Psychological Treatment Plan It is recommended that students review the e-book The Complete Adult Psychotherapy Treatment Planner (Jongsma, Peterson, & Bruce, 2014) for additional assistance in comple

116 COGNITIVE DEFICITS 1 BEHAVIORAL DEFINITIONS 1. Client or client’s family expresses concern about memory, concentration, “thinking,” judgment, social behavior, or the ability to complete tasks. 2. Client receives negative feedback about school or work performance, when performance has typically been satisfactory. 3. Client makes frequent errors in everyday activities that were previously completed accurately. 4. Noticeable deterioration in everyday tasks such as keeping appointments, paying bills on time, recalling recent conversations, and processing mail. 5. Difficulty in recall of recent events.

6. Inappropriate or embarrassing social behavior, with history of effective social functioning. 7. Changes in driving safety not explained by visual problems.

8. Marked change in client’s use of leisure time, with client reducing time spent on tasks requiring concentration (e.g., reading, woodworking, knitting, writing, puzzles, Internet searching). 9. Client reports higher levels of stress than usual when working on cognitively difficult tasks (e.g., organizing income tax information, making financial decisions, completing occupational tasks). __. _____________________________________________________________ _____________________________________________________________ __. _____________________________________________________________ _____________________________________________________________ __. _____________________________________________________________ _____________________________________________________________ 1 Content for this chapter was provided by Michele Rusin, coauthor with Arthur Jongsma of The Rehabilitation Psychology Treatment Planner (2001). Hoboken, NJ: Wiley. Jongsma, Arthur E., Jr., et al. The Complete Adult Psychotherapy Treatment Planner : Includes DSM-5 Updates, John Wiley & Sons, Incorporated, 2014. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1598282.

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COGNITIVE DEFICITS 117 LONG-TERM GOALS 1. Maintain effective functioning through the use of cognitive aids and strategies. 2. Adjust activities and responsibilities to level of cognitive capacity, cooperating with others who provide assistance or oversight. 3. Maintain physical and emotional health to maximize brain health and optimize cognitive performance. 4. Experience satisfaction in life while managing cognitive symptoms and resulting lifestyle changes. __. _____________________________________________________________ _____________________________________________________________ __. _____________________________________________________________ _____________________________________________________________ __. _____________________________________________________________ _____________________________________________________________ SHORT-TERM OBJECTIVES THERAPEUTIC INTERVENTIONS 1. Describe the history, nature, and severity of cognitive problems experienced. (1, 2, 3) 1. Ask the client and (with authori- zation) the client’s family/ support system, about the types and duration of the client’s cognitive problems, the temporal course (sudden, gradual, intermittent), and significant stressors occurring near the time of onset. 2. Ask the client and (with authori- zation) the client’s family/support system about the client’s use of prescribed and nonprescribed medications and substances (alcohol, street drugs, herbs). 3. Ask the client and (with authorization) the client’s family/support system, and/or physician(s) about the patient’s medical history, being attentive to conditions (e.g., hypothyroidism, Jongsma, Arthur E., Jr., et al. The Complete Adult Psychotherapy Treatment Planner : Includes DSM-5 Updates, John Wiley & Sons, Incorporated, 2014. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1598282.

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THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER 118 diabetes, hypertension, strokes, etc.) that might impact cognitive functioning. 2. Participate in a brief psychometric assessment to quantify cognitive and emotional functioning, and to screen for alcohol abuse. (4, 5, 6) 4. Administer tests to quantify patterns of cognitive performance (e.g., Repeatable Battery for the Assessment of Neuropsychological Status ) or to screen for dementia/ cognitive impairment (e.g., Mini Mental State Examination; Dementia Rating Scale-2 ; Memory Impairment Screen ), being attentive to the impact of age, educational level, and cultural background on the interpretation of scores. 5. Ask the client to complete inventories to assess depression (e.g., Beck Depression Inventory- II; Geriatric Depression Scale ), anxiety (e.g., Beck Anxiety Inventory; State-Trait Anxiety Inventory ), posttraumatic stress disorder (e.g., Detailed Assessment of Posttraumatic Stress ), or general emotional status ( Symptom Checklist 90-R; Brief Symptom Inventory-18 ). 6. Administer tests to screen for alcohol abuse (e.g., CAGE or AUDIT ). 3. Give the therapist permission to speak with others about the types and durations of cognitive problems, while developing a treatment plan. (7) 7. With the client’s authorization, talk with the client and family about initial impressions, and consult with the client’s physician regarding symptoms, history, assessment results, and agree on a plan of care for the cognitive problem. 4. Cooperate with comprehensive evaluation procedures to assess 8. Initiate or support referral to health care professionals skilled Jongsma, Arthur E., Jr., et al. The Complete Adult Psychotherapy Treatment Planner : Includes DSM-5 Updates, John Wiley & Sons, Incorporated, 2014. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1598282.

