Cognitive Remediation

Cognitive Remediation focuses on the domains of ‘basic’ cognition- which typically include attention, different components of 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 Cognitive Remediation.

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 “attention,” such as mentally focusing on what someone is saying to us. This is the initial cognitive process that also drives memory; we need to attend to something in order to ‘encode’ it into memory.
• Sustained attention 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 specific while ignoring other distractions- e.g. when talking to someone in a busy room, you need to focus on the person you are speaking to, while ignoring other conversations.
• Divided attention involves the deliberate ability to shift my attention across two tasks. For example, when driving, you need to watch the road ahead and monitor what’s happening around you using the mirrors.

Working memory

This is a ‘limited capacity’ memory process, which involves holding and manipulating information in mind, making it available for other cognitive processes (for planning or action), 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 the fridge and the cupboard for a recipe I am making.  Working memory can also be thought of as a component of executive functioning (see below).

Memory

This can be divided in different ways, such as into verbal and nonverbal memory, semantic memory (our memory of facts and information), episodic memory (our memory of events), or autobiographical memory (our memory of our own personal lives).

Executive functions

This is an umbrella term for the ‘higher’ cognitive processes that guide our behaviour. These typically include planning and sequencing, problem-solving, mental shifting, and inhibitory functioning, which would require stopping an automatic response in favour of a more planned alternative action.

Processing speed

This refers to the speed with which one can perform a mental task, ‘make sense’ of information received and act on it. Motor response speed is a part of processing speed.

We can think about concepts like ‘IQ’ as involving a combination of these cognitive processes. Weschler, who developed one of the most widely used IQ tests (the ‘Weschler Adult Intelligence Scale’ - WAIS) defined IQ as “the global capacity of a person to act purposefully, to think rationally, and to deal effectively with his environment”. The WAIS is broken into subdomains including ‘verbal comprehension’, ‘perceptual reasoning’, working memory and processing speed.

Social cognition

This refers to a set of cognitive processes (including executive functioning) involved in understanding other people’s actions and intentions, using that to predict what people might feel and do, and acting appropriately in different social contexts. Components of social cognition include understanding our own emotions and what other people might be feeling or thinking and picking up on social cues.

We focus here on the ‘schizophrenia spectrum disorders’, which includes schizophrenia, schizoaffective disorder, delusional disorder, schizophreniform disorder, and other unspecified psychoses. Although the characteristic symptoms of these disorders are delusions and hallucinations, a large body of research suggests that many people who struggle with these illnesses have difficulties in many of the domains of cognition outlined above. Cognitive difficulties can vary across individuals, but they may particularly have difficulties with verbal memory, executive functioning and slowed processing speed.

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 help to improve daily life functioning.

While the positive symptoms of psychosis (hallucinations such as voices, and paranoia or ‘delusional beliefs’) respond well to antipsychotic medication, these treatments do not significantly 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 Cognitive Remediation 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 of attention, memory, executive functioning and processing speed. There are two main approaches to Cognitive Remediation:

• The compensatory approach - focuses on using supports (such as smartphones, aids and strategies) to try to work around and compensate for the cognitive difficulties.
• The restorative approach - 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 using 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 using computer tasks, the growing consensus suggested that this helped improve performance on the task being practiced but did not generalize to daily life. Therefore, another component of CR involves working with a therapist to find ways to generalize these skills to daily life activities and a person’s individual goals.

To generalize improvements to the real world, the Cognitive Remediation program requires three components:

1. Challenging cognitive tasks (which are thought to increase ‘neuroplasticity’)
2. Strategy utilization
3. Generalization.

For Cognitive Remediation to be effective, it involves not just computer-based memory, attention, and planning ‘games’ but also the ability to identify one’s difficulties and strengths in those games and develop strategies to improve performance.

For this reason, Cognitive Remediation 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 Cognitive Remediation approaches also link these sessions and skills to the person’s functional goals (such as employment, return to school or independent living).

Cognitive Remediation 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). A recently completed study through Fraser Health by Drs Amy Burns and David Erickson found that Cognitive Remediation helped improve return to work and vocational outcomes when combined with Individualized Placement (IPS) for supported employment. And while it can be helpful for individuals who have struggled with psychosis for many years, it may be especially helpful if utilized early in the illness.

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 Cognitive Remediation:

• The annual Cognitive Remediation in Psychiatry conference
  Dr 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.
• The 'Dealing with Psychosis Toolkit' from EPI BC
  The toolkit provides a wealth of information and resources for coping with psychosis, and includes a section on understanding cognition and problem solving among others.
• Video Series through PSR BC and the BC Schizophrenia Society

Psychosocial Rehab BC (PSR BC) and the BC CR working group put together a video on cognition and cognitive remediation. In 2018, the BC Schizophrenia Society also held one day conference on cognitive remediation, featuring a longer, more comphrensive overview of cognition and CR by Dr Chris Bowie.

In 2022, the BC Ministry of Mental Health & Addictions (MMHA) and Ministry of Health provided funding to increase access to Cognitive Remediation for individuals living with severe mental illness in BC. The BC   Cognitive Remediation Training Advanced Practice (CRT-AP) was set up to provide training and support for clinicians in each of the health authorities in BC.

Action Based Cognitive Remediation (ABCR)

In BC, we are offering the Action Based Cognitive Remediation protocol, which Prof. Chris Bowie developed at Queen’s University. ABCR is 16 session training program that can be delivered in person or virtually. It is divided into four modules (Speed & Attention, Memory, Executive Functioning, and Social Cognition). Small groups (4-8 participants) meet for around 2 hours once or twice per week (depending on whether structured as an 8-, 12-, or 16-week program). Sessions involve computer-based drills, real-life simulations, and therapist-facilitated discussions intended to promote cognitive strategy monitoring and transfer of cognitive strategies to daily life. The clinicians also provide individualized support to clients, for the duration of the treatment, helping them work on their goals (such as return to school, work/ volunteering, or increased independence with daily life activities).

The ABCR groups are available to any clients who are connected with a mental health team in one of the health authorities. Currently, the ABCR groups are available at the following sites:

Vancouver Coastal Health

• Sea to Sky Mental Health Team – Squamish BC
• Vancouver Community Mental Health Teams (Kitsilano, West End/Three Bridges, Raven Song, South, Grandview Woodlands and North East MHT)
• VCH Early Psychosis Intervention Teams (Vancouver, Richmond, North Shore)
• HoPE Centre (virtual groups through the Sea to Sky Mental Health Team)
• BC Psychosis Program, UBC Hospital (only for BCPP clients)
• Willow Pavilion (only for Willow clients)

Fraser Health

• Rehab & Recovery Team Royal Columbian Hospital
• Surrey South EPI Team
• Surrey, Delta, White Rock Mental Health Teams (virtual groups)

Island Health

• Mental Wellness Day Program, Victoria (in person and virtual groups for Island Health clients)

Northern Health Authority

• Prince George EPI Program
• Prince George COAST/ CAST programs
• Iris House
• Seven Sisters

Interior Health Authority

• Kamloops Mental Health Team
• Vernon Mental Health Team & EPI team
• Regional Virtual group for IH clients

Provincial Health Services Authority (PHSA)

• Red Fish Healing Centre (only for RFHC clients)
• Forensic Psychiatric Hospital (only for FPH clients)

The groups may be offered virtually (by Zoom) or in person. If you are a client connected to a mental health team in BC, please get in touch with your case manager or psychiatrist to see if you can join the groups. You can also email crtap@vch.ca to get more information.