Abstract

Schizophrenia is a mental health condition characterized by broad impairments in cognition that place profound limitations on functional recovery. Social work has an enduring legacy in pioneering the development of novel psychosocial interventions for people with schizophrenia, and in this article the author introduces cognitive remediation, the latest advance in psychosocial treatments for the disorder designed to improve cognition. First, the author presents an overview of the nature of cognitive impairments and their functional consequences in schizophrenia, followed by a description of the theoretical basis and key practice principles of cognitive remediation. Next, the author reviews the latest biopsychosocial evidence for the efficacy of cognitive remediation in schizophrenia. Finally, the author presents a model cognitive remediation program, cognitive enhancement therapy, which was developed and evaluated by a social work–led multidisciplinary team. Cognitive enhancement therapy is a significant advance in cognitive remediation for schizophrenia and uses a unique holistic approach that extends beyond traditional neurocognitive training to facilitate the achievement of adult social–cognitive milestones and broader functional recovery. Cognitive remediation is an effective next-generation psychosocial intervention that social workers can use to help improve the lives of many people who live with schizophrenia.

Schizophrenia is a mental health condition that places considerable burden on the individuals who have it, their families, and society. The introduction of antipsychotic medications has helped people with schizophrenia to control the hallucinations, delusions, and other positive symptoms of psychosis, which has made it possible for many individuals to live in the community. Unfortunately, despite antipsychotic medication, most individuals with schizophrenia continue to experience significant social, functional, and vocational disability, leading to a poor quality of life (Swartz et al., 2007). The consistent observation that antipsychotic pharmacotherapy alone is often not enough to address the devastating functional consequences of this condition has highlighted the critical importance of using psychosocial interventions to help further support the recovery of people with schizophrenia.

Social workers are the primary providers of psychosocial treatments for people with schizophrenia (Substance Abuse and Mental Health Services Administration [SAMHSA], 2001) and have pioneered the development, evaluation, and use of psychosocial interventions among this population. Major contributions of social work have included early forms of social casework (Hogarty & Goldberg, 1973), assertive community treatment (Stein & Test, 1980), family psychoeducation (Anderson, Reiss, & Hogarty, 1986), strengths-based case management (Rapp, 1998), personal therapy (Hogarty et al., 1997), and many others. When combined with antipsychotic medication, these interventions have helped lengthen community tenure, prevent psychotic relapse, improve family functioning, and dramatically reduce the disability associated with this condition.

Despite researchers’ best efforts and the development of highly effective psychosocial treatments, a complete functional recovery from the illness continues to remain out of reach for most affected individuals. This has led to a concerted effort to identify novel treatment targets that might begin to offer additional hope and relief beyond the current best-available interventions.

Recently, broad impairments in cognition have emerged as important and often overlooked contributors to functional disability in schizophrenia (Green, Kern, Braff, & Mintz, 2000). Significant impairments have been observed across a variety of cognitive domains (Heinrichs & Zakzanis, 1998; Penn, Corrigan, Bentall, Racenstein, & Newman, 1997) and have been shown to be major contributors to functional disability among people with schizophrenia (Brekke, Hoe, Long, & Green, 2007; Couture, Penn, & Roberts, 2006; Green et al., 2000), even more so than the hallmark positive symptoms of psychosis. Unfortunately, these disabling impairments in cognition have to date been largely unresponsive to pharmacotherapy (Keefe et al., 2007).

Although effective medications for improving cognition in schizophrenia have yet to be developed, social workers have collaborated with colleagues from other disciplines to develop psychosocial treatments that can enhance cognition in people with schizophrenia (for example, Eack et al., 2009; Hogarty et al., 2004). Collectively, these interventions have become known as cognitive remediation approaches—psychosocial interventions designed to enhance cognition through the use of targeted cognitive exercises and training. In this article, I provide an introduction for social work practitioners and researchers to cognitive remediation for people with schizophrenia. I first present an overview and topology of cognitive impairment in schizophrenia, followed by a presentation of the theory and practice principles of cognitive remediation. I then present a critical review of the latest evidence of the effects of cognitive remediation on cognition, the brain, and behavior in schizophrenia. Finally, practice principles and the evidence base for cognitive remediation are contextualized in an overview and illustration of cognitive enhancement therapy (CET) (Hogarty & Greenwald, 2006), a novel and model approach to cognitive remediation developed by Gerard E. Hogarty and colleagues that takes a holistic view of the treatment of cognition and facilitation of functional recovery in people with schizophrenia.