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COGNITIVE DEFICITS 119 cognition and factors impacting cognitive problems. (8) in providing an in-depth assessment of cognitive disorders (e.g., neurologist, rehabilitation medicine physician, neuropsychologist, rehabilitation psychologist). 5. Provide behavioral, emotional, and attitudinal information toward an assessment of specifiers relevant to a DSM diagnosis, the efficacy of treatment, and the nature of the therapy relationship. (9, 10, 11, 12) 9. Assess the client’s level of insight (syntonic versus dystonic) toward the “presenting problems” (e.g., demonstrates good insight into the problematic nature of the “described behavior,” agrees with others’ concern, and is motivated to work on change; demonstrates ambivalence regarding the “problem described” and is reluctant to address the issue as a concern; or demonstrates resistance regarding acknowledg- ment of the “problem described,” is not concerned, and has no motivation to change). 10. Assess the client for evidence of research-based correlated disorders (e.g., oppositional defiant behavior with ADHD, depression secondary to an anxiety disorder) including vulnerability to suicide, if appropriate (e.g., increased suicide risk when comorbid depression is evident). 11. Assess for any issues of age, gender, or culture that could help explain the client’s currently defined “problem behavior” and factors that could offer a better understanding of the client’s behavior. 12. Assess for the severity of the level of impairment to the client’s functioning to determine Jongsma, Arthur E., Jr., et al. The Complete Adult Psychotherapy Treatment Planner : Includes DSM-5 Updates, John Wiley & Sons, Incorporated, 2014. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1598282.

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THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER 120 appropriate level of care (e.g., the behavior noted creates mild, moderate, severe, or very severe impairment in social, relational, vocational, or occupational endeavors); continuously assess this severity of impairment as well as the efficacy of treatment (e.g., the client no longer demonstrates severe impairment but the presenting problem now is causing mild or moderate impairment). 6. Client and/or family describe their understanding of the assessment results and recommendations. (13, 14) 13. Discuss evaluation results with the client and family members; provide them with education as the nature of the deficits found and treatment options. 14. Assess the degree of the client’s and family’s realistic appraisal of the client’s functioning by inquiring into their perception of the problem areas, the reason for the problems, and the typical clinical course; talk with the client and family about differences between their beliefs and what professionals are saying. 7. Agree to treatment of emotional disorders and/or substance dependence/abuse that may impact cognitive functioning.

(15) 15. Develop and implement a treatment plan for depression, anxiety, and/ or substance abuse that might depress the client’s cognition (see the Unipolar Depression, Anxiety, or Substance Abuse chapters in this Planner ). 8. Consistently use written records and/or alarms to remind self of commitments and planned activities. (16, 17) 16. To address all levels of memory problems, recommend use of written, visible external aids (e.g., day planners, memory books, calendars, dry erase boards) and/or alarms to cue the client to commitments and Jongsma, Arthur E., Jr., et al. The Complete Adult Psychotherapy Treatment Planner : Includes DSM-5 Updates, John Wiley & Sons, Incorporated, 2014. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1598282.

