Table 1.

Summary of Portland, Oregon, group-based Cognitive Strategy Training treatment.

Cognitive Strategy Training	Concepts	Strategies	Class Activities	Home Exercises
Psychoeducation*	The brain is complex and controls a range of functions including cognition, emotion, movement, drives, and regulatory functions. The basic definition and mechanisms of traumatic brain injury and postconcussive syndrome. The basic definition of cognitive disorder and discussion of the full range of related risk factors.	Define internal strategies and external aids. Provide examples.	Perform introductions: As an example of internal strategies, ask participants to introduce them- selves with their name and a catchy phrase to help participants remember them (e.g., “Marilyn Marathon”). Also, have participants visualize the catchy phrase that describes each person (e.g., Marilyn running). Review course overview. Review day planners and class binders. Emphasize that the day planner is an example of an external aid.	Identify a routine “home” for most important personal items—wallet, cell phone, keys, day planner, and class binder. Identify class goals.
Lifestyle Strategies	Individuals with cognitive disorders need to give their bodies and brains optimal conditions to function well.	Avoid additional head injuries. Minimize intake of and contact with substances (alcohol, caffeine, toxic fumes) that interfere with brain healing and function. Consume a healthy diet with plenty of water. Exercise the body and mind. Attend to sleep hygiene. Find some time to relax and have fun every day. Practice good pacing, take breaks, and learn limits. Stop activities before wearing out.	Write down three to four life priorities on page finder/book- mark in day planner to give a visual reminder of what is most important to spend time on in life. Are you prioritizing your health and life- style strategies? Highlight two to three lifestyle strategies summarized in the class handouts to practice more often in daily life. Practice scheduling one of these lifestyle strategies into each day in day planner for the coming week.	Practice referring to day planner at least three times per day. Use day planner as reminder to do the lifestyle strategies scheduled this week.
Organizational Strategies: Routines and Prioritization	Routines reduce risk of error, require less energy, ensure that important tasks and goals are attended to, and help manage problems with mood, anxiety, and cognition. Routines can involve a regular time, space, and/or method for doing an activity. Immediacy vs importance —we often prioritize an activity because it is happening now or has a deadline, so it feels urgent. However, many of the most important activities in life (e.g., prevention, exercise, relation- ships, planning, self- care, and pleasure) have no deadlines.	Build routines to help attend to mundane tasks (e.g., getting ready in the morning, taking medications), important life goals and priorities (e.g., exercise schedule, designated family day), or seasonal events (e.g., anniversary dinner, annual yard raking day). Use to-do lists to brainstorm and prioritize daily and monthly activities. Use day planners and calendars to help organize time and develop routines. Schedule time for the most important activities and life priorities first. Don’t sweat the small stuff.	Read a parable about filling a bucket first with large rocks, then with pebbles, then sand, and finally water, noting that if done in reverse, the rocks would never fit. The principle is to schedule the impor- tant things in life first. Use a 2 × 2 table to categorize a list of activities, first as “Important vs Not Important,” then as “Immediate vs Not Immediate.” Discuss the extent to which time is allotted in life for the items classified in the “Important/ Not Immediate” quadrant. Practice using the to- do lists in day planner to brainstorm any activities wanted for tomorrow. Then prioritize them numerically, keeping in mind the life priorities listed on the page finder. The facilitator can demonstrate an example of this on the board.	Practice using the prioratized to-do lists, appointment schedules, and monthly calendars in day planner three or more times per day to help structure each day. Try to allot enough time for the most important activities, and don’t be afraid to move unimportant items to future days. Use day planner to track appointments as they are scheduled.
Attention Strategies	There are increasingly difficult levels of attention ranging from simple focused attention to sustained attention to selective, alternate, and divided attention. Higher levels of attention require more energy and increase the chance of error. Attention strategies attempt to structure a task or situation so that it requires lower levels of attention.	Minimize internal distractions by attending to bodily needs before a task. Use mindfulness exercises to focus attention and minimize distracting thoughts or intrusive emotions. Minimize external distractions. Find a quiet space to work in. Use ear plugs or a fan to drown out noise. Avoid multitasking. Avoid interruptions. Use a “Do Not Disturb” sign, or ask others not to interrupt. Break tasks down into short, manageable steps. Take short breaks in between steps. Hang the list of steps in clear view to keep on track. Use a timer and/or day planner to help periodically evaluate task pace.	Practice one or several mindfulness/breathing exercises in class. Discuss how each attention strategy serves to bring a task down to a lower level of attention. Highlight two or three attention strategies from class handouts to practice more often in life.	Use day planner and/or another visual reminder to help practice the attention strategies highlighted several times per day this week. Identify one challenging yet important activity to do this week. Try breaking the task down into steps, and practice taking breaks in between each step.
