COGNITIVE SKILLS THERAPY GROUP: IDEAS FOR INCORPORATING EVIDENCE-BASED COGNITIVE INTERVENTIONS AFTER BRAIN INJURY

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1 COGNITIVE SKILLS THERAPY GROUP: IDEAS FOR INCORPORATING EVIDENCE-BASED COGNITIVE INTERVENTIONS AFTER BRAIN INJURY Kathleen Breslin, MA, LPC Madeline DiPasquale, Ph.D.

2 Goals for today Identify 3 common cognitive problems after brain injury Discuss three evidence-based practices for cognitive intervention after brain injury Generate three activities to improve understanding of and intervention for cognitive changes after brain injury

3 Evidence-Based Rehabilitation Services

4 What we know: Evidenced-based research Behavioral and cognitive skills can be improved by participating in neurorehabilitaiton (Braunling-Mcmorrow et al, 2010) High tech and low tech external aides improve memory performance after brain injury (Lemoncello et al, 2010, Shum et al, 2011, McDonald et al, 2011, Watanabe et al, 1998) Dual task training improves divided attention and speed of processing (Couillet et al, 2010, Fasottiet et al, 2000) But There is conflicting evidence supporting the use of group-based interventions to treat executive dysfunction after brain injury(novkovic- Apopian et al, 2011) Specific structured training programs for improving attention are ineffective or at best equivocal (Novack et al, 1996, Park et al, 1999, Ponsford and Kinsella, 1988)

5 Wait, we know more There are six personal characteristic that predict participation in behavior-change programs: self efficacy, locus of control, beliefs and expectations about the therapy program, disease characteristics, cognitive status, and psychosocial status (Sohlberg & Turkstra, 2011) Direct patient involvement in goal setting results in a significant improvement in obtaining goals (Webb and Glueckauf, 1994) Motivation increases when there is a clear connection or relevance of the therapeutic task to the long term goal (Haskins, 2012)

6 Most importantly- General cognitive rehabilitation therapy is effective for improving cognition (Rath et al, 2003, Cicerone er al, 2004)

7 No navel gazing allowed!

8 Here are the questions: How to do we deliver evidence-based treatment? How do we engage the client so they feel the treatment and interventions are relevant? How do we increase program unity? Relationships Consistency How do we measure improvement?

9 Designing Treatment Interventions

10 Rationale for developing a cognitive skills group Increase engagement and patient autonomy in treatment Creating a culture of support among survivors Discuss strategies and barriers to using cognitive strategies Provide exposure to a variety of types of interventions Provide strategies for therapists and content to work on client-focused goals Enhance team approach

11 Common Cognitive Problems Following Traumatic Brain Injury Awareness Attention Language/communication Visual-spatial functioning Memory Executive Functioning Working Memory Problem Solving Processing Speed Motor Functioning Social Skills

12 Group Structure 2 hours, 1x/week, with a one hour lunch break in the middle Client s provided with binder First hour focused on review of previous material and discussion of use of strategies Second hour focused new information and practical application Kathy s Baking a Cake story Discussion of ways the strategy could be used in client s life

13 Content Outline The group was broken down into units, primarily by cognitive domain Neuroanatomy of TBI Attention/Concentration Language/Communication Visual-spatial functioning Memory Executive functioning/working Memory/Problem Solving Social Skills

14 Content: Group Within each unit, content included neuroanatomy, evidence-based strategies (internal and external), and practical strategies, techniques and games Each unit was concluded with a game as review that allowed clients to test out knowledge (e.g. jeopardy) Length of time on each unit varied between 4 weeks and 10 weeks depending on material, client understanding and depth of content

15 Nuts and Bolts Practically, how do you run a cognitive skills group?

16 Engagement Staff Client

17 Making it fun! The Brain: Pinky and the Brain Clay brain models

18 Sample Content Attention and Concentration

19 Attention and Concentration How many times does the white team pass the ball? External Devices Time Pressure Management (Fasotti et al., 2000) Environmental Supports Seven Level Model of Attention Training (Parente & Hermann) Psychosocial Supports Attention Process Training (Sohlberg et al., 2002)

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29 Take a minute to write down the cards you remember.

