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
Occupational therapists are making valuable contribu-
tions to the research, training, promotion and delivery of
cognitive stimulation therapy (CST) (Murray et al.,
2016; Streater et al., 2017; Yuill and Hollis, 2011),
which is an activity-based social group for people with
mild to moderate dementia. The embedded principles of
CST, ‘respectfulness of individuality, recognition of
capacity for self-determination, encouragement of par-
ticipation in meaningful activities, and optimization of
overall well-being’ (Yuill and Hollis, 2011: 168), are con-
gruent with the philosophy, values and practice of occu-
pational therapy. While there is mounting evidence that
it improves cognitive function, no study has satisfacto-
rily investigated the occupational benefits of CST. That
knowledge gap puts occupational therapists’ involve-
ment into question. However, the recently reported
‘switch-on’ effect of CST is described in occupational
terms, including enhanced capabilities and social
participation (Cheung and Peri, 2014; Spector et al.,
2011). A fuller explanation of the effect will be provided
in the Background. This paper reports an exploratory
mixed methods study of ‘switch-on’ and how it might
be measured.
Background
CST is one of the few evidence-based, non-pharmaco-
logical interventions for people with mild to moderate
1
Mental Health Services for Older People, Auckland District Health Board,
Auckland, New Zealand
2
School of Occupational Science and Therapy, Auckland University of
Technology, Auckland, New Zealand
Corresponding author:
Qi Liu, Mental Health Services for Older People, Ground Floor, Building
14, Greenlane Clinical Centre, Greenlane, Auckland 1051, New Zealand.
Email: qil@adhb.govt.nz
Liu et al.
dementia (Spector et al., 2003; Woods et al., 2012). CST
falls into the category of cognitive stimulation for people
with dementia that aims at ‘general enhancement of cog-
nitive and social functioning’ through engagement with
a variety of activities and discussions, usually in a small
group setting (Woods et al., 2012: 3). CST has potential
for use alongside a reablement approach that aims to
alleviate the functional impact of dementia on people’s
lives. Indeed, Poulos et al. (2017: 452) state, ‘interven-
tions providing opportunities for social interaction, gen-
eral stimulation, or other pleasurable activities can be
applied alongside reablement’.
CST offers a manualized, 7-week, twice-weekly group
programme of themed, enjoyable activities and discus-
sions, the contents including physical, number and word
games, ‘childhood’, ‘sounds’, ‘food’, ‘current events’,
‘being creative’, ‘using memory’ and so on (Spector
et al., 2005: 5). CST is delivered in a supportive environ-
ment designed to optimize cognitive and social perfor-
mance. Originally developed in the United Kingdom,
CST has been applied and researched worldwide, includ-
ing in New Zealand (Cheung and Peri, 2014).
CST targets global stimulation of cognition and was
primarily devised based on two precedent psychosocial
interventions for people with dementia (Spector et al.,
2001), Reality Orientation (Spector et al., 2000), and a
French version of cognitive stimulation (Breuil et al.,
1994). CST developers extracted the technique of repeat-
edly presenting orientation information to enhance
memory from Reality Orientation; they then trans-
formed its rigid and insensitive style into a person-
centred programme (Spector et al., 2001). Following
Breuil et al.’s (1994) cognitive stimulation, CST taps
into implicit memory and implicit learning, relatively
well-preserved realms of cognitive function in people
with dementia (American Psychiatric Association,
2013); however, it was adapted into a light-hearted,
non-threatening delivery from its original clinical
approach (Spector et al., 2001).
A wealth of quantitative studies, including random-
ized controlled trials, have examined specific cognitive
domains and discrete outcome areas for people who
attended CST (Hall et al., 2013; Piras et al., 2017;
Spector et al., 2003, 2010). The evidence generated dem-
onstrates that CST promotes cognitive function, partic-
ularly language, memory and orientation, and self-rated
quality of life for people with mild to moderate dementia
(Hall et al., 2013; Piras et al., 2017; Spector et al., 2003;
Woods et al., 2012). An earlier study found that
improved subjective quality of life following CST was
mediated by improved cognition and reduced depression
(Woods et al., 2006). However, no further research has
explored the therapeutic effects on cognition, mood and
quality of life using a more dynamic or holistic
approach.
