Hello and welcome. I'm Amy Cohen, Associate Director for SMI Advisor and a clinical psychologist. I am pleased that you're joining us for today's SMI Advisor webinar, Cognitive Skills Training to Improve Quality of Life for People with Severe and Persistent Psychiatric Disorders. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. And now I'd like to introduce you to the faculty for today's webinar, Dr. Alice Medalia. Dr. Medalia is a professor of medical psychology in psychiatry at Columbia University Medical School. She has been instrumental in raising awareness about the need to address cognition as a central aspect of health related to functional outcome. One of her key contributions to psychiatry relates to her application of motivation theories to the treatment of cognitive disorders and, more generally, psychiatric rehabilitation. By focusing on cognitive health in addition to mental health, cognitive remediation seeks to improve critical thinking skills, enabling people to be more effective in their daily lives and pursue their goals for recovery in a purposeful and meaningful way. Dr. Medalia, thank you again for leading today's webinar. Hello, and thank you, Amy. Is everyone able to see this? Yes, we can see your slides. That's great. Okay. So, I have no disclosures for this presentation. And I am hoping that at the end of the presentation, you will be able to identify cognitive health needs and how they interfere with recovery from severe psychiatric illnesses, that you'll be able to describe at least two scalable approaches to address cognitive impairment in severe psychiatric illness. And by scalable, what I mean is two approaches that you can easily put into practice, and that you'll be able to identify at least two factors that impact positive cognitive outcomes. When you have a psychiatric illness, you still want to be learning, working, socializing, having fun, and living in a comfortable place. We treat psychological problems not just to remove symptoms, but to help people achieve these goals. Yet, many people with severe and persistent psychiatric illnesses do not achieve these goals, and that raises a question. Are we treating the right symptoms? It is, to be sure, it's difficult to deal with anxiety, depression, and psychotic symptoms like hallucinations and paranoia. But it turns out that is not why so many people with persistent severe psychiatric disorders struggle to maintain employment, have friends, stay in school. Researchers have studied what symptoms are most likely to interfere with everyday functioning, and consistently the studies show that one of the biggest reasons people struggle in everyday life is because the illnesses cause people to have cognitive problems. It can be hard to know when someone is having cognitive problems. In fact, most of us are just not trained to look for it. If a friend does not show up as planned, someone might assume they did not want to meet. But maybe the real reason is they didn't plan how long it would take to get there, and they were so late that they missed the appointment. Or if you're at a restaurant and the waiter keeps needing you to repeat your order, maybe the waiter is struggling to process information quickly. What about bills that don't get paid? Maybe the person is forgetting. Most people want to remember information. They want to be attentive. Most people want to think clearly. And it can be embarrassing not to remember things. Many people try to hide their problems with cognition. Today I'll be talking about the cognitive problems, how they manifest, and what can be done to treat them. I will also be talking about another common problem caused by severe mental illnesses, decrease in motivation. Motivation refers to the processes that lead us to start, to instigate, and sustain goal-directed behavior. For example, in a learning situation like attending an exercise class, motivation leads one to sign up for the class, to attend, to stay engaged, and to persist in attending future sessions. Motivation problems are a core symptom of schizophrenia, schizoaffective disorder, depression. They impact all aspects of functioning. Motivation problems are the result of a complex interaction of neurophysiologic and social contextual determinants. And today I'll be talking a lot about the social contextual determinants. Motivation and cognitive problems interact to affect daily functioning. Let's take an example, which I think many of you would be able to relate to you for yourself or you know someone. Imagine someone's in school, but they're having difficulty getting to class. They're just not motivated, even though they value school. Their illness is having trouble making them have problems with motivation, and they're not getting to classes. As a result, this person is not developing the competencies they need to meet their goals. And after a while, they fall behind their peers, and they start to expect failure. And that expectation of failure is one of the most significant predictors of whether they're going to initiate and start going back to classes. If someone thinks they're going to fail, they're not going to want to go back. And if on top of it, they're having attention and memory problems. It makes it very difficult to meet one's functional goals. When we talk about cognitive problems, it's important to consider them in the broader context of cognitive health. This allows us to consider both cognitive strengths and weaknesses. What is cognitive health? Researchers have asked people of all ethnic and racial groups what they think cognitive health means. The most common ways people describe cognitive health is with words like staying sharp, being right in the mind, having a positive mental outlook, being alert, having a good memory, being socially involved. Knowing these are the ways most people talk about cognitive health helps us support someone who may be having cognitive problems. We can ask them if they think it would be helpful to remember or pay attention better. We