Cognitive Impairment as a Barrier to Functional Recovery from Schizophrenia

Over the past several decades, investigators have documented a profound array of cognitive impairments in people with schizophrenia. These impairments have been classified broadly as those associated with neurocognition and social cognition. Neurocognition is defined by the basic cognitive processes involved in supporting thinking and reasoning, which includes attention, memory, and executive function abilities. Attention is critical for detecting salient and important information to be encoded and processed, and memory is necessary for storing that information. Working memory, in particular, is essential for completing everyday tasks because it is a form of memory that allows a person to hold a small amount of information in her or his mind to perform a given behavior (for example, remembering a telephone number to make a call). The executive functions are equally as important because they consist of the higher order cognitive abilities that direct mental resources (such as attention and working memory) to a given problem and inhibit cognitive responses when necessary. More than 200 quantitative studies have now been published on neurocognitive impairment in schizophrenia, and meta-analytic reviews of these studies have indicated that individuals with the condition perform on average 0.50 to 1.00 standard deviations below the mean of individuals without the illness (Heinrichs & Zakzanis, 1998). Although every neurocognitive domain that has been tested appears to be affected, areas of greatest impairment include verbal memory and attention.

The study of impairments in social cognition is a relatively recent focus in schizophrenia research. Social cognition refers to the cognitive abilities that support the processing, interpretation, and regulation of socioemotional information (Newman, 2001). Key domains of social cognition that have been studied include perspective taking, theory of mind, emotion perception, emotion regulation, social cue recognition, and causal attributions of social phenomena. Most studies have indicated medium to large degrees of impairment in these domains among people with schizophrenia compared with those without the condition (see Green et al., 2008, for review). Although it is increasingly clear that people with schizophrenia have significant impairments in social cognition, the domains of greatest impairment continue to remain unknown.

The consistent documentation of impairments in neurocognition and social cognition in schizophrenia has led social workers and other researchers to investigate the functional impact of these cognitive difficulties. Logically, difficulties in maintaining attention and holding information in memory would seem to impair the ability to work or effectively carry on a conversation. In addition, interpersonal functioning is highly dependent on understanding others’ perspectives and nonverbal communication, making social–cognitive impairments likely contributors to the marked social disability experienced by many people with schizophrenia. For more than a decade, Brekke et al. (2007) have shown that broad impairments in neurocognition, as well as in emotion perception, are important longitudinal predictors of role functioning and adjustment in individuals with schizophrenia. To date, more than 50 studies have examined the impact of cognitive impairment in schizophrenia on recovery from the illness (Green et al., 2000). Most notably, impairments in social cognition appear to have particularly negative effects on functional recovery in people with schizophrenia, especially impairments in emotion perception, cue recognition, and emotion regulation, which have been broadly associated with poor interpersonal functioning, community adjustment, and vocational functioning (Couture et al., 2006; Eack, Greeno, et al., 2010).

Neuroplasticity and the Science of Brain Change

For many years, social workers have held the proposition that the interaction between biology and the social environment is bidirectional (Germain & Gitterman, 1980). This principle has laid the foundation for theories of how certain types of environmental experiences can positively shape biological processes, such as those underlying cognitive impairments in people with schizophrenia (Keshavan & Hogarty, 1999). The brain's capacity to change on the basis of environmental experiences is known as neuroplasticity. This model of the brain recognizes that the brain is a plastic, malleable organ that is constantly undergoing reorganization and change (Bruel-Jungerman, Davis, & Laroche, 2007). Initial evidence for neuroplasticity came from animal studies demonstrating that the mere process of learning induced changes in cortical organization and the interaction between different brain systems (for example, Kleim, Barbay, & Nudo, 1998).

On the basis of the emerging field of neuroplasticity and the evidence that learning and environmental experiences can shape cognitive processing at a basic neurobiological level (Bruel-Jungerman et al., 2007), researchers began exploring ways to improve brain function, and thus the field of cognitive remediation was born. Initial studies were conducted with individuals who had experienced a traumatic brain injury or stroke. Some researchers observed that those who had lost significant motor skills as a result of brain injury could not only improve their motor functioning by practicing motor-based exercises, but also improve brain function in the motor cortex (Robertson & Murre, 1999). As such studies emerged, researchers started formulating different practice principles that could be used to target specific cognitive domains, capitalize on neuroplasticity, and enhance brain function in people with a variety of disorders (Ben-Yishay, Piasetsky, & Rattok, 1985; Hogarty & Flesher, 1999b). These principles, although diverse, eventually became some of the key guiding practice principles of cognitive remediation for schizophrenia.

