Group Cognitive Remediation for Schizophrenia: exploring the role of therapist support and metacognition
Matteo Cella1, Clare Reeder1, Til Wykes1
1 King's College London, Institute of Psychiatry, Psychology and Neuroscience London, UK
Corresponding author:
Dr. Matteo Cella
Department of Psychology,
Institute of Psychiatry,
King’s College London,
De Crespigny Park,
SE5 8AF
London, UK
Telephone: (+44) 020 7848 5001
Fax: (+44) 020 7848 0334
Abstract
Objectives: Cognitive Remediation (CR) is a therapy targeting cognitive difficulties in psychiatric disorders. We recently develop a novel CR program for people with psychosis with a focus on metacognitive skills individually supported by a therapist. This study aims to assess the acceptability and feasibility of implementing CR in small groups where therapist support is shared amongst service users.
Design: Control group design with non-randomised group allocation.
Method: Twenty-five service users with a diagnosis of schizophrenia participated. Ten received group CR and 15 individual CR (i.e. one therapist for each service user). Both therapy formats were supported by one therapist. Participants were assessed before and after therapy with neuropsychological tests assessing different cognitive domains, self-assessed cognitive complaints and psychotic symptoms. Treatment satisfaction questionnaires and therapist’s session ratings were also collected for group CR.
Results: Drop-out rate was 20% for both methods. Session attendance was 74% for group CR and 86% for individual CR. Service users evaluated positively group CR and considered it helpful; therapists rated this delivery format feasible. Exploratory analysis suggested that the two methods have similar effects on cognition. After therapy, service users showed improvements in recall memory, reduced negative symptoms and reported fewer cognitive complains.
Conclusions: It is feasible and acceptable for people with schizophrenia to take part in small CR therapy groups. The reduced therapist contact compared to individual therapy was well tolerated and may help sustain independent work. The small group format allows therapists to spend sufficient time to support the use of metacognitive strategies.
Practitioner points
· CR small groups are feasible and acceptable for service users and therapists.
· Therapist support can be shared.
· Metacognitive based CR can improve cognition and may benefit awareness and negative symptoms.
Keywords:
Schizophrenia; Psychosis; Cognitive Remediation; Cognition; Memory; Group therapy; Metacognition; Awareness.
Introduction
Cognitive problems are a landmark deficit in people with schizophrenia; they precede the disorder onset and are associated with prognosis and recovery measures (Gur et al., 2014; Kahn & Keefe, 2013; Miles et al., 2014; Seidman et al., 2013). There is consensus in considering cognitive difficulties widespread and relevant to different domains (Cella & Wykes, 2013a; McCleery et al., 2014; Rethelyi et al., 2012). Cognitive remediation (CR) was first introduced in the nineties as an intervention to tackle cognitive problems in people with schizophrenia, and was targeted predominantly to service users with longer illness experience. Over time, studies have demonstrated that CR is effective in improving global cognition, specific cognitive domains (e.g. memory, executive function and processing speed) but also functional outcomes (Wykes, Huddy, Cellard, McGurk, & Czobor, 2011). There are different types of CR programs however; differences (e.g. using abstract vs real life related tasks) do not seem to influence cognitive outcomes. Efforts have been directed at making CR more accessible and cost-effective but, more importantly, to improve its short- and long-term effectiveness (Reeder et al., 2014). The study we describe here examines the feasibility and acceptability of group CR and indirectly explores the contribution of therapists support to therapy delivery.
A number of cognitive remediation programs, do not include an active therapist role (e.g. Fisher et al., 2014; Subramaniam et al., 2012). With the advent of fully computerised programs, this feature has become more extreme with service users having very limited human contact and therapy consisting almost entirely of practice on cognitive tasks. Other approaches have preferred supporting task practice with guidance from a therapist; with this role being essentially dedicated to highlighting strategies and maintaining motivation through a focus on goals and support skills transfer to everyday life (Cella M., 2012; Wykes et al., 2007) . This is considered by some authors as a non-specific effect of CR (Vinogradov, Fisher, & Nagarajan, 2013). Notwithstanding the positive value that non-specific effects such as the therapist’s support may have on engagement and motivation only a few programs consider these factors important. More recently a report challenged the idea that therapists are of secondary significance and showed, perhaps unsurprisingly, that therapist support is important for achieving client’s goals, attending sessions and preventing drop-out (Huddy, Reeder, Kontis, Wykes, & Stahl, 2012).
