A solid evidence base for therapeutic interventions is becoming an increasing necessity in the modern healthcare world for both ethical and financial reasons. Obviously, therapists feel a moral obligation to ground their practices in the best available research, but additionally the emerging new healthcare reimbursement systems are seeking some measure of proof that treatments are effective. P. Orszag, for example, in the July/August 2011 issue of Foreign Affairs(2011) dissects President Obama's Health Care reform package. Mr. Orszag finds, among other mechanisms in the law, powerful embedded financial risks to Providers for failure to engage in evidence-based practice and very strong built-in financial incentives for them to come to the fiscal table with treatments that are based on well-designed studies.
The field of Cognitive Rehabilitation is already facing this financial scrutiny, and therapists have responded with an impressive body of evidence supporting a variety of cognitive interventions. Cicerone and colleagues (2000, 2005, 2011) have published three extensive meta-analyses of the research in cognitive treatment, categorizing the evidence for a variety of interventions for individuals with brain injury and stroke. In these meta-analyses, Cicerone and colleagues on the Cognitive Task Force of the Brain Injury Special Interest Group of the American Congress of Rehabilitation Medicine examined 370 studies of remediation of deficits in memory, attention, executive functioning, awareness, cognitive communication, language, perception, problem-solving, and comprehensive-integrated programming. Practice guidelines and recommendations were developed. These standards were based on the strength of the research designs of the studies in each area.
To their credit, M. M. Sohlberg and L. S. Turkstra in their important book, Optimizing Cognitive Rehabilitation, do provide a comprehensive literature search of their own and faithfully base the array of practical instructional materials they offer on the strong evidence they amass.
However, considering the Cicerone and colleagues mega-studies cited above, it is somewhat disappointing that Drs Sohlberg and Turkstra did not avail themselves of these extensive reviews. (It should be noted and declared here that this reviewer was one of the many authors who assisted lead author, Dr. Cicerone in developing these analyses.) While the last of these meta-analyses was published too late for consideration by Sohlberg and Turkstra, given the large number of studies scrutinized by Cicerone and colleagues, the evidence presented in Optimizing Cognitive Rehabilitation could have been enriched by consideration of the first two studies.
After a general introduction and notes on the organization of the book, Optimizing Cognitive Rehabilitation delves into the science supporting the various cognitive treatment interventions offered to individuals with Acquired Brain Injury, Dementia, Schizophrenia, and Schizo-Affective disorders. The opening sections provide the theoretical underpinnings for the practical clinical guidelines and instructional methods offered later in the book. The development of guiding general principals in these early chapters involves the consideration of various key elements that influence learning. These include program characteristics such as client personality attributes (self-efficacy, locus of control, belief systems, disease characteristics, cognitive status psychosocial status, etc.) and environmental features such as convenience and resources of the facility, level of collaboration and so forth. Throughout, the authors wisely stress the importance of the therapeutic relationship between the treating clinician and the client.
The discussions of the characteristics that influence learning feed into the overall framework for cognitive intervention advocated in the book. This organizing framework is referred to as the PIE system by the authors (Plan, Implement, and Evaluate). The PIE framework is carried throughout and is applied to all work materials provided.
Arguably, the heart and great value of this book emerge in the latter chapters when Sohlberg and Turkstra present Practitioners with an impressive series of specific practical training procedures and instructional materials. These procedures are provided in five general categories of cognitive intervention: training facts and concepts, training functional multistep routines, training the use of external cognitive aids, training the use of meta-cognitive strategies, and social skills training. In each category, further supporting research is introduced, detailed teaching methods are described, and large numbers of charts and work book materials are offered. The Appendix itself contains 18 reproducible work forms that can be used by the Cognitive Therapist. Dozens of additional forms are placed throughout the book. Used correctly, Optimizing Cognitive Rehabilitation can serve a text on research evidence in Cognitive Rehabilitation, an instructional manual for forging therapeutic interventions, and a kind of teaching curriculum, complete with ready-to-use workbook materials.
Two final minor criticisms can be offered. First, while the comprehensive and multifaceted scope of the book is a strength, it is also a bit of a weakness because weaving in highly technical theoretical research material with practical instructional aids can detract from the pragmatic workbook aspect. Some clinicians may get lost in the density of the presentation.
A related point is that a great deal of the language is highly sophisticated, even for some treating clinicians who are familiar with the field. Perhaps, the authors could have simplified their explanations of the more technical terms and concepts, especially for those Cognitive Therapists who may be in the early stages of their careers.
Minor issues aside, M. M. Sohlberg and L. S. Turkstra have given us an impressive addition to our toolboxes for working with individuals with cognitive disabilities.