Cognitive Rehabilitation and Psychosis Research at UT - Southwestern Medical Center

Hi, this is Dustin Luchmie of Happy Neuron Pro. Today with me I have Deb Bushong-Sanchez, licensed professional counselor and supervisor of the HOPE program at University of Texas Southwestern. Deb, thank you so much for joining us today.

Absolutely.

Deb, can you tell us about the HOPE program?

Sure, I'd love to. Um, so the HOPE program is, um, a program for early psychosis. It's a coordinated specialty care program that kind of has been in the works before we launched. It was in the works for about 5 years. So it's been definitely one of our precious babies we've been growing for a while. And it grew out of what basically is our sister program, which is a research program run by Dr. Carol Tamminga, who is an international leader in psychosis research. And so she and Dr. Elena Evleeva have been working on developing this early psychosis program for, like I said, about 5 years. Of course, they've both been doing psychosis research for quite a long time. Dr. Carol Tamminga has been in the field for a very long time. And I've been lucky enough to both work with each of them. I've been with Dr. Tamminga for about 16 years. And I've been working with Dr. Ivleva for about 14 of those years, I would say. And so I've been in psychosis research for a little over 16 years. And then getting the opportunity to work with the early psychosis group group of clients that we have has been something, you know, I've been looking forward to as we continually developed the project that became the HOPE program. And HOPE stands for Healing Over Psychosis Early because, you know, part of our thought that's different in a coordinated specialty care program is not about the more traditional or what we consider kind of old-fashioned thought about getting a diagnosis of psychosis where it's kind of like, okay, you've got this, we'll help you get your disability situated to kind of get you set up with some case management, straighten out your medication, the typical stuff. Our thought, you know, the forward-thinking ideas about how to handle it now is based on the hope of recovery. And that's the trajectory that we set for them when they join our program. So it is a very different feel than traditional care for psychosis.

And learning about your program, you had mentioned before that, you provide cognitive rehabilitation services for the people in the program. Can you talk about what you do for cognitive rehabilitation with the people in your program and what treatment goals they have and expect to get out of the program?

Absolutely, I'd love to go into that. Of course, that's one of my favorite parts because it's the part I offer. Besides being the team lead and kind of like overseeing everything and making sure things are getting done, we run what we call the CORE Skills Program. And that's just a catchy, just awesome name that I came up with. And CORE is basically just short for Cognitive Remediation, and skills is kind of incorporating the idea of social skills. So we put a program together that is a combination of After reviewing a whole lot of cognitive remediation material, because there's a lot of research around the idea with findings that go in both directions, you know, pros and cons, I kind of settled with Alice Medaglia's NEAR strategies. And incorporated most of her material into the cognitive remediation program. And based on that, we have 3 cognitive remediation programs, sets of computer program materials that we let the guys utilize. Sorry, I say guys because right now all of our clients are male, which is a fun dynamic. Um, and so they, um, you know, they never get to a point in the cog room where they're, um, bored or not stimulated cognitively. Um, because I have a lot of flexibility that way to kind of like keep them challenged and keep them moving. Um, And the cognitive remediation programs we're using have that built in anyway, the sense of success that the programs want the client to have where, you know, as they continue to progress through a game, let's say on visual spatial, if they get to a point where they're not succeeding any longer and they back them up to an easier level so that they can begin succeeding again. Um, you know, that's built into the program to help me as well as helping them. And then I have the additional flexibility of having more than one program I can let them choose from. So that works well. And then we take Alice Medillia's NEAR program, and we have combined that with a program called, uh, SCIT, which is Social Cognition Interactive Training, and that is created by David Coombs, David Roberts, and I always forget the third guy. I have the book in my bag, but, and so that is a process. It's a pretty, pretty well laid out 20 to 25 session program where The guys, you know, as they're doing CogRem in a room with multiple workstations where the guys are all, you know, either wearing or not wearing headphones, but they're facing their computer workstations. They're interacting mostly with me, a little bit with each other. But after that's completed, they kind of get a break. They turn and we kind of create a circle, if you will, in that room. So we create the group setting with each other, and then we go through the, the SCIT social cognition modules of training. And it's based on dealing with what is social cognition, what is it like to— how do we learn to interact in social settings and social situations while we're dealing with psychotic thinking or psychosis and its types of challenges. Um, is this a normal thought or is this a thought that I should challenge or not listen to because it's part of something that may or may not be real? And we also do a lot of normalizing in order to destigmatize some of their psychosis. Um, you know, like we might be talking about something where they're like, I think those people might be talking about me, and maybe I shouldn't, maybe I shouldn't engage in that conversation because I'm a little suspicious right now. But, you know, I can normalize that situation by saying, you know, you know, it's very interesting that you're talking about that because that's the same kind of stuff I think about sometimes. And so they're often surprised that people who don't have psychosis often think the same things and have the same struggles of like, I would think, hmm, should I go talk to them? Because what if they are talking about me? That's going to be really uncomfortable. So I have to make— we, you know, we non-psychosis people sometimes face the same struggles and they like a lot, the sense of normalization that they get from having those conversations.

