Training programs to enhance cognition

The aim of these interventions is to improve / increase / train / “restore” cognitive functioning. They focus on the elimination of damage correcting the underlying deficit,with the goal of learning how to do what was done before, more or less in the same way as before. The training is based on laboratory tests designed to improve specific abilities in areas such as perception or memory (Green, 2009). This group includes the following programs. Cognitive Remediation Therapy (CRT) developed by T. Wykes and his team based on an original program from Delahunty and Morice (1996). Interest in CRT has grown considerably in the last ten years. CRT is a term describing different methods of teaching “thinking” skills, although it has a special significance when it focuses on those cognitive skills affecting people with schizophrenia to a larger extent such as memory and attention (Wykes & Van der Gaag, 2001). It also has a great predictive power relating to a patient’s ability to function in the community. CRT objectives include: increasing the capacity and efficiency of cognitive functions; teaching global and transferable cognitive schemata to guide response; improving metacognition; increasing motivation; generalization of skills and use of social support (Wykes, Jeste, & Bellack, 2003). The program consists of three modules: Cognitive Shift Module, Memory Module and Planning Module. Evidence of its efficiency is variable and seems to depend on the specific components of training that are used in each case. In Spain, CRT has been used by Penadés et al. (2006) and yielded satisfactory results. Perhaps its greatest application lies in boosting the cognitive and motivational skills needed to properly acquire other skills of greater functional relevance within the rehabilitation process of a schizophrenic patient (De la Higuera & Sagastagoitia, 2006). The Newcastle Programs is the name given to the contribution from Australia by Morice and Delahunty (1996). These authors began their research into neurocognitive rehabilitation in 1988 and since then have examined three distinct programs. The first program they used was a modified version of Integrated Psychological Therapy for Schizophrenia (IPT) which they named The Modified Brenner Program. This program consists of four modules based on similar IPT ones (to be described later). The program was carried out with four weekly sessions of one hour over two weeks. In parallel, family members followed a psycho educational family intervention program with the support of audiovisual material. Finally, family members together with the patient participated in the IPT module for problem resolution. The second program was called The Computer-Assisted Program. It is a program based on computer exercises that have been specially designed to practise specific neurocognitive functions. It was modified from a program known as Bracy Cognitive Rehabilitation, which was originally designed for patients suffering from brain damage caused by cranial trauma. It basically focuses on attention, perceptive and reasoning functions. The results obtained in both programs (the modified Brenner and the computer assisted) showed improvements in most WAIS-R tests. However, in executive functions, while there were significant improvements in the Wisconsin Card Sorting Test (WSCT) and in the Tower of London, results continued to suggest deterioration in planning capacity and cognitive flexibility. It was from this that the need arose to create a specific program attempting to improve executive deficits, especially planning skills and cognitive flexibility, which they then called The frontal/executive program. This program is divided into three modules: Cognitive Flexibility Module, Working Memory Module and Planning Module. With this last program the authors found results that were clearly higher than the other two programs as far as frontal executive functions were concerned. Cognitive Enhancement Therapy (CET) from Hogarty and Flesher (1991a, 1999b) is a therapeutic procedure combining activities aimed at improving cognitive performance in basic cognitive functions, with interventions that have been developed to boost resources in aspects related to perceptive and cognitive abilities which are critical for the social functioning and general adjustment of people with schizophrenia (Hogarty, Flescher, Ulrich et al., 2004). CET works with the idea that the primary aim of the intervention is to achieve two basic skills: the first, really more perceptive, which seeks to adequately assess stimuli and social contexts; the second, more cognitive in nature, refers to the embracing of flexible forms of thinking that allow the presence of multiple alternatives as information sources (divergent thinking), the anticipation of possible consequences of the response and the appreciation of the points of views of others. To do these exercises, alternating use was made of computer software such as the Orientation Remediation Module of Ben-Yishay, Piasetsky and Rattock (1987) used for patients with brain damage and the PSSCogReHab of Bracy with the IPT of Roder et al. (2007). CET is a program directed at people with stable schizophrenia and it aims to improve neurocognitive skills and social cognition. It is a useful technique that goes beyond classical cognitive rehabilitation, tackling areas and disabilities of a wider functional range. Its potential is far-reaching. For example, it is beginning to be tailored to treat patients with their first-episode psychosis (Miller & Mason, 2004), but, as the authors themselves point out, it is not a therapeutic