Dci 2011

NOAMI HADAS-LIDOR, PhD, OT, PENINA WEISS, MSc, OT, and ALEX KOZULIN, PhD
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Dynamic Cognitive Intervention: Application in Occupational Therapy
n the rst part of this chapter, we present the theoretical basis of the Dynamic Cognitive Intervention (DCI) approach to cognitive modiability in the evaluation and treatment of cognition. Vygotskys (1997) concept of higher mental processes and Feuerstein s (1979, 1980) theory of structured cognitive modiability (SCM), mediated learning experience (MLE), and applied systems deriving from the theory, are the basis for the development of Hadas-Lidors DCI approach for health care professionals, with a specic focus on the role of occupational therapists. The principles and guidelines developed by Hadas-Lidor are presented in the second part of this chapter. These include clinical applications of the principles, the effect they have on the therapist, and their resulting impact on the therapeutic interaction. The third part of this chapter is dedicated to clinical and research implications for the future.
LEARNING OBJECTIVES
Understand the concepts of Feuersteins dynamic cognitive model of structural modiability; Understand the principles of Dynamic Cognitive Intervention developed by Hadas-Lidor that are an extension of Feuersteins model; Describe the Dynamic Cognitive Intervention model, target populations, intervention methods, instruments and environments; and Identify clients who potentially can benet from exposure to this approach and intervention technique.
THEORETICAL BASIS
The concept of cognition as a dynamic entity shaped by human mediation was introduced by Vygotsky in the 1920s and 1930s. His contribution was that he presented human cognition as a sociocultural phenomenon rather than a natural property of an individual. Vygotsky (1997) distinguished between lower cognitive processes, whose development is governed by the forces of maturation and direct experience, and higher cognitive functions, whose development depends on mediation provided by the society through cultural and linguistic artifacts (speech, writing, pictures, etc.) and sociocultural
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324 Cognition, Occupation, and Participation Across the Life Span
activities. The emphasis on the constructive role of both cultural artifacts and sociocultural activities (see Kozulin, 1998) seems to be particularly relevant to occupational therapy. From a Vygotskian perspective, occupational activities not only use the already-existing cognitive functions but also actively develop and shape them. This is relevant to both regular occupational life and the occupational therapeutic process. Vygotsky was also one of the rst to suggest that static assessment tests do not provide an adequate picture of the dynamics of cognitive development. He proposed that we distinguish between the childs zone of actual development, which reects functions that are fully mastered by the child, and the zone of proximal development, which reects functions that the child can master only through mediation provided by an adult or a more competent peer. Working in the same theoretical direction, Feuerstein (1980) formulated the concept of SCM, which presents the human being as an open system that can be modied regardless of age and disability status. Feuersteins approach proposes that distal factors of human development, such as genetic, organic, familial, social, and educational, are moderated by a proximal factor of the MLE. MLE is viewed as being responsible for the development of the cognitive prerequisites of human learning and problem solving. Feuersteins theory rst proposes to examine why these prerequisites fail to develop during early childhood in the absence of human mediation; second, how the cognitive functions and operations develop through learning mediated by a caring adult; and third, how identied cognitive decits can be remediated, much later than generally thought possible, by a formal cognitive intervention program. This program, called Instrumental Enrichment (IE), uses a series of pencil-and-paper tasks, covering areas such as analytic perception, comparison, classication, orientation in space and time, and so on. The program is applied to students or clients by teachers and/ or therapists trained in the MLE technique. Hadas-Lidors contributions to the eld of dynamic cognition is that her approach is therapeutically based, including both the concept of recovery as it has evolved in the eld of mental health and a rehabilitative approach, which places direct emphasis on emotion-related issues and how they affect cognitive development.
many diverse populations with special needs, facing activity limitations and participation restrictions, have been exposed to the intervention techniques developed by Feuerstein. These populations include new immigrants; students with learning disabilities; children with hearing and vision impairments; children with genetic syndromes, brain injuries, autism, and other disorders; and elderly individuals with mental retardation (Kozulin, 1997; Kozulin & Rand, 2000; Lidz & Elliott, 2000). In addition, highfunctioning populations in industrial settings, especially in France (Avanzini, 1990), beneted from exposure to the principles of MLE and IE, as did populations that are considered to have above-average intelligence, such as Israeli air force pilots. The fact that Feuersteins techniques have been used on these very diverse populations incorporates one of the unique aspects of Feuersteins theory: the belief that cognitive modiability can be induced and developed in people of all ages and with all types of disabilities and functional limitations. Furthermore, everyone can benet from structured cognitive dynamic intervention, leading to better management strategies in real life situations, especially those involving high levels of stress and quick decision making.
POPULATIONS EXPOSED TO DYNAMIC COGNITIVE INTERVENTION

The following list is a partial description of different populations that have been exposed to DCI. Figure 15.1 includes references to these populations and illustrates the diverse applications of the approach: high-functioning populations, including gifted children; affected family members (usually parents) of persons with limited occupation participation; caregivers; professionals and multidisciplinary staff members; the general public, through online Internet exposure; populations with participation restrictions and activity limitations, such as adult underachievers, geriatric populations, mental health populations, and persons with head injuries; and adults and adolescents with learning disabilities. As can be seen in Figure 15.1, the DCI intervention approach has been made applicable to a diverse range of populations. Despite the differences in the makeup of the populations described in the gure, they all share some common attributes: They all suffer from delayed or inhibited participation in life tasks and actions that deter them from achieving wholesome self-actualization of their desires and abilities. For example, parents of children with mental disabilities often pay a social price due to their total absorption with their childs life and needs and often
POPULATIONS EXPOSED TO STRUCTURAL COGNITIVE MODIFIABILITY

This method of intervention started in the 1950s, with the evaluation and treatment of adolescents suffering from cultural deprivation (Feuerstein, 1979). Since then,
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Figure 15.1 DYNAMIC COGNITIVE INTERVENTION (DCI) IN OCCUPATIONAL THERAPY
P O P U L A T I O N
DCI in Occupational Therapy Population setting goals
Parents of Children With Special Needs & Caregivers
Geriatrics
Mental Health
Adult Underachievers
Head Injuries
Adults & Adolescents With Learning Disabilities
S E T T I N G
Individual / Group
G O A L S
*Improve learning capacity *Enhance performance in areas of occupation *Facilitate participation in improving learning capacity & exibility
Develop & improve communication
OVERALL GOALS
Improve functioning & adjustment promoting engagement in occupation to support participation in context or contexts, to clients satisfaction
From Dynamic Cognitive Intervention: Application in Occupational Therapy (p. 392), by N. Hadas-Lidor and P. Weiss, in N. Katz (Ed.), Cognition and Occupation Across the Life Span: Models for Intervention in Occupational Therapy, 2004, Bethesda, MD: American Occupational Therapy Association. Copyright 2004 by the American Occupational Therapy Association. Reprinted with permission.
experience guilt, embarrassment, and fear. They limit themselves to social contact with people who are dealing with similar life situations. In spite of the differences among them, members of these populations share a need for, and willingness to, receive help. For example, an older adult dealing with many agerelated health problems can decide to voluntarily seek cognitive intervention because he or she is experiencing age-related memory impairments, to improve his or her quality of life. Researchers and educators in the eld of cognitive psychology and cognitive education in many countries, such as England, Brazil, Chile, the United States, and Israel, are working on the development and implementation of applied programs based on SCM theory (Kozulin & Rand, 2000).
THE PHILOSOPHY: THE CONCEPT OF COGNITIVE MODIFIABILITY

The individual is regarded as an open system, because modiability is considered to be the basic condition of human beings. The individuals manifest level of performance at any given point in his or her development cannot be regarded as xed or immutable, much less a reliable indication of future performance. This viewpoint has been expressed through the rejection of IQ scores as a reection of a stable or permanent level of functioning. Instead, and in accordance with the open- system approach, intelligence is considered a dynamic, self-regulating process that is responsive to external environmental intervention. The view of the human being
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as an open system is used in various occupational therapy theoretical approaches, most obviously in the model of human occupation (Kielhofner, 1995). Current trends in research on brain plasticity, together with the exponential growth in new technology, show the brain to be a far more plastic organ than previously thought (Doidge, 2007; Kleim & Jones, 2008). After injury, the brain is capable of considerable reorganization that forms the basis for functional recovery (Sohlberg & Mateer, 2001). The fact that specic alterations in behavior are reected in characteristic functional changes in the brain is currently accepted by biologists (Kandel, 1998, 2006). Thus, the ideas related to cognitive modiability expressed by Feuerstein (1979, 1980), pertaining to structural cognitive changes, are being found to be not just theoretical but also are becoming scientically validated.
THE THEORY OF MEDIATED LEARNING EXPERIENCE

