Ep. 10 - A Conversation with McKay Moore Sohlberg - Cognitive Rehabilitation

Welcome to the Academy of Neurologic Communication, Disorders and Sciences podcast. My name is Michael Beale. I'm an assistant professor at California State University Northridge and a speech pathologist at UCLA Medical Center. In this episode of the ANCDS podcast, I talk to Dr. McKay Solberg. Dr. Solberg is a full professor and director of the Communication Disorders and Sciences program at the University of Oregon and the Fellow of the American Speech Language and Hearing Association. Dr. Solberg has published numerous articles, chapters, and manuals on managing cognitive impairments following acquired brain injury and is co-author of two leading textbooks in the field. She's been funded on a number of federal projects supporting the development and evaluation of assistive technology to deliver cognitive rehabilitation and to help individuals with cognitive impairments more fully integrate into their communities. I've been interested in and have been reading Dr. Solberg's work for a number of years and I commented to her to start off our conversation that one of the things I appreciated about her work and her writing was that I always got a sense that she was writing from a clinician's perspective as well as a researcher's perspective and that it's been interesting to watch her interests in her approach to rehabilitation develop over time. Well, thank you. I consider that a compliment. I suppose sometimes I feel a little bit pseudo researcher because I am very interested in clinical questions in a very pragmatic way like what can we do within the context in which we operate that make a difference to people in their day-to-day lives when they're no longer seeing us. I think research really depends on the kinds of questions that you ask. A cognitive cycle, we base a lot of our models and things on what we know about cognitive psychology that might have been conducted in an experimental lab or what we learn about brain networks from brain imaging studies, but because my questions have been more, how can we help people who have these issues? I think I've looked to other researchers that are maybe in more experimental, formal, laboratory kinds of contexts to help give us theory and ground what we do and then see if it works for real people and real therapists and real environments. Well, you kind of, I think, started off publishing about attention, and you presented a model of attention that was, at the time, I think, different because it was really informed by clinical observations. Is that correct? Yes. I think the model of attention and thinking about attention as this multi-dimensional construct, which now is a mainstream way to think of it, but wasn't at the time, was based, in part, on factor analytic models where they give people lots of attention tests, and then they say, "Oh, look, these kinds of tasks fall together, so that must be different kinds of attention," and then observing what people complained about and what we saw, and then superimposing. Also, some of the cognitive psychology studies looking at typical attention and how it works. Again, comparing that to the kinds of things we saw in our patients and then constructing that model, and then looking to see if there were people that had different particular profiles of specific types or domains of attention that we might want to work on that particular domain. It seems like your model of attention and how you approach treating it has changed over time from attention process training one, particularly the latest version. Can you talk a little bit about how that happened? Yes, absolutely. Early on, when we were doing attention training in looking at some of those early studies, we were looking at the question, "Can people get better?" That was an era after physicians would say, "After a year, there is going to be no more improvement." It's a really different context. We're like, "Hey, look, we're doing these drills, and people get better." We can retest their attention, and they're better in the areas that we worked on. That was really exciting at the time, and I think it was an important contribution. Then the questions came, "Well, so they're better on these tests, but are they better on complex everyday tasks?" Is the attention improvement? Does it generalize? Is there sufficient far transfer? I think there's been a mix of studies suggesting that transfer may be limited. There's some studies showing that you can change brain activation networks with all these specific drills. We began to realize, "God, who cares if they get better on these tests or their brain networks change?" What really matters is, can they drive more with ease? Can hold a conversation? Are they less frustrated? I think some of the evolution that occurred was to figure out how to promote generalization and transfer. I think the particular areas that evolved were to link the attention training to strategy training, so that you're working with people manipulating their own cognition. For example, if somebody's working primarily on working memory and holding on to information, they may have drills that do that, but then they'll additionally identify strategies that they can link with that. For example, maybe self-talk or visualization or some type of pacing strategy, something that works for them. The exercises are done in conjunction with that in addition to identifying functional goals. If this attention were to get better, how would you know? Then you can set up generalization activities. I think the big changes over time have been to link the exercises to cognitive strategies that make sense for that person and that they're involved in selecting and to have it linked to meaningful outcomes that require that type of attention. I think it's important to be cautious. This direct attention training is one tool in our cognitive rehabilitation offerings. I think we don't know a ton