Learning Objectives

After reading this article, you should be able to:

1. Recognize the different types of cognitive challenges that individuals with serious mental illnesses may face.
2. Understand the principles of cognitive remediation as an evidence-based treatment for cognitive dysfunction.
3. Implement effective cognitive remediation strategies in their practice.

As psychotherapists, we know that many individuals with serious mental illnesses, such as schizophrenia and bipolar disorder, face cognitive challenges. These cognitive problems can make it difficult for clients to process information quickly, concentrate, or remember new information. Although comorbid conditions and some psychiatric medications can contribute to cognitive issues, the mental illnesses themselves are often the primary source of cognitive dysfunction. So, let's dive into the world of cognitive remediation (CR), an evidence-based treatment that can help our clients overcome cognitive deficits and improve their daily functioning.

Understanding the types of cognitive problems

Cognitive issues generally fall into two categories: neurocognitive and social cognitive deficits. Neurocognitive deficits refer to impairments in attention, verbal and visual memory, working memory, processing speed, and various executive functioning skills like problem-solving, reasoning, planning, and organization. Social cognitive deficits, on the other hand, involve difficulty recognizing facial expressions, empathizing with others, or perceiving social cues. Both neurocognitive and social cognitive skills are essential for clients to navigate daily demands and lead a fulfilling life.

Treating cognitive dysfunction: The power of cognitive remediation

Cognitive remediation (CR) is a therapist-led "skills training" intervention, falling under the umbrella of psychiatric rehabilitation. This set of services aims to assist individuals with severe mental illnesses in their recovery, focusing on daily functioning and quality of life. CR, like any psychiatric rehabilitation intervention, is a collaborative, person-centered, and recovery-oriented process.

Our objective as therapists is to help each client develop the cognitive skills and support needed to achieve their goals, which might include returning to school, becoming more efficient at work, being more socially engaged, or better managing tasks required for independent living.

There are two central tenets of cognitive remediation:

1. Cognition can be improved through behavioral learning-based interventions that promote neuropsychological and social cognitive skill performance.
2. By targeting specific areas of cognitive dysfunction, improvements in cognition make everyday functioning easier and more productive.

An example: The everyday impact of cognitive deficits

Let's consider an example of how cognitive deficits can impact a person's daily life. Scheduling a doctor's appointment requires a number of cognitive skills that many clients with mental illness may struggle with. These include attention (on the phone with the scheduling coordinator), processing speed (following the rapid instructions), memory (considering what else is going on at that time and remembering to request time off), organization (gathering insurance information, a credit card for payment, a list of current medications, etc), and planning (arranging transportation, estimating traffic, and travel time). For a quick visual, see the table, “Signs of Cognitive Problems” below.

The four core elements of effective cognitive remediation

Four treatment elements have been identified by cognitive remediation experts (Bowie CR et al, Schizophr Res 2020;215:49-53) and confirmed by meta-analytic studies (Vita A et al, JAMA Psychiatry 2021;78(8):848-858) to be crucial ingredients for the treatment to be effective. 

1. Facilitation by a trained therapist: A knowledgeable therapist conducts the sessions, ensuring that the cognitive training experience is relevant to the recovery goals of the participant. In cognitive remediation, your role as a trained therapist is vital. You'll lead the sessions, assisting your clients with cognitive exercises and encouraging them to apply their newfound cognitive skills in daily life. Unlike computerized cognitive training, where individuals work on cognitive exercises without guidance, your expertise in understanding how psychiatric illnesses impact cognition and the role of cognitive health in everyday functioning will ensure a personalized CR experience tailored to each client's recovery goals.
2. Repeated practice of cognitive exercises: To make the most of cognitive remediation sessions, it's essential to provide ample practice of cognitive exercises. This helps in achieving sustained activation of the neural networks associated with the targeted cognitive skills. Emphasizing the concept of "experience-dependent neuroplasticity," repeated practice is crucial for learning, mastery, and developing multiple strategies. As a therapist, you'll offer feedback on performance, adjust task difficulty as needed, maintain high levels of accurate performance, and coach your clients to facilitate learning. Remember, exercises should ideally be personalized to address the cognitive and motivational needs of each client.
3. Opportunities to learn effective strategies: During CR sessions, you'll have the opportunity to teach your clients effective strategies to enhance cognitive performance and become more adept at problem-solving. For example, you can introduce techniques for improving attention, memory, or devising solutions to problems. As therapists and fellow group participants share and promote effective strategy use, clients benefit from an engaging and supportive learning environment.
4. Techniques to promote real-world gains: The ultimate goal of CR is to improve cognition as it applies to everyday life. As a therapist, you must make a conscious effort to relate the in-session cognitive exercises to each client's functioning goals, which may involve work, school, social interactions, independent living, or symptom management. Leading discussions during group sessions and providing individualized support can ensure the transfer of in-session cognitive gains to real-world functioning.