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COGNITIVE DEFICITS 121 planned activities; teach the client to use these aids. 17. Inquire about the client’s use of written external memory aids, and reinforce consistent use. 9. Use computerized devices consistently to compensate for areas of cognitive weakness. (18, 19) 18. Assist the client with the selection of computerized external aids (e.g., GPS navigation systems, PDAs, smart phones) that match his/her preferences, budget, and ability to learn to use them; teach the client to use these aids. 19. Inquire into the client’s use of computerized devices and reinforce use. 10. Use internal or covert cognitive strategies to increase effective task performance. (20, 21, 22, 23, 24) 20. For clients having mild impairments, demonstrate the use of repetition and enriched imagery (e.g., learning a person’s name by repeating the name of the person during a conversation, and then associating their name with a physical feature (e.g., “Amy” has dark eyebrows that are “aiming” toward her nose). 21. For clients having mild impairments, demonstrate the use of clustering (e.g., organize grocery list items into groups: [4 fruits: bananas, blueberries, lemons, strawberries; 3 dairy items: butter, milk, yogurt; 2 bakery items: bagels, bread); remember these 3 groups, and then items within them, rather than trying to remember 9 random items) thereby focusing attention, enriching images, decreasing the cognitive load, and facilitating retrieval of information. 22. For clients having mild impairments, teach the peg word Jongsma, Arthur E., Jr., et al. The Complete Adult Psychotherapy Treatment Planner : Includes DSM-5 Updates, John Wiley & Sons, Incorporated, 2014. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1598282.

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THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER 122 rhyme (1 is a bun, 2 is a shoe, etc.; see How to Strengthen Memory by a New Process by Sambrook) and demonstrate how use of the peg word system coupled with exaggerated imagery, enhances recall of information (e.g., learn cell phone number by developing a mental picture based upon the rhyme. For example, 573-8821 becomes a huge bee hive (5) reaching to heaven (7), with a tree (3) forming a slide down from heaven. Next are two gates (8, 8) behind which are an ornate shoe (2) with a sticky bun (1) inside. 23. Recommend the client cue self silently (e.g., “Focus” “Stay on task”) to maintain concentration and facilitate persistence. 24. Inquire into the client’s use of covert aids and reinforce use. 11. Use a systematic approach to problem-solving. (25) 25. Teach patient to use a systematic problem solving strategy (e.g., SOLVE: S = Situation specified; O = Options listed with pros and cons; L = Listen to others; V = Voice a choice, implement an option; E = evaluate the outcome) (see Overcoming Grief and Loss After Brain Injury by Niemeier and Karol). 12. Link new recurring activities to existing recurring activities. (26) 26. Suggest the client use a behavioral chaining strategy to add a new recurring activity to existing recurring activity (e.g., instruct client to review day planner at the end of each meal). 13. Accept and implement environmental changes to enhance everyday performance.

(27) 27. Discuss ways to modify the client’s environment (e.g., reduce clutter, reduce distractions, maintain consistent placement Jongsma, Arthur E., Jr., et al. The Complete Adult Psychotherapy Treatment Planner : Includes DSM-5 Updates, John Wiley & Sons, Incorporated, 2014. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1598282.

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COGNITIVE DEFICITS 123 of regularly used items, label locations of commonly used objects, identify one purse/wallet that the client will consistently use) to enhance functioning. 14. Participate in cognitive rehabilitation sessions and perform homework exercises.

(28) 28. Refer the client for cognitive rehabilitation services to address deficits and learn coping skills. 15. Challenge self to accomplish cognitively difficult tasks that have been identified as “safe” by health care professionals. (29) 29. Work with the client to identify cognitively challenging, but reasonable activities (e.g., reading, puzzles, Mahjong, keeping up with sports) to build into the day. 16. Implement actions to enhance physical health. (30) 30. Talk with the client about the positive impact of a healthy lifestyle (e.g., aerobic exercise, healthy diet, adequate sleep) on maintaining and perhaps improving cognition; inquire into implementation of these behaviors. 17. Problem-solve with therapist around problems affecting adherence to treatment plan. (31) 31. Support and periodically rein- force the client’s implementation of recommendations (e.g., adherence with medications, behavioral recommendations, participation in cognitive rehabilitation, use of strategies and aids, environmental modifications); problem-solve any obstacles to consistent treatment plan compliance. 18. Family members make adjustments to cope with the client’s cognitive deficits. (32) 32. Educate family members that the client’s cognitive changes are a family problem; talk about the most commonly encountered problems and ways to deal with them, work with family to identify coping resources, encourage caregivers to take Jongsma, Arthur E., Jr., et al. The Complete Adult Psychotherapy Treatment Planner : Includes DSM-5 Updates, John Wiley & Sons, Incorporated, 2014. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1598282.

