Thinking About Thinking (part 2 of 2) July 12, 2010

Last month I talked about the components of quality cognitive rehabilitation.  The two aspects of good cognitive rehabilitation upon which all should agree are that (1) cognitive rehabilitation should seek to improve the survivor’s awareness of their own strengths and challenges and (2) that it should seek to equip the survivor with strategies to use their strengths to overcome the challenges.  A basic overview of this “thinking about thinking” process should look something like this:

1. (Prepare and Question) Before beginning a task, the survivor should generate questions about the skills required, predict challenges associated with the task, predict performance (accuracy and time required) and generate possible strategies to overcome predicted challenges.
2. (Pause and Reflect) The survivor should pause about 1/3 of the way through the task to evaluate their own performance, and modify strategies if appropriate.
3. (Review and Plan) When the task is complete, the survivor should compare performance with predicted performance, review strategies, and ask questions about what else could have improved performance.

So let’s apply these techniques to a functional activity like grocery shopping.  Pretend that you are a survivor with the following residual challenges:  1.  difficulty maintaining attention in distracting places;  2.  difficulty with short-term memory; 3.  Difficulty staying organized.  The process might look something like this:

1. (Prepare and Question) What difficulties would you predict? What strategies could be used to help overcome these difficulties?
   1. Difficulty: attention challenges might cause you to be distracted while shopping.  Strategies:  Shop at a store that has wider aisles, is less crowded, or shop at odd hours when there are fewer shoppers.  If you choose to shop at Wal-Mart at 10:30 on Saturday morning, you are likely going to be overwhelmed…I know that I am!
   2. Difficulty:  memory challenges might cause you to forget what you are shopping for, or where things are located in the store.  Strategies: Hopefully you have learned to keep a running list of items on your refrigerator.  Before you leave, organize your list into items that would be located in similar places.  Get online or visit the customer service folks and find a map of the store.  Plot out your route on the map before you shop…then stick to your route.
   3. Difficulty:  organizational challenges might cause you to pick up the same item several times, or pick out items that are not on the list (impulsivity).  Strategies:  Make sure you stick to the list as much as possible and check things off as you go.  If you are prone to impulsive shopping, make sure you have eaten before you shop.  Put 1 or 2 blanks on your list for your impulse buys…everyone buys things impulsively. You just need to allow yourself only 1 or 2 of these items during your outing.
2. (Pause and Reflect) Once you’ve worked your way through about 1/3 of your list stop and ask yourself…
   1. How am I doing so far?  Am I sticking to the list?  Do I feel overwhelmed, frustrated, or anxious?  If so, what can I do in order to change this?  Am I using my strategies?  Which ones are working?  Which ones aren’t?  What can I do differently to make this work more smoothly?
3. (Review and Plan) When the task is done, figure out what went well, and what didn’t go so well.  Use your daily planner (you do have a planner…right?) to write yourself a note about these things, or talk to your caregiver / staff member to get feedback on how it went and what you need to think about next time.

This process is not fast or easy…and it doesn’t happen over night.   It takes consistency and time in order to make the process work for you.  Most importantly, it takes someone who is trained in this type of cognitive rehabilitation process to teach you how it works and to help you work your way through it MANY times before you are ready to do it yourself.  The ultimate goal is for you to rely less on others and more on yourself to accomplish your daily goals.  The frustration I hear most often from survivors of brain injury revolves around the loss of independence.  The ultimate goal of quality cognitive rehabilitation is to move you toward a more independent life.

Thinking About Thinking (part 1 of 2) June 9, 2010

 The most common residual deficits that challenge survivors of brain injury in the long term are in the area of thinking (also known as cognition).  Thinking skills are often further divided into attention-related skills, memory-related skills, and high-level executive functioning skills.   It is these high-level cognitive skills that I would like to focus on during this month’s cognitive corner.

 If you are a survivor, how do you know whether you have executive functioning challenges?  If you, or your family / caregivers answer “yes” to any of these questions, then you may have some ongoing deficits in these areas:

• Do you often miss important details in tasks?
• Do you have difficulty maintaining mental energy?
• Do you dive into a task without planning it out first?
• Do you feel overwhelmed in situations that you would have been fine in pre-injury?
• Do you unintentionally repeat steps in tasks, or have repetitive thoughts that distract you from tasks?
• Do you find yourself straying away from your goal without intending to?
• Do you focus on the details of a task and have difficulty seeing the “big picture?”