Only five qualitative and mixed methods studies have
hitherto explored the broader benefits of CST, two of
which described ‘switch-on’ as a favourable outcome
(Cheung and Peri, 2014; Spector et al., 2011).
317
‘Switch-on’ comprised a cluster of positive behavioural
changes noted in some CST attendees that were consis-
tent with the confirmed benefits of CST in quantitative
research (Spector et al., 2010; Woods et al., 2012).
Changes included ‘a sense of being more switched on
or wanting to attend to things more’ (Spector et al.,
2011: 948), and having ‘new-found confidence, capabil-
ities and vastly improved communication skills’ (Cheung
and Peri, 2014: 7).
Of note, the term ‘switch-on’ seems to reflect an
observer’s standpoint in representing the changes,
which may not be viewed as dementia friendly. An
equivalent, more subjective label for the effect used by
participants with dementia in Cheung and Peri’s (2014)
study was ‘stimulation’ or ‘feeling stimulated’ (21).
Spector et al. (2011) associated ‘switch-on’ with
improved concentration and alertness, which are com-
monly reported cognitive benefits of CST, whereas
Cheung and Peri (2014) regarded it as a more satisfying
outcome of social engagement, a non-specific therapeu-
tic element of participation in CST. While the nature
and scope of the effect have not yet been clearly delin-
eated, three further studies using a qualitative or mixed
methods design have described similar positive changes
(Bailey et al., 2017; Kelly et al., 2017; Murray et al.,
2016). This suggests that ‘switch-on’ might be a
common but less recognized benefit of CST.
The observed behavioural change of ‘wanting to’ pay
more attention to things and having enhanced confi-
dence and capabilities suggests a volitional component
to the ‘switch-on’ effect. This is an important possibility
to explore because apathy or lack of motivation is the
most prevalent behavioural symptom in people with
Alzheimer’s type dementia (Dyer et al., 2018). Recent
research in cognitive neuroscience, psychology and
ageing has also found some evidence of interactions
between motivation and cognition (Braver et al., 2014).
Despite that, no study has yet explored the impact of
CST, a cognitive intervention, on the person’s motiva-
tion or volition, as indicated in the existing knowledge of
‘switch-on’.
That research gap indicated the need for a more com-
plete understanding of the therapeutic outcomes of CST,
including the ‘switch-on’ effect, from a holistic, occupa-
tional perspective (Law et al., 1996; Taylor, 2017;
Townsend and Polatajko, 2007). The limited knowledge
about ‘switch-on’ required an inductive qualitative
research approach to obtain a ‘thick’ description about
the effect. To examine the hypothetical correlation
between volition and ‘switch-on’, an occupation-
focused measure of volition, the Volitional
Questionnaire (VQ) (de las Heras et al., 2007), was
selected. Three research questions were formulated:
• What is the nature of the ‘switch-on’ effect as described
by people attending CST and their family or caregivers?
• At what time-points during and after the group is the
‘switch-on’ effect reported?
318
• Are the changes described as the ‘switch-on’ effect mea-
surable using the VQ?
Method
Study design
A convergent parallel mixed methods design (Creswell,
2014) merging qualitative descriptive methodology
(Stanley, 2015) and a single-subject A–B design (Carter
and Lubinsky, 2015) was implemented. Driven by the
single-subject design, qualitative and quantitative data
were collected concomitantly at participants’ homes at
three time-points: before commencement of CST (time
1); during the third week of CST (time 2) and within a
week after completion of CST (time 3). Quantitative and
qualitative data were analysed using their respective ana-
lytic methods separately and then conjointly.
Considering the scant knowledge about ‘switch-on’,
more weight was placed on the qualitative component
of the study.
Ethics approval was obtained for the study from the
Auckland University of Technology Ethics Committee
in 2016 (reference number 16/396).
