C.E.T.

COGNITVE ENHANCEMENT

THERAPY

CET* Developed by Gerard Hogarty and Samuel Flesher at the EPICS Program at the University of Pittsburgh Medical School•CET Research funded by NIMH in a very rigorous methodology•121 Subjects over three years* Study published in the Archives of General Psychiatry, Sept. 2004* Normally takes 10 to 15 years to disseminate new medical technology

Samuel Flesher Ph.D.Ray Gonzalez ACSW

PLAN of NE Ohio, Inc.

•Home based, family centered casework services provided by LISW=s.•Recovery process oriented

•Very active social/rec. and Volunteer Programs• Small, focused organization,124 Families served

In 2000 BOARD CHALLENGES STAFF:•Clients plateaued, stable, not hospitalized in many years, working some, good housing but not at full potential. What to do next.

“Optimism and schizophrenia are rarely mentioned in the

same breath!”

Michael Foster Green

Schizophrenia Revealed

Norton 2003

TYPICAL CET DAY

• 11 AM to Noon -- Computer Work

• Noon to 12:45 -- Lunch

• 12:45 to 2:15 -- CET Group

• ½ Hour of Coaching on homework questions during the week

Computer Work

• One hour a week

• Done in pairs

• Pairs support each other.

• A chance for socialization

• Prepares participants for group

• Continues during the course of the group.

Coaching on the Computer

• The coach is a mediator– Between member and the computer– Between the pair members– The coach should be asking questions that

define and clarify the problem without solving it

– The coach selects the exercises so as to provide both success and challenge.

Cognitive Enhancement Group

• Starts after the members are comfortable in the computer work.

• 1.5 hours per week• 6 to 8 members• Highly structured• A curriculum for each session.• Homework• Lasts for 55 session

October 7, 2004 Group #7

AGENDA – Session 21

Welcome Back — Ray

Selection of Chairperson

Review of Homework – Describe a time when you had to put yourself in someone else’s shoes (role).– What was difficult about that?– How did you resolve this conflict?

Educational Topic — “Motivational Account”Speaker — Carol

Exercise — “Introduce Yourself” Induction and Coach — Ray Participants — JeffFeedback — Round Robin

Homework– Give an example of a time when someone criticized something you did.– What motivational account could you have given to help explain your actions?– Next group meeting is Thursday, October 14, 2004 at 12:45 P.M.

CET Group

• Homework prepared about the lecture with a coach.

• Chairperson

• Volunteering

• Psychoeducational Lectures

• Cognitive exercises

• Feedback.

CET Group

• Members take notes

• Use notebooks to– focus attention– organize thoughts– prioritize

• Posters – educational and reference– Treatment Plans

Perspective Taking

• First Person – What is your perspective?

• Second Person– What is the perspective of the other

guy?• Third Person

– What is the perspective of a third party watching?

A Failure of Perspective Taking

• Condensed messages

• Order medication for Mark Madden

• Only a brief message

• They give all the details but

• Forget to say who the medication is for– “I need a refill for may allergy medication”

• A failure to take the perspective of the doctor

Hot Cognition vs.

Cold Cognition

Processing Speed

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

Effect Sizes of CET & EST at 12 and 24 Months by Composite Index

CETEST

12 24

Social Cognition

SocialAdjustment

Neurocognition SymptomsCognitiveStyle

Cognitive Enhancement Therapy

• Fifty years of research on cognition in schizophrenia with almost no clinical applications

• Increased interest in cognitive rehabilitation in head injury

• Recognition of some similarities in the shared deficits

• Interest in applying some of the lessons learned in head injury to schizophrenia.

Processing Speed

• Processing Speed is believed to be very important

• Increases dramatically only in CET at 12 months

• Stays that way at 24 months

DIFFERENCES

Head Injury

Focal lesion

Sudden onset

Onset at any age

Associated with well defined insult

• Schizophrenia• Non focal lesion• Developmental onset• Range of onset• Rare to find well

defined insult (exception ventricular enlargement.)

Deficits in Schizophrenia

• Memory– working memory – recall memory– chunking– schematizing

Deficits in Schizophrenia

• Problem Solving– executive function– passive vs active thinking– updating working memory

The Old Paradigm

• “Insightful” clinicians do the thinking

• Therapeutic Nihilism

• Behavioral “Lobotomy”

• Clinicians become a prosthetic ego

• Clinicians are trained to care of clients.

• Clients are trained to be taken care of

• Trained = Socialized?

Insightful Clinicians

• Clients says something that does not make sense

• Insightful clinicians makes sense for the client

• Two ways– What you really want to say is..– Or – Here is what you want and….. – I will help you get it – If you comply

Therapeutic Nihilism

• Schizophrenia is a serious illness

• Most “patients” don’t get better

• Patients can relapse and get worse

• Our job is to keep things from getting worse

• Realism dictates that this is a chronic illness

• Don’t give people false hope

Behaving or Acting

• Many behavioral techniques treat clients as if they can’t think.

• Treat clients as if they have no frontal lobe!

• Patients are taught behave.

• Social cognitive interventions (like CET) can help clients learn to think and act wisely.

Behaving versus Acting

• Behave well• Perform to criteria• Pass a test• Learn a task• Easy to measure• Situation specific• Good for the routine• Help you to diet

• Act wisely• Act appropriately• Pursue a goal• Understand intentions• Hard to assess• Not situation specific• Good for the novel• Help you decide whether

to diet or not and which diet to chose and who to tell.

