brain games - Arizona State University · memory • series of memory skills training exercises...

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Michael Franczak, PhD Mario Lippy, Psy.D. Adalesa Meek, MA, LPC, LISAC, ACS Darwyn Chern, MD, FAPA, FASAM Stephanie Miller, MSW enriching life skills through cognitive enhancement therapy brain games

Transcript of brain games - Arizona State University · memory • series of memory skills training exercises...

Page 1: brain games - Arizona State University · memory • series of memory skills training exercises that address different avenues and modalities of information intake, storage, and recall

Michael Franczak, PhD Mario Lippy, Psy.D.Adalesa Meek, MA, LPC, LISAC, ACSDarwyn Chern, MD, FAPA, FASAMStephanie Miller, MSW

enriching life skills through cognitive enhancement therapy

brain games

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agenda

intro to CET & implementation

brain games

social groups

clinician training

reimbursement

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part I: intro to CET & implementation

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CET facilitates the process of acquiring social wisdom and enhancing neurocognitionHogarty, G.E. & Greenwald, D.P. (2006). Cognitive Enhancement Therapy: The Training Manual. University of Pittsburgh.

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cognitive enhancement therapy (CET)• SAMHSA recognized Evidence Based

Practice • helps individuals recovering from

schizophrenia and other major mental disabilities

• improve their processing speed, cognition (attention, memory, and problem-solving)

• implications for becoming socially wise and vocationally effective

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evidence for CET• CET has an extensive research base with

individuals with multiple psychiatric conditions. • designed as a one-time treatment that results in

improved functioning continuing after graduation• has been tested in First Episode Programs and

with children and adults• data suggests that CET is most effective when

given in the broader context of psychosocial rehabilitation

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70-90%average attendance rate

80-85%graduation rate from CET program

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rationale for CET• there are effective medications to control

the positive symptoms of mental illness• however, many individuals still suffer from

cognitive impairments that limits their functional, social, and vocational skills

• cognitive domains most impacted in schizophrenia include memory, attention, reasoning, problem-solving, and social cognition

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cognitive impairment is a core feature of schizophrenia –strongly related to functioning in areas such as work, social relationships, and independent living

McGurk, S.R., Twamley, E.W., Sitzer, D.I., McHugo, G.J., & Mueser, K.T. (2007). A meta-analysis of cognitive remediation in schizophrenia. American Journal of Psychiatry, 164 (12), 1791-1802.

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CET engages the participant in a learning activity to enhance the neurocognitive skills relevant to overall recovery goals.

cognitive drills enhance cognitive functioning

http://www.state.gov/video/?videoid=60761567001
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cognitive functioning is a robust predictor of response to psychiatric rehabilitation

including outcomes such as work, social skills, and self-care

McGurk, S.R., Twamley, E.W., Sitzer, D.I., McHugo, G.J., & Mueser, K.T. (2007). A meta-analysis of cognitive remediation in schizophrenia. American Journal of Psychiatry, 164 (12), 1791-1802.

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neuroplasticity & CET• alterations in neuroplasticity are

hypothesized to underpin cognitive deficits• neuroplasticity may offer an avenue

towards cognitive remediation • principles to consider in designing

remediation interventions:o ensuring sufficient intensity and duration of

remediation programs, o "bottom-up" training that proceeds from simple to

complex cognitive processes, o individual tailoring of remediation regimens

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what does it do?CET is designed to improve neurocognitive abilities such as:

o attention, oworking memory, o cognitive flexibility o planning, and o executive functioning

all of which lead to improved social and vocational functioning

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implementation

individual therapy

social cognition & computer exercises

social groups

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part II: brain games

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cognitive enhancement training• planned exercises to push demands of a

patient’s cognitive skillso improves upon existing skillso helps to acquire new skill sets

Bracy, O. (2017). Neuropsychonline [The Neuropsychonline System]. Indianapolis.Hogarty, G.E. & Greenwald, D.P. (2006). Cognitive Enhancement Therapy: The Training Manual. University of Pittsburgh.

