COGNITIVE SKILLS THERAPY
GROUP:
IDEAS FOR INCORPORATING EVIDENCE-BASED
COGNITIVE INTERVENTIONS AFTER BRAIN INJURY
Kathleen Breslin, MA, LPC
Madeline DiPasquale, Ph.D.
Goals for today
Identify 3 common cognitive problems after brain
injury
¨  Discuss three evidence-based practices for cognitive
intervention after brain injury
¨  Generate three activities to improve understanding
of and intervention for cognitive changes after
brain injury
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Evidence-Based Rehabilitation
Services
What we know: Evidenced-based
research
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Behavioral and cognitive skills can be improved by participating
in neurorehabilitaiton (Braunling-Mcmorrow et al, 2010)
High tech and low tech external aides improve memory
performance
after brain injury (Lemoncello et al, 2010, Shum et al, 2011, McDonald et al, 2011, Watanabe et
al, 1998)
Dual task training improves divided attention and speed of
processing (Couillet et al, 2010, Fasottiet et al, 2000)
But…
¨  There is conflicting evidence supporting the use of group-based
interventions
to treat executive dysfunction after brain injury(NovkovicApopian et al, 2011)
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Specific structured training programs for improving attention are
ineffective or at best equivocal (Novack et al, 1996, Park et al, 1999, Ponsford and Kinsella,
1988)
Wait, we know more…
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There are six personal characteristic that predict
participation in behavior-change programs: self efficacy,
locus of control, beliefs and expectations about the
therapy program, disease characteristics, cognitive status,
and psychosocial status (Sohlberg & Turkstra, 2011)
Direct patient involvement in goal setting results in a
significant improvement in obtaining goals (Webb and Glueckauf,
1994)
¨ 
Motivation increases when there is a clear connection or
relevance of the therapeutic task to the long term goal
(Haskins, 2012)
Most importantly¨ 
General cognitive rehabilitation
therapy is effective for improving
cognition (Rath et al, 2003, Cicerone
er al, 2004)
No navel gazing allowed!
Here are the questions:
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How to do we deliver evidence-based treatment?
How do we engage the client so they feel the treatment
and interventions are relevant?
How do we increase program unity?
¤  Relationships
¤  Consistency
¨ 
How do we measure improvement?
Designing Treatment Interventions
Rationale for developing a cognitive
skills group
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Increase engagement and patient autonomy in treatment
Creating a culture of support among survivors
Discuss strategies and barriers to using cognitive
strategies
Provide exposure to a variety of types of interventions
Provide strategies for therapists and content to work on
client-focused goals
Enhance team approach
Common Cognitive Problems Following
Traumatic Brain Injury
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Awareness
Attention
Language/communication
Visual-spatial functioning
Memory
Executive Functioning
Working Memory
¤  Problem Solving
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Processing Speed
Motor Functioning
Social Skills
Group Structure
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2 hours, 1x/week, with a one hour lunch break in the
middle
Client’s provided with binder
First hour focused on review of previous material and
discussion of use of strategies
Second hour focused new information and practical
application
¤  “Kathy’s
Baking a Cake” story
¤  Discussion of ways the strategy could be used in client’s life
Content Outline
The group was broken down into units, primarily by
cognitive domain
¨  Neuroanatomy of TBI
¨  Attention/Concentration
¨  Language/Communication
¨  Visual-spatial functioning
¨  Memory
¨  Executive functioning/Working Memory/Problem
Solving
¨  Social Skills
Content: Group
Within each unit, content included neuroanatomy,
evidence-based strategies (internal and external),
and practical strategies, techniques and games
¨  Each unit was concluded with a game as review that
allowed clients to test out knowledge (e.g. jeopardy)
¨  Length of time on each unit varied between 4 weeks
and 10 weeks depending on material, client
understanding and depth of content
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Nuts and Bolts
Practically, how do you run a cognitive skills
group?
Engagement
¨ 
Staff
¨ 
Client
Making it fun!
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The Brain: Pinky and the Brain
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Clay brain models
Sample Content
Attention and Concentration
Attention and Concentration
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How many times does the white team pass the ball?
External Devices
Time Pressure Management (Fasotti et al., 2000)
Environmental Supports
Seven Level Model of Attention Training (Parente &
Hermann)
Psychosocial Supports
Attention Process Training (Sohlberg et al., 2002)
¨ 
Take a minute to write down the cards you
remember.
