Emerging Trends in The Social and Behavioral Sciences

Cognitive Remediation in Schizophrenia

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Cognitive Remediation in Schizophrenia

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Cognitive Remediation
in Schizophrenia
CLARE REEDER and TIL WYKES

Abstract
It is well established that many people with a diagnosis of schizophrenia experience
significant problems with thinking skills such as concentration, memory, comprehension of social information, reasoning, and organization. These are often experienced
by the individuals themselves as debilitating and demoralizing, but crucially, they
also can limit people in their capacity to achieve fundamental life goals, such as
working, having fulfilling relationships and living independently, which underpin
well-being and a satisfactory quality of life. Cognitive remediation for schizophrenia
is a psychological therapy that aims to improve thinking skills and consequently to
benefit other more general areas of functioning and improve quality of life.
This entry will summarize the foundational research background to the development and effectiveness of cognitive remediation; and the cutting-edge research into
the developments in our understanding of the mechanisms of cognitive change and
its relationship to improvements in everyday functioning, and new applications for
cognitive remediation. The key aims for the field of cognitive remediation are now
(i) to optimize its effectiveness in improving cognitive skills, but critically, in a way
that ensures that these cognitive improvements have a measurable impact on other
more general life skills, and (ii) to facilitate the wider dissemination of cognitive
remediation into the clinical community. To achieve these goals, we need to establish
an evidence-based, theoretical underpinning to cognitive remediation, including an
understanding of the active ingredients and how best to deliver the therapy.

INTRODUCTION
A diagnosis of schizophrenia is defined by the presence of persistent and
disabling symptoms of psychosis (delusions and hallucinations), disorganized speech or behavior, and negative symptoms, which include impoverishment in motivation, speech, and emotional expression. However, since
the very earliest descriptions by Kraepelin, Huntingdon, & Robert (1971) and
Bleuler (1950), significant and widespread problems in diverse areas of thinking skill, often referred to as cognitive or neurocognitive impairments, have
also been identified. Overall, people with a schizophrenia diagnosis show a
Emerging Trends in the Social and Behavioral Sciences. Edited by Robert Scott and Stephen Kosslyn.
© 2015 John Wiley & Sons, Inc. ISBN 978-1-118-90077-2.

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wide range of general intellectual abilities, mirroring the distribution curve
of the general population (although with a downward shift). But the vast
majority do not achieve the expected level of development, based on usual
predictive factors such as maternal IQ or education. Furthermore, most people with schizophrenia experience specific additional cognitive problems,
with widely differing individual profiles, but typically in areas such as memory, concentration, problem solving, organization, planning, thinking speed,
perceptual processing, or the understanding of social cues and situations.
Studies of cohorts of people born within a certain timespan and within a
defined geographical area show that:
•

•
•

Cognitive difficulties are apparent in those who go on to develop
schizophrenia before the specific symptoms emerge.
Cognitive difficulties significantly worsen when symptoms emerge.
With some fluctuations, these cognitive difficulties remain stable
throughout life.

For individuals, common experiences resulting from cognitive difficulties
include a significantly reduced concentration span, difficulties in remembering key personal past events or current information, or problems in thinking
in an organized or strategic way. It seems self-evident that these experiences
are likely to be detrimental to someone’s quality of life, self-esteem, and personal identity. However, they are also known to be linked to limitations in the
ability to achieve and maintain personal developmental milestones, in terms
of employment, self-care, and social relationships. Thus, cognitive problems
have emerged as a key treatment target in schizophrenia, particularly as a
means to improving valued other outcomes, seen by patients as crucial for
recovery.
Despite considerable recent interest in the field, there are currently no
effective pharmacological treatments for cognitive problems in schizophrenia. There is, however, a psychological treatment, cognitive remediation,
for which there is now a large body of evidence showing its benefits for
both cognitive and functional skills in people with schizophrenia. It was
recently defined, in 2012, by a Cognitive Remediation Experts Workshop
as “an intervention targeting cognitive deficits using scientific principles of
learning with the ultimate goal of improving functional outcomes. Its effectiveness is enhanced when provided in a context (formal or informal) that
provides support and opportunity for improving everyday functioning.” It
takes a wide variety of forms but, usually consists primarily of a collection of
tasks or puzzles targeting particular thinking skills, which appear much like
those that have frequently appeared in publically available “brain training”
programs. Tasks are practiced repetitively, usually over a period of several

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months, and frequently rely on errorless learning (so that a high degree
of success is maintained) and scaffolding (which allows patients to work
slightly above their current ability level). These tasks might be presented in
pencil-and-paper format, or increasingly, on a computer. A therapist may
or may not guide the work, which can be conducted individually or in a
group format, and the therapy may be more or less embedded within a
more comprehensive clinical intervention. The continuum of presentation
may range from a patient being given a laptop on which to practice a range
of exercises at home for payment, to daily attendance at a clinic in which
cognitive remediation is offered individually and in groups as part of a
personally tailored, recovery-focused rehabilitation package, delivered by
highly trained psychological therapists or other mental health professionals.
Cognitive remediation is beginning to be considered for clinical guidance
and has recently been endorsed by the Scottish Intercollegiate Guideline Network, the body which develops evidence-based clinical practice guidelines
for the National Health Service in Scotland, for inclusion as a part of routine clinical care. This entry describes the foundational background research
to its development and effectiveness; summarizes the cutting-edge research
into delivery enhancements and the underlying mechanisms of change; and
argues that the current priorities for cognitive remediation should be to establish an evidence-based model for therapy to ensure that the active ingredients
are sufficiently specified to ensure widespread dissemination that is both
cost-effective and maximizes clinical change.
FOUNDATIONAL RESEARCH
Originating in the field of brain injury, cognitive remediation for schizophrenia has taken many forms and is distinct in the piecemeal trajectory of its
development. No single model or group of models of how cognitive skills
may be improved, or how cognitive changes achieved in a clinic or laboratory might be generalised or “transferred” to everyday life, underlie the wide
variety of cognitive remediation programs that are available. The therapy
emerged in a context of pessimism within which cognitive problems were
considered to be immutable traits, and researchers began with a modest goal
of improving performance on specific psychological tests of brain function.
Following some initial successful forays, more comprehensive programs of
cognitive remediation have been developed, which can be broadly grouped
into two categories.
The first is often referred to as drill-and-practice cognitive remediation. This
approach is tied to the idea that throughout life the brain is able to adapt
and change in both its function and structure in response to experience. This
is known as neuroplasticity and for neuroplastic changes to take place and

