Cognitive rehab and CBT in OT groups

What is cognitive rehab?

• relearning, had skill and lost it due ti injury like stroke

• originally designed for acquired brain injuries

Why does cognitive rehab and cognitive behavior matter?

• clients with acquired brain injuries or mental health challenges struggle with COGNITION and DISTORTED thinking

What is the OT role in cognitive rehab and cognitive behavior?

help clients use strategies to improve daily occupations

Groups = safe space to practice skills, receive feedback, and build routines

COGNITIVE REHAB:

Cognitive Strategies: Multi-contextual approach

What is the multi-contextual approach: 2 steps

1. self-awareness: metacognition- retraining (still think they can do it, but they cannot bc its a safety issue)

2. the practice of cognitive strategies: graded activities to transfer learning

= Generalizing skills (real life)

COGNITIVE REHAB:

Cognitive Strategies: Multi-contextual approach step 1

Why does step 1 (self-awareness and online awareness) of the multi-contextual approach matter?

• SA: improves awareness of strengths and limitations

• OA: ability to judge task demands/anticipate problems and change behaviors

COGNITIVE REHAB:

Cognitive Strategies: Step 1: self awareness and online awareness

What does impairments in SA and OA result in?

• misjudgments of task completion resulting in danger or reduction in self-efficacy

• danger to self and others

COGNITIVE REHAB:

Cognitive Strategies: Multi-contextual Approach step 1

What does self-awareness training begin with?

• begins with familiar task - just right challenge

• can compare previous experiences with current performance and any difficulties that arise

• if person cannot successfully complete task, you might lose them so make it just right for the client

COGNITIVE REHAB:

Cognitive Strategies: Multi-contextual Approach step 1

How does self-awareness training help the client?

• training increases metacognition:

  • understanding current processes and cognition

  • developing self monitoring strategies

  • evaluation of task difficulty

  • predicting consequences

  • planning for problems

  • recognizing errors

COGNITIVE REHAB:

Cognitive Strategies: Multi-contextual approach step 1

What are some self-awareness techniques?

1. Self-prediction

2. self-rating of goals or strategy use

3. videotaped feedback

4. self-questioning

5. self-evaluation

6. journaling

COGNITIVE REHAB:

Cognitive Strategies: Multi-contextual approach step 1

How does self-awareness play into groups and some OT group examples?

• Should be addressed first before remediation or compensation

• OT group examples:

  • predict and perform, feedback, emotional check-ins

  • goal ex: client will accurately identify 1 area of difficulty during a group task in 2/4 sessions

COGNITIVE REHAB:

Cognitive Strategies: Step 2- Cognitive Strategies

What do cognitive strategies address?

• “mind tools” address cognitive impairments like:

  • orientation

  • attention

  • memory

  • motor planning

  • spatial neglect

  • vision processing

  • executive functioning

  • planning

  • organizing

  • budgeting

  • higher level processing

COGNITIVE REHAB:

Cognitive Strategies: Step 2- Cognitive Strategies'

What are some examples of cognitive mind tools?

• strategies to support daily function

• examples: sorting, categorizing, sequencing, time management, visualization, checklists

• goal example: client will use a checklist to complete a 5-step cooking task with less than 2 errors

COGNITIVE REHAB:

Cognitive Strategies: The multi-contextual approach

How do you sequence cognitive strategies?

1. start with impair cognitive fx (visual scanning, categorizing, classifications and sequencing)

2. complexity increases gradually (planning, problem solving)

3. finally moving onto practice in real life (functional tasks, paper and pencil exercises, computer work)

COGNITIVE BEHAVIORAL THERAPY:

What is CBT?

• thoughts, feelings, and behaviors influence each other

• CBT helps clients recognize unhelpful patterns and practice different responses

COGNITIVE BEHAVIORAL THERAPY:

How do OTs use CBT?

OTs use CBT to help the client to identify, analyze then modify their thinking using their own cognition

COGNITIVE BEHAVIORAL THERAPY:

What are different examples of thinking traps?

• all or nothing thinking: “if my project isn’t perfect, it’s a failure”

• overgeneralizing: “i burned my dinner once. I am terrible at cooking”

• predicting the worst: “if i make a mistake at work, i’ll lose my job”

• mind reading: “everyone in the group thinks i’m incompetent”

COGNITIVE BEHAVIORAL THERAPY:

What are cognitive strategies OTs can use? (4 steps)

1. identify automatic thoughts: what went through your mind

2. evaluate thoughts: how do you know that will happen

3. develop balanced self-talk

4. THE GOAL IS REALISTIC THINKING - NOT SIMPLY POSITIVE THINKING

COGNITIVE BEHAVIORAL THERAPY:

How does reframing to find a balanced thought works?

reframing: looking at a thought and finding a more realistic, helpful way to understand the situation

• notice: What am i telling myself?

• check: What evidence supports this? What evidence suggests something else?

• reframe: what thought considers both the difficulty and what I can do

COGNITIVE BEHAVIORAL THERAPY:

What do balanced thoughts do?

balanced thoughts acknowledge challenges and leave room for action

COGNITIVE BEHAVIORAL THERAPY:

Find a balanced thought for these unhelpful thought examples

1. “if i need help, i’ve failed”

2. “i always mess up when cooking”

3. “everyone will judge me in the group”

4. “if my project isn’t perfect, its worthless”

1. “if i need help, i’ve failed” → “asking for help is a part of learning”

2. “i always mess up when cooking” → “some meals have been difficult. I can start with a familiar recipe”

3. “everyone will judge me in the group” → “i don’t know what others will think. I can try talking to one person”

4. “if my project isn’t perfect, its worthless” → “it can have mistakes and still be useful or meaningful”

COGNITIVE BEHAVIORAL THERAPY:

Strategies to help clients take action:

Behavioral Activation

plan a meaningful activity when motivation is low

COGNITIVE BEHAVIORAL THERAPY:

Strategies to help clients take action:

Graded exposure:

start small and gradually face a feared activity (GO SLOW)

COGNITIVE BEHAVIORAL THERAPY:

Strategies to help clients take action:

Behavioral experiment:

test a prediction: try something and see what happens

COGNITIVE BEHAVIORAL THERAPY:

Strategies to help clients take action:

Solve a problem

make a plan, try it, and adjust

COGNITIVE BEHAVIORAL THERAPY:

Connecting CBT to Occupation:

Situation: a client wants to return to grocery shopping

Thought:

feeling:

behavior:

occupational impact:

Thought: “i won’t be able to handle it”

feeling: anxiety

behavior: avoids the store

occupational impact: relies on others for shopping

• OT helps the client explore the thought and practice manageable steps toward shopping

COGNITIVE BEHAVIORAL THERAPY:

How does the OT help carryover?

1. choose a small goal together

2. give the client opportunities to practice

3. discuss what worked and what they learned

4. plan what they will try at home

5. GOAL = self-efficacy

COGNITIVE BEHAVIORAL THERAPY:

CBT in OT: what are the simple steps of CBT in OT

1. choose an occupation: what does the client want or need to do

2. explore the pattern: what are they thinking, feeling, and doing

3. choose a strategy together: explore the thought, plan an action, or both

4. practice through doing: try the activity and observe what happens

5. reflect and carry over: what did they learn? What will they try in daily life?

WRAP UP:

What do cognitive rehab strategies do?

build skills for daily life

WRAP UP:

What do cognitive behavioral therapy techniques do?

challenge unhelpful thoughts in occupation

WRAP UP:

What do OTs do for CBT and cognitive rehab?

facilitators of change, awareness and participation