Compensatory Cognitive Training Facilitator Manual June 2013
Compensatory Cognitive Training Facilitator Manual June 2013
Compensatory Cognitive Training Facilitator Manual June 2013
April 2012
Elizabeth Twamley, PhD*
VA San Diego Healthcare System and UC San Diego
Marilyn Huckans, PhD*
Portland VA Medical Center
Saw-Myo Tun, PhD
Portland VA Medical Center
Lee Hutson, PhD
Portland VA Medical Center
Sarah Noonan, PhD
VA Boston and Boston University
Gauri Savla, PhD
UC San Diego
Amy Jak, PhD
VA San Diego Healthcare System and UC San Diego
Dawn Schiehser, PhD
VA San Diego Healthcare System and UC San Diego
Daniel Storzbach, Ph.D.
Portland VA Medical Center
* contributed equally
Table of Contents
Session 1: Course Introduction and TBI 101
12
22
31
38
45
54
69
79
94
Helpful suggestions:
1. Call each participant the night before the session. Most have memory problems
and have expressed their appreciation for the reminder. Also, send letters at
time of enrollment, and call 1-2 weeks before the first session.
2. Many participants have a difficult time finding the treatment room for the first
time. It has been helpful to put up signs in the hospital to assist them in initially
finding the room. Also, alert the front desk staff at appropriate clinics where
patients may arrive asking for help.
3. If administering pre-treatment assessment measures, have the participants arrive
15 minutes early to the session to complete paperwork.
4. If recording the session, wait until after introductions to begin recording. The
participants are more likely to disclose personal information if they know it won't
be recorded. Participant introductions are important as they facilitate group
bonding. We have noticed that the more connected a group feels to one another,
the more likely they are to attend the group.
Implement a class routine of taking mini-breaks (2 minutes) in class every 30 minutes.
During each mini-break, the whole class can either try different types of breaks together
or try strategies on their own. A longer break should be taken one hour into each
session.
Facilitator's Guide
Helpful Suggestions:
1. Encourage participants to share TBI handout with friends and family members.
2. When discussing common symptoms associated with TBI, ask participants to
describe the symptoms they experienced after their injury in order to make the
content more meaningful.
3. When discussing prognosis, emphasize expectation of recovery after mild brain
injury. Without additional injury, cognitive abilities should not worsen. However,
certain things can contribute to or exacerbate subjective cognitive complaints
including psychiatric distress, sleep problems, substance use, medication, pain,
etc.
4. Psychoeducation for facilitators: TBI and cognitive disorder are NOT the same
thing. A TBI can occur when a sudden trauma causes damage to the brain. The
diagnosis and severity of a TBI is based on length of loss of consciousness,
Glasgow Coma Scale score, length of posttraumatic amnesia, severity of tissue
damage, and/or imaging. Not all brain injuries result in a cognitive disorder.
Cognitive disorder is diagnosed primarily through neuropsychological or cognitive
assessment and indicates that the TBI caused residual cognitive problems.
Some cognitive problems may subside after the brain has been given time to
heal while other cognitive problems may be permanent. TBI is not the only thing
that can cause cognitive disorder. There are many risk factors for impaired
cognitive functioning which include but are not limited to substance use, toxins
(i.e. environmental exposures like poison, heavy metals, and gases), some
medications, medical problems (i.e. high blood pressure, high cholesterol,
diabetes, cardiovascular disease, lung disease, smoking, radiation treatment,
liver or kidney dysfunction, thyroid dysfunction, HIV, and seizure disorder),
neurodegenerative diseases (i.e. Alzheimers disease, Parkinsons disease,
Multiple sclerosis, and Huntingtons chorea), chronic pain, fatigue, poor sleep,
psychiatric problems (i.e. depression, anxiety, and PTSD), and life stress. If
facilitators are unfamiliar with TBI and cognitive disorder, it is strongly
recommended that they obtain further educational material on these issues in
order to ensure that they have the ability to clarify information for participants.
Facilitator's Guide
Helpful Suggestions:
1. Emphasize that participants need to mark the lifestyle strategies that they would
like to change. We will be referring to these strategies throughout the group and
some of them will likely become short- and long-term goals for the participants. It
may be helpful to provide highlighters to the participants so that they can
highlight the strategies that they would like to focus on first.
2. Remember to provide the participants with the PTSD handout when discussing
PTSD in section C. Once again, encourage them to share the information with
friends and family members.
3. The lifestyle strategies section contains a lot of information that participants can
find to be rather overwhelming. In order help them to maintain focus and to
retain the information, make sure to check-in with the participants after each
section. Ask them whether they are currently using the strategy or whether they
would like to use the strategy. Often times, if a participant hears a success story
from another participant, they are more likely to see the value of a strategy and
try it at home.
Facilitator's Guide
Helpful Suggestions:
1. Once again, in order help the participants to maintain focus and to retain the
information, make sure to check-in after each section. Ask the participants
whether they are currently using the strategy or whether they would like to use
the strategy.
2. In section H, don't forget to ask participants to share what they like to do for fun.
Sharing personal information facilitates group bonding.
Facilitator's Guide
Helpful Suggestions:
1. For section K, emphasize that one goal of this group is to help participants
establish daily routines.
2. For the bullet points after K, educate participants about the relationship between
cognitive functioning and psychiatric distress. There is a lot of overlap between
symptoms and oftentimes it is difficult to determine whether their symptoms are
due to concussion versus emotional distress.
3. To explain the misattribution bias, use this metaphor: "How many of you have
ever bought a new car? What happens when you buy a new car let's say a
Ford F150 - and take it out on the highway or road for the first time? All of a
sudden you start to notice how many F150s are on the road. Previously, you had
never noticed how many F150s there are, but now all of a sudden it seems like
everyone has an F150. Everywhere you look, you see one of these trucks. A
similar thing occurs for some people who have sustained a brain injury. Except
instead of trucks, you start to become very aware of cognitive lapses that occur
throughout the day. Every time a cognitive lapse occurs, you notice it and think
that it confirms that your brain is damaged. For example, if you lock your keys in
your car or can't find your keys in the morning, you attribute it to your "brain
injury." How common do you think misplacing your keys is? I've done it 100s of
times. However, when I lose my keys, I initially may get frustrated, but then
laugh it off and go on with my day. But for someone who has had a brain injury,
they may misattribute losing their keys to a brain injury when in fact it is a normal
part of life. We all have cognitive lapses. It doesn't mean that our brain is
broken."
Facilitator's Guide
Helpful Suggestions:
1. After educating participants about abdominal breathing, practice together for
2-3 minutes in session.
2. Ask participants when might be a good time to use this skill (i.e. before going
to bed, while driving, before taking a test, when their anxiety increases, etc.).
3. Tell participants that since anxiety and stress has been shown to impact
cognitive performance, relaxation techniques can improve cognitive abilities
like their memory and attention.
4. Encourage them to try it over the course of the week.
6. Abdominal breathing
Abdominal breathing involves two basic components:
o Breathing control
Find a quiet, comfortable spot where you won't be disturbed.
Sit in a comfortable chair, or lie down if breathing from the
diaphragm is difficult for you.
Breathe slowly, from the diaphragm (belly breathing).
Breathe in a smooth continuous motion. Do not hold your breath
prior to exhaling. Allow your breath in to be smoothly followed
by your breath out. If you become dizzy or feel faint, just stop
for a little while and then try again.
o Concentration
Imagine your breath as a full circle (see below). Imagine your
breath in and out to be a smooth, circular process without
becoming stuck or jagged (holding patterns).
Repeat the following in your mind. Inhale: In full body. Exhale:
Out letting go.
If you notice yourself becoming distracted, gently bring your
attention back to your breathing. Allow the distracting thought to
pass away.
Once you start to feel comfortable with counting, you can start
to slow the number of breaths you take.
Out Breath
In Breath
Trauma breathing pattern (jagged holding pattern)
Relaxed Circle breathing pattern
6
Facilitator's Guide
Helpful Suggestions:
1. The facilitator needs a small ball and a stopwatch for the "ball game" exercise.
2. For the first trial of the ball game, do not emphasize speed because the aim of
the exercise is to problem solve ways to do the exercise faster.
