Professors McKay Moore Sohlberg and Lyn S. Turkstra share six questions to help us plan cognitive therapy, one for each of the familiar sequence of WHO, WHAT, WHERE, WHEN, WHY, and HOW. I highly recommend their book, as well as Dr. Sohlberg’s two 2.5-hour MedBridge courses on systematic instruction. Systematic instruction is a research-based instructional method that we can use to help our patients learn and generalize facts, skills, procedures, and strategies.
Free DIRECT download: 6 questions to plan cognitive therapy (cheat sheet). (Email subscribers get free access to all the resources in the Free Subscription Library.)
Outline:
- The sources for this article.
- So, what is systematic instruction?
- The PIE training framework.
- 4 steps for planning cognitive therapy.
- Plan cognitive therapy with 6 questions.
- What do we need to know about our patient?
- How do we learn about our patient?
- Check out a research paper, book, or course to learn more.
- Related Eat, Speak, & Think posts.
The sources for this article
Systematic Instruction (MedBridge course part 1)
McKay Moore Sohlberg, PhD, CCC-SLP presented a 2.5 hour-long course titled Systematic Instruction: Training Techniques That Generalize When Clients Have Acquired Memory Impairments. (If you purchase a subscription through this affiliate link, you will support Eat, Speak, & Think at no extra cost to yourself.)
Chapter One presents the rationale for the course. Dr. Sohlberg mentions that we aren’t really taught teaching methods in graduate school, but we do have the foundation to become excellent instructors. She also compares systematic instruction with conventional instruction and includes examples. Chapter One ends with a summary of the research and recommendations for intervention.
In the second chapter, Dr. Sohlberg discusses memory theory, pointing out that we want to exploit our patients’ strengths while compensating for their weaknesses. She presents the stages for memory and the neuroanatomical correlates, then goes into detail on the different types of memory. Dr. Sohlberg finishes this section by discussing the factors that enhance memory and how to apply memory theory in therapy.
Chapter Three discusses the PIE instruction framework in depth. The three components are Planning, Implementation, and Evaluation. I give an overview below, but see the courses or her book for more detail.
In the final chapter, Dr. Sohlberg teaches the instructional techniques. She gives specific examples for how to develop a training plan for our patients. She describes the structure for the initial training session with a specific example, as well as how to monitor progress over time. Dr. Sohlberg shows how she takes data and gives several examples. She discusses how to improve engagement, mastery, and generalization. And she ends by discussing how we can evaluate our patient’s response to therapy.
Case Studies (Medbridge course part 2)
In the 2.5-hour long course titled Systematic Instruction: Case Studies, Dr. Sohlberg shares several actual therapy sessions, patient interviews, and discussion on how to implement systematic instruction. (If you purchase a subscription through this affiliate link, you will support Eat, Speak, & Think at no extra cost to yourself.)
Chapter One is dedicated to a very brief review of systematic instruction. Then she discusses how to analyze tasks, how to minimize errors, and how to modify therapy. This section concludes with a discussion on how to promote active engagement.
In the second chapter, Dr. Sohlberg shows us therapy sessions with a woman who is learning to use a LiveScribe pen* to help her with note-taking in college classes.
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In Chapter Three, she shares therapy sessions with an older woman who’s experiencing difficulty with performing daily activities, such as making an omelet or putting air in a bike tire. In the final chapter, Dr. Sohlberg interviews patients about their experiences dealing with brain injury.
I found it very helpful to watch Dr. Sohlberg implementing systematic instruction with real patients. Not only was it helpful to see how to train people in using technology or a problem solving strategy, it was also helpful to see how she dealt with little issues that arose during the session.
Optimizing Cognitive Rehabilitation (book)
Optimizing Cognitive Rehabilitation: Effective Instructional Methods* is written by McKay Moore Sohlberg and Lyn S. Turkstra. This book has 10 chapters divided into two parts.
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Part I is Foundations. This section covers the research evidence in detail. Then two guest authors wrote a chapter called “The Learning Context: Beyond Practice (What They Didn’t Teach You In Graduate School).” This section concludes with an in-depth discussion of the PIE training framework.
Part II is The Training Procedures. The six chapters in this section discuss how to provide therapy to train people to remember:
- Facts and concepts.
- Functional multi-step routines.
- External cognitive aids.
- Metacognitive strategies.
Professors Sohlberg and Turkstra present a chapter on training social skills and conclude by sharing tips for clinicians wanting to implement systematic instruction.
The book includes a 26-page digital download.
So, what is systematic instruction?
Systematic instruction is a research-based method for teaching information, procedures, or strategies to people who have a memory impairment.
The defining characteristic of systematic instruction is the deliberate and explicit delivery of information in a way designed to maximize retention.
Sohlberg, M. M., & Turkstra, L. S. (2011). Optimizing Cognitive Rehabilitation: Effective Instructional Methods. The Guildford Press
Using this approach, we would strive to keep our patient from making errors during the acquisition phase, as making mistakes may interfere with knowledge or skill acquisition. This is done through errorless learning and/or the method of vanishing cues.
I’ve written extensively about errorless learning, including this tutorial. The method of vanishing cues is a “most-to-least” cueing system, in which we start off by giving max cues to prevent errors, then gradually fade the cues.
Using systematic instruction, you may also use other training methods, such as elaboration, visualization, mnemonics, or strategy training.
Systematic instruction encompasses much more than simply how to teach during the session. It emphasizes:
- Understanding our patient through a needs assessment.
- Knowing our patient’s environment.
- Being crystal clear on what we are going to teach and why.