about candidacy and who benefits the best. There's been a whole industry and a big business that's been built up around brain training with a lot of the commercially available programs. I think it warrants caution. I think just having people do computer drills without a clear reason why that particular patient would be a candidate is important to think about. When I think about the ideal candidate and I look across the literature, I think our best guesses or hypotheses for who benefits are a person who has a predominant attention deficit where their response is on clinical interview questions and questionnaires matches their findings on neuropsych attention tests so that it's a consistent profile of an attention problem where there's not a heavy psychological overlay and where they're clear on if their attention were to improve, they have some kind of functional activities or some sort of tasks that would make a difference for them. I guess if I were to summarize, I would say that I think it's important at this point with what we know about attention training to one really look at candidacy issues to be very clear on what are kind of patient centered functional outcomes that would make a difference to make sure that the task selection and implementation of the attention training makes sense for that patient. So for example, are they really working on working memory? Are they working more on distractibility and suppression so that the task selection and how we implement it is well thought out theoretically good grounded and matches the person's profile. And again, as I said, pairing the drills with strategy training and again, being able to measure generalization to meaningful activities. So I do think it has a place. I think it's, but it's important to be able to measure progress in generalization and not continue if we're not seeing improvements. You know, I'm not that familiar with the brain training games. I mean, I know the names. I know they're out there. I think it's been a while I might have checked them out very briefly. But do you think there's for the SLP who might be using them? Maybe simply because it makes doing therapy easier in some practical way. Do you see a use for them? Can you use them skillfully? I guess that's the kind of question I'm asking. - I think there'll be people who would be on both sides of the fence. So the issue is kind of, is decontextualized therapy is a place for decontextualized therapy in our practice? And there's a number of people in our field who would say, "Absolutely not." That everything should be contextualized if it's, if you're doing some kind of drill that's divorced from anything functional that it doesn't have a place. And then you're gonna have people who look at some of the kind of data showing, oh, we get these kinds of improvements and there's some trans-evidence of transfer even if it's not far transfer. It's efficient. So I think there's been this kind of pitting against the two against each other. I would say I'm somewhere in the middle, again, with caveats that I would not set somebody to do a systematic computer-based program where I'm just, they're doing a series of exercises that I didn't select based on my own testing and observations and having individualized adaptive exercises would be something. I would say it would be a skillful use of them. So not just using something that was pre-prescribed. So as they get better then on these exercises, what would be the next step? Are you training a specific domain or are you just following a menu that's in a computer? And again, linking it to functional tasks that have that type of attention as a basis and pairing it with strategy so they're learning to engage their own, there's a metacognitive piece to it as well. - Do you think we're getting close to reaching the limits of direct attention training in terms of understanding how much improvement, how much meaningful, useful improvement we can get through that path? - That's an interesting question. I think there's way more questions than we have answers. And so I think we would have to, there's a lot more research to be done. So I think places where there's a large end and you can really sort through the numbers. So for example, a big issue is dosage. What's the, what kind of treatment dosage really results and kinds of changes and how, and that's something that you have to look at very, you need big enough numbers, you need to compare different dosage amounts. What types of activities? I guess to me, the question is it's hard to separate out all the implementation variables and the candidacy variables. So we think that people have to have enough neural reserve, for example, to benefit from attention training kind of following the NIH blueprint on neuroplasticity. That would be kind of a fundamental principle. So how much neural reserve? So we, for example, we don't tend to do it with people that are very severely impaired. We don't do it with people that are very mildly impaired and have a lot more kind of self-efficacy, anxiety, cycle emotional variables attached to their cognition. So again, I think these are complex questions. candidacy questions, a treatment implementation questions. I think are important to ask to be able to look at whether this decontextualized drill-based training has a role. And I think we're a long way from answering those. - Well, with your APT program, could you describe the kind of person who would expect to benefit from that? - Sure, let me take a clinical case that we had. So this is a young 15-year-old male who was hit by a door at school, very brief loss of consciousness, had a lot of post-concussion kinds of issues. It was very well adjusted at school and friends, missed a lot of school due to headaches and complained about attention. He was a good math student prior. He was also in a magnet art school, a musician. And that was his main area of study. He played the guitar and he also really liked