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Introduction

Environmental modification using Cognitive Adaptation Training (CAT) is based on adapting the environment to compensate for a cognitive processing impairment. The population that is appropriate for CAT are individuals with severe mental illnesses and poor executive functioning. The CAT approach is beneficial for this population because it provides a highly structured environment with numerous environmental cues, pictures, and checklists. These adaptive strategies allow the individual to engage in meaningful occupations (Draper, Stutes, Maples, & Velligan, 2009).

Theory

The Person, Environment, Occupation Model (PEO), is used in occupational therapy in order to maximize occupational performance. Occupational therapists use the PEO model to address barriers in occupational performance caused by a poor fit between the client, the environment, and the occupation (Strong, et al., 1999). Individuals with cognitive impairments may have difficulty with tasks that require higher-level cognitive processing skills such as executive function, which includes attention, organization, planning, initiating tasks, maintaining focus, regulating emotions, self monitoring, and error recognition (Team, 2014). Thus, it is extremely important that these individuals are engaging in occupations that are appropriate for their cognitive capacity and are in an environment that enhances their performance. Based on the PEO model, the intervention delivered should have a good fit between the person’s individual skills (P), the gardening activity should be appropriate for the person’s abilities, meaningful, and client centered (O), and the environment should be altered in a manner that enhances the individual’s ability to engage in the occupation (E). The PEO model states that when there is a good fit between all three of these components occupational performance is maximized (Strong, et al., 1999).

Evidence

Cognitive Adaptation Training (CAT) is a series of interventions strategies designed to compensate for cognitive impairments associated with mentally ill patients and improve adaptive functioning (Velligan & Bow-Thomas, 2000).  In two case studies, patients learned how to come up with their own compensatory strategies, such as placing a book on a ledge by the door to remember it for class, and placing large calendar by the bed. At the end of nine months, patients were working regularly and had not been re-hospitalized since the start of the CAT program (Velligan & Bow-Thomas, 2000). Participants in CAT do significantly better in reducing positive symptoms and improving motivation and community functioning (Velligan & Bow-Thomas, 2000). Research have found that cognitive adaptation training improves performance outcomes and concludes that the benefits outweigh the harms. The CAT is associated with fewer symptoms, fewer relapses and  better functioning. (Brown, 2011)

Case Study

Serena is a 35-year-old single Caucasian female. Serena battles with emotional instability and depression. She is a level 4.4 on Allen’s Cognitive Scale. When she feels depressed she sits in her chair and stays there until the end of the day until her caregiver arrives. She cries often because she says she does not have a lot to do. She says the best part of her day is when her caregiver arrives so that she can engage with her. She says she would like to take care of her household chores but does not know how.

Intervention Plan

Problem Statement

Serena is unable to engage in household management due to decreased initiation skills.

Long Term Goals

1. Serena will initiate washing 3 dishes by using visual cues in the environment 10/10 times for increased participation in household management within 4 weeks.
2. Serena will initiate washing the kitchen countertop by using visual cues in the environment 10/10 times for increased participation in household management within 4 weeks.

Short Term Goals

1. Serena will look at the environmental visual cue and verbalize the task she needs to do ⅗ times for increased participation in household management in 1 week.
2. Serena will initiate washing the kitchen countertop by using visual cues in the environment 4/10 times for increased participation in household management within 2 weeks.
3. Serena will use an environmental visual cue to demonstrate the amount of soap necessary to appropriately wash a dish for participation in household management within 2 weeks.

Intervention Format

Individual

Setting

Serena will meet with the occupational therapist individually twice a week for 30 minute in home care sessions

Supplies

3 Environmental visual cues (pictures of someone washing a counter/dishes/amount of soap necessary for washing a dish)

Agenda

• Meet with Serena and develop rapport (5 min)
• Educate Serena about environmental cues and how to use them during household management tasks (10 min)
• Have Senera practice using environmental cues, demonstrating that she knows the amount of soap to wash a dish (10 min)
• Provide a summary of the session (5 min)

Documentation

S: Serena reported that she doesn’t like having to wait until her caregiver arrives so that the dishes get cleaned. She mentions she would love to take care of her household chores as it makes her feel independent.

O: Serena engaged in a 30 minute occupational therapy session at home. During the session, Serena learned about how to use environmental cues during household management tasks. She then demonstrated washing a dish using environmental cues. Serena needed 6 visual cues to demonstrate the correct amount of soap to wash the dish.

A: Serena greatly benefited from Cognitive Adaptation Training (CAT) for her initiation skills to household chores. Serena shows impairments with initiation which interfered with her ability to engage in important IADLS. CAT benefited Serena by providing a cue when needed to independently engage in household management. Serena would benefit from future OT services to apply additional cognitive adaptation training strategies.

P: Serena will attend occupational therapy twice a week for 2 hour sessions in her home environment. During the next session Serena will continue to work on household management using CAT strategies.

References

Brown, C., Stoffel, V.C., & Munoz, J.P. (2011). Occupational therapy in mental health: A vision

for participation. Philadelphia, PA: F. A. Davis Company. ISBN-10: 0-8036-1704-6

Draper, M. L., Stutes, D. S., Maples, N. J., & Velligan, D. I. (2009). Cognitive adaptation training for outpatients with schizophrenia. Journal of clinical psychology, 65(8), 842-853.

Strong, S., Rigby, P., Stewart, D., Law, M., Letts, L., & Cooper, B. (1999). Application of the person-environment-occupation model: A practical tool. Can J Occup Ther, 66(3), 122-133. doi:10.1177/000841749906600304

Team, U. (2014). 3 Areas of Executive Function. Retrieved March 18, 2018, from https://www.understood.org/en/learning-attention-issues/child-learning-disabilities/executive-functioning-issues/3-areas-of-executive-function

Velligan, D. I., & Bow-Thomas, C. C. (2000). Rehab Rounds: Two Case Studies of Cognitive Adaptation Training for Outpatients With Schizophrenia. Psychiatric Services, 51(1), 25-29. doi:10.1176/ps.51.1.25