Practice Principles of Cognitive Remediation

The group of treatment approaches collectively referred to as cognitive remediation can vary substantially and range from completing Sudoku exercises to using highly sophisticated computerized programs designed to enhance specific domains of cognitive function. Some approaches are completed individually, some are completed with a therapist or coach, and some are completed in groups. Some cognitive remediation programs focus only on neurocognition (Fisher, Holland, Merzenich, & Vinogradov, 2009; Wykes et al., 2007), others focus on social cognition (Horan et al., 2009), and still others focus on an integration of the two during treatment (Hogarty et al., 2004). Despite the diversity of cognitive remediation approaches for schizophrenia, a set of clear practice principles has emerged. Although these principles are not universal to all approaches, they do cover the breadth of strategies used within and across the most effective programs. Regardless of the specific approach, physical exercise is a helpful analogy for cognitive remediation. When individuals have a desire to become physically stronger, they adopt a set of routines designed to exercise the specific areas of the body they wish to strengthen. Cognitive remediation can be thought of as a mental workout designed to strengthen or enhance brain function and cognition.

Some key practice principles of cognitive remediation programs for individuals with schizophrenia are listed in Table 1. Nearly every cognitive remediation approach makes use of strategic techniques, drill and practice techniques, or both. Although some approaches focus more on strategy than drill and practice or vice versa, many include components of both. Strategic training helps individuals learn to generate strategies for solving cognitive problems and enhancing performance, such as the use of mnemonic devices and the encoding of information in personally meaningful ways. Strategic training is often combined with drill and practice techniques, which consist of completing and practicing a problem or exercise until a peak level of performance is reached. Not everyone has the same cognitive capacity, so peak performance levels vary across individuals. Typically, individuals practice cognitive exercises until their performance has improved beyond their initial performance.

Table 1:

Practice Principles of Cognitive Remediation with Individuals with Schizophrenia

Principle Description 
Strategic Development of mental strategies to optimize cognitive performance and task completion 
Drill and practice Repetition of cognitive exercises over many sessions until performance has improved 
Hierarchical Progression of targeted cognitive abilities from the basic to more complex 
Cueing Use of external aids (usually auditory or visual) to support cognitive performance 
Fading Gradual removal of cues and external aids in cognitive exercises to increase difficulty 
Adaptive Adjustment of the difficulty of cognitive exercises so they remain challenging and engaging 
Anchoring Linking of cognitive exercises to real-world behaviors and the areas of functioning domains they support 
Integration with other treatments Use of additional schizophrenia treatments and supports to maximize the benefits of cognitive remediation 
Principle Description 
Strategic Development of mental strategies to optimize cognitive performance and task completion 
Drill and practice Repetition of cognitive exercises over many sessions until performance has improved 
Hierarchical Progression of targeted cognitive abilities from the basic to more complex 
Cueing Use of external aids (usually auditory or visual) to support cognitive performance 
Fading Gradual removal of cues and external aids in cognitive exercises to increase difficulty 
Adaptive Adjustment of the difficulty of cognitive exercises so they remain challenging and engaging 
Anchoring Linking of cognitive exercises to real-world behaviors and the areas of functioning domains they support 
Integration with other treatments Use of additional schizophrenia treatments and supports to maximize the benefits of cognitive remediation 

Although not all cognitive remediation programs focus on multiple cognitive abilities, the most effective programs target broad cognitive domains (McGurk, Twamley, Sitzer, McHugo, & Mueser, 2007). Cognitive abilities are not targeted at random but in a hierarchical fashion from lower order to higher order cognitive functions. This hierarchy is based on information-processing models that indicate the need for simple cognitive abilities (for example, attention) to support more complex information processing, such as reasoning, problem solving, and other executive functions. The belief is that higher order cognitive abilities cannot be fully remediated unless the basic building blocks of cognition are also improved.

Some cognitive remediation programs also use cueing and fading concepts from learning theory to help shape cognitive performance and gradually increase the difficulty of cognitive exercises. Cueing refers to the use of prompts or external aids, usually visual or auditory, to help increase the performance of individuals on a given exercise. For example, when targeting processing speed and attention during cognitive remediation, a typical exercise of this kind requires individuals to respond as quickly as possible to a given stimulus (for example, a dot on the computer screen) after waiting for a five-second interval (Ben-Yishay et al., 1985). The exercise is made easier by first saturating the cues to the upcoming stimulus to their maximum, which consists of providing an auditory beep for every second during the waiting period. This way, individuals know that at the end of the last (fifth) beep they need to respond to the stimulus. Attention is then reliant on the external cues (auditory beeps) provided by the computer. With improving performance, these cues are reduced or faded (for example, three beeps for the first three seconds and no beep for the final two seconds), and individuals have to learn to internalize the auditory cues that previously helped their performance. In this way, neural circuitry supporting attention is increasingly exercised. The same principles of cueing and fading are also practiced in cognitive exercises focusing on memory, executive functions, and social cognition.