math. So he was six months out, still feeling frustrated by not being able to hold on to information, not being able to sustain his attention for his guitar practice. So we talked about, you know, who's very clear on what changes had occurred. We gave him the test of everyday attention. He showed some impairments that matched what he talked about. And so we did some of these APT exercises that worked on working memory and sustained attention to increase the dosage. We would load up a USB drive that comes with it for him to be able to do the exercises at home. We did a six-week course. He had a goal attainment scale, which was how long he could practice his guitar before he faded. And then also what is math quiz course or so. We made levels of progress that he felt these two things would improve if his attention got better. And so we did six weeks. He came in once a week. He did the exercises dutifully at home two times a week. And he had a strategy he paired with it, which was to use a word he came up with, which I'm actually not remembering out, but it basically was like telling himself to focus. But it was more in today's teenage vernacular. So I can't quite remember what it was. So he would practice doing that. He kept some attention ratings during his tasks. And at the end of his therapy, he met his goal. He didn't feel he needed more therapy. So I would say that's a successful case. But was it the attention exercises? What if you did the attention exercises, took the mountain just to the strategy training? What if you just had done setting goals of guitar practice? Those are the types of research questions I think we need to continue to ask. Yeah, and I think in one of your recent papers looking at attention training in pediatric cases, that was one of the issues you brought up was people did well, kids did well, but why? Was it some of the motivational, self-reflective type of metacognitive engagement that was going on? Or was it the stimulation? Right. And is it going to be the same with every participant? I mean, as you know, anyone who works in brain injury knows the heterogeneity is really a hallmarked characteristic. So sometimes, do I think it maybe was just the strategies? For other people like this young man, you have the sense that these exercises were very useful for him. So I think that's also hard with the research that you probably have people responding to different aspects of the intervention. And any time you have multiple components, it's hard to sort out. But I think we do know that sitting people in front of computers and doing drills is not advisable. There's little support to show if you just put them in front of drills that are not individualized or adaptive and changing in response to their own performance that are not tied to their own functioning outside the clinic that you don't see generalizable changes. You might see changes on very like similar tasks, but they don't generalize as to more complex tasks. You mentioned goal attainment scaling and talked a little bit about goals. I've said before on the podcast, for me that's the hardest part is goal setting. Yes. Once you have a good goal, everything else pretty much falls into place often. Why is that? Well, I mean, I don't think our, well, your, your thoughts have been very influential in certainly my own thinking about goal setting. One of the, I think one of the trends in our field and cognitive rehabilitation that has been wonderful and actually a neuro rehabilitation general is this push for patient-centered outcomes, absolutely in all of medicine. So as soon as we started saying, oh, we should be doing things that make, that the patient that matter to the patients, I mean, it kind of seems ludicrous that it took us this long. I'm very grateful to our psychology colleagues and researchers and those disciplines for, for giving us models. But the whole notion of working towards something that matters to you seems so obvious. But it took us, it's taken us a long time to get there. So trying to figure out what is it that matters to the patient and then trying to set up goals to help them get there. So, you know, the classic acute setting goal when you ask someone, you know, and acute care setting is I want to get out of here. Okay. So what do you think that would take? Well, they say I have to use my call button reliably or I have to be able to do this task. So linking whatever the task is to something they want, which is discharge or moving, you know, to a different level makes sense. And our patients are us, you know, all of us rather work towards something that's motivating and important. And I think the goal attainment scale process is ideal because it gives you levels. It's not just did they meet a goal or not meet a goal. And the kind of having a hierarchy of ways people can improve. And, you know, they've been shown to be valid and reliable if you fall of certain characteristics. And so it's really revolutionized my own practice certainly. Yeah, the thing that I really like about goal attainment scaling is that it helps to move my client away from unrealistic expectations in the sense. It provides room for overly optimistic hope, but creates a context in which you can have a conversation with the patient that also encourages them to think about what's most likely. And really, I think it's a structure for guiding people through a reflective process, which it's kind of pretty straightforward when you say it, but for much of my career, I didn't do anything like that. You know, I pretty much just prescribed or, you know, then I moved from prescribing to, you know, functional treatment. So then I asked people a little bit what they want, but oftentimes as soon as I asked them, they're in initial responses, you know, just be who I was before. Right, right. Yeah. I have a very similar journey. And I think what's from a practitioner standpoint, I would say is that it's much more satisfying to join with your