What strategies do you teach, do you teach them to not go to those bad places? And I guess the next question I would ask is what cognitive rehab exercises or work would you do to then ingrain a person to be able to you know, step back, ask questions. Am I feeling something that's currently happening, or do I think it's happening? Um, how do I address that, and how do I respond?

So it's kind of funny, uh, it makes me think of one person in particular. Um, he gets— two things happen. He will get extremely distracted when he's working on cognitive remediation because he has he has all these other thoughts that he's thinking about. And so getting him to just focus on the cognitive remediation for an hour at a time sometimes is very challenging. And I have to remind him that, you know, this is an area of weakness for him. Like his cognitive skills have declined. So, and he doesn't like to hear that because he's a really bright guy. So I just have to remind him, you know, gently, like, okay, remember, we're going to work on memory today because like, um, at the last team meeting, we were all talking about, we had some concerns about your memory. We've all seen a bit of a struggle that you've been having. And so that's one of the things we're going to focus on. Um, and he struggles with the fact that in our multidisciplinary meetings where the whole team is together, we discuss every case so that we each know as we see each person what they happen to be struggling with, so that we each know what to work on. He sees that as us talking about him. And I said, yes, we are talking about you in a positive way, just as we told you from the very first time I met with you that we would discuss your case as a team every week, and we will discuss that with you because you're part of our team. But he still really has a hard time with that. So, um, he gets frustrated when he's doing cognitive remediation because he struggles to focus, um, and he tries to put the blame off on other things. So even during cogrem, we have to practice, um, um, focusing the frustration with what's really frustrating him, which is his inability to focus, or his frustrated frustration that he's maybe not doing as well as he feels like he should on a particular game. Um, and so, okay, you know, okay, Client A, um, what would help with this particular game? What would help you, um, with your frustration about your performance on this game? And he might struggle with an answer. And I was like, what if you went from level 7 to level 6 just to try it? And he was like, well, that would feel stupid. I would feel stupid because I had to go do something easier. And I was like, what if it was just a form of like taking a break?

Yeah.

So he'll try it, he'll feel better, he'll get back up to level 7, he'll be doing better, and he'll be a level 8, and then it'll all be fine and it'll blow over. And then he'll thank me at the end of group for just giving him kind of a way to— a workaround.

Yeah, so it sounds like you're working through a self-esteem issue. That's affecting his reception of the cognitive rehabilitation therapy.

Right. And then it helps him as well because then I can say, you know, when you're at home and you're really frustrated with the conversation you're having with your parents, you can use that same strategy. If you just like tell your parents, I need 5 minutes. Basically, just take yourself down from a level 6, 7 to a level 6. Go to your bedroom for 5 minutes.

Mm-hmm.

Work things down to a level 6 and come back. Then you can talk to them. And maybe, maybe it's really important for you that they hear that you get to tell them what you're frustrated about. Can you just say it's really important for me that I get to say what I'm frustrated about. Would you guys be okay with if I told you that? Yeah, maybe it's just how you word it, and they're probably fine hearing it, but it doesn't have to be an argument. And he was like, okay. So he actually tried it, and he was like, um, they actually were really receptive, and they said they would actually like to hear what I was upset about. And we had a good conversation. We didn't fight. And then we all had dinner together. And I was like, well, that sounds kind of like a win-win, actually. So I think, I think I'm really proud of how you handled yourself. I think you did an awesome job.

That's amazing. Some of the results of the program that you see with the other guys that are in it.

