Cognitive Rehabilitation
Resource:
These are my (Carolyn Dorfman) notes from the conference by Joan Toglia. They are not complete, and they
are not perfectly organized, but there are a lot of very useful ideas in this handout. I strongly recommend that
occupational therapists (and others) attend her 2-day conference on cognition.
Toglia, J. (September 13-14, 2008). Cognitive rehabilitation and the multicontext approach to awareness,
memory, and executive dysfunction. Workshop
Proceedings
1. Cognitive problems may be seen in all of the following:
 Stroke, brain tumor, brain injury

 Parkinson’s disease

 Multiple sclerosis

 Encephalitis

 Alzheimer’s disease, Vascular dementia

 Mild cognitive impairment (MCI) in the elderly

 Peripheral vascular disease
 Core feature of schizophrenia

 Bipolar disorder – during remission

 Obsessive compulsive disorder (OCD)

 Rheumatoid arthritis

 Lupus

 Chronic fatigue syndrome, Fibromyalgia, Lyme

disease, toxic exposure

 ALS
Cardiac disease
COPD
Post radiation, chemotherapy
Prolonged critical illness
Sustained hypertension, chronic diabetes,
hyperlipedemia, hyperthyroidism
Stress, anxiety, fatigue, depression, sleep
disorder
Substance abuse
Normal elderly
Learning disabilities
FAS
ADHD
MD
autism
2. Most common cognitive complaint across all 
a. Executive functions
b. Attention
c. Memory
3. Executive functions
a. What is it?
i. Central orchestrator of tasks, coordinates, modulates, and regulates actions and goal
attainment. “Central Executive”
ii. Required for adaptive responses to novel, unfamiliar, or unpredictable situations
iii. Consists of diverse and separate dimensions that may function independently
b. Impairement of executive functioning:
i. Poor impulse control
ii. Difficulties monitoring or regulating performance
iii. Planning and organizational problems
iv. Poor reasoning ability
v. Difficulty generating/ implementing strategies
vi. Mental inflexibility and perseveration
vii. Reduced working memory
viii. “goal neglect” – (when involved in an activity, client loses her goal.)
c. Clinical characteristics of EF Dysfunction
i. There is a disassociation between what one says and what one does.
ii. Difficulty with unstructured, novel situations
iii. Reduced self-monitoring and regulatory skills
d. Areas of the brain involved with executive dysfunction:
i. Dorsolateral circuit (frontal lobe):Dysexecutive Syndrome (decreased organization and
working memory)
ii. Orbitofrontal: Disinhibited, impulsive
iii. Anterior cingulate gyrus: apathetic, loss of drive & initiative, flat affect
e. Problems impact functional abilities, employability, and social participation
f. Five domains of EF most commonly identified:
i. Initiation & inhibition
ii. Cognitive flexibility/ shifting set
iii. Working memory
iv. Planning
v. Self regulation/ self-monitoring
g. Other aspects of Executive Function:
i. Attentional control
ii. Organization
iii. Prioritizing
iv. Problem soling
v. Strategic behavior
vi. Control of action
vii. Goal directed behaviors
viii. Abstract and conceptual thinking
4. Initiation is getting started and keeping going.
a. Dysfunction of initiation involves:
i. Decreased ability in initiating roles, routine activities.
ii. Stops familiar sequential activity prematurely (needs cues to go from step to step)
iii. Difficulty getting started and persisting in less familiar or less structures activities. May not
recognize the need for action.
iv. Difficulty initiating and generating plans, thoughts or ideas in unstructured or complex
situations.
b. Assessment of initiation:
i. Controlled oral word Association (COWA):
1. Rapid word generation
2. Name all the words that begin with F, A, S (3 – 60 second trials)
c. Intervention for initiation problems:
i. www.luminosity.com (web site with brain games can have free trial)
ii. Happy neuron.com (web site with games)
iii. Nintendo & wii
5. Inhibition is the ability to stop an action.
a. Dysfunction of inhibition involves:
i. Difficulty inhibiting:
1. Impulses
2. Extraneous actions or verbalizations
3. Distractions
4. Ongoing activity (and switching to another)
ii. Inability to delay gratification
iii. Tendency to interrupt
iv. Difficulty waiting for fun
v. Impulsive
vi. Cannot stop ongoing behaviors
vii. Cannot delay or prevent a response
viii. Cannot manage extraneous distractions, irrelevant information or interference
ix. perseveration
b. Assessment of inhibition:
i. Go-No-Go Tests
1. Tap once when I tap once, but do not tap at all when I tap twice.
2. Hand game: Show me you fist every time I show you my finger. Show me your finger
every time you see a fist.