patient or your client and be working towards something together collaboratively, rather than prescribing something. And also people engage more. And we know when you engage more, and you're more motivated, it's you're going to get better change, you're going to therapy will be optimized. From a research standpoint, it's also been ideal because particularly in the area of cognitive rehabilitation, where you might be giving everybody similar interventions that you're evaluating, but the way in which you're going to measure outcomes would be really different. So for example, we were talking about attention training. Well, for somebody that might mean, oh, I'm going to be able to read the whole newspaper for somebody else. The attention gets in the way mostly trying to do a work task. So it allows you to measure different change on different types of activity from the same types of intervention and be able to look at, you know, T scores and calculates statistically to look at see, you know, whether the change is significant and really measure the impact, you know, the impact and the efficacy of the particular approach. So I think there's benefits clinically and from a research standpoint. There's a group that was led by Christina, um, Cassini, Petini, who's in France. And that I was part of this international group. And we defined the characteristics for goal attainment scaling that would need to occur to be able to have use them in rigorous randomized controlled trials. And that was a very interesting process. And it's something kind of that we're really encouraging. Because that pay, for example, that paper you mentioned before looking at attention training in the pediatric population, we saw lots of kids improved on certain neuropsych tests. I mean, on different neuropsych tests. So it depended kind of what was difficult for them to begin with. So you can't just pick one measure as an indicator of whether they're better. But on the goal attainment scaling, we saw consistent improvements when the attention was tied towards things that they did in their lives. And from a practical perspective as an SLP, I mean, right now I don't have that much time to assess, you know, to give the complete test of everyday attention, you know, when I have probably other things to measure too. I mean, well, maybe I can slip it in over time. But as you kind of nicely point out, goal attainment scaling gives you a good measure. Absolutely. Do you notice? Because now I think you're involved in it with a project that's coming up. Can I mention it? Yes. The eGAPs. Yeah. So with my colleague, Don McClennan, who's at the Minnesota VA, we became really interested in the power of goal attainment scaling and then but also recognize some of the limitations for using it or the challenges I would say in cognitive rehabilitation, particularly when you try to set goals for patients and they've got difficulty with abstraction or awareness or setting goals that are linked to the cognitive areas that you're trying to address, that can be difficult for folks because it requires a certain degree of self-assessment and abstraction. Also, it's difficult to kind of be able to make this link between a cognitive process or set of processes and something functional. So we became interested and then I, and then the third thing that was difficult is that often these patients with self-awareness have difficulty with buy-in. They might not think they have a problem, for example. So all these kinds of challenges led us to come up with an idea for how to integrate motivational interviewing and those kinds of techniques into the creating the goal hierarchies with our patients. Essentially, coming up with a way to do collaborative interviews that would help us identify the meaningful goal, scale it according to the principles of goal attainment, scaling, talk about what would be the best approach, the therapeutic approach. And so this project was funded by the AFTIFoundation and resulted in a prototype of this eGAS electronic goal attainment scaling and it's an app. So we have it on Apple Test Flight, so people can download it and try it out and give us feedback. When you see SLPs or you're training them to do goal attainment scaling or they talk to you about doing it, what are some of the challenges that they commonly seem to have in terms of making the most out of it? I think the biggest challenge is that we sometimes think we're being patient centered. when we're not. It's really hard to not be overly directive. And so I think that's the biggest thing I see. So you helped us with the design of the some videos. So it takes a lot of training and demonstration. I think for people to say, oh, that's how you would ask a question. For example, a very simple technique that I didn't previously use that I learned a lot was kind of asking permission. You know, would it help if I told you about somebody else who has this issue and some things they tried rather than saying, here's a cognitive strategy that I think would be useful for you. What do you think, which is more directive. So you ask permission and they may say no, which in which case you know you're not going to get very far with that anyway. But I think the idea of having been truly collaborative and having some ways in which you can help people figure out what they want using some of these tried and true long standing interview types of and communication techniques is has been really helpful. And I think every practitioner, not just SLPs, OT, everybody is working with people should be should have a foundation in these skills. Yeah, it changed my practice considerably. But it does take some getting used to partly just because I think as you mentioned, you know, my tendency, and I think for a lot of people is to come in and rescue people to to to give them the answer and and to really not be that patient waiting for them to think of something or even now for me still, you know, I have to