Similar stuff, you know, just being, being able to learn to take the time to stop and think, because for most of them, everything right now, and unless they're, unless they're just becoming psychotic, unless they're just within the first, you know, 4 or 6 months of their illness, they, their focus for the past couple of years has been on psychosis, and their family's focus has been on psychosis. So it has been all, um, all eyes on how are you feeling, did you take your medicine, do you need anything, like, do you need to sit down, like, okay, we have a doctor's appointment, let's get to the doctor, let's talk to the doctor about how your medication is doing, be sure you're honest with the doctor about what's going on. I mean, that's been their world. So just getting— giving them a chance to talk about anything else and develop some strategies for just totally other stuff. And the thing that I swear lightens them up like anything the first time I meet them is when we tell them our expectation for them is not um, is not the road that leads to disability and just receiving a check for the rest of their life, but it's the road that is recovery. Move on with your life. Um, you're going to have challenges. You're going to have times where, um, your thinking becomes a problem and gets worse. But hopefully with what we teach you in the program, the idea is that We teach you how to learn when those stumbling blocks or those roadblocks get thrown in front of you, and you know how to deal with those. You know, the analogy that I give them frequently is like when a person goes to the doctor and finds out that they have, you know, high cholesterol and diabetes. Do they, do they just stop? Do they walk away from life? Do they quit their careers? That is not what happens. So that's what we want you to think like. You may be having to take a break because you need to make some adjustments. You need to learn how to do just like the guy with diabetes does and high cholesterol. They have to make some life adjustments. They have to talk to a nutritionist and learn how to eat differently. They have to talk to a trainer and figure out some new— figure out how to exercise because I got to make some lifestyle changes. You have to make some lifestyle changes. You're going to have to do a few things differently, you know. And so that's what we're here for, is we are those— we're that team that's going to work with you and help you figure out those lifestyle changes so that you in the end can move on with your life and still have plans for your life. You know, we don't expect you to never get married, never have kids, never have a career. It's not the life you want for you, it's not the life your parents want for you, and it's not the life we want for you. And they're all just like finally like, oh my God, someone thinks I'm gonna have a chance at having a life. They just like glow.

Yeah. And with your program, with the HOPE program, how many sessions do they complete? How long are the sessions and how do you How many times per week? How many weeks do they do it for?

Sure. Well, ideally, minus the world pandemic, but so ideally what we decided on after reading much cognitive remediation literature, which basically has no standard set for the right number of cognitive remediation sessions. What we decided on will fit well for our program and in literature is found to be a good number of sessions. We're gonna— what we're doing is 30 sessions of cognitive remediation. They're twice a week because it is found to be basically anything less than twice a week is not effective. They are— the cognitive remediation sessions are an hour each. If they— and then we are adding the SCIT sessions. So SCIT is about an hour long. So our schedule is kind of like this. They come in, say, 2 mornings a week, Tuesday and Thursday at 10 o'clock. They'll do 1-hour blocks of cognitive remediation. And then on one of those days, say Thursday, they stay for an extra hour And they'll do SCIT right after it. So we'll do cognitive remediation for an hour, 15-minute break, and then do SCIT for an hour. That's the way our core skills group is set up.

Gotcha. And do you have any advice for anybody that is working with an early psychosis population on how to foster social cognitive growth? Any tips or pointers or anything that you wish other therapists would know?

Social cognitive growth. Well, um, um, I guess a couple things I would say. Like, one thing that's been super helpful for me is having the structured, um, program in place because that's been something to help me learn, um, the best things that the guys need to learn. And I guess I just stopped saying guys and just say clients. One thing that's helped me is having the structured program in place to help our clients learn in the group setting so that we do have some structure. And but even though we have structure, it's not a stiff program. It still feels very dynamic and very flowing because young people do not respond to inflexibility. And I think the other thing, and this was really emphasized when I trained with David Roberts, one of the creators of SKID, he's kind of— he kind of scared me with it because I was like, wow, I hope I can live up to this, but he's like, you have to be a very kind of vibrant, fun person to lead this because you have to engage them enough to get their buy-in. Because if you don't get their buy-in in that program, they're not gonna learn from from it, you know, because you're going to have a mix of higher functioning and lower functioning people in a group probably. And you can try to split the groups so that you don't have people who you need to really gear it towards a different level mixed with people who really cannot work at that level. And you can split that into two groups. That works well, actually. But sometimes you're just going to have people who are at totally different levels in the same group, and you have to be able to engage all of those people. So you have to have the flexibility within yourself and the leadership ability, I guess, in a sense, to bring it. And engage them and keep it flowing. And the group is supposed to be kind of fun. And the way to get them to engage and buy in is by making it feel like it's not a chore because, you know, they're already dealing with psychosis. They don't need another hard thing in their life. Yeah.

Deb, if any therapists would like to get in touch with you, is there a way that they could contact you if they were interested in learning how to provide provide cognitive remediation therapy for their clients that are struggling with early psychosis and if they're looking to provide a social cognitive curriculum?

Sure, absolutely, I'd love to. Sometimes I feel like a loner out here doing this stuff. So you can email me, you can call my office number. I'm happy to even provide my cell number. I respond pretty well to texts. Even in the middle of the night because I can't sleep because I'm worried about keeping up with stuff.

Um, well, thank you so much for your time today. It was very lovely to have you talking about the program that you're providing for these people. It sounds like you're doing some awesome work at UT Southwestern. Thank you very much for your time.

Thanks so much.