3. Every time you see green say stop, every time you see red, say go.
ii. Modified Stroop test
iii. Interference Tasks:
1. Ignore what the word says. If the print is all caps, say large, if the print is small, say
small
SMALL, large, small, large, SMALL, LARGE, large, small, SMALL
2. Identify the number of boxes around the number and ignore what the number is. For
example, there are two boxes surrounding the number one, Say “two”. Do not read
the number.
1
2
2
1
1
2
2
3. Haylings Sentence Completion:
Response inhibition: Complete the sentence with a word that is completely
unconnected to the sentence.
 The Captain wanted to stay with the sinking
.
 He mailed the letter without a
.
4. Controlling Actions: motor sequencing and perseveration
 If I knock once, you knock twice, If I knock twice, you knock once
 Copy alternating sequences
nmnmnmnmn
5. CLOX: An Executive Clock Drawing Task (free on web)
6. Frontal Assessment Battery (free on web)
7. The Executive Interview IEXIT 25) (free on web)
8. MoCA (free on web)
iv. Intervention for Initiation problems
1. Inhibition tasks:
a. Don’t answer the telephone that is ringing
b. If a question is preceded by your name, do not answer it.
c. Wait at least 10 seconds before responding to a question
d. Name everything you see before…..touching
e. Only hit the balloon if it is the color “yellow”
f. Stop whatever you are doing when you hear the alarm signal/music
2. Impulsivity increases with:
a. Competition with habitual response
b. Increased number of stimuli/ rules
c. Increased detail
d. Novel or unfamiliar situations
e. Decreased saliency of target (Target and background are similar)
f. Increased density of stimuli
v. Intervention for shifting attention/tasks:
1. Compensatory:
a. Slow down
b. Make client write down potential problems/ issues
c. Have client verbalize instructions
d. Use clock or time for advance warning
e. Use music or visual cue for 5 minute warning
f. Use different color on worksheet or instructions as signal to switch
g. Use different color fonts on key words in instructions
h. Role play: mentally imagine responses to unexpected events
2. Card tasks
a. Separate deck of cards
i. Place odd red cards vertical
ii. Place black even cards horizontal
iii. All other cards in the middle
b. Copy card sequence:
i. Red, black, red, black  shift
ii. Hearts, diamonds, ,hearts, diamonds
6. Executive Cognitive Functions
a. Dysexecutive Syndrome = decreased working memory, cognitive flexibility, organization, and
planning
7. Working Memory:
a. Definition:
i. Ability to hold and manipulate information in one’s mind
ii. Keeping track of all aspects of an activity as it is being performed and manipulate that
information
iii. Includes attentional processes
b. Impairment of working memory: Clinical Symptoms:
i. Losing track of what was just done or said
ii. Difficulty remembering what to do next
Difficulty attending to all parts of a task or situation simultaneously
iii. Re-reading passages that were just read
iv. Can only process a small amount of information at one time
c. Makeup of working memory
i. Working memory is limited in capacity – we can only store so much
ii. We can store more if we chunk data
iii. WM is only temporary. Rehearsal is needed to hold information for more than one minute
iv. WM can get overloaded by distractions, not letting go of information (clogged up), slow
processing (new info cannot enter)
v. WM has dual channels: visual & verbal
vi. Anxiety, stress, depression, and fatigue can overload WM
vii. If a person does not use previously learned knowledge to organize information, WM gets
overloaded.
d. Assessing Working Memory:
i. Digit span backwards:
 I am going to say a list of numbers, tell it back to me backwards:
 7 9 4 2 (can try longer digit spans)
ii. Listen to the numbers
 I am going to read you a list of numbers. As soon as you hear two 5’s in arrow, tell
me the number that came before the two 5s.
iii. Alpha span
 I will give you a list of words. Tell them back to me in alphabetical order.
 House, bird, star, apple
iv. Expanding working memory “N Back” Procedure
 38 playing cared presented in random order
 Report the digit that occurred prior to the present cared (1 back, 2 back, 3 back)
v. Mental tracking
 Pack of cards randomized
 Client must sort cards in suits.
 Sorted piles are face down
e. Intervention for deficits in working memory:
i. Similar to testing items
ii. As you are putting items into the closet, name the previous item
iii. As you are emptying grocery bags, name the previous two items that you put away
iv. Keep track of the price of an airline ticket on the previous web page
v. Count and keep track of the number of envelopes (are there enough for all the letters?)
vi. Read recipe and get out first 5 ingredients
f.
