IntroductionPeople with chronic and severe psychiatric disorders such as schizophrenia experience cognitive deficits that affect their ability to function in their daily lives. These deficits are often present prior to onset of psychosis; are not ameliorated by psychiatric medication; and frequently persist even when other symptoms of the disorder have remitted (Kern & Horan, 2010). They are specifically linked to poor overall recovery (Revheim et al., 2006) and have a negative impact on real world functioning (Green et al., 2004). Given the disabling effect of cognitive impairment there is a need to identify effective interventions that can promote recovery and improve quality of life. In order to attain optimal functional recovery, the cognitive deficits associated with severe mental disorder must be addressed and this has resulted in cognitive rehabilitation therapies gaining importance, (Wykes and Spaulding 2011). There have been various meta-analyses of published CRT trials and evidence is building for the effectiveness of CRT in improving cognition for people with chronic and severe psychiatric disorders (e.g. Wykes et al., 2011). Evidence from one recent meta-analysis indicates that: for CRT to be effective it must be embedded within community-based psychosocial interventions, Wykes et al. (2011).

EMPLOY your MIND:Making Cognitive Remediation Therapy (CRT) work for people with complex psychiatric disorders

Laura Walton, Clinical Psychologist, NHS Fife; Gordon Mitchell, Consultant Clinical Psychologist NHS Fife; Craig Wilson, Assistant Psychologist NHS Fife;Norma Clark, AHP Clinical Service Manager Mental Health, NHS Fife; Inga Davidson, Occupational Therapist, FEAT; Vincent Rowantree, Occupational Therapist, NHS Fife;

Duncan Mitchell, General Manager, FEAT; Graham Maxwell, Assistant Manager, FEAT;Wendy Barbour, Pam Bruce, Liz Gibson, Diane Florence: Learning Coaches, FEAT.

explore educateshare know Relationships

OccupationWellbeing

Creativity

EVIDENCE BASE

A recent metanalysis of published trials including over 2000 participants reports that CRT

demonstrates durable, small to moderate, effects on global cognition and functioning,

(Wykes et al 2011).

CRT has been shown to be more effective when embedded within a broader psychiatric

rehabilitation service, (Wykes et al 2011)

A recent RCT has found that generalization of cognitive improvements to functional competency in everyday life is enhanced by combining CRT

with skills training,(Bowie et al 2012).

A two year RCT of Cognitive Enhancement Therapy (CET) for 121 people with chronic

schizophrenia found significant improvements in cognition at 12 months; and improvements in

cognitive style, social cognition and social adjustment in addition to continued improvement in cognition at 24 months. The study indicated that

functional improvement occurs after longer periods of cognitive remediation,

(Hogarty, Greenwald and Eack, 2006).

Consumer led research has highlighted the need for participants to perceive ongoing beneficial

effects during actual CRT in order to gain eventual improvements in cognition,

(Rose et al 2008).

88%

8%4%

Attended

Not Attended(planned)

Not Attended(unplanned)

Taking from the evidence base…

length of course community based

enhancing motivationembedded in psychosocial intervention

evidenced CRT interventions

Giving to the evidence base …

involvement context for learning

positive social interaction ehealthgeneralisability of CRT person-centred safety focus ( “risk assessment”)

Clinical Research in CRTA protocol development group, funded by the Scottish Mental Health Research Network, has been set up to explore mutual research interests in CRT. Over an 18 month period clinicians and researchers in this field will be meeting to develop research aims and design worthwhile studies of CRT in practice. The SMHRN will contribute to the costs of such meetings and provide advice and support in terms of relevant literature reviews, research design and statistical analyses.

Progress to date…Seven students, all inpatients with chronic psychiatric conditions, have completed the first phase of the project, of these five have completed the second phase (two will be given the option to continue in a later cohort). Those five are currently enrolled in phase three. All five have been travelling independently from the hospital to the FEAT premises by public transport. They have all completed Bronze Paths for walking certificates; they have completed and shared personal projects and are working towards SQA Steps to Work Level 3. Overall they have demonstrated improvement in COPM scores. The attendance rates for cohort one, phase two are presented in figure 3 (attendance rates for phase one are not applicable due to the high degree of flexibility offered). Informal feedback from Employ your Mind students and staff; nursing, OT and psychology has been positive. The first cohort have described the course as: “uplifting”, “enjoyable”, “challenging”, “rewarding”, “productive”, “interesting” and “well organised”. One hundred percent of students would recommend Employ your Mind.

