Question
What is Cognitive Rehabilitation Therapy (CRT)?
Answer
Although there are many definitions of CRT, one commonly utilized definition is that of the Brain Injury Interdisciplinary Special Interest Group (BI-ISIG) of the American Congress of Rehabilitation Medicine (ACRM), which states,
"Cognitive rehabilitation is a systematic, functionally oriented service of therapeutic cognitive activities, based on an assessment and understanding of the person’s brain-behavior deficits. Services are directed to achieve functional changes by (1) reinforcing, strengthening, or reestablishing previously learned patterns of behavior, or (2) establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems” (Harley et al., 1992, p. 63; Institute of Medicine [IOM], 2011).
Another definition that is helpful in describing CRT is the United States Department of Veterans Affairs, which stated that cognitive rehabilitation is,
"One component of a comprehensive brain injury rehabilitation program. It focuses not only on the specific cognitive deficits of the individual with brain injury, but also on [his or her] impact on social, communication, behavior, and academic/vocational performance. Some of the interventions used in cognitive rehabilitation include modeling, guided practice, distributed practice, errorless learning, direct instruction with feedback, paper-and-pencil tasks, communication skills, computer-assisted retraining programs, and use of memory aids” (Benedict et al., 2010, as cited in Institute of Medicine, 2011, p. 78).
I generally describe the treatment approach as either restoration, calibration, and/or compensation CRT. Restoration CRT seeks to improve, strengthen, or normalize an impaired cognitive function (IOM, 2011). Methods within restoration CRT involve repetition and drill or exercise-like activities that target a cognitive process, gradually increasing in difficulty and demand (IOM, 2011). The Society of Cognitive Rehabilitation refers to this type of treatment as process training, noting that the purpose is to “stimulate poorly functioning neurologic pathways in the brain in order to maximize their efficiency and effectiveness . . . using new undamaged pathways (redundant representation) and, sometimes, old particularly damaged pathways” (Malia et al., 2004, p. 32). This frame views the act of restorative treatment as overcoming damage related to TBI.
Compensation CRT seeks to provide alternative strategies for completing everyday activities, despite residual cognitive deficits (IOM, 2011). Compensation approaches are divided into internal and external strategy compensation (IOM, 2011; Malia et al., 2004). External strategies are those that rely on items external to the individual, such as alarms, notebooks, notes, calendars, and so forth. Internal strategies are those internal processes such as mnemonics, visualization, word association, and so forth (Malia et al., 2004).
As the name suggests, calibration CRT seeks to refine awareness and self-measurements of cognitive performance (e.g., thinking about thinking) and use that information to shape behavior after a TBI. Calibration approaches are common within treatment that focuses on the broader construct of metacognition and executive function. Generally, they will target both offline and online awareness skills.
These are general categories of CRT, but in reality, the distinction between approaches is not always clear as these descriptions suggest. CRT approaches are varied and often attempt to accomplish a similar goal (improving recall, attention, problem-solving, communication, and so forth in daily activities) using differing approaches (restoration, compensation, calibration, or combinations thereof). Further, many treatment programs use more than one approach simultaneously.
Please refer to the SpeechPathology.com course, 20Q: Cognitive Rehabilitation Therapy for Adults with Traumatic Brain Injury, for more in-depth information on cognitive rehabilitation therapy (CRT) and the various treatment approaches used with adults with traumatic brain injury (TBI).