Increase capacity of WM by:
i. Encouraging rehearsal of information
ii. Limit distractions
iii. Pre-select key ideas, words
iv. Provide images, words
v. Provide the overall context
8. Cognitive Flexibility
a. Ability to mentally shift ideas, thoughts, and tasks, and view situations from different perspectives.
b. Decreased Cognitive flexibility may cause:
i. Tendency to get “stuck”
 Difficulty letting go of ideas, thoughts, feelings, shifting with topic hsifts in a
conversation or discussion
 Difficulty with changes in instructions on the same page
 Difficulty with switching activities within a session
 Difficulties shifting between numerical operations (e.g. adding, then subtracting)
 Difficulties following a multi-step activity
 Confusion with shifts in story plot or characters when watching TV or reading a story
 Repeats the same errors, statement, ideas or thoughts
ii. Difficulty thinking of alternatives or different perspectives
1. Difficulty representing the same information in different ways
2. Difficulty thinking of different ways to solve a problem (brainstorming)
3. Difficulty viewing a situation from another person’s perspective
4. Difficulty generating ideas for a project, activity, or story
5. Difficulty mentally imaging different associations, connections, or possibilities
iii. Assessing Cognitive Flexibility
1. Deal out a deck of shuffled cards.
a. Rule 1 (first time through): Say “yes” to red card, say “no” to black
b. Rule 2 (2nd time through): Say “yes” if the card is the same color as the last
one, otherwise say no.
2. Trailmaking/ modified trailmaking
3. Wisconsin card sort (I am making one – my version) (original costs ~$300)
iv. Intervening with Cognitive Flexibility Deficits
1. Disorganization: Underlying characteristics
a. Unsystematic, haphazard, or random approach to tasks – may be due to
many factors:
i. Lack of attention to details
ii. Missed information, loses track
iii. Cannot tell difference between relevant vs. irrelevant information
iv. Concrete thinking
v. Difficulty shifting, anticipating
vi. Unable to simultaneously attend to the whole and parts
vii. Difficulty making connections between similar thoughts, ideas, or
objects
2. Disorganization: Clinical issues
a. Difficulty organizing materials and personal space
b. Difficulty organizing thoughts and ideas in written and verbal communication
c. Difficulty consolidating information
d. Difficulty organizing time
3. Assessing Organization/disorganization
a. Organize shopping lisrt
b. Set Game (www.setgame.com)web site with cognition games
9. Planning/Problem solving:
a. Problems with planning:
i. Unrealistic goals
ii. Underestimates time required
iii. Omits steps in the sequence
iv. Does not think ahead, fails to anticipate consequences
v. Fails to consider all aspects in planning
vi. Loss of abstraction and ability to look ahead (what if?)
vii. Narrowed attention
viii. Unable to identify priorities
ix. Haphazard approach – trial and error
x. Failure to consider alternative plans or methods
b. Assessment of Planning problems
i. Multiple Elements Test
ii. Functional problem solving tasks
iii. Planning tasks
c. Intervention: same
Dynamic Assessment with Executive Functioning
1. Not static assessment
2. Assessment and treatment at the same time
3. Client attempts a task. If client has problem, cues are given in a pre-determined sequence
4. Helps to determine, not only level of skill, but how a person learns and what is needed for a person to be
successful at a task.
5. Can help with transfer of skills and “generalization”  start with transfer of similar tasks  move on to
more dissimilar tasks
6. Examples of dynamic assessment:
a. TCA (Toglia Category Assessment)
b. Sorting pictures (French fries, TV, onion, sweater, airplane, table & chairs, scissors, saw, tie,
motorcycle, cookies, socks, cheese, shovel, bathtub, ambulance, pliers, skirt, bed, hamburger,
lamp, boat, screwdriver, fire engine, slippers) Order from: Pro-Ed, Austin Texas 78758-6897 –
Phone #: 1-800-897-3202 (item to order: Photo resource Kit (nouns))
Treatment of Executive Functioning Deficits
1. Cues in the environment
a. Signs
b. Prompt signals
c. Auditory, visual or vibrating alarms
2. Written steps or checklists
3. Photo of video prompts
4. Photo sequence of activities
5. Smartphone organization
6. Verbalization strategies – practicing in advance, learning a song/poem for sequence of activities,
7. Situational cueing: If x, then y. (If someone takes food on your tray, then you …..)
8. Checklists and fading checklists (backward and forward chaining with lists)
9. Lists
10. Multi-Context Approach:
a. M=multiple contexts are used to practice a targeted strategy to promote generalization
b. U=use a just right challenge level by modifying task or environment expectations
c. L=learn to self-monitor and regulate performance and emotional reactions across activities
d. T=tailor treatment activities to client interests and activities
e. I=Increases self-efficacy
11. Multi Context Approach:
a. Near transfer/almost identical  far transfer/completely different
b. Can use many different tasks (see list)
Intervention for Executive Function:
1. Managing Multistep Activities
a. Lists/ checklists
i. List to do a task inventory
ii. List to keep track of errands
iii. Steps to follow in a multistep task or project
b. How to use lists:
i. Use lists/ checklists to do an activity (simple to complex)
ii. Create lists (shopping list, how to make a recipe, how to program an alarm)
1. Perform a task and write down the steps or watch another person perform a task and
write down the steps
2. Create list from recall, then test the list
c. Examples of tasks:
i. Cookie decorating
1. Decorate only 15 of the 20 cookies
2. Make sure at least two cookies have both the colors green and yellow
3. Include the color red on at least four cookies
4. Decorate 5 cookies with chocolate sprinkles
5. Make three cookies like the first picture and 6 cookies like the second picture
(include pictures)
6. (can have more or less rules)
ii. Take out menus:
1. Review the take out menu and choose a dinner order for yourself and for a friend.
2. Your friend is a vegetarian
3. She eats dairy products but does not eat fish
4. She does not like peas or broccoli
5. The total amount should not be more than $25.
6. One of the items should include eggplant.
iii. Shopping: catalogs or online
You need to choose a toy for a 4 year old boy who likes to build things and a doll for
a 7year old girl. In addition, you need to find a small present for a baby (newborn)
and a green sweater for your brother who is size large. In total, you cannot spend
more than $50.
iv. Make greeting cards (www.Mycardmaker.com)
3 birthday cards, one for a child and 2 for adults. One of the adults likes animals.
Use 14 point font on one card and 16 point font in 2 careds. You cannot write the
same message twice. Each message has to be at least 10 words, but not greater
than 25 words.
v. Make a sign
Cannot have more than 10 words, and 2 colors. Needs to include a border and 3
pictures.
vi. Make a crossword puzzle: (http://puzzlemaker.school.discovery.com)
Make a puzzle that has at least 10 words and clues, but not more than 12. The
words should include 3 dairy products, 3 fruits or vegetables, 2 main meals, and 2
desserts.
vii. Word search puzzle
(http://p[uzzlemaker.school.discovery.com/WordSearchSetupForm.html)
Make a word search puzzle that is 20 by 20. Think about the words you want to put
in your puzzle. Include the name of one animal, your favorite movie, your favorite
color. Be sure to include the word “magic”. Include one word that has the letter “z”
and another word that has at least 2 letters “o” and another word that has the letter
“y”. Include no less than 8 words and no more than 15 words. Go ahead and make
your puzzle.
viii. Make a jigsaw puzzle from a digital photo ( website: Jigsaws Galore)
Make a puzzle that is at least 4 pieces, but no more than 6 pieces. Keep the pieces
un-rotated. Add one fun piece, and choose at least one piece that does not have
rounded edges.
ix. Organize medications:
1. Need a pill organizer
2. Use M&Ms for pills
3. You need to take one medication (yellow pill) every 6 hours on an empty stomach
and another medication every 4 hours (white pill) with food. You have another
medication (blue pill) to take once at noon and once at night for the next 3
consecutive days. After that you only need to take it at night before going to bed.
Place the pills in the organizer.
x. TV schedules
xi. Errand lists
xii. Choose a car to buy
d. After the task questions for client:
i. Did you have any difficulties, or challenges while you were doing these activities? If yes,
explain.
ii. Did you experience any difficulties keeping track of everything, staying focused, or
organizing all the things you needed to do?
e. Treatment Outcome measures: Were there changes in….
i. Initiation of strategies
ii. Frequency of strategies used
iii. Types of strategies reported/used
iv. Awareness: self monitoring/ anticipation/ error recognition
v. Regulation of emotions
vi. Self efficacy
vii. Self confidence
f.
Sample therapist rating of strategy use:
i. 7=Little to no strategy use observed
ii. 6=strategy use is infrequent or inconsistent, even when supported by examiner cues
iii. 5=Strategy use observed, only when performance is supported by examiner (during cues)
iv. 4=Prompts required most of the time to use strategies (75% or more).(eg. Occasional
spontaneous initiation of strategy use observed)
v. 3=Prompts required frequently to use strategies (50% of the time)
vi. 2=Prompts required occasionally to use strategies (less than 25% of the time)
vii. 1=Prompts are not required to use strategies (uses strategies independently)
2. Problem Solving, planning, processing multiple information, organization
a. Client problem: Incomplete problem representation
i. Jumps right into soling a problem without understanding the whole problem. Often focuses
on parts or pieces.
ii. Intervention: Problem representation
1. Self questioning (have I got whole picture?)
2. Self instruction: learn to break apart problems
3. Draw out/ diagram the problem
4. Seek pictures or visual representations of the concept whenever possible
5. Model strategic thinking: verbalize your thinking process out loud (compare-contrast,
problem solve aloud) and gradually encourage participation
b. Client problem: Acting before planning
i. Jumps into an activity without a plan
ii. Proceeds in a random manner
iii. Not sure what to do, skips steps.
iv. May start an activity without the necessary materials
v. May not leave enough time to complete the activity
vi. May feel overwhelmed, not know where to begin
vii. Intervention strategy:
1. Systematic self questioning
2. Breaking down multi step tasks
3. Self instruction training
c. Client problem: Unable to sense and feel the passage of time
i. Intervention strategies:
1. Questions
a. How long do you think this task will take?
b. How long have you been working?
c. How long do you think that took to complete?