accept a certain amount of uncomfortable silence and space to allow people to sit with the ambiguity of maybe not knowing exactly what they want. Yes. Yeah, but I think you you have to have some kind of framework that you're working from so that you know where you are on the map in the sense that you aren't just following your intuition. Right. And I think, you know, different than maybe some disciplines where if you're working with someone, for example, on an addiction, you know, the psychology world where this motivational interviewing was born, there's kind of people who have kind of a shared understanding of their behavior and what it means. But when you're talking about a head injury and the resulting cognitive and psychological issues, they may not have a frame of reference. So asking open ended question about what do you want to do about this problem when they don't have maybe sufficient content to the answer changes it a little bit so that sometimes what's needed is some upfront education. And so that's when we might ask permission so that they can make choices. So I think that makes it a little different. And it's when we're when we don't give them a chance to make sure they understand it and then can make a choice when we're not patient as you mentioned that I think we deprived people of this opportunity really engage with the therapy and actually probably it goes in my experience goes faster when they're working towards something that they have a stake in and they've helped define. There's a perception I think that the goal of team scaling takes a long time like I don't have an hour for an interview. And I think once you're really well versed in the skills, it doesn't take as long. But like anything in the beginning, it takes a lot of practice. And that's what we were trying to do with this eGAS tool is give sample scripts and hints and break down the interview process in order to facilitate a more targeted and quicker way to collaborate I guess. And for some of our patients, maybe for many of them, they're kind of learning how to be patients too. Right. So we have to I think recognize that and allow that to happen rather than jump in circumvent that reflective process that you know is built into a lot of the cognitive rehabilitation programs anyways. Yes. And pretty. Well as long as we're on motivation, how important is motivation in cognitive rehabilitation? It's fundamental. And we were talking earlier about our journeys and some things that have changed. And I'm not sure in my early years that I fully appreciated it. And understanding the role of motivation now it's foundational. I I would hope that every training program for SLPs is incorporating these concepts across the different areas that we learn to treat. I mean in motivation is it's complex. So I think of you know part of motivation is engagement part of its effort. So if I'm very motivated, then I put out more effort. My frontal lobes light up and I'm working harder. If I'm working harder, then I'm going to see more changes, changes my practice, you know, my whatever it is that I'm learning motivation might improve myself efficacy. I might if I really want to do it, I might be willing to try something that that I wasn't sure I could do. There's all these prongs that motivation is a part of. You might be a little bit more resilient to your failures because of the degree of motivation that you have and focus on a goal. Absolutely. Everybody's worked in brain injury knows those patients who neurologically lack quote motivation. Those patients are really difficult to work with because they don't recruit all their resources to be able to move forward. So I think when it's hard to put forth full effort and engage and work towards something because those brain networks that facilitate that are damaged, those patients have difficult time making improvements. Conversely, when you put patients work for whom that's intact or maybe it's part of their kind of free morbid personality profile, they make stronger gains. You know, you kind of touched on something that I don't see a lot of discussion out there about and that is neurologically based demotivated states, apathy, abulia, and from my reading, it could be quite prevalent in conditions like traumatic brain injury, some of the neurodegenerative diseases, Parkinson's disease, for example, and as you suggest for those individuals, they're kind of motivational limits. Absolutely. Those are really good examples. Anyone who's practiced not even very long will have those patients. I think the the the challenge or maybe the excitement for us as practitioners is what can we do to optimize motivational states? Whether you're working with in any of those disorder areas that you're talking about, what are there things that we can do? And you know, one we've talked to at length about is this patient centered goal setting, you know, making sure that the things we're working on are meaningful on that certainly one. One is working within ranges where people are sufficiently successful and sufficiently challenged, figuring out what that ranges for people. One is, you know, how you what's your language working with folks that, you know, do we use terms like impairment or do we use terms like challenges, you know, just how you talk about people's disease states or their their performance can make a difference in how how positive they feel, how much, you know, your therapeutic alliance with folks makes a big difference in how sometimes, you know, people feel that they're you're partnering with them. They're going to feel more motivated to work with you. So, you know, there's all of these areas represent different fields and different research questions. But maybe my main point is that I think there's a lot that we can learn about and do to optimize motivation, engagement, buy-in resilience that will help our patients improve. Yeah, and I think from my experience, understanding some of the