Cognitive Functioning and Remediation
Psychiatric conditions can have a negative effect on cognitive functioning (or thinking skills), which can interfere with the ability of people to achieve their personal goals. Thinking skills are mental abilities, such as paying attention, learning and remembering information, planning ahead, solving problems, and are important for learning, working, having good relationships, and living independently in the community. Cognitive remediation (or cognitive rehabilitation, cognitive enhancement) refers to a group of treatment approaches designed to help people increase cognitive skills in order to improve their functioning and achieve their goals.
One method used in cognitive remediation programs is practicing cognitive exercises on a computer with special software guided by a trained facilitator. This facilitator teaches the person more effective strategies for doing the exercises, encourages the person’s effort and persistence during the tasks, and points out gains in performance on the exercises to highlight improvements in their cognitive abilities. In some programs, such as the Thinking Skills for Work program, in order to help the person see the relevance of the cognitive exercises, the facilitator also points out similarities between different cognitive exercises and real-world tasks related to the individual’s goals, such as getting a job.
Another method used in cognitive remediation programs is to teach people more effective ways of managing the cognitive demands of their everyday life. For example, people benefit from learning practical strategies for focusing on a task when they need to, being able to remember and keep track of important information and objects, not missing appointments, planning and prioritizing tasks that need to be accomplished, and solving problems. Learning self-management strategies such as using a scheduler to keep track of appointments, and reducing distractions in one’s environment in order to improve attention and concentration, can help individuals get the most out of their cognitive abilities, and optimize their functioning in areas such as work, school, independent living, and social relationships.
Cognitive remediation programs differ in their length. Some cognitive remediation programs focus primarily on improving cognitive functioning while others focus more broadly on improving specific areas of psychosocial functioning. For example, the Thinking Skills for Work program combines cognitive remediation with vocational rehabilitation in order to improve employment outcomes. Cognitive Enhancement Therapy combines cognitive remediation with training in social skills in order to improve social functioning.
Research on Cognitive Remediation
Over 50 randomized controlled trials have been conducted over the past several decades on the effects of cognitive remediation programs for people with serious psychiatric disabilities and mental illness. The research provides solid evidence for the effectiveness of cognitive remediation in improving and maintaining gains cognitive functioning, improving functioning in areas such as employment and social relationships, and reducing the severity of symptoms. The effects of cognitive remediation are especially strong in programs where it is combined with other rehabilitation methods focusing on specific areas of functioning such as work outcomes. Research also suggests that cognitive remediation can be helpful for individuals regardless of gender, age, educational level or type of psychiatric condition.
The Thinking Skills for Work (TSW) Program
The TSW Program is a cognitive enhancement program designed for people who want to obtain competitive employment or advance within their chosen area of work. The TSW program is provided to individuals who are also receiving vocational rehabilitation and pursuing their work goals. TSW is provided by a cognitive specialist, who is a member of the vocational team and works with the person’s employment specialist.
In TSW, the cognitive specialist facilitates computer cognitive training exercises and provides coaching on strategies to improve performance on the exercises. The cognitive specialist also teaches self-management skills for helping people to improve their organization and thinking skills in everyday life. In addition, the cognitive specialist works to identify any cognitive challenges for the person in getting a job or doing their best on a job, identify possible solutions to those challenges, and to create a plan to implement those solutions.
Research on the TSW Program
The TSW program has been implemented in many different settings including community mental health centers, clubhouses, vocational agencies, and inpatient facilities. Results of seven controlled studies together suggest that people who received the TSW program improved significantly more in their cognitive functioning than those who received vocational services alone, and were more likely to obtain jobs, worked more weeks, and earned more money over the next two years. In all studies, participants in TSW have indicated high levels of satisfaction with the program.
Ongoing research on TSW at the Center for Psychiatric Rehabilitation includes the addition of TSW to the Illness Management and Recovery program for people who are looking for work; supplementing TSW with home-based practice using a tablet; determining if cognitive remediation improves cognition through brain growth, the potential value of adding exercise to cognitive remediation on cognitive improvements, and evaluating the individual contributions of the components of TSW, practicing cognitive exercises vs. using cognitive self-management strategies, to improved work and cognitive functioning so that TSW can be personalized to people’s needs for help in reaching recovery goals.
Links to a summary of research results can be found here.
Results of a recent randomized trial of TSW can be found here.