The cueing and fading techniques used in cognitive remediation are designed to adjust or tailor the difficulty of exercises both to each person's initial level of ability and to his or her progress. As such, cognitive remediation is usually adaptive and focuses on providing enough of a challenge for people with schizophrenia to engage and exercise their cognitive abilities while not being so challenging that success is impossible. In addition, the most effective cognitive remediation programs use anchoring techniques to engage individuals and promote the generalization of cognitive abilities learned during cognitive remediation. Consistent with guidelines for good clinical practice, a clear rationale for each cognitive remediation exercise is given that includes a specific anchor to real-world behaviors and functioning.

Finally, to maximize the benefits of cognitive remediation, particularly neurocognitive remediation, integrating these approaches with broader treatments and supports for schizophrenia is essential. Seminal work by Hogarty et al. (1973) documented the importance of using antipsychotic pharmacotherapy as a foundation for psychosocial treatment in schizophrenia. In addition, recovery from schizophrenia relies on improvement in many areas of community life, and other effective treatments and supports must be provided to help individuals achieve a better quality of life. This principle is consistent with the larger mental health recovery movement (Davidson, Schmutte, Dinzeo, & Andres-Hyman, 2008), which has shown that people with schizophrenia can recover (Harding, Brooks, Ashikaga, & Strauss, 1987; Harrow, Grossman, Jobe, & Herbener, 2005) but that recovery does not mean the mere resolution of symptoms (cognitive or otherwise). Recovery also does not mean that one is cured of a particular condition; rather, it refers to the maximization of a person's strengths to achieve a desired and meaningful quality of life (Anthony, 1993). As such, treatments can no longer be viewed as isolated approaches designed to cure an individual but rather as integrated into a larger program of supports to provide a holistic approach designed to enhance all aspects of well-being.

Cognitive remediation approaches have adopted this larger view of mental health recovery in people with schizophrenia and recognized that improvement in such cognitive abilities as attention and memory is of little use in the absence of meaningful life activities that rely on these abilities. Cognitive remediation is seen as a method for helping individuals with schizophrenia to enhance their cognitive abilities so that they can achieve a functional recovery—the engagement in those functional activities (for example, school, employment, living independently) that are a major recovery goal for many people with the condition. However, without integration with other treatment approaches and supports, the opportunity for such a functional recovery based on cognitive improvement alone is limited. In fact, the most innovative and effective programs have integrated other intervention approaches directly into their cognitive remediation programs (for example, Hogarty et al., 2004; McGurk, Mueser, & Pascaris, 2005), and when cognitive enhancement occurs in the context of meaningful functional activities, the level of improvement can be striking. Consequently, although cognitive remediation is an important tool for facilitating the recovery of people with schizophrenia, social work practitioners should not forget that other empirically supported treatments are available.

Empirical Support

The recognition of cognitive impairments as critical barriers to the functional recovery of individuals with schizophrenia and the development of practice principles and methods for using cognitive remediation to address these impairments has led to a number of international efforts to evaluate the efficacy of cognitive remediation in schizophrenia. To date, there have been more than 25 independent, randomized controlled trials of cognitive remediation for people with this condition. Most treatment trials have used only neurocognitive remediation and evaluated effects on neurocognition. These studies have shown short-term neurocognitive remediation (three to six months) to be effective at improving attention, processing speed, working memory, and executive functioning—many of the cognitive domains in which people with schizophrenia experience the greatest difficulty (Fisher et al., 2009; Wykes et al., 2007). However, one recent study showed no benefits of neurocognitive remediation on cognition among those with schizophrenia (Dickinson et al., 2010). Overall, meta-analytic reviews have indicated an average medium-sized (d = 0.41) level of improvement in basic neurocognitive function across all randomized controlled trials (McGurk, Twamley, et al., 2007). Such findings demonstrate that directly enhancing such cognitive domains as attention, memory, and problem solving among people with schizophrenia is feasible with a psychosocial treatment approach.