How many of these did you get?
9 of Clubs
¨  2 of Spades
¨  Queen of Hearts
¨  8 of Clubs
¨  10 of Diamonds
¨  5 of Spades
¨  Jack of diamonds
¨  8 of Hearts
¨  Queen of Diamonds
¨ 
What could you do to make this easier
or harder?
Increase/decrease the number of cards
¨  Increase/decrease interval the cards are shown for
¨  Increase/decrease how many times you see the
cards
¨  Increase/decrease distractions
¨  Any other Strategies?
¨ 
¤  Memory
palace
Language and Communication
Language and Communication
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Compensatory Strategies
¤  Drawing
¤  Gesturing
¤  Technology
Cues
¨  Social Support
¨  Cognitive Linguistics Therapy
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Memory
Memory
¤  Mnemonics
¤  References
¤  External
Aides
n  Memory
Notebook (Doneghy & Williams, 1998)
n  Alarms
n  Technology
¤  TEACH-M
n  Task
(smart phones, tablets)
(Ehlhardt et al., 2005)
Analysis
n  Errorless Learning
n  Assessing Performance
n  Cumulative Review
n  High Rates of Correct Practice Trials
n  Metacognitive Strategy Training
Social Skills
Social Skills
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Self-regulation
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Social sensitivity
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Group therapy
Interpersonal process recall (tape interaction, review in
therapy)
Social problem solving
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CBT
Stress inoculation training
Behavioral management
Social skills training
Social self-awareness
IMPROV Tasks
Engaging the Team
Common goals, common work
Content: Treatment Team
“Clinician Tip Sheet”
¨  A brief summary with resources was developed for
clinicians for each cognitive domain covered in
group
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Feedback/Outcomes
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Clients were more willing to experiment with
different techniques during group
¤  Clients
developed hypotheses about what could work
and then tested it out
¤  Clients shared ideas about what works for them with
group
¤  Identifying what was easy/challenging about a task
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Clinicians felt they had appropriate content to
address client’s goals
Modifications
Review, review, review
¨  Slow and steady
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¤  Some
units took much longer than expected
Practical games and illustrations
¨  Leave room for discussion
¨  Ways to help clients generalize?
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Thank You!
Dr. Drew Nagele for exposing me to cognitive
rehabilitation
¨  Dr. Max Shmidheiser for his patience, suggestions,
and support over the course of this year
¨  Of course to Dr. Maddie DiPasquale for the idea,
supervision, and encouragement
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References
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Cicerone, K. (2002). Remediation of working attention in mild traumatic brain injury. Brain Injury, 16, 185-195.
Cicerone, K. D., Mott, T., Azulay, J., Sharlow-Galella, M. A., Ellmo, W. J., Paradise, S., & Friel, J. C. (2008). A randomized controlled trial of
holistic neuropsychological rehabilitation after traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 89, 2239-2249.
Donaghy, S. & Williams, W. (1998). A new protocol for training severely impaired patients in usage of memory journals. Brain Injury, 12,
1061-1076.
Ehlhardt, L., Sohlberg, M., Glang, A. & Albin, R. (2005). TEACH-M: a pilot study evaluating an instructional sequence for persons with impaired
memory and executive functions. Brain Injury, 19, 569-583.
Fasotti, L., Kovacs, F., Eling, P., & Brouwer, W. (2000). Time pressure management as a compensatory strategy after closed head injury.
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Goverover, Y., Johnston, M., Toglia, J., & DeLuca, J. (2007). Treatment to improve self awareness in persons with acquired brain injury. Brain
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Haskins, E. C. (2012). Cognitive Rehabilitation Manual: translating evidence-based recommendations into practice. Reston: VA.
Levine, B., Robertson, I. et al. (2000). Rehabilitation of executive function: an experimental-clinical validation of Goal Management Training.
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Niemeier, J. P., Cifu, D. X., & Kishore, R. (2001). The Lighthouse Strategy: Improving the functional status of patients with unilateral neglect after
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Sohlberg, M. M. & Mateer, C. A. (2001) Cognitive Rehabilitation: an integrative neuropsychological approach. New York: NY.
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Von Cramon, D., Von Cramon, G., & Mai, N. (1991). Problem-solving deficits in brain-injured patients: a therapeutic approach.
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Winkens, I., Van Heugten, C., Wade, D., & Fasotti, L. (2009). Training patients in Time Pressure Management: a cognitive strategy for mental
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