3. After trial 1, ask the participants what they can do to pass the ball around the
circle quicker. Typical suggestions include huddling closer together, each person
tries harder, improving the way the ball is handed off, using two hands vs. one
hand, etc.
4. After trial 2, once again ask the participants how they can do the exercise faster.
5. After the ball game, emphasize how practice and strategies can improve one's
performance. This is a primary goal of the course!
6. After the name game, emphasize how repetition and overlearning can improve
performance.
Facilitator's Guide
Helpful Suggestions:
1. Make sure that participants decide on a "container" and "home." Have them
record their container and home in their manuals.
2. Ask participants if they would like to share their choice of home and container.
Oftentimes, a participant generates an idea that other participants haven't yet
considered. They can learn from each other.
Facilitator's Guide
Helpful Suggestions:
1. Make sure that participants decide on a calendar. Check-in with each person
individually.
2. Facilitators may want to bring in various examples of memory prosthetics such as
calendars (large and small) or smartphones.
3. Explain the purpose of the calendar and expectations around the daily use of the
calendar.
4. Demonstrate the differences between calendars some are daily planner, some
show the entire week on one page, some show the entire month on one page,
some have built-in "notes" or "to do list" sections. What is going to work best for
the participant?
5. Remind participants to choose a calendar that they are willing to carry around
with them at all times.
5. How can family members, significant others, friends, and/or caregivers support you
while you take this class?
Facilitator's Guide
Helpful Suggestions:
1. It is very important for participants to identify their goals and write their goals in
their manuals. We will be referring to these frequently throughout the course.
2. The participants are more likely to engage in treatment if they can identify their
goals and have an understanding of why they want to learn cognitive strategies.
Their goals are motivating them to participate in the course.
3. Ask participants if they are willing to share their goals with the group to facilitate a
discussion. It is likely that the participants will see similarities between their
goals.
10
Practice abdominal breathing two times over the next week. Consider
scheduling this into your calendar.
Read TBI and PTSD handouts. Consider sharing them with friends and family
members.
11
CD player (if the room does not have a computer with speakers).
Relaxation CDs (mix of CDs for CD players and CDs for computers).
Boxes of raisins.
Highlighters and pens.
Helpful suggestions:
1. Before starting to discuss the strategies, cue the participants to mark or highlight
the areas that they would like to work on.
DOWNTIME:
1 HOUR PER DAY
1 DAY PER WEEK
1 WEEK EVERY 12-16 WEEKS
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Facilitator's Guide
Helpful Suggestions:
1. Cue the participants to mark the sleep strategies that they think they will use.
2. With regard to use of the sleeping pills, note that many of our veterans are on
prescribed sleeping medications and should not be explicitly encouraged to stop
taking them. Rather, encourage them to work with their providers to balance the
advantages and disadvantages of their specific medication. Also, trazodone is a
common milder sleep medication with fewer side effects or addiction potential
than ambien, for example.
3. Let veterans know that if sleep is an issue for them, there is a sleep log included
at the end of the session, which will help them to monitor their sleep patterns.
Sleep Problems
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2) Migraine headaches
o Throbbing pain in forehead and temple
o May have nausea, vomiting, numbness, muscle weakness, and
sensitivity to light, sound, and smell
o Sleep may help symptoms resolve
o Triggers: emotional stress, physical activity, sleep problems, fatigue,
irregular eating habits, and certain foods (e.g., chocolate)
3) Post-traumatic headaches
o Pain that increases when touched, accompanied by a burning or
tingling sensation
o Similar to tension and migraine headaches
o Occur months or years after TBI
4) Cluster headaches
o Intense pain behind the eye and one side of the face, which may move
to the other side of the face
o Similar to migraine headaches, but more severe
o Lasts between 15 minutes and 3 hours
o Triggers: Nicotine, alcohol, overwork, emotional stress
5) Withdrawal (Rebound) headaches
o Result from withdrawal from extended use of pain medications
o No specific area of pain
o Symptoms may include nausea, concentration difficulties, depression,
irritability, and restlessness
If you are frequently bothered by headaches, it may be appropriate to consult with a
physician (e.g., to discuss medications)
Triggers/aggravating factors (minimize these if possible)
Stress
Depression and anxiety
Lack of sleep or changes in sleep routine
Skipping meals
Poor posture
Working in awkward positions or holding one position for a long time
Medications used for other conditions, such as depression or high
blood pressure
Overuse of headache medication
Jaw clenching and teeth grinding
Lack of physical activity
Physical activity reduces tension, fatigue, and stress and improves
sleep
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Facilitator's Guide
Helpful Suggestions:
1. Mention that at the end of the class, they will be getting a CD that includes
techniques we will be practicing in class, plus additional techniques. Learning to
use these techniques effectively takes practice, and the CD can aid with the
process. Provide examples, if appropriate. Also, individuals vary widely in terms
of personal preferences when it comes to tension reduction techniques. The CD
will allow them to explore other techniques not covered in class.
2. Abdominal breathing: Do the first few breaths with them until they get the feel for
the rhythm. Afterward, provide occasional redirection to maintain focus.
3. The raisin exercise:
Hold one of your raisins in your hand. Take several slow, deep breaths. Now look
at the raisin as if you had never seen one before. What color is it? What is its
surface like? What does its texture feel like between your fingers? What thoughts
are you having now about raisins or about food in general? Are you having any
thoughts or feelings about liking or disliking raisins? Whatever your thoughts or
feelings are, simply notice them.
Be aware of your intention to begin eating. Move your other hand slowly toward
the raisin. Note the action mentally by saying to yourself, Reaching ... reaching
... reaching. Now pick up the raisin, and say to yourself, Lifting .... lifting ...
lifting. The point is to stay aware of each movement of your hand and arm by
naming them.
Now move the raisin closer to your mouth and watch your hand as you do so. Smell
the raisin. What does it smell like? How are you reacting to the smell? Is your
mouth watering? If so, notice what it feels like to desire food.
Put the raisin on your tongue. What does it feel like? Is your mouth watering? Now
bite into the raisin. Where is the raisin in your mouth? Begin chewing slowly. What
are the sensations in your teeth? Your tongue? How does your tongue move when
you chew? What part of your tongue is experiencing the taste? Where is your arm?
Did you notice moving it to where it is now?
When you are ready to swallow, notice the impulse to do so. Now swallow the raisin.
Try to be aware of how the raisin moves in your esophagus toward your stomach.
Can you feel any sensations in your stomach? Where is your stomach? What size
is it? Is it empty, full, or in between? Imagine that your body is now one raisin
heavier.
Which three strategies would you like to try first to help address fatigue, sleep
problems, and/or headaches?
(1)
(2)
(3)
ANXIETY
COGNITIVE DIFFICULTIES
Tension reduction techniques break this cycle by decreasing tension and anxiety.
Abdominal Breathing = breathing from the depths of your abdomen.
Lets practice. Inhale through your nose, slowly, until the breath reaches your
abdomen, to a count of 5.
Release, exhaling from your nose or mouth to a total count of 10.
You can place your hand on your stomach, and if you are doing this correctly,
your hand will actually rise and fall with each breath.
Try to concentrate on your breathing, and clear your mind of anything else.
Keep this up for 3-5 minutes, and do it as often as you can throughout the
day, and in bed, before you go to sleep.
Practice abdominal breathing for 2 minutes. What did you notice?
______________________________________________________________________
______________________________________________________________________
Mindfulness = Focusing awareness on the experience of the present moment
Pay attention to what is happening in the present mind and body: what you
are thinking and feeling
Observe these thoughts and feelings without making judgments about them
Thoughts are just thoughts let them come into your consciousness and let
them go
Can be done anywhere. Examples:
o Noticing the sensations in your feet when you walk
o Noticing how tightly or loosely you hold the steering wheel when
driving
o Noticing what happens to your breathing or tone of voice when you are
content or angry or sad
The Raisin Exercise
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Facilitator's Guide
Helpful Suggestions:
1. Grounding techniques: "Lets try this in class." Provide them with an object they
can focus their attention on. For example, you may want to ask them to take out
their keys, and ask them to describe in details what they notice: the weight, the
color, the shape, the edges, etc. Are there any irregularities? Do they notice
anything they have not noticed before? Perhaps one of the participants is willing
to volunteer to demonstrate the exercise in session.