30 How many of these did you get? 9 of Clubs 2 of Spades Queen of Hearts 8 of Clubs 10 of Diamonds 5 of Spades Jack of diamonds 8 of Hearts Queen of Diamonds

31 What could you do to make this easier or harder? Increase/decrease the number of cards Increase/decrease interval the cards are shown for Increase/decrease how many times you see the cards Increase/decrease distractions Any other Strategies? Memory palace

32 Language and Communication

33 Language and Communication Compensatory Strategies Drawing Gesturing Technology Cues Social Support Cognitive Linguistics Therapy

34 Memory

35 Memory Mnemonics References External Aides n Memory Notebook (Doneghy & Williams, 1998) n Alarms n Technology (smart phones, tablets) TEACH-M (Ehlhardt et al., 2005) n Task Analysis n Errorless Learning n Assessing Performance n Cumulative Review n High Rates of Correct Practice Trials n Metacognitive Strategy Training

36 Social Skills

37 Social Skills Self-regulation CBT Stress inoculation training Behavioral management Social sensitivity Group therapy Interpersonal process recall (tape interaction, review in therapy) Social problem solving Social skills training Social self-awareness IMPROV Tasks

38 Engaging the Team Common goals, common work

39 Content: Treatment Team Clinician Tip Sheet A brief summary with resources was developed for clinicians for each cognitive domain covered in group

40 Feedback/Outcomes Clients were more willing to experiment with different techniques during group Clients developed hypotheses about what could work and then tested it out Clients shared ideas about what works for them with group Identifying what was easy/challenging about a task Clinicians felt they had appropriate content to address client s goals

41 Modifications Review, review, review Slow and steady Some units took much longer than expected Practical games and illustrations Leave room for discussion Ways to help clients generalize?

42 Thank You! Dr. Drew Nagele for exposing me to cognitive rehabilitation Dr. Max Shmidheiser for his patience, suggestions, and support over the course of this year Of course to Dr. Maddie DiPasquale for the idea, supervision, and encouragement

43 References Cicerone, K. (2002). Remediation of working attention in mild traumatic brain injury. Brain Injury, 16, Cicerone, K. D., Mott, T., Azulay, J., Sharlow-Galella, M. A., Ellmo, W. J., Paradise, S., & Friel, J. C. (2008). A randomized controlled trial of holistic neuropsychological rehabilitation after traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 89, Donaghy, S. & Williams, W. (1998). A new protocol for training severely impaired patients in usage of memory journals. Brain Injury, 12, Ehlhardt, L., Sohlberg, M., Glang, A. & Albin, R. (2005). TEACH-M: a pilot study evaluating an instructional sequence for persons with impaired memory and executive functions. Brain Injury, 19, Fasotti, L., Kovacs, F., Eling, P., & Brouwer, W. (2000). Time pressure management as a compensatory strategy after closed head injury. Neuropsychological Rehabilitation, 10, Goverover, Y., Johnston, M., Toglia, J., & DeLuca, J. (2007). Treatment to improve self awareness in persons with acquired brain injury. Brain Injury, 21, Haskins, E. C. (2012). Cognitive Rehabilitation Manual: translating evidence-based recommendations into practice. Reston: VA. Levine, B., Robertson, I. et al. (2000). Rehabilitation of executive function: an experimental-clinical validation of Goal Management Training. Journal of the International Neuropsychological Society, 11, Niemeier, J. P., Cifu, D. X., & Kishore, R. (2001). The Lighthouse Strategy: Improving the functional status of patients with unilateral neglect after stroke and brain injury using visual imagery. Top Stroke Rehabilication, 8(2), Sohlberg, M. M. & Mateer, C. A. (2001) Cognitive Rehabilitation: an integrative neuropsychological approach. New York: NY. Sohlberg, M. M. & Turkstra, L. S. (2011). Optimizing Cognitive Rehabilitation: effective instructional methods. New York: NY. Von Cramon, D., Von Cramon, G., & Mai, N. (1991). Problem-solving deficits in brain-injured patients: a therapeutic approach. Neuropsychological Rehabilitation, 1, Winkens, I., Van Heugten, C., Wade, D., & Fasotti, L. (2009). Training patients in Time Pressure Management: a cognitive strategy for mental slowness. Clinical Rehabilitation, 23,