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persist, changes in behavior which promote them should be small and incremental and done in a highly repetitive and intensive way over a sustained
period of time. Drill-and-practice-based approaches tend to isolate specific
basic cognitive skills, such as discriminating between two auditory tones or
remembering short chunks of information, and to encourage people to practice these skills in a highly repetitive way, often on a daily basis for a period
of at least a few months.
An alternative cognitive remediation approach is “strategy-based” and
involves teaching patients strategies for improving cognitive performance.
Originally conceived as a compensatory approach in which new strategies
were thought to support or replace the use of impaired cognitive skills, a
more recent conception has been that it helps people to develop a more
systematic general approach to tasks, which can also be applied to everyday
living. Thus, a clear means of transfer from the clinic to community skills is
specified and intrinsic to the learning. According to this notion, in principle,
the types of cognitive goals are likely to be different from the basic thinking skills targeted in drill-and-practice approaches, so that memory and
problem-solving, planning and organizational abilities (collectively known
as executive functions) are key. For these cognitive skills, strategy use is a
normal intrinsic part of thinking (and is known to be frequently impaired in
schizophrenia)—not a compensatory approach to impaired skills.
Traditionally, “drill-and-practice-based” cognitive remediation and
“strategy-based” cognitive remediation have been seen as competing
approaches, but, in practice, there is a common consensus that all cognitive remediation programs should include a substantial drill-and-practice
component that targets basic cognitive skills. What remains at issue is the
means by which the process of generalization or “transfer” from the clinic
to everyday life occurs, because it is well established that learning tends
to be highly context-dependent. Proponents of strategy-based cognitive
remediation suggest that transfer may be facilitated by the explicit strategic
teaching of executive skills as an intrinsic part of the cognitive remediation.
Proponents of drill-and-practice-based approaches also acknowledge the
importance of generalization, but prioritize the persistent targeting of basic
cognitive skills, with some suggestion that through the process of neuroplastic change, cognitive improvement may automatically feed-forward into
everyday tasks in which the targeted cognitive skills are in use.
An additional particular type of cognitive remediation deserves special
mention—social cognition interventions. Social cognition refers to the mental
processes involved in perceiving, attending to, remembering, thinking
about, and making sense of the social world. Social cognitive remediation
makes these processes the target and, analogous to the drill-and-practice
versus strategy-based approaches of mainstream cognitive remediation,

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social cognitive remediation tends to be targeted either to a specific domain
of social cognition (e.g., the interpretation of facial expressions of emotion)
or to incorporate a wide range of social cognitive domains to create a more
complex rehabilitative intervention.
There is now good evidence to show that cognitive remediation (including
social cognitive remediation), regardless of treatment approach, is an
effective way of improving cognitive skills in people with a diagnosis
of schizophrenia. In a recent study, which analyzed data collated from
40 controlled cognitive remediation studies published before June 2009,
collectively including more than 2000 participants, Wykes, Huddy, and
others (2011) showed that cognitive remediation leads to durable cognitive
improvements and benefits for wider functioning (employment, everyday
living skills). There were smaller positive effects for symptoms. Importantly,
these results persisted even when the methodological rigor of the studies
was taken into account. It is not unusual in research for the size of the effect
of a treatment to be reduced if only the studies which are conducted in a
very rigorous manner are considered: This was not the case for the cognitive
remediation research.
The effectiveness of social cognitive remediation has also been assessed in
a recent meta-analytic study, conducted by Matthew Kurtz and Richardson
(2012). Data from 19 controlled studies were analyzed, which collectively
included almost 700 participants. Results showed significant benefits for recognizing emotions from faces and theory of mind (the ability to attribute
mental states to oneself and others). But not all aspects of social cognition
were improved.
In addition to the overall effectiveness of cognitive remediation, the Wykes,
Huddy et al. (2011) meta-analysis investigated some of the treatment and
patient characteristics that may have affected the treatment response. In
terms of patient characteristics, age, gender, and whether or not cognitive
impairments had been used as a criterion for including participants to the
study did not have an impact. However, having fewer symptoms at the start
of therapy predicted a better response to cognitive remediation, and studies
which included only people who had a schizophrenia or a schizo-affective
diagnosis showed greater effects of cognitive remediation than studies
which included people with other diagnoses.
Many treatment characteristics including length of therapy and whether
or not a computer was used had no impact on outcome. The authors
also investigated the relative effectiveness of the drill-and-practice versus
drill-plus-strategy approaches. The positive effects of cognitive remediation
on cognition were similar for both types of therapy approach. However, the
effects on real-world functioning were considerably better for people who
had received cognitive remediation in the context of additional psychiatric

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rehabilitation (such as supported employment), particularly those who
had received drill-plus-strategy-based cognitive remediation. Although
including only a few studies, this effect was very marked: if participants
had received drill-plus-strategy cognitive remediation as well as some kind
of adjunctive therapy, the outcome was twice as good as for those who
had received drill-and-practice cognitive remediation. This suggests that
strategy-based approaches may facilitate the process of the transfer of new
cognitive skills into daily life, and as predicted from evidence that learning
is frequently context dependent, purely drill-plus-practice approaches do
not provide a mechanism by which new learning can generalize outside the
learning context. This is with the proviso that cognitive remediation may
provide a window of opportunity for people to make especially good use
of other rehabilitation programs or opportunities for practicing skills in the
community, and that without these opportunities translating learning from
cognitive remediation to everyday life may be difficult. This may be particularly true for some people with a schizophrenia diagnosis who are often
involved in few community activities and may have little social contact.
CUTTING-EDGE RESEARCH
WHICH TYPES OF COGNITIVE REMEDIATION WORK BEST?
Evidence from recent randomized controlled trials of cognitive remediation
support the finding that drill-and-practice approaches, without any direct
attempts to facilitate the transfer of learning to an everyday environment,
lead to cognitive improvements (as measured by tests of thinking skill),
but not changes in functioning in real-world social or community settings.
Consequently, increasingly cognitive remediation is appearing either as
a complex intervention including drill-plus-strategy-based approaches,
aspects of social cognitive remediation, and real-world goals; or paired with
an adjunctive additional treatment whose goal may be oriented more explicitly to general functioning. These treatment trials report success not only in
improving cognitive test performance but also in delivering improvements
in psychosocial outcomes. The results of a large, rigorous trial of a typical
combination of treatments was reported by Bowie, McGurk, Mausbach,
Patterson, and Harvey (2012) who compared (i) drill-plus-strategy cognitive
remediation, (ii) functional skills training, and (iii) a combination of the cognitive remediation followed by functional skills training. Changes following
each single mode treatment were specific to their targets: Cognition, but
not social or functional competence improved after cognitive remediation;
and social and functional competence, but not cognition improved after
functional skills training. The combination treatment not only produced each
type of change but, in addition, improvements in functional competence

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(community or household activities, and work skills) were greater and
more durable. A more novel pairing of treatments has been investigated by
Richard Drake et al. (2014). They preceded cognitive behavioural therapy for
psychosis (CBTp), a psychological therapy designed to treat the symptoms
of psychosis, with either drill-plus-strategy-based cognitive remediation or
a time-matched control therapy. Although at the end of receipt of CBTp,
both groups (cognitive remediation and active control) had a similar level of
symptoms, those who had previously received cognitive remediation had
required significantly fewer sessions of CBTp to achieve that outcome.
These studies suggest that while we can achieve cognitive improvements using only drill-and-practice cognitive remediation approaches, the
more ambitious goal of benefiting real-world function is facilitated by a
strategy-based approach, and this response is significantly enhanced in
the context of adjunctive rehabilitation or psychological therapy. Crucially,
the combination of cognitive remediation and adjunctive therapy may do
more than the sum of its parts. Cognitive remediation appears to facilitate
an enhanced response for patients with a schizophrenia diagnosis to other
interventions, so that outcomes are significantly boosted or the intervention
duration can be reduced.
HOW DOES COGNITIVE REMEDIATION WORK?
How cognitive remediation works needs to be addressed using two different
questions: (i) How does cognitive improvement occur, and (ii) how are these
cognitive improvements transferred or generalized to other areas of functioning? The studies described in the previous section tell us something about
the second of these: the mechanisms by which cognitive change may affect
other areas of functioning. There is clearly no direct relationship between
cognitive and functional change: If this were to be true, then any cognitive
change would be automatically linked to real-world changes. However, we
know that improvements in cognition known to be linked cross-sectionally
to psychosocial outcomes, are not always followed by the related psychosocial changes, and that this may depend on (i) the type of cognitive change (so
that some cognitive targets might better than others), (ii) the amount of cognitive change (so that cognitive change may need to reach a certain threshold
such as normalized performance in order to impact functional outcomes),
and (iii) the context of cognitive change (so that, for example, it may be only
influential on functional outcomes when occurring within a cognitive remediation program, or embedded within wider rehabilitation, or the person is
very motivated to change).
A few studies have investigated these issues. In terms of types of cognitive change, which appear to be associated with real-world improvements,