can ask them for examples of when forgetfulness or inattentiveness got in the way of school or socializing. And then we can understand how cognitive problems are interfering with lives well-lived, and we can recommend specific services. There are a number of specific services that can be offered. Education about cognitive health, an assessment to identify cognitive strengths and weaknesses. Maybe someone would benefit from liaison services so they get the supports they need at work and school. And maybe someone would benefit from specific treatments to improve cognition. I will be focusing on a specific treatment called cognitive remediation for the rest of this talk. All the approaches to address cognitive health involve learning. Cognitive remediation is a learning activity. A first step is to learn what the different cognitive skills are and how we use them in everyday life. In cognitive remediation, people do cognitive exercises to learn how to remember and pay attention better. They also learn about what supports are available for cognition. For example, using cell phone apps to help remember or be more organized. We learn about different ways to support good cognitive functioning. The learning that takes place in cognitive remediation relies on neuroplasticity. Cognitive skills are the result of brain activity, and our brains are able to keep changing even when they have been injured. This is because of a process called neuroplasticity, or brain plasticity, or malleability. Knowing that the brain is able to reorganize and form new connections after injury has led to excitement to study and provide treatments for cognition. Learning does not just rely on neuroplasticity. It also relies on motivation. There are different ways we're motivated to learn, but you'll see a theme in the pictures of all the books that I've put up here. Educators have come to understand that sustained motivation to learn happens when a person values learning and willingly engages in the learning activity. For example, a person may choose to learn how to cook because they see it as useful for making friends, or maybe just because it is interesting. They may choose to learn to speak another language because it is useful to get a job, or they value the ability to communicate in different languages. These are all ways somebody might value learning. Autonomous volition means the person is learning because they chose to, not because they feel controlled or forced to. Understanding the role of motivation in learning helps us design effective learning experiences. Before people understood how important motivation is to learning, there was a model of learning, and I call it here the old model. In education, the thought was the amount people learn is simply the result of their ability, but increasingly, it was understood that's not entirely true, that there are other factors that influence learning, and now in the newer model, people appreciate that there's a reciprocal interaction between people's ability to be sure, but also the instructional techniques and how motivated somebody is to learn. This has implications for cognitive remediation because it means that the cognitive remediation programs which rely on learning can incorporate motivational teaching strategies into the program, so they're not just doing drill and practice, which would be the old model of how people learn, but instead, they're focusing both on motivation and learning. At the end of the day, though, we are providing cognitive remediation and all cognitive services to enable recovery. For this reason, cognitive services fit well in the context of recovery-oriented programs. When we sit with recovery-oriented models of care, when we address cognition, we send a message of empowerment and hope that cognition can improve. By treating cognition, we help people engage with their community in ways that are personally meaningful. Everyone can support cognitive health just by showing awareness of how important it is, and when we provide ways to improve cognition, that helps consumers get the most out of the other aspects of their treatment. For example, with improved memory and attention, it's easier to keep track of medications and it's easier to follow the discussions and skills training that are offered in therapy groups. A goal of all recovery-oriented therapies, including cognitive remediation, is to promote autonomous learning. So let's talk a little bit about autonomous learning. What is it exactly, and how would it relate to cognitive remediation? An autonomous learner is someone who attends cognitive remediation because they understand its value for them. They endorse the objectives, they're interested in the activities, and they're choosing to attend the program of their own volition. It's also useful to consider what autonomous learning is not. It's not the freedom to do whatever you want when you go into the cognitive remediation session, and it doesn't mean that you go in and take no guidance. It also, interestingly, does not just mean that you're learning independently, because after all, you could be autonomously dependent. For example, if you know you have a problem processing auditory information quickly and you're an autonomous learner, you could choose to have someone take notes for you. You would be then autonomously dependent. I've been talking about motivation and how it affects learning and how important it is to cognitive remediation, and I want to tell you about a model that helps us put all of the motivational concepts in a framework. It's called the MUSIC model. Brett Jones is a psychologist and a professor who created this model to help teachers promote a motivating learning environment. Let me explain why it's called the MUSIC model. It's an acronym, and you can see here the acronym MUSIC on the right side. The MUSIC model puts motivating strategies into one of five categories. The model's based on motivational theories and research into motivation, and it's designed for instructors