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Table 1 Principles guiding cognitive remediation intervention

From: A randomized controlled trial of cognitive remediation for a national cohort of forensic patients with schizophrenia or schizoaffective disorder

Principle 1, Relationship Building: A major focus of each session is to prioritise the development of a strong therapeutic relationship. The therapeutic relationship will be strengthened by providing a credible rational for participation, explicitly linking the cognitive remediation to patients’ goals, promoting success experiences, making participation enjoyable, providing positive reinforcement, and managing ruptures, which may occur during the course of the intervention.
Principle 2, Collaborative Goal Setting: So as to promote ‘buy in’ patients will be encouraged to develop a series of short term, medium term, and long-term goals. Patients neuropsychological and risk assessments e.g. HCR-20, DUNDRUM toolkit, will be shared with patients to create a platform to develop goals. An explicit connection will also be drawn between cognitive difficulties and patients’ aspirations. Short term goals may include having the concentration required to watch a TV programme or to read a book. Medium term goals may include patients’ ability to self-medicate or move to a less secure unit. Long term goals may include returning to work, and developing relationships outside the hospital.
Principle 3, Session Structure: Each session will begin with a mood check to establish rapport or identify problems followed by agenda setting, implementation of the agenda items, and summaries before moving to the next agenda item. The session will end by giving patients the opportunity to provide feedback.
Principle 4, Content of the sessions: The sequencing of interventions will be informed both by patients’ goals and their unique strengths and vulnerabilities as documented by neuropsychological assessment. Cognitive domains at the start of the informational processing stream e.g. attention and vigilance, working memory etc. will typically be prioritised over those occurring later e.g. comprehension and social problem solving. This is because difficulties associated with higher level cognitive processes may be a result of problems with more basic processes such as attention and memory. As patients demonstrate some improvement in core cognitive skills higher level domains will be targeted. Clinical judgement will be required to determine if patients achieve a basic level of mastery in certain cognitive domains or if a ceiling has been reached before progressing to more complex domains. CRT therapists should carefully assess whether patients are improving on core domains e.g. verbal memory etc., and if these improvements are being maintained over time.
Principle 5, Pacing: Therapists are encouraged to avoid trying to squeeze too much into each session or to work on too many problems simultaneously because it takes time to consolidate skills. In other words, patients need opportunities to repeat tasks again and again to improve performance, which is referred to as massed practice. Throughout the intervention each session should build on the next and be targeted at concrete goals. Patients should be provided with feedback on their progress towards goals. Newly acquired skills should not be abandoned once developed but refreshed during future sessions. Patients may also need breaks between tasks. This down time is a good opportunity to ask patients about their lives and to strengthen the therapeutic relationship.
Principle 6, Errorless Learning and Scaffolding: Task difficulty should be set so that patients obtain a high level of success on each task to avoid faulty learning and to enhance moral. Patients will be required to obtain a success rate of 80% before the cognitive demands of the task are increased. Where problems are encountered therapists should provide scaffolding and model successful completion of tasks.
Principle 7, Meta cognitive Strategies: A major focus of each session will be to explicitly teach patients meta-cognitive strategies which are somewhat independent of basic cognitive ability and can be flexibly applied across situations. Examples of meta-cognitive strategies include goal setting, visualisation, focusing on one thing at a time, self-verbalisation, planning, breaking problems into parts, sequencing, chunking, advantage disadvantage analysis, perspective taking, monitoring performance, reflecting on performance etc. It is particularly important to explicitly model the effective use of meta cognitive strategies for patients. The effectiveness of strategies should be carefully assessed using a behavioural experiment framework. The use of particular strategies should be consolidated as evidenced by generalisation before additional meta-cognitive strategies are introduced. When mastery of basic strategies has been consolidated patients can be encouraged to simultaneously use multiple strategies.
Principle 8 Generalisation: Patients will be encouraged to utilise their cognitive skills outside of remediation sessions by participating in a support group. The focus of the support group will be helping patients to develop a shared understanding of the cognitive deficits associated with schizophrenia, to develop an awareness of how these deficits affect their lives, to identify situations where they can apply their cognitive skills, to obtain encouragement and support from other members of the group on how to implement these skills, to strengthen narratives where success has been achieved. In addition to the above positive group participation in and of itself may enhance cognitive processes as it requires patients to monitor their thoughts, reframe from interruptions, structure their contributions, and reflect on feedback.
Principle 9 Managing Ambivalence: Patients' ambivalence towards participating should be met in a non-defensive empathic manner. Advantages and disadvantages of participating should be listed using pen and paper to ease the burden on working memory and to model effective problem solving. Patents should be gently reminded of their goals and their initial commitment to participate for the duration of the intervention. Ways of making the cognitive remediation more relevant or enjoyable should be actively explored.