One of the most frequent requests I get is for ideas for cognitive therapy. Cognitive therapy is easy to grasp, but hard to master, kind of like chess! There are four steps to cognitive therapy, and every step offers challenges. I’m going to provide some solutions and resources for each step.
Free DIRECT download: Ideas for cognitive therapy (cheat sheet). (Email subscribers get free access to all the resources in the Free Subscription Library.)
Outline:
- Cognitive therapy in four steps.
- Determine what your patient wants to improve.
- Assess strengths and weaknesses.
- Write SMART goals with your patient.
- Provide focused, practical intervention.
- My take on cognitive therapy.
- Your homework assignment.
- Related Eat, Speak, & Think posts.
Cognitive therapy in four steps
At the heart of it, cognitive-communication or cognitive-linguistic therapy can be broken down into four steps:
- Determine what your patient wants to improve.
- Assess strengths and weaknesses.
- Write SMART goals with your patient.
- Provide focused, practical intervention.
Challenges and barriers
Each step, however, contains possible pitfalls. First, your patient may not be able to state what they want to improve. They may not want to improve anything. Perhaps they’re content with their family filling in the gaps, or maybe they have limited understanding of their deficits.
Second, you may not have access to the relevant medical history or the right assessment measures. You may not have time to administer a full assessment. Or your patient may not be able to or want to participate in formal measures.
Third, perhaps you struggle to write goals that are Specific, Measurable, Attainable, Relevant, and Time-bound. Or perhaps you’ve written goals without involving your patient, and you haven’t hit on what motivates them.
And finally, you may not yet have the skills or tools to provide effective intervention that helps your patient achieve their goals. Maybe your sessions are constantly interrupted. Or maybe your patient is willing but unable to fully participate due to more pressing needs or concerns.
I’m sure there are plenty of other barriers that I’m not thinking of at the moment. But these are all challenges that I’ve run into or mistakes that I’ve made.
I’d like to provide some resources and ideas for each of the four steps I’ve outlined above.
Determine what your patient wants to improve
This is the heart of what we do. To be blunt, who cares if our patient’s test scores improve if nothing in their real life does? And honestly, as long as my patient sees real improvement in their participation of daily activities, I don’t really care if their test scores improve.
The whole point of what I do is to help people improve their lives. And I’m sure that’s true for every clinician reading this. I’ve found that a collaborative approach is much more effective than simply deciding for my patient what we’ll work on.
It’s easy to identify your patient’s goals when they have a clear understanding of what they’re having trouble with. Some of my patients have good insight and can clearly state their goals for therapy.
What’s hard is when my patient has limited insight. They may say that they want to improve their memory for everything. Or they may think their problems are a part of natural aging and therapy won’t help.
Motivational interviewing
That’s when I try some motivational interviewing. I’ve written about it before, but basically, I try very hard to find at least one thing my patient is interested in improving. I may ask questions like:
- What would be better for you if you had a better memory?
- What do you need to be able to do that you can’t do now?
- Would you be willing to try some things that could help?
It’s rare that I can’t find at least one thing to work on. At the very least, I may find one small set of information my patient is interested in remembering which allows me to teach strategies that they can later apply to anything. For instance, I’ve written about one of my patients who only wanted to relearn her grandchildren’s names. Then, on her own, she used the strategies I taught her to learn the names of her great-grandchildren.
Sometimes, my patient’s family works with me to develop specific goals. For instance, I taught someone how to use their TV remote so that she didn’t call her son every couple of hours to fix the TV that keeps breaking. She didn’t recognize that as a problem, but it was a relief to her son!
What if you can’t find a goal the patient wants to work on?
If I’m doing an assessment and I can’t find a single specific problem that my patient or their family wants to address, I usually won’t pick them up for therapy. I tell them to let their nurse or doctor know if they later think of something they’d like to improve.
The exception is when the team has identified a safety concern that I may be able to help with. In this case, I’ll pick them up for trial therapy to see if I can help.
Assess strengths and weaknesses
The next step is to do a formal assessment. I try to pick a test that fits the patient, in terms of length and usefulness of the data I’ll get. I’ve rarely had a patient refuse or complain.
I make it clear that I’m giving the test to look at different types of memory and thinking, and that the test will help me know how to help them. I remain positive and respectful during the assessment, both towards my patient and towards the test. (In other words, I don’t talk disparagingly about the test.)
I pace my questions. If my patient appears to be getting tired, I’ll stop for the day. I have no problem breaking up the assessment over two visits.
In addition to a formal standardized test, I’ll often administer a questionnaire like the Neuro-QoL. This provides a glimpse into how my patient views their current cognitive abilities. Often, they’ll tell me that they’re not having trouble in the interview but then their answers on paper show that they actually are. This is a great way to find personalized goals.
