Cognitive Rehabilitation A service user`s journey

Transcription

1 Cognitive Rehabilitation A service user`s journey Dr Ena Lavelle, Consultant in Rehabilitation Psychiatry Dublin South/South West Mental Health Services Acknowledgements: Ms. Susan Kehoe, Senior Occupational Therapist, Dublin South/South West Mental Health Services Dr Pat Abbott, Consultant in Forensic Rehabilitation Psychiatry, Ashworth Hospital, UK

2 Ballyfermot Health Centre

3 Rehabilitation

4 What is Recovery? Living a satisfying, hopeful & contributing life, even with the limitations caused by the illness Anthony,

5 The Recovery Paradigm has: Potential to radically change the way in which we view mental healthcare in future Already influenced service delivery in Ireland, internationally & within the UK Service users at the centre of developments & relationship with professionals is collaborative Strong self-help & peer support ethos Emphasis upon real life rather than illness

6 Recovery is not.. Being cured Being symptom-free Not needing treatment/support/services imposing an ideology upon people living with serious and painful conditions imposing a burden of unrealistic expectation on people already struggling with stigma, disability and illness

7 Service user group in Cognitive Rehabilitation Programmes Individuals with severe and enduring mental health problems (major psychosis spectrum disorders) Comorbid diagnosis: LD, Illicit subst, alcohol, ABI, Autism spectrum disorders, major anxiety, depression Risk related behaviours Refractory to standard treatment interventions

8 Individuals with cognitive deficits: Often unidentified within Criminal Justice System Not always recognised within mental health system, or, even if recognised as mentally disordered may be perceived as personality disordered or mentally ill only Significance of cognitive impairments in challenging behaviour, offending & risk may be missed Often present intractable management problems over many years May engender negative attitudes in staff due to long term challenging behaviour & poor response to treatment & therapy Maybe moved from service to service because they do no fit or are too difficult to manage

9 The snakes & ladders care pathway:

10 Impulsive violence & other problem behaviours Dysexecutive syndrome Disinhibited Threat /control override symptoms Minor trigger Anger + arousal Impulsive violence

11 Dysexecutive cognitive difficulties lead to Inflexibility/perseveration Difficulty planning Poor foresight & judgement Poor self-monitoring Oversensitivity to environmental stimulation/distractibility Impulsivity & disinhibition Problems with arousal

12 What is Cognitive Rehabilitation (CR)? Technique based upon neuro-behavioural principles developed for population with acquired brain injury and frontal lobe deficits Emerging evidence for use with other conditions causing similar cognitive difficulties including treatment resistant schizophrenia Compensatory model within a relational framework

13 Cognitive Rehabilitation Relational : recognises prime importance of therapeutic engagement Collaborative: harnesses hope & active involvement in care planning & goal setting Non-aversive: actively avoids negative interactions by using alternatives such as distraction, positive behavioural support and communication via compensatory systems Total environment approach: aims to support individuals in such a way as to enable them to function at their best & minimise problematic behaviours

14 Cognitive Rehabilitation: Interventions Avoid triggers for problem behaviour (Antecedent control) Use compensatory aids personal & environmental Provide a structured programme of enjoyable activity with appropriate rest periods Apply coaching model using errorless learning techniques to build skills increase self efficacy & competencies Ensure consistency across all staff/settings Giles 2008

15 Awareness of cognitive deficits/ Adaptation of expectations to meet client s ability Controlled environment Consistent approach Routine & Structure Client s deficits compensated for Increased self confidence Increased self esteem Increased self efficacy Psychological well being Feeling accepted Motivation Sense of control Good at something! Boredom alleviated Better problem solving skills. New response options It works! REDUCED BEHAVIOURAL DISTURBANCE 15

16 Cognitive Rehabilitation Potential benefits: To the individual: improves social functioning, self esteem & ability to achieve their chosen lifestyle To others: reduces risk of offending & challenging behaviours To the system: reduces behavioural problems & potentially longer term cost implications

17 Need to use predictability & distraction rather than confrontation & boundary-setting Therapists may struggle with the neuropsychosocial approach when it conflicts with their perceptions about how people ought to behave.they may express the view that treatment techniques should follow those they use with their own unruly children. It has been known for a long time that this notion is misleading (Meehl,1973)

18 Communication style is very important.. He has to learn, NO means NO!

19 Cognitive Rehabilitation Longer term goals to: reduce sensitivity to adverse environmental triggers increase tolerance Reduce need for high levels of structure & predictability support progress to less secure, less controlled settings 19