Measures
The Volitional Questionnaire (de las Heras et al., 2007)
was selected as a possible measure of ‘switch-on’ because
of its theoretical foundation in the Model of Human
Occupation (Taylor, 2017) and the alignment observed
between most items in the measure and the descriptions
about ‘switch-on’ in CST literature. The instrument has
good construct validity, internal validity and intra-rater
reliability (Chern et al., 1996; Li and Kielhofner, 2004).
The Addenbrooke’s Cognitive Examination – III
(ACE-III) is a commonly used neuropsychological test
with sound psychometric properties for screening cogni-
tive impairment and dementia diagnosis (Hsieh et al.,
2013). The ACE-III was used in this study for estimating
cognitive function and severity of dementia of the par-
ticipants with dementia.
Service delivery context of the study
CST is a best-practice example in the national
Framework for Dementia Care in New Zealand
(Ministry of Health, 2013). CST is delivered in a variety
of settings, including the public health system, non-
government community organizations, dementia day
care centres and aged care residential facilities. Like
most health and disability services in New Zealand,
CST is government-funded and accessible for people
with dementia free of charge.
CST group and participant recruitment
Research participants were people with mild to moder-
ate dementia who attended a standard CST programme
and/or their associated family member or caregiver.
British Journal of Occupational Therapy 83(5)
Dementia Auckland, a non-government community
organization that offers CST to people with dementia
in the greater Auckland area, was identified and
approached as a suitable CST provider for the study.
The staff involved in delivering CST were provided
with a full briefing about the study design and aims
prior to recruiting four men with mild dementia and
their wives from a CST group run between 27 March
2017 and 11 May 2017. The staff explained the research
project to people with dementia and their family who
met the inclusion criteria. Their verbal consent was
obtained to forward contact details to the researcher.
Six people with dementia and five family members
expressed interest and four couples were finally recruited
to the study. Facilitation of the programme closely fol-
lowed the CST manual (Spector et al., 2005), which
allows some flexibility in the choice of activities in
response to the specific programme participants. All par-
ticipants provided written informed consent for partici-
pating in the research. None of the study authors were
involved in running the CST group.
Data collection
All data were gathered by the first author. The demo-
graphic information of participants with dementia,
including age, ethnicity, education, past occupations
and relationship with their caregiver, was collected at
first contact. Qualitative data collection involved con-
ducting semi-structured interviews of the eight partici-
pants at the three time-points, using the same set of
open-ended questions. These explored the men’s engage-
ment with daily activities, including their interests, rou-
tines, feelings, concentration and communication with
others. For example, ‘What are some of the things you
have been doing over the last month?’ ‘How do you
spend your time on a typical day?’ and ‘Have you
noticed any changes?’ Questions to family members
were framed in relation to their observation of their
spouse. Participant recall was supported by conducting
interviews in their own homes, where there were familiar
objects to prompt memories of activities. Most inter-
views were conducted separately, to encourage those
with dementia to express their views fully rather than
deferring to their spouse. However, there were a few
interviews involving both husband and wife, who sup-
ported recall. In these cases, focus on the intended inter-
viewees was maintained. All 24 interviews were digitally
audiotaped and transcribed verbatim by professional
transcribers.
Quantitative data collection consisted of administer-
ing the ACE-III at time 1 and the VQ at the three time-
points. Following the single-subject A–B design (Carter
and Lubinsky, 2015), each participant with dementia
was observed while carrying out two daily activities of
their choice at home and rated on the VQ before, during
and after the CST programme, with time 1 being base-
line (phase A) and times 2 and 3 being post-intervention
measures (phases B1 and B2).
Liu et al.
Data analysis
The qualitative data analysis was primarily conducted
by the first author, with the second and third authors
involved in peer review of analytic decisions. Data were
analysed using open coding and thematic analysis
(Stanley, 2015) manually and electronically in NVivo
11 Pro (QSR International, 2015). The outcome of the
qualitative analysis was a coding matrix, with three ‘col-
umns’ representing the three time-points and four ‘rows’
categorizing four thematic areas, Doing, Feeling,
Relating, and Thinking and Reflecting. Similar codes
were grouped and collapsed and eventually merged
into three sub-themes for each matrix cell. Descriptive
statistics and visual analysis (Vogt, 2014) were applied to
calculate and present the VQ measurement results over
the three time-points. Qualitative and quantitative data
were further converged and analysed together in relation
to the three research questions (Creswell, 2014).