2. Visualization: "Lets try this in class." Here, the facilitator can play the
visualization exercise included on the CD. If preferred, the facilitator can read the
instructions for visualization exercise in class.
3. PMR: "One of the aims of PMR is to notice the difference between the sensations
of tension versus relaxation in your muscles. Studies have shown the act of
actually tensing the muscle can create a sense of deep relaxation. Lets practice
in class." Can use the PMR exercise included on the CD. The instructions for the
PMR exercise are provided in case the participants would like to practice it on
their own later. Remind them that PMR exercise is also included on the CD.
16
Facilitator's Guide
Helpful suggestions:
1. When discussing depression, it may be helpful for some veterans to hear that
they do not have to feel sad or tearful for depression to be present.
Tense (5-7 seconds) and then release (15-20 seconds) muscle groups one at
a time.
When tensing muscles, focus on the feeling of tightness.
When releasing, focus on the feeling of limpness.
Avoid tightening injured muscles.
Progress through muscle groups as follows:
1. Right hand and forearm
2. Right biceps
3. Left hand and forearm
4. Left biceps
5. Forehead and top of head
6. Eyes, nose, and top of the cheeks
7. Mouth, jaw, and the side of the cheeks
8. Neck
9. Upper chest, back and shoulders
10. Abdomen
11. Right upper leg
12. Right calf
13. Right foot (only tense for 2-3 seconds)
14. Left upper leg
15. Left calf
16. Left foot (only tense for 2-3 seconds)
After releasing final muscle group, relax for 5-10 minutes then slowly awaken.
What did you notice this time while doing PMR?
______________________________________________________________________
______________________________________________________________________
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Anxiety
o Excessive anxiety and worry that interferes with functioning.
o Anxiety can be generalized (i.e., not specific to one thing or a specific
situation) or may be due to specific circumstances, such as a fear of social
situations or things (i.e., animals, heights, crowds).
o As with depression, anxiety can cause problems attention, concentration,
memory and problem solving.
o The vicious cycle: You feel anxious about your cognitive problems, and the
anxiety makes it harder for you to concentrate and remember; then you feel
more anxious, which causes you to have more cognitive problems.
PTSD
o Is a type of anxiety disorder.
o After experiencing a traumatic event, one may feel intense fear, helplessness,
or horror.
o After the event is over, one may have recurrent and distressing memories of
the event, nightmares, flashbacks, avoidance of things that are associated
with the trauma, diminished interest or participation in activities, feelings of
detachment from others, sleep difficulties, anger outbursts, concentration
difficulties, and hypervigilance.
o It is difficult to know whether cognitive problems are due to PTSD, TBI or
both.
o It is important to treat PTSD symptoms if you have them, as your cognitive
problems may be worsened by this disorder.
Do you suspect that you have Depression, anxiety, and/or PTSD and are not
currently being treated for your symptoms?
o First, talk to your provider at the end of session, especially if you are having
suicidal thoughts. We can make a referral to the most appropriate provider.
o It is best to discuss your treatment options with your doctor. These options
may include medications, psychotherapy and/or other treatment
recommendations.
o Eating right, exercising, socializing, and using relaxation strategies may help
with your symptoms.
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Facilitator's Guide
Helpful suggestions:
1. Ask for a volunteer to read the parable.
19
Facilitator's Guide
Helpful suggestions:
1. When discussing scheduling regular breaks, mention that this can be a
particularly hard concept for veterans to learn as it is just the opposite of military
training. Hence, this may require practice and retraining!
2. When reviewing the sleep log, make sure they have a very clear understanding
of the log, and how to fill it out.
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21
23
Facilitator's Guide
Helpful suggestions:
1. Prior to discussing the time management matrix, re-read the parable from
Session 2.
2. Have participants fill out the time management matrix in class. Afterward, draw
the matrix on the board, and ask for a volunteer to share their matrix to help
illustrate the point.
3. Additional examples of large rocks that have deadlines: taxes, school homework,
work-related project deadline, childs sporting event or recital, doctor
appointment, refill prescription, utility bills, etc.
4. Additional examples of large rocks that do not have deadlines: spending time
with spouse and children, vacations or travelling, hobbies like fishing or hiking,
volunteer work, socializing with friends, meaningful employment, etc.
Important
Not As
Important
Immediate/Deadline
Large Rocks/Pebbles
Emergencies
Important appointments
Important deadlines
Pressing problems
(car dies, roof is leaking)
Sand:
Interruptions
Phone is ringing
Someone is knocking on door
Popular activities (TV shows,
shopping)
The goal is to move toward spending most of our time in the Important/Not
Immediate quadrant. These are the large rocks/pebbles.
If you spend more time on planning and prevention, you will not need to spend as
much time in the Important/Immediate quadrant.
What are your big rocks, pebbles, sand, and water? How do they fit into your time
management matrix?
Immediate/Deadline
Important
Not As
Important
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25
Facilitator's Guide
Helpful suggestions:
1. When completing the calendar exercise, remind them that they can write things
in shorthand.
2. Calendar Exercise: They will need to schedule activities on Monday to remind
themselves of tasks on Tuesday, or in support of tasks on Tuesday.
6. Calendar exercise
Based on the following scenario, enter these things to do on your calendar.
(Use the next page for calendar entries.)
YOUR TUESDAY:
Sometime during the day, you need to call your friend, Scott, and remind him
about the party at the Recreation Center this Saturday at 7:00 p.m.
Sometime between 9:00 and 10:00 a.m., you need to drop off your job
application at Blockbuster Video.
At 11:00 a.m., you have a doctors appointment with your physician, Dr.
Stevens, and you want to ask about the side effects of amoxicillin. You also
want to report that you have been having severe headaches about once a
week and even threw up because of one of them last Tuesday.
Before you visit the doctor, you need to stop at Rite Aid to buy deodorant and
shampoo (someone suggested a new brand called Aveeno), and to pick up a
refill of amoxicillin.
At 4:00 p.m., you need to meet with the social worker, Jane Dunne, to discuss
your housing options.
You want to meet Joe for dinner at a new restaurant, Dominics, at 7658
Poway Rd (858-748-1265) at 7:00 p.m.
What kind of reminders might you want to enter before this day occurs?
What would you need to do ahead of time, before picking up your refill of
amoxicillin? (e.g., call in refill request to pharmacy)
What would you need to do ahead of time, before going to your geography
class? (e.g., make sure homework is done and in your bag)
What would you need to do ahead of time, before meeting with Jane Dunne?
(e.g., make copies of financial information)
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Monday
Tuesday
Wednesday
7 am
7 am
7 am
8 am
8 am
8 am
9 am
9 am
9 am
10 am
10 am
10 am
11 am
11 am
11 am
12 noon
12 noon
12 noon
1 pm
1 pm
1 pm
2 pm
2 pm
2 pm
3 pm
3 pm
3 pm
4 pm
4 pm
4 pm
5 pm
5 pm
5 pm
6 pm
6 pm
6 pm
7 pm
7 pm
7 pm
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Facilitator's Guide
Helpful suggestions:
1. Problem solve ways that participants will remember to check their calendars.
One solution might be to provide participants with post-it notes and have them
post notes in a place where they perform an activity everyday (e.g. bathroom
mirror, fridge door).
2. Some participants may benefit from placing post-it notes in multiple locations.
Brainstorm examples of places in session. Examples include front door, home
telephone, nightstand, microwave, closet, and television.
28
Facilitator's Guide
Helpful suggestions:
1. Give the participants time to identify and think about upcoming appointments.
The idea is to enter all the appointments for the day into the calendar. They can
start by entering the date and the time of the next group. If they have difficulty
remembering what the upcoming appointments are, and have them written down
somewhere else at home, they can schedule a time to go back and transfer that
information into the calendar.
2. Then, from the to-do list, have the participants add the most important items to
the calendar. This is to help them structure the day and to make time for the big
rocks.
3. Consider mentioning that many calendars have or can have a page
finder/bookmark that can be used to help them keep track of their big rocks. The
back of the page finder could be a prioritized to-do list that carries forward with
them. If the calendar does not come with a page finder, they could use a piece of
paper as their page finder, or a sticky note, or something else. The idea is that
they can look at their big rocks each day or during their weekly planning sessions
to make sure they scheduled enough time for these rocks.