The theory of MLE is the underlying basis for the concept of cognitive modiability. The theorys basic assumption is that the major factor causing cognitive differences among people is the MLE. A decit in or lack of MLE is a stronger explanation than any etiologic differences. Feuerstein and Feurstein (1991) conceived the development of cognitive structures in the organism as a product of two interactions between the organism and its environment: (a) direct exposure to sources of stimuli and (b) mediated learning. The rst and most universal modality is the organisms direct exposure to all sources of stimulation that it receives from the very earliest stage of development. This exposure changes the organism by affecting its behavioral repertoire and its cognitive orientation. These changes, in turn, affect its interaction with the environment, even when the environment itself remains constant and stable. Direct exposure to stimuli continues to affect the organisms learning throughout its life span, to the extent that the stimuli present are varied and novel. The second modality, which is far less universal and is characteristic of human beings, is MLE, a quality of interaction that explains the universal phenomenon of SCM and is considered the proximal factor that determines the exibility and plasticity of the human mind that then leads to SCM (Feuerstein, Feuerstein, & Schur, 1997). It is conceived as a contextual environmental facilitator, determining the way in which stimuli emitted by the environment are transformed by a mediating agent (e.g., a parent, teacher, or therapist). This mediating agent, guided by his or her intentions, culture, and emotional investment, selects and organizes the world of the stimuli for the client (e.g., student). The mediator selects stimuli that are most appropriate and then frames, lters, and schedules them. He or
she determines when certain stimuli appear or disappear and ignores others. Through this process of mediation the cognitive structures of the client are affected. The client acquires behavior patterns and learning sets, which in turn become important ingredients of his or her capacity to become modied through direct exposure to stimuli. Because direct exposure to stimuli over time constitutes the greatest source of the individuals experience, the individuals cognitive development is inuenced signicantly by whether he or she has sets of strategies and repertoires that permit him or her to efciently use this exposure. The relationship between MLE and direct exposure to stimulithe two modalities for the development of cognitive structurescan be set forth as follows: The more often and the earlier an individual is subjected to MLE, the greater will be his or her capacity to efciently use and be affected by direct exposure to sources of stimuli. On the other hand, the less MLE the developing individual is offered, in terms of both quantity and quality, the lower his or her capacity will be to be affected and modied by direct exposure to stimuli. Feuerstein and Feuerstein (1991) outlined 12 parameters that describe the quality of the MLE. The three crucial parameters of the MLE are (a) intentionality and reciprocity, (b) transcendence, and (c) mediation of meaning: 1. Intentionality and reciprocity. MLE requires a degree of intentionality on the part of the mediator. The voluntary nature of the mediated interaction is evident in certain well-dened instances. The purpose is to increase the intentionality of the recipient and raise his or her awareness of the ways he or she acts. 2. Transcendence. An interaction that provides mediated learning must be also directed toward transcending the immediate needs or concerns of the client by venturing beyond the here and now, in space and time. The premise of the approach is that working on transcendence is an integral part of the process of intervention. Transcendence, in terms of the ability to make generalizations, is done according to MLE during the process of intervention. 3. Mediation of meaning. In contrast to the rst two parameters, mediation of meaning deals mainly with the energetic dimensions of the interaction (i.e., with why things happen or are done). It raises the individuals awareness and understanding and makes explicit the implicit reasons and motivations for doing things. Mediation of meaning focuses on the interaction of the individual with the environment and aims to increase his or her ability to make choices. The parameter of meaning is closely related to the concept of recovery that today leads the approach to the person with a mental health disability and disabilities at large (Friedli, 2010). The concept of recovery was developed by mental health consumers and adapted for use by mental health service providers, because it emphasizes the importance of personal
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meaning in an individuals life as an inducer of motivation and activity (Deegan, 2001; Friedli, 2010; Hadas-Lidor, Shar Keisar, & Lacman, 2007). The concept of recovery is achieving recognition as a social entity in which each and every person is entitled to a feeling of purposeful meaning in his or her life (Frankl, 1984; Friedli, 2010). The remaining nine parameters, unlike the rst three, are not universal but contextual (Feuerstein & Feuerstein, 1991). The quality of mediation may sometimes be achieved without them. In certain contexts, however, these parameters become crucial. One such additional parameter, mediation of competence, was adopted by Hadas-Lidor (1996) as being crucial to the success of the MLE, because research in the eld of recovery has shown that a feeling of competence is a dominant feature of the recovery process. The therapist plays a crucial role in establishing this feeling in the client (Lachman & Roe, 2003). 4. Mediation of competence. This parameter deals with the way the mediator helps the individual feel a sense of competence and ability, in relation to him- or herself and to the task he or she undertakes. To achieve a sense of compatibility and nurture friendship and a sense of community and belonging, an additional parameter of Feuersteins was dened by Hadas-Lidor, Redlich, and Weiss (2011) as being central to the mediation process: 5. Sharing. Sharing behavior implies the need of the individual to go out of him- or herself in the direction of the other; to share his or her feelings, thoughts, and experiences with another person. Loneliness and social exclusion are characteristic of many populations with disabilities. Sharing, a way to overcome this setback, has two aspects: (a) sharing your world, your difculties, your successes, and so on, with someone else, and (b) doing and experiencing things together, such as brainstorming, decision making, playing, traveling, and so on. Two additional parametersmediation for behavior modication and coexistence of competence and dysfunctionhave been identied by Hadas-Lidor et al. (2007) as being crucial in specic populations. One is a parameter identied earlier by Feuerstein, and one is adopted from the core concepts of recovery. 6. Mediation for behavior modication. This ability is often lacking in populations with learning disabilities and attention decit disorders: persons who act before they think, give up easily during reading or writing tasks that are experienced as being difcult, tend to have outbursts and ts of anger, and are, at times, indifferent to their surroundings. These clients need constant reinforcements
and encouragement. In adults, typical behaviors include leaving a secure job without giving thought to the difculty of nding a replacement job during a recession; a lack of understanding that at times, in order to progress, you have to stop and accept a temporary setback; lack of social skills, including argumentative behavior; and difculty leaving social settings at appropriate times. This parameter is central for social integration. Mediation for behavior modication involves the matching of a persons internal sense of action and reactions to the external world. The mediation is focused on promoting self-control and awareness in order to achieve internal discipline. An additional parameter, identied initially as one of the core recovery concepts, was adopted by Hadas-Lidor as being a crucial parameter for inclusion in MLE-based interactions from a therapeutic standpoint. 7. Coexistence of competence and dysfunction. In the journey of recovery of people with mental health disabilities, the coexistence of competence and dysfunction is an essential component that must be addressed over and over again, in order to achieve equilibrium between the two focal points, as addressed in the following typical samples of interactions between DCI rehabilitation specialists and consumers: At this particular moment you may feel helpless . . . but the sun will come out tomorrow, or consider the following scenario: A client comes to a meeting with an occupational therapist, who specializes in DCI, complaining about his difculties in communication and social skills and his lack of partners for conversation. The specialist responds by acknowledging and mirroring the clients sense of a lack of competence yet also relates to his abilities and strengths, thus trying to place the qualities of competence and dysfunction on a similar plane. Specialist: I really understand how difcult it is for you to engage in a conversation, and I feel for you. Pay attention to the fact that right now you are handling a conversation with me, just ne! Did you notice that? The following is another example: Specialist: So, how are you? Client: Im doing very poorly; nothings changed. Specialist: How was your week? Client: I didnt sleep all week. I made 10 jars of jam. Specialist: Well, notice that although you havent slept all week, and that must be very frustrating and exhausting, you still managed to prepare 10 jars of jam!
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Other ways to mediate the equilibrium between competence and dysfunction include using cognitive and literacy skills to learn about the mental disability itself, through reading books, surng the Web, and so on; encouraging the client to give a lecture about him- or herself, or about his or her ability to cope with illness; asking the client to keep a diary about living with a mental illness, and so on. Another approach to promote the balance between disability and competence is by working in peer support services. These services are an initiative in which trained supporters and consumers/clients of mental health programs group together to form nonprot self-help organizations and help support each other to challenge associated stigma and discrimination. The belief is that the parameter of mediation between competence and dysfunction can be applied to all populations with disabilities (Friedli, 2010). The intentionality of the mediator and the transcendent (i.e., generalization) nature of mediative interaction is directed toward building new cognitive structures and broadening the individuals system of needs for functioning. Thus, MLE can take place in any interaction between human beings that is goal oriented, depending on the parameters of the specic interaction, whether between parent and child, employer and employee, shopkeeper and client, teacher and student, therapist and client, and so on. In Feuerstein and Feuersteins (1991) MLE model, a human being is the agent who mediates between stimuli and organism. The DCI pyramidal multidimensional model (see Figure 15.2), developed by Hadas-Lidor and Weiss (2005), expands the model developed by Feuerstein and Feuerstein by specically including detailed factors that are pertinent to MLE from a health perspective, according to current International Classication of Functioning, Disability and Health terminology (World Health Organization, 2001), and to the recovery concept, and that have also been adopted by occupational therapists (American Occupational Therapy Association, 2008). The expert mediatorfor the purposes of this chapter, an occupational therapistplays a crucial role in bonding, and in synchronizing, when mediating among the client, environment, activity, and participation. Occupational therapists are constantly redening their interactional approach with the clients they treat (HahnMarkowitz & Roitman, 2000), as can be seen in the clientcentered approach that guides evaluation and intervention, in, for example, the development of measurement tools such as the Canadian Occupational Performance Measure (Law et al., 1998; McColl et al., 2006), which emphasizes the mutual responsibility of the therapist and client toward the intervention goals and procedures (Law, Baum, & Baptiste, 2002). Thus, the role of the mediator is in some ways similar conceptually to the role of the occupational therapist as a facilitator.
Figure 15.2 THE DYNAMIC COGNITIVE INTERVENTION PYRAMID MULTIDIMENSIONAL MODEL
Human
The Mediator
Enviromental Factors
Activities & Participation
From Dynamic Cognitive Intervention: Application in Occupational Therapy (p. 395), by N. Hadas-Lidor and P. Weiss, in N. Katz (Ed.), Cognition and Occupation Across the Life Span: Models for Intervention in Occupational Therapy, 2004, Bethesda, MD: American Occupational Therapy Association. Copyright 2004 by the American Occupational Therapy Association. Adapted with permission.
An individual may lack MLE because of the following two main reasons: (a) the nature of his or her environment (i.e., poverty, cultural deprivation, and disturbed families) and (b) his or her condition at a given point in development (i.e., learning disabilities, brain injuries, emotional disturbances, and mental retardation). According to Feuerstein and Feuerstein (1991), a lack of MLE has greater implications on functional outcomes than any other factor or diagnosis. The goal of any intervention based on MLE is always to restore a normal pattern of development. The purpose of MLE, as reected in the IE program and in DCI, is never to train the individual merely to master a set of specic skills that will enable him or her to function only in a limited way but to change the cognitive structures of the poor performer and to transform him or her into an autonomous, independent thinker, capable of initiating and elaborating actions. Thus, the focus is not on a functional approach but more on a cognitiveremediation approach (Doidge, 2007). During the intervention process, the therapist works directly on helping the individual mediate structural generalizations. In short, according to the theory of MLE, the goal set for cognitively poor performers is adaptation to a normal environment, as opposed to adapting the environment to meet the specic needs of these performers.
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APPLICATIONS OF THE MEDIATED LEARNING EXPERIENCE IN THE DYNAMIC COGNITIVE INTERVENTION APPROACH
The applications described in this chapter refer to various aspects of the inuence and change brought about by exposure to MLE: On the individual or a group being treated, On peers, On caregivers (usually represented by parents), Online Internet-based applications of MLE, On multidisciplinary staff members, and Within educational academic settings.
INFLUENCE OF THE MEDIATED LEARNING EXPERIENCE ON THE INDIVIDUAL CLIENT OR TREATMENT GROUP
In her pioneering single case study, Sharma (2002) described a 2-year MLE-based intervention with a child who underwent a left hemispherectomy. The child, born with SturgeWeber syndrome, excited a great deal of attention in scientic circles when, following a complete left hemispherectomy at the age of 8 years, he began to speak for the rst time at the age of 9, thus overturning the theory that the critical period for speech and language development is limited to age 6. Although he showed remarkable development in the area of language, his cognitive function remained restricted, in that he failed to learn to read and write and to develop number skills and concepts. The prognosis made by the British researchers regarding his learning skills was not optimistic. Sharmas study documented an MLE-based process of developing this childs cognitive skills and successfully teaching him reading, writing, and math. Lebeer and Rijke (2003) compared the severity of impairment, quality of MLE provided by parents, and cognitive outcomes, in 20 children with brain impairment. The study conrmed that the quality of mediation has a signicant impact on the cognitive outcomes and that, in contrast, the initial severity of impairment is not highly predictive of the later performance. Moreno (1996) described the treatment process of a 20-year-old man, who had suffered from the effects of a brain injury for 3 years. The treatment followed all 12 MLE components and adapted the principles to the special needs of the client and his physical difculties. As a result of this intervention, the client became increasingly cooperative, less impulsive and more independent and, together with his family, viewed the future with optimism.
Alice, a 76-year-old woman, was referred to an occupational therapist DCI specialist in an outpatient memory clinic because of concentration and memory difculties. Alice is a Holocaust survivor. She was 10 years old at the time of the Holocaust. After the war, she immigrated to Israel, together with her brother. She was married briey and has one son, who lives with his wife and daughter in close proximity to her. She worked for many years as a radiation technician. Her medical background includes coping with bipolar disorder. She resides on her own. She is an independent, highly intelligent woman who spends a lot of time reading. She participates in activities for older adults at local community centers. In an in-depth functional interview, it became apparent that she was dealing with spatial orientation difculties. As she described, My apartment building is a few houses away from my sons. Every time I walk over, I dont remember exactly which house is his. She also shared the following anecdote: Over the weekend I visited the museum with my son and his family. After our visit, we returned to the parking lot, and my son led us straight to his car. When I asked him how he had managed to nd it in the very large parking lot, he told me that it was easy, since his car was the cleanest one on the lot. Im not sure if he answered me honestly or was making fun of me. During the initial interview, it became clear that Alice had a tendency to overfocus and pay attention to every small detail, sometimes overlooking the total picture. In addition, she found dual-tasking to be difcult. This caused a spatial functional difculty with participation, because she lacked the ability to shift between relevant and nonrelevant information while going from one place to the next. She was eager to learn and to overcome her difculties. Faith in the persons ability to change, learn, and develop at every age, and in every medical condition, lies at the heart of every therapeutic intervention. The DCI therapist used a number of Feuersteins intervention instruments (orientation in space, analytic perception), including the Positional Learning Test, which is designed to evaluate the efciency of a positional learning experience and assess the subjects capacity to discover and use principles of organization (Feuerstein, Feuerstein, Falik, & Rand, 2002). This test, adapted from the Rey Auditory Verbal Learning Test (Rey, 1941), includes a spatial orientation component as well as a relational one. The intervention included awareness training with an emphasis on cognitive communication using MLE principles to promote feelings of competency, and used intervention tools meaningful to the client.
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The therapeutic interaction also contributed to a positive outcome and facilitated a signicant improvement in Alices quality of life. The mediation process used in the intervention was bidirectional. First was mediation of internal and external strategies from therapist to client, using intentionality, reciprocity, meaning, competency, and transcendence to teach qualities and skills of orientation in space. Second, the therapist used mediation techniques to teach Alice to mediate her behavior on her own: I no longer have to stop and ask people for the way. I look for meaningful cues along the way, I count rows in the parking lot, and pay attention to directions more carefully . . . I am much more aware of the type of details I have to look for along my route. Alice was able to change her point of view from the egocentric viewpoint to which she was accustomed to a point of view that enabled her to dene and choose goals for herself and lter stimuli more efciently in accordance with her chosen goal. After her successful intervention, Alice shared her recorded and videotaped personal testimony in a historical narrative of her Holocaust experience at the Yad Vashem, the world center for commemoration of the Holocaust. In it, she described how she survived by using her instincts and her ability to focus on small details to navigate the streets of a very large European city. She was able to lead her brother through a hole in the wall of a church in which Jewish children were gathered, awaiting certain death, to the safety of the home of one of her fathers employees. Apparently, her ability to focus on seemingly irrelevant details was a critical skill that saved her life as a child. Alice had never been aware of the unique manner in which she experienced the world. Through the intervention she received and the meditative techniques she learned, she came to understand her special ability, after which she was able to part with it safely. Dynamic assessment was originally designed to evaluate the cognitive modiability and learning potential of children and young adults. Currently, more attention has been directed to the cognitive functioning of older people, and researchers have found that cognitive gains are possible for them as well as for people coping with cognitive decline (Navarro & Calero, 2009). In a multicenter international study, Kozulin et al. (2010) investigated the effectiveness of an MLE-based cognitive intervention program on young children with cognitive decits associated with genetic or neurological impairments (developmental coordination disorder, cerebral palsy, and genetic syndromes). The children who took part in the experimental groups received up to 90 hours of MLE-based intervention during the 30- to 45-week period of the study, whereas the children in the control groups received typical
occupational therapy, sensorymotor training, cognitive enrichment, or curricular interventions, over the same period of time. Analysis of the pre- to posttest gain scores demonstrated a signicant advantage of the experimental groups on three subtests of the Wechsler Intelligence Scale for ChildrenRevised (Wechsler, 1974) and in the Raven Colored Matrices (Raven, 1965). Greater cognitive gains were demonstrated by children who received the MLE-based program in a setting in which all the teachers and therapists were committed to the principles of mediated learning. Nir-Gal and Klein (2004) designed a study that examined the effect of different kinds of adult mediation on the cognitive performance of young children who used computers. The study sample included 150 kindergarten children ages 5 through 6. The ndings indicated that children who engaged in adult-mediated computer activity improved the level of their cognitive performance on measures of abstract thinking, planning ability, vocabulary, and visualmotor coordination, as well as on measures of response style, including reectivity. Their performance on these measures was better than that of children engaged in computer activities without adult mediation or with very little mediation (accompaniment). On the basis of these ndings, one may conclude that integrating teacher and/or parent mediation within computer learning environments for young children facilitates informed use of computer technologies in their learning system and enhances thinking processes and work habits. Hadas-Lidor, Katz, Tyano, and Weizman (2001) conducted a study based on DCI principles that differed from the studies described earlier in that it incorporated therapeutic and rehabilitative aspects. They investigated the effectiveness of cognitive dynamic treatment through the use of IE with adults with mental illness. The participants included 60 clients who had been diagnosed with schizophrenia and required treatment at a rehabilitation day center. The clients were randomly assigned into two groups; one was given IE as the treatment, and the other was treated according to traditional methods. The length and scheduling of the treatment were equal for both groups. The study had a prepost quasi-experimental design and lasted for 6 months. The following variables were measured before and after treatment: cognitive performance, self-concept, and daily functioning. The results after treatment showed signicant differences between the study group and the control group in the areas of cognitive performance and daily functioning, within both the home and work environments. No signicant differences were found regarding self-concept. The ndings of this study, which was the rst to examine the treatment effectiveness of IE on adults with schizophrenia, has important implications. It suggests not only that the IE program is effective but also that clients with schizophrenia can improve their cognitive skills and everyday functioning.
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INFLUENCE OF THE MEDIATED LEARNING EXPERIENCE ON PEERS

