Incorporating Cognitive Interventions

FEGS is a not-for-profit human services agency with mental health programs throughout the New York metropolitan area, serving 18,000 people with mental illness annually. For the past eight years, FEGS has been committed to integrating the latest developments in cognitive interventions into all of its rehabilitation programs. This has meant developing extensive relationships with academic and clinical researchers in the field of cognition and mental illness, to provide modern tools and interventions to enhance clients' outcomes in rehabilitation programs.

The first steps to incorporating cognition in treatment initially were funded through a grant by the New York State Office of Mental Health and were focused on implementing cognitive remediation. Building upon this initiative, FEGS is developing further interventions for treating cognitive deficits, focusing on two important areas: first, assessment and measurement of cognitive processes and, second, improving individualized interventions to improve cognitive skills (e.g., cognitive remediation). This two-pronged approach is necessary to assess the impact of cognitive interventions on functional outcomes (e.g., achieving employment) in the SPMI population. FEGS recognizes the importance of underpinning any new treatment developments with a methodology for assessing and measuring outcomes.

Creating Cognitive Assessments

While we have used well-established methods of assessing symptomatology and its impact on activities of daily life, we recognize that this is not the same as ascertaining specific domains of cognitive deficits that may be impeding progress. We are working with leading researchers of cognitive assessment to introduce simple and useful performance-based assessments that can be administered by rehabilitation staff in 20 minutes.

In particular, Dr. Philip Harvey, professor of psychiatry at Mount Sinai School of Medicine, has worked on refining the cognitive assessment process, which can be more easily utilized in rehabilitation programs.7,8 We are working with him in the deployment of performance-based skills assessment in our rehabilitation programs, with the intention of using such assessments to direct service planning and intervention. These short assessments will allow us to quantify a variety of daily activity skills including communication skills and financial management and planning.

Measuring Outcomes

We currently are piloting a new computer-based cognitive testing system called Mindstreams (http://www.neurotrax.com) in our rehab programs. Any staff member with a college-level education can administer the assessment software and be trained in understanding and using the results for treatment planning. As well as providing data for guiding treatment, the software also allows the consumer and staff to track outcomes and identify strengths and deficits. The program has been widely used by neurologists in a dementia population9 and is now developing wide support for use in both adult and child psychiatry.10 The system taps into four major cognitive domains instrumental for recovery and achieving outcomes such as employment or further education: Executive Functioning (decision making), Memory, Attention, and Information Processing. Information about these cognitive domains helps staff plan more effective and individualized cognitive remediation interventions.

Cognitive Remediation

There is now established evidence for the use of computer-based activities in cognitive remediation, leading to recovery and positive work outcomes.11 FEGS introduced cognitive remediation with computers more than eight years ago, and the program is now well established in all rehabilitation services. The implementation of this novel program was facilitated by working closely with the two leading researchers in the field: Dr. Alice Medalia, and Professor Susan McGurk. These two researchers have shown positive outcomes while utilizing different approaches.

Medalia, from Montefiore Hospital in New York City, takes a more holistic approach to cognitive remediation and utilizes different commercially available software to promote many cognitive skills, often at the same time.12 She considers this a more real-world methodology, as we do not break down everyday activities into separate cognitive tasks. Her methodology requires strict adherence to her cognitive remediation model with specific training and supervision on a regular basis. The majority of cognitive remediation groups have fewer than ten consumers.

McGurk, from Dartmouth College, utilizes more of a building-blocks approach to cognitive remediation, working with a software package developed in Europe: COGPACK (http://www.markersoftware.com).11,13 This computer package consists of hundreds of activities that tap individual cognitive domains. McGurk's approach to using this software is to find the tasks that best mimic the kinds of work activities in which a consumer might engage. Built into her system is a tracking booklet in which the consumers themselves monitor their progress with the support of group facilitators. Again, typical groups have fewer than ten consumers and last up to two hours.

The feedback from consumers and clinicians toward both cognitive remediation approaches has been extremely positive, and there are many anecdotal accounts of positive outcomes. Janice, a 40-year-old Caucasian woman, attended an Intensive Psychiatric Rehabilitation Treatment program with the goal to live in her own supported apartment and work toward being a beautician. She had numerous cognitive difficulties such as weak short-term verbal memory, poor attention, and a deficit in executive functioning, which also contributed to her feelings of frustration and worthlessness. She worked methodically through the computer-based cognitive remediation, practicing and improving her cognition, in conjunction with social skills and anger management groups. When she left the program, she had moved into her own apartment and had enrolled in a “beauty” school, while working part-time in a clothing store.

Improving Social Cognition

We also are collaborating with Dr. David Penn from the University of North Carolina to test a manual-based intervention for improving social cognition in persons with chronic mental illness.14 Social cognition interaction training (SCIT) consists of 18 group-based sessions, with a pre- and post-outcomes measure to assess effectiveness. The material draws on the work of Aaron Beck and cognitive behavioral therapy, and was developed specifically to use with individuals with schizophrenic symptoms.

SCIT targets three fundamental building blocks of social cognition: emotional perception (i.e., detecting emotions on people's faces), Theory of Mind (i.e., understanding the mental states of others), and attributional style (i.e., interpreting other people's actions). We consider SCIT to be an emerging best practice and have worked closely with Dr. Penn in carefully assessing its impact. Thus far, both the staff and consumers have been engaged by SCIT, and there have been good anecdotal reports of improvements in social cognition.

James, a 64-year-old Caucasian man with a history of bipolar disorder with psychotic features, came to a psychiatric rehabilitation program with the goal of developing the necessary skills to enter a full-time psychosocial club. When he started the program he was noncommunicative, lacked insight, and found it difficult to manage activities of daily living. He graduated recently from the program having achieved his goal, and James spoke of the importance of taking part in SCIT and learning to maintain eye contact in social interactions, developing ways to better articulate his needs and interests, and being able to initiate positive social interactions.

Putting Together the Pieces

The term “cognition” describes many different kinds of processes involved in learning and social interaction that most people take for granted. We believe that these processes need to fit together to form a clear continuity of intervention, which itself is informed by using cognitive assessment tools. We hope to become far more sophisticated in developing rehabilitation curricula that delineate the steps to recovery, from basic cognitive skills development to developing higher-level thinking skills, and then expanding social cognition. We think that this is best achieved in working synergistically with our different research partners, who are all on the cutting edge of cognition in the SPMI population. In this way, we hope to enable our consumers to have the greatest opportunity for recovery through regaining cognitive skills for work and developing better social support networks.