2. Break the task down by time segments
a. It is 2:00, what will this look like by 2:15?
b. Set a timer or alarm to go off at specific intervals
d. Client Problems: Forgets own goals in a task or generally
i. Client recalls goals, but loses sight of them during an activity and actions become random or
stuck on subgoals.
ii. Intervention strategy: Goal management training:
1. Stop current activity. Orient the client and alert to the task goal. “Wait a minute”
Teach client to visualize a stops sign
2. Define main task – setting goal and subgoals
3. List the steps needed to achieve the goal
4. Learn / rehearse steps necessary to tackle the problem
5. Do it – Carry out the steps
6. Check – Monitor the outcome
e. Planning interventions:
i. Plan a weekend schedule for a person who is visiting a city for the first time
ii. You need to plan a weekend get away trip (Friday & Saturday night) to a place that is within
2 hours from here. Find three possible places and estimate the costs of each place.
iii. You will be making lunch this Friday. Let me know what you are going to make and
everything you will need to make it.
iv. Self questioning:
1. What do I need to do?
2. Do I need more information
3. What do I have to do next?
4. Am I getting stuck?
5. Have I identified the critical information/ priorities?
6. Do I understand the problem?
7. Am I getting side tracked?
8. Am I sticking to the main goal?
v. You are planning a surprise party for a close friend. List all the things you will need to do.
vi. You will be away for 6 weeks. Write down all the things you will need to do before you leave
home.
vii. You need to arrange for a business breakfast meeting for 10 people. List everything you will
need to consider and do.
viii. Task specific self evaluation
Did I consider the following?
1. Determine number of people, budget, date, time, investigate and decide on place.
2. Obtain names, addresses of people to invite
3. Choose invitations, complete and mail them
4. Keep an RSVP checklist
5. Decorations, menu, cake, paper goods
6. Consider how to keep the party a surprise and get birthday person to party.
f. Mental Imagery as Intervention
i. A behavior or performance is rehearsed mentally, as if the person is actually performing it
ii. Client asked to identify task steps by mentally imagining the task
iii. Visualize own performance
iv. Identify possible obstacles and solutions in each step and imagine performance with
obstacles
v. Use picture cards, video of performance to enhance imagery, if necessary
g. Other activities:
i. Managing money
1. Materials: newspapers, paper, pencil, calculator
2. Salary = $1700 monthly (take home pay)
3. Find an apartment in the newspaper
4. What other information do you need?
5. Figure out other monthly expenses
6. Provide for unexpected emergencies
ii. Airline schedules (online)
1. Need to be in Florida by 2pm and home by 7 pm
iii. Organize CDs or books: what are different ways to organize CDs or books
h. Compare and contrast activities:
i. What is the cheapest plane fare to XXX?
ii. Order pizza for 10 people. How much?
iii. UPS: rates for mailing a 30 lb package
iv. Beauty salon: hours and rates
v. Bank: hours and fees for checking
vi. Hotel: features and prices
vii. Flowers: lowest price of arrangements to send
viii. Museums: hours and prices
ix. Transportation: train vs bus: time and price
i. Other activities:
i. How to websites:
1. Origami
2. Pot a plant
3. You-tube  simple magic tricks
ii. After video plays:
1. What does client remember
2. Take notes during video
3. Summarize content
j. Problem solving around disability: (might be an individual or group activity)
i. Wrapping a package with one hand
ii. Folding clothes with one hand
iii. Spreading toast with butter and jelly with one hand
iv. Opening an umbrella with one hand
v. Arrive at train station in wheelchair but elevator is broken
vi. Home health aide never shows up
vii. Lost credit card
viii. Charged for items never bought. Overcharged.
k. Group activities:
i. Plan holiday party
ii. Plan meal
iii. Write a story
Self-Awareness
1. Unawareness = Failure to gain conscious or explicit access to information regarding perceptual, cognitive
or motor function
2. Denial = Psychologically motivated symptom that serves to protect the individual against internal or
external stressors.
