Practicing Psychotherapy with adults Who Have Cognitive Impairments
Psychotherapy is a dynamic process that is facilitated by full engagement of the individual who sought out or was referred for psychotherapeutic services. However, full engagement could be hindered for individuals who have compromised cognitive functioning secondary to any number of neuropathologies or developmental or aging processes. Modification of the therapeutic process can ensure that these individuals are afforded the opportunity to fully benefit from such services despite the presence of more limited cognitive resources. Additionally, quite frequently these individuals experience distress characterized by anxiety and frustration, as well as other emotions and feelings of inadequacy related to the impairments in their abilities and functioning and the impact on their daily life. Thus, the individual may present to services with issues related to loss, changes in sense of self, learned dependency, and other such topics. By adapting the psychotherapeutic process and being mindful of some of the main presenting issues, the therapeutic relationship and process can be facilitated and be quite effective for helping an individual with cognitive impairments to improve his or her daily life functioning.
An essential variable in most types of interventions is engagement of the individual in the process, and psychotherapeutic interventions are no different. As proposed by Lequerica and Kortte (2010), engagement occurs through effortful involvement in a task or process in which the level of engagement can be influenced by aspects of the person (p. 281) and/or by the environment. In general, the person by environmental factors that contribute to engagement are the same in all therapeutic relationships; however, attention to these factors when working with individuals with cognitive impairments will enhance true engagement in the process and enhance the potential for successful outcomes in this population specifically. Without full engagement, the individual may attend the therapy session without truly investing in the process and thus benefitting from it.
Therapeutic engagement is a multifaceted construct that has been hypothesized to include the perceived need for treatment, perceived self-efficacy for making change occur, expectancies for a successful outcome from treatment, and willingness to attend the appointments (i.e., showing up; Lequerica & Kortte, 2010). Part of the psychotherapeutic process initially should be to partner with the individual to understand his or her thoughts and beliefs about his or her needs for intervention and attitudes toward therapy and the ability to make changes. Exploring these thoughts and beliefs will assist the psychotherapist in tailoring interventions to assist the individual in understanding the need for interventions and enhancing his or her perceptions about being able to make positive behavioral changes and reach goals. Through this process, the individual is more likely to show up and engage in discussion and skill development to address the key issues.
Structuring and Accommodating in the Therapeutic Environment
Conscious attention to the therapeutic environment can facilitate maximal engagement through structural modifications that will accommodate the needs of individuals with cognitive impairments. Given that psychotherapy is bound in communication between an individual and a psychotherapist, the therapeutic environment must support effective communication. Additionally, psychotherapy is geared toward helping the individual with cognitive impairments understand and cope with reality (Prigatano, 1999), and thus the cognitive domains of attention, memory, and executive functioning are foundational. For some individuals, their ability to communicate, process information, and incorporate past learning has been hindered by cognitive impairments. These disabilities do not mean that these individuals cannot benefit from psychotherapy; rather, it means that the environment and process needs to be modified to accommodate so they can engage fully. Outlined in Table 58.1 are recommendations for modifying the typical structure of the physical environment and session format to facilitate engagement of the individual. These modifications can reduce the impact of distractibility, fatigue, and poor memory encoding, which are all common cognitive impairments. In addition, simple accommodations built into the therapeutic process will assist the individual in carrying-over information from session to session, following through on “homework” assignments, comprehending and communicating more complex ideas, and adopting new skills. See Table 58.2 for recommendations for accommodating for cognitive impairments in the therapeutic environment. The overarching goal of these accommodations is to reduce the processing the brain on its own has to do (e.g., recalling, conceptualizing, visualizing) by providing the information in a written or visual form. For an in-depth discussion of adapting the psychotherapy process and environment to work with individuals with cognitive impairments, see Langer, Laatsch, and Lewis (1999) and Lawton and Rubinstein (2000); (p. 282) and for greater discussion on how to facilitate learning in a therapeutic environment for individuals with cognitive impairments (or actually for everyone!), see Sohlberg and Turkstra (2011).