recurring themes and the principles involved with motivation, you can apply them, if you know the principles, you can apply them to different ranges of severity and ability, but just a principle of choice. Exactly. You know, some people can make more choice, some people need guidance, some people need a menu, et cetera, et cetera, but at the end of the day, it's still choice. Yes, well said. I have a few questions from Facebook. I told people on Facebook that I was going to be interviewing you and they were very excited, and I got some questions. So I'm going to look at some that I don't think that we've touched on yet. One is how to build insight in patients who were that's an issue. Yes, one of the most intriguing areas we work on in brain injury is our challenges in self-awareness and insight, and we've touched a little bit on that already. Many have been very influenced by the work of our Australian colleagues, many of whom are psychologists, and their work and the role of feedback. And I think that let me back up and say that probably the first question to ask is, what's the cause of lack of insight? Is it kind of an organically based, you know, anti-segnosure kind of profile? I don't have awareness about myself. Is it more psychologically mediated? I don't show any insight because I really have denial because I need to be spared from the frustration or the pain of admitting or understanding that I've got these limitations now that may be chronic. So I think part of our first task is to kind of parse out where it's coming from because that may dictate what we do. But for our clients who have difficulty kind of understanding their own performance, anticipating errors, I think across a few different arenas, it's been shown that verbal and video feedback is very powerful. So I like the study. We're doing a Meal Preparation Task and showed that the condition where they gave patients both video and verbal feedback resulted in the lead in the most significant decrease in errors during this meal preparation task and was associated with an improvement in intellectual awareness or kind of under. And so my call is inside. So I think and some of the work that's been done in social communication training where you have people look at videos of their conversational exchanges and identify what they want to change as had similar results. And maybe for some of the milder clients motivational interviewing that you've you've cited the paper by medley. A lot of people cite that paper. It's kind of a position statement in the sense on how motivational interviewing could be used in cognitive rehabilitation. I think that was those authors that was one of the things that they were focused on was that these set of counseling techniques give. So there's a way to guide some patients to kind of have the inside. Absolutely. Rather than us get into trying to convince people. Let me see what other questions I have here. I've got a trivia question, but I'll save that till the end. I was never very good at trivia. Well, it's trivial about your work. So let's hear. I think we've recovered that. Well, one person was saying something I'm going to paraphrase their question. It's about people with TBI going back to work where many of their kind of primary. The lack of a better can primary cognitive skills they've learned to manage them their attention issues memory issues, but the social skills are difficult to manage any. I know that's a big topic. Well, it's a it's a great question and really important topic because the as the person's pointing out that you can be able to perform on the job, but if you're irritating or you're not picking up social cues, you may not be able to maintain that employment. I think the most important thing that you know is is trying to understand where what the social communication limitation is. So this would be an example where contextualized training is absolutely critical. So if they're talking too much, let's say, and it's irritating to people rather than you know that can be hard to work on in a clinical setting and get that to transfer because there's all kinds of triggers that may have maybe they talk too much. And it's triggered by the work context because they want to feel like they're successful and they know something about the topic. So as much as possible to be able to understand the challenging behaviors and set the, you know, again, videotaping is extremely useful, having people rate themselves working on the insight. Often you can have two people working together rating the same video sample setting goals, having them look and enlist others in kind of the feedback process. So I guess the big idea would be really understanding the defining what the social communication behavior that's desired is and what the context are that might be preventing that from happening. And then providing a practice, once there's insight established and agreement, providing a practice context that allows generalization and self reflection. Certainly way back in the beginning, motivational interviewing might be what you're using like, you know, sounds like you're this job is important to use, you know, my right about that, you know, what's going well, what's not going well. What other people say is going, well, not, you know, kind of some of using some of the open ended questions, seeing if you can help them understand some of the liabilities of whatever their social communication issues are. And then moving towards being able to kind of get video samples and moving through that progression, I mentioned with understanding the context, providing practice and self reflection. Do you think that as far as motivational interviewing goes, that getting the formal training is necessary. I'm kind of on the fence about it, I have gotten training in the people who do motivational training are very big on the fact that you need to get lots of training. On the other hand, you know, part of me says, well, you