Fewer studies have targeted social cognition during remediation. A 12-week social cognition training program with 31 individuals with schizophrenia found large but circumscribed improvements in emotion perception (Horan et al., 2009). Another study with 31 individuals with schizophrenia used a 20-week group-based social cognition training program and again found significant, although circumscribed, benefits for emotion perception (Roberts & Penn, 2009). To date, CET (Hogarty & Greenwald, 2006), a comprehensive approach to the remediation of social and nonsocial cognitive impairments in people with schizophrenia, continues to represent one of the most rigorously evaluated and effective cognitive remediation approaches that targets impairments in both neurocognition and social cognition. The approach builds on neurocognitive training strategies initially developed for those with traumatic brain injury and incorporates in a novel fashion small-group-based methods to enhance social cognition. Two large-scale National Institute of Mental Health–supported trials of CET with more than 170 individuals with schizophrenia have been conducted. Results have indicated that CET can produce large (d > 1.00) and significant improvements in broad social–cognitive domains, including emotion regulation, emotion perception, foresight, supportiveness, and other areas. Improvement in these aspects of social cognition is critical for recovery from schizophrenia because they provide the foundational cognitive abilities needed to succeed in interpersonal relations and most social situations. More important, because CET also targets impairments in neurocognition, significant and sizable benefits (d = 1.46 in long-term schizophrenia and d = 0.57 in early course schizophrenia) in this domain have also been observed (Eack et al., 2009; Eack, Hogarty, Greenwald, Hogarty, & Keshavan, 2007; Hogarty et al., 2004). The integration of neurocognitive and social–cognitive remediation approaches into a single treatment in CET has been viewed as essential (Hogarty & Flesher, 1999a) and may be one of the principal reasons why the approach has been so effective.

The marked effects of cognitive remediation on neurocognition and social cognition have increased interest in the possibility that these psychosocial intervention programs result in direct benefits to the brains of people with schizophrenia. If the principles of neuroplasticity are supported and cognitive remediation capitalizes on them, then one should expect that these changes in cognition are reflective of changes in underlying neurobiologic processes. Evidence in this area has only recently emerged. Two early studies using functional magnetic resonance imaging found that after short-term neurocognitive remediation, individuals with schizophrenia demonstrated significant increases in frontal brain function (Wexler, Anderson, Fulbright, & Gore, 2000; Wykes et al., 2002), and these studies were recently replicated (Haut, Lim, & MacDonald, 2010). Recently, CET was shown to prevent the typical brain loss seen in schizophrenia in areas associated with social cognition when applied as an early intervention strategy (Eack, Hogarty, et al., 2010). Together, these findings provide exciting early support that cognitive remediation approaches may enhance the structural and functional integrity of the brain in schizophrenia.

Of course, for social workers, and indeed for the clients they serve, the improvement of cognition is but a means to an end. All cognitive remediation approaches have held the assumption that if cognition can be broadly improved, meaningful gains in functioning and personal recovery will be achieved. Findings with regard to functional recovery, however, have been mixed. Short-term (three- to six-month) neurocognitive remediation programs have yielded little, if any, benefits on functioning and recovery in the disorder (Dickinson et al., 2010; Fisher et al., 2009; Wykes et al., 2007). However, evidence has indicated that individuals who participate in these programs are generally satisfied with the cognitive training exercises. In fact, a study specifically examining the consumer perspective during cognitive remediation found high levels of satisfaction among participants (Rose et al., 2008). Moreover, some studies have demonstrated improvements in such domains as personal autonomy and satisfaction with cognitive abilities (for example, Lecardeur et al., 2009; Penadés et al., 2006), which may not stem from large functional gains but nonetheless reflect important improvements in consumer perceptions of their own recovery.

Longer term programs and those that integrate neurocognitive training with social–cognitive remediation and broader psychosocial treatment strategies, such as CET, have shown much larger benefits to functional and personal recovery outcomes. In CET, large (d > 1.00) functional benefits have been observed in social adjustment, activities of daily living, social functioning, and instrumental task performance (Eack et al., 2009; Hogarty et al., 2004), which were durable one year after the completion of treatment (Eack, Greenwald, Hogarty, & Keshavan, 2010; Hogarty, Greenwald, & Eack, 2006). The increased socialization and satisfaction with social relations that people experience during CET are critical aspects of recovery from schizophrenia, which open the doors to enhancing social networks, building friendships and intimate partnerships, and becoming more integrated into the community. Moreover, examinations of perceived and actual benefits to employment, another key domain of recovery for many consumers, have shown that after completing CET, individuals were more likely to be employed in competitive jobs, earn more income, and be more satisfied with their employment situation (Eack, Hogarty, Greenwald, Hogarty, & Keshavan, 2011). McGurk, Mueser, Feldman, Wolfe, and Pascaris (2007) have also combined neurocognitive remediation with supported employment programs and found significant benefits to employment. Indeed, a recent meta-analysis found that only those cognitive remediation programs that also included broader psychosocial treatment strategies demonstrated benefits to functional recovery (McGurk, Twamley, et al., 2007). With regard to consumer perceptions of such interventions, high levels of satisfaction have been reported along with perceived relevance to daily life (Horan et al., 2009).