3. Denial vs. Unawareness
Unawareness
Denial
Direct effect
Indirect effect
Lack of information
Coping strategy
Reactions to feedback:
Reactions to feedback:
 Perplexed
 Resistance
 Confused
 Anger
 Surprised
 Hostility
 Indifferent or neutral
 Over-rationalization
4. Denial:
a. Adaptive early in the injury process – allows information to slowly sink in
b. If denial lasts longer, it becomes maladaptive
c. May see denial in family members because they do not understand
d. Denial is often related to pre-morbid characteristics:
i. History of denying inadequacies & problems
ii. Compulsive, conscientious
iii. Achievement oriented
iv. Need for control, need to be independent\
v. Has always resisted help or assistance
e. Clients tend to use denial in the more important tasks rationalize
i. Driving
ii. Work
f. Denial is very difficult to treat because does not respond to awareness training – always an excuse
5. Unawareness
a. Not one disorder
b. Varies across domains:
i. Cognitive
ii. Physical
iii. Social-emotional-behavioral
iv. Functional – motor
c. Greater awareness in:
i. Self care activities
ii. Motor and sensory impairments
iii. Memory
d. Less awareness in:
i. IADL (driving, managing finances)
ii. Abstract reasoning/ problem solving
iii. Socio-emotional/ behavioral changes
6. Components of self-awareness:
a. Knowledge of limitations and abilities
b. Self monitoring and error detection skills
c. Self evaluation
d. Ability to judge task difficulty
7. Assessing awareness:
a. Compare client self-rating with client ratings on tasks by significant other, clinician, objective test
scores
b. Patient Competency Rating Scale (PCRS) (free on web)
c. Awareness Questionnaire (free on web)
d. Self Awareness Deficits Interview (SADI) (free on web)
e. Assessment of Awareness of Disability (AAD) (there are articles about the AAD on line, but I could
not find the actual test on line – I don’t know how to order)
f. Contextual memory test (Toglia test – must buy) – has some awareness questions
Intervention for increasing Awareness
1. Set the stage for this kind of intervention:
a. Create a safe environment
b. Discuss cognitive symptoms directly but supportively
c. Provide opportunities for “control” and success
2. Maintain the balance between increasing awareness and minimizing frustration and anxiety
3. Awareness is likely to emerge when activities are familiar and within the “Just Right Challenge” level.
4. Awareness training involves helping the client to develop a new understanding of his/her own limitation and
abilities
5. There is a gradual transfer of responsibility from therapist to client
a. At first, the therapist takes more responsibility for
i. structuring information
ii. Goal setting
iii. Monitoring activities
b. The client gradually assumes more responsibility for
i. Identifying problem areas
ii. Developing goals
iii. Monitoring own performance
6. Subgoaling
Activity
Strengths within
Subskills that need to
Simulated task agreed
activity
be strengthened
upon
Meal Prep
Generates ideas, finds Organization, keeping
Planning a trip,
needed items, makes
track of information
birthday party
snacks
Subgoaling: Resume participation in previous interests and activities
Strengths
Potential
Helpful strategies Tasks for
Short term goals
difficulties
practicing
strategies
Motivated
Decreased
Notebook,
Conversations,
Decreased
communication,
memory,
Summarize with
Phone calss,
reliance on
well liked, friends,
Keeping track of
key words
Things that I have others for
walks
information
Checklist,
to do
information
independently
during an activity, Self check
Preparing lunch
Decreased
for homeless
Keep track of
function of left
shelter
things while
arm,
making lunch
Decreased
balance
Subgoaling:
Areas of concern
Strengths
Subskills that need to be
Tasks for practicing
(sub goals)
within skill
strengthened and sample
strategies
areas
strategies
Following
Can follow
-Sometimes gets stuck on
Practice tasks with multiple
instructions and
routine lists
pieces “gets thrown off”
step task instructions (eg.
lists to completion
-Misinterprets instruction due Following a list requiring
w/o verbal
to failure to “shift”
photo-copying and collating
reminders
-underline key steps
forms according to rules,
-Self-checking and
follow directions for an
comparison to original
unfamiliar electronic device,
instructions
follow directions on a map)
-Time monitoring strategies
Example: A client wants to live independently, but only wants to play video games in therapy.
Create a step illustration about what she needs to do:
Goal Ladder
Live
independently
Pay bills
Prepare own
meals
Laundry
Enter
appointments
in planner and
keep track of
own
appointments
Take shower
without
reminders
7. Goal rating: (client rates self on task & family rates client on task)
Stays on task
5=all the time
4=most of the time
3=some of the time
2=occasionally
1=does not stay on task, wanders off task
8. Self-Monitoring within activities:
a. Anticipation / prediction
i. General (predict level of task challenge)
ii. Specific (predict score, time, number of cues needed)
b. Recognition of errors during task:
i. “let’s stop and monitor”
ii. Self cues/self questions
c. Task evaluation
i. General (overall rating)
ii. Specific task checklist / assessment
9. Self estimation:
a. How difficult do you think this task will be for you?
1=very easy
 Before we start, let’s think of the best
2=easy
way to go about doing this. Are there
3= somewhat difficult
any tricks you can use?
4= difficult
 Let’s think of special things that you
5=very difficult
can do to help you _____ (go slower,
be more careful, pay attention,
remember what you need to do, etc.
