Cognitive retraining

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Definition

Cognitive retraining is a therapeutic strategy that seeks to improve or restore a person's skills in the areas of paying attention, remembering, organizing, reasoning and understanding, problem-solving, decision making, and higher level cognitive abilities. These skills are all interrelated. Cognitive retraining is one aspect of cognitive rehabilitation, a comprehensive approach to restoring such skills after brain injury or other disability.

Purpose

The purpose of cognitive retraining is the reduction of cognitive problems associated with brain injury, other disabilities or disorders, and/or aging. The overall purpose of the therapy is to decrease the everyday problems faced by individuals with cognitive difficulties, thereby improving the quality of their lives.

Precautions

The extent to which a person with a brain injury can recover from or compensate for cognitive problems related to the injury requires more information about the person and about their injury. Therapy must be tailored to each individual's needs and abilities. Some cognitive retraining techniques require higher levels of skill, and therefore would be more suitable for persons who have made some progress in their recovery. Moreover, a person's moods and emotions have an effect on their cognitive skills. Someone who is depressed, for example, may need psychotherapy and/or medication before he or she can engage in and benefit from cognitive retraining. Some persons with brain injuries may find it difficult to transfer a skill learned in one setting, such as a clinic, to another setting, such as their home. Although a specific individual may show some improvement on training tasks, his or her cognitive skills may not be considered improved or restored unless there is some evidence that the skills have been transferred to everyday settings and can be maintained over time.

Description

Professionals from a variety of fields, such as psychology, psychiatry, occupational therapy, and speech-language pathology , may be involved in cognitive retraining. The techniques of cognitive retraining are best known for their use with persons who have suffered a brain injury. Cognitive retraining has also been used to treat dementia , schizophrenia , attention-deficit disorder, learning disabilities, and cognitive changes associated with aging.

Cognitive retraining includes a considerable amount of repetitive practice that targets the skills of interest. In fact, repetition is essential for the newly retrained skills to become automatic. Regular feedback is another important element of cognitive retraining, as is the use of such rewards as money. Retraining usually begins with simpler skills and proceeds to more complicated skills. The therapist may address cognitive skills while the person is practicing real-life tasks, in an effort to improve their performance of these tasks. In fact, practicing skills in the ways and settings they will be used in real life is critical to the success of retraining efforts. The length of time for cognitive training varies according to the type and extent of the injury and the type of retraining skills used. For example, retraining memory may take months or years. In comparison, it may take only a few days or weeks to retrain someone to organize his or her home or workplace. The use of computers for cognitive retraining has become an increasingly common practice.

Types of cognitive retraining

Attention and concentration retraining. This type of cognitive retraining aims to improve several abilities, including focusing attention; dividing attention; maintaining attention while reducing the effects of boredom and fatigue ; and resisting distraction. Attention has been considered the foundation of other more complicated cognitive skills, and therefore an important skill for cognitive retraining. This area of cognitive retraining has been widely researched, and has been shown to improve patients' abilities in various tasks related to attention.
Memory retraining. Memory retraining involves teaching the patient several strategies that can be used to recall certain types of information. For example, rhymes may be used as a memory aid. A series of numbers, such as a phone number with an area code, may be broken down into smaller groups. A person may be taught to go through each letter of the alphabet until he or she remembers someone's name. Both memory and organization problems are common and disabling after head injury.
Organizational skills retraining. This approach is used when the person has difficulty keeping track of or finding items, doing tasks in a set order, and/or doing something in a timely manner. Strategies may include having one identified place for an item ("a place for everything and everything in its place"). In addition, the person can be taught to keep the items that are used most frequently closer to him or her (the front or the lower shelves of a cabinet, drawer, closet, or desk, for example). Items that are often used together (such as comb and brush, toothbrush and toothpaste) are placed beside each other. Items may be put into categories (Christmas decorations, Easter decorations, for example). These strategies help individuals function better in their home or work environment.
Reasoning. Reasoning refers to the ability to connect and organize information in a logical, rational way. Reasoning retraining techniques include: listing the facts or reality of a situation; excluding irrelevant facts or details; putting the steps to solve a problem in a logical order; and avoiding irrational thinking, such as jumping to conclusions based on incomplete information, or focusing on the negative aspects of the situation and ignoring the positive. When the person can connect relevant information in a logical way, they are better able to understand or comprehend it.
Problem solving. Problem-solving retraining aims to help people define a problem; come up with possible solutions to it; discuss the solution(s) with others and listen to their advice; review the various possible solutions from many perspectives; and evaluate whether the problem was solved after going through these steps. This sequence may be repeated several times until the problem is solved. This process is referred to as "SOLVE," from the first letter of the name of each step: Specify; Options; Listen; Vary; and Evaluate. The "SOLVE" technique is more appropriate for use with individuals at a higher level of functioning.
Decision making. Decision-making retraining is used when a person must choose among a number of options. The goal of this retraining is to help him or her consider the decision thoroughly before taking any action. The considerations may range from such practical matters as money, people, rules and policies, to personality issues.
Executive skills. Executive skills retraining refers to teaching individuals how to monitor themselves, control their thinking and actions, think in advance, set goals, manage time, act in socially acceptable ways, and transfer skills to new situations. These are higher-level cognitive skills. Charts and videotapes may be used to monitor behavior, and a variety of questions, tasks, and games may be used in retraining these skills.

Preparation

Cognitive retraining usually takes place in a quiet room without distractions. It is also important for the person to feel relaxed and calm while they are being retrained in cognitive skills. Engaging in cognitive retraining is not recommended when someone is emotional distressed; for example, if they have recently lost a loved one. The therapist usually evaluates the person's level of cognitive skills and the extent of their cognitive problems before retraining begins. This evaluation provides a way to monitor improvement by comparing the patient's skill levels during and after retraining to his or her skill levels before retraining. Cognitive retraining requires patience and persistence from everyone involved.

Aftercare

The therapist will try to promote the transfer of skills learned using cognitive retraining techniques to the patient's everyday life settings and demands. Training may be continued until the patient's skills are improved, transferred to, and maintained in real world activities.

Risks

It is important for the therapist, patient, and the patient's friends or family members not to assume that improvement on training exercises and tests automatically leads to transfer of the skills to real-life settings.

Normal results

Cognitive retraining may be considered successful if performance on a behavior related to a particular cognitive skill has improved. It is ultimately successful if it helps the injured person improve his or her functioning and meet his or her needs in real-life situations and settings.

Resources

BOOKS

Mateer, Catherine A., and Sarah Raskin. "Cognitive Rehabilitation." In Rehabilitation of the Adult and Child with Traumatic Brain Injury, 3rd ed., edited by M. Rosenthal, E. R. Griffith, J. S. Kreutzer, and B. Pentland. Philadelphia: F. A. Davis, 1999.

Parente, Rick, and D. Herrmann. Retraining Cognition: Techniques and Applications. Gaithersburg, MD: Aspen, 1996.

Ylvisaker, Mark, and Timothy J. Feeney. Collaborative Brain Injury Intervention. San Diego: Singular, 1998.

Joneis Thomas, Ph.D.