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.