The third type of information I gather is non-standardized information. For instance, I’ll consider how easy it was to schedule the assessment visit. How organized is their home? Are the medications organized and is someone helping with that? How does my patient handle distractions?
And finally, I’ll interview any family that’s around or ask permission to call someone. Family can often provide good insight into how a person’s cognitive communication skills have changed. They can suggest specific goals that would make life easier and less frustrating for the patient and for themselves.
Write SMART goals with your patient
I think having SMART goals is critically important for successful therapy. SMART is an acronym standing for:
- Specific.
- Measurable.
- Attainable.
- Relevant.
- Time-bound.
An un-SMART goal
I used to write very broad, generic goals like:
“Patient will complete short term memory (STM) exercises with 80% accuracy independently.”
An un-SMART goal
Not specific
This goal isn’t specific. If you handed this goal to 10 different SLPs, you’d probably get 10 different treatment plans.
Not measurable
It’s also not truly measurable. A physical therapy goal like “Patient will walk 50 feet without loss of balance while using the cane appropriately and independently with 100% accuracy to improve safety by 12/31/2019” is measurable. Anyone could ask the patient to stand up and walk 50 feet and judge if the patient can do it or not.
But the ST goal above isn’t measurable like this. If we had 10 different SLPs ask the same patient to do STM exercises, we’d get a range of performances because STM exercises range from very easy to very challenging. So I might say that the patient has met the goal, whereas another SLP may say the patient hasn’t.
And when exactly would the goal be met? When they did two exercises with 80% accuracy independently in one session? Would that really change their life?
Not relevant
Another problem is that this goal isn’t relevant. It doesn’t tie into anything that’s going on the patient’s life. According to this goal, I may not even explicitly teach memory encoding or retrieval strategies that would be helpful to them.
Not time-bound
The goal isn’t time-bound, because we haven’t projected an end date. Do I expect to meet this goal in a week? In a month?
So this goal isn’t specific, measurable,relevant, or time-bound.
A better cognitive goal
Instead, the goal could be written like this:
Patient will demonstrate ability to use at least two memory encoding or retrieval strategies independently during short term memory exercises in 4 of 5 trials across three sessions to improve ability to recall important information by 12.30.2019.
A SMART goal
- Specific: If you hand this goal to 10 SLPs, you’d likely get very similar treatment plans because the focus is on teaching the independent use of strategies.
- Measurable: The goal is measurable because you can either see or hear the patient using the strategies, or you can ask them what they did to be successful in the task.
- Attainable: It’s reasonable to expect that a patient will learn how to use two memory strategies and be successful across three sessions in one month.
- Relevant: This goal focuses on teaching the patient how to use memory strategies independently. The patient can then begin to use the same strategies for things they want to remember in their daily life.
- Time-bound: We expect the goal to be met by a specific date.
Example SMART goals
This is where your interview and assessment process is crucial. If you can find one specific thing that your patient wants to improve, then you can set goals that are motivating.
Here are some example goals that I’ve written for specific patients. Patient will…
- Verbalize and demonstrate the sequence of steps to transition from sit to stand and from stand to sit using a walker with 100% accuracy independently across three sessions to improve safety and independence by 12/31/2019.
- Independently update and use personal calendar to prepare for scheduled appointments with 100% accuracy independently for one week to improve independence and reduce reliance on caregivers by 12/31/2019.
- Demonstrate ability to use at least two memory encoding or retrieval strategies to independently relearn five pieces of personally relevant information to reduce frustration and improve communication by 12/31/2019.
Writing goals before you know what is relevant
I have to write goals after the first session, but I don’t always know what specific goals we’re going to target. In these situations, I do use a more generic SMART goal similar to the one above. But I personalize the goal in the execution during therapy, when I tailor the activities to what the patient specifically wants to improve.
Therapy ideas
Here are some specific things I’ve helped people work on. I want to stress that these are things that were important to my patients or for their families. Even if my next patient has trouble with any of these areas, it doesn’t mean it’s an appropriate target for therapy for them.
- Learning and remembering names.
- Recalling the year.
- Remembering who the president is.
- Automatically looking at the calendar or watch instead of asking for the date or time.
- Remembering to go to lunch on time.
- Keeping track of desired activities and appointments.
- Automatically following the steps to use a cane or walker.
- Finding the laundry room or wellness center.
- Using a chin tuck with thin liquids automatically.
- Counting money.
- Using voice mail.
- Turning the channel and adjusting the volume on the TV.
- Using a cell phone to call family.
- Finding or remembering information instead of repeatedly asking spouse.
- Learning how to use a medication reminder device.
Provide focused, practical intervention
Now the rubber meets the road. You’ve worked with your patient to find specific goals to work on. You and your patient both know that therapy will be successful if your patient is able to do X, whatever X may be.