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what do you see?

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how do computer exercises fit?

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does training improve social skills?

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what do the exercises do?increase mental stamina

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attention

executive

memory {tasks levels

Neuropsychonline Psychological Software Services

visuospatial

problem solving

communication

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exercises• each task has approximately 15 exercises

o each exercise has 3-4 levels

• mastery of the required skill in order to graduate to the next levelo 3 consecutive passes at a given level

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• exercises range from simple, focused attention to complex, multiple simultaneous attention with stimulus discrimination and differential response requirements

• speed, accuracy, and consistency are measured

attention skills

Bracy, O. (2017). Neuropsychonline [The Neuropsychonline System]. Indianapolis. Hogarty, G.E. & Greenwald, D.P. (2006). Cognitive Enhancement Therapy: The Training Manual. University of Pittsburgh.

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executive skillsrange from simple concept formation to complex sequencing, organizing, and multiple simultaneous mental operations

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memory

• series of memory skills training exercises that address different avenues and modalities of information intake, storage, and recall

• learn and practice different techniques of compensation as well as the direct improvement of memory skills through better attention and executive skills

Bracy, O. (2017). Neuropsychonline [The Neuropsychonline System]. Indianapolis. Hogarty, G.E. & Greenwald, D.P. (2006). Cognitive Enhancement Therapy: The Training Manual. University of Pittsburgh.

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visuospatial skillsvisual intake and processing skills ranging from simple perception of luminosity to line, angle, shape and motion detection and analysis Bracy, O. (2017). Neuropsychonline [The Neuropsychonline System]. Indianapolis.

Hogarty, G.E. & Greenwald, D.P. (2006). Cognitive Enhancement Therapy: The Training Manual. University of Pittsburgh.

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problem solving• focus on information intake, information

analysis, inductive and deductive reasoning, and solution development.

• learn and practice different techniques of data analysis and problem solving.

Bracy, O. (2017). Neuropsychonline [The Neuropsychonline System]. Indianapolis. Hogarty, G.E. & Greenwald, D.P. (2006). Cognitive Enhancement Therapy: The Training Manual. University of Pittsburgh.

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communication skillslearn and practice skills involved in communication and speech/language functioning ranging from auditory attention, perception, processing, comprehension, and expression.

Bracy, O. (2017). Neuropsychonline [The Neuropsychonline System]. Indianapolis. Hogarty, G.E. & Greenwald, D.P. (2006). Cognitive Enhancement Therapy: The Training Manual. University of Pittsburgh.

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prescription of exercises• recommend to conduct therapy in Automated Mode

– cycles through the tasks vs completing one task at a time

• patients want to focus on what they like and avoid their weaknesses

• skills learned from the completion of one exercise in one task will be used in the successful completion of other exercises in other tasks

• can make a custom exercise list• or complete exercises randomly

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everyday conversation• sports or hobbies• talking about coworkers• news and local events• books and TV shows

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result of building skillsconcentration reaction speed

… friends

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“One must keep in mind that cognitive rehabilitation is not a

process that can occur overnight, even when one is using high tech

software and computers.”

Neuropsychonline, 2017

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set-up to utilize Neuropsychonline

• who will work with the patient?

• where do you do the work?

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coaching

• important to go through the same experience as the patient– gain empathy

– learn or reinforce skills that have to be taught to the client

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a note about coaching

It’s nice when someone remembers every little detail

about you, not because you keep reminding them but because they actually pay attention.

