Lecture Six
Summary: We have discussed in some depth the history of the treatment of individuals with severe mental illness. The changes in philosophy, society in general, the economy, understanding of the nature of mental illness, and the discovery of highly effective medications which control the acute symptoms of severe mental illnesses have made it possible to move to a community-based service model. These community-based services make it possible for people with severe and persistent mental illness to participate in the activities of normal life including employment.
Modern treatment of psychiatric disability recognizes the ability of idividuals with severe andlong term mental illness to benefit from rehabilitation interventions which maximize existing abilities, accommodate and supplement limitations, and create remedies for societal exclusion from educational, vocational, and social opportunities.
The remainder of our sessions together will focus on various programmatic approaches which have been found to be effective with individuals with severe, long term mental illness. This lecture will address techniques which improve cognitive functioning in people with severe mental illness.
Questions to be answered:
What is normal cognitive functioning?
How does severe, long term mental illness effect the cognitive abilities of an individual?
How is cognitive ability measured?
How can cognitive functioning be expected to improve with rehabilitation?
Hector returned home from the hospital after a six month stay during which he was placed on a number of medications, some of which seemed to help while others seemed to exacerbate existing problems or create unpleasant side effects. Hector had been a good student all the way through high school and had completed his first year of college with a 3.8 GPA. As the stress of college grew, Hector appeared to be struggling with coursework that should have been a breeze. He often missed classes and rarely completed assignments. His parents had been devastated to learn that Hector had schizophrenia but found comfort in the knowledge that medication for Hector’s condition appeared to be controlling the delusions and most of the most acute symptoms. However, he sat in the living room as if he were dazed. He seemed somehow "dull", choosing to sit for hours without moving. When he spoke, his speech was slow and garbled. He appeared to have lost his words, fumbling over simple words like "chair" and "door", using phrases like "what do you call it?" instead of nouns. He seemed to be unable to make simple connections between objects and the functions they performed, using a pencil to stir his coffee and propping a spoon behind his ear. Hector’s parents were frightened, fearing that somehow Hector had lost the fine mind that had beenhis trademark.
What is normal cognitive functioning?
Cognition is the mechanism by which one thinks and reasons. It is the processing of information taken in by the senses and the establishment of connections between isolated bits of information. Cognition and intelligence are not the same. Intellectual ability involves a variety of mechanisms for receiving and processing information. It is a raw ability to problem solve that is present in all intelligent species, that is species which have the ability to take in information and apply it to meet needs. Cognitive ability, on the other hand, is a conscious process which deals with an individual’s mental processing if information and is based in part on the emotional content of the information and the individual’s personal experiences with the information.
Normal intellectual development begins with the exercise of simple reflexes with the development of internal or symbolic representations of actions such as use of words or gestures. Children have developed the ability to use trial and error behavior and goal seeking activity to produce novel results and utilize and vary movements to create a desired result. By age two to seven, children have language and can begin to engage in symbolic representations of life. They use language in a purposeful way. By age eleven, children have developed conversation skills and can apply their mental ability to real objectsor events. After eleven years of age, individuals can think abstractly, formulate hypotheses, use deductive reasoning, and check solutions.
How does severe mental illness effect cognitive functioning?
Many individuals with severe long term mental illness show impairment in the use of executive processes, verbal memory, and attention or concentration. This means that some individuals may find verbal communication, both receptive and expressive, difficult. They may also find it difficult to make appropriate connections between pieces of information and may not be able to initiate activities without concrete direction. Other individuals may find that short term memory is affected by medication and long term memory is confused.
How is cognitive functioning measured?
There are a variety of standardized tests which measure both intellectual functioning and cognitive abilities. These tests must be administered by qualified professionals trained in the administration and interpretation of these instruments. However, the following checklist can provide useful information about the ways in which an individual is currently functioning cognitively. An accurate understanding of the cognitive abilities of clients with a psychiatric disability becomes extremely important in selecting appropriate methods for vocational assessment, training, and eventual job placment.
Cognitive Skills Checklist
Attention and concentration
Loses track of date and time
Seems confused, wanders off, or gets lost
Follows a daily routine independently
Understands what he hears or reads
Is able to clearly express his/herself
Has to have things explained
Follows directions
Seems absentminded
Seems to get distracted in the middle of things
Loses track of what he/she was doing or talking about
Has trouble following a conversation
Just stares into space
Has trouble concentrating
Remembering things
Remembers birthdays, holidays, and anniversaries
Remembers where he/she left things
Has to be reminded what to do
Forgets to keep appointment, go to social events, etc.
Forgets to take medications
Seems to pick up new information readily (people’s names, current events, etc.)