4. Dont forget to review goals on page 10. The participants may want to break
down large goals into smaller goals or steps. Ask the participants whether any of
the skills learned in this session can help with that?
5. If time allows, it may be helpful to encourage them to share their goals and
discuss how they might go about it.
29
Facilitator's Guide
Helpful suggestions:
1. Remember to provide participants with your work number, so that they can call
and leave a message on Saturday.
Set up your calendar so you can use it for appointments, important activities,
and routines. Think about your class goals and use your system to address
these goals first.
Practice using your calendar every day and start a to-do list (or lists).
Continue to look at your calendar at least three times a day.
Add new appointments at the time they come up. Dont wait to write them
down later.
Add tasks to your to-do lists when they occur to you (so you dont forget
them). Decide whether you should put them on the calendar for a certain day
or whether they should go on your to-do list.
When you check your calendar in the evening, plan the next days
schedule:
o Think about what you need to do tomorrow and schedule these items
in your calendar.
o Review your to-do list and make any necessary additions. Cross off the
things you got done.
o Do you need to schedule time to work toward other important life
goals? Did you schedule time for healthy life strategies and breaks?
This Saturday, call and leave a message at _____-_____-______. This is a
challenge to see how the calendars are working for you, so put a reminder note in
your calendar right now to call on Saturday.
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Facilitator's Guide
Helpful suggestions:
1. Have each participant identify ways to overcome the barriers that are
interfering with their ability to use strategies. Make sure they write the
solution in their manual.
2. Make sure each participant identifies a day and time for the weekly planning
session. Have the participants write the day and time in their manuals and
then enter the day and time into their calendars.
Facilitator's Guide
Helpful Suggestions:
1. Review the page that contains suggestions for things that go on a to-do list.
2. Give the participants 5-10 minutes to work on the exercise.
3. Walk around the room to ensure that everyone is understanding and
completing the exercise.
4. Make sure the participants enter the high priority items into their calendars.
5. Ask participants if they want to share items on their to-do list.
Things that need to get done on a certain day should go in your calendar for that
day. Other to-do items should go on your to-do list.
If you need ideas, look on the next page.
Consider the time management matrix as you think about what is important
versus unimportant.
Exercise:
1. Fill in the to-do list.
2. Enter high priority items into your calendar.
TO DO:
High Priority
(today or tomorrow)
Enter into calendar
Medium Priority
(within a week or so)
Low Priority
(within a month or so)
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Facilitator's Guide
Helpful Suggestions:
1. Make sure to review the to-do list categories.
2. If interested, some participants may want to keep a copy of the to-do list
categories in their calendars.
TO DO List Categories
(Keep in calendar)
APPOINTMENTS
Scheduling
Preparing Materials
Transportation
Social outings
Exercise (more likely to happen if its
an appointment!)
TRANSPORTATION
Schedule Rides
Bus Pass/Schedules
Automobile Maintenance
WORK
Job search
Job interviews
Follow-up calls
Work schedule
File pay stubs
ERRANDS
Grocery shopping
Bank
Pharmacy
Clothing/Shoes
Post Office
PAPERWORK
Pay bills/balance check book
Correspondence (letters, cards, email)
HOUSEHOLD CHORES
Cooking
Cleaning
Laundry
SCHOOL/LEARNING
Homework
Reading
PHONE CALLS
Appointments, Doctors, etc.
Friends
Family
KITCHEN
Mop floors
Clean stove/oven
Clean out cupboards (toss old food, clean shelves, organize)
Scrub trash can/under sink
Clean refrigerator (throw out old food, clean shelves, clean
outside)
Scrub counters & sink
Wipe down cabinets
Wipe down top of refrigerator and other appliances
BATHROOM
Clean out medicine cabinet (throw out all expired medications)
Clean shower curtains/stall doors
Organize items under sink/on shelves
Launder bath mats
Mop floor/vacuum carpet
Scrub sink/counters
BEDROOM
Clean out closets (Donate clothes that dont fit or are damaged)
Collect and complete mending (lost buttons, rips, hems, etc.)
Shoes: polish or get repaired
Reorganize dresser drawers
LIVING ROOM
Clean carpet spots
Wipe fingerprints from doors/walls/sills
Wash windows
Clean hanging lamps/chandeliers
Test smoke alarm
OFFICE
Organize files
Organize desk/supplies
Catch up on correspondence
Redo/Update Address book
Complete a will
Arrange photos in albums
Organize craft/art/hobby supplies
Organize computer files
File emails
Sync cell phone, iPod, etc., with computer
Print photos
34
Facilitator's Guide
Helpful Suggestions:
1. Have every participant open their calendar/smartphone and examine the
various sections. Most calendars have sections for to-do lists, notes,
addresses, phone numbers, etc. If the calendar has blank sections, have the
participants think about what they would like to dedicate the sections to.
Some participants may want to label each section. Spend a sufficient amount
of time orienting the participants to their calendars and assisting them in
seeing the many uses of their calendars.
2. Have each participant identify a place to write their to-do lists.
35
Facilitator's Guide
Helpful Suggestions:
1. When discussing "can't miss reminders," ask if anyone needs additional postit notes. Hand them out if needed.
2. When discussing long term goals, have participants turn back to page 10 to
review their goals. Remind them that goals can change over time. Make
changes to long-term goals if necessary.
3. If the long-term goals seem overwhelming to the participants, consider having
them break down the goals into simpler, more manageable steps.
4. When assigning the homework, do not forget to provide the participants with a
phone number.
36
Facilitators Guide
Helpful Suggestions:
1. Once again, do not forget to provide participants with your office phone
number so that they can call and leave a message for you over the weekend.
Have a planning session (5-10 minutes) with your calendar at the end of the week to
plan for the upcoming week.
This Saturday, call and leave a message at _____-_____-______. This is a
challenge to see how the calendars are working for you, so put a reminder note in
your calendar right now to call on Saturday.
37
Facilitator's Guide
Helpful Suggestions:
1. When discussing acronyms, explain to participants that they will be covered
again when we discuss memory strategies.
To get a sense of what this looks like, lets practice it for a couple of minutes in
session, and lets observe our experience of being here, in this room, right now.
What is that like? How is your body feeling as it sits here? Do you notice the
points of tension? Do you notice where your body touches the seat? What does it
feel like? What else do you notice in this moment?
FOUR PRINCIPLES:
1) Preparation
2) Energy Conservation (STEP BACK)
3) Active Effort
4) Self-talk
Preparation
Break a task into simpler parts, understand the steps it will entail.
Rehearse the steps mentally or write them down.
Visualize completing the task.
Energy Conservation
Remember to STEP BACK and conserve energy to avoid fatigue and its
effects on cognition.
Be open to help
Avoid interruptions
Cut distractions
Keep it simple
39
Facilitator's Guide
Helpful Suggestions:
1. Do the self-talk exercise together in session to demonstrate the utility of selftalk.
2. Make sure that the participants think about how they can use self-talk in their
daily lives. Have them write down their ideas in their manual and try to
facilitate a brief discussion. Common examples include making a grocery list,
assembling a piece of furniture, driving, preparing to leave the house for work
or school, paying bills, etc.
Self-Care: sleep enough and take care of yourselfeat well, stay hydrated,
and avoid alcohol/drugs.
Take breaks when you need to re-focuseven 30 seconds off can help you
re-energize.
o 30 seconds of neck stretches.
o Give yourself a neck rub.
o Close your eyes and count to 30.
o Physical activity to get your blood pumping and help you feel alert.
Such as fast walking or jumping jacks.
o Point and flex your feet.
o Rest your head on your knees.
o Look out the window.
o Shake out your hands.
o Drink some water.
Exercise regularly for better relaxation, sleep, and blood flow to the brain.
Pace yourself and do your most difficult work when you are most alert.
Be open to help and ask for help when you are struggling with a task.
Avoid Interruptions, which make tasks take longer.
o Turn off your phone ringer; consider a Do Not Disturb sign.
Cut distractions, which use up cognitive energy you need for the task
o Turn off radios and TVs, close curtains, use earplugs, and mask
sounds with a fan or white noise machine.
