Introduction
Cognitive difficulties in people with a diagnosis of schizophrenia spectrum disorder are well-documented, and include impairments in memory, attention, executive function and social cognition with moderate to large effect sizes reported on neurocognitive testing (Heinrichs & Zakzanis, Reference Heinrichs and Zakzanis1998). The subjective experience of cognitive impairment in schizophrenia indicates problems with forgetfulness, difficulties in concentrating and an inability to plan ahead (Wood et al. Reference Wood, Cupitt and Lavender2013). This is an area of clinical importance, as chronic cognitive difficulties are predictive of poorer outcomes for service users with psychosis in terms of social functioning and community based rehabilitation (Green et al. Reference Green, Kern, Braff and Mintz2000). Whilst anti-psychotic medication remains the cornerstone of recommended treatments in schizophrenia and for many can be effective in controlling positive symptoms, it often fails to improve social and vocational outcomes for service users (Marder, Reference Marder2006). In addition to providing evidence-based interventions designed to address symptom-related distress and impact of the illness on families (cognitive behavioural therapy and family interventions; NICE, 2014), the need for interventions to specifically target cognitive impairments in schizophrenia are indicated.
Currently, the leading psychological therapy to help improve cognitive functioning in schizophrenia is cognitive remediation therapy (CRT). This is ‘an intervention targeting cognitive deficits using scientific principles of learning with the ultimate goal of improving functional outcomes’ (Cognitive Remediation Experts Working Group, 2012, minutes from the CREW meeting; paper presented at the Schizophrenia International Research Society, Florence, Italy). It is important therefore to keep in mind the overall goal of CRT; cognitive remediation is not seen as an end-point in of itself, but rather as a stepping stone to improving people's functioning in their everyday lives. CRT has also been successfully applied to other psychiatric and developmental disorders including anorexia nervosa (Tchanturia et al. Reference Tchanturia, Lloyd and Lang2013) and attention deficit hyperactivity disorder (Vidal-Estrada et al. Reference Vidal-Estrada, Bosch-Munso, Nogueira-Morais, Casas-Brugue and Ramos-Quiroga2012).
The two main approaches to cognitive remediation are: (1) ‘drill and practice’; and (2) the use of compensatory strategies. The drill and practice approach is based on the idea that performance on tasks will improve with sustained and intensive practice, given the brain's lifelong potential for neuroplasticity. In the case of cognitive deficits that may remain stable or resistant to improvement, the second approach focuses more on the development of compensatory strategies. For example, this might include writing things down to help compensate for memory difficulties. Earlier CRT programmes employed drill and practice techniques using low-tech materials such as paper and pen. Neuropsychological targets commonly included attention/vigilance, processing speed, working memory, visual and non-visual memory, planning and problem-solving (Wykes & Reeder, Reference Wykes and Reeder2005). Later, computerised programmes were developed in which participants completed tasks and puzzles on computers, with the support of a therapist and with a greater emphasis on the development of compensatory strategies for cognitive impairments rather than a sole focus on remediation of the under-lying deficit itself. There are several advantages to computerised versions of CRT compared to equivalent paper and pen exercises. These include greater ease of administration; automated session planning; immediate feedback on task performance; tracking of progress over time and easier adjustment of difficulty levels. Furthermore, computerised CRT may be more appealing to some service users and also helps with improving general information technology skills.
Several meta-analyses have been conducted on the efficacy of CRT in schizophrenia, including both inpatient and outpatient settings. An early meta-analysis of CRT by Pilling et al. (Reference Pilling, Bebbington, Kuipers, Garety, Geddes, Martindale, Orbach and Morgan2002) reported outcomes from four randomised control trials (RCTs) but concluded that there was no clear evidence of any benefits on attention, verbal/visual memory, planning, cognitive flexibility or mental state. Later meta-analyses reported much more favourable outcomes based on a larger number of RCTs. McGurk et al. (Reference McGurk, Twamley, Sitzer, McHugo and Mueser2007) reported medium effect sizes for the impact of CRT on cognitive performance and psychosocial functioning and small effect sizes for symptoms, based on 26 RCTs. Wykes et al. (Reference Wykes, Huddy, Cellard, McGurk and Czobor2011) included 40 RCTs in their subsequent meta-analysis and reported durable effects of CRT on global cognition and functioning. Furthermore, they found that CRT worked equally well, regardless of whether service users were classified as taking high or low doses of anti-psychotic medication. In line with McGurk et al. (Reference McGurk, Twamley, Sitzer, McHugo and Mueser2007), they also found that the strongest effects on functioning occurred when CRT was combined with psychiatric rehabilitation. Grynszpan et al. (Reference Grynszpan, Perbal, Pelissolo, Fossati, Jouvent, Dubal and Perez-Diaz2011) reported a meta-analysis just focusing on RCTs of computerised CRT and report a small effect size on general cognition overall, and a medium effect size for social cognition. The studies varied in the duration and intensity of CRT delivery, ranging from 4–75 hours of intervention overall, with CRT usually being delivered several times a week. Service-user led research indicated high levels of satisfaction and acceptability of CRT from a service user perspective, although unintended side-effects were also highlighted such as the detrimental effect on self-esteem if CRT is perceived to not be working (Rose et al. Reference Rose, Wykes, Farrier, Doran, Sporle and Bogner2008).
