Rehab Rounds: Identifying and Addressing Cognitive Barriers to Rehabilitation Readiness

Mr. B is a 42-year-old single Caucasian male with chronic, disorganized schizophrenia who was hospitalized continuously for the past 12 years. Before the initiation of the token economy system, he rarely attended groups, and when he did, he was disruptive and incoherent and often left the group after about ten minutes.

After the initiation of the token economy in which token distribution was linked to attendance and participation, Mr. B's attendance improved from an average of 32 percent of sessions in the five months before initiation of the token economy to 100 percent of sessions in the month after it began. Moreover, his disruptive behavior rating (7) dropped from 2.83 to 1.15 (on a scale ranging from 1, rarely, to 3, frequently). In addition, his alogia score, which included measures of both poverty of speech and incoherence (13), dropped from 1.93 to .20 (on a scale from 0, normal, to 2, mildly impaired). For Mr. B, the initiation of procedures that reinforced group attendance and meaningful participation led to dramatic changes in both behavior and verbal functioning.

In skills training groups. For lower-functioning residents who had previously demonstrated a poor response to groups, smaller groups of four or five members were established to provide a less distracting environment and opportunities for more consistent involvement in the learning process. An important feature of such groups is an attention check at regular intervals, such as every ten minutes, or longer for higher-functioning patients. At each interval, group members are given feedback about their level of attention and progress toward their individualized participation goals during the most recent segment of the group. For individuals who meet criteria, a check is entered on a chart next to their name, and they are given a token. The combination of small group size, the use of individualized participation criteria that change as individuals show small performance improvements, and frequent checking of performance against criteria has led to increases in attention span and participation in skills training groups.

To increase attention span. For the most cognitively impaired individuals who are unable to benefit from modified skills training formats, groups based entirely on the goal of shaping attention span are an effective first step in psychiatric rehabilitation (5-7). These treatments involve the performance of relatively simple tasks. They reinforce individuals for incremental increases in attention span and performance accuracy using traditional shaping procedures, including immediate administration of reinforcers after a goal, such as working for 12 minutes at 80 percent accuracy, is met.

Mr. D is a 39-year-old single Caucasian male with a diagnosis of chronic, disorganized schizophrenia. His intellectual functioning is within the range that represents borderline mental retardation. Mr. D had numerous psychiatric hospitalizations beginning at age 19, and his current hospitalization exceeds nine years. He was included in a four-member shaping group due to his extreme distractibility, his tendency to get up repeatedly and attempt to leave the room during groups, and his tendency to frequently interrupt groups and perseverate on idiosyncratic and irrelevant material.

Before Mr. D joined the shaping group, his maximum attention span, or period of continuous work performance, was 14 minutes. However, after 28 sessions of shaping over a period of seven weeks, he was able to work without stopping for 50 minutes. This change was maintained for another 24 sessions, until shaping classes ended. After several weeks of shaping, art therapy staff reported that Mr. D was, for the first time, sitting through entire art therapy sessions without getting up. He is now in a traditional skills training group, where he has sat through the entire group for each session (6).

Mr. J is a 36-year-old single Caucasian male with a diagnosis of chronic, undifferentiated schizophrenia. He was first hospitalized at age 18, and he has had a total of ten hospitalizations. He has spent the majority of his adult life in psychiatric institutions, and his current admission has lasted more than 13 years. Mr. J was included in shaping classes because of his poor attention span, his inability to answer questions in groups, and his tendency to fall asleep during group sessions.

Mr. J's baseline attention span before beginning shaping classes was under ten minutes. After 26 sessions in six weeks, he was able to work continuously for 50 minutes. When Mr. J reached a 30-minute attention span, he began the basic conversation skills module, in which he demonstrated significant acquisition of new skills and knowledge. He maintained a 40- to 50-minute attention span for his remaining 26 shaping sessions. Mr. J was discharged three months after completing shaping classes (6).

Many individuals with chronic psychosis are characterized by cognitive deficits that limit the rate of skill acquisition in psychiatric rehabilitation. We have found our cognitive screening battery to be a practical method to assess the presence of these deficits. The recognition that severely cognitively impaired persons in long-term inpatient settings may be unable to benefit from conventional treatments behooves practitioners to find ways to improve patients' cognitive functioning. In our experience, significant advances toward this goal have resulted from instituting a token economy and shaping procedures that focus on reinforcing attentive behavior.

± ±Afterword by the column editors: This effective program in Rochester illustrates the importance of specialized behavioral or psychosocial interventions—in addition to the benefits possible from atypical antipsychotic drugs—in services for persons with treatment-refractory schizophrenia. The token economy or social learning program is a comprehensive, 24-hour- a-day special education environment in which individuals who have neurocognitive deficits can be motivated to improve their attentional capacities and daily living skills. Token economy systems provide explicit procedures for participants' earning, spending, and losing tokens, coins, chips, cards, or points that are vested with reward value because they can be exchanged for desired goods, services, and activities. The conditions for earning and spending are the contingencies of reinforcement that, as in the Rochester program, can be flexibly applied for shaping small increments of improvements in instrumental, self-care, social, and recreational behaviors.

Structured and highly specified inpatient and day hospital programs that have used token economies have been shown to yield shorter hospital stays, longer community tenure, and substantial improvements in symptoms, social functioning, goal attainment, and self-care skills among persons with otherwise treatment-refractory illnesses (14-16). Moreover, the effectiveness of social learning programs appears to be additive and supplementary to the benefits from atypical antipsychotic drugs (17).

The authors are affiliated with the University Services Psychiatric Rehabilitation Program, University of Rochester, Rochester Psychiatric Center, 1111 Elmwood Avenue, Rochester, New York 14620. Alex Kopelowicz, M.D., and Robert Paul Liberman, M.D., are editors of this column.