Who can benefit from cognitive remediation?

CR is used to help people with a range of psychiatric disorders, such as schizophrenia, schizoaffective disorder, affective disorders, ADHD, autism, and anorexia nervosa. It has been effective with children and adults, ranging in age from five to 90. It has also been applied to a variety of settings, from the home, to school, hospital, clinic, correctional facility, and residential care facility.

CR is sometimes confused with cognitive behavioral therapy. While both therapies are related to cognition, CR targets neurocognitive skills, such as processing speed, attention, and memory, while other cognitive treatments target higher-level cognitive problems such as patterns of maladaptive thinking.

The research behind cognitive remediation

Numerous studies have demonstrated the efficacy of cognitive remediation in improving cognitive performance and functional outcomes for individuals with mental illness. For example, a meta-analysis found that cognitive remediation significantly improves cognitive and functioning outcomes in individuals with schizophrenia (Wykes et al, Am J Psych 2011;168(5):472-485). A specific form of cognitive remediation, known as cognitive enhancement therapy, has developed a broad evidence base for use in psychotic disorders (Wojtalik JA et al, Psychiatr Serv 2022;73(5):501-509). Moreover, CR has been shown to enhance treatment outcomes for affective disorders and improve overall cognitive functioning and daily living skills in those with ADHD, autism, and anorexia nervosa.

Integrating cognitive remediation into your practice

If you are interested in offering CR, a first step is to consider how you address cognitive health in your practice. Do you consider the effect of illness and treatments on cognition? Do you talk to patients and families about cognition, how it may be impacting recovery goals and healthy habits to optimize brain health? Do you routinely assess cognition and use the results as part of your treatment planning? You can learn tips for talking to patients about cognitive health at Let’s Talk About Cognitive Health (link to www.teachrecovery.com).

It is relatively easy to set up a clinic-based or virtual CR program, especially now that specialized training for mental health clinicians to run CR groups can be done virtually. Implementing CR in large systems of care has the expected challenges of scaling technology and workforce readiness, but feasibility has been demonstrated by the New York Office of Mental Health which has been offering CR to patients systemwide since 2016 (Medalia A et al, CNS Spectr 2019;24(1):163-173). As a low-risk, high-benefit treatment, there is considerable interest in making CR more widely available. There are a number of published and web-based resources to help you get started with CR (see the Resources table below).

Carlat Verdict: Cognitive remediation is an evidence-based intervention that can help clients with mental illness overcome cognitive challenges and lead more productive and fulfilling lives. By understanding and implementing CR in your practice, you can make a powerful positive impact on your clients’ path to recovery. 

References in order of appearance in this article

Bowie, C. R., Depp, C., McGrath, J. A., Wolyniec, P., Mausbach, B. T., Thornquist, M. H., Luke, J. R., Twamley, E. W., & Patterson, T. L. (2020). Prediction of real-world functional disability in chronic mental disorders: A comparison of schizophrenia and bipolar disorder. Schizophrenia Research, 215, 49-53. doi:10.1016/j.schres.2019.10.024.

Medalia, A., Saperstein, A. M., Erlich, M. D., & Sederer, L. I. (2019). Cognitive remediation in large systems of psychiatric care. CNS spectrums, 24(1), 163–173. https://doi.org/10.1017/S1092852918000822.Vita, A., Barlati, S., Ceraso, A., Nibbio, G., Ariu, C., Deste, G., Wykes, T. (2021). Effectiveness, core elements, and moderators of response of cognitive remediation for schizophrenia: A systematic review and meta-analysis of randomized clinical trials. JAMA Psychiatry, 78(8), 848–858. doi:10.1001/jamapsychiatry.2021.0620

Wojtalik, J. A., Mesholam-Gately, R. I., Hogarty, S. S., Greenwald, D. P., Litschge, M. Y., Sandoval, L. R., Shashidhar, G., Guimond, S., Keshavan, M. S., & Eack, S. M. (2022). Confirmatory Efficacy of Cognitive Enhancement Therapy for Early Schizophrenia: Results From a Multisite Randomized Trial. Psychiatric Services (Washington, D.C.), 73(5), 501–509. https://doi.org/10.1176/appi.ps.202000552

Wykes, T., Huddy, V., Cellard, C., McGurk, S. R., & Czobor, P. (2011). A meta-analysis of cognitive remediation for schizophrenia: methodology and effect sizes. The American Journal of Psychiatry, 168(5), 472–485. https://doi.org/10.1176/appi.ajp.2010.10060855.