Cognitive Remediation (CR) is an “evidence based, recovery oriented behavioural intervention that focuses on reducing cognitive deficits and enhancing life skills in people with serious mental illnesses” (Medalia et al, 2017). In this page, we would like to provide you, the reader, with an overview of Cognitive Remediation, along with links to other useful and informative articles and videos. We will briefly explain what is meant by ‘cognition’, what are the real life ‘functional’ consequences of cognitive difficulties that occur in psychosis, and how CR can address these difficulties.
CR focuses on the domains of ‘basic’ cognition- which typically include attention, different components of memory (such as verbal and non-verbal memory, and working memory), domains of executive functioning, and processing speed. Perhaps a good place to start would be to delve (very briefly) into what these refer to in the context of CR.
Attention: The ability to “pay attention” can be developed in a number of different ways, as attention is itself a multifaceted concept. Simple attention usually describes what we might think of when we hear the word, such as paying attention to what someone is saying to you. This is the initial cognitive process that also drives memory; we need to attend to something in order to ‘encode’ it into memory. A related domain is sustained attention which involves focusing on a stimulus over a longer period of time, such as when reading a book. Selective attention is the process of focusing on something in particular, while ignoring other distractions- e.g. when talking to someone in a busy room, I need to focus on the person I am speaking to, while ignoring other conversations. By contrast, divided attention involves the deliberate ability to shift my attention across two tasks. For example, when driving, I need to watch the road ahead, while also monitoring what’s happening around me using the mirrors.
Working memory: This is the ‘limited capacity’ memory, holding information in mind, making it available for other cognitive processes such as holding a phone number in mind while I type in the number into my phone, or remembering a list of items I need to grab from my room before leaving the house.
Memory: This can be divided in different ways, such as into verbal and non-verbal memory, as well as into semantic memory (our memory of facts and information) and episodic or autobiographical memory (our memory of events that have happened in our lives).
Executive functions: This is an umbrella term for the ‘higher’ cognitive processes, which control our behavior, much like the ‘executives’ of a company. These typically include planning and sequencing, problem solving, and inhibitory functioning – which would require stopping an automatic response, in favor of a more planned alternative action.
Processing speed: This refers to the speed with which one can do a mental task, or ‘make sense’ of information that they receive, and act on it. Motor response speed is a part of processing speed.
Cognition in Severe Mental Illnesses
We focus here on the ‘schizophrenia spectrum disorders’, which includes schizophrenia, schizoaffective disorder, delusional disorder, schizophreniform disorder, and other unspecified psychosis. Although the characteristic symptoms of these disorders are delusions and hallucinations, a large body of research suggests that almost all the domains of cognition outlined above are impacted in individuals struggling with this illness. These cognitive impairments can be persistent over the course of the illness. The severity of the cognitive difficulties a person experiences is not correlated with the severity of their delusions or hallucinations- meaning that a person might continue to struggle with memory and attentional problems even if their voices and paranoia improves. Moreover, the severity of cognitive difficulties is a predictor of their ability to work, socialize and live independently. Therefore, finding ways to improve cognitive performance can serve to improving daily life functioning. While the positive symptoms of psychosis (hallucinations such as voices, and paranoia or ‘delusional beliefs’) respond well to antipsychotic medication, these do not typically improve cognition. However, we encourage people to continue to take their medication as prescribed, since taking medications can have an overall effect on functioning, and CR is an adjunctive treatment, rather than an alternative to medication.
