CLINICAL HANDBOOK OF SCHIZOPHRENIA

25. Cognitive Rehabilitation 255apy. Initially the therapist provides two patient partners with experience of computer presentationsof tasks involving attention or memory skills. The therapist, as well as patientpartners, help to guide the use of the computer, providing positive reinforcement and suggestionsabout ways to approach the tasks. In addition, participants also attend groups inwhich they present and discuss information on how they might solve individual social orwork problems. After 3 months of computer training, participants also enter largergroups of six to eight people. The group program takes an additional 6 months and comprisesexercises that focus on “gistful” interpretations of information, such as summingup an article in a newspaper to another person. Unlike most treatment programs for inpatients,this program is aimed at higher functioning patients (i.e., “stable outpatients”).The evaluations of cognitive enhancement and a similar program specific to supportedemployment both indicated positive effects for cognition and specific functioningoutcomes, such as number of hours worked. What this type of training offers is an immediatetransfer of training into the functioning domain, which is likely to increase the generalizationof cognitive improvements from the specific cognitive rehabilitation therapy(CRT) part of the program (Hogarty et al., 2004).Educational and Remediation Software ProgramsTwo types of software have been used in computer presentations: (1) that designed totreat head injury and (2) educational software that is easily available and designed to beengaging. Both sets of programs are based on models of practice, and individuals progressthrough the various levels of the program. Currently there is no specific theoreticalguidance on the presentation or inclusion of particular tasks. Rather they are chosen fortheir face validity, their appeal (in the case of educational software) and their comprehensiveness,in terms of the underlying skills required. Software designed for educational usehas not only been tested for its efficacy but it also provides the opportunity to controltask levels and to introduce complex problem-solving and concept formation tasks. Thetasks have some ecological validity, although, of course, much of the presentation can betoo child oriented.Computerized training has shown mixed effects, with some studies showing generalizationand durability and others showing no between-group effects and no differentialimprovement compared to other types of cognitive skills therapy. The effects on functioningare also mixed. The difficulty with the use of this therapy is that it is quite possible forthe therapist to be involved and have high levels of contact, or for the participant to interactonly with the computer. Higher levels of initial contact with a therapist may beresponsible for cognitive improvement, because the therapist can respond with sensitivityand flexibility to the strengths and difficulties of the participant. There is little currentevidence on the efficacy of computer- versus therapist-driven therapy, because most programsstudied have included supervision from a clinical specialist. It seems likely thatsuch a person will be necessary, at least until a computer can suggest that a break and acup of tea are needed.Executive Skills TrainingSeveral programs have been developed in this area, but the best-known one, initially designedin Australia, comprises three modules: cognitive flexibility, memory, and planning.Each of the 40 or so hour-long sessions contain different paper-and-pencil tasks, all ofwhich had relevance to specific cognitive processing problems. The cognitive flexibilitymodule includes a range of tasks that required engagement, disengagement, and reengagementof various cognitive information sets. Memory is targeted by a range of set mainte-