Mind Stimulation Therapy

Cognitive Interventions for Persons with Schizophrenia

Mohiuddin Ahmed, Charles M. Boisvert

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781136216367
• Edition: 1
• Topic: Psychology
• Subtopic: Cognitive Psychology & Cognition
• Index: Psychology

This book presents a psychotherapy intervention model called Multimodal Integrative Cognitive Stimulation Therapy (MICST). It is grounded in information processing and cognitive stimulation techniques and operates out of a positive psychology framework. This model, designed for group work with clients with schizophrenia, can be easily tailored to working with clients in individual therapy sessions. The three core MICST group activities include: 1) body movement-mindfulness-relaxation (BMR); 2) cognitive stimulation using group discussions; and 3) cognitive stimulation using paper-pencil cognitive exercises and self-reflection exercises. A chapter is devoted to each of these core areas with actual case vignettes to illustrate ways that these activities can be implemented in clinical practice. Homework recommendations are included at the end of each chapter, devoted to a core MICST group activity and providing suggestions on ways to practice various skills and exercises in between group sessions. Also provided are several handouts and worksheets which can be used with clients.

Chapter 1

Introduction

This book presents a psychotherapy intervention model called Multimodal Integrative Cognitive Stimulation Therapy (MICST). The model emphasizes mind stimulation techniques and is designed for group work with clients with schizophrenia. The model can also be easily tailored to working with clients with schizophrenia in individual therapy, and can be applied to substance abuse clients as well as geriatric and physically compromised clients in nursing home settings. The MICST model is grounded in information processing and mind stimulation techniques and uses a positive psychology framework. The model is characterized by stimulating and enhancing clients’ “intact” areas of memory and cognitive functioning so as to enhance their information processing and ability to engage in “reality-based” communication.

We present a therapeutic intervention model that makes intuitive clinical sense and is grounded in several years of clinical practice characterized by consistently high participation from group participants independent of their “cognitive and emotional disability.” The model outlines a group protocol, which clinicians of all experience levels will find easy to adapt and implement in their ongoing clinical work with persons with schizophrenia.

The book begins with a brief discussion of the “historical development” of MICST and how this approach grew out of the authors’ success in using the model in clinical practice with inpatient and outpatient clients with schizophrenia. Following this, we provide a brief historical perspective of schizophrenia, highlighting how schizophrenia has come to be understood as a “neurocognitive disorder.” This understanding of schizophrenia provides the conceptual framework for discussing the central concepts of the MICST model: information processing and mind stimulation.

The book then describes the three core MICST group activities:

1. body movement–mindfulness–relaxation (BMR);
2. mind stimulation using group discussions;
3. mind stimulation using paper–pencil cognitive and self-reflection exercises.

Chapters 3, 4, and 5 are devoted, respectively, to each of these core areas, with actual case vignettes to illustrate ways that these activities can be implemented when conducting MICST groups.

The book is designed to provide a theoretical and practical framework to teach clinicians the conceptual underpinnings of the model as well as to give directions to clinicians for implementing the various facets of the group. The rationale and goals for each of the group components are discussed as well as specific guides for implementing the different group activities. At the end of each chapter devoted to a core MICST group activity, we include homework recommendations, suggesting ways that clinicians can assist clients in practicing various skills and cognitive stimulating exercises. Following these three chapters devoted to the core MICST activities, Chapter 6 focuses on managing and evaluating (e.g., using various self-evaluation questionnaires) the group process.

Many of the MICST group activities can be modified or tailored to individual sessions with clients. Chapter 7 shows how the MICST framework, philosophy, and activities can be adapted to individual work with clients. Chapter 8 then discusses how MICST has been used with substance abuse clients and Chapter 9 focuses on using MICST with geriatric clients and populations with physical disabilities.

The back of the book includes several handouts, worksheets, and appendices. Some of these handouts are designed for clinicians and describe the core MICST group activities and the fundamental features and goals of MICST. These handouts can be used by clinicians to market the group and to inform colleagues and prospective clients about the nature of the group. Other handouts are for clients and include, for example, instruction sheets on practicing the relaxation exercises and redirection strategies to manage distracting thoughts. Various worksheets are also included such as goal-setting worksheets, a problem-solving worksheet, a coping strategies worksheet, a daily schedule worksheet, and a self-care recovery plan worksheet. Finally, the appendices include, for example, client feedback questionnaires, sample self-evaluation tools, and various paper–pencil mind stimulating exercises.

