How to Hone Your Skills to Patients with Cognitive Impairment
By Maureen Colket, MA, CCC-SLP
Speech-Language Pathologist
“In every job that must be done, there is an element of fun. You find the fun and snap! The job’s a game.” While providing speech-language pathology treatment is far more complex, we can borrow Mary Poppins’ spoonful of sugar concept for success in our field.
Treatment of cognitive impairment by speech-language pathologists has traditionally followed a medical model. In this model, the SLP identifies the problem and sets goals tied specifically to the impairment; in other words, the clinician is the decision-maker. Countless resources have since been created over the years — from workbooks to smartphone apps — to serve as stimuli for cognitive skills development. These resources cover a wide array of materials and can be selected according to the level of impairment. But there’s something missing here. I’ll set the scene for you.
Bill is referred for speech-language pathology services due to having a mild cognitive impairment as a result of a stroke. He completed inpatient rehabilitation but is now home. He is having trouble using his mobile phone and often gets confused when making appointments. His wife can help somewhat, but she is not home all of the time and gets very frustrated with Bill. The SLP completes an evaluation and sets goals for memory and problem solving based on his assessment. In their first treatment together, the SLP asks Bill to remember 3 words and repeat them back. They do this for 15 minutes. Then, the SLP gives Bill a worksheet and asks him to complete it. When Bill is on number four of a set of “unscramble the words”, he looks at his SLP, sighs, and says, “I don’t know why I’m doing this.”
This situation, though hypothetical, sadly does happen even with the best of intentions. The stimulus materials might be appropriate for the patient in terms of the level of difficulty and general goals targeted, but where is the functional aspect of therapy. Where is the fun?
Follow the Evidence
Current research in speech-language pathology, and healthcare at large, supports a shift from the medical model to the use of a functional, person-centered approach. Brummel-Smith et. al elucidate that “person-centered care means that individuals’ values and preferences are elicited and, once expressed, guide all aspects of their healthcare, supporting their realistic health and life goals.” Togher notes that patients should be trained in the context of the task they wish to be able to perform rather than a simulation or representation of the skill, which can “minimize the need for generalization.” Allowing the patient to be a decision-maker, as well as the clinician, results in an “increase in satisfaction with, and perception of the quality of, the care received” Dilollo & Christin. Intuitively, this sounds like a great idea. So why is it difficult to put into practice?
The Patient Variable and Motivational Interviewing
Providing assessment and treatment based solely on impairments is methodical. Clinicians like proven methods, structure, and linear progression in therapy progress. However, we all know the greatest barrier to a simple plan like this is the patient. The first step to functional treatment of cognitive impairment is to truly get to know your patient as a person. This will allow you to set meaningful and attainable goals that the patient will be motivated to work toward. My advice is to start with a conversation and then go deeper. Find out what your patient likes and dislikes. What are his or her hobbies (past and present)? What kind of music do they enjoy? Who are the most important people to the patient and why? Are religious or cultural customs important to the patient?
Cognitive therapy is very personal. Share information about yourself as well that the patient might like to learn. Would you really want to get involved with a clinician if you felt no connection?
Next comes the deeper dive. Motivational Interviewing (MI) is a counseling technique originally developed for addiction counseling that has been recommended for broader use across healthcare professions. MI is defined by Miller & Rollnick as a “client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” and it entails four main principles:
- Express empathy
- Develop discrepancy
- Roll with resistance
- Support self-efficacy
To read more about employing this technique, see McFarlane’s article linking MI to the field of speech-language pathology. McFarlane notes that MI can be used in the rehabilitation process to encourage a “therapeutic alliance.” What a powerful way to think of the clinician/patient relationship! Through MI, the SLP will discover how the patient feels along the way during the rehabilitation process and can make appropriate adjustments as needed.
Now for the FUN Part in FUNctional
Once you have identified interests unique to your patient, it’s time to set functional goals. This process involves the clinician AND the patient. There is no denying that the skills of a clinician are required to set SMART goals (specific, measurable, attainable, relevant, and time-based). However, the client input here is key. Let’s say you have a patient who has poor sequencing and problem-solving skills and you discover he is highly motivated to return to guitar playing. He can play fairly well but rushes through tuning his guitar and when he plays, the sound is less than stellar. Here is your sequencing goal: patient will tune each of the six strings of his guitar in order using his guitar tuner given minimal, occasional verbal cues from the SLP for instructions. Sounds pretty fun, right?
Perhaps you have a patient who has difficulty staying on task and she perseverates, giving you the same responses repeatedly. You have also discovered she formerly wrote poetry. Your goal might involve naming topics for poems or contributing words or lines for a poem. Cognitive function is required for every task our patients complete. The sky is the limit in functional goal setting and comes quite easily once you have your patient’s backstory.
Improved Outcomes with Functional Cognitive Therapy
Tougher et al. notes that “rehabilitation of individuals with cognitive-communication disorders should consider premorbid communication status; be individualized to the person’s needs, goals, and skills; provide training in the use of assistive technology where appropriate; include training of communication partners, and occur in context to minimize the need for generalization.”
As clinicians providing treatment for patients in their home setting, we have a unique opportunity to take advantage of access to tasks performed in context. There is no need for simulated tasks when the real thing is available. Carryover within individual tasks, goal areas, and, most importantly, overall functional outcomes can be vastly improved. When therapy tasks are more personalized and meaningful to our patients, they are highly motivated throughout the process and more likely to remain successful after the date of discharge.