In summary, empirical support for the benefits of cognitive remediation on cognition, the brain, and recovery in schizophrenia is growing. The feasibility of improving cognition in people with the disorder has now been firmly documented, despite hearty initial skepticism about whether cognition could or needed to be improved in people with schizophrenia (Bellack, 1992). Neurobiological studies are increasingly showing just how much of an impact psychosocial interventions can have on the brain in schizophrenia. However, what has also emerged from this evidence is that the isolated short-term remediation of limited domains of neurocognition is unlikely to translate into meaningful improvements in functional recovery in the condition. Rather, long-term and integrative approaches that take a holistic view of individuals and their recovery, such as CET, appear to be needed to realize the potential functional benefits of cognitive remediation.

Model Program: CET

CET is a model cognitive remediation program developed by Gerard E. Hogarty and colleagues at the University of Pittsburgh. This intervention illustrates the key practice principles of cognitive remediation for schizophrenia and how these principles were extended in innovative directions by a social work–led multidisciplinary team to arrive at a uniquely holistic, empowering, and effective intervention for people with the condition.

CET is comprehensive approach to the enhancement of neurocognition and social cognition in schizophrenia that focuses on the achievement of adult social–cognitive milestones (for example, perspective taking, social context appraisal) through the shifting of information processing from a reliance on effortful, serial processing that is characteristic of preadolescent thinking styles to a more rapid, parallel and “gistful” abstraction of social and nonsocial information. The treatment is provided over the course of 18 months and consists of 60 hours of computer-based neurocognitive training in attention, memory, and executive function using software originally developed by Ben-Yishay et al. (1985) and Bracy (1994) for people with traumatic brain injury and 45 social–cognitive group therapy sessions that use experiential learning exercises designed to further improve neurocognitive abilities and enhance social cognition. Neurocognitive training is conducted weekly for one hour, and the social–cognitive group sessions are conducted concurrently every week for 1½ hours after participants have completed a few months of neurocognitive training. A complete description of the treatment is available in the training manual (Hogarty & Greenwald, 2006).

Neurocognitive training begins in a hierarchical fashion with training in attention and then proceeds to memory and executive function or problem solving. The cognitive exercise routines total 16 (three attention, seven memory, and six problem solving), and Figure 1 presents an example of each type of exercise. In the attention training example (Figure 1A), individuals must react quickly to press the space bar on the keyboard when the center light flashes. An initial cue is given to let the participant know the exercise is beginning, and then a series of adjustable auditory cues are given during a five-second interval, after which the center light will turn on. Individuals must respond within a short (for example, 300-millisecond) window to illuminate all nine of the feedback lights that form a triangle across the screen. Gradually, as individuals master the exercise, the auditory cues are faded and the window of response time is reduced to provide a progressively more difficult attention exercise. In the memory training example (Figure 1B), several objects from the bottom of the screen are flashed on the upper part of the screen for a brief period (three seconds). Individuals are then asked to remember the objects and their locations. Participants must learn to encode the objects and their locations in meaningful ways, which usually involves inventing a system for naming the objects and a gestalt of their particular arrangement (for example, a sideways L). In the problem-solving training example (Figure 1C), individuals are asked to place a series of numbers in order. The position of the numbers can be changed by clicking on them with the mouse, which results in the clicked number moving to the beginning of the series and all the numbers to the left of it reversing their position. The key to this exercise is to first figure out the rule for or gist of moving the numbers and then to plan carefully what numbers to click on to solve the task in the shortest number of trials. Together, these and the other exercises in CET help improve the information processing abilities needed for good work performance, organization, mental stamina, and other key functional abilities.