 Let’s think of a signal I can give you or
a word I should say if I see you are
going “to fast”.



This task will be easy for me. I
do not need to do anything
special.
This task will be challenging. I
may need to think ahead of
special strategies
This task will be difficult. I will
need to think of a good
strategy.
b. How much time will be required to complete this task?
c. How accurate do you think you will be? How many errors do you think you will make?
d. How many cues (or how much assistance) do you think you will need for this task?
10. Other awareness training techniques:
a. Self questioning cards:
i. Am I staying focused?
ii. Am I paying attention to all the details?
iii. Am I looking all the way to the left?
iv. Am I remembering to repeat the instructions to myself?
v. Am I remembering to look at my list?
vi. Am I remembering to use my finger to help me go slowly?
vii. Am I keeping track of everything that I need to know?
b. Stop & Check
i. How am I doing?
ii. Am I staying focused and on task?
iii. Am I using a strategy?
iv. Alarms, timers, vibrating signals as strategy cues or self monitoring cues.
c. Journaling and self reflection
i. Monitor progress or change sin thinking
ii. Tool used to identify changes in self-efficacy, self-esteem, strategy use, and awareness.
iii. Designed to help clients self-reflect and evaluate what they learned
iv. Helps client relate information in the group to other everyday activities
v. Helps client integrate what they are learning
Activity
Self Evaluate
What did I learn
What strategies
Satisfied?
about myself?
could I use next
Need more practice?
time?
What could be done
differently?
Specific activity journaling
Activity: making Dinner
Predicted performance
Actual performance
What I learned
No problem, I’ll do the
same as always
I got distracted by the
noise outside and lost
track of what I was
doing
What can I do next
time
My concentration is not
as strong as it used to
be
d. Self Evaluation:
i. Did I complete everything I set out to do?
ii. Did I keep track of time?
iii. Did I remember to use strategies?
iv. Could I have done things in a more organized of efficient way?
v. Have I checked my work?
vi. Have I remembered to pay attention to all the details?
vii. How confident do I feel with my results?
viii. Did I meet my goal?
e. Self Generation Scale: Can you think of strategies that might help you?
i. 1=Self-generated more than one strategy
ii. 2=Self-generated on strategy
iii. 3=Self-generated : attempts to think of strategy – vague
iv. 4=Prompt: needs prompt to generate strategy
v. 5=No strategies even with prompts
f. Role reversal and role playing
11. Specific activities:
a. Letter writing:
i. Pre-evaluation
1. How much time will it take to write the letter?
ii. Self-evaluation after writing letter:
1. How organized are sentences and thoughts?
2. Does it make sense?
3. Does it contain all the essential information (who, what, when ,where)?
4. Is there any unnecessary information?
5. Did it take you longer than you anticipated?
6. Did your thoughts stay focused?
b. Cooking activity
i. Instructions
1. Find cookbook
2. Select recipe (prep time less than 20 minutes, cooking time less than 30 minutes,
majority of ingredients already in kitchen)
3. Make shopping list (no more than 6 items)
4. Estimate cost (cannot exceed $15)
5. Shop – (choose smallest size and least expensive brand)
6. Prepare the meal
7. Estimate time
8. Self-evaluate
ii. General Self-Evaluation
1. On a scale of one to five (1=not well at all & 5=very well) , how would you rate your
overall performance in this activity?
2. On a scale of 1-5 (1=not well at all & 5= very well), how well do you feel you did
keeping track of the directions?
3. On a scale of 1-5 (1=very difficult & 5=very easy), how difficult do you fell this activity
was?
iii. Task specific evaluation (client completes after cooking activity):
1. Was the
____prep time less than 20 minutes?
____cooking time less than 30 minutes?
____majority of ingredients in the kitchen?
____shopping list no more than 6 items?
____did not spend more than $15?
____purchased smallest size, cheapest brand?
iv. Self Evaluation
1. How much time did it take?
2. If the goals were not met, explain why?
3. Was there anything you could have done differently?
4. Could two things be done at the same time?
5. Did thought interfere?
12. Different types of feedback
a. Supportive but direct feedback
b. Peer feedback
c. Immediate feedback with re-enactment
d. Direct confrontation – defensive reactions
e. Videotape feedback
Memory
1. Types of memory
a. Working memory
i. Memory problem example: losing track of what was just done or said
b. Procedural memory:
i. How to perform a task or activity
ii. Problem: forgetting how to do something
c. Prospective memory:
i. What do I have to do in the future?
ii. Forgetting things that need to be done at a future time (taking medication, appointments)
d. Declarative memory:
i. Able to describe something that happened or a task completed
ii. Forget events, facts, or conversations that occurred the day before or in the past.