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therapist vs. peer coach• at minimum recommend therapists as coaches

as they are better suited to:– help keep patient on task– help understand tasks and exercises– help patient make gradual, reasonable changes– help process feelings of frustration– provide supportive feedback vs confrontational

feedback– model positive interactions that may not happen with

peer coaches– better understanding/tolerance for differing patient

cognitive styles

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optimal physical setup• need to have adequate quiet space to work on

the cognitive exercises– exercises put increased cognitive demands that can

lead to frustration in a distracting environment• need to have the correct technical equipment

– speakers to have appropriate sound discrimination on auditory attention skill exercises

– big enough screens to adequately see stimulus material

– patients need to have access to a home/community computer to practice

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practice with exercisescan I have a volunteer?

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practice with exercises

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part III: social groups

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peer support specialists

schizophrenia

substance abuse

autism spectrum disorder

schizo-affective

transitioning youth

depression

adolescents

cognitive impairment

appropriate populations

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target populations• originally designed for individuals

diagnosed with schizophrenia and schizoaffective disorder

• CET is for individuals whose mental illness related impairments cause significant functional disability

• people who have been sober for a few months and maintain sobriety

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non-CET appropriate• people with florid psychotic symptoms are

not able to benefit for CET• unable to read at a fifth grade level• individuals with borderline personality

disorder may need another treatment

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social groups• after neurocognitive training • groups are 1.5 hours each and are held

weekly• 45 social-cognitive group sessions in the

program • groups of six to eight participants

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manage emotions

practice taking perspectivesimprove social-

cognitive abilities

enhance social comfort understand the “gist” in

social interactions

purpose of social groups

work towards individual recovery goal

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group objectives• participants feel more comfortable in

social settings• become more aware of others• increase appropriate behavior• increase motivation in social and

vocational goals

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components of social groups• experimental learning and real-life

cognitive exercises • present homework and lead homework

reviews • provide feedback to peers• receive psychoeducation on mental illness

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each group is formatted to provide consistency

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group design• CET Manual from Gerald E. Hogarty,

MSW and Deborah P. Greenwald, Ph.D. as reference

• participants feel more comfortable in social settings

• become more aware of others• increase appropriate behavior• increase motivation in social and

vocational goals

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part IV: clinician training

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guide greater elaboration & organization in thinking

provide active, supportive coaching

keep participants on task

encourage greater understanding of social cognition

foster flexibility in thinking and communication

role of clinicians

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clinicians must be flexible

…and willing to learn new ways of thinking

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basic considerations for clinicians• clear level of interest• knowledge of the population• an open mind• an ability to resist a traditional psychotherapy

stance • being curious• perseverance

Hogarty, G.E. & Greenwald, D.P. (2006). Cognitive Enhancement Therapy: The Training Manual. University of Pittsburgh.

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clinician characteristics• tolerance for ambiguity • cognitive flexibility • able to adapt to new ways of thinking and

acting• ability and the disposition to think

abstractly• master a theoretical understanding of the

disorders they are treating

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clinician characteristics…cont’d• desire for and a love of learning• open to intellectual growth • similar role as teacher - an educator and a

mentor• desire to work as part of a team• a sense of playfulness • optimistic• creative

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agency support to clinicians

• what is CET• why in AZ?• train-the-trainer process• modalities• plan for the agency• target population

• characteristics of clients and staff

• overview of online exercises

• categories of exercises and order

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becoming a CET coach• introduction via demonstration to the

exercises • attempt exercises with trainer and raise

awareness to the challenge of the exercises

• process the experience of practicing exercises with trainer

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developing strategies to coach clients

• allows clinicians-in-training to struggle• coach staff to develop their own strategies• strategies are validated and expanded

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methods to train clinicians• screenshots of exercises with strategies

and tips• video recording with instructions voice-

over• assign reading• model coaching while staff completes

exercises

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part IV: reimbursement

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CET in AZArizona Covered Services Guide

Cognitive Enhancement Therapy (CET) is also know as Cognitive Remediation Therapy (CRT)

• Currently, only independently licensed practitioners can bill

• Plan to add BHPs for billing• BHTs can use “Skill building” code

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AZ Covered Services GuideII. B. 2. Cognitive Rehabilitation General Information

