Cognitive therapy is challenging for many reasons. In some areas, I usually get the results I expect. But in other areas, I sometimes fail to help as much as I expect. Writing this post actually has helped me to discover a reason for that.
In the next several posts, I’ll be sharing specific strategies, resources, and tools for doing cognitive-communication therapy.
Read along to find out why I think cognitive therapy is challenging, and what I’m going to do to improve my own practice.
Outline of this post
- Why cognition is difficult to improve.
- We can control some factors.
- Our journey from technician to clinician.
- The subset of people I struggle with.
- Now I know what’s holding me back.
- I plan to improve my success rate with systematic instruction.
- Join me in learning how to improve our practice.
Why cognition is difficult to improve
The heart of the problem is that cognition is not well-understood by scientists and researchers. We’re still learning how:
- normal cognition develops.
- it normally changes over a lifetime.
- cognitive processes interact.
- illness, injury, and disease affect cognition.
- diet, exercise, environment, and medication affect cognition.
Cognition includes many processes, each of which is a complicated domain. For example:
- Consciousness.
- Sensory perception (sight, hearing, smell, taste, touch, pain, proprioception).
- Attention.
- Emotion.
- Memory.
- Language.
- Reasoning.
- Problem solving.
- Pragmatics.
- Executive function.
Of course, it’s all interwoven. We can’t isolate “immediate memory” in therapy.
At a minimum, sensory perception for the stimuli and attention to task are also directly involved. Likely, the person engaged in the immediate memory exercise is also engaged in other cognitive processes such as:
- Sensory perception (looking out the window, hearing the TV or other noise)
- Language (listening to you and repeating what you say).
- Executive function (monitoring own performance).
And to further complicate matters, other internal factors may affect our patient, such as:
- Pain.
- Fatigue.
- Thirst or hunger.
- Feeling ill.
- Worries or concerns.
- Bodily functions (example, needing the bathroom).
Since cognition is complicated and we don’t have all the answers, it’s no wonder that we don’t have fool-proof methods for how to assess and treat each person we work with.
Instead, we have some working models (for example, how memory works), and we have some guidelines based on current theory and research (for example, aphasia clinical pathway or severe TBI clinical guidelines).
We can control some factors
Cognitive therapy can fail for many reasons outside of our control. For instance:
- Patient’s health is failing.
- Cognitive impairment is worsening.
- Patient isn’t motivated.
- Other issues are more pressing.
Some patient-related factors are within our control. For example, we can:
- Work with our patient to select motivating goals.
- Try to schedule therapy on days or times when patient won’t be distracted or fatigued.
- Eliminate (or reduce) distractions.
- Make sure our patient is wearing glasses and hearing aids (as needed).
- Create a positive learning experience.
Our journey from technician to clinician
In my opinion, we SLPs start off as technicians during our clinical fellowship. We’re still laying the foundation of our understanding and skills, and learning how to apply that to real people in a supervised environment.
According to Merriam-Webster:
- Technician: “a specialist in the technical details of a subject or occupation. Someone who has acquired the technique of an art or other area of specialization”.
- Clinician: “a person qualified in the clinical practice of medicine, psychiatry, or psychology as distinguished from one specializing in laboratory or research techniques or in theory”.
In my opinion, we begin to work as a true clinician in any specific area once we:
- Have a deep understanding of the theory and current research in that area.
- Are able to use a variety of evidence-based assessment and treatment approaches.
- Can assess the response to our intervention and make appropriate adjustments to treatment to achieve our patient’s goals.
Technicians are skilled but limited
Technicians are skilled at giving and scoring standardized tests, writing goals, and providing therapy. As long as they have solid basic skills and understanding, they can follow the steps to get a positive outcome in most cases.
However, they lack the skills of a clinician. They may not:
- Be able to interpret assessment results as fully as a clinician.
- Know what to do in a new situation.
- Understand the current evidence.
- Know how to change therapy when they’re not getting the results they expect.
Clinicians achieve better outcomes
Over time, we gradually develop into clinicians by:
- Understanding more about how the brain and body work.
- Learning more about what other people have found that works or doesn’t work, ideally in the form of rigorous research.