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there is some consistency in the finding that executive function improvement is a frequent specific cognitive predictor of real-world improvement.
Executive functions refer to higher order thinking skills used in processing
novel or goal-directed activities, and include aspects such as strategy use,
organization, planning and self-monitoring. These are all generally targets of
strategy-based cognitive remediation, and so this fits with the suggestion that
strategy-based approaches are needed to facilitate the generalization of learning in cognitive remediation to daily life. They are also closely allied to the
concept of metacognition, which has been suggested as a possible moderator
of the relationship between cognition and social functioning. The suggestion
is that it is only when people are able to understand their own cognitive
strengths and difficulties (metacognitive knowledge) and effectively monitor and regulate their own thinking (metacognitive processing) that they are
able to transfer new cognitive skills to an everyday context. A recent study
by Wykes and colleagues (2012) examined a number of complex models for
the relationship between cognitive change and work outcomes, investigating
the impact of both types and levels of cognitive change. They showed that of
a number of cognitive measures that improved following remediation, only
planning improvement was associated with improved work quality. Those
who had poorer memory and/or better cognitive flexibility were more likely
to make planning improvements.
The issue of the amount of cognitive change that is necessary to achieve
functional change has emerged in a number of studies, but has been little
investigated. In a few studies of cognitive remediation (e.g., by Silverstein &
colleagues, 2005), little or no measurable cognitive change was apparent,
despite functional changes emerging. Thus, the benefits of therapy may have
been mediated through its nonspecific effects on other areas of functioning,
such as self-esteem, or it may be that our traditional tests of cognitive function
are not sensitive enough to detect certain types or minimal levels of cognitive change. On the other hand, some studies, including those by Wykes and
colleagues have shown that only when cognitive change reached a certain
level has a measurable impact on social functioning been observable. Our
understanding of this issue is in its infancy.
The context of cognitive change calls into question what other factors
might be necessary to mediate or moderate a relationship between cognitive
change and functional outcomes. Other factors that have been investigated
so far have included learning potential (or the extent to which someone has
the capacity to learn from experience), social cognition, motivation, cognitive
reserve (or protective cognitive resources derived from experience), and
metacognition (thinking about thinking). Although this research is in the
early stages, there is emerging evidence that motivation and social cognition
may need to be boosted to maximize cognitive improvements are to take

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place and to be transferred to everyday living. Both these factors are very
frequently reduced or impaired in people with schizophrenia. Motivation
may be a particularly crucial factor to explore further, because massed
practice is so important for cognitive remediation: Patients need to complete
sessions daily over several months. Generally, cognitive remediation programs have either involved a therapist to offer social reinforcement and to
ensure the intervention is tailored to an individual’s needs and goals or they
have offered monetary rewards. Both these methods have cost implications
for the delivery of cognitive remediation, but there are also ethical issues
arising from payment of patients. But the relative merits of either approach
or their effects on either motivation or learning have not been investigated.
Studies have also begun to investigate biological correlates of cognitive
improvement, which offer the potential to identify more sensitively the process of change. Early brain imaging studies showed increased activation following cognitive remediation in areas of the brain known to be frequently
underactive in schizophrenia and associated with cognitive or social cognitive impairment (e.g., the frontal lobe for cognitive function, or recently,
in one study the postcentral gyrus for emotion recognition). More recently,
a study of brain morphology by Eack and colleagues (2010) showed that
2 years of a comprehensive and broad-ranging cognitive remediation program provided to people early in the course of a schizophrenia diagnosis,
provided a neuroprotective effect. People who had received cognitive remediation showed preserved or even increased gray matter compared to those
who had received an enriched supportive therapy. This is consistent with the
proposition that cognitive remediation facilitates neuroplastic changes in the
brain and has led to the suggestion that cognitive remediation may best be
targeted at young people with a diagnosis of schizophrenia, when neuroplasticity potential may be greatest and to protect against future neurobiological
decline.
The application of cognitive remediation to specific subgroups of the
population, such as those early in the course of the disorder, is another
cutting-edge development in the field. Studies of cognitive remediation
with young people, even those at high risk of developing psychosis, rather
than those with established symptoms, are increasing although there are
difficulties in recruitment as individuals who do not yet have a diagnosis
are less engaged with services.
KEY ISSUES FOR FUTURE RESEARCH
A consensus regarding the importance of some elements of cognitive
remediation, including massed practice, strategy-based learning to facilitate
transfer, and enhanced motivation, is beginning to emerge. However, to

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allow widespread dissemination, we need to optimize effectiveness while
continuing to be cost-effective and this is most likely to be achieved by
generating a unifying model of change. Any such model needs to address
two related questions: (i) How can we optimize cognitive improvement,
and (ii) how can cognitive change best be transferred to everyday life? It
is apparent that there are currently two predominant levels of explanation
emerging in response to these questions, one based on cognitive psychology
and the other on neuroscience. Cognitive levels of explanation for how cognition is improved have tended to refer to the development of new mental
models or “schemas” that may become automatized over time, while the
prevailing neuroscientific explanations emphasize the importance of brain
adaptations or neuroplastic changes to compensate for impaired or declining
processes. Cognitive-level explanations have also primarily been offered
for the transfer process from cognitive learning to everyday living skills,
emphasizing the development of metacognitive or social cognitive strategic
processing to help people learn how to use new or existing cognitive skills
to improve performance across a wide variety of domains. Neuroscience has
suggested that new brain functions may be automatically recruited in new
situations or that there may be an automatic feed-forward of change from
one area of cognitive function to another. Both levels of explanation need
to be developed, and compared or linked, if we are to understand change
more comprehensively.
In relation to understanding the process of change, we need to consider
the role of other factors that may mediate or moderate cognitive change and
its transfer to functional outcomes. In particular, we need to identify patient
and therapy characteristics. Patient characteristics may not only help target
treatments more effectively but also aid our understanding of the intrapersonal processes involved in change. Therapy characteristics will allow us
to identify active ingredients, which can in turn be used to provide insight
into the types of interpersonal, cognitive, or brain processes that may facilitate change. In relation to these, patient characteristics that appear to hold
promise in elucidating change are age and cognitive reserve (measured using
behavioral neuropsychological assessment and brain imaging methods).
One therapy characteristic which still deserves attention is the long-standing
difference between the drill-and-practice versus strategy-based approaches.
It is not clear whether the addition of an optimal strategy-based approach to
drill-and-practice training within cognitive remediation can be sufficient to
promote transfer to daily living skills, whether a strategy focus is necessary
to facilitate transfer for drill-and-practice approaches, or whether some kind
of additional adjunctive therapy is always necessary for generalization to
take place.