The therapist role may also allow a focus on domains of cognition that may be difficult for service users to tackle only with computer practice. A domain where therapist support may be important is metacognition. The role of metacognition is progressively being reconsidered as part of CR programs and its inclusion as a target domain is emerging (Lalova et al., 2013). There are several reasons why a metacognitive based approach to CR may be particularly beneficial to people with schizophrenia. Firstly, individuals with schizophrenia have poor insight into their cognitive problems (Cella, Swan, Medin, Reeder, & Wykes, 2014; Medalia & Thysen, 2010; Medalia, Thysen, & Freilich, 2008). This may negatively influence engagement in therapy as service users may perceive cognitive task practice as irrelevant to their problems. A focus on metacognitive knowledge could promote better understanding and engagement. Secondly, cognitive tasks not only require basic cognitive competences but also require monitoring skills including planning, regulation and revision. A focus on these steps may allow a more strategic approach to tasks. For example, thinking about how difficult the task may be before starting it, what strategy may be useful, what result can be realistically achieved and considering how to prevent mistakes. This set of competencies, often referred to as metacognitive regulation help prevent failure and maintain control over task performance. It is plausible to hypothesise that given the complexity of these skills automated programs may find it difficult to “teach” a proficient use of metacognitive skills. This, indeed, may be an area where the help and support of a therapist may be critical and difficult to replace.
The prominence of metacognitive problems in people with schizophrenia prompted the proliferation of psychological interventions focussed on this domain (e.g. Bargenquast & Schweitzer, 2014; Moritz et al., 2013; Morrison et al., 2014). As part of this “new wave” of metacognitive informed psychological interventions different authors have produced models of how metacognition may contribute to schizophrenia. Lysaker and co-workers (Lysaker & Dimaggio, 2014; Lysaker et al., 2014; Salvatore et al., 2012) for example, consider the value that metacognitive skills have in making sense of illness experience and how problems in this area may compromise people’s integrity and personal goals. An alternative approach rooted in pedagogy and cognitive psychology considers metacognitive skills primarily as learning components (Dignath, Buettner, & Langfeldt, 2008; Flavell, 1979; Thiede, Anderson, & Therriault, 2003). This approach postulates that individual learning potential is facilitated by two metacognitive skills: metacognitive knowledge and regulation. Metacognitive knowledge in what people know about their cognition. In the context of cognitive difficulties in people with schizophrenia this is generally thought of as the insight people have in their cognitive strengths and difficulties (e.g. how difficult is to remember people’s name?). Metacognitive regulation is the process responsible for improving and maintaining cognitive execution. This process includes three stages: planning (e.g. bring to mind relevant information, organise a sequence actions), monitoring (e.g. supervise operations as executed and adapt them if needed) and revision (e.g. reconsider cognitive performance and strategies use for future use).
Recently we applied this approach to CR and introduced a new software programme called CIRCuiTS (Computerised Interactive Remediation of Cognition Training for Schizophrenia). CIRCuiTS is a CR software employing a range of cognitive tasks providing a platform to exercise key cognitive domains such as: memory, executive function, working memory, attention, concentration, and processing speed. Unlike other programs CIRCuiTS employs a metacognitive interface prompting users to consider element of metacognitive knowledge (e.g. estimating the task difficulty level) but also elements of planning, regulation and assessment (e.g. prompting the evaluation of the strategies used before and after task completion). The software also allows monitoring and revising of personal goals and maps performance on the different tasks across sessions. It includes more basic (e.g. visual attention tasks) but also more ecologically valid tasks (e.g. plan a journey) so that task relevance is increased. The software was developed for independent use but it is generally administered with the support of a therapist.
We have previously used CIRCuiTS with people with psychosis with individual therapist support (Drake et al., 2014). This is because we believe that the uptake of metacognitive skills in this population requires a level of individualised support that cannot be easily delivered by the computer. In this study we aim to evaluate the acceptability and feasibility of delivering CIRCuITS in group format. We also aim to gain a preliminary indication of whether reduced levels of therapist contact is sufficient to support the uptake of a CR program based on metacognition, which may be more difficult to complete without constant supervision. We hypothesised that the group CR would have similar acceptability and feasibility outputs compared to the individual approach.
Method
Design
Control group design with non-randomised group allocation. All participants were assessed before and after intervention.
