Linking Cognitive Strategies to Patients’ Goals

We know that impaired cognitive abilities (eg, slow processing speed and deficits in attention, working memory, learning, and executive functioning) are the most significant contributors to poor outcomes in schizophrenia (eg, unemployment, lack of ability to live independently, and social impairments). Given that medications have very limited effects on cognition, how do we best treat the cognitive impairments of schizophrenia?

My colleagues and I have been investigating a compensatory strategy–based approach to cognitive training for the past decade. We call it Compensatory Cognitive Training (CCT), and we focus on teaching strategies to work around cognitive impairments in the real world. The 4 domains that we target are prospective memory (ie, remembering to do things), attention, learning/memory, and executive functioning. Our recent results were very encouraging, indicating that CCT, compared to treatment as usual, had positive effects on attention, memory, functional capacity, negative symptoms, and quality of life. We’ve learned that simple strategies (like using a calendar and checking it regularly) can be very helpful to our clients. One of my favorite aspects of CCT is the overt linkage of cognitive strategies to each client’s real-world goals. From the man who used his calendar to track his glucose levels to the woman who used flashcards to learn the names of her new friends in Alcoholics Anonymous, the ability of our clients to creatively apply the CCT strategies to their own circumstances was really impressive.

In our current NIMH-funded trials, we’re comparing CCT to robust control conditions that match CCT for therapist time, so we’ll be able to demonstrate that the effects of CCT aren’t just due to nonspecific therapeutic factors. We’re also studying CCT in the context of supported employment and in other populations, such as people with first-episode psychosis and veterans with traumatic brain injury.

The CCT manual was designed to be easy to use without extensive training and has now been distributed to hundreds of clinicians.* To make it even easier for clinicians, we’ve created a therapist version of the manual that has tips on the back sides of the pages. The front sides of the pages are identical to those in the client version of the manual, so therapists and clients are literally on the same page during sessions.

CCT and other psychosocial treatments are showing real promise for treating the cognitive deficits, negative symptoms, and functional impairments of schizophrenia.^1–4 My hope is that in the next 50 years, psychosocial treatments will become a mainstay of treatment for schizophrenia, along with the antipsychotic medications that have been the mainstay of treatment for the last 50 years. It may even be possible to enhance the effects of CCT and other cognitive therapies for schizophrenia by pairing treatment with pro-cognitive medications.

This research was possible because of funding from the Brain and Behavior Research Foundation and because of the partnerships we have with our clients, which will be invaluable as we further develop these therapies.

*If you would like to obtain a copy of the CCT manual, email etwamley@ucsd.edu.

Financial disclosure:Dr Twamley had no relevant personal financial relationships to report.

References

1. Kurtz MM, Mueser KT. A meta-analysis of controlled research on social skills training for schizophrenia. J Consult Clin Psychol. 2008;76(3):491–504. PubMed

2. Kurtz MM, Richardson CL. Social cognitive training for schizophrenia: a meta-analytic investigation of controlled research. Schizophr Bull. 2012;38(5):1092–1104. PubMed

3. Wykes T, Huddy V, Cellard C, et al. A meta-analysis of cognitive remediation for schizophrenia: methodology and effect sizes. Am J Psychiatry. 2011;168(5):472–485. PubMed

4. Wykes T, Steel C, Everitt B, et al. Cognitive behavior therapy for schizophrenia: effect sizes, clinical models, and methodological rigor. Schizophr Bull. 2008;34(3):523–537. PubMed​