Keep it simple and avoid multi-tasking. Do one thing at a time, particularly
when one of the things you are doing is potentially dangerous. Example: If
you are driving, just drive. No talking on the cell phone, no texting, no mapreading, no distractions!
Active Effort
Consciously attending to details, closely analyzing.
Be prepared to work more slowly than you might usually work.
When reading, allow time for re-reading sections.
Check your work for errors.
Self-talk during tasks
Repeat the steps of the activity to yourself as you complete them.
Talk to yourself about your progress.
Helps you remember completing the task.
Examples: simple (e.g., programming contacts into your phone), and complex
activities (e.g., rebuilding an engine; troubleshooting a computer problem).
Self-talk exercise: Self-talk makes tasks easier. Try this sequence:
o Tap your fist on the table, then the side of your hand, then your palm.
o Keep going for 30 seconds.
o Now try talking to yourself while you do it. Say out loud, Fist, Side, Palm.
o Does self-talk make it easier to stay on track?
40
Facilitator's Guide
Helpful Suggestions:
1. Since this chart contains a lot of information and participants may have
difficulty sustaining focus, go around the room and have them each read a
problem aloud.
2. Emphasize that they should highlight or mark with a star the strategies that
they would like to try.
What kinds of activities could you use self-talk for in your life?
Strategy
- Make sure you have eaten properly, get a glass of water, and go to the
bathroom.
- Take all medications as prescribed. Do you need any medications for pain
or discomfort?
- Get enough rest each night.
- If you are tired, throw some water on your face, do some jumping jacks, or
take a vigorous walk.
Internal
- Deep breathing.
Distractions:
- Mindfulness exercises.
memories,
- Quickly write down things you want to attend to later (if you keep thinking
stress
about what you need to do later) and then return to the task at hand.
Forgetting
- Use your calendar to prioritize and schedule the task. Refer to your
what you are
calendar to make sure you are on task.
supposed to
- Before you begin an important task, post a sign near you that reminds you
be doing.
what task you are on. For example, Bills.
Difficulty
- If you find yourself not completing any one task, or failing to do tasks well,
multi-tasking.
do one thing at a time!
External
- Turn off unnecessary noises like TV or radio.
distractions,
- Use a fan or white noise machine to drown out street noise or nearby
interruptions.
conversations.
- Use earplugs.
- Remove visually distracting items like computer screen savers or
interesting magazines or pictures.
- Find a quiet room and close the door.
- Think about creating a quiet space in your house or work setting that
you can use regularly.
- Try to be alone, or ask others to be quiet.
- Use a DO NOT DISTURB sign.
- Ask others not to interrupt.
- Decide not to answer phone calls or emails until after the task is complete.
Losing focus/ - Take regular breaks! If frequent, they can be quite short (e.g., do three
fatiguing.
jumping jacks or a quick stretch).
- Break tasks down into smaller steps, and take breaks in between steps.
Losing track
- Index cards, rulers, or paper to track what line you are on.
of what you
- Use a highlighter to underscore important points.
are reading.
- Take notes or make an outline as you read. Make it more interactive.
41
FOUR PRINCIPLES:
1) Listen Actively
2) Eliminate Distractions
3) Ask Questions
4) Paraphrase
Listen actively
Use nonverbal behaviors to convey that you are listening.
o Turn toward the speaker.
o Open your posture, relax, avoid closed body language.
o Lean toward the speaker.
o Maintain adequate eye contact.
Eliminate distractions
What sorts of distractions affect your conversations? Phones? Kids? TV?
Pets? How can you reduce these distractions?
Ask questions
Ask questions for clarification.
Ask the speaker to slow down, repeat information, or explain something in
a different way.
Paraphrase
Repeat information back in your own words, which will help you
understand, pay attention to, and remember the information later.
Helps ensure that you have heard correctly and understand; gives the
speaker a chance to correct any misunderstandings.
Here is an example of how paraphrasing and asking questions can help you
pay attention during conversations.
Lets say that you are at your doctors office, and the doctor says, Ive been
looking over your records, and Im a little concerned about your cholesterol level.
Its been high in the past it was over 230 back in August of last year. Its 205
right now, but your goal should be to get it down to 200 or below. Sometimes we
prescribe medication to lower cholesterol, but in your case, I think you can take
some steps to lower it without medication. Be sure to limit your dietary fats,
including meats, eggs, butter, cheese, and ice cream. Exercising three times a
week should also help lower your cholesterol. I want to keep a close eye on it, so
lets continue to check it every six months to see how youre doing.
42
Facilitator's Guide
Helpful Suggestions:
1. When doing the LEAP exercise, explain to the participants that they will each
take a turn sharing a story with the group about one of the sample topics
listed in the table. They should speak for approximately 1-2 minutes. The
group should be encouraged to use the LEAP principles, particularly asking
questions and paraphrasing. If participants appear to be uncomfortable with
the idea of speaking in front of the group, another option would be to do the
exercise in pairs.
2. It will be important for the participants to link the attention strategies that they
learned today with their long-term goals. Have everyone turn back to page 10
to review their goals. Once again, emphasize that goals can change over
time and that it is OK to make changes as necessary. The participants are
more likely to use a strategy if it can help them reach their goals. Give the
participants 5 minutes to review the strategies, choose the strategies they
plan to use, and write the strategies in their manual.
That is a lot of information the doctor just gave you, and you want to make sure
you understand everything. So you can paraphrase what the doctor said, and say
back, Okay, let me make sure I understand you. My cholesterol is a little high
right now, but if I cut back on the eggs, butter, and fatty foods, and if I exercise
three times a week, I can lower it without taking any medication. Were going to
check it in another six months and see how I did. Does that sound right?
If the doctor was speaking too quickly, you may need to ask for repetition, or you
may have to ask the doctor to slow down. You could say, That was a lot of
information, and I want to be sure I heard you right. Could you tell me again what
I shouldnt eat, and could you say it a little more slowly?
Exercise: Lets practice using the LEAP principles. Pick a topic and speak to the group
for 1-2 minutes about one of the sample topics below. Everyone should try to Listen
actively, Eliminate distractions, Ask questions, and Paraphrase what was said by the
speaker.
The worst weather Ive ever experienced.
Why its important to help people who need it.
The most important thing I learned in the past year.
Why its important to take care of your health.
The last time I went out of town.
My favorite part of the city (or country).
My favorite teacher.
A challenge I overcame.
The music I like best.
My favorite movie.
My hobby.
My favorite TV show.
43
Continue to use your calendar on a daily basis. Make sure to schedule a weekly
planning session to enter your appointments for the week. Use the calendar to prioritize
and make to-do lists.
44
45
Facilitators Guide
Helpful Suggestions:
1. If there is a white board in the room, it may be helpful to draw the model on
the board when explaining the components of memory.
2. When discussing distractibility in the model, emphasize how things like
emotional distress (PTSD, depression, and anxiety) and poor sleep can
interfere with how will you can attend to, encode, and store information.
Memory Terminology:
ENCODING
STORAGE
Info goes in
RETRIEVAL
Info comes out
Cognitive training focuses on encoding and retrieval, but not storage (which is
not under our control).
Strategies will help you:
o Decide what is important enough to remember and simplify information
to be remembered.
o Reduce the amount of information to be remembered.
o Make information personally meaningful to you in order to remember it
more easily.
Storage is most efficient when you are alert and well-rested.
Alcohol and drugs interfere with encoding and retrieval, as well as storage.
Everyday memory problems are usually due to encoding problems or not
paying attention in the first place.
o Again, you have to pay attention to something first to remember it later!
4. Memory Strategies
Attention strategies remain critical you need to actively attend to information to
move it into memory. Better attention better encoding better memory.
Simplify, prioritize, reduce distractions, do one thing at a time.
Attention skills:
o Enhancing attention to the situation with self-talk (e.g., Im putting my
keys on the kitchen counter, Im closing the garage door, or Im
taking my vitamins) better encoding better remembering less
worry and more energy.
o Pay better attention to conversations by actively Listening to the
person speaking, Eliminating distractions in the environment, Asking
questions as needed, and Paraphrasing what the other person says
(remember LEAP).
46
Facilitators Guide
Helpful Suggestions:
1. When discussing the what we remember table, emphasize that we learn
best when teaching, experiencing, and discussing. Tie this in with the class
experiential exercises.