Memory Strategies	Memory is the ability to store and retrieve information. There are different levels of memory ranging from sensory to short-term to long-term memory. Attention helps move information from sensory to short-term memory. Active memory strategies help organize information so that it is easier to retrieve later. They help move information from short-term to long-term memory. Active memory strategies require time and energy. Because not all information is important to store in long-term memory and because time and energy are limited, it is better to use external aids to help track short-term details only (e.g., appoint- ments, telephone numbers, grocery lists).	Work with information in multiple modalities —listen, read, write, draw, act out, or experience it. Process information at higher levels of thought—reorganize the information into meaningful chunks or categories, discuss it with someone, teach it to someone, do something creative with it. Turn the information into something more memorable—mnemonics, catchy phrases, jokes, songs, stories, or rhymes. Turn the information into visual images— draw pictures of it, imagine it as a movie or visual story, make charts or graphs of it. Use day planners, PDAs, calendars, and to-do lists. Write important information down for later reference and store/file notes in an organized manner. Use timers, alarms, automated prompts voice recorders, and navigational devices.	Review four lists of words, one at a time. Listen to the first list and immediately write down as many words as recalled. Read the second list individually and immediately write down as many words as recalled. Organize the third list of words into categories and then turn the items and categories into a mnemonic before recall. Draw the fourth list of words into a picture or visual story before recall. Discuss which modalities and strategies worked best. Highlight two or three memory strategies on class handouts to practice more often in life. Label tabs in day planner behind which important information can be stored by project, goal, or activity (e.g., finances, grocery, health, work, home repair, recreation, addresses/contact numbers).	Use day planner and/or another visual reminder to help practice the highlighted active memory strategies several times per day. Practice using a timer or alarm each day to help remember to do something important. Practice using the daily note pages in day planner to jot down important information through- out each day (e.g., directions to an appointment). Store information to refer to regularly behind the labeled tabs in day planner.
Planning and Problem- Solving Strategies	Long-term problems, goals, and projects often appear over- whelming, but plan- ning worksheets can be used to get started, break the goal down into manageable steps, and keep on track.	Schedule time to plan. Define goal, project, or problem. Examples could include addressing a relationship or health concern or working toward a new career. Brainstorm many small steps that might address goal. Prioritize several of these items as “next steps” based on importance, feasibility, and/or a logical sequence. Begin using day planner to schedule a few of these steps at a time. Consider developing a routine time, place, or method to work toward goal. Schedule time to plan again. Periodically reevaluate progress toward goal, and then rebrainstorm, reprioritize, and reschedule as needed. Stay flexible and revise plans and goals periodically.	Practice using a planning worksheet in class toward an important life problem or goal. The facilitator can also demonstrate an example of this on the board. Label a tab in day planner devoted to this goal. Store the worksheet in that section for later ref- erence and planning.	Practice using a planning worksheet toward a different life goal or problem. Evaluate the progress made toward original class goals. What are the most important changes made? Identify one or two cognitive problems that still need to be addressed.
Review and Integration†	Class binder and handouts are a toolbox of strategies that can be used to compensate for cognitive problems. Each strategy requires practice and may not work the first time or for all problems. It is also normal to forget to use strategies after a period, so review them periodically. If cognitive problems become more prevalent, reread handouts and select one or several tools to help address concerns. Also, consult with healthcare providers or trusted others.	—	Review lifestyle, attention, and memory strategies using handouts that briefly summarize each module in a new way. Use active memory strategies during the review to consolidate the information. For example, draw a picture of each life- style strategy and then turn the attention strategies into a song, story, or rhyme.‡ Name and describe one or two cognitive strategies found to be most useful. Use a planning work- sheet to develop a plan to work on remaining cognitive problems after the class is over.‡ Say good-byes.	—

^*Participants can optionally bring family member, friend, or support person to attend psychoeducation session.

^†Participants can optionally bring family member, friend, or support person to attend review section of final class.

^‡Not offered consistently to all groups. However, all other concepts, strategies, class activities, and home exercises listed in this chart were offered to all participants in all groups.

PDA = personal digital assistant.