INTERPERSONAL COGNITIVE REMEDIATION
Most individuals in our society profess a fear of memory loss. When their brain processing is slower than expected, when they cannot find the apt word, they cite “senior moments” or even, “early Alzheimer’s “ as the cause. Yet, it is rarely so. It is the lack of being present in the present, an omnipresent problem of modern industrial life. People’s minds are wandering about from the there and then to the proximate and perchance. Individuals may have intact neuropsychological structures but still not perform well. This may be due to emotional issues which interfere with their performance.
Worse, lacking frustration tolerance, they turn to the immediate gratification of the smart phone and make themselves the dumber.
Cognitive remediation aims to improve such neuropsychological functions as attention, perception, retention, imitation, and motivation in order to enhance recall of learned material. Cognitive remediation draws upon the approach of Gardner’s multiple intelligences, which conceptualizes intelligences as an ability, or a “potential.” Potentials can be enhanced through conscious, structured practices. Everybody possesses cognitive abilities and, as such, can increase these potentials via structured, regular rehearsals, or practice. Lastly, Gardner includes bodily-kinesthetic as a type of intelligence. Therefore, physical exercises are included in each session, to not only increase blood flow to the brain, which by itself increases brain health; but to increase kinesthetic intelligence, the ability to know bodily boundaries and increase bodily control.
Cognitive remediation also draws upon both auditory and visual learning. Perception is a skill, and skills can be honed and improved.
This is not psychotherapy. It is an intense encounter with materials which focus on each of aforementioned cognitive abilities in the service of creating a more orderly mind. Interpersonal cognitive remediation makes use of the interpersonal nature of modelling. For a participant to believe in the success of the endeavor, the psychologist, or model, must be seen as relevant, engaging, and offer success experiences with the task.
The length of cognitive remediation is usually 16 weeks, with three sessions of 45 minutes per week. Homework is assigned at the end of the session, so that the participants can practice strategies learned to further enhance their abilities and remedy their deficits. The participant is encouraged to observe themselves and to self-reinforce during these times. Even small improvements are encouraging and enhance the person’s self-efficacy, which in turn motivates them to practice further.
Cognitive remediation is continuously improving itself. Measurements are taken during each session, and improvements can be seen within three months.
The typical cognitive remediation course takes place in a group setting, where each individual works on a computer. However, this concept of a group violates the idea of group as an interpersonal encounter, as everyone is placed on a computer and works on their own. Furthermore, when individuals learn to rely on computer functions to nudge them along, they become more apt technicians, better researchers, but the primary issue of cognitive remediation remains unresolved. For a participant to see themselves as improved, they must learn and rehearse strategies, or compensatory, organized mental tool use, which can be learned.
Additionally, learning does not take place in an arid, sterile laboratory. As Vygotsky wrote, learning and neuropsychological development occur through mediators, or tools. Vygotsky, as the second of eleven children, knew that learning does not take place in isolation but through the intervention, or scaffolding, of more expert others. Thus, the interpersonal field intervenes to fortify higher mental forces.
Interpersonal cognitive remediation can be done either in a group setting, or, lacking a group, as 1:1 with the therapist fully participating as a more knowledgeable other. The group, or the therapist, serves as a more skilled mediator to enable the client to respond to the task in an increasingly accomplished fashion. Mental processing becomes faster and more efficient. With this increase in processing speed comes decreased anxiety about aging.
Regardless of the number of participants, the psychologist ensures that all members are fully present in the present and are engaged in the task. The psychologist provides models problem solving, reframes issues, offers structure, offers to deconstruct the task into smaller segments, and offers positive reinforcement to keep the client engaged and on-task. The therapist reframes client frustrations in a positive fashion, referencing the sessions as skills training and mental tool training. If needed, a less frustrating task is put in place to ensure a success experience, which becomes self-reinforcing.
Interpersonal cognitive remediation is structured. Each session lasts 45 minutes, thus, each week, the remediation consists of three 45 minute sessions. The client knows what to expect each time. For example:
Orientation Session: Formal Cognitive Testing: Baseline. WRAT-5 Reading Subtest. ROMBOM Brief Neuropsychological Evaluation. Clinical Interview. Collateral Interview, if possible. Clients would sign an informed consent form and agree to have a thorough physical before the first session, to ensure they are able to participate in the calisthenics and body control sessions. Clients would be encouraged to wear comfortable clothing and gym shoes to sessions.
Session 1: Concentration: Concentration game, Carmen Santiago Game. Calisthenics and Body Control (Statues).
Session 2: Listening and Recall: Simon game and Improv. Calisthenics and Body Control (Statues)
Session 3: Listening and Processing Speed: Improv games. Calisthenics and Body Control (Statues).
Each week would following a similar format.
The therapist, besides being a participant, also needs to keep statistics. How long (in minutes) how many (in number). Pulses need to be taken before the session and after. How long after the calisthenics does it take for the pulse to return to baseline.
At the end of 4 weeks, the WRAT-5 Reading subtest would be readministered, and similarly, at 8 weeks, 12 weeks, and 16 weeks.
The clientele who may benefit from ICR include individuals who are at least six months sober and reliably abstinent from all non-medicinal drugs, individuals who have a history of decompensation without mental structure, people who are too dependent upon computer chipped devices (those who have no ability to recall frequently dialed telephone numbers, cannot do basic mathematical calculations, etc.
Psychologists who offer such courses must be aware that insurance is unlikely to pay for such courses. Psychologists must also be sure to have on hand decks of cards, SIMON, and a computer with access to “Where in the world is Carmen Santiago.”
References:
Bandura, A. (1977). Social learning theory. Englewood Cliffs: Prentice-Hall
Cooper, LA & Regan, DT (1982). Attention, perception, and intelligence. In
Handbook of human intelligence. Cambridge: Cambridge University Press.
Gardner, H (1983). Frames of mind. NY: Basic Books.
Gregory, RL (1966). Eye and brain. NY: McGraw Hill
Neisser, U. (1976). Cognition and reality. San Francisco: WH Freeman
Vygotsky, LS (1978). Mind in society. Cambridge: Harvard University Press.