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Introduction

Cognitive interventions are a vital resource for clients with impaired cognitive functioning due to complications of diagnoses such as: neurodegenerative diseases, developmental disabilities, mood and personality disorders. Cognitive impairments can affect function in processing, attention, vigilance, and memory and can also affect higher level executive functioning such as categorization, problem solving, planning, sequencing, organization and insight (Brown, 2011).

Through remediation and compensation strategies we can target improvements in the client and the environment to enhance overall functioning. Cognitive remediation and direct training focuses on helping the client regain skills to complete a task to improve the targeted impairment (Reeder et al, 2004). Cognitive compensation strategies main goal is to facilitate the ability to perform an occupation through learning new skills so the client can successfully function within their environment.

Theory

The PEO model adapts a transactional approach between the three components. These three factors are fluid throughout the lifespan and vary depending on the interactions and factors that currently present in a person’s life (Law et al., 1996). For optimal functioning, it is important that the three components overlap as much as possible. If the there is minimal overlap in any of the three areas it is known as a poor fit, therefore leading to occupational dysfunction (Law et al., 1996). The person component is unique to the individual and assumes the person has multiple roles that cannot be separated from the contextual influences. The occupation component looks at the meaningful activities and occupations the person wants or needs to accomplish. Whereas the environment is where the occupational performance takes place and is uniquely catered to the perspective of the person. By identifying the factors affecting each component as well as identifying how the three components interact, an occupational therapist is more suited to address the needs of the client (Law et al., 1996).

Evidence

Compensatory thinking is a problem solving approach utilizing verbal self-instruction. Another approach to compensatory thinking is Goal Management Training (GMT). GMT is a metacognitive intervention used to help the client become aware of the process of task completion (Krasny, Chevignard, & Evans, 2014). The therapist teaches the client using a list of questions, which gives the client the ability to self-monitor while working toward their goal (Brown, 2011):

1. Stop
2. Define – what is the task or goal?
3. List – what are the steps?
4. Learn – do I know the steps? Do I need to go back?
5. Check – am I doing what I planned to do?

A systematic review concluded that Goal Management Training has been known to have better effects when paired with other approaches such as Problem Solving Therapy. It also highlighted that GMT increases in participation in activities of daily living rather than highlighting support on the measures of executive impairment. Lastly, according to the systematic review, there is not enough evidence to use GMT alone (Krasny, Chevignard, & Evans, 2014).

Case Study

Samuel is a 28-year old veteran of the army national guard. As a combat medic on patrol in Afghanistan his convoy encountered an improvised explosive device (IED). Due to this traumatic event Samuel experienced a TBI. Unfortunately, the transition from military to civilian life has been difficult for Samuel. He is having trouble maintaining a job because of poor problem solving skills. When faced with problematic situations at the workplace, he has a hard time deciding the best way to move forward and does not consider better options. Often, Samuel finds himself making quick decisions that result in altercations. He currently found a new job as a cook in a local restaurant and would like to learn how to problem solve more efficiently so that he can continue working at his current job.

Intervention Plan

Problem statement

Client is unable to complete works tasks secondary to difficulties in problem solving.

Long term goals

1. When given 5 items from his work menu the client will be able to identify all the ingredients with no errors using a self-selected strategy to complete work orders in 4 weeks.
2. Client will demonstrate improved problem solving skills for work by completing 3/3 simulated work tasks with no errors using a compensatory strategy in 4 weeks.

Short term goals

1. Client will accurately identify ¾ of the ingredients that are missing to make an item on his work menu using a self selected strategy with 1 verbal cue in 2 weeks.
2. Client will identify 2 compensatory strategies to use on a work simulated task to improve problem solving skills in 2 weeks.
3. Client will create a checklist to complete various tasks for work to reduce the cognitive demand in 2 weeks.

Intervention format

Individual

Setting

Samuel will meet with the occupational therapist individually in an outpatient clinic 2x week for 40 minutes.

Supplies

Menu from his job

Agenda

• Meet with Samuel to discuss the issues he is having at work relating to problem solving (5 minutes)
• Client will identify a compensatory to use for preparing menu items at his work
  • Therapist will provide goal management strategies to facilitate this process
  • Ex. What is the task? What steps are needed to create the item? (10 minutes)
• Client will attempt to make an item from his work menu using his compensatory strategy
  • Therapist will provide cues if necessary
  • Ex. Did you miss any steps? How do you know you have all the ingredients?  (10 minutes)
• Therapist will go over the work simulated task and review the outcome with Samuel (10 minutes)
  • Questions the OT might ask after each noise:
    • How do you think you did?
    • Did your strategy help solve your problems?
    • Did your strategy help you find alternative solutions?
    • How did this work task make you feel?
• Provide encouragement / feedback / discuss next tx session (5 minutes)

Documentation

S: “I want to improve my problem solving skills at work”

O: Client participated in a 40 minute OT session working on his problem solving skills at work. During the treatment session the OT used a compensatory approach that incorporated goal management training. Client mentioned that he often has problems identifying how to solve tasks at work. Client stated that he becomes overwhelmed because he cannot remember how to make items on his menu causing him to make an incorrect order. Client was then asked to create a sheet for work based on his preferred preferences that identified the correct order, ingredients, and necessary steps to complete an order. Goal management strategies were incorporated to guide the client through the process. During the work simulated task the client needed cues because he could figure out what to do when he ran out of an ingredient needed for an ordered item. The client was able to modify his sheet to include going to the freezer to get more supplies. The client expressed that he was pleased to find a strategy that helped him at work.

A: The client seems to lack problem solving skills secondary to his TBI. Based on his current level of functioning, a compensatory approach will be the most beneficial at improving his occupational performance at work. The client needs more time to process information therefore it will be helpful to create a sheet for his work tasks to reduce the need for him to cognitively process incoming information. Goal management strategy is beneficial by creating verbal cues to allow the client a successful attempt. The client seems motivated for therapy and willing to work toward solutions to reach his goals.

P: Continue working on problem solving skills for work. Client would benefit from treatment activities that give scenarios requiring him to pick the best option. Recommend therapy 2x a week for 40 minute sessions. Next treatment session have the client perform a work simulated task using his compensatory strategy with a time limit to simulate the pace of his place of work.

References

Brown, C. (2011). Cognitive Skills, in Occupational Therapy in Mental Health: A Vision for Participation. Brown, Stoffel, Editors. FA Davis: Philadelphia.

Krasny-Pacini, A., Chevignard, M., & Evans, J. (2014). Goal management training for rehabilitation of executive functions: A systematic review of effectiveness in patients with acquired brain injury. Disability & Rehabilitation, 36(2), 105-116.

Law, M., Cooper, B,. Strong, S., Stewart, D., Rigby, P. & Letts, L. 1996. The Person-Environment-Occupation Model: A transactive approach to occupational performance. Canadian Journal of Occupational Therapy. 63(1):9-23.

Reeder, C., Newton, E., Frangou, S., & Wykes, T. (2004). Which executive skills should we target to affect social functioning and symptom change? A study of a cognitive remediation therapy program. Schizophrenia Bulletin, 30(1), 87-100. http://dx.doi.org.ezproxy.fiu.edu/10.1093/oxfordjournals.schbul.a007070