Novel Situations

• Much of the difficulty experienced by schizophrenics in social cognitive tasks has to do with “novel” situations

• (Penn et al 1997)

Novel Situation

• Young schizophrenic man behaviorally trained to meet girls.

• Role play is set up.

• Young female therapist in beach chair!

• Client is instructed to walk up to girl!

• Start a conversation

• And find something in common with her.

So the client walks up to the girl and says…

“Excuse me miss are you a veteran too?”

• Social Cognition• The Ability to

Understand Self and Others

• May be the foundation of the ability to act wisely

• Both controls and CET improve

• CET significantly better than controls at 24 months

Warren

• Client in his mid fifties.

• Impaired attention

• Impaired working memory

• Kept forgetting what he was saying

• Verbal production was often tangential

• Verbally impoverished

More on Warren

• Warren comments – Out of context– Tangential

• Terry in group says in group “I am getting along much better at the group home.”

• Warren interrupts “My group home is on the West Side.”

• Warren adds “The food is pretty good.”

Warren can still lose it

• Terry is discussing the upcoming marriage of her sister– CET coach “Are you just a little jealous that

your sister is getting married?”– Terry responds “Yes but I’ll get over it. There

are other ducks on the pond.”– Warren “Have you been in the park and seen

the ducks on the pond?”– Terry “Yes! The ducks are really cute.”

Warren

• BUT!• “Warren has stopped parroting.” • Therapist asks “did you target that

behavior?”• Answer “No” • Hypothesis: Warren was not thinking so he

just repeated whatever he heard.• Now he is thinking therefore he has an

answer to the question

Warren Now

• Warren’s comments more contextual– Vivian, a group member Warren’s age, says in

response to a question about alliances “I have a slight alliance with someone at the place where I volunteer.”

– Warren says “Vivian, do find as you get older it gets harder to meet new people?”

More on Warren

• Linda talks about an incident at work

• Warren asks Linda with a hint of warmth– “Did you take that personally?”– Linda responds “Yes!”– Warren asks “Linda, do your feelings get hurt

easily?”– Linda responds “Yes they do. My feelings get

hurt easily.”

CET Vocational Outcomes• Chad was

– 56 years old and schizophrenic– Sat at home drank coffee and smoked – Talked endlessly about his guitar being stolen by

his landlord 10 years ago– Worried about the neighbors talking about him– Became paranoid on the bus– Could not organize is thoughts– Wanted to work – Would only accept a high paying job

CET Vocational Outcomes

• Chad participated in CET– Began to organize his thoughts better– Improved his attention and memory– Changed his attitude about his illness– Agreed to work for less money– Agreed to apply for a job– Has been successfully employed for two

years

CET Vocational Outcomes• Rex was

– Employed in sheltered employment– Very disorganized in his thinking– Had severe attention and memory problems– Obsessed with being arrested while he was

psychotic years ago– Convinced that his real career was in the NBA– Unable to pass a test he needed to stay

employed

CET Vocational Outcomes

• Rex participated in CET– Improved his attention and memory– Became more organized in his thinking– Became a basketball fan instead of “a player

to be drafted”– No longer obsesses about being arrested– Kept his job and began working part time in

non-sheltered employment

Cognitive Behavior Therapyor

Cognitive Enhancement Therapy• Cognitive Behavior Therapy

– Identifies dysfunctional thoughts– Effective in treating depression– Effective in treating paranoid symptoms in schizophrenia

• Cognitive Enhancement Therapy– Identifies deficits in social cognition– Provides strategies for addressing deficits in social cognition– Improves social adjustment (functioning)– Is fun

–

Socialization

And

Suppose your development is delayed!

Suppose you just don’t “get it”!

Then what happens?

Desocialization

• Children are told what to do

• Adults are expected to “get it”

• If they don’t “get it” people walk away

• When people walk away – Socialization stops– Learning stops– deviance grows– people become desocialized

Desocialization

Desocialization

ACTION!We are all Actors

INTER -ACTIONACTIONAdult actors interacting

Social Cognitive Group Experience

• Things we’ve seen when partners try to work together

Failures to negotiate a shared understanding

•I did one! Its your turn!

•Just do it!

•Whatever you say!

•Talk but don’t listen

•My way or highway

Reaction Time

MEMORY

Executive Function

PLAN CET Group Attendance and Graduation Rates 2/01 to 5/05

Group Attendance Graduation

1 86% 63% (5 of 8)

2 95% 100% (8 of 8)

3 95% 100% (6 of 6)

4 82% 88% (7 of 8)

5 90% 88% (7 of 8)

6 90% 88% (7 of 8)

7 92% 88% (7 of 8)

Average 90% 88%

Anita’s Reconmendation

When Anita, a CET Graduate, was asked why would you recommend CET to other people recovering from a mental illness, she answered:

I would recommend CET to help those with mental illnesses reach their true potential. And while potential can sometimes be measured in terms of work and productivity, I would say that even more importantly is the subjective aspect, enjoying the lives that we were meant to live.

 

CONTACT INFORMATION

PLAN of NE Ohio, Inc.Ray Gonzalez, Executive DirectorSamuel M. Flesher, Ph.D. Director of CET2490 Lee Blvd., Suite 204Cleveland Hts., OH 44118216-321-3611, ext. 204; fax 216-321-0021email: rgonzalez@planneohio.orgwebsite: www.planneohio.org