Rigour
A main strength of the study design was the repeated
interviews with both people with dementia and their
family caregivers. Extended engagement and triangula-
tion of the men’s and their wives’ perspectives enhance
the credibility and confirmability of the study outcomes
(Guba and Lincoln, 1982).
The VQ is a technical, interactive, observational mea-
sure that can be administered easily in any setting (de las
Heras et al., 2007). These features make the measure
suitable for use in a single-subject design as a consider-
ation of rigour (Carter and Lubinsky, 2015).
The convergent parallel mixed methods design of the
study aimed to optimize rigour and trustworthiness of its
qualitative and quantitative components. The rich qual-
itative data compensated for the limitations of the A–B
design, such as lacking repeated baseline measurements
and not addressing confounding factors following treat-
ment. Measurements using the VQ served as a triangu-
lation strategy to strengthen the credibility and
objectivity of the qualitative findings.
Findings
Table 1 shows the demographic information and the
ACE-III scores of the participants with dementia,
using pseudonyms. They were males aged 69 to 82
years and had backgrounds in engineering and
construction.
Table 1. Demographics of participants with dementia and the Addenbrooke’s Cognitive Examination – III (ACE-III) scores.
Pseudonym Gender Age Ethnicity
Frank Male 82 European
John Male 79 European
Mark Male 69 Polynesian
Peter Male 81 European
319
Nature of ‘switch-on’
Table 2 displays the sub-themes that were identified
from thematic analysis of the interview data in a
coding matrix.
Doing. A marked common change in Doing at times 2
and 3 was that all participants with dementia were ‘keen’
to attend CST and engaged with the programme actively
and enthusiastically. They also started ‘talking more
about stuff’, including CST, at home.
The main thing that stands out is he’s so happy to go
to this course and talk about it afterwards. (Frank’s
wife, time 2)
When he goes to these sessions, he gets goals, like
things to do, and he busies himself with that. He
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
speech! (John’s wife, time 2)
Three men at time 2 and all four of them at time 3
reported purposeful adjustment of activities and routines
at home, with improved deliberation, initiative and
effort in their actions and coping behaviours. They
engaged more with activities that they felt interested in
and competent at, or found meaningful to do, particu-
larly in taking more responsibility for household chores
with an intention to help their wives. Meanwhile, they let
go of activities and responsibilities that they felt were no
longer necessary or realistic.
I’m taking less responsibility [for our finances]
because Ann [wife] is doing so much more. . . . But I
actually probably do a little bit more around the
house. . . . if she [wife] wanted any help, she’d ask
for it. Now she doesn’t have to, I just go and do it.
(Frank, time 3)
Feeling. Changes in feelings were similarly reported at
times 2 and 3 by all participants with dementia, charac-
terized by increased experience and expression of posi-
tive emotions. These positive emotions included getting
more enjoyment from, and feeling more interested in and
motivated to participate in, occupations, having a sense
of achievement and satisfaction from participation,
becoming more positive, confident and accepting of
Highest education Past occupations ACE-III
Diploma Engineer 82/100
Secondary school Carpenter and joiner 69/100
Intermediate school Construction labourer 52/100
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.
there, like hugging a lamp post, he was not willing to
give. But he had a lovely hug! (Frank’s wife, time 3)
In addition, all the men demonstrated increased commu-
nication and social engagement in the family and/or
community, which made three of them ‘more like his
old self’ to their families.
What did the girls say the other day? ‘He did some-
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.
(John’s wife, time 3)
Thinking and reflecting. An altered, more lively presenta-
tion was noted in three men at time 2, characterized as
‘waking up’ and becoming more aware of ‘what’s going
on around him’.