Cognitive remediation therapy or training (CRT) refers to a set of tools and approaches aimed to improve cognitive functioning, which typically targets the domains outlined above (attention, memory, executive functioning and processing speed). There are two main approaches to CR. The compensatory approach focuses on using supports (such as smart phones, aids and strategies) to try to work around, and compensate for the cognitive difficulties. The restorative approach, on the other hand, attempts to directly improve the compromised cognitive domains using a mixture of ‘drill and practice’ and strategies to generalize these skills. One component of this restorative approach therefore involves the use of paper and pencil or computer based tasks, which increase in difficulty level, acting as a sort of ‘brain gym’. Although earlier studies had focused on just the use of computer tasks, the growing consensus suggested that this helped improve performance on the task being practiced, but did not generalize to daily life. Some CR approaches focus on improving processing speed or basic perceptual training , allowing the person to process information more efficiently, which might in turn lead to better attention and memory. However, some recent work by Drs Michael Best, Chris Bowie and colleagues at Queen’s University in Kingston suggests that CR approaches that focus on improving executive functioning might have a longer lasting effect on other domains of cognition, although this is an ongoing area of research and debate. In order to generalize improvements to the real world, the CRT program requires three components- cognitive tasks that are challenging (which are speculated to increase ‘neuroplasticity’), along with strategy utilization and generalization. These are typically combined in an approach that Dr. Alice Medalia and her group in New York refer to as “Neuropsychological Educational Approach to Remediation” (NEAR). Dr Medalia’s groundbreaking work developing this approach is outlined in detail in her book. There are a number of commercially available ‘drill and practice’ style computer based CR programs, such as happy neuron , CogPack, and BrainHQ among others. The programs have games that focus on the different domains of cognition, and these get more challenging as the participant continues to improve. The programs typically use an ‘errorless learning’ model, wherein a participant must be able to complete a level perfectly before moving to the next level, or an ‘adaptive learning’ model, where the task gets easier if the person makes an error, and harder as they get more items right, to stay at a particular difficulty level. Other commercially available packages like CogSmart , as well as treatments like Cognitive Adaptation Training (CAT) focus on the use of compensatory strategies, without the computerized drill and practice component. These highlight the idea that for CR to be effective, it involves not just the games, but also the ability to identify one’s difficulties and strengths on those games, and strategies to improve performance. For this reason, CR programs are typically carried out with a therapist (but can be done individually or in a group). The therapist works with the client to identify difficulties, as well as adaptive and compensatory strategies- to be used during the computer task, and in real life. The most successful CR approaches also link these sessions and skills to the person’s own functional goals (such as employment, return to school or independent living). CR has been shown to be particularly effective in the context of vocational rehab and in conjunction with social skills training (where the cognitive strategies can be combined with social knowledge to improve daily life functioning). And while it can be helpful for individuals who have struggled with psychosis for many years, it can be particularly helpful if utilized early in the illness.
Supporting Individuals With Psychosis
For care givers, it can be helpful to understand the cognitive difficulties that can accompany the illness, and integrate some of the compensatory strategies. Here are some links providing useful information on CR-:
- The annual Cognitive Remediation in Psychiatry conferenceDr Medalia’s group at Columbia University in New York hosts an annual conference on Cognitive Remediation in Psychiatry, which provides a venue for up to date research on the topic. Their group also has a free video series that is designed to help staff lead cognitive remediation programs. And here is a video on what CR looks like using the NEAR approach.
- The ‘Dealing with Psychosis Toolkit’ from EPI BCThe toolkit provides a wealth of information and resources for coping with psychosis, and includes a section on understanding cognition and problem solving among others.
- Cognitive Remediation in British ColumbiaThis is a growing area of interest, and led to the first Canadian conference on CR, which was organized by the the BC Schizophrenia society with help from the BC Psychosis Program, the University of British Columbia, BC EPI and Psychosocial Rehabilitiation BC. The presentations by Drs Chris Bowie and Alice Medalia, as well as BC clinicians and researchers are available to view through the BCSS link. The program is offered to inpatients at the BC Psychosis Program. A recently completed study through Fraser Health, by Drs Amy Burns and David Erickson, found that CR helped improve return to work and vocational outcomes when combined with Individualized Placement (IPS) for supported employment. Although it is not yet widely available, our lab periodically offers CR groups as part of a research study. If you live in BC and are interested in CR, speak to your case manager, or people in your health authority about availability and ways to access CR.