ReferencesBowie, C., McGurk, S., Mausbach, B., Patterson, T. & Harvey, D., (2012). Combined Cognitive Remediation and Functional Skills Training for Schizophrenia: Effects on Cognition, Functional Competence and Real-World behaviour. American Journal of Psychiatry 169, 710-718 . Green , M., Kern R. & Heaton, R. (2004). Longitudinal studies of cognition and functional outcome in schizophrenia: implications for MATRICS. Schizophrenia Research 72, 41-51.Hogarty, G.E., Greenwald, D.P. and Eack, S.M., (2006). Durability and mechanism of effects of cognitive enhancement therapy. Psychiatric Services, 57, 1751 -1757 http://ps.psychiatryonline.org/article.aspx?articleid=97409 Kern, R.S. & Horan, W.P., (2010). Definition and measurement of neurocognition and social cognition. In Roder, V, & Medalia, A. (eds). Neurocognition and social cognition in schizophrenia patients. Basic concepts and treatment. Basel: Karger.Medalia A, Freilich B., (2008). The NEAR Model: practice principles and outcome studies. Am. Journal of Psychiatric Rehabilitation, 11, 123–143. Revheim, N., Schecter, I., Kim, D., Silipo, G., Allingham, B. et al., (2006). Neurocognitive and symptom correlates of everyday living skills in schizophrenia. Schizophrenia Research, 83, 237-245.Rose, D., Wykes, T., Farrer, D., Doran. A. M. & Sporli, T., (2008). What do clients think of cognitive remediation therapy: a consumer-led investigation of satisfaction and side effects. American Journal of Psychiatric Rehabilitation, 11, 181-204 Wykes, T., Huddy, V., Cellard, C., McGurk, S.R. & Czobar, P., (2011). A meta-analysis of cognitive remediation for schizophrenia. American Journal of Psychiatry, 168, 472-485.Wykes, T. & Spaulding, W.D., (2011). Thinking about the future of Cognitive Remediation Therapy – what works and what could we do better? Schizophrenia Bulletin, 37, S80-S90.

eHealth The authors are currently developing a website* which, it is intended, will provide an online host for Employ your Mind. Students will register for a private user account which they will access to record a personal log of their progress, issues, problems and can include uploading of files and commentary from support staff. The ability to download e-documentation from both CRT and tutored provision to a range of computer devises (PCs, laptops and mobile phones) also allows students to review and develop their work.

*The Learning Arcade under development at http://theallotment.eu/arcade/

Figure 1. The four phases of Employ your Mind

Figure 2: Values based action (“the ripple”)

Figure 3: Attendance rates: cohort one; phase two.

Flexibility Interaction Employability Reflection

Engagement Communication Self-management Planning

Assessment Learning SQA module Occupation

Values-based livingCRT is incorporated into a broader agenda of working with the students personal values: drawing on Acceptance and Commitment Therapy (ACT). Cognitive impairment and the impact it has on function can often be an obstacle to valued living. “The Ripple” (figure 2) is a graphic metaphor used to: help the students to identify their values (e.g. enjoying music, caring for others); describe values in the context of areas of their lives (e.g. relationships); and decide how engaged they are with each value at present, i.e. stuck in the centre of the ripple, not able to do activities associated with that value, or moving outwards and therefore acting in a way that is consistent with their own values. The Ripple is referred back to throughout the course and forms the basis for enhanced motivation and engagement in CRT.Cognitive Remediation Therapy in Employ your Mind

The CRT programme is a interdisciplinary approach between Clinical Psychology, Occupational Therapy, Nursing and FEAT’s “Learning Coaches”. The remediation approach used in this project is based on the Neuropsychological Educational Approach to Rehabilitation (NEAR) (Medalia & Freilich, 2008). The model includes computer-assisted learning and group treatment. The educational emphasis maximises intrinsic motivation and works on a hierarchy of cognitive domains, such as attention, memory, information processing and social interaction before more complex skills such as problem-solving are addressed. The CRT element of Employ Your Mind will therefore enable specific individual issues to be addressed by the multidisciplinary team. This enables the programme to be client-centred and enable the staff team to cope with a variety of clients with differing requirements and at different stages of recovery.

Employ your MindNHS Fife PIP Service and Occupational Therapy have collaborated with Fife Employment Access Trust (FEAT), a local third-sector mental health employment service, to successfully gain five year funding from the Big Lottery Fund to develop a CRT project integrated within a wider psychosocial rehabilitation framework: Employ your Mind. The aim of the project is to offer access to employment support to people with chronic psychiatric disorders, including people with long-term inpatient admissions. Existing employment support does not meet the needs of people with such problems. Employ your Mind fills this gap by supporting people to engage in the activities that interest them and move towards voluntary and paid employment.

The Employ Your Mind course is developed around its students. The course includes four, six week phases: Explore your Mind; Share your Mind; Educate your Mind; and Know you Mind (see figure 1). The course begins in hospital, and gradually moves out to a community setting. Preparing participants to access the community resources is part of the course. The course includes: direct support from Occupational Therapy and Psychology; Cognitive Remediation Therapy; employment training; work placements and support to access voluntary work or education. Participants are also be offered the opportunity to complete an SQA approved qualification within the course.

Project Aims

improve neuropsychological processes and functional outcomeprovide a positive learning experiencepromote independent learning skills

promote a positive attitude about learningincrease awareness about learning style, strengths and weaknessespromote a sense of competence and confidence in skill acquisition

increase awareness of social-emotional context of cognitive functionpromote optimal cognitive functioning in different social contexts