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Cognitive Skills Training to Improve Quality of Li ...
Presentation Q&A
Presentation Q&A
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So, Dr. Medalia, questions have been rolling in. So I wanted to start with one where someone asked, how do I know where to find a cognitive remediation program for my clients? That's such a great question because there isn't an easy way to know. But I think that there are a couple of resources I would recommend. There's something called rtor.org, which would be a starting place to ask that question. I think if there's a local, if there are universities in the area, going to the psychiatry department might be a way to ask the question. Cognitive remediation is not at all widely available. It's really just beginning to become available. And so it's a bit of a challenge to try to find the programs. And to be honest, I get many emails from people asking me those questions and I'm always happy to try and answer it. But the other place to go maybe would be NAMI and to see if they're aware of any resources. So I guess I'm suggesting rtor.org and NAMI and certainly nearby universities, Department of Psychiatry. Or to talk to your therapist or psychiatrist, other people on the team to see if they're aware of places that are offering it. Great. Are there smaller time-limited interventions that a psychiatrist could use in a session with a patient? In one session? Is that the question? Well, over a couple of sessions. Basically, are there things that a psychiatrist could do to improve cognitive health within a session? I do think that just helping people to become aware of the concept of cognitive health, to start talking about it openly, to think about attention and memory, so just incorporating it into the discussion, it is really helpful because that increases what we call metacognition, someone's ability to think about their thinking. When someone becomes more aware of when they're having problems and when they're not, then they can start to develop strategies. So in a psychiatric session, it's possible to suggest compensatory strategies. So if somebody says, I keep forgetting things, then you can have a discussion with somebody about when does this happen or would it help to take notes? Would it help to have an agenda? Would it help to be more organized? So those are very important and helpful ways to address cognitive health that are not as intensive. Wonderful. So a lot of people are, I've had several people write in that they know someone or have a family member who's done cognitive remediation and found it difficult to find, but once they found it, it was really, really helpful. So someone also wrote in and said, I'm an employment specialist working a Medicaid benefits supported employment program. How do we go about getting trained so that we can offer cognitive remediation as part of this program? How does someone become a trainer or be able to deliver cognitive remediation? So right now, the cognitive training is sort of offered by a few people in a few places. I have a formal program with certificates and there's a website called teachrecovery.com with lectures and those are ways with systematic training how to deliver cognitive remediation. So if you go to www.teachrecovery.com, that is one place where you could learn about training for it. There are also books available. There's some manuals that will teach you how to set up a cognitive remediation program that's available. And there are websites that offer manuals and workbooks to people so that they can learn how to deliver it. There's a website called Cogsmart that has manuals and training materials so you can learn how to do compensatory style cognitive remediation. Wonderful. And someone pointed out that the Cogsmart app is available within SMI Advisor and has said that they found that to be helpful. So that's great. Yeah. Yeah. Yeah. This person wrote in and said, I work in a forensic state hospital and I work with clients who often function at a much lower level than you described in the research database. Are you aware of any research around cognitive remediation taking place in settings like hers? There actually is a growing literature in that area. First of all, it's such an important question, an important area to do this kind of work. So there are a few studies. And I would say at this point, people are still trying to figure out what's the best way to go about addressing cognitive health in those settings. But there's definitely interest in it. And there are some papers on the topic. And whoever wrote that question is absolutely right. Because in forensic settings, there's a very, very high incidence of learning disabilities and attention deficit disorders. So people who then later develop severe psychiatric illnesses, they're coming into those illnesses already with cognitive problems. So it is a challenging population. But I would say that many of the things that I've actually done a little bit of work in forensic settings, and many of the things I talked about today about setting up learning environments that are motivating, it really, it's very, very true for those settings as well. You just have to be quite sure that you are providing exercises that are appropriate for the person's level, so that they can experience success. Terrific. Good news. Someone wrote in and said, I'm also at a state forensic facility. We have cognitive remediation, and we're writing up our results. So that's great. Okay. I hope they would let me know for the next Cognitive Remediation and Psychiatry Conference was canceled this year because of COVID, but we will be