Figure 1:

Example Attention, Memory, and Problem-Solving Computer Exercises Used in Cognitive Enhancement Therapy for People with Schizophrenia

Figure 1:

Example Attention, Memory, and Problem-Solving Computer Exercises Used in Cognitive Enhancement Therapy for People with Schizophrenia

The cognitive difficulties experienced by individuals with schizophrenia are not limited to attention, memory, and problem solving. Even if these domains were significantly improved, many individuals would remain markedly socially disabled because of impairments in social cognition. CET is one of the few, if not only, cognitive remediation approaches that specifically targets impairments in both neurocognition and social cognition. In the earliest phases of the treatment, CET targets basic problems in social cognition through the use of client pairs in neurocognitive remediation, which embeds the computer-based training in a social context that encourages socialization and provides opportunities to practice giving support. After approximately three months of neurocognitive training in attention, three to four client pairs join to form a social–cognitive group. The group environment is essential for enhancing social cognition. In CET, a broad range of social–cognitive abilities are targeted on the basis of developmental theories of social cognition (Hogarty & Flesher, 1999a; Selman & Schultz, 1990) and range from abstracting the gist or main point of social interactions to perspective taking, social context appraisal, and emotion management. In the initial CET group sessions, each client works with a coach to develop recovery plans that are displayed on poster boards in the CET group and used to anchor personal treatment goals to meaningful functional outcomes (see Table 2).

Table 2:

Example Recovery Plans Used in Cognitive Enhancement Therapy (CET) for People with Schizophrenia

Example Example Recovery Plans 
Example A 
 Goal To improve my attention during conversations 
 Problem Difficulty maintaining attention, easily distracted 
 Strategies 1. Cue myself to pay attention. 
 2. Take notes in the CET group to avoid distraction. 
 3. Actively listen and ask questions in conversations. 
 4. Focus on the gist when talking with others. 
 5. Paraphrase back to the other person in conversations. 
 6. Use computer training to boost attention. 
Example B 
 Goal To better understand other people 
 Problem Difficulty with understanding others’ thoughts and feelings 
 Strategies 1. Use active listening (observe verbal and nonverbal cues; take the person's emotional temperature; ask open-ended questions). 
 2. Evaluate whether this is a good time for the person to talk. 
 3. Ask questions to better understand the other person's point of view and check whether my understanding is correct. 
 4. Practice active listening and perspective taking during CET computer and group sessions. Make supportive statements (“I like what you said [did]”). 
 5. After giving my feedback after a CET group exercise, see whether my observations of the participants’ thoughts and feelings are correct. 
Example C 
 Goal To increase my network of friends 
 Problem A small social network 
 Strategies 1. Assess situations to decide who I want to get to know better. Work on initiating and maintaining conversations. 
 2. Use CET strategies: active listening, perspective taking, foresightfulness, social context appraisal. 
 3. Make an effort to get to know new people while keeping up with current friends. 
 4. Use humor in conversations. Try to be less serious and more relaxed. Coach myself using positive self-talk. 
 5. Express myself more to others; use elaborated speech. 
Example Example Recovery Plans 
Example A 
 Goal To improve my attention during conversations 
 Problem Difficulty maintaining attention, easily distracted 
 Strategies 1. Cue myself to pay attention. 
 2. Take notes in the CET group to avoid distraction. 
 3. Actively listen and ask questions in conversations. 
 4. Focus on the gist when talking with others. 
 5. Paraphrase back to the other person in conversations. 
 6. Use computer training to boost attention. 
Example B 
 Goal To better understand other people 
 Problem Difficulty with understanding others’ thoughts and feelings 
 Strategies 1. Use active listening (observe verbal and nonverbal cues; take the person's emotional temperature; ask open-ended questions). 
 2. Evaluate whether this is a good time for the person to talk. 
 3. Ask questions to better understand the other person's point of view and check whether my understanding is correct. 
 4. Practice active listening and perspective taking during CET computer and group sessions. Make supportive statements (“I like what you said [did]”). 
 5. After giving my feedback after a CET group exercise, see whether my observations of the participants’ thoughts and feelings are correct. 
Example C 
 Goal To increase my network of friends 
 Problem A small social network 
 Strategies 1. Assess situations to decide who I want to get to know better. Work on initiating and maintaining conversations. 
 2. Use CET strategies: active listening, perspective taking, foresightfulness, social context appraisal. 
 3. Make an effort to get to know new people while keeping up with current friends. 
 4. Use humor in conversations. Try to be less serious and more relaxed. Coach myself using positive self-talk. 
 5. Express myself more to others; use elaborated speech. 