The Nature of MICST

The MICST model provides a set of core group activities that allow for flexibility in the actual clinical encounter. Providing this flexibility reinforces a fundamental characteristic of everyday psychotherapy practice; namely, that being spontaneous and innovative in the clinical encounter is more often the rule rather than the exception. We also believe that a “prescriptive manual” with highly structured guidelines, while appearing to be logically and theoretically consistent, and “structurally appealing,” may have limited practical value in most inpatient and outpatient clinical settings serving persons with schizophrenia. In these settings, clinicians typically have limited resources, limited time, and competing job duties that often preclude them from implementing a highly structured curriculum or a “prescriptive” therapy protocol.

The MICST approach recognizes “the clinical reality” that no one specific theoretical and practical therapy intervention model has been identified that works uniformly well with schizophrenia populations, and that persons with schizophrenia often demonstrate variability in their cognitive skills, mood, and behavioral functioning at both intra- and interpersonal levels. As indicated by Roder, Müller, Brenner, and Spaulding (2011), “despite the prevalence and severity of cognitive impairment in schizophrenia, there is no single type or profile that characterizes the illness. Heterogeneity, in both the quality and severity of impairments, is the rule” (pp. 12–13).

MICST was designed for patients in long-term psychiatric inpatient facilities and for outpatient clients receiving services from community mental health centers (CMHCs). Given the variability in functioning that these patient populations display, for example, in their fund of knowledge, ability to recall factual information, and ability to understand and manage their mental health symptoms, it makes it difficult to design and implement a “sequential program” or curriculum requiring “mastery of skills” at each level. Additionally, capacity for new learning (analogous to laying new neural networks or connections as is implied in the learning of “new cognitive skills”) may be “stress inducing” in already “stress compromised” persons with a history of schizophrenia. Factors such as cognitive rigidity and anxiety associated with “new” situations or “task expectations” may affect clients’ learning of new tasks. Thus, clients may demonstrate particular difficulties in responding to approaches that focus primarily on learning new skills. Therefore, we believe that sequential learning of skills, which can require time-consuming remediation programs, may not be practical or useful to these particular patient populations for the reasons cited above.

The MICST model therefore is flexible in format and does not present a sequential or hierarchy-based program or “curriculum.” We have avoided presenting the material in a way that is too prescriptive or curriculum-based. The MICST model emphasizes simultaneous stimulation of skills at various levels. Depending on what the clients in a particular group demonstrate, clinicians are encouraged to use their own judgment and intuition in determining what aspects of the MICST model to emphasize for any given group session. Our focus on cognitive stimulation for persons with schizophrenia stems from the view that all persons with schizophrenia, independent of the severity of their cognitive deficits, have some degree of intact cognitive skills and functioning, which may be underutilized or “unrecognized” by clinicians in typical interactions with clients.

The flexible MICST format provides every client with opportunities to demonstrate his or her own skill level, knowledge, and interests through the varied “mind stimulating” group activities. For example, a client may have considerable difficulty in accurately completing simple mathematical exercises—involving, for example, addition and subtraction— but may be able to recite poetry, accurately recall excerpts from literature, or recall other detailed and factual information. During the MICST group, this particular client may demonstrate his or her strongest skills during the discussion phase and not necessarily during the paper–pencil exercise phase. Alternatively, some clients may demonstrate, for example, poverty of speech and minimal contributions during group discussions, yet excel at paper–pencil exercises that are stimulating areas of “intact” cognitive functioning and exposing them to topics that are inherently interesting.

The model also allows clinicians to integrate their unique clinical training and expertise from other psychotherapy intervention models. That is, the traditional therapy approaches in which clinicians may be trained or are more accustomed to using can be easily blended in with the core MICST components in conducting groups or individual therapy sessions. The model encourages clinicians to learn to trust their judgment and to find ways both to adhere to the core group activities and to incorporate clinical material that emerges spontaneously in the group. We believe that this is how most clinical work evolves in actual clinical practice, that is by incorporating clients’ spontaneous verbalizations and explorations into a theoretical structure and framework that is used to guide interventions.

The MICST approach teaches both clients and clinicians how to develop confidence and skills in managing the spontaneity of everyday conversations. The model also teaches clients how to use their own judgment, interests, and extemporaneous thinking to initiate and sustain meaningful conversations with others with the goal of promoting their well-being and competency to function in the social world.

We present the rationale that the traditional outcome evaluation “design” for psychotherapy, which follows an “ABA” design—i.e., A = pre-treatment or prior to intervention condition; B = change from baseline functioning where a treatment is provided and evaluated for efficacy; and A = baseline or desired state of functioning and cessation of the intervention—may not be a “viable” outcome model to use with persons with chronic schizophrenia. The “ABA” model assumes that the patient is able to internalize the treatment effects during the intervention phase (B) and that such internalized treatment effects will generalize following “withdrawal” or cessation of the intervention. These expected treatment outcomes may be unrealistic with persons with “chronic schizophrenia.”