2. Prospective memory:
a. Remembering intentions
b. Carrying out a task or activity in the future
c. Example: remembering appointments, to pay a bill, mail a letter, make a phone call at a particular
time
d. Prospective memory tasks:
i. These tasks require self-initiated retrieval:
1. Return a telephone call in 10 minutes
2. In 5 minutes, check the pot on the stove
3. In 20 minutes, pick up a message from ______
ii. These activities have an external support or cue for action
1. Mail a letter when you pass a mailbox
2. Sign your name when you are finished
3. When number changes to 3 digits, switch pencil
4. When alarm rings, ask for the message
3. Causes of memory problems
a. Memory and aging:
i. Working memory is reduced: slowed processing, decreased divided attention
ii. Episodic memory (recent) is reduced
iii. Learning is intact
iv. Semantic and procedural memory least affected
b. Memory & schizophrenia:
i. Wide range impairment
c. Primary amnesia
i. Korsakoffs syndrome, encephalitis, bilateral damage to hippocampus
ii. Rapid forgetting
iii. Normal immediate recall
iv. Working memory intact
v. Other cognitive skills relatively intact
vi. Preserved procedural memory
d. Secondary amnesia:
i. Accompanied by one or more cognitive deficits such as decreased attention, initiation,
organization, or abstract thinking.
ii. Immediate recall is usually impaired
iii. Decreased amount of data goes in, but it does go in and it can be stored.
e. Depression
i. Underestimate before and after task
ii. Intact incidental learning (memory without trying)
iii. Errors are likely to be omissions
iv. Normal recognition compared to free recall
v. Better on retrieval with increased time and encouragement
4. Assessing memory:
a. Very few tests look at prospective or procedural memory
b. PRMQ memory test: difference between prospective vs. retrospective memory (free on web)
c. MFQ: Memory Function Questionnaire
d. Rivermead Behavioral Memory Test – (available commercially)
e. MARS: Memory Awareness Rating Scale (available commercially)
f. The Contextual memory test (Toglia) (Available commercially)
5. Intervention for Memory
a. General
i. External adaptations and devices
ii. Task specific training
1. Vanishing cues:
2. Expanded rehearsal (spaced retrieval)
3. Errorless learning
iii. Memory strategy training
1. External strategies (memory notebook)
2. Multicontext approach 0 strategy training framework
3. Internal strategies
4. Awareness / Metamemory training
iv. Memory groups
b. General methods to enhance retention and recall:
i. Encourage person to repeat / rehearse or ask person to paraphrase back
ii. Space learning
iii. Sentence completion rather than provision of information or encouraging guessing
iv. Make sure client attention is focused – keep direct eye contact
v. Use key-words, select what is most important, keep it short and simple
vi. Be aware of distractions in the environment
vii. Describe context first (or make sure context is attended to)
viii. Provide connections to meaning: associate, elaborate during encoding
ix. Present information in meaningful chunks
c. External devices – memory aids
i. Alarms
ii. Checklists
iii. Voice memos
iv. Task reminders (digital or other)
v. Calendars (digital or paper)
d. Vanishing cues (functional task training)
i. Repetitive practice with gradually vanishing cues
ii. Process:
1. Divide task into substeps
2. Count number of tactile, verbal, and visual cues for each substep
3. Gradually fade cues
4. Training involves rote, repetitive practice within natural contexts
5. Training for a specific task
e. Spaced retrieval (expanded rehearsal)
i. Recalling information repetitively over gradually longer time periods (30 seconds, 1,2,4,8
minutes, etc)
ii. If retrieval is successful, length is increased
iii. Can be used to learn small amounts of information, facts, external aides
iv. Can be combined with errorless learning
f. Errorless learning
i. Minimizes or prevents errors during learning
ii. Automates performance and reduces cognitive burden
iii. Guidelines:
1. Break task into components
2. Use tasks with high degree of success
3. Gradually increase demands
4. Repetitive and frequent practice – overlearning
5. DO NOT:
a. Give the person a chance to make a mistake
b. Encourage guessing
c. Use trial and error learning or expect the person to figure out how to do
something alone
6. Provide partial information, cues, tactile guidance or aids to prevent errors
iv. Most effective in tasks that lend themselves to implicit/ procedural learning
v. Works with people who have sever memory impairements
vi. More effective than vanishing cues
vii. Examples of tasks:
1. Learning a wheelchair transfer
2. Learning how to operate a device: microwave, washing machine
3. Recalling name/ face associations
g. Memory Compensatory Training
i. Memory notebook
1. Sections
a. Personal facts
b. Names/ people to remember
c. Calendar / schedule
d. Things to do
e. Daily log
f. Reading summary
g. Medication schedule
h. Last week section
2. Obstacles to use of memory notebook
a. Decease awareness/acceptance of memory deficit
b. Remembering to carry notebook
c. Remembering to write in and refer to notebook
d. Finding the correct place in the notebook
e. Including relevant information in the notebook