Table 58.1. Structuring the Therapeutic Environment
Table 58.2. Accommodating in the Therapeutic Environment
Clinical Focus for Interventions
The focus of psychotherapy with individuals with cognitive impairments depends on many factors, including, etiology, age at onset, constellation and extent of impairments, and the level of impact of the neurobehavioral and cognitive impairments on functioning. A central feature of psychotherapy that cuts across diagnostic groups is the development of a therapeutic alliance (Prigatano, 1999). Because many individuals with cognitive impairments are referred by others, including family members, community agencies, or medical professionals, the individual may have a limited appreciation of the reason for psychotherapy. As noted earlier, one of the key elements to facilitate engagement is the individual believing that intervention is needed. Development of a strong therapeutic relationship will allow the psychotherapist to explore the need for intervention services with the individual regardless of the initial source of the referral. Matching to the individual’s treatment needs and his or her priorities or goals will help to maximize engagement in the therapeutic process. Initial goals focus on developing the collaborative relationship necessary to improve awareness of self and behavior. The alliance and the contextual information specific to the individual’s brain functioning provides the basis for tailoring psychotherapy to guide the person’s behavior and adjustment to life.
One of the most challenging aspects of working with individuals with cognitive impairments is the potential for limited awareness of the changes in their cognitive and behavioral functioning. However, to some extent this is a matter of degree because awareness of oneself and monitoring of our own behavior is a challenge for every human being. Individuals with cognitive impairment have the potential of having greater challenges in being psychologically minded, monitoring their own behavior, learning from past mistakes, and recognizing areas of weakness or deficit secondary to their neurologic dysfunction. One goal of the therapeutic process is to facilitate the individual’s understanding of maladaptive, ineffective, or inefficient behaviors that he or she may not even be aware of as problematic. Given that it is difficult to tease out whether the ineffective behaviors are new or have always been part of the individual’s behavior repertoire, the psychotherapist is encouraged to consider the person as he or she presents for interventions and explore how that individual can maximize life functioning by capitalizing on strengths and minimizing or compensating for weaknesses rather than worry about the etiology of the problems per se. The goal for interventions is for the individual to improve his or her understanding of his or her own functioning and learn skills for engaging in life appropriately (p. 283) and effectively. For a summary discussion of impaired awareness with a suggested theoretical model, see Toglia and Kirk (2000).
In addition to impaired awareness, presenting issues of loss, poor self-esteem, reduced feelings of personal control, and issues of learned dependency are quite common for individuals with cognitive impairments. Creating a safe, nonthreatening, accepting, and trusting environment is critical to decrease anxiety and facilitate discussion of very sensitive topics. Psychotherapeutic approaches focus on goals of providing an environment for emotional outlet, enhancement of self-esteem and role functioning, minimizing psychological and behavior problems, and increasing coping skills (see Langer, Laatsch, & Lewis, 1999; Lawton & Rubinstein, 2000). Quite frequently family/caregivers are integrated into the therapeutic process to ensure that they are provided with guidance on how to appropriately support their loved one emotionally as well as functionally with daily life task completion as needed (Lawton & Rubinstein, 2000; Prigatano, 1999). There is a strong need to develop a shared understanding between the family and the individual with cognitive impairment about situations in which assistance is needed and when assistance hinders personal growth, feelings of self-sufficiency and self-esteem, and positive feelings for the relationship. As stated by Prigatano (1999), the goal of psychotherapy is to teach individuals to learn to behave in their own best interests, not selfish interests, and this goal applies just as well to family members. By encouraging everyone to partner together with the ultimate goal of improving life engagement, the engagement of the individual with cognitive impairments as well as the family members is enhanced. This process is, of course, delicate because quite often family members have so strongly adopted the caregiving role that they have difficulty recognizing how they can get their own needs met without feeling that they are neglecting the needs of their loved one. However, if each person learns the skills to enhance his or her own well-being, then the burden of care is reduced and the feeling of mutual appreciation enhanced.