Kaufman and Burden (2004) conducted a study aimed at using the sociocultural perspective to elucidate the process and outcome of peer-learning interactions between young adults with those with serious learning disabilities. A heterogeneous group of 10 young adults between the ages of 18 and 27 participated in a year-long cognitive program based on the principles of MLE and IE (Feuerstein, 1980). Six of the participants had Down syndrome, and the others had a variety of disabilities, including brain damage and cerebral palsy. The program included 178 hours of IE cognitive intervention. The peer mediation process was supplemented by an additional component of collaborative group discussion, which was included at the end of every session. The authors used a postpositivist research design, similar to the design experiment of Russian Vygotskians, to evaluate both the process and the outcomes of the intervention program. The results indicated that, after the 1-year intervention, the participants perceptions of their ability to learn were above average. Moreover, their reections about how they had changed as a result of their involvement in the program, and their descriptions of what was required to provide effective mediation, demonstrated high levels of cognitive, emotional, and social development. A group intervention based on DCI, administered in a community mental health center, is described in Takdim, a recently developed manual for professional DCI specialists (Hadas-Lidor et al., 2008). Each of the sessions during this 6-month intervention program included the following: a brief discussion about the highlights of the previous weeks meeting; an explanation of the current meetings goals; an opportunity to select a therapeutic intervention tool or exercise for that weekly meeting; the execution of the exercise; and a discussion about the session, which related the content of the meeting to the theme of the meeting as well as to a homework assignment. Working in a group promotes social interaction, specically in the areas of verbal and cognitive communication and sharing. Within the groups, emphasis is placed on the ability of members to share personal dilemmas with others, if the need arises, as well as self-appraisal of ability, and relating to the others (changing ones viewpoint).
INFLUENCE OF THE MEDIATED LEARNING ENVIRONMENT ON CAREGIVERS

