Difficulty Thinking is a Symptom of Mental Illness
During my worst depressions, my thinking was slow and torturous. My memory was poor. I had difficulty concentrating and solving problems. I could not perform more than one task at a time. I had trouble thinking ahead.
If I knew these cognitive symptoms could have been treated separately from my emotional distress, I might have gotten better sooner. I might have climbed the career ladder faster instead of tripping over it.
Fortunately, a pilot program now exists to help consumers stay on track mentally at Mt. Sinai Vocational Services, directed by Thomas DeRosa. Susan R. McGurk, PhD, Assistant Professor of Psychiatry at the Mt. Sinai School of Medicine, has designed an intervention to improve cognitive functioning in consumers with severe mental illness. These folks receive employment services at four agencies in the New York City area--Mental Health Association (MHA) of New York City, Goodwill Industries, Brooklyn Bureau of Community Services, and the Institute for Community Living.
The study is funded by the New York State Office of Mental Health and sponsored by the New York Work Exchange. NYWE wants smaller employment agencies involved because they do not always have access to resources, such as novel treatments to help improve work outcomes.
Cognitive Rehabilitation and Supported Employment
Each program provides supported employment, a rehabilitation service that helps consumers with rapid job searches and follow-along job supports, such as learning job tasks and performing them quickly. Some of the employment agencies involved in the study have integrated clinical and employment services, a practice that is consistent with the Individual Placement and Support model of supported employment, developed by Drake and colleagues at the Dartmouth School of Medicine.
Barbara Cohen is Director of MHA's Fast Track to Employment. At a meeting this year of the National Alliance for the Mentally Ill (NAMI), Metro NYC affiliate, Cohen stated that many of her group's clients lose jobs because they react slowly, can't remember instructions, and/or adapt poorly to new situations.
These are different than reasons consumers often cite for job losses: lack of motivation, paranoia that creates problems with authority, falling asleep on the job because of medication side effects, hallucinations and delusions that alienate co-workers, and low self-esteem that inhibits learning. Employment specialists often respond to these job losses by recommending less demanding, often less interesting work.
Cognitive Rehabilitation and Computer Programs
According to Dr. McGurk, the principal investigator of the study, cognitive problems, such as trouble paying attention or remembering new information, sometimes occur with serious mental illness, and can serve as a barrier to work. Thus, in order to help improve people's ability to reach their work goals, Dr. McGurk uses computerized software that practices thinking skills. This approach is modeled after rehabilitation for people whose thinking skills have been impaired by a brain injury.
McGurk works with the consumer to identify and evaluate cognitive problems that have contributed to past problems on the job. Then, the consumer practices on computer software designed to improve important areas of thinking skills and works with a job coach to apply those skills to the workplace. Although these cognitive problems occur in individuals with bipolar disorder, they are sometimes more serious and enduring for people with schizophrenia.
Said Dr. McGurk, "Some entry-level positions place a premium on speed (for example, clerical, food services, counter work, stocking, or cashier), and some consumers report job loss because they are 'too slow.' Consumers have also reported difficulties with attention, memory, problem-solving, and planning."
She continued, "Cognitive problems also reveal themselves on the job when people experience difficulties with other people, such as customers, bosses, or co-workers. Impairments of these skills are called impairments in "social cognition." That's why cognitive remediation should involve some attention to solving common interpersonal problems."
Experiments with Computers Improve Thinking
The Mt. Sinai program signs up volunteers who are receiving supported employment services at one of these agencies and have had a recent job loss. The project is a randomized, controlled study. (So some clients get employment supports alone and some receive cognitive training in addition to employment supports.)
The idea is to work with consumers on their cognitive skills and also train the staff at each agency so the staff can continue the cognitive training program themselves. Five to 15 people are currently enrolled in each of the four affiliated programs. Eventually, there will be a total of 80 participants whose job activities will be tracked for a year. Only then will the project's staff know whether cognitive remediation helps consumers get and keep jobs.
Although some of the clients' goals have been medical assistant, cook, medical records clerk, and bookstore clerk, the program doesn't tailor remediation to the job. Rather, the goal is to improve cognitive skills that are necessary for many types of jobs, including paying attention, remembering job instructions, solving problems, planning ahead, and responding quickly.
After looking for two years, Dr. McGurk found the software she wanted in several German clinics. "It's an audiovisual program that practices multiple areas of cognitive skills, for 24 sessions of 45 minutes each. We combine it with standardized tests. Then, the job coach intervenes to help implement these computer-based skills on the job. He or she evaluates the thinking skills that are necessary for each job's tasks."
Added McGurk, "These exercises work; they improve many areas of cognitive functioning. They are fun and engaging. We look at consumers' speed and accuracy on the computer as well as their performance on pre- and post-tests."
Here are examples of what clients learned: "concentrate under pressure;" "feel better about myself;" "find my way out of labyrinths;" "operate the computer, problem-solve, and pay attention;" "understand other clients' jobs;" "remember my weak and strong points in the work inscribed;" and "keep a file entry of company names and numbers."