Cognitive Training in Supported Employment in Severe Mental Illness

1
Cognitive Training in Supported Employment in
Severe Mental Illness

• Susan R. McGurk, Ph.D.
• New Hampshire-Dartmouth Psychiatric Research
  Center

2
Cognitive Impairment in Schizophrenia

• Severe impairment on cognitive tests
• Subjective reports of cognitive impairment
• Reports from caretakers and relatives
• Not caused by medication or environment
• Present from premorbid periods to end-stage
• More strongly associated with function than any
  other symptom domain

3
Importance of Cognitive Functioning to Mental
Health

• Impaired cognitive functioning increases risk of
  developing mental illness
• Cognitive abilities are related to a broad range
  of psychosocial functioning (e.g., self-care,
  independent living, social relationships,
  school/work)
• Impaired cognitive functioning predicts less
  benefit from psychosocial treatment

4
What is Cognition Functioning?

• Mental processes
• Five major areas
• Attention
• Psychomotor speed
• Memory
• Problem-solving
• Social cognition

5
Neuropsychological Scale Scores in First-Episode
Patients Compared to Healthy Comparison Group
Visuo-spatial
Attention
Executive
Memory
Language
Motor
Standard Deviation
Bilder RM, et al. Am J Psychiatry.
2000157(4)549-559.
6
Working Memory Digit Sequencing Task

• Digit strings presented in random order
• Ex 3-9-8-1-4
• Patient reports string in ascending order
• Ex 1-3-4-8-9

7
BACS Tower of London
How many moves does it take to make A look like B?
Answer 2
Duke University, 2000
8
BACS Tower of London
How many moves does it take to make A look like B?
Answer 3
Duke University, 2000
9
Social Cognition

• Ability to perceive and understand relevant
  social cues
• Facial expression voice tone
• Hints and indirect suggestions
• Social/cultural norms (e.g., difference between a
  co-worker and friend)
• Rules of personal disclosure (i.e., gradually
  increase level of disclosure, matched to other
  persons level)

10
Subjective Reports of Cognitive Impairment

• I have something I want to say and then it flies
  right out of my mind before I say it.
• I forgot what I was supposed to do today at
  work. My boss got really annoyed with me.
• In class, my mind wanders fairly frequently and
  its upsetting. When Im reading for school, my
  mind wanders- I would have to reread the sections
  several times.
• I tend to repeat myself, do things over and
  over I forget what my friends tell me. I forget
  where I put things. I forget about medications.

11
Why Target Cognitive Functioning in Supported
Employment Programs?

• Cognitive impairment is common in schizophrenia
• Cognitive functioning predicts work in general
  psychiatric populations and in vocational
  rehabilitation participants
• Evidence suggests that cognitive rehabilitation
  improves cognitive functioning but there are
  questions about transfer of cognitive skills

12
Cognitive Functioning Relates to Employment

• Vocational rehabilitation participants
• Cross-sectional comparisons of employed vs.
  unemployed clients
• Retrospective analyses in clients with good vs.
  poor vocational outcome
• Prospective studies

For review McGurk Mueser, 2004
13

• Better cognitive functioning relates to better
  employment outcomes

14
Example of Work Problems Related to Attention
Impairment

• Mary had trouble finishing her job tasks on time,
  which included washing the pots and pans and
  cleaning the spice rack. Initially it appeared
  that the clients job was lost due to motor speed
  problems. However, more careful examination
  revealed something quite different. She stated
  I would begin washing a spot on a pot and then
  lose focus and 20 minutes would go by and I would
  find myself still washing the same spot. I would
  lose my concentration.

15
Example of Job Performance Problem Related to
Memory Impairment

• A client, Ed, stated I couldnt remember what
  produce my boss had just told me to bring up from
  the cellar so I would have to page him to ask him
  to tell me the items again. My boss was getting
  really annoyed with me. My coworkers said to me
  that I cant remember anything.

16
Example of Job Performance Problem Related to
Problem-Solving Impairment

• John was given a raise in job duties from setting
  up the salad bar to seating customers at tables
  in the restaurant. He proceeded to sit customers
  on only one side of the restaurant. Despite
  numerous complaints from his supervisor and
  co-workers, John could not learn to seat
  customers evenly throughout the restaurant.