To highlight the inuence of MLE on caregivers, we provide an example of parental counseling by a DCI occupational therapist expert. A 4-year-old girl with cerebral palsy
was being treated at the Infant and Toddler Center for Severe Motor Disabilities in Pardes Hanna-Karkur, Israel. The parents requested the therapists help in coping with their daughters behavioral difculties, which they had interpreted as stubbornness, inexibility, and an inability to deal effectively with changes. For example, if one of the parents had to put the car in reverse while driving with the girl, she would start crying uncontrollably. Furthermore, if her diaper-changing routine was disrupted, such as when her mother left the room to get a new package of wipes, she would throw a tantrum. The expert decided to intervene through parental guidance. She identied two major problems. The rst related to the childs decient episodic memory, which resulted in stressful situations for the parents, and the second related to the childs difculty interpreting and understanding situations that differed in context or content from the normal routine. The therapist asked the parents to describe all the steps involved prior to and during the performance of activities with their daughter. She then advised them to vary the order of the routines; for example, when dressing her, they should sometimes put on her pants before her shirt, and at other times put the shirt on before her pants. She further recommended that the routines always be accompanied by a verbal description of the process. The therapist also encouraged the parents to vary the environmental settings of everyday activities, such as dining on the balcony instead of in the kitchen. Moreover, because the child had a developed sense of humor, the therapist recommended that the parents spend time showing the girl absurd pictures, based on those in Feuersteins IE program, including pictures of a baby driving a car, or of a dog sitting and eating at the dining room table. An important part of the therapist intervention with the parents was to verbally call attention to the girls successes and improvements. Using a technique referred to as knowledge translation, the therapist taught the parents about the theoretical foundations of their daughters medical and functional difculties, thus providing them with practical tools traditionally used by therapists, to help them translate effective therapeutic components (this is discussed further in Chapter 5). The parents reported a positive meaningful change after only three sessions. Despite some residual uctuations in the girls ability, the parents reported that they felt more able to manage difcult situations that came up, and they reported that their daughter responded positively to their verbal input. The group model named Keshet (advancement, participation, and communication), based on the principles of MLE, was developed by clinicians in the eld of DCI, and headed by Hadas-Lidor (Hadas-Lidor & Chasdai, 2004; HadasLidor & Weiss, 2005). Program development and steps taken to
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ensure delity are described in Chapter 5. Figure15.3 depicts the DCI model as applied in the intervention with parents and illustrates the process of the involved parent developing skills in mediation with the guidance of an expert mediator. A study conducted by Redlich, Hadas-Lidor, Weiss, and Amirav (2009) examined whether the Keshet program effectively increases family members hope for themselves versus hope for their ill relative. The experimental group
was composed of 49 family members who participated in the Keshet program for 6 months, in contrast to the control group, which comprised 22 family members, who underwent no structural intervention. Hope was measured at baseline and after 6 months using the Hope Scale, developed by Snyder (1998). No difference in self-perception was detected in Hope Scale scores between groups; however, the Keshet program signicantly increased the hope of families concerning the ill
Figure 15.3 THE DYNAMIC COGNITIVE INTERVENTION PROCESS MODELMEDIATION TO PARENTS
Child
The Expert Mediator (EM)
Mediator Parent
Expert Mediator Parent (MP)
Expert Mediator (EM)
Environmental Factors
Environmental Factors
Parent
Expert Mediator (EM)
Enviromental Factors
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person while decreasing the gap between the hope of family members regarding themselves and the affected person. Thus, the program may increase the families feeling of hope during the journey toward recovery of family members with mental illness. The inuence of the familial context of people with mental illness has come to be recognized as being signicant to the course of mental illness; however, the role of culture in the manifestations of the dynamics within families of persons with mental illness has been an unexplored subject. A study was performed (Weiss, Shor, & Hadas Lidor, submitted) of 24 ultra-orthodox Jewish mothers of persons with mental illness, who live in a relatively closed religious community in Israel. As part of their participation, the members of two groups of the Keshet educational program designated for family caregivers of persons with mental illness were asked to write meaningful interactional life episodes (MILEs), which focused on stressful events in their lives. Qualitative analysis of 50 MILEs illuminated the signicant role that religious and cultural norms had in the perceptions of what the participants considered stressors and the dynamic in the families in regard to these stressors. Four themes were identied: (a) conicts between religious rituals and the disability; (b) stressors that stem from the need to maintain the secrecy of familial events in a collectivist society; (c) stressors that stem from timerelated events, such as holidays; and (d) mothers as a major bearer of the burden of caregiving. The authors emphasized the importance of relating to cultural factors in family educational programs and interventions, because this may contribute to the potential use and success of mental health services within a population that essentially underutilizes these services. Weiss, Shor, and Hadas-Lidors (2011) study was the rst of its kind to explore the role of the cultural component in familial conicts in ultra-orthodox Jewish families with a son or daughter with a mental illness. It is indicative of the need to take the cultural component into consideration in developing and implementing educational programs and interventions for this population. The MILEs written by the participants proved to be an efcient method to learn about the role that religious and cultural norms have in understanding what are considered stressors in these families, and the dynamic in these families in regard to these stressors. Accruing this knowledge is essential if therapists want to adapt the methods of interventions in educational programs, such as Keshet, to the needs of parents living in a closed religious collectivist society. The MILEs could also be applied as a means of developing culturally oriented techniques with other cultural populations and members of racial/ethnic minority groups that underutilize mental health services because of cultural barriers.
Over the last 2 years, Keshet has been adapted for the population of parents of children with learning disabilities and attention decit hyperactivity disorder. Two groups were conducted in this period of time, with participating parents reporting positive changes after the course. As one mother stated, The difcult situations in our lives are starting to evaporate, and I have no urgent dramas to present, and I dont need your immediate help. The relationship with Guy is calmer, there is more communication at eye level and more listening . . . I can say I learned something. The ability to listen has restored my sense of worth and my title as Guys mother. The following two MILEs illustrate the personal development of one parent, who participated in Keshet, over the course of his participation in Keshet. This father, a senior lecturer and researcher, joined Keshet with very low expectations and a lack of belief in his sons ability to change and recover. The following excerpt is based on an MILE handed in after the fourth meeting. It focuses on the monthly blood test the son must have: Father: By the way, tomorrow its time for the blood test. Son: Oh no. Father: It shouldnt be a problem, you know the procedure. Son: Itll be very difcult for me. [Becomes irritable] Cant it be put off? Father: No. We have an appointment with the psychiatrist on Sunday, and you have to do the blood test beforehand. Son: Why do I actually have to do it? A few years ago (before he started taking medication) it wasnt necessary. Father: I explained the reason . . . Its important that you be ready on time. Ill meet you at 8:20 at the latest. Son: Itll be very hard for me. I cant promise anything. Well see. Father: Over and above his word, he conveys bitterness and a lack of cooperation. I already know that eventually he will cooperate and reasonably sure that he will show up on time, or 5 minutes late. I feel helpless and I feel there has to be some other way to handle the situation. Analysis of this MILE using mediation principles indicates the fathers and sons clear intentions, although the difculty in the conversation lies in the meaning and signicance that the tests have for father and son.
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The father makes it clear that his son must comply with doing the blood test. He is very practical in his approach. The son makes it clear that the blood test is very difcult for him. The father, as mediator, expresses his intent clearly, but he is not sensitive enough to the emotional difculty his son expresses. He does not communicate and mediate a sense of competency to his son. He doesnt relate to the signicance of the blood tests for the son. After a few months in Keshet the father shared a similar but yet very different MILE with the group: My son forgot to take a blood test that he has to take each month in order to go on receiving a certain medication he uses. I knew that if I reminded him, hed get angry about my interfering in his life. I sat next to him with my notepad and I told him that each morning I look through my notepad to remind myself of the tasks I have to accomplish for the same day. He suddenly remembered, and told me that hed forgotten to look in his diary and that hed forgotten to take the blood test, and actually asked me if I could drive him to the clinic to take the test. I said the following to him: I greatly appreciate your remembering what youd forgotten and the responsibility in recovering the information and you initiative in asking me to drive you. Ill do it gladly. Thus, without an argument, everything was settled peacefully. In this MILE, it is clear that the father has changed the way he communicated, and listened and reacted to his son, as well as subtly providing him with an alternative method of dealing with his problem, using a cognitivefunctional solution through mediation.
ONLINE INTERNET-BASED APPLICATION OF THE MEDIATED LEARNING EXPERIENCE

A group of dynamic cognitive therapists initiated an online forum for therapists, and interested surfers of the Web, to be used as a medium for the exchange of ideas and strategies for coping with real life situations. This medium allows people to deal with everyday situations according to MLE criteria and in relation to the intervention principles of the DCI. The forum also provides a place for the fruitful exchange of ideas among dynamic cognitive therapists. The forum apparently lls an existing need, because it is being used by the general public to improve their ability to cope with daily situations and dilemmas. For example, a special education arts teacher
presented a question regarding the management of an art class for children with attention decit disorder and attention decit hyperactivity disorder who do not respond well to medication (i.e., Ritalin), so that most of the class time was spent dealing with problematic behavioral issues. Suggestions from therapists have included that the teacher encourage the students to work together in setting up rules and guidelines for the art class. The rules were to be expressed in a positive, encouraging manner, and not as a list of Donts and Nos. The teacher was advised to copy the selected rules onto a large poster sheet and have the children decorate the poster, turning it into a work of art. The art teacher reported that she had followed this advice, with success, and that the children participated in class with much interest. As another example, an 18-year-old high school senior presented the forum with his dilemma regarding his plans after high school. Members of the forum advised him to draw up a table comparing criteria for the different possibilities he was considering. He needed help in structuring the comparison but ended up with a well-put-together table that portrayed a very clear and extensive picture of all the aspects of his dilemma. He attached the table as a document when he thanked the forum, and he stated that the cognitive intervention helped him dene the issues more clearly, thus helping him feel less confused. Online internet use of DCI, through the use of MILEs for academic learning and education, was also successfully implemented in a course for graduate students. The methodology is described in an article by Hadas-Lidor, Arbel, Odes, and Weiss (in press). In order for the DCI principles and MLE parameters to have a genuine impact on the students personal and professional lives, the course coordinator, a DCI specialist (Noami Hadas-Lidor, the rst author of this chapter), developed a model for online interactional studying through MILEs. This model guided the studying throughout the course, and in some cases continued after the completion of the course. Between the rst and second lesson, the students were required to e-mail a MILE, either from their personal or professional life, to the course instructor. The instructions for the students were minimal: Write an event that you were involved in from your personal or professional life, which happened recently. Describe where and when it took place, and who the participants were. You yourself are one of the participants! The event you describe should be presented in the form of a dialoguea conversation between the people involvedlike a mini-drama. Choose an event in which the dilemma you describe remains unresolved. At the end of your written-up conversation, describe the question you remained with.
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The purpose of this assignment was to have one personal meaningful episode to accompany the students throughout the semester, while making use of online interaction with the course instructor. This enabled each student to develop an understanding of the course content through his or her own personal experience and not via a client, a caregiver, or anyone else. The student him- or herself was at the center of this intervention.Through the MILE, the students could realistically learn and assimilate the mediation and DCI principles and be personally exposed to the process of change through which he or her went. At the end of the course, the students reported that the fact that the elements of the curriculum meshed with events occurring in their personal lives, and that these were addressed in the e-mails, caused them to reconsider the topics and content raised in the classes between one lesson and the next. A strategy for the application of learning was thus developed that was authentic and relevant to the students themselves. The students reported that they looked forward to the e-mail posts throughout the week. Two of the students even compared the experience to that of anticipating a letter from their lovers (Hadas-Lidor et al., in press).
focus on mediating skills such as self-image; learning habits; communication and interpersonal skills; writing skills; and computer prociency, which may be lacking or weak in this population. These programs enable people a gradual entrance into the academic world. Another type of program offered that is based on the DCI approach is that of supported education programs for people coping with mental health illness within Israeli universities. Students with mental illness who attend these programs are assisted in academic, social, and accessibility skills by other students, who have ongoing supervision from DCI experts. The following is an example of an event that took place in a central cafeteria on campus, between a student and an aide, and was handed in by the aide as a MILE to the DCI expert who was supervising the aide. The student and the aide were in the midst of an instruction session, when friends from the students university classes strolled over to him and started up a conversation. Although they included me in the conversation I didnt know how to handle the situation, and I felt embarrassed. I didnt know what to say and I felt the situation made the student uncomfortable. How should I have acted in such a situation? Should I have interrupted, said that we should carry on with our lesson (even though I felt that the social interaction was important for the student)? How should I have presented myself? How should I instruct the student to cope with such a situation? The DCI expert supervising the aide pointed out the importance of relating to the various perspectives of the people involved: the student, the aide, and the friends. For this purpose, the DCI expert provided the aide with a number of point-of view exercises. The following are two examples: 1. Illustrations, which emphasize the different points of view and the legitimacy of the different viewpoints and leaves room for conict and unanswered dilemmas. 2. Orientation in space, which enables a person to understand that, from a certain position, things are viewed in a certain way, but that if we change our perspective, we see things differently. The DCI experts purpose was to provide the aide with the legitimacy of his decision to waste a session for the benet his students opportunity to practice social skills. The aides ability to see different perspectives can potentially aid in dealing with the dilemma of disclosure, because the students decision to disclose his problem has to take into account the reactions of the meaningful people in his environment, who may interpret the disclosure as a weakness and cause distancing.
INFLUENCE OF THE MEDIATED LEARNING EXPERIENCE ON MULTIDISCIPLINARY STAFF MEMBERS