It [attending CST] didn’t excite him exactly, but it
sort of gets him and it wakes him up. (John’s wife,
time 2)
He’s more alert in other things that he used to be slow
at, like . . . I said to him ‘in the morning when you get
up, you can go and open all our curtain[s]’ and some-
times he forgets, but lately he will remember. (Mark’s
wife, time 2)
Two men reflected and articulated extensively at time 3
that CST gave them ‘stimulation to think more about
things’.
So for stimulation, I’ve found it has helped because if
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)
All the men showed changed thinking patterns that were
more positive and/or ‘extended’ at time 3. Instead of
focusing on themselves and the past, all of them started
to consider relationships and the future, either in a prac-
tical way or a spiritual or philosophical sense.
Just this morning he said, . . . ‘when we’re settled there
[retirement village], let’s just go away for a couple of
days’. It’s always been me who’s suggested that, not
him. Quite a few things have changed. (Frank’s wife,
time 3)
I start to think about some other part. I don’t know
what happened, which one of us [him and his wife]
gonna go, ’cos that’s life. . . . We die, we go to heaven
and that’s the only place you go, gonna meet again.
(Mark, time 3)
All the men reported making more effort to remember
and/or use memory strategies at time 2 and/or time 3.
321
All of them gained some improvement in remembering
names or orientation to day and date.
I had a bad blank [in the CST group] in catching the
ball and say name, one of your grandchildren, and
absolutely nothing there at all. . . . I can name most of
them now. . . . Instead of saying ‘woo, I’ve lost it’,
‘let’s find it again’. So, I went back and wrote out
my family tree. (Peter, time 3)
Occurrence of ‘switch-on’
The qualitative data indicated that all participants with
dementia experienced the ‘switch-on’ changes, which
occurred in a gradual, advancing fashion towards com-
pletion of CST in both CST and home environments.
However, each man appeared to have his own trajectory
of ‘switch-on’ with varied onset, presentation and
timing. Three wives were able to report a specific time
range for noticing the ‘switch-on’ changes at home.
It happened as soon as he started the group, right
from day one. He was picking up an interest and
looking for things and looking to go to the group.
(Peter’s wife, time 2)
Not the first week, the first week is much the same as
usual but he just, quite quickly started changing
really. Well he’s only been to five [sessions]. Yeah
especially the last two. (John’s wife, time 2)
Probably the last two weeks [of CST] I’d say, it’s been
gradual, up to then there was no noticeable change.
(Frank’s wife, time 3)
Measurement of ‘switch-on’
Table 3 presents means of the overall VQ scores and
three sub-scores for each participant with dementia at
the three time-points. Rated on a four-point scale, mean
scores of the VQ and its sub-scales range from 1 to 4,
with higher scores suggesting higher volition. Given the
small number of participants and the single pre- and
post-test assessment points, the statistical significance
of the change was not calculated. The data are visually
depicted using line charts in Figures 1 and 2, as recom-
mended in a single-subject research design (Carter and
Lubinsky, 2015).
Figure 1 shows that all the men obtained high overall
VQ scores, even at baseline. While John stayed at the
maximum consistently, there was an increasing trend
towards the maximal score over time for the other
three participants. Figure 2 demonstrates the relatively
low achievement sub-scores at baseline for three men,
with a similar improving pattern after engaging in
CST. This indicates that the improved overall VQ
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
on the volitional continuum (de las Heras et al., 2007).
Discussion
The nature of ‘switch-on’ revealed in this study com-
prised of simultaneously enhanced activity and strength
in multiple areas of Doing, Feeling, Relating, and
Thinking and Reflecting. These changes were across
environments, deliberate, with intentional goals, driven
by positive feelings, and manifested in social and occu-
pational contexts. Although there was individual varia-
tion, ‘switch-on’ occurred in a gradual, progressive
fashion towards completion of CST in all participants
with dementia. Corresponding to the qualitative data,
the VQ measurements, particularly the achievement
sub-scores, showed similar improvement in three men.