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In addition, with the increasing need to create a cost-effective, easily disseminated version of cognitive remediation, the therapy is being transferred
to computers, minimizing the need for a therapist. What is not clear is the
extent to which a therapist is important in facilitating change and other
related factors, such as engagement and motivation, and how much a patient
can gain from working alone, with or without monetary incentives. In relation to this, and of importance in considering more widespread adoption of
cognitive remediation into clinical services, is the level of training required
for clinicians offering cognitive remediation to therapists and whether this
is best done by psychologists or other mental health professionals.
Finally, one promising area of new research is in the interaction of cognitive
remediation with biological factors such as medication use and genes, which
may enhance response to help us to identify and target groups of people with
a schizophrenia diagnosis who may benefit from different approaches. These
may provide yet another neurobiological level of explanation for the process
of cognitive and concomitant changes. Medication might also allow us to
remove the rate limiter on neuroplastic change, particularly in older clients,
thus allowing for further effects of cognitive remediation as synergistic
treatments.
REFERENCES
Bleuler, E. (1950). Dementia praecox or the group of schizophrenias. New York, NY: International Universities Press.
Bowie, C. R., McGurk, S. R., Mausbach, B., Patterson, T. L., & Harvey, P. D. (2012).
Combined cognitive remediation and functional skills training for schizophrenia:
Effects on cognition, functional competence, and real-world behavior. American
Journal of Psychiatry, 169, 710–718.
Drake, R. J., Day, C. J., Picucci, R., Warburton, J., Larkin, W., Husain, N. … Marshall, M. (2014). A naturalistic, randomized, controlled trial combining cognitive
remediation with cognitive-behavioral therapy after first episode schizophrenia
Psychological Medicine, 44, 1889–1899.
Eack, S. M., Hogarty, G. E., Cho, R. Y., Prasad, K. M., Greenwald, D. P., Hogarty, S.
S., & Keshavan, M. S. (2010). Neuroprotective effects of cognitive enhancement
therapy against gray matter loss in early schizophrenia: Results from a 2-year randomized controlled trial. Archives of General Psychiatry, 67, 674–682.
Kraepelin, E., Huntingdon, N. Y., & Robert, E. (Eds.) (1971). Dementia praecox and
paraphreni. Melbourne, NY: Krieger Publishing Co, Inc.
Kurtz, M. M., & Richardson, C. L. (2012). Social cognitive training for schizophrenia: A metaanalytic investigation of controlled research. Schizophrenia bulletin, 38,
1092–1104.
Silverstein S. M., Hatashita-Wong, M., Solak B. A., Uhlhaas, P., Landa, Y., Wilkniss,
S. M., … Smith, T. E. (2005). Effectiveness of a two-phase cognitive rehabilitation

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intervention for severely impaired schizophrenia patients. Psychological Medicine,
35, 829–837.
Wykes, T., Huddy, V., Cellard, C., McGurk, S. R., & Czobor, P. (2011 May). A
meta-analysis of cognitive remediation for schizophrenia: Methodology and effect
sizes. American Journal of Psychiatry, 168(5), 472–85.
Wykes, T., Reeder, C., Huddy, V., Taylor, R., Wood, H., Ghirasim, N., … Landau,
S. (2012). Developing models of how cognitive improvements change functioning: Mediation, moderation and moderated mediation. Schizophrenia Research, 138,
88–93.

FURTHER READING
Eack, S. M., Greenwald, D. P., Hogarty, S. S., Cooley, S. J., DiBarry, A. L., Montrose,
D. M., & Keshavan, M. S. (2009). Cognitive enhancement therapy for early-course
schizophrenia: Effects of a two-year randomized controlled trial. Psychiatric Services, 60(11), 1468–76.
Green, M. F. (1996). What are the functional consequences of neurocognitive deficits
in schizophrenia? American Journal of Psychiatry, 153, 321–330.
Green, M. F., Kern, R. S., Braff, D. L., & Mintz, J. (2000). Neurocognitive deficits
and functional outcome in schizophrenia: Are we measuring the “right stuff”?
Schizophrenia Bulletin, 26, 119–136.
Heinrichs, R. W., & Zakzanis, K. K. (1998). Neurocognitive deficit in schizophrenia:
A quantitative review of the evidence. Neuropsychology, 12, 426–445.
Reeder, C., Smedley, N., Butt, K., Bogner, D., & Wykes, T. (2006). Cognitive predictors of social functioning improvements following cognitive remediation for
schizophrenia. Schizophrenia Bulletin, 32(Suppl. 1), S123–S131.
Wexler, B. E., Anderson, M., Fulbright, R. K., & Gore, J. C. (2000). Preliminary evidence of improved verbal working memory performance and normalization of
task-related frontal lobe activation in schizophrenia following cognitive exercises.
American Journal of Psychiatry, 157(10), 1694–1697.
Wykes, T., Brammer, M., Mellers, J., Bray, P., Reeder, C., Williams, C., & Corner, J.
(2002). Effects on the brain of a psychological treatment: Cognitive remediation
therapy functional magnetic resonance imaging in schizophrenia. British Journal
of Psychiatry, 181(2), 144–152.
Wykes, T., & Reeder, C. (2005). Cognitive remediation therapy for schizophrenia: Theory
and practice. London, England: Brunner Routledge.

CLARE REEDER SHORT BIOGRAPHY
Clare Reeder is a clinical lecturer at the Institute of Psychiatry, King’s College London. She has been involved in cognitive remediation research since
1995 and co-wrote a book with Til Wykes (2005) entitled “Cognitive remediation therapy for schizophrenia: Theory and practice. London: Brunner
Routledge.”

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TIL WYKES SHORT BIOGRAPHY
Til Wykes is a Professor of Clinical Psychology and Rehabilitation at the Institute of Psychiatry, King’s College London. She has been at the forefront of
cognitive remediation research across the world for many years and has published widely in the area. She was recently awarded the Marie Kessell prize
for outstanding contributions to psychiatric rehabilitation.
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Dissociation and Dissociative Identity Disorder (DID) (Psychology), Rafaële
J. C. Huntjens and Martin J. Dorahy
Computer Technology and Children’s Mental Health (Psychology), Philip C.
Kendall et al.
Cultural Neuroscience: Connecting Culture, Brain, and Genes (Psychology),
Shinobu Kitayama and Sarah Huff
Mechanisms of Fear Reducation (Psychology), Cynthia L. Lancaster and
Marie-H. Monfils

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

Understanding Risk-Taking Behavior: Insights from Evolutionary Psychology (Psychology), Karin Machluf and David F. Bjorklund
Evolutionary Perspectives on Animal and Human Personality (Anthropology), Joseph H. Manson and Lynn A. Fairbanks
Disorders of Consciousness (Psychology), Martin M. Monti
Social Classification (Sociology), Elizabeth G. Pontikes
Cognitive Bias Modification in Mental (Psychology), Meg M. Reuland et al.
Born This Way: Thinking Sociologically about Essentialism (Sociology),
Kristen Schilt
Clarifying the Nature and Structure of Personality Disorder (Psychology),
Takakuni Suzuki and Douglas B. Samuel
Taking Personality to the Next Level: What Does It Mean to Know a Person?
(Psychology), Simine Vazire and Robert Wilson
A Gene-Environment Approach to Understanding Youth Antisocial Behavior (Psychology), Rebecca Waller et al.
Crime and the Life Course (Sociology), Mark Warr and Carmen Gutierrez
Rumination (Psychology), Edward R. Watkins
Emotion Regulation (Psychology), Paree Zarolia et al.



