CLINICAL HANDBOOK OF SCHIZOPHRENIA

25. Cognitive Rehabilitation 257these same improvements may not have an effect on nonroutine actions becausemetacognitive skills are also needed. To ensure improvement in nonroutine actions,metacognition, as well as cognition, must be a target.To target metacognition one needs to include opportunities for the participant to reflecton current goals, strategies, and rewards. This means that one should not provide acognitive strategy as if it were a precise number of steps. Patients need to understand thepositive value of effortful processing, to be encouraged to modify and personalize a generalheuristic, and to be given opportunities and incentives. General problem-solvingschemas must lead to the development of broad cognitive schemas that may be used in avariety of settings. The therapist must allow reflection and teach different approaches explicitly,because they may not arise by chance and just mentioning them (as may happenin a computer program) is not always effective. It seems likely that a dependence on practicedoes capitalize on chance learning, and this is not the most efficient method of improvingmetacognition. Participants should be encouraged to articulate their cognitiveand motivational processes during learning and problem solving, because this promotesmetacognitive processing and knowledge.Another added factor in the model is the notion of transfer, which is not a new concept,but it has been recently defined as the ability to use knowledge, experience, motivations,and skills in a new situation. The role of CRT is to train for this essential transfer, iffunctioning is to improve. A focus on specific task-related routines does not facilitatetransfer, and a huge number of routines suited to every occasion need to be taught individuallyif cognitive rehabilitation is to lead to everyday behavior improvements. The developmentof broad, generic schemas has the most utility and may be facilitated by theuse of multimedia learning environments and by helping people to connect verbal explanationsto visual representations.In summary, our model of cognitive rehabilitation should include instruction, notmentioning; the flexible use of a range of strategies, not ritualistic adherence to specificstrategies in a rigid manner; and the development of broad, generic schemas, not behavioralroutines that are not easily transferable between situations.A CLINICAL MODEL OF CRTCRT aims to provide the participant with a comprehensive cognitive structure to reducestimulus overload and facilitate efficient cognitive processing. A detailed description ofthe process of therapy is given in Wykes and Reeder (2005). The current therapy involvespaper-and-pencil tasks that help people to consider thinking strategically and to approachtasks in the most efficient way. The three parts of the manual stress engagement of cognitiveflexibility, memory, and planning. The tasks are initially very simple and graduallyincrease in difficulty to ensure that information-processing strategies can be developedand then practiced. Within the therapeutic session, the responsibility for providing a cognitivestructure at first lies with the therapist, but it is gradually surrendered to the participantas his or her skills improve. It is possible that this is where computerized therapymay fit, in the secondary part of therapy, when the engagement and strategic processeshave been instantiated. Teaching people to adapt flexibly and efficiently to novel situationsis achieved through provision of different sorts of tasks that use similar sets of strategicskills. These skills then are not context-bound but allow for the development of anew style of thinking that can be used in all aspects of the participant’s life.Finally, and most important for transfer, through therapist prompts and discussionsabout their use, we emphasize how the skills might be used in the real world. These trans-