The social–cognitive groups are a uniquely rich component of CET, and social cognition is directly targeted using psychoeducation, cognitive exercises, and homework. Psychoeducation lectures introduce a new social–cognitive concept (for example, perspective taking, cognitive flexibility) to members during the group session. A cognitive exercise is also performed that makes use of experiential learning strategies to practice and enhance social–cognitive abilities. Almost all group exercises require that participants take another person's perspective, and every exercise relies on multiple aspects of social and nonsocial cognition. For example, in an exercise called “Condensed Message,” two participants are asked to solve a social problem. They are given a written social scenario in which an individual has encountered a problem (for example, his father's wallet was found at a restaurant in the airport), and he must send a brief (for example, 10 words or fewer) message through the airport public address system to his father. The participant pair must work together to create a concise message that will get the recipient to act accordingly to solve the problem. This cognitive exercise requires participants to take the perspective of the person encountering the problem and generate a “gistful” but meaningful message to encourage appropriate and immediate action. Participants must judge the social context (for example, what consequences could arise from announcing that someone's wallet is available at the restaurant over the airport public address system). At the same time, the other group members are given feedback sheets asking questions about the intellectual, emotional, and teamwork performance of the participant pair during the exercise. This feedback is then presented verbally by the other group members to practice expressing tactful and supportive feedback and to facilitate groupwide engagement. Finally, homework is used to strengthen the everyday application of social–cognitive abilities learned in the group setting and is based on a previous psychoeducational talk given by a coach on a new CET concept. Completed homework is presented by every participant in the group, and consistent with the active nature of CET, homework sessions are chaired by a client who calls on her or his peers to present and on the coaches to ask questions. Together, these small-group social–cognitive activities are integrated with neurocognitive training to provide a holistic cognitive remediation program that targets the wide array of cognitive impairments that limit recovery from schizophrenia.

Conclusion

Schizophrenia is characterized by marked cognitive impairments that are unresponsive to current pharmacotherapies and place significant limitations on functional recovery from the condition. Social workers are the primary providers of psychosocial treatment to individuals with schizophrenia (SAMHSA, 2001) and have led the effort to develop and test more effective psychosocial interventions for this population. In this article, I have presented an overview of cognitive remediation, part of a new generation of psychosocial interventions designed to enhance cognition and functional recovery among people with schizophrenia. As with previous psychosocial advances, social workers have taken a leading role in developing and testing cognitive remediation programs for people who live with this condition.

Evidence to date has supported the use of cognitive remediation in community and social work practice settings in combination with pharmacotherapy and other psychosocial treatments. Unfortunately, many social work practitioners are not aware of the availability of these approaches and their potential benefits. My hope is that this overview of the practice principles and evidence supporting cognitive remediation with individuals with schizophrenia will encourage practitioners to adopt this considerable advance in schizophrenia treatment. I also hope that the presentation of CET as a model cognitive remediation approach will provide practitioners with a concrete example of the principles of cognitive remediation in practice and encourage them to use creative and comprehensive cognitive remediation interventions that are more likely to translate into meaningful functional gains for their clients.

The widespread implementation of cognitive remediation for individuals with schizophrenia is just beginning, and the social work workforce will have the largest impact in bringing this next generation of psychosocial treatments to the many underserved individuals who have this condition. Practitioners and agency directors interested in implementing cognitive remediation programs should encounter little difficulty. All of the programs for schizophrenia that have been developed and tested are available from the developers, and many of them can be obtained online. A comprehensive CET training manual has also been completed to facilitate its implementation in community settings (Hogarty & Greenwald, 2006). Technological resources are minimal and largely limited to several computers, neurocognitive training software, and standard office supplies. Most training programs will operate adequately on older computers, and many community agencies already provide computer access to their consumers. Some practitioner training is usually recommended, although several programs have very complete training manuals that reduce the need for large amounts of directed training. Programs focusing on social cognition usually rely on small-group techniques, which is a common area of practice expertise in social work. Our group has also had success in obtaining third-party reimbursement for CET, which is essential for most agencies. As a consequence, social work practitioners interested in implementing cognitive remediation should find the process feasible.

In addition to introducing cognitive remediation as a new evidence-based practice that many social workers may find helpful to implement in their agencies, I hope that this review of cognitive impairment in individuals with schizophrenia will raise awareness of the importance of this domain among practitioners and the availability of effective strategies social workers can use to address impairments in cognition. Finally, I hope that the evidence presented on the effects of cognitive remediation on brain impairment in schizophrenia previously thought to be intractable will renew social workers’ faith in the power of psychosocial intervention for this population. The strides social workers have made in expanding the treatment options for people with schizophrenia beyond antipsychotic medications have helped many realize a greater quality of life and experience of recovery. Cognitive remediation represents the latest advance in this effort, and its inclusion in routine clinical practice could substantially improve the lives of the many individuals who have this condition.

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