- Gaining more experience from working with people ourselves.
- Improving our skills as we try different assessment and treatment techniques.
But our development into true masters of our craft is gradual and uneven. We don’t cross some magic line and suddenly transform from technicians into clinicians in one fell swoop. It doesn’t simply happen by virtue of working as an SLP for a certain number of years. It takes time and effort.
I’m a technician in some areas, a clinician in others
In some areas, I know I’m a technician. I feel like I have some knowledge and understanding, but I often look for guidance from people who are more experienced than I am. In these cases, I have to judge whether I’m competent to provide therapy (such as in AAC) or whether I should defer to others (such as ventilated patients).
I nearly gave the wrong advice for facial paralysis
One specific example from earlier this year comes to mind. I evaluated someone who had facial paralysis following surgical resection of a unilateral vestibular shwannoma. My instinct was to have her do massage and oral exercises, but I don’t have a strong understanding of the neurophysiology involved. So I reached out to experts and found out that my instinct was partly WRONG and could have harmed her.
I learned the appropriate recommendations: apply moist heat and massage to encourage circulation, and then see a physical therapist trained in neuromuscular retraining once muscle twitching or movement starts. If I had given her oral motor exercises, it could have resulted in abnormal muscle movements.
I passed that information on to her and discharged her. In that situation, I was a technician. I had just enough understanding to be able to educate her. If something else had emerged, I would have had to consult the experts again.
Why I think I’m working at clinician-level in other areas
In other areas, I believe I’m operating as a true clinician. I have a solid understanding of current theory and research, with plenty of personal experience. I generally get the results I expect. If something unexpected arises, I can come up with a list of possible reasons and solutions. Often, I can adjust on the fly. If not, I know where to look for an answer. Even so, I’ll never stop learning because I’ll never know everything!
The subset of people I struggle with
But there’s a subset of people that I struggle with. I have inconsistent success with people who have a moderate impairment, but who still want to be independent with high-level tasks. These people tend to have significant difficulty with self-monitoring, error-detection, and self-correction.
I feel like I’m a technician working with this population. I usually get decent results, but too often I feel as though my patients should be more successful.
Now I know what’s holding me back
I’m excited that by learning a new teaching model, I should improve my success rate.
I plan to improve my success rate with systematic instruction
Systematic instruction is an evidence-based teaching method which has a long history in many fields. Dr. McKay Moore Sohlberg and others have been researching how to apply systematic instruction to cognitive therapy.
You can see the steps of systematic instruction laid out in Powell et al (2012), which is freely available (pages 2 and 7 of the PDF).
If you’d prefer to have all the research and treatment recommendations laid out in a book, McKay Sohlberg and Lyn Turksta have written Optimizing Cognitive Rehabilitation: Effective Instructional Methods*. I’ve just ordered the book for myself.
You don’t have to buy the book, since I’ll share enough of what I learn for you to be able to get started with systematic instruction. You can find good information in the free “Look Inside” feature (the Kindle preview is easier to read).
*This is an Amazon affiliate link. As an Amazon associate, I may earn a small commission on qualifying purchases. There is no extra charge to you, and it will help keep Eat, Speak, & Think sustainable.
If you have access to Medbridge, Dr. Sohlberg has a two-part course on systematic instruction.
- Systematic instruction: Training techniques that generalize when clients have acquired memory impairments.
- Systematic instruction: Case examples.
I think this teaching method will be helpful for my patients who have impaired cognition but aren’t so severely impaired that the strict protocol of spaced retrieval with errorless learning is appropriate.
Join me in learning how to improve our practice
My plan is to read the Dr. Sohlberg’s book and take the Medbridge courses. I plan to start using systematic instruction with the patients it’s appropriate for, and I’ll write about my experience.
In the meantime, I’ll write about the tools, materials, and strategies that are already working well for me.
Take a look at Powell et al’s 2012 paper and see how many steps you’re already following (page 2 and 7 of the PDF).
If you’re already using systematic instruction, I’d love to hear your success stories!
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.
Looking forward to learning more about this. Thanks for sharing.
Thank you! I’m slowly making progress and look forward to writing an update once I’ve reached a milestone of some sort!