalescence as a way to Hilda’s future family

Factors affecting others Parents have to pay constant attention, control and care

Parents have to accompany her out of doors

Friends avoid private communication (they are afraid to do harm)

Friends have to be more tactful, attentive and sympathetic

Factors affecting society in general Successful studying; achievements; mutual help and support

Social Services involvement

Friends can understand that in such a condition one has to overcome great difficulties, develop one’s will-power and purposefulness

APC (Alternatives, Possibilities, Choice)

1. To make a diary your one close friend (Start keeping a diary)
2. Think of interesting grounds to meet friends
3. Extravagant dresses would attract attention and prevent nudging at school or in the street.

OPV (Other People Views)

1. Some children of the same age (schoolmates) think a disabled to be an improper friend; others do not know how to behave themselves, feel awkward.
2. Mother tries to control Hilda’s every step; she thinks long-term contacts with friends exhaust her daughter, quarrels depress and prevent from getting well.
3. Father thinks it is better to pay more attention to studying and other useful things, but not to friends
4. School teacher explain pupils how to be more attentive and careful to each other
5. Grandmother thinks Hilda could do more about the house, communicate with friends by phone, and not take friends’ mistakes to heart.

Effect: Hilda gained self-confidence and positive outlook on relationship with her parents, thought of ways to avoid conflicts and preconception in relationship; started to attend 1-2 classes at school.

Fatma, 6 years old

Diagnosis: Elisarov’s congenital extremities defects correction device at the shin of a shorter leg.

Psychological state: disquiet and fear reinforced by pain, which is caused by movements and slow recovery; enuresis causes problems in communication with other children in the ward, tearfulness and petulance, troubled sleep. Depression increases when the mother leaves the hospital at night.

3 days work with the psychologist of 1 hour each, using projective testings.

Psycho-diagnostics:

Projective testing - “House-Tree-Man”, “Non-existent Animal”, “My Family”, “My Fear” etc.

Psycho-correction: PMI (Plus-Minus-Interesting)

PMI: the idea “Hospital is not so bad” Plus Points Minus points Interesting Points I can ask others to share tasty things and toys with me I cannot reach a toilet at the moment Bedpan used under the blanket is imperceptible and convenient I can watch video………… (which is impossible to do at home I don’t like hospital food Home food could be brought to the hospital I can play games with other children in the ward, they do not mind that I miss my home Sister’s drawings could be given to me and mine to her The leg hurts I am afraid of the hospital staff and injections Disquiet removed, the boy was more communicative; took a great interest in drawing; his walk grew firmer. In two days he stopped weeping at his mother leaving the hospital. The mother noticed her child becoming kinder and more communicative with children. Enuresis cases grew infrequent.

Maria (5), Hans (7)

Post-traumatic aphasia (speech loss). PMI is performed together with the psychologist – children reacted in gestures. Speech faculty restored in 3-4 days (pronunciation, articulation and sentence construction).

Thank you Galina Bobrovina for this star burst of hope and magic. Thank you also Vladimir Baronovsky who has sponsored my training in Siberia and without this help these wonders would not have taken place.

-Peter de Bono

Submitted April 2000