Cognitive Remediation
in Schizophrenia
CLARE REEDER and TIL WYKES

Abstract
It is well established that many people with a diagnosis of schizophrenia experience
significant problems with thinking skills such as concentration, memory, comprehension of social information, reasoning, and organization. These are often experienced
by the individuals themselves as debilitating and demoralizing, but crucially, they
also can limit people in their capacity to achieve fundamental life goals, such as
working, having fulfilling relationships and living independently, which underpin
well-being and a satisfactory quality of life. Cognitive remediation for schizophrenia
is a psychological therapy that aims to improve thinking skills and consequently to
benefit other more general areas of functioning and improve quality of life.
This entry will summarize the foundational research background to the development and effectiveness of cognitive remediation; and the cutting-edge research into
the developments in our understanding of the mechanisms of cognitive change and
its relationship to improvements in everyday functioning, and new applications for
cognitive remediation. The key aims for the field of cognitive remediation are now
(i) to optimize its effectiveness in improving cognitive skills, but critically, in a way
that ensures that these cognitive improvements have a measurable impact on other
more general life skills, and (ii) to facilitate the wider dissemination of cognitive
remediation into the clinical community. To achieve these goals, we need to establish
an evidence-based, theoretical underpinning to cognitive remediation, including an
understanding of the active ingredients and how best to deliver the therapy.

INTRODUCTION
A diagnosis of schizophrenia is defined by the presence of persistent and
disabling symptoms of psychosis (delusions and hallucinations), disorganized speech or behavior, and negative symptoms, which include impoverishment in motivation, speech, and emotional expression. However, since
the very earliest descriptions by Kraepelin, Huntingdon, & Robert (1971) and
Bleuler (1950), significant and widespread problems in diverse areas of thinking skill, often referred to as cognitive or neurocognitive impairments, have
also been identified. Overall, people with a schizophrenia diagnosis show a
Emerging Trends in the Social and Behavioral Sciences. Edited by Robert Scott and Stephen Kosslyn.
© 2015 John Wiley & Sons, Inc. ISBN 978-1-118-90077-2.

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

wide range of general intellectual abilities, mirroring the distribution curve
of the general population (although with a downward shift). But the vast
majority do not achieve the expected level of development, based on usual
predictive factors such as maternal IQ or education. Furthermore, most people with schizophrenia experience specific additional cognitive problems,
with widely differing individual profiles, but typically in areas such as memory, concentration, problem solving, organization, planning, thinking speed,
perceptual processing, or the understanding of social cues and situations.
Studies of cohorts of people born within a certain timespan and within a
defined geographical area show that:
•

•
•

Cognitive difficulties are apparent in those who go on to develop
schizophrenia before the specific symptoms emerge.
Cognitive difficulties significantly worsen when symptoms emerge.
With some fluctuations, these cognitive difficulties remain stable
throughout life.

For individuals, common experiences resulting from cognitive difficulties
include a significantly reduced concentration span, difficulties in remembering key personal past events or current information, or problems in thinking
in an organized or strategic way. It seems self-evident that these experiences
are likely to be detrimental to someone’s quality of life, self-esteem, and personal identity. However, they are also known to be linked to limitations in the
ability to achieve and maintain personal developmental milestones, in terms
of employment, self-care, and social relationships. Thus, cognitive problems
have emerged as a key treatment target in schizophrenia, particularly as a
means to improving valued other outcomes, seen by patients as crucial for
recovery.
Despite considerable recent interest in the field, there are currently no
effective pharmacological treatments for cognitive problems in schizophrenia. There is, however, a psychological treatment, cognitive remediation,
for which there is now a large body of evidence showing its benefits for
both cognitive and functional skills in people with schizophrenia. It was
recently defined, in 2012, by a Cognitive Remediation Experts Workshop
as “an intervention targeting cognitive deficits using scientific principles of
learning with the ultimate goal of improving functional outcomes. Its effectiveness is enhanced when provided in a context (formal or informal) that
provides support and opportunity for improving everyday functioning.” It
takes a wide variety of forms but, usually consists primarily of a collection of
tasks or puzzles targeting particular thinking skills, which appear much like
those that have frequently appeared in publically available “brain training”
programs. Tasks are practiced repetitively, usually over a period of several

Cognitive Remediation in Schizophrenia

3

months, and frequently rely on errorless learning (so that a high degree
of success is maintained) and scaffolding (which allows patients to work
slightly above their current ability level). These tasks might be presented in
pencil-and-paper format, or increasingly, on a computer. A therapist may
or may not guide the work, which can be conducted individually or in a
group format, and the therapy may be more or less embedded within a
more comprehensive clinical intervention. The continuum of presentation
may range from a patient being given a laptop on which to practice a range
of exercises at home for payment, to daily attendance at a clinic in which
cognitive remediation is offered individually and in groups as part of a
personally tailored, recovery-focused rehabilitation package, delivered by
highly trained psychological therapists or other mental health professionals.
Cognitive remediation is beginning to be considered for clinical guidance
and has recently been endorsed by the Scottish Intercollegiate Guideline Network, the body which develops evidence-based clinical practice guidelines
for the National Health Service in Scotland, for inclusion as a part of routine clinical care. This entry describes the foundational background research
to its development and effectiveness; summarizes the cutting-edge research
into delivery enhancements and the underlying mechanisms of change; and
argues that the current priorities for cognitive remediation should be to establish an evidence-based model for therapy to ensure that the active ingredients
are sufficiently specified to ensure widespread dissemination that is both
cost-effective and maximizes clinical change.
FOUNDATIONAL RESEARCH
Originating in the field of brain injury, cognitive remediation for schizophrenia has taken many forms and is distinct in the piecemeal trajectory of its
development. No single model or group of models of how cognitive skills
may be improved, or how cognitive changes achieved in a clinic or laboratory might be generalised or “transferred” to everyday life, underlie the wide
variety of cognitive remediation programs that are available. The therapy
emerged in a context of pessimism within which cognitive problems were
considered to be immutable traits, and researchers began with a modest goal
of improving performance on specific psychological tests of brain function.
Following some initial successful forays, more comprehensive programs of
cognitive remediation have been developed, which can be broadly grouped
into two categories.
The first is often referred to as drill-and-practice cognitive remediation. This
approach is tied to the idea that throughout life the brain is able to adapt
and change in both its function and structure in response to experience. This
is known as neuroplasticity and for neuroplastic changes to take place and