2. When discussing the internal and external strategies, remind the participants
to highlight or put a star next to the strategies that they might want to try.
3. When discussing association, ask the participants whether they can use
association to learn the other participants names. Remember, discussing
and experiencing reinforces learning!
WHAT WE REMEMBER:
Read only
Hear only
Observe only
Observe and Hear
Discuss
Experience
Teach
10%
20%
30%
50%
70%
80%
90%
Committing information to long-term memory takes energy, time, and effort. Since
energy and time are limited, try to reduce the number and complexity of things you
want to remember. Routine and organization may be more important than memory!
Internal Memory Strategies: These are some Active strategies the A in RITA.
Association
o Linking new information with information you already know.
o Focus on the similarities and differences between the new information
and the old information.
o Association works well when you meet new people. Lets say you are
meeting someone new, and her name is Jane. You could remember
her by comparing her to your friend Jane (e.g., This new Jane has
blue eyes, but my Jane has brown eyes. Both Janes are tall, though.)
o Exercise: Try it yourself. How would you use association to learn the
names of your classmates?
47
Facilitators Guide
Helpful Suggestions:
1. For the categorizing exercise, give the participants time to work independently
then discuss results together.
2. For the acronym discussion, facilitate a discussion of acronyms they know or
have used in the past. Many participants will recall acronyms from their
childhood, which clearly demonstrates how powerful this tool is. Emphasize
how it helped them to learn information that they were exposed to over 20-40
years ago!
Categorizing or Chunking
o Dividing a large amount of information into smaller groups or chunks to
be remembered.
o Chunking is typically used for remembering numbers.
o The most common example of chunking is a 10-digit phone number
(6192993510 versus (619) 299-3510.
o Categorizing puts information together in a logical way.
o Exercise: For example, lets say that you want to get ice cream,
ketchup, toilet paper, mustard, shaving cream, popsicles, soap, relish,
and frozen pizza at the grocery store. Thats 9 items, and it probably
would be hard to remember all those items without a list. But if you
organize the items in a logical way, they are easier to remember, and if
you wrote them down in a certain way on your list, you might get to the
grocery store and not even need to look at your list. How could you
categorize these 9 items into 3 groups? Categorizing the 9 items into 3
categories makes it so we only need to remember 3 things instead of
9.
Group 1: _________ Group 2:
_________
_________
_________
Acronyms
o Acronyms like RITA are words that are made up of initials that
stand for a series of words.
o Acronyms reduce the amount of information you have to recall
because each letter is a cue.
o Common acronyms: ROYGBIV for the colors of the rainbow red,
orange, yellow, green, blue, indigo, violet. NBA for National Basketball
Association. HOMES for the Great Lakes Huron, Ontario, Michigan,
Erie, Superior.
o Exercise: What other acronyms do you know? Any from the military?
Creativity Turn the information into something catchy and easy to
remember. Using your creativity will also elaborate the information, which
leads to better encoding and memory.
o Catchy phrases: Like remembering someones name by imagining
their catchy phrase (e.g., Marilyn Marathon.).
o Stories: Turn the information into an exciting or interesting story.
o Rhymes: Turn the information into a rhyme (songs are easy to
memorize because lyrics usually rhyme).
o Songs: Turn the information into a song.
48
Facilitators Guide
Helpful Suggestions:
1. After discussing all of the internal memory strategies, tell the participants that
some strategies might work better for them than others. Also, some
strategies might work better in certain contexts or situations. The only way to
find out is to give them all a try!
2. When discussing external memory aids, ask the participants whether they
have used any of these techniques in the past. Sometimes success stories
may motivate other participants to use the strategies or help them to figure
out when or where to use the strategies.
Visual Imagery
o Pictures: Turn the information into a memorable picture. Draw this
picture out. The weirder or funnier, the better. This strategy works well
to remember peoples names. Example: Your new doctor is Dr. Burns,
who has dark, stubbly hair, as if there had been a big brush fire (burn)
on top of his head! Once you create that image, you are much more
likely to remember Burns. Or lets say you are meeting your new
neighbor, Sandy Reese. You can picture her eating Reeses peanut
butter cups on a sandy beach.
o Movies: Turn the picture into a visual story or movie, and imagine the
movie in your mind. Again, the weirder or funnier, the better.
o Acting: Even better, act out the information yourself.
o Graphs/Charts/Maps: Incorporate the information into a graph or chart
or map, if this makes sense.
External Memory Strategies
Is it really important to memorize information? If not, this is an opportunity to use an
aid or routine to reduce effort, energy, and time demands. Can you instead build this
into a routine to reduce its attention and memory demand? Once you have a routine
or habit, you dont need to remember the associated items again.
Calendars: To remember appointments and events. Instead of having to
remember each individual appointment, all you have to do is remember to use
your calendar effectively each day (a routine).
Note Taking and Filing: The #1 way to remember something is to write it
down. Consider using a section of your calendar. Instead of having to
remember each piece of information, all you have to remember is to file the
information appropriately each day (a routine).
o Dont trust your memory! Write it down!
o Writing helps encode information in multiple ways, multiple times
hear it, write it, read it as you write, say it out loud after you write.
o Easy, works every time.
o Shopping lists, sticky notes in calendar, section in your phone or
computer, writing on your hand, any other system that is easily
accessible.
Voice Recorders: Good for lectures or talks. Also for instructions from
doctors or bosses. You can then review and actively process later.
Visual Cues and Signaling Devices: Sticky notes, string on your finger,
other cant miss reminders (e.g., placing what you need to bring with you in
front of the door). Remember, it really helps if you have to touch the reminder.
49
Facilitators Guide
Helpful Suggestions:
1. When doing the memory exercise, it seems to work best when questions are
discussed one at a time. For example, give the participants time to write in an
answer to the first question and then discuss as a group. Then give them
time to write in the answer to the second question and discuss as a group.
Timers, Alarms, and other Auditory Cues: Alarms on your cell phone or
watch. Also, consider buying a device capable of multiple or complex alarms
there are ones you can attach to your keychain (see epill.com for ideas).
Automated/Computerized Prompts: e.g., Automated billing; Outlook
reminders to water plants once a week, call Mom every Sunday, check tire
pressure once a month, etc.
Navigational Systems: To help you remember directions as you drive.
2. You are given these directions to get to Ralphs: Take La Jolla Village, left on Villa
La Jolla, Left after 3rd signal.
3. You want to memorize your neighbors names: Nicole, Penny, Ann, Susie, Tom.
50
Facilitators Guide
Helpful suggestions:
1. The last 4 examples require more than note-taking because you need to
commit the information to your long-term memory. Emphasize the difference
between note-taking versus committing information to ones long-term
memory by using more active learning strategies.
6. Your roommate reminds you that its your turn to clean the kitchen today. She
tells you that the dishwasher needs unloading, there are dishes in the sink, the
floors a mess, and the pizza that you baked last night leaked melted cheese all
over the bottom of the oven. She says she also noticed a couple of yogurt
containers of yours in the refrigerator that are past their expiration date.
7. Information you need to memorize for work because it slows you down to look it
up every time you need it (fruit and veggie codes if you are a cashier at a grocery
store; steps for using a piece of machinery; information about products that
customers often ask you about).
8. Names of all the medications you take and the reason why you take it.
9. Types of food you can and cannot eat because of medical concerns.
10. Contents for an exam that you are taking for a class.
51
Answers:
1. Chunking, note-taking.
2. Paraphrasing, note-taking, association (its the same way one would go to the
AMC Theatre or Trader Joes).
3. Acronym PANTS, note-taking.
4. Acronym DRY, note-taking, association, rhymes (Robert Ying likes to sing,
wears a ring, stands on the wing of an airplane).
5. Note-taking, preferably in calendar!
6. Paraphrasing, acronym D-FOY or FlOYD, note-taking.
7. All of the strategies!
8. Note-taking, acronyms. categorizing
9. Note-taking, pictures, acronyms, rhymes/songs
10. All of the strategies!
52
53
3. Class exercise
Remembering a list of words.
List 1: Listen to the list without looking at the next page.
List 2: Read and study the list.
List 3: Read and categorize the list.
List 4: Read, categorize, and use visual imagery.