A course for managers of rehabilitation units from the eld of mental health have been held at Tel Aviv University in Israel over the past 10 consecutive years. The course is based on the principle of on-the-job training and is intended for professionals from various elds, including social workers, occupational therapists, educators, and others, who manage different types of rehabilitation units, including vocational, home settings, and leisure units. In addition, the participants varied widely with respect to their ages and years of professional experience. The course is structured around central topics related to rehabilitation, including recovery, organization, analysis of managerial dilemmas with staff members, supervision, and how to deal with the families of clients, and the analyses of the managerial dilemmas were performed through MLE parameters.
THE MEDIATED LEARNING EXPERIENCE IN EDUCATIONAL SETTINGS

A number of preacademic programs based on DCI have been developed in Israel to enable populations coping with mental health illness access to higher education. These programs
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A group of occupational therapists specializing in the eld of cognitive dynamic therapy participated in a workshop intended to add an extra dimension to their professional ability. The workshop was devised to train the participants to become instructors in an educational program that would teach therapists from diverse health allied professions to become dynamic cognitive therapists. The emphasis was on incorporating, encouraging, and promoting the belief in ones ability and commitment to personal change. The workshop was developed on the basis of a model of collaborative learning and the parameters of MLE. Qualitative and quantitative data revealed that the workshop facilitated changes in the participants attitudes toward teaching on emotional, cognitive, and practical levels. After the workshop, most participants were integrated as instructors and teachers in the educational program (Hadas-Lidor, Naveh, & Weiss, 2003).
DYNAMIC COGNITIVE INTERVENTION APPLICATIONS IN OCCUPATIONAL THERAPY BASED ON STRUCTURED COGNITIVE MODIFIABILITY
This section is divided into three general parts: (a) dynamic cognitive assessment, (b) DCI, and (c) modifying the environment.
problems, Haeussermann designed a system in which a child is rst presented with a target task and then supplied with modications that methodically manipulate the assessment process, including the complexity of stimuli, response modality, and modeling by the evaluator, that could be used if the child failed to perform the task. The Learning Propensity Assessment Device (LPAD; Feuerstein, 1979) is an assessment that was initially developed as an alternative to standard IQ tests that were systematically biased when applied to new immigrant and minority students. A distinctive feature of LPAD is that the assistance provided during the assessment is based on the principles of MLE. The LPAD gradually started to be used with clinical populations, such as children with Down syndrome (Minzker, 2002), adolescents with schizophrenia (Skuy et al., 1992), and adults with traumatic brain injury (Haywood & Miller, 2003). Although the LPAD is suitable for the assessment of learning potential and cognitive modiability of school-age children and adults, the downward extension, called the LPADBasic (LPADB; Feuerstein et al., 2002), has been developed for the assessment of younger children and clients with severe organic, developmental, and behavioral disabilities. Whereas the LPAD was built to identify and remediate decient cognitive functions, the LPADB often operates to reveal emergent cognitive functions. The goals of the LPADB deviate from current preschool evaluations in three ways: 1. Instead of obtaining samples of the examinees performance to identify his or her position within a developmental scale, the LPADB aims to assess the clients openness to the processes of mediation. 2. The ndings from the LPADB are not interpreted by comparing them with an external norm or standard but are used to ascertain the thinking and learning processes that underlie a persons performance. 3. The ultimate goal is to evaluate the clients propensity for modiability and determine the most appropriate mediational intervention. Another dynamic assessment battery developed for the preschool children is that of Tzuriel (2001). It is based on Vygotskys and Feuersteins theories and is uniquely suitable for young children. These include the adaptation of test materials to address developmental requirements, bridging concrete operations to abstract levels of functioning, assessment of nonintellective factors and their modiability as integrative components of dynamic assessment, use of transfer problems as a component of testing, and use of a mediation phase with transfer problems. Currently, a considerable variety of dynamic assessment approaches are available, and a growing amount of data support the realization of this type of assessment as a valuable
DYNAMIC COGNITIVE ASSESSMENT APPROACH

The dynamic assessment approach is derived from the assessment principles rst elaborated for educational contexts. Vygotskys (1934/1986) concept of the zone of proximal development is often considered to be the foundation for all subsequent forms of dynamic assessment. Working in the context of developmental and educational psychology, Vygotsky suggested that cognitive functions that are fully formed and can be displayed by children during independent problem solving should be distinguished from the emergent functions that are revealed only under conditions of assisted performance. Standard cognitive assessment techniques are restricted to those cognitive functions that are fully formed and mastered but miss the emergent or recovering functions. Vygotskys concept of zone of proximal development assessment was used by Luria (1961) for the evaluation of learning potential in children with mental retardation. Later, Haeussermann (1958) published a classic work describing the development of the dynamic assessment construct in the late 1950s and the 1960s. Responding to the need for a more accurate developmental and educational prole of young children with sensorymotor and cognitive
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resource in understanding peoples potential (Haywood & Lidz, 2007; Sternberg & Grigorenko, 2002). New assessment tools have been developed in the eld of occupational therapy that are based on the principles of dynamic assessment, such as the dynamic interactional assessments developed by Toglia (2005). Moreover, cognitive researchers have been examining the efcacy of applying dynamic assessment techniques within traditional assessment instruments, as demonstrated by the work of Bartal-Bahat (2001) on the Test of Visual-Motor Skills; Bar-Korzen (2003) on the BeeryBuktenica Developmental Test of VisualMotor Integration; and Weiss (2001), who examined the use of the Rey Complex Figure Drawing test with healthy adults and clients diagnosed with schizophrenia. Original assessment tools are also being developed to cater to specic needs, such as the Puzzle Assessment (Ginton & Gelis, 2000), which assesses childrens learning ability. The child completing the Puzzle Assessment undergoes a structured learning process of puzzle construction and is then required to use the strategies he or she learned to construct another, different puzzle. During this process, special emphasis is put on determining which cognitive functions the child uses to complete the task and his or her capacity for transference and learning potential after receiving MLE. Katz, Golstand, Traub Bar-Ilan, and Parush (2007) adapted and modied the Lowenstein Occupational Therapy Cognitive Assessment (Itzkovich, Elazar, Averbuch, & Katz, 2000) for use with children and youth ages 6 through 12. The Dynamic Occupational Therapy Cognitive Assessment for Children (Katz, Parush, & Traub Bar-Ilan, 2005) battery includes 22 subtests in ve areas: (a) Orientation, (b) Spatial Perception, (c) Praxis, (d) Visuomotor Construction (with memory), and (e) Thinking Operations. The test includes a baseline score, a mediation score (based on a ve-level cueing system adapted from Toglia, 1994, with her permission), and a posttest score. Reliability and validity were established for the test on groups of children ages 6 through 12 (Katz et al., 2005, 2007). More recently, the adult and geriatric versions underwent a similar transformation process to include dynamic methods, and the psychometric properties for the Dynamic Lowenstein Occupational Therapy Cognitive Assessment and the Dynamic Lowenstein Occupational Therapy Cognitive AssessmentG, for individuals age 70 and older, have been studied (Katz, BarHaim Erez, & Averbuch, 2011; Katz, Livni, Bar-Haim Erez, & Averbuch, 2011; see also Chapter 13) The computerized Wisconsin Card Sorting Test (Heaton, Chelune, Talley, Kay, & Curtiss, 1983) represents a new direction in the dynamic assessment of clients with schizophrenia. Sergi, Kern, Mintz, and Green (2005) demonstrated that the learning potential derived from the testtraintest performance of patients with schizophrenia is a better predictor of their ability to learn work skills than the static pretest scores. Watzke,
Brieger, Kuss, Schoettke, and Wiedl (2008) showed that individual learning potential assessed through the dynamic version of Wisconsin Card Sorting Test was associated with the improvement of work-related learning ability during rehabilitation and with the level of functioning and vocational integration at a 3-month follow-up (about 15 months after the initial testing). Although learners and nonlearners started at comparable levels at the beginning of the rehabilitation, learners beneted more from the program, whereas nonlearners showed a rather unfavorable rehabilitation outcome. Elderly individuals with and without cognitive deterioration represent another group that have begun to enjoy the benets of dynamic assessment. The results of a study conducted by Navarro and Calero (2009) indicated that dynamic assessment techniques based on a format of self-guided retesting are appropriate for assessing cognitive plasticity in elderly people. Cognitive plasticity, as measured through dynamic assessment techniques, appears to be an important modulating variable on the effects of age on cognitive performance and decline. Fernndez-Ballesteros, Zamarrn, and Trraga (2005) developed a battery of dynamic tests for assessing dementia (which includes visualspatial, verbal recall, executive control, and verbal uency tests). The battery was evaluated for its ability to discriminate between healthy people and those diagnosed with mild cognitive impairment and Alzheimers disease. A total of 89% of the cases were correctly classied by this battery: 95.7% of the healthy participants, 90.6% of participants with Alzheimers disease, and 71.1% of the patients with mild cognitive impairment. The dynamic component appears to have added value in comparison to standard static assessment tests.
THERAPEUTIC DYNAMIC ASSESSMENT APPROACH

The therapeutic dynamic assessment approach presented in this chapter is based on a number of principles, elaborated on in the following sections. The initial intervention always begins with an interview, in which the therapist helps the client clearly dene his or her functional needs. Next, the therapist chooses the standardized, dynamically adapted, or dynamic tools that can provide him or her with a deeper understanding of the clients needs, as expressed by the client.
Principle 1
The intervention approach is structured according to individual needs; therefore, the diagnosis or etiology in itself is not the central criterion that will dene the appropriate approach to intervention. As a result, the assessment and treatment protocols are exible and adapted specically to each individual. This approach differs from models of
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dynamic assessment that have a standardized sequence of prompts or cues (Haywood & Lidz, 2007; Toglia, 2005). In contrast, the initial approach to evaluation and assessment is client centered, meaning that it is guided by dening goals as chosen jointly by the assessor and the client. In certain cases when this cannot be accomplished, the goals are dened with the help of the caregiver.
To search for the individuals preferred modalities, which represent areas of relative strength and weakness in terms of both his or her existing inventory of responses, and preferred strategies for achieving the desired modication in the most efcient and economical way.
Case Study
During Toms evaluation, it became apparent that verbal mediation was a preferred mode of MLE for him. While reproducing the Rey Osterrieth Complex Figure (Feuerstein, Rand, Haywood, Hoffman, & Jensen, 1983) from memory, Tom guided himself by verbal instructions, said aloud. This behavior was repeated in additional parts of the evaluation, in which he initially demonstrated insecure and hesitant behavior, with a request for many verbal explanations before any attempted action. These verbal explanations improved his performance. The initial purpose was to strengthen Toms sense of security; therefore, the treatment process began with the use of IE tools that rely heavily on clear and detailed verbal instruction and tools that emphasize self-perception and a social sense of adequacy. In using dynamic assessment techniques, the therapist is not interested in passively collecting data about skills the client may or may not possess; instead, the therapist assesses general learning modiability by measuring the individuals capacity to acquire a given principle, learning set, skill, or attitude, depending on the specic task at hand. The extent of modiability and the amount of treatment investment necessary to bring about the change are assessed, respectively by (a) measuring the clients capacity rst to grasp and then to apply these new skills to a variety of tasks that are progressively more distant from the one in which the principle was taught; and (b) measuring the amount of explanation and training investment required to produce the desired result. The signicance of the attained modication is measured by the clients developing patterns of behavior that demonstrate his or her efciency in areas other than those that were actively modied by the training process. The use of this dynamic approach in assessment assumes that the individual represents an open system that may undergo important modications through exposure to external stimuli, internal stimuli, or both (Lidz, 1987). However, the degree of the individuals modiability through direct exposure to various sources of stimulation is considered to be a function of the quantity and quality of the MLE.
Principle 2
According to the DCI concept of dynamic assessment, an interview, observation, and dynamic and static evaluation tools are used concurrently to obtain a comprehensive picture of the clients functional abilities and learning potential. Dynamic assessment differs essentially from classic assessment. The major components that make up the dynamic assessment are as follows: The structure of test instruments (i.e., cognitive tests are analyzed for their components and divided into various graded exercises); The test logistics and testing procedures (i.e., the relationship of testertestee is transformed into teacher student or therapistclient, as described in the MLE, and the assessment is not timed; only the length of the whole process is considered); Mediation, an integral part of the assessment process, the goals of which are to analyze and grade the test material in a way that enables the testee to accomplish the task and identify his or her style of thinking and strategy for dealing with the task at hand (meta-cognition); The interpretation of the results (i.e., the focus is on the change process and the individuals investment in it, and the score is not the sole end product taken into account); and The general orientation of the test (from product to process). The goals of a dynamic cognitive evaluation are as follows: To assess an individuals modiability when he or she is confronted with conditions that aim at producing a change in him or her; To assess the extent of the observed modiability in terms of both the functional levels made accessible to the individual through the process of modication and the signicance of the levels he or she attained in the hierarchy of cognitive operations; To determine how much intervention is necessary to bring about a given amount or type of modication; To determine how much signicance the modication achieved in one area can have for other general areas of functioning; and
Principle 3
In the DCI intervention approach, evaluation, treatment, and follow-up elements are continuously intertwined throughout
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the intervention procedure. As described earlier, the initial assessment is based on the needs and wishes as expressed by the client. It is difcult to dene exactly when the assessment ends and the treatment process begins. Furthermore, the initial assessment process is accomplished by MLE and therefore, by denition, a process of change has already been put into motion. Additionally, after initial goals have been set and the therapeutic process has begun in a more focused manner, there is a constant reevaluation of these goals, which are always related to function.
Case Study
A student with attention decit hyperactivity disorder requested strategies to help him plan how he uses his time before exams. During the evaluation, he displayed problems in estimating time, and he had difculty working along the time continuum that he had initially established for himself. Moreover, he displayed a lack of ability to sustain attention. To address his time management needs, the intervention included having the client estimate the length of time that it took him to complete various activities, both before and after the activity. The DCI therapist included exercises from Temporal Relations, Instructions, and Representational Stencil Design tasks of Feuersteins (1980) IE program, which require working along a continuum, in a set order. During the initial evaluation that led naturally into the therapeutic aspects of the intervention, the therapist had the client map out his daily schedule for a typical day that included study activities. The therapist repeated this exercise with the client a number of times and, after the analysis, this enabled the therapist to identify the students most optimal hours of the day for efcient learning. The topic of planning strategies for time management of learning was also addressed using a diary, in which the client wrote his plan for learning every day, including when he was going to learn, how much time was needed, what he had to learn, and where he planned to do it.
it is incorporated into the DCI approach, which also includes variety of activities (some of which are more familiar to occupational therapists), such as reading and writing exercises, analysis of life events and family picture albums, games, and the cognitive map. DCI is a unique cognitive model that combines remedial and adaptational interventions that directly and simultaneously enhance participation in major life areas (see Figure 15.4). The model presents a circular connection among disability, activity, and participation. The links among these three elements could potentially result in a vicious cycle that leads to acquired helplessness. For example, disability may create performance difculties and a reduced capacity to learn and apply knowledge. These performance difculties may in turn result in feelings of low self-esteem and acquired helplessness, which inuences a persons affect, motivation, activity, and participation in major life areas. As can be seen in Figure 15.4, the DCI makes a critical difference by challenging the vicious cycle before the performance and learning difculties can cause undesirable end results. This is accomplished by improving and expanding learning ability and self-perception, through treatment via DCI, in the areas that the client identies as important to him or her and chooses to focus on in the course of the intervention. It is important to emphasize that DCI views participation not as an outcome of the intervention but as an accompanying element that simultaneously broadens and expands a persons ability to be active and participate (see also the second parameter of MLE, transcendence, discussed earlier in this chapter).
INSTRUMENTAL ENRICHMENT: AN INTERVENTION PROGRAM FOR COGNITIVE MODIFIABILITY

There are two primary types of MLE-based intervention programs. Programs of the rst type infuse the principles of MLE into educational or treatment programs without introducing specially designed learning materials or tools. Representative of such programs are Kleins (1996) MLE-based parental training program and Deutsch and Mohammeds (2008) Cognitive Abilities Prole. The second type of program, exemplied by Feuersteins (1980) IE and Haywood, Brooks, and Burnss (1992) Bright Start, is organized around specially designed learning materials that serve as tools for the enhancement of cognitive modiability. The IE program is used in the DCI approach as a central axis for the redevelopment of cognitive structures in clients with low cognitive performance. The IE program is designed as a direct and focused approach to remediation of those processes that, because of
DYNAMIC COGNITIVE INTERVENTION: PRINCIPLES AND INSTRUMENTS

In this section, we present a dynamic cognitive therapeutic intervention approach developed by Hadas-Lidor. This approach evolved from the dynamicdeductive-based approach of Feuerstein (1980), which initially was focused on the needs of individuals with special needs within the educational system. The model describes the role of DCI in breaking the cycle of adjustment difculties and adaptation that often follows a disability. This is followed by a description of Feuersteins (1980) IE program and an explanation of how
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Figure 15.4 MODEL OF THE RELATIONSHIP BETWEEN PARTICIPANT RESTRICTIONS AND DYNAMIC COGNITIVE INTERVENTION
Dynamic Cognitive Intervention (DCI)
Disability
Participation restrictions
Difculty in performance and capacity for learning and applying knowledge
Activity limitations in major life areas
Difculties in changing
Rigidity and inexibility
their absence, fragility, or inefciency, are responsible for poor intellectual performance, irrespective of underlying etiology. The IE program consists of more than 500 pages of pencil-andpaper exercises, divided into 14 instruments (see Table 15.1). A detailed description of IE tools can be found in Feuerstein, Feuerstein, Falik, and Rand (2006). Each instrument focuses on a specic cognitive area, such as analytic perception, comparison, classication, orientation in space and time, and so on. At the same time, deciencies in the ability to systematically gather and compare information, plan and control activity, advance and check hypotheses, and attune responses to its intended recipient are addressed in all instruments, irrespective of their domain specicity. The IE program is organized methodically so that more basic instruments serve as prerequisites for the higher-level instruments while similar cognitive tasks appear in different modalities (verbal, graphic, pictorial, numerical, etc.) and on various levels of complexity in the different instruments. This structured approach assists the therapists or/and teachers in their choice of the materials to be used and the sequence of presentation. Intervention is performed either individually or
in groups, during approximately three to ve sessions per week (Feuerstein, 1980). A relatively new downward extension of IE, the IEBasic (Feuerstein & Feuerstein, 2003), includes a series of instruments intended for cognitive development and/or remediation of younger children or older, low-functioning clients for whom the standard IE program is unsuitable (see Table 15.1). The IEBasic program directly addresses the domain of feelings, emotions, and moral development that appear only implicitly in the standard IE program. The major goal of IE is to increase the individuals cognitive modiability and, in this way, to enhance his or her capacity to be modied through direct exposure to stimuli and experiences that occur throughout life in formal and informal learning contexts. To attain this major goal, the following six subgoals should serve as guidelines for the administration of the IE program (see Feuerstein, 1980): 1. Correcting the decient functions to change the structure of the cognitive behavior
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Table 15.1 INSTRUMENTAL ENRICHMENT (IE) MATERIALS

IE MATERIALS FOR SCHOOL-AGE CHILDREN AND ADULTS Organization of dots Analytic perception Illustrations (cartoons) Orientation in space 1 Orientation in space 2 Comparisons Family relations Numerical progressions Stencil design Categorization Instructions Temporal relations Transitive relations Syllogisms BASIC IE FOR YOUNG CHILDREN Organization of dots Orientation in space Tri-channel attentional learning From empathy to action Compare and discover the absurd Identifying emotions From unit to group Think and learn to prevent violence Know and identify Learn to ask questions for reading comprehension
Note. From Dynamic Cognitive Intervention: Application in Occupational Therapy (p. 405), by N. Hadas-Lidor and P. Weiss, in N. Katz (Ed.), Cognition and Occupation Across the Life Span, 2004, Bethesda, MD: American Occupational Therapy Association. Copyright 2004 by the American Occupational Therapy Association. Adapted with permission.
2. Acquiring basic concepts, labels, vocabulary, operations, and relationships necessary for solving IE tasks, which themselves are purposely content neutral and do not coincide with any specic curricular area 3. Developing (producing) intrinsic motivation through habit formation. Successful application will lead to the formation of cognitive habits and their spontaneous manifestation without the need for external incentives. 4. Producing reective, insightful thinking processes in students/clients as a result of their exposure to IE tasks, in the case of both success and failure 5. Creating task-intrinsic motivation, which has two aspects: (a) the enjoyment of a task for its own sake and (b) the social implications of succeeding in a task that is difcult even for competent adult learners 6. The development of an active learning attitude and the transformation of the low-functioning individual from a passive recipient of information into an active generator of knowledge, and in this way revising his or her self-image. Using the more up-to-date terminology that is now prevalent in the occupational therapy and cognitive psychology literature, one can say that the IE program aims to develop both cognitive and meta-cognitive processes and self-awareness. Bright Start is another structured intervention program based on the principles of mediation. Developed by Haywood
et al. (1992) for preschoolers and primary-grade children, who may have pervasive developmental disorders or are at high risk of learning failure, the essence and most distinguishing feature of the program is the mediation of psychological tools in the context of the zone of proximal development. It is a program of cognitive education and remediation aimed at enhancing the development of basic cognitive processes and thinking skills, developing task-intrinsic motivation, and increasing learning effectiveness and readiness for school learning. This is accomplished by introducing a mediation teaching style using process-oriented questions rather than content-oriented ones, within seven cognitive instructional units (Gindis, 2003). At present, the literature on IE-based research and implementation studies includes several hundred publication. The main recipients of IE are students with learning disabilities and low-achieving students in regular schools, gifted students, immigrant students and students who are members of racial/ ethnic minority groups (both children and young adults), as well as students with vision and hearing impairments (Kozulin & Rand, 2000). The IE program has proven to be rich and exible enough to be applicable to different populations of learners. Most applications of this program took place in educational settings, with IE lessons given by specially trained teachers coached in the principles of MLE and the technique of IE application. Conclusions drawn from analysis of the IE studies point to several issues that should be further explored, including the amount of IE teaching that is sufcient for producing desirable results, the range of IE instruments to be used, and the importance of monitoring teachers mediation style by experienced IE supervisors. The majority of IE studies demonstrated signicant changes in students cognitive performance, but only some of them showed enough transfer to improve students performance in curricular areas (Romney & Samuels, 2002). Apparently, different intervention goals require corresponding didactical changes in the IE teaching and bridging to curricular areas. More recent studies, however, allow for a more optimistic view of IE as a cognitive method leading to the improvement of students achievement in curricular areas (Kinard & Kozulin, 2008; OHanlon, 2010). The Bright Start program also proved to be effective in enhancing cognitive performance, motivation, learning potential, and motivational skills in a wide range of young learners. The populations involved in Bright Start studies include preschool children dened as mildly to moderately mentally retarded, children with severe learning disabilities, children from immigrant and low-socioeconomic families, and typically developing children. The Bright Start program was shown to be effective with at-risk preschool children, preventing their placement in special education frameworks
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and instead promoting their integration into regular classrooms (see Brooks & Haywood, 2003, for a comprehensive review).
Principle 5
The treatment stage is commenced using the IE exercises in a horizontal, free-choice, need-specied approach, in accordance with the chosen goal of treatment and with the clients consent. A maximum exposure to IE exercises is desirable, to enhance the development of a wide range of strategies and promote mental exibility. This approach differs from Feuersteins (1980) educational approach to intervention, in which clients/ students are given a structured preset sequence of the IE program according to specic cognitive deciencies.
DYNAMIC COGNITIVE INTERVENTION IN OCCUPATIONAL THERAPY

The DCI approach uses a persons learning potential as a base for enabling, broadening, and expanding participation in the environment. Occupational therapy, as a profession, encompasses these elements across all target populations, stages of illness, types of disability, and at all stages of the life cycle. Feuersteins (1979, 1980) SCM approach and IE program have been used in Israel with adult populations since the 1980s (Katz & Hadas, 1995). At the outset, it was used mainly by occupational therapists who specialized in the rehabilitation of adolescent and adult populations with various dysfunctions (physical, cognitive, emotional, and behavioral). IE is used in conjunction with evaluation and treatment of daily living skills (activities of daily living), vocational/professional skills, and social skills, as well as during transitions from the hospital to the community. An independent model of intervention, the DCI, was proposed by Hadas-Lidor and Weiss (2005) and was introduced in this chapter. This approach enables the exposure of a broader range of populations to this type of intervention; moreover, it integrates IE instruments with other tools commonly used by occupational therapists, and it introduces new techniques and instruments. The goals of the occupational therapist in the DCI approach are To improve independent learning ability; To develop awareness, insight, and feelings of competence; and To expand a persons ability to participate in activities in his or her natural environment in accordance with his or her interests, intentions, and wishes.
Principle 6
Match the tool to the client, so that it is the most meaningful to the person and is most appropriate for his or her ability, culture, desire, and need. The intervention is a constant dialogue. This principle is based on recovery concepts relating to the right of persons with a disability to live a meaningful life, to direct his or her own personal process of change and to design his or her goals and realize them (Anthony, Cohen, Farkas, & Gagne, 2002).
Principle 7
Motivation is a product of ability. Lack of motivation is a product of low self-esteem, and lack of skills, strategies, or both. For example, previously, people diagnosed with mental health disorders spent years in psychiatric hospitals, with only a bed and a bedside dresser. All of their personal belongings were contained in a plastic bag. When asked if they were interested in changing anything in their lives, they expressed satisfaction with the way things were, and claimed that nothing needed to be changed. Following the current trend of communitydwelling solutions for this population, these same people, who now have their own rooms, beds, closets, personal possessions, work, or occupations, express additional needs; such as to have money, lead a family life, and/or to take a trip abroad. This can be seen as an expression of increased competence and belief in their abilities. Hadas-Lidor et al. (2001) studied the effect of DCI principles on clients with chronic schizophrenia. One of their assumptions was that the treatment would cause an increase in self-esteem and satisfaction. Surprisingly, the results pointed to a slight decrease in these parameters despite an increase in ability and living status. The principal explanation for this nding is that an increase in ability may result in a decrease in satisfaction with the status quo and a desire for further change and development.
ADDITIONAL DYNAMIC COGNITIVE INTERVENTION PRINCIPLES AND GUIDELINES DEVELOPED BY HADAS-LIDOR FOR THERAPISTS Principle 4
Always focus on the existing, on the positive; emphasize the persons strength, and believe in that strength. Therapists often explore and explain clients mistakes; rarely do they interpret and empower success and strength. Spend more time on successful experiences, analyze them, explore them, and explain them; this attitude leads to a growth of future successes.
Principle 8
The intervention is an ongoing process that integrates multifaceted aspects: cognition, emotions, and function.
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Principle 9
The intervention involves a constant reference to metacognition via Feuersteins (1979, 1980) MLE criterion of transcendence. Transcendence is accomplished by relating to life situations and roles (family, work environment, studies, etc.). This can be achieved by performing an ongoing analysis of what Im doing (a denition of task at hand), how Im accomplishing the task (the process), and why Im doing it (choosing among strategies). This principle differs from the remedial approach in that it does not assume that the transfer of skills will happen automatically following cognitive intervention. It is similar to Toglias (2005) approach, which views generalization, establishing criteria for transfer, practice in multiple environments, and meta-cognitive training as being crucial to the treatment process. The DCI approach assumes that the application of strategies to real life situations occurs only if treated directly during intervention.
were attending a community rehabilitation center. All of the participants were diagnosed before and after the intervention. The experimental group received 18 weekly 1-hour DCI sessions. The control group participated in the centers regular activities, which included support treatment, psychotherapy, treatment management, and workshop or work units. After 6 months, a signicant improvement in the social, cognitive, and occupational measures was noted in the experimental group participants compared with the participants in the control group. The results of this study support short-term DCI for individuals with schizophrenia in the community.
Principle 12
The intervention is almost always individualized. Group intervention is a short-term procedure that functions to help members with a specic identied issue or problem, such as how to prepare a curriculum vitae to obtain work.
Principle 10
The intervention is multidisciplinary; all professionals and caregivers take part in enhancing intervention goals. To this end, all involved are exposed to MLE principles. This cooperation enables further fulllment of transcendence from DCI to other areas of the clients life. One way to accomplish this was through the introduction of a study program developed by Hadas-Lidor of the Occupational Therapy Department at Tel Aviv University (described later in this chapter), which is intended for multidisciplinary health professionals.
Principle 13
The client is encouraged to maximize independence during the intervention procedure and between intervention sessions. This is accomplished by providing IE exercises, similar to those worked on during the intervention, as well as homework. The homework is analyzed according to the criteria of the cognitive map (described later in this chapter).
Principle 14
When tasks other than the IE exercises are added to the inter vention, they are to be constructed in a similar fashion and used according to the same principles (see Tables 15.2 and 15.3).
Principle 11
In DCI, affect and emotional issues that arise and are identied as deterrents to functional ability are treated directly and intentionally, through the use of MLE and effective cognitive functions (see Table 15.2). The use of family picture albums is an example of a tool used in DCI to stimulate discussion about relationships, culture, values, emotions, and family difculties. This technique is also benecial in that the cognitive analysis of emotional issues allows a person to distance him- or herself from the problem somewhat, thus enabling him or her to cope with and deal more effectively with sensitive life situations. This is an innovative approach for occupational therapists, who would not be able to deal with emotional aspects of an individual through the use of traditional cognitive approaches. Keisar-Speier, Hadas-Lidor, Lachman, and Tal (2007) examined the efcacy of DCI on the cognitive and social functioning of individuals with schizophrenia who live in the community. The sample included two matched groups of 28 individuals with schizophrenia, ages 23 through 37, who
Principle 15
DCI views the client as an equal partner in the therapeutic process. Not only do the therapist and the client choose the goals together, but also the therapist explains to the client the central concepts of cognition, cognitive development and processes, and the clinical reasoning behind the intervention techniques. Clients are educated as to how cognitive communication skills, based on mediation, can enhance learning, adaptability and recovery. This attitude leads to the empowerment of all those involved in the therapeutic process (Hadas-Lidor & Weiss, 2007; Weiss, 2010). The caregivers are also provided with practical tools traditionally used by therapistsa technique referred to as knowledge translation to help them translate components that have been proven to be effective in research, into actual practice (Sudsawad, 2007; World Health Organization, 2005).
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Table 15.2 WRITING OF LIFE EVENTS: A CASE STUDY USING THE PRINCIPLES OF DYNAMIC COGNITIVE THERAPY
IE EXERCISES INTENDED FOR EXPANSION, VARIETY, AND DISTANCING
INTERVENTION PROCESS Client chooses life event to work on
WRITING TASK My mother shut off the television at 11:00p.m., during my favorite program. Spontaneous, subjective writing Topic Place where event took place Time of event Participants Order of events Proper structure Clarity of language Proper use of conjunctions Sequencing Consideration of addressee Suitable equilibrium among parts: feelings, cognition, and behavior
Unstructured writing of the event Choosing a suitable structure for reporting the event
Inspection of the writing
Categorization Analytic perception Stencil design
Writing of event from mothers perspective Comparison of structure
What did mother think, feel, and do Examination according to Proper structure Clarity of language Proper use of conjunctions Sequencing Consideration of addressee Suitable equilibrium among parts: feelings, cognition, and behavior Compare your story with your mothers story.
Orientation in Spaces 1 and 2 Comparisons
Comparison of content
Cartoon that depicts a topic from two points of view, such as the mouse and the cheese; family relations, viewing the same event from different points of view
Note. IE Instrumental Enrichment. From The Dynamic Cognitive ApproachA Means and Not a Goal in Itself, by N. Hadas-Lidor, 2004, Paper presented at A Journey Towards Myself: Implementations of the Cognitive Dynamic Therapy, Tel Aviv University, Tel Aviv, Israel. Adapted with permission.
THE COGNITIVE MAP