17
McGurk Mueser, Schizophrenia Research, 2004
18
Percentage of Studies Reporting Significant
Associations Between Cognitive Functioning,
Symptoms, and Work in General Psychiatric Samples
and Samples of Clients in Vocational
Rehabilitation
Cognitive Functioning
General Symptoms
Psychotic Symptoms
Negative Symptoms
McGurk Mueser, 2004
19
Cognitive Training StrategiesRestorative
Approaches

• Goal is to improve cognitive impairments by
  correction of underlying neuropathology
• Accomplished by repeated practice of cognitive
  functions using computerized or paper and pencil
  exercises or tests, with or without strategy
  coaching.
• Evidence that 20, 30 min sessions over 3-6 weeks
  can produce meaningful cognitive performance
  improvements (e.g., Twamley et al., 2003).
• Evidence of improved brain function (e.g., Wykes
  et al. 2002 Wexler et al., 2003)

20
Limits of Cognitive Rehabilitation Research

• However, there are questions about transfer of
  cognitive skills
• Lack of clear focus on functional outcome
• Not addressing client-centered goals
• Not attending to transfer of cognitive skills to
  in vivo settings
• Failure to integrate cognitive rehabilitation
  with established interventions for improving
  functional outcomes

21
The Thinking Skills for Work Program

• Designed for clients not benefiting from
  supported employment
• Fully integrated with supported employment
• Combines computer cognitive training with in vivo
  applications

22
Components of the Program

• Assessment
• Computer cognitive training
• Job search planning
• Job support consultation

23
Assessment

• Cognitive Assessment
• Job ending analysis
• Review with client and employment specialist
• Enhancement of motivation for program

24
Computerized Cognitive Training

• Based on CogPack, a commercially available
  software program
• Full spectrum of cognitive skills covered in
  first 6 sessions
• 24 sessions over 12 weeks

25
Job Search Planning

• Timing is client preference
• Match to client interest
• Consider cognitive strengths and limitations
• Consideration of job complexity

26
Job Support Consultation

• Collaboration between cognitive and employment
  specialists
• Coping strategies
• -Remediative
• -Compensatory
• -Both

27
Study Design

• RCT Cognitive Training (CT) and Supported
  Employment (SE) vs. Supported Employment only
• Three month cognitive and symptom follow up
• Two mental health agencies in Brooklyn, NY
• Integrated supported employment programs
• Two year follow up tracking competitive work

28
(No Transcript)
29
Inclusion/Exclusion

• Severe mental illness
• Not currently employed
• Wants competitive work
• Enrolled in SE
• History of recent job loss

30
Cognitive and Symptom Measures

• Positive and Negative Syndrome Scale
• Cognitive battery
• Digit Span WAIS III
• Digit Symbol WAIS III
• Trail Making A and B
• California Verbal Learning Memory
• Wisconsin Card Sorting Test

31
Work Outcomes

• Competitive work activity over 2 year follow up
• Number of jobs
• Hours worked
• Wages earned
• Job duration

32
DEFINITION OF COMPETITIVE EMPLOYMENT

• Work that pays at least minimum wage, is in an
  integrated community setting, is a job owned by
  the client, and is a job that a non-disabled
  individual could obtain.

33
Statistical Analyses

• Compare sites
• Compare CT and SE vs. SE only groups at baseline
• Cognitive training characteristics
• Baseline-3 month differences in cognition and
  symptoms
• Employment outcomes

34
Sample Characteristics
35
Sample Characteristics
36
Sample Characteristics
37
Site Differences

• Fidelity Assessment
• Supported Employment Fidelity Scale (Bond, 1997,
  revised, 2001)
• Staffing, organization, services (range 15-75)
• MHA 1 60 Fair implementation
• MHA 2 66 Good implementation

38
Computer Training Exercises

• Average number of computer sessions
• M19.6 (SD6.9), range 4-24
• Average weeks of duration of sessions M13.6
  (SD6.0), range 2-28
• 92 of clients exposed to 6 or more sessions

39
Assessment Results

• The neurocognitive assessment confirmed that
  problems with attention, not motor speed, were at
  the root of Marys work-related difficulties.
  Computerized cognitive training exercises helped
  her improve her attention-concentration span.