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

persist, changes in behavior which promote them should be small and incremental and done in a highly repetitive and intensive way over a sustained
period of time. Drill-and-practice-based approaches tend to isolate specific
basic cognitive skills, such as discriminating between two auditory tones or
remembering short chunks of information, and to encourage people to practice these skills in a highly repetitive way, often on a daily basis for a period
of at least a few months.
An alternative cognitive remediation approach is “strategy-based” and
involves teaching patients strategies for improving cognitive performance.
Originally conceived as a compensatory approach in which new strategies
were thought to support or replace the use of impaired cognitive skills, a
more recent conception has been that it helps people to develop a more
systematic general approach to tasks, which can also be applied to everyday
living. Thus, a clear means of transfer from the clinic to community skills is
specified and intrinsic to the learning. According to this notion, in principle,
the types of cognitive goals are likely to be different from the basic thinking skills targeted in drill-and-practice approaches, so that memory and
problem-solving, planning and organizational abilities (collectively known
as executive functions) are key. For these cognitive skills, strategy use is a
normal intrinsic part of thinking (and is known to be frequently impaired in
schizophrenia)—not a compensatory approach to impaired skills.
Traditionally, “drill-and-practice-based” cognitive remediation and
“strategy-based” cognitive remediation have been seen as competing
approaches, but, in practice, there is a common consensus that all cognitive remediation programs should include a substantial drill-and-practice
component that targets basic cognitive skills. What remains at issue is the
means by which the process of generalization or “transfer” from the clinic
to everyday life occurs, because it is well established that learning tends
to be highly context-dependent. Proponents of strategy-based cognitive
remediation suggest that transfer may be facilitated by the explicit strategic
teaching of executive skills as an intrinsic part of the cognitive remediation.
Proponents of drill-and-practice-based approaches also acknowledge the
importance of generalization, but prioritize the persistent targeting of basic
cognitive skills, with some suggestion that through the process of neuroplastic change, cognitive improvement may automatically feed-forward into
everyday tasks in which the targeted cognitive skills are in use.
An additional particular type of cognitive remediation deserves special
mention—social cognition interventions. Social cognition refers to the mental
processes involved in perceiving, attending to, remembering, thinking
about, and making sense of the social world. Social cognitive remediation
makes these processes the target and, analogous to the drill-and-practice
versus strategy-based approaches of mainstream cognitive remediation,

Cognitive Remediation in Schizophrenia

5

social cognitive remediation tends to be targeted either to a specific domain
of social cognition (e.g., the interpretation of facial expressions of emotion)
or to incorporate a wide range of social cognitive domains to create a more
complex rehabilitative intervention.
There is now good evidence to show that cognitive remediation (including
social cognitive remediation), regardless of treatment approach, is an
effective way of improving cognitive skills in people with a diagnosis
of schizophrenia. In a recent study, which analyzed data collated from
40 controlled cognitive remediation studies published before June 2009,
collectively including more than 2000 participants, Wykes, Huddy, and
others (2011) showed that cognitive remediation leads to durable cognitive
improvements and benefits for wider functioning (employment, everyday
living skills). There were smaller positive effects for symptoms. Importantly,
these results persisted even when the methodological rigor of the studies
was taken into account. It is not unusual in research for the size of the effect
of a treatment to be reduced if only the studies which are conducted in a
very rigorous manner are considered: This was not the case for the cognitive
remediation research.
The effectiveness of social cognitive remediation has also been assessed in
a recent meta-analytic study, conducted by Matthew Kurtz and Richardson
(2012). Data from 19 controlled studies were analyzed, which collectively
included almost 700 participants. Results showed significant benefits for recognizing emotions from faces and theory of mind (the ability to attribute
mental states to oneself and others). But not all aspects of social cognition
were improved.
In addition to the overall effectiveness of cognitive remediation, the Wykes,
Huddy et al. (2011) meta-analysis investigated some of the treatment and
patient characteristics that may have affected the treatment response. In
terms of patient characteristics, age, gender, and whether or not cognitive
impairments had been used as a criterion for including participants to the
study did not have an impact. However, having fewer symptoms at the start
of therapy predicted a better response to cognitive remediation, and studies
which included only people who had a schizophrenia or a schizo-affective
diagnosis showed greater effects of cognitive remediation than studies
which included people with other diagnoses.
Many treatment characteristics including length of therapy and whether
or not a computer was used had no impact on outcome. The authors
also investigated the relative effectiveness of the drill-and-practice versus
drill-plus-strategy approaches. The positive effects of cognitive remediation
on cognition were similar for both types of therapy approach. However, the
effects on real-world functioning were considerably better for people who
had received cognitive remediation in the context of additional psychiatric

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

rehabilitation (such as supported employment), particularly those who
had received drill-plus-strategy-based cognitive remediation. Although
including only a few studies, this effect was very marked: if participants
had received drill-plus-strategy cognitive remediation as well as some kind
of adjunctive therapy, the outcome was twice as good as for those who
had received drill-and-practice cognitive remediation. This suggests that
strategy-based approaches may facilitate the process of the transfer of new
cognitive skills into daily life, and as predicted from evidence that learning
is frequently context dependent, purely drill-plus-practice approaches do
not provide a mechanism by which new learning can generalize outside the
learning context. This is with the proviso that cognitive remediation may
provide a window of opportunity for people to make especially good use
of other rehabilitation programs or opportunities for practicing skills in the
community, and that without these opportunities translating learning from
cognitive remediation to everyday life may be difficult. This may be particularly true for some people with a schizophrenia diagnosis who are often
involved in few community activities and may have little social contact.
CUTTING-EDGE RESEARCH
WHICH TYPES OF COGNITIVE REMEDIATION WORK BEST?
Evidence from recent randomized controlled trials of cognitive remediation
support the finding that drill-and-practice approaches, without any direct
attempts to facilitate the transfer of learning to an everyday environment,
lead to cognitive improvements (as measured by tests of thinking skill),
but not changes in functioning in real-world social or community settings.
Consequently, increasingly cognitive remediation is appearing either as
a complex intervention including drill-plus-strategy-based approaches,
aspects of social cognitive remediation, and real-world goals; or paired with
an adjunctive additional treatment whose goal may be oriented more explicitly to general functioning. These treatment trials report success not only in
improving cognitive test performance but also in delivering improvements
in psychosocial outcomes. The results of a large, rigorous trial of a typical
combination of treatments was reported by Bowie, McGurk, Mausbach,
Patterson, and Harvey (2012) who compared (i) drill-plus-strategy cognitive
remediation, (ii) functional skills training, and (iii) a combination of the cognitive remediation followed by functional skills training. Changes following
each single mode treatment were specific to their targets: Cognition, but
not social or functional competence improved after cognitive remediation;
and social and functional competence, but not cognition improved after
functional skills training. The combination treatment not only produced each
type of change but, in addition, improvements in functional competence