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THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER 124 breaks, and recommend participation in recreational, social, and spiritual activities. 19. Client and family verbalize questions, anxiety, sadness, and other emotions triggered by this change in client’s functioning.

(33) 33. Assist the client and family members in working through grief, anger, and other emotions associated with the change in the client’s functioning and their expectations for the future. 20. Express hope for the ability to experience satisfaction, love, and pleasure while managing the cognitive deficit. (34) 34. Work with the client and family to create reasonable expectations about the client’s capacities and to bolster confidence in everyone’s ability to have a satisfying life as they manage this problem. 21. Participate in an evaluation of driving skills, accepting results and recommendations. (35, 36, 37, 38) 35. Talk with the client and family members about the potential impact of the cognitive deficit on the client’s driving safety. 36. Develop a plan with the client and family to informally assess the client’s driving skills (e.g., have client navigate through empty parking lot, observing the client’s ability to maintain appropriate speed, to keep vehicle within a lane, to pull car into a parking space, to observe posted signs). 37. Refer the client for an evaluation of driving skills administered by a professional trained to assess the impact of cognitive disorders on driving-related capacities. 38. Talk with the client and/or family about the state law governing responsibilities to report persons having medical conditions that affect driving skills; follow state laws and HIPAA in taking action (e.g., making a report directly to a Jongsma, Arthur E., Jr., et al. The Complete Adult Psychotherapy Treatment Planner : Includes DSM-5 Updates, John Wiley & Sons, Incorporated, 2014. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1598282.

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COGNITIVE DEFICITS 125 state agency, discussing concerns about driving with the client’s physician); suggest the client voluntarily surrender his/her license and promise to not drive. 22. Utilize public transportation, or accept transportation with family and friends. (39) 39. Assist the client in identifying alternate transportation resources (e.g., public transportation, handicapped- accessible public transportation, volunteer drivers, friends, extended family); if applicable, recommend supervision while the client learns to use these services. 23. Consider the advice of professionals and others in selecting “safe” activities in which to invest one’s time. (40) 40. Work with the health care team and family to identify which activities are safe and what restrictions are necessary; provide counsel to the client regarding deciding which activities one is free to engage in, which may require supervision or partial restrictions, and which must be abandoned. 24. Family and client implement restrictions in a way that preserves client’s experience of choice, while reducing confrontation. (41) 41. When possible, offer safe options for daily activities (e.g., provide small amounts of spending money for client to carry in a wallet, provide credit card with a low spending limit, review checks written by the client prior to mailing them); create impediments to the client engaging in dangerous behavior (e.g., keeping the client’s car keys, disconnecting the car battery), if necessary. 25. Family members respond with empathy to the client’s experience and allow the client to manage responsibilities and problems that are within his/her capacity. (42) 42. Educate family members about the positive effect of empathic responding and emotional support; describe the negative impact on functioning if excessive instrumental support Jongsma, Arthur E., Jr., et al. The Complete Adult Psychotherapy Treatment Planner : Includes DSM-5 Updates, John Wiley & Sons, Incorporated, 2014. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1598282.

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THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER 126 is provided, or the client is being “over-helped.” 26. Seek out reputable sources of information, advice, and support related to the underlying disease/injury. (43) 43. Refer the client and family to resources to enhance coping effectiveness through education, skills-building, and emotional support; suggest written materials, web-based resources (see the Bibliotherapy Suggestions in Appendix A), and community support groups. 27. In consultation with an attorney, complete legal documents regarding proxy decision making and other legal issues. (44) 44. Talk with the client and family about the impact of cognitive impairment on a person’s ability to make legally binding decisions (e.g., contracts, advance directives, power of attorney designations, will); refer the client/family to attorneys with expertise in these areas (e.g., elder law). 28. Verbalize an understanding of the Americans with Disabilities Act and ways to request accommodations in academic, work, or community settings.