40
Job Support ConsultationAttention

• In order to help Mary focus more effectively at
  work, the cognitive training specialist and
  employment specialist developed a strategy in
  which she was taught to set a portable vibrator
  alarm that would go off every 10 minutes to help
  her stay on task. The combination of computer
  training exercises and cognitive coping
  strategies helped Mary stay on the job longer
  than any prior jobs she had held since developing
  her mental illness.

41
Assessment Results

• The preliminary analysis of the role of Eds poor
  memory in his job loss was supported by his poor
  performance on the neuropsychological learning
  and memory assessment. Practice on the
  computerized training exercises improved his
  memory significantly.

42
Job Support ConsultationMemory

• In addition, the cognitive training specialist
  and employment specialist helped the client
  develop some strategies for minimizing work
  demands on his memory. Specifically, when the
  client got a new job at a grocery store, they
  taught him to carry a note pad and pencil to work
  everyday and to write down all orders involving
  more then three items (his memory capacity). Six
  months after getting this job the client was
  still working at it and Ed obtained a raise for
  his good performance.
• .

43
Job Support ConsultationProblem Solving

• For John, the client with difficulty planning
  how to seat restaurant customers, the employment
  specialist, with the consultation of the
  cognitive specialist, instructed the client to
  alternate seating first customers are seated on
  the right side, the next customers are seated on
  the left side, etc., thus reduceing the need for
  planning on the part of the client.

44
California Verbal Learning and Memory Test
Trials 1-5
45
Trail Making, Part B
46
Post Treatment Cognitive Composite Scores

plt0.01
47
Positive and Negative Syndrome Scale Depression
Subscale
48
The Thinking Skills for Work Program

• The CTSE group worked more attained
  significantly more jobs, worked more hours, and
  earned more wages than the SE only group.

49
Mean Total Hours Worked Post Treatment

50
Mean Total Wages Earned Post Treatment

51
Total Jobs CT SE vs SE Only
MHA 1 MHA 2
52
Thinking Skills for Work Program 2-3 Year
Employment Outcomes
53
Strengths of the Study

• Randomized controlled trial
• Fully integrated program with supported
  employment services
• Community based effectiveness study
• Replicated across two different sites
• Minority population with low educational
  attainment and minimal work history
• Extended follow up (2-3 years) tracking work
  outcomes

54
How do Employment Specialists Help Clients Cope
with Cognitive Problems?

55
Cognitive Coping Strategies in Supported
Employment

• 25 employment specialists were surveyed regarding
  coping strategies they use to help clients cope
  with cognitive difficulties in the areas of
  problem solving, memory, attention, and
  psychomotor speed
• Approximately 20 coping strategies were
  identified in each of the 4 cognitive domains
• 50 employment specialists in 11 supported
  employment programs in 6 states were surveyed
  regarding their and effectiveness rating
• Employment specialists were also surveyed
  regarding their educational level, number of
  clients on their caseload, and the percentage of
  clients on their case load who were working

McGurk Mueser, Psychiatric Services, 2006
56
Cognitive Coping Strategies in Supported
Employment

• Employment specialists reported using an average
  of 48 (out of 76) different coping strategies
• Strategies were rated on average as just below
  effective
• Strategies for dealing with attention problems
  were rated as more effective than the other three
  domains
• The number of coping strategies employment
  specialists reported using was significantly
  correlated with perceived effectiveness
• Specialists who used more coping strategies had a
  higher percentage of their clients working

McGurk Mueser, Psychiatric Services, 2006
57
Relationship of Number of Coping Strategies Used
by Employment Specialist and Percentage of
Clients Working
58
Coping Strategies Employment Specialists Reported
Using on-the-job for Cognitive Domains of
Attention, Psychomotor Speed, Memory, and
Problem-Solving
59
Cognitive Coping Strategies

• Most widely used and useful strategies were
  based on learning principles
• Breaking larger tasks into smaller ones
• Modeling
• Practice
• Providing positive reinforcement and
  encouragement