doing it next year in June. And we always welcome research. Wonderful, wonderful. So another person wrote in and said, and I think you've covered this, but if you could just review, what are the criteria for symptoms or level of recovery to be able to participate in cognitive remediation? That's such a great question. And I actually, I don't think I did specifically cover that. So I'm really glad that was asked. You know, it's fine for people to be symptomatic and participate as long as somebody has sufficient behavioral control to be able to sit for a period of time at the computer and to participate. That's fine. I have had participants who are very actively hallucinating and are experiencing delusions, but they are sitting in the sessions and working on the exercises. So it's not so much whether their symptoms are there, but whether someone has sufficient behavioral control to be working, sitting at the computer. And so that's pretty much most people. And so, I mean, we've even done cognitive remediation in inpatient settings and where you might expect more behavioral discontrol, but many people were happily participating in the program. Is there a minimum level of daily exercises and a length of period of exercises that have to be done before you can see a real change in cognition? That's another really great question. Those are some of the kinds of questions that researchers are still trying to get a better handle on. So right now, if you look at the meta-analytic studies that are combining all of the studies, they're showing that on average, people had 32 sessions twice a week. So over 16 weeks, they went twice a week, but there's a tremendous amount of variability in programs. Some programs have many more sessions during the week. There's a trend for younger people to be participating in less sessions, like maybe 24 sessions and showing improvement. So I think this is an area that we're still understanding. But I would say that, you know, there's some evidence that even 10 sessions or 12 sessions can be helpful to some people. But the bulk of the literature is showing that people maybe are participating in at least 24 sessions. And another interesting thing is that often the benefits are a little bit delayed. And some of that is, you know, as people actually get out there and start using the skills and getting more confident, it seems like that's helpful. Have you seen any differences by age groups or by gender? Another great question. So gender, not so much, but age group is certainly an area of a lot of interest. There's some evidence that the younger people, as I was describing just a minute ago, maybe need less sessions to start showing gains. They're a little quicker. But you know, at the end of the day, I think it's really important to be trying to be flexible and personalized in your treatment. So it's useful to sort of think, well, on average, a younger person might need 24 sessions. A person in their 30s and 40s might need, and older might need 32. But to be flexible, maybe somebody needs a lot. One person needs a lot less and another person needs a lot more. And I think the last question that we'll take is, how do you begin a conversation with a client about cognitive remediation? If they don't have the insight into their cognitive problems? Another really great question. So I usually like to take a more strengths-based approach. And my conversation is usually, I'm interested to know what they value. What do they care about? And so my questions are, what is it you want to be doing in the next month or so? And usually I'll say, you know, would it be helpful to you if you could remember better? And asking the question that way, I tend to get a very different kind of response than if I say, do you have memory problems? Because a lot of times if I say, do you have problems with whatever it is, the answer could be no. But if I say, do you wish that you could remember better, you know, people are much more comfortable having that conversation. So that's what I would suggest is that you sort of link it to what somebody values and use a strengths-based approach. Wonderful. Well, I'm going to stop with the question.
Video Summary
In this video discussion, Dr. Medalia answers questions related to cognitive remediation programs. She recommends resources such as rtor.org, NAMI, and local universities' psychiatry departments to find such programs. Dr. Medalia also suggests smaller interventions that psychiatrists can use during sessions to improve cognitive health, such as discussing cognitive health openly, increasing metacognition, and suggesting compensatory strategies. She mentions teachrecovery.com, books, manuals, and websites like Cogsmart as resources for training in delivering cognitive remediation programs. Dr. Medalia acknowledges the growing literature on cognitive remediation in forensic settings and highlights the importance of providing appropriate exercises for success in learning environments. She also addresses criteria for participation, the duration and frequency of exercises, and the potential delayed benefits of cognitive remediation. Lastly, Dr. Medalia advises initiating conversations about cognitive remediation by linking them to the client's values and using a strengths-based approach.
Keywords
cognitive remediation programs
smaller interventions
learning environments
forensic settings
strengths-based approach
Funding for SMI Adviser was made possible by Grant No. SM080818 from SAMHSA of the U.S. Department of Health and Human Services (HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, SAMHSA/HHS or the U.S. Government.
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