54
List 1: Listen to the entire list of words, then write them down.
How many did you remember? _____
55
List 1:
Hammer
Monkey
Toyota
Jazz
Saw
Zebra
Country & Western
Honda
Drill
Giraffe
Rock n' Roll
Ford
Screwdriver
Classical
Lion
Cadillac
56
Facilitators Guide
Helpful Suggestions:
1. Second list: The participants study the list for one minute. They flip the page
and write down as many words as they can remember. Give them time to
write down the words. Have them tally their score when they are done.
List 2: Study the following list of words for one minute, then turn the page
and write them down.
Falcon
Spark Plug
Elm
Eagle
Diamond
Hub cap
Pine
Maple
Hawk
Owl
Alternator
Ruby
Emerald
Oak
Sapphire
Wheel
57
List 2: Now write them down. How many did you remember? ____
58
Facilitators Guide
Helpful suggestions:
1. Third list: Give the participants a few minutes to read and categorize the
words. Have them flip the page and give them time to write down the words.
Have them tally their score they are done.
List 3: Read the following list of words. Put the words into categories to
help you remember them, then turn the page and write them down from
memory.
Cat
Carrot
Broccoli
Bread
Mop
Hose
Asparagus
Milk
Sponge
Eggs
Vacuum
Dog
Bird
Juice
Hamster
Onion
Category 1:__________
Category 2:__________
Category 3:__________
Category 4:__________
59
List 3: Now write them down. How many words did you remember?_____
60
Facilitators Guide
Helpful suggestions:
1. Fourth list: Give the participants a few minutes to categorize and visualize the
words. Encourage the participants to use drawings since often times a few
people in the room will learn for the first time that they are visual learners.
Moreover, drawing is more active than imagining. Once the participants are
done with their drawings, have them flip the page and give them time to write
down the words. Have them tally their score when they are done.
List 4: Read the following list of words. Put into categories and use visual
imagery to help you remember the categories or words. Then turn the page
and write down the words from memory.
Grass
Chair
Stapler
Lawnmower
Tree
Eraser
Pick
Table
Pen
Rake
Ruler
Shovel
Flower
Sofa
Shrub
Bed
Category 1:__________
Image:
Category 2:__________
Image:
Category 3:__________
Image:
Category 4:__________
Image:
61
List 4: Now write them down. How many words did you remember?_____
62
Facilitators Guide
Helpful suggestions:
1. Once all the exercises are complete, facilitate a discussion of which technique
they found most helpful. Have them write their impressions in their manuals.
Did this exercise convince you that some of these strategies will help you
remember more information? What did you notice? What worked best for
you?
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
63
Facilitators Guide
Helpful suggestions:
1. Overlearning: Can anyone think of examples of what they may need to overlearn
(e.g., learning the most routine aspects of a new job)?
4. Overlearning
Learning what you need to remember over and over.
Things we overlearn: facts, our names, our birthdays, the names of our
siblings and parents, the name of our high school, the name of our street, the
name of our pets, the order of the letters in the alphabet, the happy birthday
song, how to tie our shoes, etc.
Anything can be overlearned.
Overlearned information is very resistant to forgetting.
Strategies for overlearning: Flashcards that you carry with you and study
throughout the day. Works well for learning facts for school exams.
If you are having trouble, break the learning task down into smaller chunks
and learn one chunk at a time.
Overlearning example: Lets say you have to memorize the steps of a new
task at work. You could write each step on a separate card, then shuffle the
cards and put them back in order. You would not stop after getting it right
once though overlearning means you keep going over and over the
material, even after you know it. In addition to using the flashcards, you would
also want to actually do the task repeatedly, in the right order, to memorize it.
64
Facilitators Guide
Helpful suggestions:
1. Discuss the list of name learning strategies. Check in to see if they have any
questions or if they could provide other examples.
2. Also, ask them to highlight or mark the ones that they would like to try using.
3. After reviewing the name learning strategies, conduct the class exercise that
asks participants to think of ways that they can remember each others names
and the list of 5 names their classmates give them. Encourage creativity!
Class Exercise: Which of these strategies would you use to remember each
of your classmates names? Certain names call for certain strategies. Have a
classmate tell you five names of people who are important to them. Use some of
these strategies to remember those names.
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Facilitators Guide
Helpful suggestions:
1. Review the memory model on the board if necessary.
2. In reviewing the relaxation portion, check in with the group members as to
whether they have been using the relaxation strategies taught in class.
3. Mental retracing: it can be very frustrating to realize that you have
misplaced an item. Most of us have encountered this! Mental retracing can
be a useful alternative to getting frustrated.
6. Retrieval strategies
Think back to our memory model: Encoding Storage Retrieval.
All strategies thus far will help with encoding. The next ones will help with retrieval.
Retrieval problems mean that a piece of information is in your brain somewhere, but
you have difficulty getting it out (e.g., a name that is on the tip of your tongue).
Relax
Anxiety leads to difficulty retrieving information.
Using relaxation strategies can enhance memory.
Mental Retracing
To retrieve a lost item.
Mentally retrace your steps and reconstruct the events leading up to when
you last had the item.
Alphabetic Searching
To remember a word or a name.
Go through the alphabet, starting with A, and ask yourself, Does it start with
A? Does it start with B? and so on. If you can identify the first letter, use the
same process to get to the second letter, and so on.
Recreating the Context
Good strategy when you can remember where you were or what you were
doing when you learned the information.
For example, if you remember that you were eating at a certain restaurant
when your friend told you about a class that you wanted to take, recreate that
context. Either imagine the restaurant or actually go there, and it will be easier
for you to remember the details about the class.
Organization
Great strategy for encoding, storage, and retrieval.
Organization in your environment and in your daily routines will help you
remember things more easily.
Automatic places for things: locations in your environment where you always
keep certain things that way you will always know where to find them.
Plan automatic places for:
o Valuable papers.
o Important phone numbers.
o Your calendar/smartphone/iPod etc.
o Your keys.
Stick to a structured schedule: Identify your daily routine and schedule things
you want to do but often have difficulty remembering to do or motivating
yourself to do (e.g., medications, exercise, etc.).
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Facilitators Guide
Helpful Suggestions:
1. Ask the group to go back to their original partner and tell back the 5 names they
learned earlier. Could they use alphabetic searching to aid with recall? If they
are having trouble recalling those facts, what are some of the strategies that
would have helped with recall? Could they have asked the partner to repeat the
name and rehearse it? Would it have helped to have them spell it out?
2. Section 8 Class Exercise: Consider spending approximately 10 minutes
scheduling in skills they would like to practice next week. There could be class
discussion and problem solving during this to encourage reflection and
engagement.
3. Section 9 Relaxation Exercise: The following technique is a combination of a
breathing technique and a visualization technique.
Start by closing your eyes if that is comfortable for you. If not, leave your eyes open. We
will start by doing some deep breathing and slowing down our breath. Place one hand
on your chest and the other on your stomach. Become aware of your breathing. Notice
how quickly or slowly you breath and how deeply. Notice if one or both of your hands
moves as you breathe. Gradually begin to slow down your breath and with each breath,
try to breathe in a bit more deeply. Notice if the hand on your abdomen begins to move
more than the hand on your chest. Continue taking in a few more slow, deep breaths,
becoming aware of a growing feeling of relaxation. (pause)
Now visualize yourself on a beach. If you have a particular beach you like, you can go
there. See the waves rolling up the sand, the seagulls flying overhead, and as you look
up, you also notice some puffy clouds. Listen to the sound of the waves, and then the
quiet as the surf recedes. Hear the alternating sounds of the waves, quiet, loud, and
then quiet. Over the sound of ocean, you can hear the seagulls calling. Now feel the
warm sand on your body. Imagine it covering your body, warm and heavy. Really feel
the weight of the sand on your arms and legs. Feel surrounded by its warmth and
comfort. Just stay with it for a little longer. (pause)
While visualizing the sand, continue to breathe as deeply as you can comfortably.
Notice the rhythm of your breath. As you breathe in, say the word warm to yourself.
Try to feel the warmth of the sand around your body. When you breathe out, say the
word heavy to yourself. Experience the weight of the sand on your arms and legs.
Continue to breathe deeply, thinking warm on the inhale and heavy on the exhale.