60
Coping Strategies for Attention

• 1. Encouragement1
• 2. Positive reinforcement for good performance2
• 3. Match the time of day of job to clients best
  time of day5
• 4. Verbal repetition of instructions
• 5. Point out how clients work performance has
  improved over time3
• 6. Prompt client to stay on task
• 7. Repeated practice of task
• 8. Break complex tasks into smaller steps
• 9. Job shadow with specialist (modeling) 4
• 10. Set up the steps of the job in front of
  client

61
Coping Strategies Psychomotor Speed

• 1. Help client develop a routine on the job1
• 2. Help client find better strategies (short
  cuts) to do the job faster
• 3. Demonstrate (model) the skill for client3
• 4. Inform client how fast he or she needs to work
  to get the job(s) done on time4
• 5. Do the job with the client and then provide
  feedback as he/she does it on his/her own
• 6. Encourage client to go a little faster
• 7. Repeated practice of task on the job2
• 8. Use practice and repetition for each job task
  to increase speed
• 9. Advocate with the employer on behalf of client
  to arrange job tasks to accommodate slowness
• 10. Break down the job task into steps and use
  shaping to help client perform each part of the
  task5

62
Coping Strategies for Memory

• 1. Encourage client to ask questions when given
  instructions about a task
• 2. Encourage client to remember the information
• 3. Model (demonstrate) how to do the job1
• 4. Break complex tasks into smaller steps
• 5. Repeated practice of job tasks5
• 6. Write down instructions for job tasks for
  client
• 7. Encourage client to take notes when learning
  tasks
• 8. Write down frequently used information and
  keep in wallet or purse (e.g., addresses, phone
  numbers) 3
• 9. Use multiple modalities to help client
  remember information (e.g., use different color
  highlighters to mark to-be-remembered
  information) 4
• 10. Do specific tasks at a certain times of day
  when memory is best2
•  

63
Coping Strategies for Problem Solving

• 1.Problem solve with client how to handle
  problems2
• 2. Encourage client to call employment specialist
  to help solve a problem4
• 3. Prompt client to discuss problem with
  supervisor
• 4. Help client develop a routine in order to stay
  organized3
• 5. Try to anticipate problems and develop
  strategies to deal with them
• 6. Prompt client on steps of problem-solving5
• 7. Build on clients current problem-solving
  strategies to address new problems
• 8. Break the task down into smaller tasks
• 9. Role-play how to handle problem situations
• 10. Problem solve with employer on behalf of the
  client1

64
Coping Strategies Clinical Examples

• Help client find better strategies to do the job
  faster.
• The client and I developed a more efficient way
  of doing his job task of preparing food trays for
  refrigeration we completed each component of the
  task for all the trays before moving on to the
  next part (i.e., laid out 6 trays, filled them
  all, then covered in plastic wrap, then labeled
  with date, then loaded for the refrigerator)
  rather than doing one tray at a time.

65
Coping Strategies Clinical Examples

• Demonstrate (model) the skill for client.
• A client working in the stock room of a deli got
  a raise to sandwich maker. He had difficultly
  with the sequence of making the sandwich, so I
  filled several sandwich orders with him watching
  the sequence of toasting the bread, putting on
  the condiments, slicing the meat and the cheese,
  putting on the onions, etc. He found it useful
  to watch me before trying it. What was most
  helpful to him was realizing that I needed
  practice too.

66
Coping Strategies Clinical Examples

• Point out how someones work performance has
  improved over time.
• This is particularly effective for clients with
  low self esteem and confidence. One client
  stated Ill never learn this job. Specific
  tasks that the client had mastered were pointed
  out by the employment specialist, which helped
  her stay on the job.

67
Coping Strategies Clinical Examples

• Help client develop a routine on the job.
• Team work helps some clients pick up their work
  pace. For example, a client was working too
  slowly completing a food service job on his own,
  such as loading the refrigerator with drinks and
  stocking the condiments. I suggested he work as
  part of the food assembly team which improved his
  speed considerably.

68
Conclusions

• The Thinking Skills for Work Program is feasible
  and can be implemented into routine supported
  employment programs
• Clients can be engaged in the program with high
  rates of completion of the cognitive training
  exercises
• Participation in program was associated with
  modest improvements in cognitive functioning and
  depression
• Cognitive training, which included computerized
  practice and on-job compensatory strategies.
  improved competitive work outcomes
• Further research needed to better understand the
  effects of the Thinking Skills for Work Program