(45) 45. Talk with the client and family about the Americans with Disabilities Act and inform as to how this act allows the client to obtain accommodations at school, work, or in other settings. 29. Identify and apply for benefits triggered by disability. (46) 46. Educate the client and family about potential financial support benefits (e.g., disability insurance benefits, Social Security Disability, activation of long- term care policy benefits) and how to apply for them. __ . ___________________________ ___________________________ __ . ___________________________ ___________________________ __ . ___________________________ ___________________________ __ . ___________________________ ___________________________ __ . ___________________________ ___________________________ __ . ___________________________ ___________________________ Jongsma, Arthur E., Jr., et al. The Complete Adult Psychotherapy Treatment Planner : Includes DSM-5 Updates, John Wiley & Sons, Incorporated, 2014. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1598282.

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COGNITIVE DEFICITS 127 DIAGNOSTIC SUGGESTIONS Using DSM-IV/ICD-9-CM: Axis I: 294.9 Cognitive Disorder, NOS 294.10 Dementia of the Alzheimer’s Type, Without Behavioral Disturbance 294.11 Dementia of the Alzheimer’s Type, With Behavioral Disturbance 290.40 Vascular Dementia Uncomplicated 290.41 Vasc ular Dementia With Delirium 290.42 Vascular Dementia With Delusions 290.43 Vascular Dementia With Depressed Mood 294.1x Dementia Due to (Axis III Disorder) ______ ______________________________________ _ ______ ______ ________________________________ _ Axis II: 799.9 Diagnosis Deferred V71.09 No Diagnosis ______ ______________________________________ _ ______ ______________________________________ _ Using DSM-5/ICD-9-CM/ICD-10-CM: ICD-9-CM ICD-10-CM DSM-5 Disorder, Condition, or Problem 799.59 R41.9 Unsp ecified Neurocognitive Disorder 294.11 F02.81 Probable Major Neurocognitive Disorder Due to (specify disorder), With Behavioral Disturbance 294.10 F02.80 Probable Major Neurocognitive Disorder Due to (specify disorder), Without Behavioral Disturbance 331.9 G31.9 Possible Major Neurocognitive Disorder Due to (specify disorder) 331.83 G31.84 Mild Neurocognitive Disorder Due to (specify disorder) 290.40 F01.51 Probable Major Vascular Neurocognitive Disorder With Behavioral Disturbance 290.40 F01.50 Probable Major Vascular Neurocognitive Disorder Without Behavioral Disturbance 331.9 G31.9 Possible Major Vascular Neurocognitive Disorder 331.83 G31.84 Mild Vasc ular Neurocognitive Disorder 310.1 F07.0 Personality Change Due to Another Medical Condition 294.8 F06.8 Other Specified Mental Disorder Due to Another Medical Condition Jongsma, Arthur E., Jr., et al. The Complete Adult Psychotherapy Treatment Planner : Includes DSM-5 Updates, John Wiley & Sons, Incorporated, 2014. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1598282.

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THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER 128 294.10 F02.80 Major Neurocognitive Disorder Due to Another Medical Condition, Without Behavioral Disturbance 294.11 F02.81 Major Neurocognitive Disorder Due to Another Medical Condition, With Behavioral Disturbance 291.2 F10.27 Alcohol-Induced Major Neurocognitive Disorder, Nonamnestic-Confabulatory Type, With Moderate or Severe Alcohol Use Disorder 291.1 F10.26 Alcohol-Induced Major Neurocognitive Disorder, Amnestic-Confabulatory Type, With Moderate or Severe Alcohol Use Disorder 291.89 F10.288 Alcohol-Induced Mild Neurocognitive Disorder, With Moderate or Severe Use Disorder Note: The ICD-9-CM codes are to be used for coding purposes in the United States through September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9- CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition, or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD- 9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental Disorders (2013) for details. indicates that the Objective/Intervention is consistent with those found in evidence-based treatments. Jongsma, Arthur E., Jr., et al. The Complete Adult Psychotherapy Treatment Planner : Includes DSM-5 Updates, John Wiley & Sons, Incorporated, 2014. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1598282.

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