Cognitive Remediation in Schizophrenia

7

(community or household activities, and work skills) were greater and
more durable. A more novel pairing of treatments has been investigated by
Richard Drake et al. (2014). They preceded cognitive behavioural therapy for
psychosis (CBTp), a psychological therapy designed to treat the symptoms
of psychosis, with either drill-plus-strategy-based cognitive remediation or
a time-matched control therapy. Although at the end of receipt of CBTp,
both groups (cognitive remediation and active control) had a similar level of
symptoms, those who had previously received cognitive remediation had
required significantly fewer sessions of CBTp to achieve that outcome.
These studies suggest that while we can achieve cognitive improvements using only drill-and-practice cognitive remediation approaches, the
more ambitious goal of benefiting real-world function is facilitated by a
strategy-based approach, and this response is significantly enhanced in
the context of adjunctive rehabilitation or psychological therapy. Crucially,
the combination of cognitive remediation and adjunctive therapy may do
more than the sum of its parts. Cognitive remediation appears to facilitate
an enhanced response for patients with a schizophrenia diagnosis to other
interventions, so that outcomes are significantly boosted or the intervention
duration can be reduced.
HOW DOES COGNITIVE REMEDIATION WORK?
How cognitive remediation works needs to be addressed using two different
questions: (i) How does cognitive improvement occur, and (ii) how are these
cognitive improvements transferred or generalized to other areas of functioning? The studies described in the previous section tell us something about
the second of these: the mechanisms by which cognitive change may affect
other areas of functioning. There is clearly no direct relationship between
cognitive and functional change: If this were to be true, then any cognitive
change would be automatically linked to real-world changes. However, we
know that improvements in cognition known to be linked cross-sectionally
to psychosocial outcomes, are not always followed by the related psychosocial changes, and that this may depend on (i) the type of cognitive change (so
that some cognitive targets might better than others), (ii) the amount of cognitive change (so that cognitive change may need to reach a certain threshold
such as normalized performance in order to impact functional outcomes),
and (iii) the context of cognitive change (so that, for example, it may be only
influential on functional outcomes when occurring within a cognitive remediation program, or embedded within wider rehabilitation, or the person is
very motivated to change).
A few studies have investigated these issues. In terms of types of cognitive change, which appear to be associated with real-world improvements,

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

there is some consistency in the finding that executive function improvement is a frequent specific cognitive predictor of real-world improvement.
Executive functions refer to higher order thinking skills used in processing
novel or goal-directed activities, and include aspects such as strategy use,
organization, planning and self-monitoring. These are all generally targets of
strategy-based cognitive remediation, and so this fits with the suggestion that
strategy-based approaches are needed to facilitate the generalization of learning in cognitive remediation to daily life. They are also closely allied to the
concept of metacognition, which has been suggested as a possible moderator
of the relationship between cognition and social functioning. The suggestion
is that it is only when people are able to understand their own cognitive
strengths and difficulties (metacognitive knowledge) and effectively monitor and regulate their own thinking (metacognitive processing) that they are
able to transfer new cognitive skills to an everyday context. A recent study
by Wykes and colleagues (2012) examined a number of complex models for
the relationship between cognitive change and work outcomes, investigating
the impact of both types and levels of cognitive change. They showed that of
a number of cognitive measures that improved following remediation, only
planning improvement was associated with improved work quality. Those
who had poorer memory and/or better cognitive flexibility were more likely
to make planning improvements.
The issue of the amount of cognitive change that is necessary to achieve
functional change has emerged in a number of studies, but has been little
investigated. In a few studies of cognitive remediation (e.g., by Silverstein &
colleagues, 2005), little or no measurable cognitive change was apparent,
despite functional changes emerging. Thus, the benefits of therapy may have
been mediated through its nonspecific effects on other areas of functioning,
such as self-esteem, or it may be that our traditional tests of cognitive function
are not sensitive enough to detect certain types or minimal levels of cognitive change. On the other hand, some studies, including those by Wykes and
colleagues have shown that only when cognitive change reached a certain
level has a measurable impact on social functioning been observable. Our
understanding of this issue is in its infancy.
The context of cognitive change calls into question what other factors
might be necessary to mediate or moderate a relationship between cognitive
change and functional outcomes. Other factors that have been investigated
so far have included learning potential (or the extent to which someone has
the capacity to learn from experience), social cognition, motivation, cognitive
reserve (or protective cognitive resources derived from experience), and
metacognition (thinking about thinking). Although this research is in the
early stages, there is emerging evidence that motivation and social cognition
may need to be boosted to maximize cognitive improvements are to take

Cognitive Remediation in Schizophrenia

9

place and to be transferred to everyday living. Both these factors are very
frequently reduced or impaired in people with schizophrenia. Motivation
may be a particularly crucial factor to explore further, because massed
practice is so important for cognitive remediation: Patients need to complete
sessions daily over several months. Generally, cognitive remediation programs have either involved a therapist to offer social reinforcement and to
ensure the intervention is tailored to an individual’s needs and goals or they
have offered monetary rewards. Both these methods have cost implications
for the delivery of cognitive remediation, but there are also ethical issues
arising from payment of patients. But the relative merits of either approach
or their effects on either motivation or learning have not been investigated.
Studies have also begun to investigate biological correlates of cognitive
improvement, which offer the potential to identify more sensitively the process of change. Early brain imaging studies showed increased activation following cognitive remediation in areas of the brain known to be frequently
underactive in schizophrenia and associated with cognitive or social cognitive impairment (e.g., the frontal lobe for cognitive function, or recently,
in one study the postcentral gyrus for emotion recognition). More recently,
a study of brain morphology by Eack and colleagues (2010) showed that
2 years of a comprehensive and broad-ranging cognitive remediation program provided to people early in the course of a schizophrenia diagnosis,
provided a neuroprotective effect. People who had received cognitive remediation showed preserved or even increased gray matter compared to those
who had received an enriched supportive therapy. This is consistent with the
proposition that cognitive remediation facilitates neuroplastic changes in the
brain and has led to the suggestion that cognitive remediation may best be
targeted at young people with a diagnosis of schizophrenia, when neuroplasticity potential may be greatest and to protect against future neurobiological
decline.
The application of cognitive remediation to specific subgroups of the
population, such as those early in the course of the disorder, is another
cutting-edge development in the field. Studies of cognitive remediation
with young people, even those at high risk of developing psychosis, rather
than those with established symptoms, are increasing although there are
difficulties in recruitment as individuals who do not yet have a diagnosis
are less engaged with services.
KEY ISSUES FOR FUTURE RESEARCH
A consensus regarding the importance of some elements of cognitive
remediation, including massed practice, strategy-based learning to facilitate
transfer, and enhanced motivation, is beginning to emerge. However, to