Asks the same questions over and over
Remembers familiar people’s names
Solving Problems
Seems mentally slower than others
Starts activities on his/her own
Makes the same mistakes over and over again
Seems confused by changes in routine
Finishes what he/ she starts
Sleeps or sits around unless told to do something
Shows common sense
Does things that seem foolish or dangerous
Has reasonable plans and ideas
Carries out activities in an orderly way
Does things impulsively
Adapts to unexpected events
Makes good decisions
Plans ahead
Gets stuck on particular ways of thinking or doing things
Solves practical problems
Recognizes and corrects his/her own mistakes
Considers several possibilities before settling on a preferred course of action
Appropriately asks for help when needed
Getting around
Keeps him/herself clean (bathed, washed, etc.) brushed teeth, shaved, combed hair
Plans and cooks his/her own meals
Eats a proper diet
Shows good table manners
Gets to places on his/her own
Spends his/her own money wisely
Does his/her own shopping for food and personal items
Independently does routine tasks around the home
Plans and carries out his/her own activities
Seems tactless, insensitive, or intolerant of others
It is evident from looking at the checklist above that many of the behaviors or presentations identified could appear to be the result of lack of motivation, poor social learning or lack of social exposure, level of dependency, behavioral problems, etc. However it is also apparent that these same manifestations could be the result of an inability to make concrete or abstract associations between a behavior, social expectations, and consequences. The behaviors described may be the results or errors in the thought process or an inability to process certain types of information. When the cause of these errors is a mental illness, rehabilitation can be effective in increasing or changing cognitive function.
How can cognitive functioning be improved with rehabilitation?
This class is designed to provide students with an overview of the psychiatric rehabilitation process. More detailed information on any of the topics discussed in this course are provided in other courses in the curriculum. The following section is intended to introduce you to a series tasks which can be effectively addressed in rehabilitation. The methods for addressing these tasks are covered in detail in the second course in this series,"Vocational Implications of Psychiatric Disability".
To effectively address cognitive functioning in the rehabilitation process, interventions should be aimed at the following tasks:
Identifying the contextual considerations
The type of environment the individual must adapt to (living, learning, working)
The difficulty of environmental demands (simple/complex, familiar/novel, time pressures)
Behavioral repertoire (automatized or habitual vs. capacity to respond to novelty)
Amount of structure provided by the evaluator, environment, test
The goal of clinical involvement "(teach the individual to adapt to or shape present environment
vs. change to a more fitting environment
Cognitive capacities
Attention and concentration
Adequate attention span (Digit Span)
Ability to focus on relevant information
Ability to maintain focus in the face of distractors
Ability to manipulate symbols and icons in working memory
Ability to shift focus of attention among competing stimuli
Ability to respond simultaneously to multiple tasks
Ability to learn and remember
Type of memory involved
Verbal vs. nonverbal
Declarative (facts and ideas) vs. procedural (strategies) memory
Type of materials involved (list, paired associate, narrative)
Acquisition of new information
Ability to comprehend simple and complex information
Ability to organize and rehearse new information and relate it to
existing information
Retrieval of learned information
Immediate vs. delayed recall
Amount of cuing required (free vs. cued recall vs multiple choice)
Errors of omission/commission
Ability to respond rapidly to simple, complex, competing stimuli
Ability to use information to solve problems
Ability to recognize that a problem exists
Ability to define or redefine a problem so that it can be addressed
Ability to establish an overall or long term goals and/or specific or short term goals
Ability to generate multiple solutions to a problem (verbal fluency)
Ability to use reasoning processes to organize a response
Ability to discover relationships between objects or events (part/whole,
similarities, differences)
Ability to differentiate important and/or central features from trivial details
Ability to use analytic (whole to part) and synthetic (part to whole) reasoning
processes
Ability to use inductive (specific to general) reasoning
Ability to use deductive reasoning (general to specific) reasoning (math and
logic)
Ability to think abstractly
Ability to plan an orderly sequence of steps that will lead to a solution to the
Problem
Ability to anticipate consequences (cause and effect, necessary and sufficient
conditions).
Ability to execute plans efficiently and effectively
Ability to delay a response until sufficient thinking and planning has taken place
(impulsive vs. reflective vs. obsessive style)
Ability to make a decision and initiate action.
Ability to follow an orderly plan over time
Ability to allocate time wisely
Ability to monitor progress toward the goal (vs. doing and
undoing)
Ability to persevere in the face of frustration.
Ability to evaluate the appropriateness of the response (judgment, quality
control, error monitoring)
Ability to change approach on the basis of new information
(flexibility vs. rigidity-perseveration)
Ability to change approach on the basis of new information.
Ability to generalize knowledge and skills to new situations.
Food for Thought:
Think about two of your clients, one who has a psychiatric disability and one who does not. How are they different in terms of their cognitive functioning? How are they same?
Think of the tasks in the section above as a continuum going from the simplest most basic cognitive tasks to the most complex ones. Which of the tasks are most necessary for an individual to be successful in a vocational setting? You may say that the setting determines which areas of cognitive functioning are most important. That is correct! So now think of several different types of job settings and identify those abilities which are most crucial to working in that particular setting.
What activities can you think of which would encourage cognitive development in some the areas you identified?
We will be discussing some specific activities and programs which encourage cognitive development in future sessions. In the meantime, spend some time this week focusing on the cognitive abilities of your clients and how these abilities effect their efforts to seek and maintain employment.