We believe that any given psychological intervention for these patients, if found to improve functioning, should follow the pattern of and rationale for how medication is conceptualized as an intervention for any chronic and persistent condition such as diabetes, hypertension, or “chronic schizophrenia.” This way of conceptualizing treatment works from an “ABB” design rather than an “ABA” design, in that an intervention that is found to be effective is maintained in the patient’s treatment regimen to promote continued enhanced functioning. In fact, medication management programs and associated community support programs offered through, for example, CMHCs have been instrumental in maintaining many hospital-discharged persons with schizophrenia in the community by operating under this type of “ABB” design. We need to provide clients with ongoing opportunities to practice cognitive and mind stimulation techniques no matter what their treatment or “recovery status” is. The recovery model can sometimes use the language of “graduating” from services, which can mean a reduction in services. Those clients who “graduate” or achieve a reduction in services will still benefit from ongoing cognitive stimulation opportunities to maximize their functioning.

Theoretical Foundation of MICST: Principles and Features

Some of the learning and social “principles” that have guided the development of MICST include:

1. principles of operant conditioning (i.e., behavior is influenced by reinforcement and reward consequences);
2. principles of classical conditioning or counter-conditioning (i.e., positively valued behavior when prompted and elicited or structured in one’s environment displaces negatively valued incompatible behavior, as only one type of behavior can occur at any given time);
3. the innate pleasures people have in exchanging information about “factual” and other types of information or interests (e.g., when we go to a social gathering, we typically enjoy exchanging facts and opinions about various topics and interests);
4. the high interest that people in all cultures demonstrate in engaging in problem-solving exercises (e.g., games and puzzles);
5. the importance of having an awareness of one’s body movement in relation to one’s physical and social surroundings to promote adaptation;
6. the “resiliency” that people can demonstrate under all kinds of circumstances to “survive” and adapt;
7. recognizing that all human beings have many “positive” characteristics and behaviors, which may not be immediately evident, but can be elicited to improve functioning and adaptation (e.g., positive psychology principles); and
8. recognizing the importance of the “principle of normalization” (e.g., exposure to “real life” situations and activities), which has become an important principle guiding the mental health recovery movement.

The MICST model uses a variety of communication modalities and interventions and underemphasizes the more “traditional approach” in psychotherapy whereby the therapist may relate to the client by focusing on unique pathology, or “disordered” memories, or negative associations. A deficit-focused approach in psychotherapy may unwittingly generate a negative relationship framework between the therapist and the client and may reinforce clients’ preoccupation with their own negative feelings and thoughts (Ahmed & Boisvert, 2006b; Boisvert & Faust, 2002). MICST has four underlying characteristics:

1. It uses a Multimodal approach.
2. It employs an Integrative framework of intervention.
3. It focuses on providing Cognitive Stimulation to access areas of intact cognitive and memory functioning.
4. It uses a positive psychology framework (Seligman & Csikszentmihalyi, 2000) to enhance self-esteem and well-being.

The Multimodal aspect of MICST refers to using both auditory and visual modalities (e.g., written exercises and handouts), as well as using a blackboard, easel, or PowerPoint-based handouts to illustrate concepts more effectively and facilitate discussions of various topics. Using multiple modalities of communication enhances “reality-based” discussions and goal-directed thinking.

The Integrative aspect of the model r...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Foreword
• About the Authors
• Acknowledgments
• Chapter 1: Introduction
• Chapter 2: The MICST Model and Schizophrenia
• Chapter 3: Body Movement–Mindfulness–Relaxation (BMR) Exercises
• Chapter 4: Group Discussion Exercises: Mind Stimulation of Episodic Memory, Semantic Memory, Personal Interests, Existential Perspectives, and Mental Health Topics
• Chapter 5: Paper–Pencil Exercises: Mind Stimulation of Attention, Logical Thinking, Reasoning, General Knowledge, and Self-reflection
• Chapter 6: Managing and Evaluating the Group
• Chapter 7: Adapting MICST to Individual Therapy Sessions
• Chapter 8: Expanding the MICST Model to Substance Abuse Clients
• Chapter 9: Expanding the MICST Model to Geriatric Clients and Populations with Physical Disabilities
• Chapter 10: Concluding Thoughts
• Handouts
• Worksheets
• Appendices
• References
• Index