However, the instrument failed to detect the ‘switch-on’
changes in John due to its ceiling effect (Salkind, 2010),
which confines its usefulness for measuring the ‘switch-
on’ effect.
These findings suggest that volitional changes were
part of the ‘switch-on’ effect from participation in CST
as an occupation. Volition is theorised as patterns of
thoughts and feelings that inspire, propel and energize
a person to participate in an occupation (Taylor, 2017).
Volition consists of three relatively stable components:
personal causation, values and interests, with a dynamic
and cyclic volitional process of the person anticipating,
choosing, experiencing and interpreting the occupations
they engage in. The ‘pervasive influence’ of volition
(Taylor, 2017: 52) was evident in the multi-dimensional
nature of ‘switch-on’ discovered in this study, involving
synchronized activation of and mutual enhancement
between the four areas (Doing, Feeling, Relating, and
Thinking and Reflecting) of the person. Volition was
also reflected in the spatial and temporal features of
the occurrence of ‘switch-on’, characterized by sponta-
neous transfer of the effect across environments and the
gradually improving pattern of ‘switch-on’ over time.
The VQ measurement data further verified the ‘switch-
on’ of the higher achievement level of volition in three
men, which motivated them to strive towards goals and
attain internal satisfaction (de las Heras et al., 2007).
Although no previous study has explicitly examined
the volitional benefits of CST, the ‘generalized’ effects of
this cognition-oriented therapy for improving self-rated
quality of life have been confirmed and discussed in
quantitative studies (Spector et al., 2003, 2010; Woods
et al., 2006). Further, all the earlier qualitative and
mixed methods studies described expanded positive
changes outside the CST environment (Bailey et al.,
2017; Cheung and Peri, 2014; Kelly et al., 2017;
Murray et al., 2016; Spector et al., 2011).
These findings in CST literature align with the ‘per-
vasiveness’ of volition and the ‘switch-on’ changes noted
in this study, which signalled two implications for future
research. First, more general investigations on the voli-
tional outcomes and mechanisms of CST are needed,
especially from an occupation-based theoretical perspec-
tive. Second, given the ceiling effect of the VQ and its
partial measurement of the broader ‘switch-on’ effect, it
Liu et al.
would be beneficial for further study to either develop a
new, specific measure for ‘switch-on’ or apply a more
holistic and sensitive instrument for measuring the
effect, such as the Engagement in Meaningful
Activities Survey (Goldberg et al., 2002).
Woods et al. (2006) found some evidence that the
cognitive focus of CST promoted quality of life and well-
being. In contrast, Cheung and Peri (2014), who first
named ‘the switch-on phenomenon’, emphasized the
therapeutic value of the non-specific aspect of social
engagement in CST groups. The present study, using
occupational frameworks (Law et al., 1996; Townsend
and Polatajko, 2007), suggests that ‘switch-on’ is an out-
come of the transactional dynamics occurring between
the person, environments and occupations throughout
the course of CST. An example was the reciprocal ‘stim-
ulation’ that attendees brought ‘to and from each other’
through engagement with CST in the group setting.
Further, some qualitative data in Relating, such as meet-
ing the ‘like-minded’ people, being ‘in the same boat’
and developing bonds and ‘comradeship’ in CST, sug-
gested the sub-culture in CST was a therapeutic element.
This has not been explicitly identified in CST literature
previously, although Dugmore et al. (2015: 964) recog-
nized ‘peer identification, support and membership’ as
one of five common ‘active mechanisms’ that could
make a psychosocial intervention ‘work’.
The sub-cultural element of CST and its contribution
to the positive outcomes of the intervention, including
‘switch-on’, may require further exploration. A possible
implication could be placing more emphasis on the
social and cultural connections between CST group
members in maintenance CST programmes and even
working towards building an ongoing post-CST commu-
nity for people with dementia.
Limitations
This was a small-scale study that involved only four
community-dwelling couples from the same CST
group. The four participants with dementia had several
commonalities, including being male, married, living
with a wife who was the main caregiver, and having a
similar interest or background in engineering, technolo-
gy or construction. Demographic information about
their wives was not collected, but it may have influenced
their perceptions of their husbands’ experiences. The
lack of variety in participant characteristics in this
study limits the transferability of the findings.