Implementing CRT Within Routine Clinical Practice On Inpatient Wards
Pharmacological treatments are the main interventions offered to service users with psychosis. Treatment delivery in the UK is primarily via community based mental health teams. However, for individuals requiring a greater level of, and/or specialist, care an inpatient admission will be provided. As outlined above, the existing evidence base does include studies on CRT conducted within inpatient settings, however little is known about implementing CRT within routine clinical practice. This is perhaps partly due to the fact that CRT is not yet recommended in NICE guidelines for schizophrenia as a treatment to be offered as standard (NICE, 2014). Nevertheless, where research studies have been conducted within inpatient settings, extra resources are available from the research team in terms of provision of CRT therapists in addition to the regular staff employed on the ward. Can CRT be implemented as part of routine clinical practice without these extra resources? There are several challenges to re-creating the intervention as delivered as part of a research trial. To begin with, most studies have delivered the intervention intensively, offering service users up to five sessions a week, with a minimum of three sessions a week being thought effective. This intensity of intervention is very difficult to recreate within standard practice, as levels of staffing and funding for psychologists or psychological practitioners on wards are very limited, with some guidelines suggesting one-half day a week as an adequate minimum standard for psychological input to a ward (Cresswell & Beavon, Reference Cresswell and Beavon2010).
Implementing CRT in A Psychosis Inpatient Service
This paper aims to describe an innovative attempt to provide a CRT service on an inpatient unit with all the restrictions and limitations in staffing noted above. The National Psychosis Unit is a specialist unit for people with complex and treatment resistant psychosis who have failed to respond to standard treatments elsewhere. Computerised CRT was included within the therapies programme with the aim of helping people improve their cognitive functioning, combined with other recovery-based work. The model of delivery was that of a group session provided on a weekly basis, with enough spaces for up to four service users to attend at any one time depending on their level of need. The group was facilitated by a part-time clinical psychologist (PJ) working with two health-care assistants (HCAs), who were both graduate psychologists and alternated co-facilitating the group (FO & GS). Having two HCAs sharing the role meant that the co-facilitator role could be filled on most weeks, although on occasion the nursing shift pattern still meant that both HCAs were unavailable on the day of the group. After an initial training period, regular clinical supervision was provided for the HCAs by the clinical psychologist to ensure treatment fidelity.
Reflections on delivering CRT in an inpatient setting
This reflective section is written by FO and GS from a first person perspective.
The primary role of an HCA on the ward lies in supporting the service users with their daily physical and psychological needs. We work as part of the nursing team to facilitate a service user's engagement with the therapeutic milieu including attendance at a broad range of occupational and psychological therapy groups. In addition, we perform a number of basic nursing interventions that monitor both the physical and mental heath of service users including on-going assessment of risk and mental state. We also help by encouraging service users to wake up in the mornings, plan the structure of the day, support their efforts in attending to basic personal care (e.g. ranging from oral hygiene to tidying their bedroom), and prompting inpatients for their meals and medication and to engage in therapeutic one to one talking sessions.
At the time of writing this paper, we started co-facilitating the CRT group over a year ago. This was in response to an opportunity to participate in new ways of working on the ward, under the supervision of the ward psychology team. Service users on the ward typically have long illness lengths and difficulties with engaging with the ward therapeutic programme. Deficits in different areas of social functioning are often immediately apparent with many inpatients, which in turn can adversely affect their ability to form positive social relationships and derive benefits from the therapeutic interventions on offer.
One of the most rewarding parts of co-facilitating the CRT group was the particular emphasis placed on positive reinforcement and reminding service users of what they already could do, with a view to further improving their skills. This approach was a refreshing change to many group members who often had a tendency to focus on areas of their functioning they perceived, or had been told hitherto, they were not doing so well with. We found this to be an important motivational tool and a boost to service users' self-esteem, which was often negatively affected by illness related stigma.