who don't want to or don't need to know every motivation theory and who are particularly focused on what works. The purpose is to provide an organizational framework for instructors to use when they're designing learning programs or if they're trying to diagnose why somebody is not motivated. Let's go through the model. The empowerment, that M stands for empowerment, and in the cognitive remediation session, that would mean the person believes they have some control over an aspect of their learning. The U is for usefulness, and it means someone would understand why they are there, why it's useful to them. The S is for success, that a person believes they can succeed if they put forth the effort. The I is for interest, they're interested in what they're supposed to be learning. And the C is for caring, which stands for that belief that the people involved in the learning experience are caring and are interested in them as a person. How does this model work? Well, the idea in cognitive remediation, for example, would be that a clinician creates a motivating learning environment, that the participant perceives that, and so they feel empowered, they see the usefulness, they feel they can be successful, they find the exercises interesting, and they feel that the clinician and the people involved in the experience are caring. The person then becomes more engaged, focused, and curious, and actually learns more. And other people around can perceive that success. So does this really work? Well, there's actually some research emerging to support that. In this study that was done by Marie Hansen and colleagues from all over the world, they gave the music inventory to people before they started cognitive remediation, and also at the end. What they found across all of these sites is that people who rated their learning environment as more motivating attended the sessions with greater intensity. So you could see that those five factors are related to whether or not someone's actually showing up for the sessions. But let's go into a little more detail about how this might work in the sessions. So if you're trying to create a learning environment that is empowering, one way to do that would be to use shared decision-making about what the learning focus should be. You would speak with the person about what are the cognitive issues that are bothering them and what's important to them. How do they want to use their improved cognition in everyday life? You would offer meaningful choices to them if, for example, they're planning on focusing on attention and memory and processing speed in the session, they could have a choice about what they do first. So those are examples of two ways that you can empower a person during a session. What about the other aspects of that music model? Well, the U stands for usefulness and the I is for interest. And both of those are the way we value something. So how could the program support the value of learning? Well, one way to do that is to choose tasks that are going to be perceived of as interesting or even enjoyable. Another way to do that is to make sure that the person understands why doing these tasks is useful to them, how it helps them achieve their goals and be the kind of person they want to be. There's research to support that the way people value cognitive remediation does influence cognitive remediation outcomes. For example, in one study that I was involved with, we found that at baseline, the way people valued the cognitive treatment predicted was a significant predictor of how much cognitive change they made during cognitive remediation. In another study, they found that people who saw tasks as more useful attended sessions more regularly. In another study, they found that when you compared completers to people who were dropping out of the cognitive remediation, the completers were people who started to show more interest and enjoyment in the tasks as opposed to the non-completers whose rating of interest and enjoyment declined. In a study from Bryce's group, they found that baseline reports of how they perceived the value of the program were the only significant multivariable predictor of attending sessions when including global cognition and psychiatric symptoms. The odds of reliable cognitive improvement significantly increased with greater improvements in their interest in the program and how they valued it from baseline to end of treatment. Let's talk a bit about promoting competence and expectations of success. How does one do that in a cognitive remediation session? Well, one of the most important ways to do it is to very carefully set the difficulty level of the exercises. Set that level at a point where it's challenging, but the person can still experience success. I think another important way to promote expectations of success is to deal directly with cognitive errors or thinking errors that might involve negative self-efficacy beliefs. Take, for example, a person who sits down to do an exercise on memory and they do poorly the first time on the first trial. They look utterly dismayed and say, I give up, I'm never gonna be any good at this. Well, that's an example of a cognitive error. They made one mistake and now they think they'll never be good. And those kinds of errors can be dealt with with cognitive behavior therapy. When we believe that we can be competent and can do something, it impacts the way we choose tasks. We tend to choose more challenging tasks. We tend to put more effort onto tasks, persist longer at them. And actually those people who have more confidence in their ability to succeed tend to achieve more. There's lots of research on that in people who don't have psychiatric illnesses, but there's also research on that in people who do. So for example, here are two studies. One found that the expectation of success was associated with attendance to cognitive remediation. And in another study from Choi and his group, they found that baseline expectations of success predicted persistence