Further, the current study rendered a ‘thick’ descrip-
tion about ‘switch-on’ with ‘low-inference’ interpreta-
tion (Sandelowski, 2000: 335). However, it was not
designed to explore deep meaning or lived experience
of ‘switch-on’ for participants with dementia. Neither
did the study intend to examine the active mechanisms
that underlie ‘switch-on’, the internal dynamic relations
between the ‘switched-on’ areas, or the exact timing of
its occurrence.
323
In addition, there were several limitations related to
the VQ measurement. The VQ was administered by the
researcher rather than an independent rater, which
might have resulted in observer bias, affecting the
rigour of the study. Due to its opportunistic recruitment,
the study did not achieve multiple baseline measure-
ments as recommended for a single-subject A–B design
(Carter and Lubinsky, 2015). The measure showed a
ceiling effect due to its psychometric weakness in differ-
entiating higher levels of volition (Chern et al., 1996).
Conclusion
This was the first study that explored the ‘switch-on’
effect of CST using a parallel convergent mixed methods
design and incorporating an occupation-based perspec-
tive. The findings of the study indicated that ‘switch-on’
was multi-dimensional in nature, consisting of simulta-
neous positive changes in the areas of Doing, Feeling,
Relating, and Thinking and Reflecting. The ‘switch-on’
changes occurred synchronously in both CST and home
environments, with incremental improvement towards
completion of CST. Concurrent with the ‘switch-on’
descriptions were the improving trend of the VQ
scores, particularly on the achievement sub-scale, in
three of the participants with dementia. Although the
instrument was deemed to not effectively capture
‘switch-on’, this was the first study that measured the
impact of CST on volition. The evidence from the pre-
sent study suggests that the ‘switch-on’ effect could be a
desirable outcome of occupational participation in CST,
which warrants further investigation. Other indicated
areas that deserve more research in the future are the
volitional benefits and the therapeutic value of CST for a
sub-cultural group for people with dementia.
Key findings
• ‘Switch-on’ involved enhanced engagement in Doing,
Feeling, Relating, and Thinking and Reflecting,
which occurred in an incremental fashion.
• Three participants with dementia showed improve-
ment on the achievement sub-scale of the VQ.
What the study has added
This study provided a more comprehensive under-
standing of the ‘switch-on’ effect, a positive and
little-known outcome of CST from an occupation-
based theoretical perspective.
Acknowledgements
The authors thank Rhonda Preston-Jones, Barbara Fox, Nicola
Brenton, Zhi Chen, Lynn Hubbert and Maria Co from Dementia
Auckland, who provided the cognitive stimulation therapy pro-
gramme and assisted with recruitment of the research participants.
Dr Gary Cheung is acknowledged for mentoring the research proj-
ect in guiding the ethics approval application and selection of the
cognitive screening tool for the study.
324
Research ethics
Ethical approval was obtained from the Auckland University of
Technology Ethics Committee in 2016 (reference number 16/396).
Consent
All participants provided written informed consent to be inter-
viewed for the study. All participants with dementia provided writ-
ten informed consent to complete the selected measures for the
study.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect
to the research, authorship and/or publication of this article.
Funding
The first author disclosed receipt of the Occupational Therapy
Innovation, Learning and Development Fund for post-graduate
study from her employer, Auckland District Health Board, towards
completion of this research, which was undertaken in partial fulfil-
ment of the requirements of a Master of Health Science degree from
Auckland University of Technology.
Contributorship
All authors contributed to development of the research proposal,
methodology, design and application for ethical approval. Qi Liu,
under the supervision of Margaret Jones and Clare Hocking,
researched the literature and collected the data. All authors con-
tributed to interpretation of the data. Qi Liu drafted the manu-
script. All authors reviewed and edited the manuscript and
approved the final version.
ORCID iD
Qi Liu https://orcid.org/0000-0002-1518-088X
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