- Deciding how we will teach.
- Implementing strategies to increase our patient’s engagement with therapy.
- Providing intervention following best practices.
- Collecting data and evaluating our patient’s response.
- Adjusting therapy as needed.
- Training a caregiver to provide errorless teaching at home.
The PIE training framework
Sohlberg & Turkstra (2011) adopt the PIE framework, a general model that is applied to many fields to measure the impact of a program or intervention. PIE stands for Plan, Implement, Evaluate.
Just as we teach our patients executive function strategies, like PLAN – DO – REVIEW, we also should apply the same steps to our own performance as clinicians, specifically, assessing how our intervention is impacting our patients.
Planning is a critical component of systematic instruction, and it’s something that we may not always give enough consideration to. There are four steps to planning cognitive therapy.
4 steps for planning cognitive therapy
Sohlberg & Turkstra (2011) have laid out four steps for planning effective therapy (page 66):
- Identify key learner characteristics.
- Define the treatment target.
- Specify the desired outcome.
- Design an individualized training plan.
We can complete these four steps by asking ourselves the following six questions.
Plan cognitive therapy with 6 questions
Sohlberg & Turkstra (2011) have identified the following six questions as important to consider as we plan treatment for our patients (page 66):
- WHO is the learner?
- WHAT am I teaching that will support life participation for this learner?
- WHERE is the target environment?
- WHEN will the learner implement it?
- WHY am I training this target?
- HOW will I teach the target?
In this article, I’ll discuss the first step in planning therapy, which is identifying key learner characteristics or understanding WHO your patient is as a learner.
The WHAT, WHERE, WHEN, and WHY questions are likely self-explanatory to the clinician.
The WHAT and WHY are related to making the therapy meaningful. We should make sure that we are teaching something that is going to be functional for that specific patient. It should result in some meaningful improvement in their day-to-day life. You can read more about how to decide WHAT to teach and WHY in this post on collaborative goal setting.
The WHERE and WHEN are important to consider, as well. If at all possible, practice the skill in the target environment (or a similar one). Knowing WHEN our patient will be using that skill may influence how we teach it.
Covering HOW is beyond the scope of this article, as I can’t begin to imagine how to summarize the content of five hours of MedBridge courses and a 292-page book in a blog post!
What do we need to know about our patient?
The first question, “WHO is the learner?,” is all about getting to know your patient. It’s very important that we understand our patient so that we can:
- Decide whether systematic instruction would be a good fit.
- Choose therapy targets that will be meaningful.
- Design a good instructional plan.
For each client, we should consider five domains:
- Cognitive-linguistic strengths and weaknesses.
- Physical ability and limitations.
- Sensory abilities.
- Psychological concerns, including self-awareness and motivation.
- Social support.
Depending on the situation, we may be teaching a care partner rather than our patient. It’s still important to consider these factors as they relate to the care partner, being mindful that this instruction may add stress to their life. In the long run, our instruction should reduce the burden of caring for our patient, but it’s important that the caregiver is willing and able to dedicate the time to learn and practice what we teach.
Sohlberg & Turkstra (2011) discuss how to identify key learner characteristics in detail in their book (pages 66 – 68) along with a detailed example of how each of the five domains may affect the therapist’s decision-making for training the use of an external memory aid.
How do we learn about our patient?
We likely have a solid understanding of how to learn about our patient. We can engage in various assessment activities, such as:
- Chart review.
- Patient/family/staff interview.
- Patient or informant questionnaires.
- Observation.
- Standardized assessment.
- Dynamic assessment.
- Motivational interviewing.
As we move through our initial assessment process, we’re building a picture of our patient’s strengths and weaknesses. We’re learning about their frustrations and desired outcomes for therapy. And we’re learning about possible supports or barriers to benefiting from intervention, such as emotional state, insight, preconceptions about their prognosis, and their social situation.
Check out a paper, course, or book to learn more
Learn more by checking out one of the following papers, the MedBridge courses or the book mentioned above, or by searching online for other resources.
- Powell, L. E., Glang, A., & Ettel, D. (2013). Systematic Assessment and Instruction of Assistive Technology for Cognition (ATC) Following Brain Injury: An Introduction. Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders, 23(2), 59–68. https://doi.org/10.1044/nnsld23.2.59
- Powell, L. E., Glang, A., Ettel, D., Todis, B., Sohlberg, M. M., & Albin, R. (2012). Systematic instruction for individuals with acquired brain injury: results of a randomised controlled trial. Neuropsychological rehabilitation, 22(1), 85–112. https://doi.org/10.1080/09602011.2011.640466 [open access]
- Spencer, K. A., Paul, J., Brown, K. A., Ellerbrock, T., & Sohlberg, M. M. (2020). Cognitive rehabilitation for individuals with Parkinson’s disease: Developing and piloting an external aids treatment program. American Journal of Speech-Language Pathology, 29(1), 1–19. https://doi.org/10.1044/2019_AJSLP-19-0078
Related Eat, Speak, & Think posts
- 18 free cognitive assessment tools.
- Useful tools to help people with cognitive impairment.
- Assess readiness to change for better therapy outcomes.
- Collaborative goal-setting to identify meaningful cognitive goals.
- Tutorial: How to use spaced retrieval with errorless learning to improve memory.
- Writing SMART memory goals for a reluctant patient.
Free DIRECT download: 6 questions to plan cognitive therapy (cheat sheet). (Email subscribers get free access to all the resources in the Free Subscription Library.)
Featured image by Tero Vesalainen from pixabay.
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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