General Definition The facilitation of recovery from cognitive impairments in order to achieve independence or the highest level of functioning possible. Goals of cognitive rehabilitation include: relearning of targeted mental abilities, strengthening of intact functions, relearning of social interaction skills, substitution of new skills to replace lost functioning and controlling the emotional aspects of one’s functioning. Treatment may include techniques such as auditory and visual attention directed tasks, memory training, training in the use of assistive technology, and anger management. Training can be done through exercises or stimulation, cognitive neuropsychology, cognitive psychology and behavioral psychology, or a holistic approach to include social and emotional aspects. Training is generally provided one-on-one and is highly customized to each individual’s strengths, skills, and needs.

https://www.azahcccs.gov/PlansProviders/Downloads/GM/CoveredServiceGuide/covered-bhs-guide.pdf

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AZ Covered Services GuideII. B. 2. Cognitive Rehabilitation General Information

Service Standards/Provider Qualifications Cognitive rehabilitation services must be provided by individuals who are qualified behavioral health professionals as defined in 9 A.A.C. 10 and who can bill independently using the appropriate CPT codes. Code Specific Information CPT Codes CODE DESCRIPTION-Cognitive Rehabilitation 97532 Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one on one) patient contact by the provider, each 15 minutes.

https://www.azahcccs.gov/PlansProviders/Downloads/GM/CoveredServiceGuide/covered-bhs-guide.pdf

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Neuropsychonline Indianapolis, Indiana

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questions & discussion

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referencesBowie, C. R., Grossman, M., Gupta, M., Holshausen, K., & Best, M. W. (2017).

Action-based cognitive remediation for individuals with serious mental illnesses: Effects of real-world simulations and goal setting on functional and vocational outcomes. Psychiatric Rehabilitation Journal, 40(1), 53-60. doi:http://dx.doi.org.ezproxy1.lib.asu.edu/10.1037/prj0000189

Bracy, O. (2017). Neuropsychonline [The Neuropsychonline System]. Indianapolis.

Bell, M. D., Richardson, R., & Grieg, T. (2008). Ego functioning, cognition, and illness characteristics of persons with schizoaffective disorder: Distinctive features and response to vocational rehabilitation. In Schizoaffective Disorders: International Perspectives on Understanding, Intervention and Rehabilitation (pp. 135-152). Nova Science.

Choi, J., & Medalia, A. (2005). Factors associated with a positive response to cognitive remediation in a community psychiatric sample. Psychiatric Services (Washington, D.C.), 56(5), 602-4.

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referencesEack, S., Greenwald, D., Hogarty, S., Cooley, S., Dibarry, A., Montrose, D., &

Keshavan, M. (2009). Cognitive enhancement therapy for early-course schizophrenia: Effects of a two-year randomized controlled trial. Psychiatric Services (Washington, D.C.), 60(11), 1468-76.

Fisher, M., Holland, C., Subramaniam, K., & Vinogradov, S. (2010). Neuroplasticity-Based Cognitive Training in Schizophrenia: An Interim Report on the Effects 6 Months Later. Schizophrenia Bulletin, 36(4), 869-879.

Fisher, M., Nahum, M., Howard, E., Rowlands, A., Brandrett, B., Kermott, A., . . . Vinogradov, S. (2017). Supplementing intensive targeted computerized cognitive training with social cognitive exercises for people with schizophrenia: An interim report. Psychiatric Rehabilitation Journal, 40(1), 21-32. doi:10.1037/pg0000244

Green, M. F. (1996). What are the functional consequences of neurocognitive deficits in schizophrenia? American Journal of Psychiatry, 153(3), 321-330.

