CLINICAL HANDBOOK OF SCHIZOPHRENIA

256 IV. PSYCHOSOCIAL TREATMENTnance, set manipulation, and delayed response tasks. Finally, planning involves tasks forset formation and manipulation, reasoning, and strategy development. The focus here ison both the development of new and efficient information-processing strategies and practiceof these strategies in new contexts and with different forms of information (e.g., verbaland visual). This emphasizes the generalization from task to task within the trainingprotocol. Tasks are easy but can be adapted to higher functioning participants, so that thetasks require some effortful processing, which is known to be helpful for cognitive training.The randomized controlled trial data show changes with this form of therapy in bothcognition and social functioning. In particular, this form of training has shown improvementsin patients’ memory abilities that were durable 6 months after the end of therapy.MedicationCognitive rehabilitation is also being approached from the viewpoint of medication to restorefunction. Double-blind, randomized controlled trials have shown that there aresmall effects of antipsychotic medication on cognition. More recently, drug therapieshave been developed that specifically target the cognitive system rather than being a sideeffect of current medications for positive symptoms. Although these possible cognitiveenhancers may offer an initial boost to the cognitive system, it seems likely thatpsychosocial rehabilitation will also be required. One metaphor for this is mending a brokenbone. Although it is possible to set the bone in place for it to grow, it is also necessaryto provide some physiotherapy to improve functioning and to develop the bone structurefurther. This is perhaps how cognition-enhancing drugs will be used within the comprehensiveset of rehabilitation techniques that mental health services will offer. Their usewith cognitive rehabilitation techniques will be synergistic rather than a replacement forpsychosocial techniques.A MODEL FOR THERAPYWhat is needed is a theoretical model for therapy development, and currently few exist.As discussed earlier, most theories were provided post hoc and have not been supportedby current data. They are mostly descriptive and give little guidance for the developmentof the most efficacious therapy. Most of the attention has been given to the types of cognitionthat predict poor functioning, with little consideration of what cognitive abilitieswould be required to carry out real-life actions. Clare Reeder and I have considered whatis required for cognition to be transferred into actions. Figure 25.3 shows our model,which contains a new component, metacognition. We categorize actions into those thatare routine (i.e., are specified by cognitive schema as soon as the goal or intention hasbeen defined) and nonroutine (i.e., not completely specified by a cognitive schema). Mostactions are not routine. For example, if I intend to make a meal, I need to decide whatkind of meal I would like to make, to look in a recipe book, to consider what ingredientsare available, and so on. I must reflect upon my intention, my goals, my past experience,and the way in which these interact with the current circumstances to select a certain setof appropriate actions that will allow me to achieve my goal. This ability to reflect uponand regulate one’s own thinking is referred to as metacognition. It is the key to carryingout nonroutine actions successfully. This has profound effects on what we need to includein a cognitive rehabilitation program. Improvements in cognitive processes have a directeffect on routine actions because they improve the efficiency of cognitive schemas. But,