 So how do you improve on these skills?  Brain injury rehabilitation professionals are currently debating this very topic.  The challenges faced by professionals and survivors as they try to come up with a suitable answer to this question lies in the nature of brain injury itself.  Because each brain injury…and each survivor of brain injury is unique, it is very difficult to standardize techniques that will work for each and every survivor.

 The two aspects of good cognitive rehabilitation upon which all should agree are that cognitive rehabilitation should seek to improve the survivor’s awareness of their own strengths and challenges and that it should seek to equip the survivor with strategies to use their strengths to overcome the challenges.  A basic overview of this “thinking about thinking” process should look something like this: 

• Before beginning a task, the survivor should generate questions about the skills required, predict challenges associated with the task, predict performance (accuracy and time required) and generate possible strategies to overcome predicted challenges.
• The survivor should pause during the task to evaluate their own performance, and modify strategies if appropriate.
• When the task is complete, the survivor should compare performance with predicted performance, review strategies, and ask questions about what else could have improved performance.

 I know this all sounds overwhelming.  During part 2 of this series I will walk you through a step-by-step process for completion of a task using this model for a common daily task.  In the mean-time, practice the first step during some of your daily tasks (setting the table, grocery shopping, basic meal preparation).  It’s the first step in facilitating your highest level of independence.

 Thanks for listening.  Talk to you next month.

Dave

What Can Geese Teach Us About Support Group? (part 2) May 4, 2010

Last month I began a 2 part series based on my interpretation of a presentation given by Angeles Arrien, based on Milton Olson and his work with geese.  The presentation was originally given to business leaders with the intent to help them build healthier companies.  However, I immediately related Arrien’s goose analogies to building a healthier brain injury support group.  Last month’s article focused on the following goose facts:

 1.  A goose flying in formation can extend it’s range by 71% as compared with a goose flying alone.  Analogy:            Survivors and caregivers feel they are alone in their experience.  Think of your local support group as your “flock” and extend the range of your knowledge, insight, and connection to others by 71%.

 2.  When a goose falls out of formation, it immediately experiences drag and has to work much harder.  Analogy:            We are fortunate to have several consistent support group attendees who possess an uncanny ability to respond to negative statements with positive ones.  These are the survivors who help keep the “flock” moving forward and help the more negative survivors feel the drag that nudges them back in a more positive direction.

 This month I would like to focus on the last 3 goose facts.  Again…you may think you are smarter than a goose…but they do some amazing things!

 3.  When the lead goose tires, it rotates back and lets another take it’s place.

It is important to remember that one’s ability to get the most out of support group…or any challenge in life…is to figure out that delicate balance of give and take.  We use the term “sharing and caring” to help illustrate that balance.  As a facilitator, part of my job is to help you find that balance…to make sure everyone who wishes to do so, gets a chance to share.  If you are one of those survivors who talks a lot during support group, that is fine…but it is also important to give others a chance to talk.  You never know what you might learn!

 4.  The geese flying in formation honk to encourage those up front to keep up their speed.

Again…communication and attitude are at the core of this analogy.  Keep comments positive and forward-focused.  Encourage those around you.  Share your experiences in a way that illustrates how you’ve overcome obstacles, developed strategies, and bettered your life.  These are the keys to making support group a worthwhile experience for all.

 5.  When a goose gets sick or wounded, two geese drop out of formation and follow it down to help and protect it.  They stay until it dies or can fly again.

Connections are at the heart of any support group.  While making a connection with the facilitator is important, it is even more important for the facilitator to foster connections among support group members.  An ideal support group seeks to facilitate bonds within the support group audience. Survivor to survivor connections, caregiver to caregiver connections, and professional to caregiver/survivor connections are the best way to foster personal growth and understanding of the “big picture” of brain injury. 

 Thanks for listening.  I hope to see you on Sunday, the 16^th of May for burgers, hot dogs, and a compelling movie that details the amazing story of a New York guitarist who suffers a severe stroke on stage.  The story is nothing short of a miracle (I’d wager that if you are a survivor and you are reading this article…you are a miracle as well).  Come and experience what CASG has to offer.