Cognitive adaptation training

1. Introduction

Version followed: Velligan and colleagues' outpatient CAT (UT Health San Antonio), as described in the 2000 RCT and case-study papers that report on the unpublished therapist manual (Velligan, 2000). Later changes are added where named: the FrSBe for behaviour rating and the Environmental and Functional Assessment (EFA), Pharm-CAT (adherence only), remote CAT (2022), and nurse-led or inpatient adaptations (Netherlands, finCAT). The manual itself was not available, so session-level detail beyond the published descriptions is marked [synthesis] or [uncertain].

Cognitive adaptation training (CAT) is a home-based, manualised psychosocial treatment for people with schizophrenia and other serious mental illness. It does not try to retrain cognition. It works around ("bypasses") cognitive and motivational impairments by changing the person's surroundings: signs, checklists, alarms, pill containers, labelled and reorganised belongings, and removal of distractions. These supports cue and sequence everyday behaviour at the point of action. [source: Velligan et al., 2000 AJP; Draper et al., 2009 abstract; ICEEBP course page]

How change happens: deficits in executive function (planning, initiating, sequencing, inhibiting) block daily functioning. Supports placed in the environment trigger and order behaviour without relying on the person's impaired internal control. Supports are matched to the person's behavioural style (apathy, disinhibition or mixed) and level of executive impairment. Because they stay in place between visits, they keep working when the therapist is absent. Repeated cued performance is expected to build routines, though the authors found that functional gains faded once home visits stopped. [source: Velligan & Bow-Thomas, 2000 Psychiatric Services; Velligan et al., 2008 Schizophr Bull abstract; Stiekema et al., 2020] The idea that routines become habits is partly [synthesis]: the developers' framing of "automatic" processes appears in a 2012 conference abstract title that is not drawn on [uncertain].

2. Framework

CAT is a single individual treatment with a fixed assessment-to-plan logic. The published papers do not number its phases. The phases below are reconstructed from the trial papers and from the developer's training site, which groups home-visit videos as EFA, early, early-to-middle, and middle-to-late phase. [source: ICEEBP training videos page; Velligan et al., 2000 AJP; finCAT protocol NCT04294719]

Format and dose [source: Velligan et al., 2000 AJP; Velligan et al., 2013 Schizophr Bull (Pharm-CAT); finCAT protocol; Kidd/Canada and Australia in Velligan 2018 symposium abstract]

Individual sessions in the client's home, and at work or day programmes where relevant. Remote delivery is possible (see 4.27).
Weekly visits. The trials used brief weekly visits, and Pharm-CAT visits lasted about 30 minutes. finCAT describes 1–2 hours per week per client while the strategy profile is built.
Total length: 9 months in the original US trials (roughly 36 weekly visits). Canada uses about 4 months by an occupational therapist, then hands over to a caseworker. finCAT used 4 weeks of intensive set-up plus 2 months of staff-led maintenance.
Delivered by bachelor's- and master's-level clinicians, occupational therapists, psychiatric nurses or case managers after CAT certification. Certification is an 18-module, 6.5-hour eLearning course or a 2-day live workshop. Supervision is ongoing, and group supervision is used to generate new strategies.

Phase A: Assessment (about the first 2–4 weeks [synthesis on timing])

Goals: build a profile of cognition, behavioural style, functional needs and home environment.
Contents: neurocognitive testing (4.1), behavioural style rating (4.2), functional assessment (4.3), home environmental assessment (4.4) and goal-setting (4.5).
Move on when: the person can be classified (see the Phase B grid) and has at least one agreed target domain [synthesis].

Phase B: Treatment planning

Goals: choose target domains and match supports to the person's profile.
Classification grid: behavioural style (apathy, disinhibition or mixed) × executive functioning (poor or fair) gives six profiles. [source: finCAT protocol; Velligan et al., 2013]
Plan rules:
- Poor executive function: more structure and larger, brighter, closer, more obvious cues.
- Fair executive function: less structure and subtler cues.
- Apathy: prompt and sequence each step.
- Disinhibition: remove distractors and triggers, redirect, and organise supplies to prevent misuse.
- Mixed: combine both approaches.
- Then adjust for specific attention, memory and fine-motor strengths and weaknesses. [source: Velligan et al., 2000 AJP; Velligan & Bow-Thomas, 2000]
Move on when: you have a written plan with specific supports for 1–3 domains [synthesis on number].

Phase C: Early phase, setting up supports

Goals: install the first supports with the client, and get quick, visible wins in high-priority domains such as medication, hygiene, safety and orientation.
In the Mr C case, brief weekly visits over the first month established the initial supports. [source: Velligan & Bow-Thomas, 2000]
Move on when: the first supports are being used on most days, as checked by observation, checklists, pill counts or reports from others [synthesis].

Phase D: Middle phase, maintaining, modifying and expanding

Goals: at each visit, explain, maintain or change supports. Troubleshoot supports that are not working. Add new domains such as cleaning, leisure, transport, social and role functioning, and work. Encourage strategies the client generates. [source: Velligan et al., 2000 AJP; ICEEBP webinar topics]
Full CAT covers many domains. The 2008 trial found that comprehensive multi-domain supports, not adherence supports alone, produced functional gains. [source: Velligan et al., 2008 abstract]

Phase E: Late phase, consolidation and transition

Goals: build independence (the developers' training lists homework for this), hand over to carers, staff or caseworkers, and plan continued support.
Adherence gains held after visits were withdrawn. Functional gains did not, and the authors concluded that continued intervention may be needed. [source: Velligan et al., 2008 abstract; ICEEBP webinar list; Canada and finCAT handover models]
Exit criteria are not specified in the sources [uncertain]. Suggested criteria: goals reached on the functional measures, supports kept up by the client or a named supporter for several weeks without therapist changes, and a maintenance plan agreed [synthesis].

Outcome monitoring used in studies: Functional Needs Assessment (FNA), Multnomah Community Ability Scale, Life Skills Profile, Goal Attainment Scaling, clutter ratings and pill counts. Use whichever is available locally. [source: Velligan & Bow-Thomas, 2000; Velligan et al., 2000; finCAT protocol]

3. Guiding principles

[source for 1–9: Velligan et al., 2000 AJP; Velligan & Bow-Thomas, 2000; finCAT protocol; for 10–15: Velligan et al., 2013; Stiekema et al., 2020; ICEEBP pages; 16–18 as tagged]

Compensate, do not remediate. Change the environment to fit the brain. Do not drill cognitive skills.
Support at the point of performance. Put the cue where and when the behaviour happens: on the mirror, the drawer, the door or the pill box. Avoid general notes elsewhere.
Supports must work when you are not there. CAT differs from case management in that the support stays in the home all week. If something works only while you are present, it is not a CAT support yet.
Match the behavioural style. Apathy: cue and sequence initiation. Disinhibition: remove distractors and triggers, and limit access to the means of misuse.
Match the executive level. The poorer the executive function, the more structure and the bigger, brighter and closer the cue.
Use individual strengths and weaknesses. For example, use picture checklists when visual memory is better than verbal, audio cues when auditory attention is good, and Velcro for fine-motor problems.
Fight habituation. People stop noticing old signs, so change colour, background or position on a planned schedule.
Assess in the real setting. Rate what you actually see at home, not only what is reported in clinic. Adjust clinic scores using home findings.
Make supports with the client. The client helps choose, make and place supports wherever possible.
Follow the client's goals. Build the plan around goals the person states. If years of institutional care make goal-setting hard, derive goals from assessment answers and keep checking that the client agrees.
Review every visit. At each visit, check whether each support is used, and keep, change or drop it.
Link supports to recovery goals and reinforce. Praise use. Tie adherence and routines to what the person wants, such as a job, staying out of hospital or seeing family.
Remove practical barriers as part of treatment. Examples: side effects raised with the prescriber, prescription pick-ups, missing supplies, sore teeth.
Address many domains. Functional gains needed comprehensive supports across domains.
Plan for maintenance. Gains can fade when support stops, so arrange a handover to staff, family or a caseworker, or continue at low intensity.
Recruit the natural support network. With the client's permission, brief carers and unit staff on the goals and supports so they reinforce rather than undo them. [source: finCAT protocol]
Use Motivational Interviewing style for engagement. It is part of the certification curriculum. How it is integrated is not described in the sources [uncertain].
Safety and fit with the setting. Supplies must be safe and allowed in the setting, and ideally things the person could buy themselves. [source: finCAT protocol]

4. Intervention inventory

This inventory lists every assessment, planning step and support type named in the sources, grouped A (assessment and planning), B (support types), C (domain packages) and D (delivery processes). The specific examples come from the published cases. Example wording is illustrative throughout. The sources print no therapist scripts.

A. Assessment and planning

4.1 Neurocognitive assessment

Purpose: Grade executive functioning as poor or fair and map attention, memory and motor strengths. This sets how much structure and how prominent cues should be. [source: Velligan et al., 2000 AJP; Velligan & Bow-Thomas, 2000; finCAT protocol]
Steps:
1. Give a brief battery covering executive function (planning, flexibility, problem-solving), attention (verbal and visual), memory (verbal and visual) and fine motor skill. In the trials, master's-level psychologists ran the testing and passed results to the CAT therapist. The exact battery and cut-offs used in the manual were not in the sources [uncertain].
2. Classify executive functioning as poor or fair.
3. Note relative strengths, such as Mr V's intact visual memory, and plan to build supports around them.
Example language (illustrative): "These puzzles show me how you take in and remember things. Then I can set up reminders that fit how your brain works best."
Watch for: fatigue and test anxiety. If formal testing is not available, use observed task performance during the EFA and mark the classification provisional [synthesis].

4.2 Behavioural style rating (apathy, disinhibition or mixed)

Purpose: Decide whether a support should cue and start behaviour, or restrain and redirect it.
Instruments: Earlier versions used the Frontal Lobe Personality Scale (46 items covering interest, neglect of tasks, impulsivity, perseveration and derailment). Later and international versions use the Frontal Systems Behavior Scale (FrSBe), which is licensed: use the official forms and do not reproduce items. [source: Velligan & Bow-Thomas, 2000; finCAT protocol; Stiekema et al., 2020]
Steps:
1. Rate from observation at home and from informants such as family or staff.
2. Classify as apathetic (poverty of speech and movement, trouble starting and finishing sequences), disinhibited (distractible, impulsive, misuses objects, off-track) or mixed.
3. Record the classification. The developers report it is stable over 3–6 months.
Example language (illustrative), to an informant: "When he has a task, does he tend not to start it, or start lots of things and get pulled off course?"
Watch for: do not confuse depression or sedation with apathy, or agitation and mania with disinhibition. Check medication effects with the prescriber [synthesis].

4.3 Functional assessment (FNA, later EFA)

Purpose: Identify which activities of daily living are impaired and choose target domains.
Steps:
1. Rate performance across domains: grooming and hygiene, dressing, laundry, care of belongings and living space, meals, shopping and money, medication and appointments, safety and hazard avoidance, transport, leisure, social contact, and work or school.
2. The original FNA had 26 items and was performance-based. Clinic scores were corrected using home findings, so dirty clothes seen at home lowered the dressing and laundry ratings.
3. The current Environmental and Functional Assessment (EFA) combines this with 4.4. Its exact form was not available [uncertain]. [source: Velligan & Bow-Thomas, 2000; Stiekema et al., 2020; ICEEBP]
Example language (illustrative): "Can you show me how you usually get ready in the morning? I just want to see where things are kept."
Watch for: reports of independence that do not match the home. Rate what you see.

4.4 Home (environmental) assessment

Purpose: Find triggers for maladaptive behaviour, safety hazards, missing equipment or supplies, how belongings are organised, and the level of natural support.
Steps:
1. With permission, walk through each room, including bathroom, bedroom, closet, kitchen and the place medication is kept.
2. Note where supplies are, clutter, distractors such as a TV beside the task area, objects that could be misused, and hazards.
3. Rate natural supports: how structured the home is, which tasks others do for the person, and how much family or residence staff understand about mental illness.
4. Also observe how the person carries out goal-directed activities.
Remotely, the client can show areas of the home over video. [source: Velligan et al., 2000; Velligan & Bow-Thomas, 2000; Velligan et al., 2022]
Example language (illustrative): "Would it be OK to look in the bathroom cupboard? I'm checking whether the things you need are easy to reach."
Watch for: shame about the state of the home. Normalise it, go at the client's pace, and never open spaces without consent [synthesis].

4.5 Goal-setting and treatment plan

Purpose: Turn the assessment into a plan with specific, placeable supports.
Steps:
1. Elicit the client's own goals, such as staying out of hospital, getting a job or keeping the flat. Where the client cannot generate goals, propose goals drawn from the EFA and check agreement. [source: Stiekema et al., 2020]
2. Choose 1–3 starting domains. Prioritise safety, medication and the client's top goal, plus a quick win [synthesis].
3. For each domain, pick supports from the classification grid (Section 2, Phase B), then adjust for strengths and weaknesses.
4. Write down each support: what it is, where it goes, the behaviour it cues, and how use will be checked.
5. List the supplies needed. Programmes use flexible funding or adaptive-aid billing for these. [source: Velligan et al., 2022]
Example language (illustrative): "You said you want your sister to stop worrying about you. Which of these would make the most difference to that: meds, getting out of the flat, or keeping the place tidy?"
Watch for: plans the therapist wants but the client does not. Expect low use of supports that are not linked to the client's goals.

B. Support types (the CAT toolkit)

4.6 Signs at the point of action

Purpose: Prompt the start or the completion of a single behaviour at the place it happens. These are mainly for apathy.
Steps:
1. Write a short prompt, often as a question to self.
2. Place it where the behaviour happens. Examples from the sources: on the bathroom mirror; at the bottom of the underwear and sock drawers (laundry cue: an empty drawer exposes the sign).
3. Size and colour it by executive level: poorer executive function means larger, brighter and closer.
4. Have the client help write or decorate it. [source: Velligan & Bow-Thomas, 2000; finCAT]
Example language (illustrative): "Where would you be standing when you need to remember this? Let's put it right there."
Watch for: checking whether the target behaviour happens, not whether the sign is still up.

4.7 Checklists for multi-step tasks

Purpose: Sequence tasks with several steps, such as tooth-brushing, showering, appearance before leaving, cooking and cleaning.
Steps:
1. Break the task into concrete steps by watching the client do it, not from theory.
2. Make a list in words or pictures. Picture checklists suit poor verbal skills or a visual memory strength, as with Mr V.
3. Mount it at the task site. Mr C had an appearance checklist on a full-length mirror on the bathroom door.
4. Optionally add tick boxes or a dry-wipe surface so the client can track completion, which also gives you data. [source: Velligan et al., 2000; Velligan & Bow-Thomas, 2000]
Example language (illustrative): "Talk me through brushing your teeth step by step, and I'll write it down the way you say it."
Watch for: lists that are too long. Shorten them, and later combine steps as routines strengthen [synthesis].

4.8 Placing equipment and supplies in view

Purpose: Put the materials themselves where they cue the task.
Steps: Group the supplies for a task into one container and place it at eye level at the task site. Examples: a basket on the bathroom mirror with toothbrush and toothpaste; a large bright basket at eye level for shower supplies; a comb attached to a mirror with a sign. [source: Velligan & Bow-Thomas, 2000; Velligan et al., 2000; finCAT]
Example language (illustrative): "If your toothbrush were sitting right here when you washed your face, would you be more likely to use it?"
Watch for: supplies running out. Add a restock cue (4.17).

4.9 Organising belongings

Purpose: Reduce search demands and loss of items, and make the right item the obvious one.
Steps:
1. Reorganise closets and cupboards with the client so frequently used items are easy to reach.
2. Provide a single file box for important papers so documents can be found for appointments.
3. Use a waist pack or other single carry-pouch for belongings taken outside, to stop items being lost.
4. Have one fixed spot for keys and other essentials. Clients may invent their own spots, such as Mr C leaving his class book by the door. [source: Velligan & Bow-Thomas, 2000]
Example language (illustrative): "Let's give your important papers one home, so when the clinic asks for your ID you always know where it is."
Watch for: the system drifting back into disorder. Review it each visit.

4.10 Packaging clothing into complete outfits

Purpose: Prevent layering, mismatched or season-inappropriate dressing. This is mainly for disinhibition.
Steps:
1. Remove ill-fitting and out-of-season items, with the client's agreement, and store them elsewhere.
2. Assemble complete outfits into separate containers or closet boxes, labelled by day of the week.
3. Rotate seasonal clothing at planned points. [source: Velligan et al., 2000; Velligan & Bow-Thomas, 2000]
Example language (illustrative): "What if each day had its own box, so the morning decision is already made?"
Watch for: distress about clothes being removed. Store them rather than discard, and keep the client in control.

4.11 Removing distractors, triggers and means of misuse

Purpose: For disinhibition, cut stimuli that pull the person off-task or invite misuse or unsafe behaviour.
Steps:
1. Identify triggers from 4.4, such as items used inappropriately (Mr V cleaned his ears with paper clips), a TV or radio by the task area, or clutter.
2. Agree with the client to remove or relocate them.
3. Provide the appropriate substitute next to where the misuse happened, such as washcloths for ear cleaning.
4. At work, set up a workspace with distractions removed and obvious cues for work behaviour. [source: Velligan & Bow-Thomas, 2000; Velligan et al., 2000]
Example language (illustrative): "Paper clips can hurt your ears. Can we swap them for these cloths and keep the clips in the office?"
Watch for: autonomy. Removal must be negotiated and not imposed. Take care with hazards that may suggest self-harm risk, and assess per standard practice (Section 5).

4.12 Labels and colour-coding

Purpose: Make categories and locations visible without relying on memory.
Steps: Label drawers, shelves and containers. Use colour-coded bins, for example separate colours for clean and dirty laundry. Use a consistent colour per domain if helpful [synthesis]. [source: Velligan et al., 2000]
Example language (illustrative): "Blue bin for clean, red for dirty. Want to pick the colours?"
Watch for: clean and dirty laundry mixing again, which suggests the bins are too far apart or poorly placed.

4.13 Alarms and electronic cueing devices

Purpose: Cue behaviour that depends on time, such as medication, appointments and leaving the house.
Steps:
1. Choose the device. The sources name medication containers with alarms, tape recorders, and menu-driven electronic cooking instructions. Later work uses phones and other technology, particularly with young people.
2. Set the cue at the time and place of the behaviour, and pair it with a sign or checklist at the site.
3. Teach the client to respond to it and practise in the session. [source: Velligan et al., 2000; Velligan & Bow-Thomas, 2000; Velligan et al., 2013; 2018 symposium (Australia)]
Example language (illustrative): "When this beeps at 8, the box is right here. Let's try it now."
Watch for: alarms switched off or ignored. Change the tone, the timing or the device, or link the alarm to an existing routine such as breakfast.

4.14 Audio self-recordings

Purpose: Give a portable cue in the client's own voice for a situation, especially when auditory attention is good or memory is weak.
Steps: Help the client record a short personal reminder they can play in the situation. Mr C recorded that his thoughts were private and played it on the bus, where he feared others could hear his thoughts. Audiotapes to sequence behaviour are also listed. [source: Velligan & Bow-Thomas, 2000; finCAT]
Example language (illustrative): "What would you want to remind yourself of when you're on the bus and that worry starts? Say it in your own words and we'll record it."
Watch for: the recording becoming reassurance-seeking or arguing with delusions. Keep it short, agreed and coping-focused, and coordinate with any CBTp clinician [synthesis].

4.15 Calendars, schedules and orientation aids

Purpose: Support orientation to date and time and organise weekly tasks.
Steps:
1. Orientation: Mr V had a large bedside calendar with a marker to cross off each day at bedtime, plus a watch.
2. Weekly tasks: put recurring tasks such as laundry on a weekly activity schedule, or a cleaning calendar with prompts.
3. Use a notebook for appointments and for questions to ask the prescriber. [source: Velligan & Bow-Thomas, 2000; finCAT; Velligan et al., 2013]
Example language (illustrative): "Every night before bed, cross off today. Then tomorrow morning you'll know the date at a glance."
Watch for: calendars that are not being used. Check whether days are being crossed off, and ask orientation questions.

4.16 Adaptive and sensory accommodations

Purpose: Remove physical or sensory barriers that make a task aversive or impossible.
Steps:
1. Ask why a task is avoided before assuming apathy. Mr V refused to brush his teeth because his teeth were sore.
2. Provide the fix: an extra-soft toothbrush and toothpaste for sensitive teeth, or Velcro instead of buttons for fine-motor problems.
3. Refer on to dental or medical care where needed [synthesis]. [source: Velligan & Bow-Thomas, 2000; Velligan et al., 2000]
Example language (illustrative): "Is there anything about brushing that's uncomfortable or annoying?"
Watch for: physical-health problems that look like 'negative symptoms'. The developers run training on supporting physical health. [source: ICEEBP webinar list]

4.17 Rotating and refreshing cues

Purpose: Stop people tuning out cues that never change.
Steps:
1. Change sign colours and backgrounds on a schedule. Mr C's were changed every other visit.
2. Use fluorescent colours for poor attention.
3. Move or resize a cue that has stopped working.
4. Add a restock cue, such as a sign at the bottom of a supply basket, so supplies do not run out [synthesis]. [source: Velligan & Bow-Thomas, 2000; finCAT]
Example language (illustrative): "This sign has been up a while. Let's give it a new colour so it catches your eye again."
Watch for: a drop in the target behaviour after weeks of success, which is often habituation.

C. Domain packages (combine B-tools per domain)

4.18 Medication and appointment adherence (the Pharm-CAT core)

Purpose: Improve adherence to oral medication and attendance at appointments. Pharm-CAT is the stand-alone version and full CAT includes this domain. [source: Velligan et al., 2008; Velligan et al., 2013]
Steps:
1. Assess where and how medication is kept, current routines, organisation problems and triggers that disrupt dosing or appointments.
2. Set up a pill container. The client fills it with you, and remotely clients filled pillboxes under video guidance.
3. Pair the container with an alarm, a sign at the site, and a checklist or calendar to tick doses.
4. Provide a notebook for appointment dates and questions for the prescriber.
5. Solve side-effect problems. Example from the source: ask the prescriber whether a sedating medicine can be taken at night. Never adjust doses yourself.
6. Handle logistics only where they affect adherence, such as prescription pick-up and transport to the clinic.
7. Reinforce adherence socially and link it to the client's recovery goals.
8. Check with pill counts or tick-sheets at each visit.
Pharm-CAT visits were weekly and about 30 minutes. [source: Velligan et al., 2013; Velligan et al., 2022]
Example language (illustrative): "Taking these is part of how you keep your job. Let's make it so the box reminds you, not your mum."
Watch for: stockpiling or large supplies in the home when there is suicide risk. Agree safe storage, such as a weekly-filled box with the rest held by a carer or pharmacy, under standard risk procedures [synthesis]. Persistent non-adherence may reflect beliefs about medication rather than memory (Section 5).

4.19 Hygiene and grooming

Purpose: Daily tooth-brushing, showering, combing hair and a tidy appearance.
Steps: Combine 4.6–4.8 and 4.16:
- a supply basket on the mirror
- a self-question sign
- a step checklist (in pictures if needed)
- a full-length mirror with an appearance checklist or a comb attached
- an eye-level shower basket. Track completion daily, with informant checks if available. [source: Velligan & Bow-Thomas, 2000; finCAT]
Example language (illustrative): "Before you head out, the mirror checklist is your last stop."
Watch for: informant reports of how many days the person looked neat. The case study used family reports of neat days per week.

4.20 Dressing and laundry

Purpose: Appropriate, clean, weather-suitable clothing.
Steps: Use day-labelled outfit containers (4.10), remove problem items, put colour-coded clean and dirty bins (4.12), and add laundry to the weekly schedule. Put signs at the bottom of underwear and sock drawers so that an empty drawer cues washing. [source: Velligan et al., 2000; Velligan & Bow-Thomas, 2000; finCAT]
Example language (illustrative): "When you see this sign, it means it's laundry day."
Watch for: staff or family doing the task for the person. Agree whether the goal is independence or a supported routine.

4.21 Care of living space: cleaning and clutter

Purpose: A safe, usable home, and in inpatient settings an organised room.
Steps:
- a cleaning calendar with prompts
- step-by-step instructions attached to cleaning supplies
- bins in plain sight where wrappers collect, with prompts to use them
- reorganising belongings (4.9) Clutter can be rated with a clutter image scale (the CIRS in finCAT). [source: Velligan & Bow-Thomas, 2000; finCAT]
Example language (illustrative): "Monday's job is just the kitchen counter. The steps are on the spray bottle."
Watch for: hoarding-level clutter, which needs a separate, graded plan [synthesis].

4.22 Leisure and structured activity

Purpose: Reduce empty time, boredom and isolation. Boredom at home was a presenting problem for Mr C.
Steps:
1. Make a large, colourful list of activities for when bored and put it in a prominent spot (Mr C's was on the fridge).
2. Provide the means: a bicycle, movie tickets, comic books, a radio.
3. Connect the person to structured activity such as a class or a psychosocial group.
4. Track hours out of the home. Mr C went from 3 to 12 hours a week. [source: Velligan & Bow-Thomas, 2000; ICEEBP webinar list]
Example language (illustrative): "When you're bored at home, what's one thing on this list you'd actually enjoy?"
Watch for: whether the person begins to choose from the list mentally without looking. Mr C did this by 3 months, which is a sign of internalisation.

4.23 Community mobility and transport

Purpose: Independent travel to activities, work and appointments.
Steps: Provide a bus pass. Agree landmark cues along the route to reduce distraction and getting lost. Practise the route together. Use portable cues such as a waist pack or audio reminders. [source: Velligan & Bow-Thomas, 2000] Practising the route together is [synthesis].
Example language (illustrative): "When you see the red petrol station, that's your stop next."
Watch for: symptom-driven fear on transport (see 4.14) and safety on the route.

4.24 Work, school and role functioning

Purpose: Support getting and keeping work or study. Recent-onset adaptations focus on returning to work or school and use more technology.
Steps:
1. Assess the workplace or study environment.
2. Set up the workspace with distractions removed and obvious cues for work behaviour.
3. Use phone reminders and task checklists for job routines.
4. Coordinate with vocational services [synthesis]. [source: Velligan & Bow-Thomas, 2000; Velligan 2018 symposium abstract] The vocational CAT paper (Allott et al.) is not drawn on [uncertain].
Example language (illustrative): "Let's make the first ten minutes of your shift automatic: this card lists the order."
Watch for: disclosure. Agree with the client what the employer is told before any workplace visit [synthesis].

4.25 Safety and hazard reduction

Purpose: Remove hazards found in the home assessment and support safe routines.
Steps: Use the 4.4 findings. Remove or secure hazards and objects being misused, provide safe substitutes, and add signs for safety steps such as turning off the stove [synthesis on stove example]. [source: Velligan et al., 2000; Velligan & Bow-Thomas, 2000]
Example language (illustrative): "Let's put a 'Stove off?' check by the door, the same place you look for your keys."
Watch for: checking routines turning into compulsive checking [synthesis].

4.26 Meals and food preparation

Purpose: Regular meals and safe cooking.
Steps: Use menu-driven electronic cooking instructions or step-by-step recipe cards at the stove, supplies organised in view, and a shopping list kept in a fixed place [synthesis on list]. Remote programmes delivered groceries during illness. [source: Velligan et al., 2000; Velligan et al., 2022] Specific nutrition targets are outside CAT.
Example language (illustrative): "This card has three steps for your eggs. It lives right here by the hob."
Watch for: stove safety (4.25).

D. Delivery processes

4.27 Remote CAT

Purpose: Deliver CAT when home visits are not possible.
Steps:
1. Do the EFA by video, with the client showing areas of the home.
2. Mail supplies such as containers and signs, and guide placement and use by video.
3. Guide pillbox filling remotely.
4. Make visits shorter and more frequent to keep engagement.
5. Add virtual activities such as tours, cooking and exercise videos, and groups. [source: Velligan et al., 2022]
Example language (illustrative): "Hold the phone so I can see the cupboard. Great. Now put the basket on the left shelf."
Watch for: technology barriers. The developers name these as the main obstacle for both clients and therapists.

4.28 Weekly review, maintenance and troubleshooting

Purpose: The core activity of every visit after set-up.
Steps:
1. Check each support: is it in place, is it being used, is the target behaviour happening (look at checklists, pill counts, the room)?
2. Praise use.
3. For a support that is failing, decide why: wrong place, too subtle for the executive level, habituation, the wrong behavioural-style strategy, missing supplies, or a client who does not value the goal.
4. Change one thing at a time.
5. Add a new domain when current ones are stable.
Interventions are explained, maintained or altered at each weekly visit. The developers also train on designing interventions around executive functioning and troubleshooting ineffective ones. [source: Velligan et al., 2000; ICEEBP webinar list] The step order is [synthesis].
Example language (illustrative): "The tick sheet shows Tuesdays and Thursdays got missed. What was different on those days?"
Watch for: adding supports without retiring any. Too many cues compete with each other [synthesis].

4.29 Social reinforcement and linking to goals

Purpose: Strengthen use of supports and motivation.
Steps: Give specific praise at each visit, link progress explicitly to the client's goals, and use electronic messages where available. [source: Velligan et al., 2013] MI-consistent engagement is part of certification training, but the detail is not drawn on [uncertain].
Example language (illustrative): "Nine out of ten mornings this week. That's the routine that's going to get you through a work shift."
Watch for: reinforcement that sounds patronising. Match the person's age and preferences.

4.30 Client-generated strategies and homework

Purpose: Build independence and generalisation.
Steps: Invite the client to create their own strategies (Mr C put his class book by the door) and adopt the ones that work. Set small between-visit tasks, such as setting up a cue for a new task. [source: Velligan & Bow-Thomas, 2000; ICEEBP webinar list on homework] The homework format is [uncertain].
Example language (illustrative): "You came up with the book-by-the-door idea yourself. Where else could that trick help?"
Watch for: client-made supports used without prompting, which is a sign of transfer.

4.31 Briefing carers and staff

Purpose: Make sure the natural support network reinforces supports and does not undo them.
Steps:
1. With the client present and consenting, explain CAT, the client's goals and each support to family or residence or unit staff.
2. Agree who restocks, who prompts and who reports.
3. Use informants for outcome data.
In the Dutch trial the whole team supported CAT use. [source: finCAT protocol; Stiekema et al., 2020; Velligan & Bow-Thomas, 2000]
Example language (illustrative): "These are Sam's boxes for the week. If they're empty on Sunday, that's the cue for laundry. Please don't refill them for him."
Watch for: staff doing tasks for the person, or tidying supports away.

4.32 Handover and maintenance

Purpose: Keep gains after intensive CAT, since functional gains faded once visits were withdrawn.
Steps: Follow one of the models in the sources:
- Canada: about 4 months of OT-delivered CAT, then training the caseworker to continue.
- finCAT: 2 months of maintenance by trained unit 'champions' with clinician support.
- Continue at lower frequency. Transfer the written plan and supplies list, and do joint visits [synthesis]. [source: Velligan et al., 2008; 2018 symposium abstract; finCAT protocol]
Example language (illustrative): "Alex will be checking your boxes from next month. Let's show her how everything works."
Watch for: supports deteriorating within weeks of handover. Schedule booster checks [synthesis].

4.33 Setting adaptations

Purpose: Apply CAT outside outpatient homes.
Variants named in sources:
- Long-stay residential care: delivered by nurses within routine contacts, with a manual slightly adapted (Netherlands).
- Forensic inpatient units: focused on room organisation and hygiene, using supplies allowed on the unit (finCAT).
- Moving from nursing home to community: combined with substance-use treatment and service coordination.
- People who use hospitals and emergency services heavily: CAT used to identify the causes of repeated admissions and set up supports.
- First-episode psychosis: more technology, with work and school goals. [source: Stiekema et al., 2020; finCAT; 2018 symposium abstract] A multimodal CAT variant is listed by the developers, but the paper is not drawn on [uncertain].
Watch for: instability in acute settings. Unplanned discharges and room changes undermined inpatient CAT. [source: finCAT]

5. Handling problems

The sources say little about problem-handling. Items tagged [source] are documented. Everything else is [synthesis] grounded in CAT's own planning rules (Section 2, Phase B).

Supports are installed but not used (stuck progress)

Work through the troubleshooting order in 4.28.
Cue too subtle for the executive level: make it bigger, brighter and closer, or add an alarm. [source: Velligan et al., 2000]
Habituation: rotate colours or positions. [source: Velligan & Bow-Thomas, 2000]
Wrong strategy for the behavioural style. An apathetic client needs initiation cues, not just a tidier room. A disinhibited client needs distractors removed, not more signs. [source: planning rules] [synthesis in application]
The goal is not the client's own. Go back to the client's goals (4.5). [source: Stiekema et al., 2020 noted goals did not always reflect intrinsic motivation]
Change one variable per week [synthesis].

Apathy and low engagement with visits

Keep visits brief and predictable, and bring the supplies yourself.
Do the first set-up together in the session so the client gets an immediate success.
Use MI-consistent elicitation of goals; MI is part of the certification curriculum, but how it is integrated is not drawn on [uncertain].
When visits were remote, shorter and more frequent contacts helped keep people engaged. [source: Velligan et al., 2022]
Developer training covers maintaining momentum and goal focus. [source: ICEEBP webinar list]

Resistance to changes in the home, privacy and stigma [synthesis]

Ask before moving, removing or posting anything.
Store removed items rather than discarding them.
Offer discreet versions for visible areas, such as a phone alarm instead of a sign by the front door, or a small symbol the client understands.
Let the client design or word cues.
Accept a smaller plan rather than impose one. The client's home is their territory, and a refused support is information for the plan, not defiance.

Paranoia or suspicion about home visits and 'monitoring'

finCAT excluded people with high paranoia and called home-based CAT "more problematic" for them. [source: finCAT protocol]
Response [synthesis]:
- Be fully transparent about what you record and who sees it.
- Give the client control over which rooms you enter.
- Use cues that do not look like surveillance, such as the client's own handwriting or voice.
- Avoid pill counts the client experiences as checking up; use self-tick sheets instead.
- Coordinate with the treating team, and with CBT for psychosis if available. Mr C's self-recorded reassurance is one documented way CAT supports coping with symptom-related fear. [source: Velligan & Bow-Thomas, 2000]

Overwhelm (too many cues, cognitive overload) [synthesis]

Start with 1–3 domains.
Keep checklists short.
Remove supports once a routine is solid, before adding others.
Poorer executive function calls for more structure, not more items, so simplify the environment rather than adding to it.

Non-adherence to medication despite supports

Separate 'forgets' from 'chooses not to'.
CAT supports address forgetting and disorganisation.
For side effects: plan with the client and contact the prescriber, for example about taking a sedating medicine at night. [source: Velligan et al., 2013]
For attitudinal non-adherence, add MI or adherence-focused psychoeducation and refer to the prescriber [synthesis].
Never adjust medication.
Note that better adherence in Pharm-CAT did not by itself improve symptoms or functioning, so keep functional domains in the plan. [source: Velligan et al., 2013; Velligan et al., 2008]

Disinhibited misuse of supports or supplies

Organise supplies to prevent misuse: one outfit per box, and only the needed items within reach. [source: Velligan et al., 2000]
Lock away or relocate tempting items by agreement.
Use redirection cues [source: Velligan et al., 2000; Velligan & Bow-Thomas, 2000].

Carers or staff undo the plan

Brief them with the client present (4.31). [source: finCAT]
Agree roles in writing [synthesis].
In residential settings, staff time and attitudes affected delivery. [source: Stiekema et al., 2020]

Clients who cannot set goals (long institutionalisation)

Derive goals from the CAT intake instruments, then check them repeatedly with the client and revise as preferences emerge. [source: Stiekema et al., 2020]

Relapse or symptom exacerbation during CAT

Refer clinical concerns to the treating team; in trials, therapists passed concerns to clinic staff. [source: Velligan et al., 2000]
Pause new domains and keep only the essentials going, such as medication, food and hygiene.
Brief family on increased supervision needs. In one trial relapse, family provided 24-hour supervision. [source: Velligan et al., 2000]
Resume the plan after stabilisation [synthesis].

Suicide or self-harm risk emerging [synthesis, standard practice]

CAT does not address risk directly.
If risk indicators appear, do a structured risk assessment per local policy, inform the treating team, and complete a safety plan.
Apply lethal-means counselling to home supports: keep only short-term medication supplies in the home, with the rest held by a carer or pharmacy. Remove or secure hazards found in the home assessment.

Ruptures in the working relationship [synthesis]

Common triggers in home-based work: a support the client experienced as controlling, a therapist who moved belongings without asking, or missed visits.
Name the rupture and apologise for your part.
Restore the client's control by letting them choose what stays, goes or changes.
Simplify the plan to what they value.

Gains fade after the programme ends

This is documented: functional gains were not maintained at 6-month follow-up. [source: Velligan et al., 2008]
Plan a handover from the start (4.32).
Leave supports in place, and train a caseworker, carer or staff member to keep them up.
Schedule booster visits [synthesis].

Unstable housing, room moves or abrupt discharge

In acute inpatient settings, unplanned discharges and room changes disrupted CAT. [source: finCAT]
Use portable supports (waist pack, phone alarms, a pill container that travels with the person), and re-set up quickly in the new setting [synthesis].

Remote delivery problems

The main barrier was lack of suitable technology and unfamiliarity with it, for both clients and providers.
Responses: shorter, more frequent visits; mailed supplies; video-guided set-up; and group supervision to generate ideas. [source: Velligan et al., 2022]

Who may not suit CAT

In the Dutch trial, older participants and those with more positive symptoms were less likely to take part or complete. [source: Stiekema et al., 2020]
Consider stabilising symptoms first or adding CBTp, and offer a narrower plan [synthesis].

Practitioner difficulties [source: ICEEBP webinar list names practitioner anxiety] [synthesis for responses]

Home visits bring anxiety, boundary questions and safety concerns.
Responses:
- Follow lone-working policy and check in with the team before visits (finCAT used check-ins and alarms on units).
- Use group supervision.
- Keep the goal of each visit explicit.

Funding for supplies

Programmes used flexible funds, donations or adaptive-aid billing. [source: Velligan et al., 2022]
Prefer cheap items the client could buy themselves. [source: finCAT]

Sources

Sources:

Further reading (not drawn on) [uncertain where relied on]:

Velligan, D. I. (2000). Cognitive Adaptation Training: The use of compensatory strategies in the psychosocial rehabilitation of patients with schizophrenia (therapist manual). UTHSCSA, Department of Psychiatry.
Maples, N. J., & Velligan, D. I. (2008). Cognitive adaptation training: establishing environmental supports to bypass cognitive deficits and improve functional outcomes. American Journal of Psychiatric Rehabilitation, 11, 164–180.
Draper, M. L., Stutes, D. S., Maples, N. J., & Velligan, D. I. (2009). Cognitive adaptation training for outpatients with schizophrenia. Journal of Clinical Psychology, 65, 842–853 (abstract only).
Velligan, D. I., et al. (1996). Preliminary evaluation of cognitive adaptation training to compensate for cognitive deficits in schizophrenia. Psychiatric Services, 47, 415–417.

Further reading (not drawn on): the Europe PMC search, PMC copies of the Stiekema 2015 protocol and Velligan 2008, and the HSE (Ireland) CAT page and leaflet.

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