Now, how are you going to make that happen? Probably not with a bunch of worksheets! (Don’t get me wrong, I sometimes use worksheets to help patients learn how to use the skills or strategies I’m teaching. But if that’s the bulk of what I do, then it’s not likely to help them achieve their goals.)
Do the thing you want to improve
I think it’s just like with swallowing: in order to improve swallowing ability, you have to swallow a lot in therapy. Specificity is key: you have to do the thing you want to improve.
So for cognitive-communication therapy, if my patient wants to improve his ability to use his cell phone, then we’re going to be using his cell phone in each session. If my patient wants to improve their memory for their grandchildren’s names, then we’re going to be working with those names in each session.
Our skill lies in our teaching methods
The skill that we bring to the table is HOW we teach and train.
If someone has a very mild impairment, then trial and error learning will probably work well. But if you find yourself teaching the same information over and over again across two or three sessions, then you’re probably not using the right teaching method.
This is where you can look into other teaching methods such as systematic instruction, executive function training, spaced retrieval, and spaced retrieval + errorless learning.
You can see the steps of systematic instruction on pages two and seven of the PDF for “Systematic instruction for individuals with acquired brain injury: Results of a randomized controlled trial.”
Executive function training includes teaching patients to use a system such as Goal – Plan – Do – Review or Goal Attainment Scaling.
Spaced retrieval is simply asking your patient to recall something or perform some task after an interval of time has passed since instruction or the last attempt. It’s an inherent part of therapy, since we’re asking our patient to do these things when we see them perhaps once, twice, or three times a week. We can also have multiple repetitions within the session.
Adding errorless learning to spaced retrieval makes it more likely that the person will successfully learn the information or task. I’ve written about spaced retrieval with errorless learning several times:
- Spaced retrieval case study: Using a cane.
- 7 tips to maximize errorless learning for moderate to severe memory loss.
- How to use spaced retrieval with errorless learning to improve memory.
My take on cognitive therapy
At the core, cognitive-communication therapy is easy to grasp. Find out what our patient wants to improve, why they’re having trouble with it, and then improve their ability to do that thing.
But cognitive therapy is hard to master. Each step offers challenges and barriers.
I’ve been delivering cognitive-communication therapy for 11 years now. While I often achieve good outcomes, I know I can improve my skills. We can all improve our skills and knowledge, because new methods and technologies are created all the time.
When I begin to feel overwhelmed by all the books and papers waiting to be read and by all the technology waiting to be learned, I take a deep breath and focus on the patient in front of me. It all comes down to what they want out of therapy.
My job is to do what I can to help them achieve their goals. I may not have all the answers, but if I’m truly stuck, I know I have plenty of resources I can tap into.
Your homework assignment
Because I get so many questions about cognitive therapy, I think that perhaps you may feel overwhelmed at times too. If that’s so, then I suggest that you set a goal for yourself to try one new thing.
Perhaps try one of these things this week with a new patient:
- Ask your next patient a motivational interviewing question.
- Focus on finding one specific thing your patient wants to improve.
- Use a self-rating form such as the Neuro-QoL.
- Write a goal jointly with your patient.
- Use Goal – Plan – Do – Review or Goal Attainment Scaling.
- Read about a different training technique, such as systematic instruction or spaced retrieval with errorless learning.
Let us know how it went in the comments below! Or contact me directly if you prefer. I’d love to hear what you tried.
Related Eat, Speak, & Think posts
- Collaborative goal-setting to identify meaningful cognitive goals.
- Writing SMART memory goals for a reluctant patient.
- Treating cognition in the real world.
- Spaced retrieval case study: Using a cane.
- 7 tips to maximize errorless learning for moderate to severe memory loss.
- How to use spaced retrieval with errorless learning to improve memory.
- 18 free assessment tools for cognition. (See comments for more.)
Free DIRECT download: Ideas for cognitive therapy (cheat sheet). (Email subscribers get free access to all the resources in the Free Subscription Library.)
Featured image by JESHOOTS.COM on Unsplash.
Lisa earned her M.A. in Speech-Language Pathology from the University of Maryland, College Park and her M.A. in Linguistics from the University of California, San Diego.
She participated in research studies with the National Institute on Deafness and other Communication Disorders (NIDCD) and the University of Maryland in the areas of aphasia, Parkinson’s Disease, epilepsy, and fluency disorders.
Lisa has been working as a medical speech-language pathologist since 2008. She has a strong passion for evidence-based assessment and therapy, having earned five ASHA Awards for Professional Participation in Continuing Education.
She launched EatSpeakThink.com in June 2018 to help other clinicians be more successful working in home health, as well as to provide strategies and resources to people living with problems eating, speaking, or thinking.
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