CRT is not a symptom-based or mental illness diagnosis specific intervention. As reported above, CRT aims to help people further develop their cognitive skills and functioning including attention, memory, processing speed and problem solving. Although these cognitive impairments are commonly associated with schizophrenia spectrum disorders, they are not exclusive to this condition and can be found in other clinical and non-clinical groups. For example, people with depression often have problems with concentration and older adults can experience an age-related decline in memory function. Therefore, we found it helpful to ‘sell’ the CRT group to inpatients and facilitate their attendance and engagement by actively using normalising language (i.e. improving thinking skills). It also helped to explain that the sessions would be like a series of computer games and we referred to widely available brain-training packages aimed at the general public.
It has been rewarding to observe service users experiencing a sense of surprise at their own abilities and the success of their achievements. One of the great things about CRT was that the benefits and rewards were immediate as well as long-term. The positive reinforcement we were able to provide a service user with, helped to boost their self-esteem and confidence immediately. When beginning any task that might present a potential challenge, our service user group often experienced anxiety over their ability and fear of failure. As we were able to adjust the difficulty of the tasks to suit a service user's ability, we could match the pace and content of the session to the individual's needs.
As we expected from our own knowledge as HCAs, and our clinical supervision, service users did sometimes decline the offer of CRT initially. However, it was often helpful to give reminders every week about the sessions, and it was nice to see that with time and active engagement, service users who struggled to engage in many ward based activities began to attend.
Rose et al. (Reference Rose, Wykes, Farrier, Doran, Sporle and Bogner2008) highlighted the risk of service users’ self-esteem being lowered if they perceive CRT to be not working, so we were careful to always remind service users of what they were doing well and to problem solve areas with which they may have encountered more difficulty. Working on the tasks together promoted an idea of team work between the service user and therapist. This is an important feature of CRT as it allowed service users to feel supported throughout the session. On completing the task, there was always positive feedback to be given. Even if a service user did not complete a task successfully, we provided feedback and attempted to explore difficulties they were facing, including problem solving, attention and concentration. We were able to change the difficulty level to match the ability of the service user and endeavoured to prevent future mistakes by stepping in and providing guidance when needed. We never returned from a session with a group member who did not feel more positive after a session. We continued to build on this week by week, and often reminded service users about what gains had been made in the previous session to provide further evidence of their progress.
The improvement seen over time from some of our service users was significant and ultimately highly rewarding for service users and for us. It gives service users more confidence to do everyday tasks independently, which is vital for them in preparing for discharge from hospital. It felt good as an HCA to be able to offer a therapy based wholly on encouragement and positive feedback, in an environment that is usually challenging. Our experience with co-facilitating the CRT group also helped us to develop skills highly pertinent to our goal of pursuing a career in clinical psychology. The clinical psychologist explained the relevant skills needed to deliver this therapy, gave feedback on what she had observed from seeing us working with service users, and provided guidance on ways to improve these skills. These skills prove invaluable as they can be used to run other groups on the ward but most importantly can be transferred and used to develop the delivery of care to service users on a daily basis. Regular supervision from the clinical psychologist was very important as it allowed us to reflect on our own practice and troubleshoot areas of difficulty in our therapeutic relationship. It was an opportunity to discuss positive interactions and observations made during the group, and also to address challenges that had come up. Supervision allowed us to link theory to practice which helps in being able to deliver CRT with greater understanding and effectiveness. The experience of co-facilitating the group also enabled us to gain greater insight into the role of a clinical psychologist on a ward and more broadly, and the importance and benefits of multidisciplinary work.
Summary and Conclusions
CRT is an evidence-based psychological therapy aimed at improving cognitive functioning in schizophrenia. In a period of limited resources but with a widely acknowledged need to provide more psychological provision in inpatient settings (The Schizophrenia Commission, 2012), the current paper leads the discussion on whether CRT can be effectively delivered within an inpatient setting by HCAs who have undergone training and are supervised by a trained therapist. Though we offer no data on the effectiveness of the application of CRT in inpatient settings, HCAs are in an ideal position to undertake this therapeutic work given that they work closely with service users on a day-to-day basis. They can recognise in what areas service users may be having difficulties (e.g. forgetting appointments, poor self care) and can also encourage service users to put into practice what they may have learnt during CRT sessions to help overcome any cognitive difficulties. As reported in this paper, HCAs can also find the experience richly rewarding and value the opportunity to work with service users in this way.
