What Are Examples of Adjusting Therapeutic Approaches for Patients With Cognitive Impairments?

As a therapist, I adjust my treatment to accommodate clients with cognitive impairments by simplifying and structuring the process to meet their specific needs. I ask one question at a time, ensuring the conversation remains clear and manageable, rather than overwhelming them with multiple questions. I use visual aids or hands-on techniques when appropriate to support understanding and reinforce key concepts. My approach is flexible, allowing clients to process information at their own pace while focusing on achievable goals. When it comes down to it, every client has special needs, and it's wonderful to have actionable ideas I can take to support these clients.

You have to meet the client where they are, and that applies whether they have a cognitive impairment or not. It doesn't do any good to start talking about goals and things that you want the clients to achieve that are way above their skill level. If a client has a cognitive impairment or TBI, you will want to do a thorough assessment of their strengths and limitations and then design a treatment plan that incorporates tasks that they are capable of accomplishing. You never want them to feel like a failure, so they should be able to readily achieve the tasks in the plan, thereby decreasing their feelings of depression and increasing their feelings of success and achievement.

One practical technique is using more concrete, step-by-step interventions. Here's how this can look in practice:

1. Simplified language and instructions: Avoiding complex jargon and breaking down concepts into easily understandable terms. For instance, instead of using abstract ideas like "challenging negative thoughts," we might say "let's write down a thought you had and see if it helps or hurts you."

2. Frequent summarization and repetition: Since cognitive impairments can affect memory, we regularly summarize key points and review progress more often. Repetition of important concepts over several sessions helps reinforce learning.

3. Visual aids and structured tools: Using written notes, visual aids, or worksheets during the session can help the client better understand and retain information. We might also incorporate structured tools like checklists or schedules to guide the patient step-by-step through exercises.

4. Shorter, more focused goals: Cognitive impairments may make long-term or abstract goals difficult to achieve. Instead, we work with the client to set small, attainable goals and celebrate incremental progress to build confidence and engagement.

Often, when working with clients with severe cognitive impairments, I find it crucial to make sure that clients are leaving with written information about our session. Whether it was homework or exercises to practice, or key therapeutic takeaways, I will either have the client write down the key points or provide them my own brief summary to take home and review. This adds a little extra work on my part but strengthens the therapeutic relationship and allows the client to effectively extend the session into their daily activity.

Psychological trauma exposure results in a biological injury where people become stuck in "fight-or-flight" mode—potentially for years, or even decades. This is associated with cognitive changes that can decrease the efficacy of talk therapy. A traumatized mind is a continuously distracted mind. Difficulties in concentrating are also common with unaddressed trauma. Advances in neuroscience-based approaches can allow us to deploy more effective treatments for addressing these cognitive barriers to success in therapy. For example, Stellate Ganglion Block (SGB) involves injecting a common anesthetic medication into a cluster of nerves in the neck, which can restore calm to an overactive fight-or-flight system. Research has shown consistently that SGB can reduce PTSD symptoms by 50%* and is particularly helpful in improving symptoms of irritability, surges of anger, difficulty concentrating, and trouble falling or staying asleep (Lipov & Ritchie, 2015; Navaie et al., 2014). As the Chief Psychologist for Stella, I have seen this pattern in the context of my organization providing care to over 10,000 patients since 2020. Based on our outcomes, it is clear that changing the cognitive context of therapy can change everything about a patient's experience in therapy and can accelerate and enhance long-lasting positive outcomes.

As a geriatric psychiatrist, I frequently help patients who are struggling with varying stages of cognitive loss. It is essential to meet a patient where they are and also to have realistic expectations of how much they can learn and apply what I teach them. One strategy I like to use is to give my patients a brief written summary of my recommendations, so they can have something to reference in-between sessions. It is also essential to invite family and/or caregivers, if possible, for both collateral information and also to support the patient in their goals.