20 Consistent implementation of programmes is not always easy.. CR principles simple but difficult to implement consistently A different neurorehabilitation environment must be created for each person in the same physical space May be conflicting needs Karol,2005

21 Introduction to Cognitive Adaptation Training (CAT) Developed in psychology field (Dr. D. Velligan, UTHSCSA) Systematised approach to the use of compensatory strategies or environmental support Based on the idea that we can re-arrange the environment and bypass some cognitive difficulties and negative symptoms, leading to improved functioning Strategies applied based on level of impairment in executive function and behaviours associated with these impairments Manualised format

22 CAT Assessments Tests of cognition such as executive function Service user rated as fair or poor Measure of overt behaviour (Frontal Systems Behaviour Scale, FrSBe) Service user rated as apathetic, disinhibited or mixed Environmental Assessment Functional Assessment

23 Frontal Systems Behaviour Scale (FrSBe) 46-item behaviour rating scale has difficulty starting an activity, lacks initiation, motivation 3 subscales: Apathy Disinhibition Executive dysfunction Can be administered by experienced clinicians such as OTs and SLTs

24 Treatment Plans in CAT Based on comprehensive assessment of cognition, functional abilities, behaviour and the environment Intervention for each functional deficit on 2 dimensions 1) level of impairment in executive functions 2) whether overt behaviour of individual is characterised by apathy (poverty of speech and movement and the inability to initiate and follow through an behavioural sequences) dis-inhibition (distractibility and behaviour that is highly driven by external cues in the environment) or a combination of these styles.

25 General Intervention Strategies using CAT OVERT BEHAVIOUR TYPE APATHY DISINHIBITION MIXED IMPACT ON FUNCTION Does not initiate activities Distracted by irrelevant stimuli Trouble initiating tasks and distracted during task CAT STRATEGIES INDICATED Prompting and cueing to complete each step in a sequenced task Removal of distracting stimuli and cues for appropriate behaviour Both prompting of steps and removal of distracting stimuli

26 Example of difficulties with dressing APATHY DISINHIBITION MIXED Sleeps in clothes or stays in pyjamas all day. Does not complete steps in dressing due to inability to initiate and follow through on behavioural sequences Wears 3 shirts just because that is what they see when they open the cupboard door. May skip steps in dressing due to being distracted by unrelated environmental stimuli May exhibit behaviours listed under both apathy and disinihibition. Likely to put on the same clothes they wore the previous day because that is what they first see upon awakening

27 Examples of CAT intervention strategies Dental Hygiene Apathy, poor executive functioning

28 Results of US research to date CAT improves social and occupational functioning and community adjustment Largest effects on functional outcomes are found with intensive, individualised intervention When intensity of intervention is reduced, some individuals maintain gains while others do not Improvement in motivation measured through greater participation and interest in activities

29 Cognitive Adaptation Training (CAT): Case Study M.O C Service user of Rehabilitation Service since 2010 Group and individual rehabilitation intervention provided. Formal assessment of functional ability used to track progress Functional ability has remained unchanged/stable despite rehabilitation intervention This is an indication that environmental adaptation rather than cognitive remediation is the more appropriate intervention

30 CAT Process CAT assessment: Poor executive functioning Difficulty organising himself and task Difficulty terminating tasks Difficulty noticing and responding to problems Disinhibited behaviour type easily distracted impulsive CAT intervention: Needs to be in many areas May need to identify all steps in a task Distractions to be removed/ clutter to be reduced Signs/equipment placed exactly where activity takes place

31 Examples of strategies Sign on mirror in bedroom exactly where activity takes place Written instruction booklet on how to make fried eggs on toast. One instruction per page as M.O C gets distracted if there is too much information. Able to remain focused with booklet

32 Basket for clothes/towels etc for shower that MO C refills every night ready for the next day. Follows a checklist to gather the necessary items Clear washbags combined with checklist for gathering needed items

33 Conclusion CAT is a series of manual-driven compensatory strategies and environmental supports (signs, checklists, electronic cueing devices, and the organization of belongings) to bypass cognitive impairments and to cue and sequence adaptive behaviour in the home. CAT has been found to improve specific target behaviours (e.g. self-care, medication adherence) and to improve motivation on the Negative Symptom Assessment suggesting increasing engagement and interest in activities Case studies highlight the complex issues which service users present with, who are referred to a rehabilitation service and the benefit which a cognitive rehabilitation intervention may have (e.g. CAT) improving their outcome in relation to ADLs. Cognitive rehabilitation interventions can improve the outcomes of individuals with mental health illness and complex problems, which supports in turn their progression to a greater level of independence and may have a impact in reducing health and social care economic burden in society.