Summary of key article on CRT

Evaluation of Cognitive Rehabilitation as a treatment paradigm
Larry Schutz & Karen Trainor
Brain Injury (2007); 21(6):545-557

• The authors define CRT very well – there are a lot of words here but break it down, they are all carefully chosen: ‘A systematic, theory based programme of integrated didactic, experiential, procedural and psychosocial training activities, conducted to restore cognitively compromised adaptation, including decrements in interpersonal and vocational participation, self awareness and self determination’.

• ‘A focus on the psychosocial/emotional aspects of recovery is central, as defective insight and the consequent dearth of adjustive motivation are major rehabilitation obstacles’

• The doubts raised about CRT are mainly from people ‘who do not practice it’. This article discusses 5 of the major concerns which have been raised.

• The doubts raised about CRT have ‘damaged the development of the field and limited access to services’

• ‘Criticism of the efficacy of an established therapy model should be based on a careful definition of that model.’ To this end the authors usefully categorise practice of CRT into 3 models:

Model 1: Holistic treatment programmes. Emphasising the ‘combination of systematic treatment of cognitive/behavioural deficiencies, psychotherapy and milieu therapy'’

The rationale is that ‘trainees need to be optimally engaged, motivated and taught self-discipline, and this is best accomplished through:
1) a programme philosophy that places the responsibility for recovery on the patient,
2) strong group cohesion and identification
3) the use of confrontative (as well as supportive) peer feedback as a primary vehicle for establishing insight’.

This model programme is lengthy, complex, expensive and cumbersome to organise. So not many such programmes exist in the world.

Model 2: Modified Holistic treatment programmes. The methods used to develop insight are more varied, and treatment is conducted in a conventional clinical environment. Otherwise the programme is the same as the holistic type. They are cheaper and easier to run.

Both models ‘approach vocational, social, behavioural and practical disabilities as expressions of underlying cognitive impairments. Most assume that the cognitive deficits require intensive intervention’.

In both models ‘generalisation training is systematically staged across several phases of the programme’.

Model 3: Non Holistic. ‘This model does not stipulate the integration of cognitive treatment with any other intervention. Consequently the therapy tends to consist largely or entirely of decontextualised exercises…it is the most common as well as the least specialised variant of cognitive rehabilitation’

Concern # 1: Does CRT work at all?

Model 1 and 2 programmes: ‘Substantive reviews of the research note statistically significant gains in approximately three quarters of the studies, as measured by neuropsychological tests, behaviour ratings, symptom checklists and behaviour ratings by family members and observations and reports of ongoing, successful use of the compensation strategies in functional tasks’

Model 3 programmes: ‘Research findings concerning the effectiveness of CR for the non holistic treatment of isolated cognitive symptoms or compensation strategies are less consistent and compelling’

Some critics argue that whilst CRT improves function it does not eliminate the impairments. The authors point out that this is a hollow argument, since the aim of CRT is not to reduce impairment, but to improve function.

Concern # 2: Can treatment factors be defined adequately?

The scientific approach is to dismantle the holistic programme to see which bits of it work; ‘the practitioner of holistic therapy, viewing the whole programme as an integrated curative process, can be expected to regard a dismantling design as inappropriate….many of the criticisms of CR are presented from an explicitly behavioural orientation. Alternative schools of thought not only accept broad, general causes but also prioritise concepts reflecting human intention or individual self determination. Current evidence suggests that holistic therapy does not ‘decompose’ into smaller causal units…CR appears to resist dismantling because it functions as the unitary process it is designed to be, achieving its impact on adaptation primarily by altering general attitudes and beliefs, not specific skills or specific contexts.’

Concern # 3: Does cognitive rehabilitation generalise?

Many theorists have argued that therapies should only be performed in the specific situation in which the behaviours are intended to be used – contextualised. This may be appealing at one level. However, it ignores the traditional approaches to education and career development which have worked for a long time. ‘Perhaps the most unfortunate corollary of this behaviour analysis is the pessimism it promotes about the adaptive potential of CR trainees…contextualised accomodations can even be iatrogenic, preventing trainees from learning self-transferring skills that they may need to use in the future’. ‘Thus one danger of the contextualised approach is that it can actually impede the transfer of skills and strategies to new situations and usages’.

‘The argument against transfer is far from consensual, both in cognitive psychology and education’.

The authors argue that the development of insight and effort – the focus of the holistic programmes – promote high level transfer of training. They cite the fact that ‘long term studies have consistently found approximately half of the programme graduates maintaining competitive jobs over multi-year follow up intervals, as late as 11 years post discharge’.

‘Experienced therapists do not rely entirely on either decontextualised cognitive exercises or situative learning…. It is common practice for clinicians to treat general compensation training and in vivo conditioning as complementary tools rather than incompatible alternatives.’

Concern # 4: Is cognitive rehabilitation appropriate for everyone?

‘Factors associated with the failure of CR have been documented by prior research: injuries of profound diffuse severity, or debilitating multifocal damage, and cases of protracted antisocial behaviour, low motivation or defensiveness, most often associated with major personality or character disorder. In addition, decontextualised treatment is unlikely to be effective with children who have not completed cognitive development’.

Concern # 5: Is cognitive rehabilitation too expensive to be practical?

‘Health insurance companies routinely refuse coverage for Model 1 therapy. Model 2 programmes are impacted by managed care, but authorisation can be obtained for limited services. A few programmes are supported by special funding….this restriction of services to a tiny fraction of the clinical population prevents CR from being the standard of care’.

The authors suggest modifications to the training model can still lead to good results, whilst maintaining cost effectiveness.

Conclusions:

• ‘The case against CR is largely a stereotype error. Some Model 3 practitioners offer a naïve, ineffectual form of neurorehabilitation that only attempts to drill impaired cognitive skills’

• ‘Well developed neurorehabilitation programmes…work by creating strong rapport and a conditional expectation of success to harness motivation, training insight and familiarity with generic strategies and taking steps to assure that the strategies will be used in the real world.’

• ‘The evidence for holistic CR is voluminous and diverse.’