Continue that for a few minutes. (pause)
Now gradually become aware of being in your chair in class today. Feel the solid chair
under your body and the feel of your feet on the floor. Become aware of any sounds in
the room. When you are ready, you can open your eyes.
Now use your retrieval strategies to remember those 5 names you learned earlier.
_____________________________________________________________
_____________________________________________________________
8. Class exercise:
Schedule in the calendar the strategies you would like to practice using next
week. For example, if you know that you are attending a social event on
Saturday, plan on using some of the name learning strategies. Or, you may
want to schedule in a time for creating automatic places.
9. Relaxation exercise:
Brief Combination Technique
Advantages of a brief combined technique
o It is quick and convenient.
o It can increase the effectiveness of the technique by drawing you
deeper into relaxation.
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Facilitators Guide
Helpful suggestions:
1. Consider asking the participants to schedule a time in their calendars to re-read
the memory strategies.
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Facilitators guide
Helpful suggestions:
1. In doing the planning exercise, consider using someones goal as an example
and problem-solving it on the board. Afterwards, have the group members pick
one of their goals and have them work on it in class.
Example Goal: By December 10, I will have all of my holiday cards mailed out.
Target Date
11/1
11/5
11/10
11/20
11/25
12/1
12/5
12/10
Step
Make a list of card recipients and addresses.
Purchase holiday cards.
Start writing cards, 30 minutes per night.
Have 50% of cards written.
Obtain any missing addresses.
Have all cards written and addressed.
Purchase stamps.
Mail cards.
Planning exercise:
Use the worksheet on the following page to plan out an important goal. Transfer
tasks/dates into your calendar.
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Facilitators guide
Helpful suggestions:
1. While the participants are working on the planning exercise, walk around the
room to offer your assistance. Some participants may get overwhelmed by this
exercise.
Target Date
Step
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Facilitators guide
1. When discussing brainstorming, provide examples of when they might use
brainstorming (e.g., meetings at work or a topic for a school project). Encourage
them not to filter responses as silly or bad responses.
3. Brainstorming
BRAINSTORMING =
COMING UP WITH AS MANY IDEAS AS POSSIBLE ON A PARTICULAR TOPIC
Think of as many ideas as possible without making judgments about them.
Dont edit out any ideas because they seem silly or bad. Just let the ideas
keep coming because you never know when a silly idea will trigger a good
one.
Brainstorming is key to cognitive flexibility and problem-solving, which will be
the focus of the next session.
Brainstorming practice exercises: Try to come up with at least 30 ideas for
each of the following scenarios.
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Facilitators guide
Helpful suggestions:
1. Do the first example of brainstorming on the board. Encourage creativity!
Facilitators guide
Helpful suggestions:
1. Participants should do the second brainstorming exercise on their own. Give
them 2-3 minutes to work on it. Walk around the room to provide assistance and
encouragement. Once the exercise is over, discuss results as a group.
Emphasize that sometimes it helps to brainstorm with other people because it is
likely that they will think of things that you hadnt!
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Target Date
Step
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Target Date
Step
77
Target Date
Step
78
Facilitators guide
Helpful suggestions:
1. Do this 6-step problem-solving method exercise as a group, but have all the
participants fill out the worksheet in their manuals.
Facilitators guide
Helpful suggestions:
1. Do this 6-step problem-solving method exercise as a group, but have all the
participants fill out the worksheet in their manuals.
Facilitators guide
Helpful suggestions:
1. Have the participants do this exercise on their own. Encourage them to use a
current problem that they are trying to solve. Once the participants have
completed the exercise, discuss as a group and ask for a volunteer to share their
work.
Easy? Cost
OK?
Likely to
work?
Other notes
Facilitators guide
Helpful suggestions:
1. Spend approximately 2-3 minutes on the puzzles. Make sure to remind the
participants to solve two of the puzzles using self-talk and two of the puzzles
using self-monitoring.
2. For the second class exercise, the goal is to link self-talk and self-monitoring with
real life applications.
4. Self-talk
Self-talk while you are solving a problem helps you generate alternatives,
keep your mind on the task, remember the steps you have done or
alternatives you have tried, and catch errors in thinking.
o Examples: troubleshooting a software problem on a computer, trying to
figure out which remote control button to use to change a setting on
your TV, getting a large couch through a small doorway.
o Self talk practice: Use self talk while solving the first two puzzles in the
pages ahead.
5. Self-monitoring
Step 6 of the problem solving method is Evaluate.
Self-monitoring is a way of taking a step back and evaluating your problem
solving strategy to make sure it is effective.
o If a strategy is working, you want to keep using it.
o If a strategy is not working, you want to shift strategies.
If something is not working or you find yourself frustrated, it is a good time to
take a step back.
Be sure to gather evidence that you are wrong, as well as evidence that you
are right.
Real-world example: Your physical therapist prescribed neck stretches for
you to do every 4 hours. Your first strategy for remembering to do your
stretches was to schedule the stretching sessions on your calendar. You
found that you were stretching once a day with this method. Evaluating your
strategy, you found evidence that it was not working as well as it should
because you were not meeting the goal of stretching every 4 hours. Then,
you decided to try a different strategy. You tried linking stretching to every
meal and found that you were able to remember to stretch 3 times a day
(about every 4 hours). This strategy worked, so you stuck with it.
Class Exercise: Self-monitoring practice: Solve the remaining two puzzles,
this time using both self-talk and self-monitoring. Be sure to look for evidence
that your answer is wrong by examining the answers you are not selecting.
Class Exercise: What situations come to mind at home, school, or work that
could be helped by some of these self-monitoring strategies?
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84
85
86
six
IIIIIIIII
nine
III
IIIIII
15
D
III
E
three
six
F
nine
87
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Facilitators guide
Helpful suggestions:
1. Remind participants that family members are allowed to attend final session.
Answer any questions or concerns participants may have about inviting family
members.
89
Easy? Cost
OK?
Likely to
work?
Other notes
Easy? Cost
OK?
Likely to
work?
Other notes
Easy? Cost
OK?
Likely to
work?
Other notes
Easy? Cost
OK?
Likely to
work?
Other notes
Facilitators Guide
Helpful suggestions:
1. It is important to help the participants develop a plan for addressing
cognitive problems in the future. Typical plans include reviewing skills
learned in this course, asking friends or family for support, and seeking
help from providers.
Attention strategies
Name one attention strategy you are using:
_________________________
___________________________________________________________________
Name one attention strategy you would like to focus on over the next month:
___________________________________________________________________
Memory strategies
Name one memory strategy you are using:
_________________________
___________________________________________________________________
Name one memory strategy you would like to focus on over the next month:
___________________________________________________________________
Planning or problem solving strategies
Name one planning or problem solving strategy you are using:
_________________________
___________________________________________________________________
Name one planning or problem solving strategy you would like to focus on over the
next month:
___________________________________________________________________
In the future, if you find you are having significant problems related to cognitive
issues, what can you do to address them?
What do you think your friends, family, and support persons can do from here on out
to best support you as you continue to work on skills to help you manage your
cognitive disorder?
What final questions or feedback do you or your support persons have for the
instructors?
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Facilitators Guide
Helpful suggestions:
1. If you have handouts about local resources, provide them to the participants
at this time.
2. Educate them about referral sources available at your facility.
3. If calendars are provided by your facility, let the participants know how they
can go about getting refills for their calendars.
Individual therapy
Therapy/Support/Peer-run Groups
Marital/Family therapy
Pain clinic
Physiotherapy
Vocational rehabilitation
Assistance with education
*For additional assistance with education, visit the
www.studentveterans.org website. They have a resource called the
Military to College Guide which addresses issues related to returning
to school. The guide can be found in the websites resource library at
http://www.studentveterans.org/resourcelibrary/
TBI resources
o Several groups help people with concussion or mild TBI and their families.
They provide information and put people in touch with local resources,
such as support groups, rehabilitation services, and a variety of health
care professionals.
o The Brain Injury Association (BIA) has a national office that gathers
scientific and educational information and works on a national level to help
people with concussion or mild TBI. You can reach the BIA office by
calling the toll-free BIA National Help Line at 1-800-444-6443. You can
also get information through the national BIA Website at www.biausa.org
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