Presentation on theme: "CET: Physical Therapy for the Brain FADAA/FCCMH Annual Conference August 25, 2011 Ray Gonzalez, ACSW, LISW-S Center for Cognition and Recovery, LLC."— Presentation transcript:
1 CET: Physical Therapy for the Brain FADAA/FCCMH Annual Conference August 25, 2011 Ray Gonzalez, ACSW, LISW-SCenter for Cognition and Recovery, LLC
2 True or False ?Cognitive problems are due to laziness and lack of effortCognitive problems will go away when symptoms like hallucinations go awayCognitive problems are all caused by medicationsCognitive problems are caused by being in the hospital or nursing home or at home too long
3 DisclosuresRay Gonzalez the Executive Director of The Center for Cognition and Recovery (CCR) which is a nonprofit LLC joint venture of JFSA of Cleveland and PLAN of NE OhioThe CCR is currently conducting CET groups in the greater Cleveland areaThe CCR has received grants from The Cleveland, Morgan, Mount Sinai Health Care and Woodruff Foundations for the development of CET
4 Anita’s Recommendation When Anita, a CET Graduate, was asked why she would recommend CET to other people recovering from a mental illness, she answered:I would recommend CET to help those with mental illnesses reach their true potential. And while potential can sometimes be measured in terms of work and productivity, I would say that even more importantly is the subjective aspect, enjoying the lives that we were meant to live.
6 What is CET (Cognitive Enhancement Therapy)? Aims to remediate the brainFor stable clients who have plateaued but have not fully recoveredCombination of specialized computer exercises and social cognition groupsUtilizes a coaching methodology48 once-a-week sessions90% attendance rate85% graduation rate
7 Components of CET 1. Specialized computer exercises done in pairs 2. Homework reporting in class, no one can hide3. Weekly Psycho-ed talks4. Cognitive Group Exercises done in pairs5. Individual ‘coaching’ once a week
8 Why CET?50 plus years of research showed that there were major cognitive deficits associated with schizophrenia but no active treatmentsDeveloped in response to the observation that lack of vocational success was not due to lack of skills training or general intelligenceRather, what vocational success there was had more to do with improved social cognitionMany clients were stable but not in full recovery
9 "It's important for the field to recognize that while we've been waiting now for 30 years for a drug that will improve social outcomes, we've been ignoring the results of many studies showing that psychosocial treatment achieves psychosocial results.And that most of those results are in some ways more meaningful for patients and their families than just the absence of a relapse.”William McFarlane, MD, Director of the Center for Psychiatric Research at the Maine Medical Center Research Institute, 9/10/10
10 History of CETDeveloped by Gerard Hogarty and Samuel Flesher at the EPICS Program at the University of Pittsburgh Medical SchoolCET Research funded by NIMH grant121 Subjects CET (N=67) or EST (N=54) and treated for two years, between January 1995 and February 2002Initial study published in the Archives of General Psychiatry, Sept & study on the Neuroprotective Effects of CET Against Gray Matter Loss in Early Schizophrenia also in the Archives of General Psychiatry, May, 2010Additional CET studies published on durability 12/06, 11/09; for persons in early psychosis 11/09, all in Psychiatry Services
11 Effect Sizes of CET & EST (Enriched Supportive Therapy) at 12 and 24 Months by Composite Index Hogarty, Flesher--Archives of General Psychiatry, Sept. 2004CETESTNeurocognitionProcessing SpeedCognitiveStyleSocial CognitionSocialAdjustmentSymptoms
12 CET For Chronic Schizophrenia: Lasting Effects (N = 106) Processing SpeedNeurocognitionMeanYearYearHogarty, Greenwald, & Eack, Psychiatry Serv. 57:
13 Cognitive remediation is based on Neuroplasticity, also called brain plasticity or brain malleabilityNeuroplasticity refers to the brain’s ability to re-organize itself through forming new neural connections or by adding cellsAllows the neurons in the brain to adjust their activity and organization in response to new situations or to changes in the environment
14 CET may increase gray matter through the increase in the number of new synaptic connections
15 CET ImprovesSocial cognition (the awareness to interact wisely with others)Processing speed (enables timely responses)Cognitive functioning (attention, memory, problem solving)Meaningful roles (e.g., employment, student, volunteer)Self-management of mental and physical healthAdjustment to and acceptance of disability
16 Typical CET Day 11:00 – 12:00 Computer Exercises 12:00 – 12:30 Break 12:30 – 2:00 GroupIndividual coaching session held with each client during the week to work on homework questions
17 Computer Work One hour a week Done in pairs Pairs support each other A chance for socializationPrepares participants for groupContinues during the course of the groupProgressively more challenging and more abstract