format applicable to all. This is why the intervention is designed for patients with a certain intellectual level (with an IQ above 80) who are psychopathologically stable (De la Higuera & Sagastagoitia, 2006). Attention Shaping is a program based on approaches to modifying behaviour, including cognition (Menditto, Baldwin, O’Neal, & Beck, 1991; Spaulding, Storms, Goodrich, & Sullivan, 1986). “Shaping” involves selective reinforcement of successive approximations to desired behaviour. Behaviour that is close to what is required is reinforced; inappropriate behaviour is not. At the beginning, training focuses on behaviours that have a high probability of being displayed within the behavioural repertoire of an individual. Once behaviour is established, criteria for reinforcement moves forward encouraging the patient to behave closer to a final model. The new behaviour is then reinforced selectively from then on and these steps are repeated until the desired behaviour is achieved. Behavioural shaping shares methodological procedures of other training programs such as errorless learning. A key difference is that in shaping, training is not designed to specifically prevent errors or potential behaviour that might occur, whereas in errorless learning, the trainer takes active steps to prevent them. Integrated Psychological Therapy for Schizophrenia (IPT) (Brenner, Roder,Hodel, & Corrigan, 1994; Brenner, Hirsbrunner, & Heimberg, 1996; Roder, Brenner, Kienzle, & Fuentes, 2007) is probably the one cognitive training program that has attracted the largest quantity of empirical studies on its effectiveness (34). It has now been admi- nistered to approximately 1507 patients, which has allowed its authors to carry out a meta-analysis (Müller & Roder, 2008; Roder, Müller, Mueser, & Brenner, 2006; Müller & Roder, 2010), that reveal important effects of IPT compared to different control groups. A review of studies published on IPT in Spain can be found in Fuentes, Jimeno, and Cangas (2007). This is a program which goes beyond influencing the non-social cognitive function, to include, within the treatment process, a varied range of psychosocial intervention procedures (i.e. Fuentes, García, Ruiz, Soler, & Roder, 2007) aiming to ultimately achieve ecological evidence of the changes. It is based on the theoretical premise that there is a close relation between basic cognitive disorders appearing in the illness and functional deficits in the patient (Brenner, 1989; Brenner, Hodel, Roder, & Corrigan, 1992; Brenner, Roder, Hodel, & Corrigan 1994). The implicit idea is that tackleing the former will enable faster and more profound improvement in the latter. It is administered to groups and consists of five sub-programs: cognitive differentiation, social perception, verbal communication, social skills and interpersonal problem solving. These programs are hierarchically organized to achieve optimum effectiveness in the intervention. Basic skills such as concentration, concept forming, abstracting ability, perceptive ability and memory need to be practiced first to allow later development of more complex forms of social behaviour (Brenner, 1986; George & Neufeld, 1985; Hemsley, 1977; Liberman, 1982; Neale, Oltmanns, & Harvey, 1985). To sum up, the programs to improve cognition have the advantage of being short and intensive, and succeed in achieving improvements in the execution of neuropsychological tests for cognitive functioning. On the other hand, the programs in this group that are not part of integral psychosocial rehabilitation programs, as is the case, for instance, with CRT, do not show effects on global functioning or on psychopathology. When the intervention is integral, as in the case of IPT, there is indeed evidence of positive effects in global terms and not merely at a cognitive level (Roder et al., 2007). In this group of programs, there are aspects that need to be expanded by empirical studies, such as, for example, the assessment of their effectiveness when administered individually rather than to groups of patients, as is the case with most programs. (Corrigan 1994). The implicit idea is that tackleing the former will enable faster and more profound improvement in the latter. It is administered to groups and consists of five sub-programs: cognitive differentiation, social perception, verbal communication, social skills and interpersonal problem solving. These programs are hierarchically organized to achieve optimum effectiveness in the intervention. Basic skills such as concentration, concept forming, abstracting ability, perceptive ability and memory need to be practiced first to allow later development of more complex forms of social behaviour (Brenner, 1986; George & Neufeld, 1985; Hemsley, 1977; Liberman, 1982; Neale, Oltmanns, & Harvey, 1985). To sum up, the programs to improve cognition have the advantage of being short and intensive, and succeed in achieving improvements in the execution of neuropsycho- logical tests for cognitive functioning. On the other hand, the programs in this group that are not part of integral psychosocial rehabilitation programs, as is the case, for instance, with CRT, do not show effects on global functioning or on psychopathology. When the intervention is integral, as in the case of IPT, there is indeed evidence of positive effects in global terms and not merely at a cognitive level (Roder et al., 2007). In this group of programs, there are aspects that need to be expanded by empirical studies, such as, for example, the assessment of their effectiveness when administered individually rather than to groups of patients, as is the case with most programs.