Improving Function with Cognitive Remediation
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Some people with serious mental illness suffer from cognitive problems, such as not being able to process information quickly, concentrate, or remember new information. While some psychiatric medications have cognitive effects, it’s now understood that the mental illnesses themselves can cause much of the cognitive dysfunction.
Cognitive dysfunction is a primary symptom of schizophrenia and some affective disorders, such as bipolar disorder and recurrent depressions.
At this time, the strongest evidence base for treating cognitive deficits in mental illnesses such as schizophrenia is cognitive remediation (CR).
CR is a behaviorally-based therapy that aims to improve cognitive deficits that are a barrier to everyday functioning for people with serious mental illness. For example, this intervention can help someone with attention and memory problems who may have difficulty following directions from his or her boss or going to school, or it can help them manage everyday tasks such as taking medication, grocery shopping, or getting to appointments.
Types of Cognitive Problems
Cognitive problems fall into two categories: neurocognitive and social cognitive deficits. Neurocognitive deficits are impairments in attention, verbal memory, working memory, or processing speed.
Social cognitive deficits, on the other hand, refer to difficulty recognizing facial affect, taking another person’s perspective, or perceiving social cues. Together, neurocognitive and social cognitive skills enable a person to negotiate daily demands and lead productive lives.
Treating Cognitive Dysfunction
Cognitive remediation (CR) is a “skills training” intervention provided under the umbrella of psychiatric rehabilitation (which helps people with serious mental illness with recovery, daily function, and quality of life). Like any psychiatric rehabilitation intervention, CR is a collaborative process that is person-centered and recovery-oriented.
The objective is help each client develop the cognitive skills and/or supports needed to achieve their goals, which might include returning to school, being more efficient at work, being better able to converse with family members, or keeping track of money.
There are two central tenets to CR:
- Cognition can be rehabilitated through behavioral learning-based interventions that promote neuropsychological and social cognitive skill performance
- Through targeting specific areas of dysfunction, improvements in cognitive performance are translated to produce changes in real-world functions
Let’s consider an example of how cognitive deficits can impact a person’s daily life. Something as simple as scheduling a doctor’s appointment requires a number of cognitive skills that many people with mental illness may struggle with. These include attention (on the phone with the scheduling coordinator), processing speed (following the rapid instructions), memory (thinking about what else is going on at that time; remembering to request the time off), organization (on the day of the appointment, gathering insurance information, credit card for payment, etc), and planning (lining up a ride; estimating traffic and travel time).
How Cognitive Remediation Works
Approaches to CR can be grouped into three major categories:
Restorative approaches target cognitive deficits directly through repeated task practice, careful titration of task difficulty, and maintenance of high levels of accurate performance. These exercises are often web-based and are practiced under a therapist’s supervision. Task practice is typically organized with basic sensory processing or attention training first, followed by training in higher-order memory and problem-solving skills. The drill-and-practice approach is based on the idea of “experience-dependent neuroplasticity.” Basically: practice makes perfect. So, in the example of a client making it to a doctor’s appointment, he or she might do attention or memory exercises so it will become easier to focus on directions and remember information.
Strategy-based approaches focus on learning techniques for avoiding cognitive difficulties. In these interventions, the therapist provides alternate ways to manage a cognitive task, for example, using a list to remember items, or a planner to stay organized. If someone is better at visual attention than auditory, they are taught to write things down and use visual cues to accompany the auditory input. Cognitive skills are discussed in relation to their use in everyday life. So, to help make it to a doctor’s appointment, a therapist might work with the client to teach him or her how to keep a daily schedule, to check the schedule at night to see what is coming up the next day, and create reminders such as a sticky note for the bathroom mirror or an alarm on the phone.
Hybrid approaches typically involve a combination of both restorative drill-and-practice training and strategy approaches, and include additional elements for deficits in motivation, social cognition, and/or social skills.
Who Benefits from CR?
CR is used to help people with a range of psychiatric disorders, such as schizophrenia, schizoaffective disorder, affective disorders, ADHD, autism, and anorexia. 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, jail, 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 disordered thinking.
What the Research Shows
The largest research base is for the use of CR to treat the cognitive deficits of people with psychotic disorders. There have been several meta-analyses of 59 independent studies on CR that included more than 2,600 patients with psychotic disorders (Wykes et al, Am J Psychiatry 2011;168(5):472–485; Kurtz MM & Richardson CL, Schizophr Bull 2011;38(5):1092–1104).
These meta-analyses demonstrate that CR for psychotic disorders is moderately effective at improving neurocognitive and social cognitive skills, regardless of quality of trial methodology and version of CR approach used. However, the impact of CR on functional outcomes is more variable. The ability of CR to improve function is greatest when individuals are given opportunities to practice the cognitive skills in real world settings. CR programs that do not solely rely on drill and practice, but instead incorporate strategy teaching and methods to address beliefs and motivation, are associated with better psychosocial outcomes.
Although much of the focus of CR research over the last decade has centered on schizophrenia-spectrum disorders, emerging evidence suggests that CR is also an effective intervention for mood disorders and that these treatment effects translate into improvements in cognitive performance and, possibly, functioning (Bowie CR et al, Can J Psychiatry 2013;58(6):319–325).
Cognitive deficits in mood disorders have a different course and are associated with different co-morbidities, such as anxiety disorders, than those in schizophrenia. Therefore, the CR approaches used for this population may vary from those used with schizophrenia spectrum disorders. While CR for affective disorders uses both restorative and compensatory methods, it may require a different intensity and duration, or attention to motivational and cognitive belief systems.
The use of CR for children and adolescents with ADHD has garnered much attention in the last decade. These programs differ from those designed for people with psychotic and affective disorders because they are typically offered in the home or school and use parents or teachers as coaches. Much of the focus of CR for ADHD is on improving working memory and executive functioning. The research indicates restorative approaches can improve cognitive skills in this population, and the benefits can transfer to other cognitive skills and, sometimes, behavior (Rutledge KJ et al, Neurotherapeutics 2012;9(3):542–558).
People with autism, anorexia, and age-related cognitive decline are increasingly being studied as possible candidates for CR. The research is promising, though there is still a lot to learn about which methods work best.
If you are interested in offering CR, a first step is to consider generally how you address cognitive deficits in your practice. Do you consider the effect of illness and treatments on cognition? Do you talk to patients and families about cognition and how it may be impacting recovery goals? Do you routinely assess cognition and use the results as part of your treatment planning?
It is relatively easy to set up a CR program, although the therapy does require specialized training for mental health clinicians. 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 learn about CR, including The Alliance for the Study of Cognitive Disorders, which provides information on where to get training for this therapy (contact Paul Johannet, firstname.lastname@example.org, for more information).