know, there are these principles and it and motivational interviewing doesn't have a lock on these principles anyways. What do you think? Well, as a, you know, as our friend Don McClennan says, Socrates was using these principles before. So whether you go to a formal workshop by people who have the certification for MI, or whether you're mentored by somebody who's particularly skilled in it. I think like anything and the same principles hold true when we're getting our patients to practicing, it's practicing, getting feedback, setting goals, watching yourself on videotape. And some of the most powerful kind of self reflections as a clinician were watching myself when I thought I was being patient centered and using motivational interviewing kinds of techniques and how far I was from that. And how deliberate I still have to be I'm kind of a problem solver and I take two. many turns. It's hard for me to leave enough silence. And so I think it's, it's not much different than our clients. You have to have motivation to be able to, you know, seek the information, practice, watch yourself, get feedback. Does that have to occur to workshop? I don't think so, necessarily. Does it easier to do it that way? Probably. Recording yourself and watching yourself, I try to do that as often as I can, is cringe worthy as it is. You know, and like you said, it is kind of amazing, but even though some of these things we've mentioned sound so simple, we have such, I think most of us have such strong kind of instincts or impulses that I have to be quite vigilant, or else, you know, I fall back into certain behaviors. Well, let's finish with our trivia question. So the question is here, and maybe you'll understand the question, maybe you won't. It's regarding the first APT program. And the person asks, what is he reading from in the original APT program? Sports page from the Seattle Times question mark. I've spent hours in therapy sessions trying to get some sense of it. Do you remember? The context for that, in all honesty, we never set out to make a program that was commercially available. It was a research project, and we had these attention exercises, which were audio recorded in my apartment bathroom in the bathtub, because it had better acoustics. And my husband was between medical school and residences, so we paid a minimum wage to make those exercises. And then we ran the experiment and showed that people got better, at least on these neuropsych tests. And then we got all these requests for the program. So that's kind of, and so we sort of slapped a few together and then eventually gave it to a publisher. So that's the real genesis. As for the sports page, it was a sports page, and we lived in Seattle at the time, so that would be a really good guess. But I can't, for sure, say which newspaper, or which there was, but I'm impressed that somebody, that's very impressive. Yeah, well, someone could go a step further and they could transcribe it and perhaps do a search. You never know. There you go. Well, McKay Soulberg, thanks a lot for spending an hour or so talking with me. What's going on right now for you and what's in the future? Well, we're waiting to hear on this NIH grant. We've got really high reviews, so we're hoping to be able to take this electronic goal attainment scaling project to move it forward and look more at feasibility, widen it for use in not just cognitive rehabilitation, but for other areas, disaster and motor speech of Asia. And look at feasibility of implementation in the rehab setting. So that's something we're excited about. I'm working a lot with persistent concussion effects, and we've just submitted a grant for kind of a virtual concussion clinic. I'm interested in those five to 20% of individuals who have significant issues that chronic cognitive and somatic issues. So that's some work that we've been doing and setting up protocols to treat, which is a very interesting kind of full circle since we started talking about history and getting into the field in the beginning. Maybe I can end with that. Now we talk about persistent post concussion effects, but decades ago, we talked about the treatment of mild traumatic brain injury, MTBI, and it's the same individuals that just weren't really recognized or it wasn't legitimized. And now with returning injured combat vets and with football and sports injuries, there's a resurgence and interest and more of a validity behind this population. So it's been interesting to look at it in new and different ways. So those are two biggies that I'm working on right now. That's enough. With the eGAS app, you get funded in the general sense of when it might be available. Well, it's available anybody that would want to try it. You can just download it from Apple test flight. They could email me at [email protected]. If somebody wanted to take a look at the app, they will see you doing some teaching on it. There's a prescriptive manual, it's kind of a smart manual and there's examples and it's free and we love getting feedback because everybody gives us feedback then we are kind of doing this iterative development and I should acknowledge the programmer, the software engineer Jason Prado who's done a really good job and my doctoral student Priya Kachiria and Don McLean and I kind of been the team working on it. So we're hoping to make goal attainment scaling very accessible for SLPs and invalid and reliable as a way to measure meaningful outcomes. Yeah, it's a great app. I definitely encourage people to check it out. I think it's a good way to get started with goal attainment scaling if you're not familiar with it. All right, well thanks again. Let's pleasure. Thank you, Mike. Thank you for listening to this episode of the ANCDS podcast. Please visit the Academy of Neurologic Communication Disorders and Sciences at ANCDS.ORG. You can find our other podcasts there. You can also subscribe to our podcast that iTunes and find them on SoundCloud. [Music]