Structured group interventions can provide another avenue for facilitating adaptive change in individuals with cognitive impairments. Given the social and emotional aspects of cognitive impairments, there are abundant opportunities for the individual to benefit from the interactions with peers within the safe and structured setting. Group psychotherapy provides opportunities for receiving feedback for self-evaluation, sharing of compensatory strategies for cognitive and social skill deficits, comparison of strengths and limitations, and facilitating interpersonal dynamics of feeling helpful to and accepted by others (Langer et al., 1999). Typically this modality of treatment when used with individuals with cognitive impairments is focused on rebuilding basic social skills (e.g., eye voice volume, listening skills, and body language) and providing practice for managing emotional reactions through structured activities (e.g., modeling, role playing, and educational presentations). The goals parallel those of individual treatment modalities for this population, including improving emotional stability, social interaction skills, problem-solving skills, self-monitoring, self-acceptance, and awareness.
When the psychotherapist has more limited experience in working with persons with disability, there are some additional issues to consider when undertaking psychotherapy with individuals with cognitive impairments. The therapist must guard against the bias that individuals with cognitive impairments are permanently disabled and will not benefit from psychotherapy because behavior change is not possible. It is well demonstrated that individuals with these deficits may benefit from psychotherapy and behavior change techniques to improve psychosocial function. And there are no data or rationale that the nonspecific factors of the psychotherapeutic relationship are any different or less important for achieving positive outcomes.
(p. 284) The psychotherapist should also be mindful of personal biases and assumptions in order to better avoid subscribing to a moral or medical model of disability. Such a model may bias the psychotherapist toward viewing persons with impairments as innately disabled or as individuals with shameful conditions, leading the psychotherapist to assume a paternalistic role (Olkin, 1999). Whereas adopting a more social or minority model, in which the disability is viewed as occurring at the interface of the person and his or her environment, may encourage the psychotherapist to be aware of the strengths and abilities of the individual and to focus on the individual’s interpersonal and physical environment as key targets for intervention (Olkin, 1999).
After extensive experience with individuals with impairments in cognitive functioning, Prigatano (1999) proposed that “psychotherapy is about achieving a greater understanding of one’s self and one’s behavior” (p. 205). Through greater personal understanding and growth, an individual can learn to value and capitalize on his or her strengths and compensate and/or adapt to weaknesses. The psychotherapeutic process can facilitate the individual understanding the reasons that problems arise in his or her life and how to cope, adjust, adapt, and/or compensate. These are the overarching goals of psychotherapy regardless of the nature of the individual’s cognitive functioning. Psychotherapy can be very helpful for individuals with cognitive impairments and, thus, psychotherapists can facilitate their engagement by appropriately structuring the therapeutic environment and process so that everyone can benefit.
References and Readings
Langer, K. G., Laatsch, L., & Lewis, L. (Eds.). (1999). Psychotherapeutic interventions for adults with brain injury or stroke: A clinician’s treatment resource. Madison, CT: International Universities Press.Find this resource:
Lawton, M. P., & Rubinstein, R. L. (Eds.). (2000). Interventions in dementia care: Toward improving quality of life. New York: Springer.Find this resource:
Lequerica A. H., & Kortte, K. B. (2010). Therapeutic engagement: A proposed model of engagement in medical rehabilitation. American Journal of Physical Medicine and Rehabilitation, 89(5), 415–422.Find this resource:
Olkin, R. (1999). What psychotherapists should know about disability. New York: Guilford Press.Find this resource:
Prigatano, G. P. (1999). Principles of neuropsychological rehabilitation. New York: Oxford University Press.Find this resource:
Rusin, M. J., & Uomoto, J. M. (2010). Psychotherapeutic Interventions. In R. G. Frank, M. Rosenthal, & B. Caplan (Eds.), Handbook of rehabilitation psychology (pp. 359–371). Washington, DC: American Psychological Association.Find this resource:
Sohlberg, M. M., & Turkstra, L. S. (2011). The learning Context: Beyond Practice. In M. M. Sohlberg & L. S. Turkstra (Eds.), Optimizing cognitive rehabilitation (pp. 49–64). New York: Guilford Press.Find this resource:
Toglia, J., & Kirk, U. (2000). Understanding awareness deficits following brain injury. NeuroRehabilitation, 15, 57–70.Find this resource: