Research Article

British Journal of Occupational Therapy

2020, Vol. 83(5) 316–325
Describing and measuring the ‘switch-on’ ! The Author(s) 2019
Article reuse guidelines:
effect in people with dementia who participate sagepub.com/journals-permissions
DOI: 10.1177/0308022619899301
in cognitive stimulation therapy: A mixed journals.sagepub.com/home/bjot

methods study
Qi Liu1 , Margaret Jones2, Clare Hocking2

Abstract
Introduction: Cognitive stimulation therapy is an evidence-based group intervention for promoting cognition and quality of life in
people with dementia. This New Zealand study aimed to describe and measure the ‘switch-on’ effect, a recently reported benefit
involving enhanced participation.
Method: A convergent parallel mixed methods design was implemented. Interviews guided by qualitative descriptive method-
ology were conducted with four community-dwelling men with mild dementia and their wives, before, during and after cognitive
stimulation therapy. Concomitantly, participants with dementia were scored on the Volitional Questionnaire following a single-
subject A–B design. Qualitative and quantitative data were analysed using NVivo-assisted thematic analysis and descriptive
statistics respectively and conjointly.
Findings: ‘Switch-on’ was found to be multi-dimensional in nature, with increased engagement and expanded scope in Doing,
Feeling, Relating, and Thinking and Reflecting. ‘Switch-on’ occurred with a noticeable onset within 3 weeks, which was sustained
and consolidated towards completion of cognitive stimulation therapy in both group and home environments. Three men showed
concurrent improvements on the achievement sub-scale of the Volitional Questionnaire. However, the measure did not effectively
capture ‘switch-on’ due to its ceiling effect.
Conclusion: Findings about ‘switch-on’ suggest broader, under-researched benefits of cognitive stimulation therapy that merit
further exploration from an occupational therapy perspective.

Keywords
Cognitive stimulation therapy, dementia, the ‘switch-on’ effect, occupational participation, the Volitional Questionnaire,
mixed methods, occupational therapy
Received: 5 July 2019; accepted: 16 December 2019

Introduction
participation (Cheung and Peri, 2014; Spector et al.,
Occupational therapists are making valuable contribu- 2011). A fuller explanation of the effect will be provided
tions to the research, training, promotion and delivery of in the Background. This paper reports an exploratory
cognitive stimulation therapy (CST) (Murray et al., mixed methods study of ‘switch-on’ and how it might
2016; Streater et al., 2017; Yuill and Hollis, 2011), be measured.
which is an activity-based social group for people with
mild to moderate dementia. The embedded principles of
CST, ‘respectfulness of individuality, recognition of Background
capacity for self-determination, encouragement of par- CST is one of the few evidence-based, non-pharmaco-
ticipation in meaningful activities, and optimization of logical interventions for people with mild to moderate
overall well-being’ (Yuill and Hollis, 2011: 168), are con-
gruent with the philosophy, values and practice of occu-
1
pational therapy. While there is mounting evidence that Mental Health Services for Older People, Auckland District Health Board,
it improves cognitive function, no study has satisfacto- Auckland, New Zealand
2
School of Occupational Science and Therapy, Auckland University of
rily investigated the occupational benefits of CST. That
Technology, Auckland, New Zealand
knowledge gap puts occupational therapists’ involve-
Corresponding author:
ment into question. However, the recently reported Qi Liu, Mental Health Services for Older People, Ground Floor, Building
‘switch-on’ effect of CST is described in occupational 14, Greenlane Clinical Centre, Greenlane, Auckland 1051, New Zealand.
terms, including enhanced capabilities and social Email: [email protected]
Liu et al. 317

dementia (Spector et al., 2003; Woods et al., 2012). CST ‘Switch-on’ comprised a cluster of positive behavioural
falls into the category of cognitive stimulation for people changes noted in some CST attendees that were consis-
with dementia that aims at ‘general enhancement of cog- tent with the confirmed benefits of CST in quantitative
nitive and social functioning’ through engagement with research (Spector et al., 2010; Woods et al., 2012).
a variety of activities and discussions, usually in a small Changes included ‘a sense of being more switched on
group setting (Woods et al., 2012: 3). CST has potential or wanting to attend to things more’ (Spector et al.,
for use alongside a reablement approach that aims to 2011: 948), and having ‘new-found confidence, capabil-
alleviate the functional impact of dementia on people’s ities and vastly improved communication skills’ (Cheung
lives. Indeed, Poulos et al. (2017: 452) state, ‘interven- and Peri, 2014: 7).
tions providing opportunities for social interaction, gen- Of note, the term ‘switch-on’ seems to reflect an
eral stimulation, or other pleasurable activities can be observer’s standpoint in representing the changes,
applied alongside reablement’. which may not be viewed as dementia friendly. An
CST offers a manualized, 7-week, twice-weekly group equivalent, more subjective label for the effect used by
programme of themed, enjoyable activities and discus- participants with dementia in Cheung and Peri’s (2014)
sions, the contents including physical, number and word study was ‘stimulation’ or ‘feeling stimulated’ (21).
games, ‘childhood’, ‘sounds’, ‘food’, ‘current events’, Spector et al. (2011) associated ‘switch-on’ with
‘being creative’, ‘using memory’ and so on (Spector improved concentration and alertness, which are com-
et al., 2005: 5). CST is delivered in a supportive environ-
monly reported cognitive benefits of CST, whereas
ment designed to optimize cognitive and social perfor-
Cheung and Peri (2014) regarded it as a more satisfying
mance. Originally developed in the United Kingdom,
outcome of social engagement, a non-specific therapeu-
CST has been applied and researched worldwide, includ-
tic element of participation in CST. While the nature
ing in New Zealand (Cheung and Peri, 2014).
and scope of the effect have not yet been clearly delin-
CST targets global stimulation of cognition and was
eated, three further studies using a qualitative or mixed
primarily devised based on two precedent psychosocial
methods design have described similar positive changes
interventions for people with dementia (Spector et al.,
(Bailey et al., 2017; Kelly et al., 2017; Murray et al.,
2001), Reality Orientation (Spector et al., 2000), and a
2016). This suggests that ‘switch-on’ might be a
French version of cognitive stimulation (Breuil et al.,
1994). CST developers extracted the technique of repeat- common but less recognized benefit of CST.
edly presenting orientation information to enhance The observed behavioural change of ‘wanting to’ pay
memory from Reality Orientation; they then trans- more attention to things and having enhanced confi-
formed its rigid and insensitive style into a person- dence and capabilities suggests a volitional component
centred programme (Spector et al., 2001). Following to the ‘switch-on’ effect. This is an important possibility
Breuil et al.’s (1994) cognitive stimulation, CST taps to explore because apathy or lack of motivation is the
into implicit memory and implicit learning, relatively most prevalent behavioural symptom in people with
well-preserved realms of cognitive function in people Alzheimer’s type dementia (Dyer et al., 2018). Recent
with dementia (American Psychiatric Association, research in cognitive neuroscience, psychology and
2013); however, it was adapted into a light-hearted, ageing has also found some evidence of interactions
non-threatening delivery from its original clinical between motivation and cognition (Braver et al., 2014).
approach (Spector et al., 2001). Despite that, no study has yet explored the impact of
A wealth of quantitative studies, including random- CST, a cognitive intervention, on the person’s motiva-
ized controlled trials, have examined specific cognitive tion or volition, as indicated in the existing knowledge of
domains and discrete outcome areas for people who ‘switch-on’.
attended CST (Hall et al., 2013; Piras et al., 2017; That research gap indicated the need for a more com-
Spector et al., 2003, 2010). The evidence generated dem- plete understanding of the therapeutic outcomes of CST,
onstrates that CST promotes cognitive function, partic- including the ‘switch-on’ effect, from a holistic, occupa-
ularly language, memory and orientation, and self-rated tional perspective (Law et al., 1996; Taylor, 2017;
quality of life for people with mild to moderate dementia Townsend and Polatajko, 2007). The limited knowledge
(Hall et al., 2013; Piras et al., 2017; Spector et al., 2003; about ‘switch-on’ required an inductive qualitative
Woods et al., 2012). An earlier study found that research approach to obtain a ‘thick’ description about
improved subjective quality of life following CST was the effect. To examine the hypothetical correlation
mediated by improved cognition and reduced depression between volition and ‘switch-on’, an occupation-
(Woods et al., 2006). However, no further research has focused measure of volition, the Volitional
explored the therapeutic effects on cognition, mood and Questionnaire (VQ) (de las Heras et al., 2007), was
quality of life using a more dynamic or holistic selected. Three research questions were formulated:
approach.
Only five qualitative and mixed methods studies have • What is the nature of the ‘switch-on’ effect as described
hitherto explored the broader benefits of CST, two of by people attending CST and their family or caregivers?
which described ‘switch-on’ as a favourable outcome • At what time-points during and after the group is the
(Cheung and Peri, 2014; Spector et al., 2011). ‘switch-on’ effect reported?
318 British Journal of Occupational Therapy 83(5)

• Are the changes described as the ‘switch-on’ effect mea- Dementia Auckland, a non-government community
surable using the VQ? organization that offers CST to people with dementia
in the greater Auckland area, was identified and
Method approached as a suitable CST provider for the study.
The staff involved in delivering CST were provided
Study design with a full briefing about the study design and aims
prior to recruiting four men with mild dementia and
A convergent parallel mixed methods design (Creswell, their wives from a CST group run between 27 March
2014) merging qualitative descriptive methodology 2017 and 11 May 2017. The staff explained the research
(Stanley, 2015) and a single-subject A–B design (Carter project to people with dementia and their family who
and Lubinsky, 2015) was implemented. Driven by the met the inclusion criteria. Their verbal consent was
single-subject design, qualitative and quantitative data obtained to forward contact details to the researcher.
were collected concomitantly at participants’ homes at Six people with dementia and five family members
three time-points: before commencement of CST (time expressed interest and four couples were finally recruited
1); during the third week of CST (time 2) and within a to the study. Facilitation of the programme closely fol-
week after completion of CST (time 3). Quantitative and lowed the CST manual (Spector et al., 2005), which
qualitative data were analysed using their respective ana- allows some flexibility in the choice of activities in
lytic methods separately and then conjointly. response to the specific programme participants. All par-
Considering the scant knowledge about ‘switch-on’, ticipants provided written informed consent for partici-
more weight was placed on the qualitative component pating in the research. None of the study authors were
of the study. involved in running the CST group.
Ethics approval was obtained for the study from the
Auckland University of Technology Ethics Committee Data collection
in 2016 (reference number 16/396).
All data were gathered by the first author. The demo-
Measures graphic information of participants with dementia,
including age, ethnicity, education, past occupations
The Volitional Questionnaire (de las Heras et al., 2007) and relationship with their caregiver, was collected at
was selected as a possible measure of ‘switch-on’ because first contact. Qualitative data collection involved con-
of its theoretical foundation in the Model of Human ducting semi-structured interviews of the eight partici-
Occupation (Taylor, 2017) and the alignment observed pants at the three time-points, using the same set of
between most items in the measure and the descriptions open-ended questions. These explored the men’s engage-
about ‘switch-on’ in CST literature. The instrument has ment with daily activities, including their interests, rou-
good construct validity, internal validity and intra-rater tines, feelings, concentration and communication with
reliability (Chern et al., 1996; Li and Kielhofner, 2004). others. For example, ‘What are some of the things you
The Addenbrooke’s Cognitive Examination – III have been doing over the last month?’ ‘How do you
(ACE-III) is a commonly used neuropsychological test spend your time on a typical day?’ and ‘Have you
with sound psychometric properties for screening cogni- noticed any changes?’ Questions to family members
tive impairment and dementia diagnosis (Hsieh et al., were framed in relation to their observation of their
2013). The ACE-III was used in this study for estimating spouse. Participant recall was supported by conducting
cognitive function and severity of dementia of the par- interviews in their own homes, where there were familiar
ticipants with dementia. objects to prompt memories of activities. Most inter-
views were conducted separately, to encourage those
Service delivery context of the study with dementia to express their views fully rather than
deferring to their spouse. However, there were a few
CST is a best-practice example in the national
interviews involving both husband and wife, who sup-
Framework for Dementia Care in New Zealand
ported recall. In these cases, focus on the intended inter-
(Ministry of Health, 2013). CST is delivered in a variety
viewees was maintained. All 24 interviews were digitally
of settings, including the public health system, non-
audiotaped and transcribed verbatim by professional
government community organizations, dementia day
transcribers.
care centres and aged care residential facilities. Like
Quantitative data collection consisted of administer-
most health and disability services in New Zealand,
ing the ACE-III at time 1 and the VQ at the three time-
CST is government-funded and accessible for people
points. Following the single-subject A–B design (Carter
with dementia free of charge.
and Lubinsky, 2015), each participant with dementia
was observed while carrying out two daily activities of
CST group and participant recruitment their choice at home and rated on the VQ before, during
Research participants were people with mild to moder- and after the CST programme, with time 1 being base-
ate dementia who attended a standard CST programme line (phase A) and times 2 and 3 being post-intervention
and/or their associated family member or caregiver. measures (phases B1 and B2).
Liu et al. 319

Data analysis Nature of ‘switch-on’

The qualitative data analysis was primarily conducted Table 2 displays the sub-themes that were identified
by the first author, with the second and third authors from thematic analysis of the interview data in a
involved in peer review of analytic decisions. Data were coding matrix.
analysed using open coding and thematic analysis
(Stanley, 2015) manually and electronically in NVivo Doing. A marked common change in Doing at times 2
11 Pro (QSR International, 2015). The outcome of the and 3 was that all participants with dementia were ‘keen’
qualitative analysis was a coding matrix, with three ‘col- to attend CST and engaged with the programme actively
umns’ representing the three time-points and four ‘rows’ and enthusiastically. They also started ‘talking more
categorizing four thematic areas, Doing, Feeling, about stuff’, including CST, at home.
Relating, and Thinking and Reflecting. Similar codes
were grouped and collapsed and eventually merged The main thing that stands out is he’s so happy to go
into three sub-themes for each matrix cell. Descriptive to this course and talk about it afterwards. (Frank’s
statistics and visual analysis (Vogt, 2014) were applied to wife, time 2)
calculate and present the VQ measurement results over
the three time-points. Qualitative and quantitative data When he goes to these sessions, he gets goals, like
were further converged and analysed together in relation things to do, and he busies himself with that. He
to the three research questions (Creswell, 2014). gets stuck in and spends hours like doing the last
one he did and that was on current events and he
went into it with great guns, and to present his little
Rigour
speech! (John’s wife, time 2)
A main strength of the study design was the repeated
interviews with both people with dementia and their Three men at time 2 and all four of them at time 3
family caregivers. Extended engagement and triangula- reported purposeful adjustment of activities and routines
tion of the men’s and their wives’ perspectives enhance at home, with improved deliberation, initiative and
the credibility and confirmability of the study outcomes effort in their actions and coping behaviours. They
(Guba and Lincoln, 1982). engaged more with activities that they felt interested in
The VQ is a technical, interactive, observational mea- and competent at, or found meaningful to do, particu-
sure that can be administered easily in any setting (de las larly in taking more responsibility for household chores
Heras et al., 2007). These features make the measure with an intention to help their wives. Meanwhile, they let
suitable for use in a single-subject design as a consider- go of activities and responsibilities that they felt were no
ation of rigour (Carter and Lubinsky, 2015). longer necessary or realistic.
The convergent parallel mixed methods design of the
study aimed to optimize rigour and trustworthiness of its I’m taking less responsibility [for our finances]
qualitative and quantitative components. The rich qual- because Ann [wife] is doing so much more. . . . But I
itative data compensated for the limitations of the A–B actually probably do a little bit more around the
design, such as lacking repeated baseline measurements house. . . . if she [wife] wanted any help, she’d ask
and not addressing confounding factors following treat- for it. Now she doesn’t have to, I just go and do it.
ment. Measurements using the VQ served as a triangu- (Frank, time 3)
lation strategy to strengthen the credibility and
objectivity of the qualitative findings.
Feeling. Changes in feelings were similarly reported at
times 2 and 3 by all participants with dementia, charac-
Findings terized by increased experience and expression of posi-
Table 1 shows the demographic information and the tive emotions. These positive emotions included getting
ACE-III scores of the participants with dementia, more enjoyment from, and feeling more interested in and
using pseudonyms. They were males aged 69 to 82 motivated to participate in, occupations, having a sense
years and had backgrounds in engineering and of achievement and satisfaction from participation,
construction. becoming more positive, confident and accepting of

Table 1. Demographics of participants with dementia and the Addenbrooke’s Cognitive Examination – III (ACE-III) scores.
Pseudonym Gender Age Ethnicity Highest education Past occupations ACE-III

Frank Male 82 European Diploma Engineer 82/100

John Male 79 European Secondary school Carpenter and joiner 69/100
Mark Male 69 Polynesian Intermediate school Construction labourer 52/100
Peter Male 81 European Trade certificate Engineer 70/100
320 British Journal of Occupational Therapy 83(5)

living with dementia, and showing more appreciation

CST has given me stimulation to think about things

and consideration towards their wives.

Bonding and comradeship in the CST group

When I come away, I always feel good, had a good

Going on his normal pattern pretty well

Improved relationship with their wives

time. I look forward to going to it. (Frank, time 2)

Thinking about life and the future

Occupational adjustment at home

Feeling good and more accepting

More interested and motivated
I am enjoying life, I am really enjoying, even liking

Improved social participation

Doing CST as an occupation

Positive impact on memory

watching that . . . making a 3D pack. I’ve done three
Getting more enjoyment

3D puzzles, and they are quite stimulating. They’re

not very hard to do but I get a bit of enjoyment out of
it. (Peter, time 3)
Time 3 (post-CST)

He is accepting things better and understanding

things better, not to be selfish . . . and demanding.
(Mark’s wife, time 3)
•
•
•
•
•
•
•
•
•
•
•
•

Intensity of emotional changes was noted in two men

through their words, affective display and behaviours.
Meeting like-minded people and having fun in the CST group

For example, Mark broke into tears when trying to

express his appreciation towards his wife in the time 3
interview. He said in tears and with smiles that ‘I’m
allowed to cry because I’m happy’.
Intentional adjustment in doing things at home

CST shows me where the memory blanks are

Relating. All participants with dementia developed a

Improved relationship with their wives

sense of ‘comradeship’ and bonding with the ‘like-

Doing little things to help their wives
Feeling happier and more positive

minded’ peers in the CST group, which was apparent

Our days go in the same manner

CST gets him and wakes him up

at time 2 and strengthened towards time 3.

More interested and motivated

Positive impact on memory

Active participation in CST

Getting more enjoyment

We accept it [dementia]. We try [to] sort of improve

on it, it doesn’t worry us. It’s been interesting being
with a group of like-minded people, because that’s
Time 2 (during CST)

what we are. (Frank, time 2)

The stimulation really comes from the group, and it’s

what they bring to and from each other that does the
stimulating. . . . You can’t make things stimulating if
•
•
•
•
•
•
•
•
•
•
•
•

the people aren’t stimulated within themselves and

Table 2. The coding matrix and sub-themes for describing ‘switch-on’.

get the comradeship that you feel for one another.

Dementia hasn’t proceeded as fast as I thought

. . . You feel for each other ’cos you know you’re in

Getting enjoyment and positive feelings in life

the same boat. (John, time 3)

Having trouble with memory and thinking
Relating to others becoming problematic
Likes to still be involved and do things

Feeling down and frustrated at times

Difficulties impacting on their wives

Doing things becoming problematic

Further, three men at time 2 and all of them at time 3

Getting social contact and support

Thinking about life and the past

I’ve got to accept my limitations

were noted to become more empathetic towards, consid-

erate of and helpful to their wives, which led to
Seeming to occupy himself

improved spousal relationships.

I feel sorry for my wife ’cos [she] only do it for me.

And I said, ‘that’s my job, I was told to do it, so I
Time 1 (pre-CST)

have to do it myself’. (Mark, time 3)

CST: cognitive stimulation therapy

I’ve noticed that there’s still that being very self-

centred, but since I think he’s done this course, it
•
•
•
•
•
•
•
•
•
•
•
•

has expanded it and that if he sees I’m struggling,

he’ll get up and do something whereas before he
Thinking and

wouldn’t. (Peter’s wife, time 3)

reflecting
Relating
Feeling
Doing

[He] gave me a hug and that’s unusual. Sometimes

I’ve tried to hug him and there was this rigid thing
Liu et al. 321

there, like hugging a lamp post, he was not willing to All of them gained some improvement in remembering
give. But he had a lovely hug! (Frank’s wife, time 3) names or orientation to day and date.

In addition, all the men demonstrated increased commu- I had a bad blank [in the CST group] in catching the
nication and social engagement in the family and/or ball and say name, one of your grandchildren, and
community, which made three of them ‘more like his absolutely nothing there at all. . . . I can name most of
old self’ to their families. them now. . . . Instead of saying ‘woo, I’ve lost it’,
‘let’s find it again’. So, I went back and wrote out
What did the girls say the other day? ‘He did some- my family tree. (Peter, time 3)
thing that was like the old Dad’. His personality is
changing a little back to [his old self], he’s getting
more [involved], he’s making jokes about things. Occurrence of ‘switch-on’
(John’s wife, time 3)
The qualitative data indicated that all participants with
dementia experienced the ‘switch-on’ changes, which
Thinking and reflecting. An altered, more lively presenta- occurred in a gradual, advancing fashion towards com-
tion was noted in three men at time 2, characterized as pletion of CST in both CST and home environments.
‘waking up’ and becoming more aware of ‘what’s going However, each man appeared to have his own trajectory
on around him’. of ‘switch-on’ with varied onset, presentation and
timing. Three wives were able to report a specific time
It [attending CST] didn’t excite him exactly, but it range for noticing the ‘switch-on’ changes at home.
sort of gets him and it wakes him up. (John’s wife,
time 2) It happened as soon as he started the group, right
from day one. He was picking up an interest and
He’s more alert in other things that he used to be slow looking for things and looking to go to the group.
at, like . . . I said to him ‘in the morning when you get (Peter’s wife, time 2)
up, you can go and open all our curtain[s]’ and some-
times he forgets, but lately he will remember. (Mark’s Not the first week, the first week is much the same as
wife, time 2) usual but he just, quite quickly started changing
really. Well he’s only been to five [sessions]. Yeah
Two men reflected and articulated extensively at time 3 especially the last two. (John’s wife, time 2)
that CST gave them ‘stimulation to think more about
things’. Probably the last two weeks [of CST] I’d say, it’s been
gradual, up to then there was no noticeable change.
So for stimulation, I’ve found it has helped because if (Frank’s wife, time 3)
we’ve been given a subject, it is for the next time we
go. I’d have to dig into something and have a think
about it. (John, time 3) Measurement of ‘switch-on’
Table 3 presents means of the overall VQ scores and
All the men showed changed thinking patterns that were
more positive and/or ‘extended’ at time 3. Instead of three sub-scores for each participant with dementia at
focusing on themselves and the past, all of them started the three time-points. Rated on a four-point scale, mean
to consider relationships and the future, either in a prac- scores of the VQ and its sub-scales range from 1 to 4,
tical way or a spiritual or philosophical sense. with higher scores suggesting higher volition. Given the
small number of participants and the single pre- and
Just this morning he said, . . . ‘when we’re settled there post-test assessment points, the statistical significance
[retirement village], let’s just go away for a couple of of the change was not calculated. The data are visually
days’. It’s always been me who’s suggested that, not depicted using line charts in Figures 1 and 2, as recom-
him. Quite a few things have changed. (Frank’s wife, mended in a single-subject research design (Carter and
time 3) Lubinsky, 2015).
Figure 1 shows that all the men obtained high overall
I start to think about some other part. I don’t know VQ scores, even at baseline. While John stayed at the
what happened, which one of us [him and his wife] maximum consistently, there was an increasing trend
gonna go, ’cos that’s life. . . . We die, we go to heaven towards the maximal score over time for the other
and that’s the only place you go, gonna meet again. three participants. Figure 2 demonstrates the relatively
(Mark, time 3) low achievement sub-scores at baseline for three men,
with a similar improving pattern after engaging in
All the men reported making more effort to remember CST. This indicates that the improved overall VQ
and/or use memory strategies at time 2 and/or time 3. scores in three men were attributable to their improved
322 British Journal of Occupational Therapy 83(5)

Table 3. Means of overall Volitional Questionnaire (VQ) scores and sub-scores for each participant at three time-points.
Time 1 (pre-CST) Time 2 (during CST) Time 3 (post-CST)

E C A VQ E C A VQ E C A VQ

Frank 4 3.8 1.25 3.14 4 4 2.25 3.46 4 4 3.75 3.93

John 4 4 4 4 4 4 4 4 4 4 4 4
Mark 3.6 4 3 3.57 3.8 4 3.25 3.71 4 4 4 4
Peter 4 4 3.25 3.75 4 4 3.75 3.93 4 4 4 4
Mean 3.9 3.95 2.88 3.62 3.95 4 3.31 3.78 4 4 3.94 3.98
Notes: E, C and A refer to three VQ sub-scores representing three volitional levels: exploration, competency and achievement. VQ refers to the
overall VQ score.
CST: cognitive stimulation therapy

Mean Overall VQ Scores at Three Time-points Mean Achievement Sub-scores at Three Time-points

Mean Achievement Sub-scores

4 4
Mean Overall VQ Scores

3.5 3.5
3 3
2.5 2.5
2 2
1.5 1.5
1 1
Time 1 Time 2 Time 3 Time 1 Time 2 Time 3
Time-points Time-points
Frank John Mark Peter Frank John Mark Peter

Figure 1. Mean overall VQ scores for each participant at three Figure 2. Mean achievement sub-scores for each participant at
time-points. three time-points.

achievement level of volition, the highest level of volition (Taylor, 2017: 52) was evident in the multi-dimensional
on the volitional continuum (de las Heras et al., 2007). nature of ‘switch-on’ discovered in this study, involving
synchronized activation of and mutual enhancement
between the four areas (Doing, Feeling, Relating, and
Discussion
Thinking and Reflecting) of the person. Volition was
The nature of ‘switch-on’ revealed in this study com- also reflected in the spatial and temporal features of
prised of simultaneously enhanced activity and strength the occurrence of ‘switch-on’, characterized by sponta-
in multiple areas of Doing, Feeling, Relating, and neous transfer of the effect across environments and the
Thinking and Reflecting. These changes were across gradually improving pattern of ‘switch-on’ over time.
environments, deliberate, with intentional goals, driven The VQ measurement data further verified the ‘switch-
by positive feelings, and manifested in social and occu- on’ of the higher achievement level of volition in three
pational contexts. Although there was individual varia- men, which motivated them to strive towards goals and
tion, ‘switch-on’ occurred in a gradual, progressive attain internal satisfaction (de las Heras et al., 2007).
fashion towards completion of CST in all participants Although no previous study has explicitly examined
with dementia. Corresponding to the qualitative data, the volitional benefits of CST, the ‘generalized’ effects of
the VQ measurements, particularly the achievement this cognition-oriented therapy for improving self-rated
sub-scores, showed similar improvement in three men. quality of life have been confirmed and discussed in
However, the instrument failed to detect the ‘switch-on’ quantitative studies (Spector et al., 2003, 2010; Woods
changes in John due to its ceiling effect (Salkind, 2010), et al., 2006). Further, all the earlier qualitative and
which confines its usefulness for measuring the ‘switch- mixed methods studies described expanded positive
on’ effect. changes outside the CST environment (Bailey et al.,
These findings suggest that volitional changes were 2017; Cheung and Peri, 2014; Kelly et al., 2017;
part of the ‘switch-on’ effect from participation in CST Murray et al., 2016; Spector et al., 2011).
as an occupation. Volition is theorised as patterns of These findings in CST literature align with the ‘per-
thoughts and feelings that inspire, propel and energize vasiveness’ of volition and the ‘switch-on’ changes noted
a person to participate in an occupation (Taylor, 2017). in this study, which signalled two implications for future
Volition consists of three relatively stable components: research. First, more general investigations on the voli-
personal causation, values and interests, with a dynamic tional outcomes and mechanisms of CST are needed,
and cyclic volitional process of the person anticipating, especially from an occupation-based theoretical perspec-
choosing, experiencing and interpreting the occupations tive. Second, given the ceiling effect of the VQ and its
they engage in. The ‘pervasive influence’ of volition partial measurement of the broader ‘switch-on’ effect, it
Liu et al. 323

would be beneficial for further study to either develop a In addition, there were several limitations related to
new, specific measure for ‘switch-on’ or apply a more the VQ measurement. The VQ was administered by the
holistic and sensitive instrument for measuring the researcher rather than an independent rater, which
effect, such as the Engagement in Meaningful might have resulted in observer bias, affecting the
Activities Survey (Goldberg et al., 2002). rigour of the study. Due to its opportunistic recruitment,
Woods et al. (2006) found some evidence that the the study did not achieve multiple baseline measure-
cognitive focus of CST promoted quality of life and well- ments as recommended for a single-subject A–B design
being. In contrast, Cheung and Peri (2014), who first (Carter and Lubinsky, 2015). The measure showed a
named ‘the switch-on phenomenon’, emphasized the ceiling effect due to its psychometric weakness in differ-
therapeutic value of the non-specific aspect of social entiating higher levels of volition (Chern et al., 1996).
engagement in CST groups. The present study, using
occupational frameworks (Law et al., 1996; Townsend Conclusion
and Polatajko, 2007), suggests that ‘switch-on’ is an out-
come of the transactional dynamics occurring between This was the first study that explored the ‘switch-on’
the person, environments and occupations throughout effect of CST using a parallel convergent mixed methods
the course of CST. An example was the reciprocal ‘stim- design and incorporating an occupation-based perspec-
ulation’ that attendees brought ‘to and from each other’ tive. The findings of the study indicated that ‘switch-on’
through engagement with CST in the group setting. was multi-dimensional in nature, consisting of simulta-
Further, some qualitative data in Relating, such as meet- neous positive changes in the areas of Doing, Feeling,
ing the ‘like-minded’ people, being ‘in the same boat’ Relating, and Thinking and Reflecting. The ‘switch-on’
and developing bonds and ‘comradeship’ in CST, sug- changes occurred synchronously in both CST and home
gested the sub-culture in CST was a therapeutic element. environments, with incremental improvement towards
This has not been explicitly identified in CST literature completion of CST. Concurrent with the ‘switch-on’
previously, although Dugmore et al. (2015: 964) recog- descriptions were the improving trend of the VQ
nized ‘peer identification, support and membership’ as scores, particularly on the achievement sub-scale, in
one of five common ‘active mechanisms’ that could three of the participants with dementia. Although the
make a psychosocial intervention ‘work’. instrument was deemed to not effectively capture
The sub-cultural element of CST and its contribution ‘switch-on’, this was the first study that measured the
to the positive outcomes of the intervention, including impact of CST on volition. The evidence from the pre-
‘switch-on’, may require further exploration. A possible sent study suggests that the ‘switch-on’ effect could be a
implication could be placing more emphasis on the desirable outcome of occupational participation in CST,
social and cultural connections between CST group which warrants further investigation. Other indicated
members in maintenance CST programmes and even areas that deserve more research in the future are the
working towards building an ongoing post-CST commu- volitional benefits and the therapeutic value of CST for a
nity for people with dementia. sub-cultural group for people with dementia.

Limitations Key findings

This was a small-scale study that involved only four • ‘Switch-on’ involved enhanced engagement in Doing,
community-dwelling couples from the same CST Feeling, Relating, and Thinking and Reflecting,
group. The four participants with dementia had several which occurred in an incremental fashion.
• Three participants with dementia showed improve-
commonalities, including being male, married, living
ment on the achievement sub-scale of the VQ.
with a wife who was the main caregiver, and having a
similar interest or background in engineering, technolo-
gy or construction. Demographic information about What the study has added
their wives was not collected, but it may have influenced This study provided a more comprehensive under-
their perceptions of their husbands’ experiences. The standing of the ‘switch-on’ effect, a positive and
lack of variety in participant characteristics in this little-known outcome of CST from an occupation-
study limits the transferability of the findings. based theoretical perspective.
Further, the current study rendered a ‘thick’ descrip-
tion about ‘switch-on’ with ‘low-inference’ interpreta-
tion (Sandelowski, 2000: 335). However, it was not Acknowledgements
designed to explore deep meaning or lived experience The authors thank Rhonda Preston-Jones, Barbara Fox, Nicola
of ‘switch-on’ for participants with dementia. Neither Brenton, Zhi Chen, Lynn Hubbert and Maria Co from Dementia
Auckland, who provided the cognitive stimulation therapy pro-
did the study intend to examine the active mechanisms
gramme and assisted with recruitment of the research participants.
that underlie ‘switch-on’, the internal dynamic relations Dr Gary Cheung is acknowledged for mentoring the research proj-
between the ‘switched-on’ areas, or the exact timing of ect in guiding the ethics approval application and selection of the
its occurrence. cognitive screening tool for the study.
324 British Journal of Occupational Therapy 83(5)

Research ethics de las Heras CG, Geist R, Kielhofner G, et al. (2007) A User’s
Ethical approval was obtained from the Auckland University of Manual to the Volitional Questionnaire (VQ) (Version 4.1).
Technology Ethics Committee in 2016 (reference number 16/396). Chicago: University of Illinois.
Dugmore O, Orrell M and Spector A (2015) Qualitative studies
Consent of psychosocial interventions for dementia: A systematic
review. Aging & Mental Health 19(11): 955–967.
All participants provided written informed consent to be inter-
Dyer SM, Harrison SL, Laver K, et al. (2018) An overview of
viewed for the study. All participants with dementia provided writ-
systematic reviews of pharmacological and non-
ten informed consent to complete the selected measures for the
study. pharmacological interventions for the treatment of behav-
ioral and psychological symptoms of dementia.
International Psychogeriatrics 30(3): 295–309.
Declaration of conflicting interests
Goldberg B, Brintnell ES and Goldberg J (2002) The relation-
The authors declared no potential conflicts of interest with respect ship between engagement in meaningful activities and qual-
to the research, authorship and/or publication of this article. ity of life in persons disabled by mental illness. Occupational
Therapy in Mental Health 18(2): 17–44.
Funding Guba EG and Lincoln YS (1982) Epistemological and meth-
The first author disclosed receipt of the Occupational Therapy odological bases of naturalistic inquiry. Educational
Innovation, Learning and Development Fund for post-graduate Communication and Technology 30(4): 233–252.
study from her employer, Auckland District Health Board, towards Hall L, Orrell M, Stott J, et al. (2013) Cognitive stimulation
completion of this research, which was undertaken in partial fulfil- therapy (CST): Neuropsychological mechanisms of change.
ment of the requirements of a Master of Health Science degree from International Psychogeriatrics 25(3): 479–489.
Auckland University of Technology. Hsieh S, Schubert S, Hoon C, et al. (2013) Validation of the
Addenbrooke’s Cognitive Examination III in frontotempo-
Contributorship ral dementia and Alzheimer’s disease. Dementia and
All authors contributed to development of the research proposal, Geriatric Cognitive Disorders 36(3–4): 242–250.
methodology, design and application for ethical approval. Qi Liu, Kelly ME, Finan S, Lawless M, et al. (2017) An evaluation of
under the supervision of Margaret Jones and Clare Hocking, community-based cognitive stimulation therapy: A pilot
researched the literature and collected the data. All authors con- study with an Irish population of people with dementia.
tributed to interpretation of the data. Qi Liu drafted the manu- Irish Journal of Psychological Medicine 34(3): 157–167.
script. All authors reviewed and edited the manuscript and Law M, Cooper B, Strong S, et al. (1996) The person-
approved the final version. environment-occupation model: A transactive approach to
occupational performance. Canadian Journal of
ORCID iD Occupational Therapy 63(1): 9–23.
Qi Liu https://orcid.org/0000-0002-1518-088X Li Y and Kielhofner G (2004) Psychometric properties of the
Volitional Questionnaire. Israel Journal of Occupational
Therapy 13(3): E85–E98.
References
Ministry of Health (2013) New Zealand Framework for
American Psychiatric Association (2013) Diagnostic and Dementia Care. Wellington: Ministry of Health.
Statistical Manual of Mental Disorders: DSM-5, 5th ed. Murray CM, Gilbert-Hunt S, Berndt A, et al. (2016) Promoting
Washington, DC: American Psychiatric Association. participation and engagement for people with dementia
Bailey J, Kingston P, Alford S, et al. (2017) An evaluation of through a cognitive stimulation therapy programme deliv-
cognitive stimulation therapy sessions for people with ered by students: A descriptive qualitative study. British
dementia and a concomitant support group for their Journal of Occupational Therapy 79(10): 620–628.
carers. Dementia 16(8): 985–1003. Piras F, Carbone E, Faggian S, et al. (2017) Efficacy of cogni-
Braver TS, Krug MK, Chiew KS, et al. (2014) Mechanisms of tive stimulation therapy for older adults with vascular
motivation-cognition interaction: Challenges and opportu- dementia. Dementia & Neuropsychologia 11(4): 434–441.
nities. Cognitive Affective Behavioral Neuroscience 14(2): Poulos C, Bayer A, Beaupre L, et al. (2017) A comprehensive
443–472. approach to reablement in dementia. Alzheimer’s &
Breuil V, De Rotrou J, Forette F, et al. (1994) Cognitive stim- Dementia: Translational Research & Clinical Interventions
ulation of patients with dementia: Preliminary results. 3(3): 450–458.
International Journal of Geriatric Psychiatry 9(3): 211–217. QSR International (2015) NVivo 11 for Windows help.
Carter R and Lubinsky L (2015) Rehabilitation Research: Available at: http://help-nv11.qsrinternational.com/desk
Principles and Applications, 5th ed. St. Louis, MO: top/concepts/About_theme_nodes.htm (accessed 7 July
Elsevier Health Sciences. 2018).
Chern JS, Kielhofner G, de las Heras CG, et al. (1996) The Salkind NJ (2010) Encyclopedia of Research Design. Thousand
Volitional Questionnaire: Psychometric development and Oaks, CA: SAGE.
practical use. American Journal of Occupational Therapy Sandelowski M (2000) Focus on research methods: Whatever
50(7): 516–525. happened to qualitative description? Research in Nursing &
Cheung G and Peri K (2014) Cognitive Stimulation Therapy: A Health 23(4): 334–340.
New Zealand Pilot. Auckland: Te Pou o Te Whakaaro Nui. Spector A, Gardner C and Orrell M (2011) The impact of cog-
Creswell JW (2014) Research Design: Qualitative, Quantitative, nitive stimulation therapy groups on people with dementia:
and Mixed Methods Approaches, 4th ed. Los Angeles, CA: Views from participants, their carers and group facilitators.
SAGE. Aging & Mental Health 15(8): 945–949.
Liu et al. 325

Spector A, Orrell M, Davies S, et al. (2000) Reality orientation implementation in practice: A cluster randomised trial.
for dementia. Cochrane Database of Systematic Reviews International Journal of Geriatric Psychiatry 32(12):
2000(2): CD001119. e64–e71.
Spector A, Orrell M, Davies S, et al. (2001) Can reality orien- Taylor R (2017) Kielhofner’s Model of Human Occupation:
tation be rehabilitated? Development and piloting of an Theory and Application, 5th ed. Philadelphia, PA:
evidence-based programme of cognition-based therapies Lippincott Williams & Wilkins.
for people with dementia. Neuropsychological Townsend EA and Polatajko HJ (2007) Enabling Occupation
Rehabilitation 11(3–4): 377–397. II: Advancing an Occupational Therapy Vision for Health,
Spector A, Orrell M and Woods B (2010) Cognitive stimulation Well-being and Justice through Occupation. Ottawa: CAOT
therapy (CST): Effects on different areas of cognitive func- Publications.
tion for people with dementia. International Journal of Vogt WP (2014) Selecting the Right Analyses for your Data:
Geriatric Psychiatry 25(12): 1253–1258. Quantitative, Qualitative and Mixed Methods. New York:
Spector A, Thorgrimsen L, Woods B, et al. (2003) Efficacy of Guilford Press.
an evidence-based cognitive stimulation therapy programme Woods B, Aguirre E, Spector AE, et al. (2012) Cognitive stim-
for people with dementia: Randomised controlled trial. ulation to improve cognitive functioning in people with
British Journal of Psychiatry 183(3): 248–254. dementia. Cochrane Database of Systematic Reviews
Spector A, Thorgrimsen L, Woods B, et al. (2005) Making a 2012(2): CD005562.
Difference: An Evidence-based Group Programme to Offer Woods B, Thorgrimsen L, Spector A, et al. (2006) Improved
Cognitive Stimulation Therapy (CST) to People with quality of life and cognitive stimulation therapy in demen-
Dementia. London: Hawker Publications. tia. Aging & Mental Health 10(3): 219–226.
Stanley M (2015) Qualitative descriptive: A very good place to Yuill N and Hollis V (2011) A systematic review of cognitive
start. In: Nayar S and Stanley M (eds) Qualitative Research stimulation therapy for older adults with mild to moderate
Methodologies for Occupational Science and Therapy. dementia: An occupational therapy perspective.
Abingdo: Routledge, 21–36. Occupational Therapy International 18(4): 163–186.
Streater A, Spector A, Hoare Z, et al. (2017) Staff training and
outreach support for Cognitive Stimulation Therapy and its