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

allow widespread dissemination, we need to optimize effectiveness while
continuing to be cost-effective and this is most likely to be achieved by
generating a unifying model of change. Any such model needs to address
two related questions: (i) How can we optimize cognitive improvement,
and (ii) how can cognitive change best be transferred to everyday life? It
is apparent that there are currently two predominant levels of explanation
emerging in response to these questions, one based on cognitive psychology
and the other on neuroscience. Cognitive levels of explanation for how cognition is improved have tended to refer to the development of new mental
models or “schemas” that may become automatized over time, while the
prevailing neuroscientific explanations emphasize the importance of brain
adaptations or neuroplastic changes to compensate for impaired or declining
processes. Cognitive-level explanations have also primarily been offered
for the transfer process from cognitive learning to everyday living skills,
emphasizing the development of metacognitive or social cognitive strategic
processing to help people learn how to use new or existing cognitive skills
to improve performance across a wide variety of domains. Neuroscience has
suggested that new brain functions may be automatically recruited in new
situations or that there may be an automatic feed-forward of change from
one area of cognitive function to another. Both levels of explanation need
to be developed, and compared or linked, if we are to understand change
more comprehensively.
In relation to understanding the process of change, we need to consider
the role of other factors that may mediate or moderate cognitive change and
its transfer to functional outcomes. In particular, we need to identify patient
and therapy characteristics. Patient characteristics may not only help target
treatments more effectively but also aid our understanding of the intrapersonal processes involved in change. Therapy characteristics will allow us
to identify active ingredients, which can in turn be used to provide insight
into the types of interpersonal, cognitive, or brain processes that may facilitate change. In relation to these, patient characteristics that appear to hold
promise in elucidating change are age and cognitive reserve (measured using
behavioral neuropsychological assessment and brain imaging methods).
One therapy characteristic which still deserves attention is the long-standing
difference between the drill-and-practice versus strategy-based approaches.
It is not clear whether the addition of an optimal strategy-based approach to
drill-and-practice training within cognitive remediation can be sufficient to
promote transfer to daily living skills, whether a strategy focus is necessary
to facilitate transfer for drill-and-practice approaches, or whether some kind
of additional adjunctive therapy is always necessary for generalization to
take place.

Cognitive Remediation in Schizophrenia

11

In addition, with the increasing need to create a cost-effective, easily disseminated version of cognitive remediation, the therapy is being transferred
to computers, minimizing the need for a therapist. What is not clear is the
extent to which a therapist is important in facilitating change and other
related factors, such as engagement and motivation, and how much a patient
can gain from working alone, with or without monetary incentives. In relation to this, and of importance in considering more widespread adoption of
cognitive remediation into clinical services, is the level of training required
for clinicians offering cognitive remediation to therapists and whether this
is best done by psychologists or other mental health professionals.
Finally, one promising area of new research is in the interaction of cognitive
remediation with biological factors such as medication use and genes, which
may enhance response to help us to identify and target groups of people with
a schizophrenia diagnosis who may benefit from different approaches. These
may provide yet another neurobiological level of explanation for the process
of cognitive and concomitant changes. Medication might also allow us to
remove the rate limiter on neuroplastic change, particularly in older clients,
thus allowing for further effects of cognitive remediation as synergistic
treatments.
REFERENCES
Bleuler, E. (1950). Dementia praecox or the group of schizophrenias. New York, NY: International Universities Press.
Bowie, C. R., McGurk, S. R., Mausbach, B., Patterson, T. L., & Harvey, P. D. (2012).
Combined cognitive remediation and functional skills training for schizophrenia:
Effects on cognition, functional competence, and real-world behavior. American
Journal of Psychiatry, 169, 710–718.
Drake, R. J., Day, C. J., Picucci, R., Warburton, J., Larkin, W., Husain, N. … Marshall, M. (2014). A naturalistic, randomized, controlled trial combining cognitive
remediation with cognitive-behavioral therapy after first episode schizophrenia
Psychological Medicine, 44, 1889–1899.
Eack, S. M., Hogarty, G. E., Cho, R. Y., Prasad, K. M., Greenwald, D. P., Hogarty, S.
S., & Keshavan, M. S. (2010). Neuroprotective effects of cognitive enhancement
therapy against gray matter loss in early schizophrenia: Results from a 2-year randomized controlled trial. Archives of General Psychiatry, 67, 674–682.
Kraepelin, E., Huntingdon, N. Y., & Robert, E. (Eds.) (1971). Dementia praecox and
paraphreni. Melbourne, NY: Krieger Publishing Co, Inc.
Kurtz, M. M., & Richardson, C. L. (2012). Social cognitive training for schizophrenia: A metaanalytic investigation of controlled research. Schizophrenia bulletin, 38,
1092–1104.
Silverstein S. M., Hatashita-Wong, M., Solak B. A., Uhlhaas, P., Landa, Y., Wilkniss,
S. M., … Smith, T. E. (2005). Effectiveness of a two-phase cognitive rehabilitation

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EMERGING TRENDS IN THE SOCIAL AND BEHAVIORAL SCIENCES

intervention for severely impaired schizophrenia patients. Psychological Medicine,
35, 829–837.
Wykes, T., Huddy, V., Cellard, C., McGurk, S. R., & Czobor, P. (2011 May). A
meta-analysis of cognitive remediation for schizophrenia: Methodology and effect
sizes. American Journal of Psychiatry, 168(5), 472–85.
Wykes, T., Reeder, C., Huddy, V., Taylor, R., Wood, H., Ghirasim, N., … Landau,
S. (2012). Developing models of how cognitive improvements change functioning: Mediation, moderation and moderated mediation. Schizophrenia Research, 138,
88–93.

FURTHER READING
Eack, S. M., Greenwald, D. P., Hogarty, S. S., Cooley, S. J., DiBarry, A. L., Montrose,
D. M., & Keshavan, M. S. (2009). Cognitive enhancement therapy for early-course
schizophrenia: Effects of a two-year randomized controlled trial. Psychiatric Services, 60(11), 1468–76.
Green, M. F. (1996). What are the functional consequences of neurocognitive deficits
in schizophrenia? American Journal of Psychiatry, 153, 321–330.
Green, M. F., Kern, R. S., Braff, D. L., & Mintz, J. (2000). Neurocognitive deficits
and functional outcome in schizophrenia: Are we measuring the “right stuff”?
Schizophrenia Bulletin, 26, 119–136.
Heinrichs, R. W., & Zakzanis, K. K. (1998). Neurocognitive deficit in schizophrenia:
A quantitative review of the evidence. Neuropsychology, 12, 426–445.
Reeder, C., Smedley, N., Butt, K., Bogner, D., & Wykes, T. (2006). Cognitive predictors of social functioning improvements following cognitive remediation for
schizophrenia. Schizophrenia Bulletin, 32(Suppl. 1), S123–S131.
Wexler, B. E., Anderson, M., Fulbright, R. K., & Gore, J. C. (2000). Preliminary evidence of improved verbal working memory performance and normalization of
task-related frontal lobe activation in schizophrenia following cognitive exercises.
American Journal of Psychiatry, 157(10), 1694–1697.
Wykes, T., Brammer, M., Mellers, J., Bray, P., Reeder, C., Williams, C., & Corner, J.
(2002). Effects on the brain of a psychological treatment: Cognitive remediation
therapy functional magnetic resonance imaging in schizophrenia. British Journal
of Psychiatry, 181(2), 144–152.
Wykes, T., & Reeder, C. (2005). Cognitive remediation therapy for schizophrenia: Theory
and practice. London, England: Brunner Routledge.

CLARE REEDER SHORT BIOGRAPHY
Clare Reeder is a clinical lecturer at the Institute of Psychiatry, King’s College London. She has been involved in cognitive remediation research since
1995 and co-wrote a book with Til Wykes (2005) entitled “Cognitive remediation therapy for schizophrenia: Theory and practice. London: Brunner
Routledge.”

Cognitive Remediation in Schizophrenia

13

TIL WYKES SHORT BIOGRAPHY
Til Wykes is a Professor of Clinical Psychology and Rehabilitation at the Institute of Psychiatry, King’s College London. She has been at the forefront of
cognitive remediation research across the world for many years and has published widely in the area. She was recently awarded the Marie Kessell prize
for outstanding contributions to psychiatric rehabilitation.
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