18 Attention, Memory, Problem Solving Establish setMaintain setShift setMemoryRecall, recognition, proceduralWorking Memory is most impaired in mental illnessProblem Solving
21 Next Group Meeting is Tuesday January 23, 2007 COGNITIVE ENHANCEMENT THERAPYTuesday, January 16, 2007Group #9Session 20Welcome Back: JudySelection of Chairperson:Review of Homework:a) Describe a recent situation in which you disagreed with another personb) Describe your perspectivec) Describe their perspectivePsycho-Educational Talk: ForesightfulnessSpeaker: RayExercise: Word SortCoach: JudyParticipants: Sam and JoFeedback: EveryoneHomework:Tell about a time when you could have been more foresightful.Tell how being foresightful would have made the situation different.Next Group Meeting is Tuesday January 23, 2007
22 Socialization Children are told what to do Adults are expected to “get it”
23 But…..Suppose your memory is impaired and it’s hard to follow a conversation much less participate in it.Suppose your thought processing is slowed down and it takes extra effort to process and respond to what is happening around you.Suppose you can’t trust your judgment.Then what happens?
24 DesocializationIf adults (your clients) don’t “get it” people walk awayWhen people walk awaySocialization stopsLearning stopsDeviance growsPeople become desocialized
25 Desocialization Deviant roles are established Others begin to reinforce deviant rolesDeviance becomes familiar if not always comfortableNo learning about the generalized otherSocial deviance can reinforce the neuropsychological deficits.The best mental exercise is social interaction
26 Social Cognition and Social Cognition Topics CET works to increase social cognition, i.e., the ability to act wiselyImpairments to brain function can seriously affect social cognitionPerspective Taking, Motivational Account, Cognitive Flexibility…..
33 Motivational Account What is your perspective? What is your audiences’ perspective?Is your behavior acceptable and credible?Can you give a clear and gistful explanation of your behavior?
34 Homework on Motivational Account Give an example of the situation in which it was important to give a motivational accountTell why was important to give a motivational accountHow could you have given a better motivational account?
36 Idealism and Realism Idealism motivates us Realism allows us to get things doneIdeals sometimes come trueRealism keeps us anchoredIdealism makes us feel goodIdealism isn’t always as glamorous as we imagine
37 Homework on Idealism vs. Realism Tell about a time when your ideals conflicted with reality. What was the ideal and what was the reality.Tell about a time when you could have used a little more idealism
39 Social Cognition Exercise: Condensed Message The Facts: an art dealer went to Paris on one of his frequent trips and took up residence at a hotel where he used to stay whenever he was in the city. He was just about to conclude a series of promising deals with some art galleries when he came down with the flu and developed a high temperature.Since he was such a good customer of the hotel, he received excellent medical care and plenty of attention from the staff. He was quite comfortable, but his business mission was about to fail if help did not arrive within two days at the most. His wife, who currently held another job, had been his able and trusted business partner in previous years.The art dealer decided to inform his wife of his condition, without alarming her, and ask her to come and help out with the business. Unable to reach her by phone or fax, he arranged to send his wife an which she would receive early the next morning when she went to work.The Circumstances: the server at the hotel limits outgoing s to 12 words or less.Assumptions:The wife could get away from her job at a moment’s notice.The couple had an excellent relationship. They communicate with each other in direct and precise language.What would the twelve word (or less) be?______ ______ ______ ______ ______ ______
40 CET Attendance &Graduation Rates Average attendance and graduation rates are % across all sitesMuch of the attendance success can be attributed to how much participants value the program.“I like coming to CET because they treat me like I have a brain”“We feel that we got our son back after he went through CET.” Marty and Gerry Conway, parents of PLAN Member Neil.“CET was invaluable, I learned to laugh again and it brought out the happy side of me”
41 A Meta-Analysis of Cognitive Remediation for Schizophrenia; T. Wykes Am. J of Psychiatry, May 2011 Conclusions: cognitive remediation benefits people with schizophrenia, and when combined with psychiatric habilitation, this benefit generalizes to functioning, relative to rehabilitation alone.What is more important than the surface characteristics (e.g., using a computer) is the technique of specific and explicit training of strategies and the use of various transfer techniques, as shown in the improved functioning outcomes for these approaches.