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referencesGreen, M. F., Kern, R. S., Braff, D. L., & Mintz, J. (2000). Neurocognitive

deficits and functional outcome in schizophrenia: Are we measuring the "right stuff"? Schizophrenia Bulletin, 26(1), 119-136. doi:http://dx.doi.org.ezproxy1.lib.asu.edu/10.1093/oxfordjournals.schbul.a033430

Harvey, P. D., & S.E. Keefe, R. (2012). Technology, Society, and Mental Illness: Challenges and Opportunities for Assessment and Treatment. Innovations In Clinical Neuroscience, 9(11/12), 47-50.

Hogarty, G., Flesher, S., Ulrich, R., Carter, M., Greenwald, D., Pogue-Geile, M., . . . Zoretich, R. (2004). Cognitive Enhancement Therapy for Schizophrenia: Effects of a 2-Year Randomized Trial on Cognition and Behavior. Archives of General Psychiatry, 61(9), 866-876.

Hogarty, G.E. & Greenwald, D.P. (2006). Cognitive Enhancement Therapy: The Training Manual. University of Pittsburgh.

Kurtz, M., & Richardson, C. (2012). Social Cognitive Training for Schizophrenia: A Meta-Analytic Investigation of Controlled Research. Schizophrenia Bulletin, 38(5), 1092-1104.

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referencesLindenmayer, J., McGurk, S. R., Khan, A., Kaushik, S., Thanju, A., Hoffman, L.,

. . . Herrmann, E. (2013). Improving social cognition in schizophrenia: A pilot intervention combining computerized social cognition training with cognitive remediation. Schizophrenia Bulletin, 39(3), 507-517. doi:10.1093/schbul/sbs120

McGurk, S. R., & Meltzer, H. Y. (2000). The role of cognition in vocational functioning in schizophrenia. Schizophrenia Research, 45(3), 175-184. doi:10.1016/S0920-9964(99)00198-X

McGurk, S. R., Mueser, K. T., Feldman, K., Wolfe, R., & Pascaris, A. (2007). Cognitive training for supported employment: 2-3 Year outcomes of a randomized controlled trial. American Journal of Psychiatry, 164(3), 437-441.

Mcgurk, S., Twamley, E., Sitzer, D., Mchugo, G., & Mueser, K. (2007). A meta-analysis of cognitive remediation in schizophrenia. American Journal Of Psychiatry, 164(12), 1791-1802.

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referencesMcgurk, S., Mueser, K., Xie, H., Welsh, J., Kaiser, S., Drake, R., . . .

Mchugo, G. (2015). Cognitive Enhancement Treatment for People With Mental Illness Who Do Not Respond to Supported Employment: A Randomized Controlled Trial. The American Journal of Psychiatry, 172(9), 852-61.

Medalia, A., & Richardson, R. (2005). What Predicts a Good Response to Cognitive Remediation Interventions? Schizophrenia Bulletin, 31(4), 942-953.

Popov, Jordanov, Rockstroh, Elbert, Merzenich, & Miller. (2011). Specific Cognitive Training Normalizes Auditory Sensory Gating in Schizophrenia: A Randomized Trial. Biological Psychiatry, 69(5), 465-471.

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referencesSilverstein, S., Hatashita-Wong, M., Solak, B., Uhlhaas, P.,

Landa, Y., Wilkniss, S., . . . Smith, T. (2005). Effectiveness of a two-phase cognitive rehabilitation intervention for severely impaired schizophrenia patients. Psychological Medicine, 35(6), 829-837.

Spaulding, Reed, Sullivan, Richardson, & Weiler. (1999). Effects of Cognitive Treatment in Psychiatric Rehabilitation. Schizophrenia Bulletin, 25(4), 657-676.

Van Der Gaag, Kern, Van Den Bosch, & Liberman. (2002). A Controlled Trial of Cognitive Remediation in Schizophrenia. Schizophrenia Bulletin, 28(1), 167-176.

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thank you!

Michael Franczak, PhD [email protected]

Mario Lippy, [email protected]

Adalesa Meek, MA, LPC, LISAC, ACS [email protected]

Darwyn Chern, MD, FAPA, [email protected]

Stephanie Miller, [email protected]


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