Participants
Participants were recruited from outpatient clinical teams within the South London and Maudsley National Health Service (NHS) Foundation Trust. Inclusion criteria were: age between 18 and 65 years; DSM-IV diagnosis of schizophrenia; cognitive performance of one standard deviation (SD) below the population average on at least two out of the four cognitive domains considered (i.e. Memory, Executive Function, Processing Speed and Working Memory). Potential participants were excluded if they had: a history of learning disability/developmental disorder; a history of organic brain disorder or head trauma or a primary diagnosis of substance dependence; a poor command of the English language.
Procedure and intervention
The study received favourable opinion from a local Research Ethic Committee (REC number 08/H0807/26). All participants gave written informed consent to participate in this study. Prior to entering treatment, participants were screened for eligibility and assessed (see measures below). Participants were allocated to group or individual CR on the basis of therapist availability and service resources. The allocation procedure was conducted independently from the therapists who administered the intervention. Both CR interventions consisted of up to three one-hour sessions weekly for 10 weeks (i.e. 30 sessions). Group CR was conducted in small groups with up to five clients and facilitated by one therapist. Each client had a laptop computer allocated and, on the first session, was provided with a unique CIRCuiTS ID allowing login to their unique profile. All activities conducted on the computer are recorded remotely on a server. This information is accessible in full to therapists and summary graphical representation of progress is available for service users once logged in. The CIRCuiTS tasks sequence is preloaded; participants start with easier and progress to more difficult levels of each task. CIRCuiTS includes more than twenty different tasks, training various domains including memory, executive function, attention, information processing and working memory. Participants’ progress to more difficult levels is dependent on proficiency and success rate on each task. Progression to more difficult tasks is managed by the computer but it can be modified by the therapist (e.g. users or therapists may want to return to a task successfully completed). CIRCuiTS targets metacognition explicitly through a ‘metacognitive journey’; this includes metacognitive tips, goal formulation, strategy use, apply learning to daily life and review achievements. Service users set goals and identify personal strengths and difficulties, which are regularly reviewed and modified. The programme poses questions between tasks to encourage metacognitive discussion and reflection. Learning supports accompany each task and encourage the use of metacognition. Before each task, service users are asked to rate the anticipated difficulty of the task, estimate how long it will take and identify strategies that may help completing the task. After the task, service users see their score and are asked to rate task difficulty and strategies usefulness. Individual CR used the same procedure and software with the only difference being the service user and therapist one-to-one interaction.
The therapists employed in this study were graduate psychologists trained to deliver CR for people with schizophrenia using CIRCuiTS (i.e. CR basic training is first conducted in workshops and then via supervised practice). In the initial sessions after an introduction to CIRCuiTS the therapist leads some computer familiarization exercises and asks participants to attempt initial tasks to familiarise themselves with the software. Service users are also introduced to the concept of cognitive SMART goals (i.e. Specific; Measurable; Attainable; Relevant and Time-bound; Cog-SMART) and encouraged to think of their therapy goals. Cog-SMART goals are SMART goals with a clear cognitive focus (e.g. “I would like to remember peoples’ faces” or “I would like to be able to pay attention to a conversation”). Therapists review Cog-SMART goals regularly and help service users to shape them from session to session. After the first week, service users spend most of each session practicing CIRCuiTS tasks. The main focus of the therapist support is to raise the client’s awareness of the difficulties encountered during particular tasks so that this can be prevented, managed or overcome. Each CIRCuiTS task prompts service users to consider strategies. The therapist helps service users to review strategies and consider how those found useful might apply to the identified Cog-SMART goals. Towards the end of therapy service users are encouraged to formulate, with the help of the therapist, a plan to sustain progress on their Cog-SMART goals and sustain strategy in everyday life. All these therapists’ guided activities promoted metacognitive knowledge (e.g. clients learn that strategy use can improve performance) and metacognitive regulation (e.g. planning and regulating performance can lead to higher success rates).
All participants were assessed again after therapy.
Measures
Cognition
Memory was assessed with the Rey Complex Figure (Meyers, Bayless, & Meyers, 1996). Executive function was assessed the Hayling Sentence Completion Test (Burgess & Shallice, 1997). Processing speed was assessed with the Digit Symbol Coding and working memory with the Digit Span from the Wechsler Adult Intelligence Scale – Fourth Edition (Wechsler, 2008) (. Full-scale current IQ was estimated from two WAIS-IV subtests: Vocabulary and Block Design. Pre-morbid IQ was estimated with the Wechsler Test of Adult Reading (Holdnack, 2001). All these measures have been extensively used o assess cognition in people with schizophrenia.