of learning on tasks three months after the cognitive remediation ended. Even after accounting for variance attributable to different instruction, baseline ability, attention and self-reports of task interest and task value. So both of these studies highlight how important perceived competency is. And finally, let's talk about the C in the music model, caring. How can a learning environment support relatedness so that people feel connected to others and feel they belong and they matter? Well, convey respect for the individual, provide opportunities for them to feel valued and significant, convey concern when they face challenges, create an atmosphere of warmth and inclusion so the participant feels liked and provide opportunities for each participant to give not just receive. So for example, maybe one person wants to show another how to do a cognitive exercise. There's research to support the importance of relatedness. Some of the studies look at the relationship to the therapist and other studies look at the relationship to peers. In two studies, they found that the relationship to the therapist was important. When the therapeutic alliance was stronger, people made more cognitive and functional gains. And when people view the alliance favorably, they stayed in treatment longer and were more likely to improve on their main cognitive complaint. There's also evidence that when people perceive peers positively, that's helpful. When participants work with peers, they might make more cognitive gains. That's what was shown in the Sandoval study than those who don't work with peers. And one of my favorite quotes, I often ask people in cognitive remediation, why do you like to come here? Or why do you come here? What are you hoping to do here? And one woman said to me, I come here for the people, the socializing. She didn't say she was there to improve her memory or cognitive skills. She very clearly said she was there primarily for the socializing. So putting this all together, when we design cognitive remediation programs, it's important to think about motivation and to think that individuals are gonna be most motivated to engage in tasks if they believe they had a choice, that they made the decision to be engaged, if they value learning and think they will be competent at the task and they experience the accompanying social interactions positively. Now I'm gonna shift, cause I want to address some of the most common questions I often get about cognitive remediation. I call this the who, how and what. So the first question we get asked a lot is, do we have to call this cognitive remediation? And I think that's a really great question because it acknowledges that in fact, it's not a very pleasant name. Who would really want to join a group called cognitive remediation? Names matter. And when I talk to people who are participating in the program and say, what would you like to call the program? What do you think is a good name? They usually come up with names like learning center, brain gym, thinking well. And indeed that's what many programs will call themselves. But what exactly goes on in a cognitive remediation session? I think one of the most helpful things is to actually look at a session. And so I want to show you a video. Recovery is possible. I feel better about myself. It gives me hope. I'm happy. It's the support and the friendship. I look forward to each day. It's just a great resource to have. I think the thinking well program has helped him a lot. Plus I see he's a little bit more focused. He remembers things. It has really made a big difference. Even after symptoms of mental illness have been treated and controlled, certain levels of cognitive impairment interfere with daily life. At Laurel House, our thinking well program is addressing that with working on all around wellness and improving cognition. Thinking well starts with a technique called cognitive remediation. So you got two things to pay attention to. One is the menu, right? This part of the program centers on computer-based drills that help people practice and improve their thinking skills in areas like memory, attention, problem solving. Thinking well is basically a fitness program for the brain. It gives your brain a workout. What cognitive skill were you using? Then we follow up with additional cognitive training that helps people apply those skills to real life situations. I get lost because I've been on the computer and I've been chatting away and I have trouble paying what? Attention. Yeah. I think because of Laurel House and of the thinking well program, something triggered in him that he said, no, I have to get my health together. So it has made a huge, huge difference in Shoal's life, in our life. So that gave you a picture literally of what a cognitive remediation group might look like. And that's at a place in Connecticut, Laurel House, and they call their program thinking well. And you could see that in the sessions, there was a portion of the session where people actually were doing exercises. And then there was a discussion group afterwards where they talk about how to use cognitive skills in everyday life. So that's a bit of an overview of what might actually happen. Another common question is who exactly should we be referring for this treatment? So let's talk about that. One way of thinking about who should be referred is to consider who participates in the research that shows that cognitive remediation is effective. From that vantage point, we learn that in the research base, cognitive remediation is effective when it's provided to people who are 18 to 65 years old. They have a psychiatric illness, usually in the largest research bases with people who have schizophrenia, schizoaffective disorder, and some of the affective disorders. So there's a number of studies with participants with those diagnoses. People who are participating in the cognitive remediation research have IQs that are intellectual functioning broadly within normal limits, at least a fourth