42 Clients who are candidates for CET StableImproved functioning but not well with poor attention, concentration, focus and especially poor working memoryStuck in their recovery processHave problems with social cognition and vocational functioning================================================Response to CET: Initial interview and graduation talk
43 Lessons Learned CET works best with clients who: Are stable but not fully recoveredHave major cognitive deficitsAre recovering from schizophrenia or have major social cognition disabilitiesAre able to read at a fifth grade levelHave had some prior vocational or educational successesAre at least marginally interested in recovery although CET is designed to work on amotivation
44 Ways CET benefits clients AttentionMemoryMotivationAffectAwareness of social contextVocational effectivenessInterpersonal effectivenessActive ThinkingAwareness of illness/disabilityDependabilitySpontaneityForesightfulnessPerspective TakingCognitive FlexibilityMental Stamina
45 CET Effects on Early Schizophrenia (N = 58) 1yr. 2yr.CETEST% ImprovementNeurocognitionProcessing SpeedCognitiveStyleSocial CognitionSocialAdjustmentSymptomsEack et al., Psychiatry Serv. 60:
46 Effects of CET on Employment Outcomes in Early Schizophrenia; Eack, et al
47 Agencies that have trained staff PLAN of Northeast Ohio, LyndhurstMercy Behavioral Health, PittsburghCommunity Support Services, AkronJewish Family Services (JFSA) ClevelandPLAN of Southwest Ohio, CincinnatiNorthcoast Behavioral Healthcare, Ohio DMHPLAN of North Texas, Dallas TexasWest Virginia University Hospitals, Morgantown W VACenter for Cognition and Recovery, Cleveland
48 86 CET groups completed as of 7-11 with 580 CET Graduates 14 CET groups currently running Disseminations started: City Mission of Washington, PA 4/6/10; JEVS of Philadelphia, PA 9/17/10; JF&CS of St. Louis MO started 2/23/11; Bridgehaven MHS started 7/19/11 7 new CET sites in development in California, Colorado, Maryland, Ohio and Pennsylvania
49 Second National CET Coaches’ Conference August 31, 2010
50 Being a CET Coach is a challenge “The role of a cognitive habilitation therapist is not unlike that of a jazz musician. A simple theme is introduced. As that theme becomes familiar, variations of increasing complexity are introduced….Thus the art of cognitive habilitation is the timely introduction of variations in predictable themes. These variations serve as preparation for dealing with increasingly complex environments.”Sam Flesher, 1990
51 Lessons Learned-Coaching Involves: Relearning patterns of interacting with group members, i.e. the support and challenge that coaching requiresDeveloping a new awareness of functional impairments of group membersDeveloping skill to ask thoughtful questions of group members that challenge them to think for themselves rather than guess at what is expected of them.Being able to allow clients to fail and succeed with supportLearning a remediation/rehabilitation treatment orientationBecoming competent in neurocognitive software programs
52 Daryl’s Comments on how CET has helped CET helped, but how, I still do not know. Some- thing inside me changed in social situations. I started to think about how others might feel or think, (perspective taking).I remember working with Anita and she became discouraged doing the computer exercises because I mastered them quicker. I had to learn to be a partner and not a competitor.I also got more of the gist and found myself not assuming what others knew, but gave them a motivational account for my actions or thought processes.
53 CONTACT INFORMATIONCenter for Cognition and Recovery, LLCRay Gonzalez, ACSW, LISW-S,Executive Director3659 S. Green Road, Suite 308Beachwood, OH 44122website:
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