The cognitive map is a conceptual instrument developed by Feuerstein (1979, 1980) to facilitate the application of LPAD and IE tasks and the analysis of the outcomes. The conceptualizes the relationship between the characteristics of a cognitive task and its performance by an individual. HadasLidor (1997) adapted the cognitive map for use with different age groups, as an instrument to facilitate the activity analyses of therapeutic tasks and enhance the intervention process by serving as a communication device in the interaction between
the therapist and client. The DCI goals that are applied to the intervention process through the use of the adapted cognitive map include To arouse the clients awareness regarding his or her performance and ability; To establish or restore the clients belief in his or her ability, desire, and need for improvement; To create a contract between therapist and client in regard to the intervention process; and To develop the clients ability for self-assessment.
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Table 15.3 COMPARING FEUERSTEINS (1980) COGNITIVE MAP WITH HADAS-LIDORS (1997) APPLICATION OF THE MAP AS AN INTERVENTION INSTRUMENT FOR CHILDREN
FEUERSTEIN (1980) Content Modality/language HADAS-LIDOR (1997) What is the subject of the exercise? How is the exercise presented (e.g., words, sentences, numbers, tables, designs, geometricshapes)? How should you think in order to do the exercise? (Collect information, learn new phrases, carefully read instructions, ask for advice, summarize, etc.)Cognitive functions: What steps should you take in order to do the exercise? (Write, draw, calculate, cut, make draft, etc.)Process Cognitive operation Level of complexity Level of abstraction What should the end product of the exercise be? (Summary, picture, table, graph, etc.) How difcult was the exercise for you? (Easy, moderate, difcult) Did the exercise deal with material familiar to you? (Very familiarthings I can see, hear or touch; familiarthings I know but cant see or touch, e.g., square, circle; not familiar, abstractlove, honor, cognition, etc.) How did I accomplish the exercise with a minimum of mistakes and at suitable speed?
Phase of mental act: Input, elaboration, output (cognitive functions)
Level of efciency
Note. From Dynamic Cognitive Intervention: Application in Occupational Therapy (p. 408), by N. Hadas-Lidor and P. Weiss, in N. Katz (Ed.), Cognition and Occupation Across the Life Span: Models for Intervention in Occupational Therapy, 2004, Bethesda, MD: American Occupational Therapy Association. Copyright 2004 by the American Occupational Therapy Association. Adapted with permission.
The cognitive map technique can be used directly with clients (for an example with pediatric clients, see Table 15.3), DCI therapists, teachers, and parents, as a tool for making choices and selecting suitable tasks for intervention. The use of the cognitive map as an intervention strategy together with the client is another aspect of knowledge translation within DCI.
THE DYNAMIC MODIFIABLE ENVIRONMENT

Three conditions need to be met in order to design and transform environments so that they can serve to promote changes in a person. An environment that fosters change is (a) encouraging, (b) obligating, and (c) enabling. The stages involved in creating a dynamic environment are the assessment of ability, the assessment of pathways to change, and the creation of an enabling environment. It should be noted that certain environments, by denition, are not enabling, such as those that specically cater to populations with special needs. Environmental contexts based on beliefs that were popular in the past, which viewed genetic structure as xed and immutable, led to the establishment of sheltered work or study environments, such
as special education settings and workshops. A preferable type of environment is one that empowers the individual to work toward change. If the individual will not adapt himor herself internally to it, it will be difcult for him or her to be integrated into the environment (Anthony et al., 2002; Feuerstein & Rand, 1997). The theory behind and the practice of the IE program and the LPAD dynamic assessment is still under development, and research is being conducted in many countries worldwide and by different types of professionals. The DCI approach has also been recommended for inclusion in the framework of cognitive rehabilitation, for populations of adults with brain injuries (Groverman, Brown, & Miller, 1985; Hadas-Lidor, 1996; Toglia, 1989, 1991).
ADDITIONAL ACADEMIC APPLICATIONS

In addition to the advances being made in the elds of treatment, assessment, and research, programs based on SCM theory and DCI are being developed in academic frameworks, led by prominent occupational therapists. A postprofessional diploma program in SCM and DCI theory and their application to the health professions has
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been designed by Noami Hadas-Lidor, at Tel Aviv University in Israel. The program is the rst of its kind; it is based exclusively on DCI and is facilitated by occupational therapists. The curriculum includes the theoretical aspects of brain development and function; learning theories; and applied courses in the elds of assessment, treatment, and mediated learning. A unique aspect of the program is concurrent supervision based on group discussion and analysis of events. Program participants come from diverse health-related professions, including occupational therapists, psychologists, speech therapists, nurses, and social workers, and common grounds for communication and intervention principles are enhanced while their professional identity is maintained. The efcacy of the program was assessed by research, in which attitude questionnaires, given to participants before and after the conclusion of their studies, demonstrated signicant changes in the participants beliefs, emotions, and behaviors in relation to their roles as dynamic cognitive therapists, including their belief in their clients ability to change and develop as a result of the therapeutic intervention and interaction (Hadas-Lidor et al., 2006). The Israeli Ministry of Health is currently encouraging and participating in a comprehensive program aimed at integrating cognitive dynamic therapy techniques in the eld of mental health. Occupational therapists play a central role in this project, which includes the appointment of subcommittees, each of which concentrates on a different aspect of the
endeavor, for example, research, comprehensive models for treatment applications in mental health, the applicability of a program within the available medical services, and privileges that should be granted to populations with special needs.
SUMMARY
In this chapter, we have presented the DCI, an applied model of intervention for persons with special needs. This approach is based on concepts developed by Feuerstein (1979, 1980) and Vygotsky (1934/1986) and includes evaluation and intervention methods and techniques based on their theories. We presented 13 unique principles that portray the uniqueness of the approach as compared to other treatment approaches. DCI principles enable rehabilitation professionals to service populations that previously were not a focus of intervention, for example, underachievers, adults with learning disabilities, families, and caregivers. The DCI approach integrates aspects of cognition, emotion, and function and simultaneously focuses on all of them throughout the stages of intervention. We also described applications of DCI in the eld of research and academic and clinical programs. Our aim is to further the development of DCI by encouraging evidencebased research, both on evaluation and treatment aspects of intervention.
REVIEW QUESTIONS
1. 2. 3. 4. In what way are DCIs preferable to static approaches? Compare Hadas-Lidors DCI approach with Feuersteins SCM approach. How does the DCI encompass emotional aspects in the intervention process? To what populations would you apply DCI principles?
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NOAMI HADAS-LIDOR, PhD, OT, PENINA WEISS, MSc, OT, and ALEX KOZULIN, PhD

Dynamic Cognitive Intervention: Application in Occupational Therapy

324 Cognition, Occupation, and Participation Across the Life Span

POPULATIONS EXPOSED TO DYNAMIC COGNITIVE INTERVENTION

POPULATIONS EXPOSED TO STRUCTURAL COGNITIVE MODIFIABILITY

Dynamic Cognitive Intervention: Application in Occupational Therapy

Figure 15.1 DYNAMIC COGNITIVE INTERVENTION (DCI) IN OCCUPATIONAL THERAPY

DCI in Occupational Therapy Population setting goals

Parents of Children With Special Needs & Caregivers

Adults & Adolescents With Learning Disabilities

Develop & improve communication

THE PHILOSOPHY: THE CONCEPT OF COGNITIVE MODIFIABILITY

326 Cognition, Occupation, and Participation Across the Life Span

THE THEORY OF MEDIATED LEARNING EXPERIENCE

Dynamic Cognitive Intervention: Application in Occupational Therapy

328 Cognition, Occupation, and Participation Across the Life Span

Figure 15.2 THE DYNAMIC COGNITIVE INTERVENTION PYRAMID MULTIDIMENSIONAL MODEL

Activities & Participation

Dynamic Cognitive Intervention: Application in Occupational Therapy

330 Cognition, Occupation, and Participation Across the Life Span

Dynamic Cognitive Intervention: Application in Occupational Therapy

INFLUENCE OF THE MEDIATED LEARNING EXPERIENCE ON PEERS

INFLUENCE OF THE MEDIATED LEARNING ENVIRONMENT ON CAREGIVERS

332 Cognition, Occupation, and Participation Across the Life Span

Figure 15.3 THE DYNAMIC COGNITIVE INTERVENTION PROCESS MODELMEDIATION TO PARENTS

Expert Mediator Parent (MP)

Expert Mediator (EM)

Activities & Participation

Activities & Participation

Expert Mediator (EM)

Activities & Participation

Dynamic Cognitive Intervention: Application in Occupational Therapy

334 Cognition, Occupation, and Participation Across the Life Span

ONLINE INTERNET-BASED APPLICATION OF THE MEDIATED LEARNING EXPERIENCE

Dynamic Cognitive Intervention: Application in Occupational Therapy

INFLUENCE OF THE MEDIATED LEARNING EXPERIENCE ON MULTIDISCIPLINARY STAFF MEMBERS

THE MEDIATED LEARNING EXPERIENCE IN EDUCATIONAL SETTINGS

336 Cognition, Occupation, and Participation Across the Life Span

DYNAMIC COGNITIVE ASSESSMENT APPROACH

Dynamic Cognitive Intervention: Application in Occupational Therapy

THERAPEUTIC DYNAMIC ASSESSMENT APPROACH

338 Cognition, Occupation, and Participation Across the Life Span

Dynamic Cognitive Intervention: Application in Occupational Therapy

INSTRUMENTAL ENRICHMENT: AN INTERVENTION PROGRAM FOR COGNITIVE MODIFIABILITY

DYNAMIC COGNITIVE INTERVENTION: PRINCIPLES AND INSTRUMENTS

340 Cognition, Occupation, and Participation Across the Life Span

Dynamic Cognitive Intervention (DCI)

Difculty in performance and capacity for learning and applying knowledge

Activity limitations in major life areas

Rigidity and inexibility

Dynamic Cognitive Intervention: Application in Occupational Therapy

Table 15.1 INSTRUMENTAL ENRICHMENT (IE) MATERIALS

342 Cognition, Occupation, and Participation Across the Life Span

DYNAMIC COGNITIVE INTERVENTION IN OCCUPATIONAL THERAPY

Dynamic Cognitive Intervention: Application in Occupational Therapy

344 Cognition, Occupation, and Participation Across the Life Span

INTERVENTION PROCESS Client chooses life event to work on

Inspection of the writing

Categorization Analytic perception Stencil design

Writing of event from mothers perspective Comparison of structure

Orientation in Spaces 1 and 2 Comparisons

THE COGNITIVE MAP