grade reading level. Usually there's no substance dependence. And I do wanna highlight there, it's dependence. It may be that people have some use of substances, but they're not dependent. And usually there's no recent head trauma. So the bulk of the research showing that cognitive remediation is effective is based on participants who kind of meet these criteria. So that's one way of looking at who should participate. But there's another way of looking at it, and that's in your clinical practice. I think when you're trying to figure out who should be referred, it actually starts with two questions. What is it you wanna be accomplishing in the next months? And would better cognitive health help you meet that goal? So if somebody is saying, you know what? Yeah, I think if I could attend better, or a lot of people will say, I am having so much trouble reading, or they might say I'm having trouble paying attention. If that is being discussed as something that's interfering with them being able to accomplish the things that matter to them, then it's important to consider a referral for cognitive health services. What does that exactly mean? Well, maybe a first step is just to be sure that there's nothing easy to fix that is causing cognitive problems. I mean, if the person, for example, is not sleeping, most people don't attend well if they're not getting enough sleep. So it's important to address things like sleep or make sure they're taking their medications as prescribed so that they're not sleepy during the day. But once you are sure that all of those things have been addressed, if someone's still having cognitive problems, it makes sense to refer them to cognitive remediation. Let's talk about John as an example. John's somebody who was at college when he first got depressed. He couldn't concentrate on his schoolwork, was having trouble remembering new information. He fell behind and actually wasn't able to pass his courses. He took medical leave from school and got treatment. The medication and psychotherapy helped his mood improve and he returned to school. However, the cognitive deficits remained untreated and he continued to have problems with attention and memory. He got behind in his schoolwork and this caused him tremendous stress and anxiety. He actually spiraled into another depressive episode and needed to leave school once again. But this time he was referred to cognitive remediation. So let's talk about whether attending cognitive remediation helps and how it helps. As I mentioned earlier, the bulk of studies on cognitive remediation have been done with people who have schizophrenia, schizoaffective disorder and affective disorders. Within that research base, there's evidence that cognitive remediation is effective across the adult lifespan for both cognition and functional outcome. There's evidence also that cognitive remediation pairs very well with many of the treatments that are offered in recovery oriented programs. In fact, when cognitive remediation is paired with something like social skills training or supportive employment or supportive education, there's evidence that the outcomes, functional outcomes are even better than if you didn't pair it with those treatments. Finally, when you do cognitive remediation, there's evidence that you can see benefit not only in cognition and in functional outcome, but also in brain physiology. So that's what the research base shows, but I think it's really important to consider what the individual's perspective is. And so I want to show you the video where Steve describes what it was like for him to participate in cognitive remediation in the context of a broader recovery program. Steve recently came to Laurel House suffering from anxiety and fear of socialization. He joined the Thinking Well program and noticed immediate improvement. I felt like, in my head at least, that I had more social skills than people were giving me credit for. And Thinking Well has really proven to me that yeah, I do have those skills. When you do brain exercises, you definitely see, well, basically you see more clearly. It really sharpens all your thinking skills. These will translate out to pretty much any aspect of your life. Navigating traffic, navigating the grocery store, it just improves your overall skills in navigating life, essentially. I guess it gives me more of a sense of normal. I think one of the biggest things I've taken away from Laurel House is being able to trust myself. All those years of feeling like I'm doing something wrong or just things just weren't connecting and my mind wasn't doing what I wanted it to do, now I find that I have this skillset and I have a better understanding of who I am and kind of what my values are, which has led to a greater sense of self-trust. And I think that's the biggest thing for me, is if I have that trust in myself, I can do anything. So that's one person's perspective on what it was like for them to participate. And so now we're coming to the end of this webinar and I just wanna sum up some of the things that we talked about. We talked about how cognitive remediation is a way of addressing cognitive health so that it's easier for somebody to function in everyday life and to achieve their goals. We talked about how important motivation is for learning and for cognitive remediation and specifically talked about how important it is that people feel engaged in the tasks, they feel they had a choice to come to the treatment, they value it, that the experience is empowering, that they find that they can be successful experience interpersonal interactions to be caring and supportive. At the end of the day, cognitive remediation is a recovery oriented service. So that's the end of this webinar and I thank you very much. I think now we can move on to the next part, which is questions and answers.

cognitive skills training

severe and persistent psychiatric disorders

cognitive remediation

functional outcomes

cognition

motivation

MUSIC model

cognitive health