Cognitive Remediation Therapy for Schizophrenia: How It Works, What It Helps, and More

Cognitive impairment is a common but often overlooked symptom of schizophrenia. From difficulties in social settings to remembering how to take the bus to work, decreased cognitive function can significantly impact day-to-day living among people with the condition.

This is often where cognitive remediation therapy comes in, according to Alice Medalia, PhD, a professor of medical psychology at Columbia University Medical Center in New York City, the director at New York State Cognitive Health Services, and the director of the Lieber Recovery Clinic in New York City.

“Cognitive remediation targets the fundamental cognitive processes that underlie thinking — your attention, processing speed, memory, problem-solving, multitasking,” says Dr. Medalia, who has performed research on cognitive dysfunction in schizophrenia and cognitive remediation.

If you or your loved one has schizophrenia, here’s everything you need to know about cognitive remediation therapy, how it works, and how to access this resource.

The therapy originated in the treatment of brain injuries, from concussions and strokes to brain damage from severe car accidents, says George Keepers, MD, a professor of psychiatry at Oregon Health and Science University in Portland, and the lead author of the American Psychiatric Association’s practice guidelines for the treatment of schizophrenia.

Also known as cognitive remediation, cognitive enhancement therapy, or cognitive rehabilitation therapy, it tackles everything from organizational skills and executive functioning to boosting memory and strengthening information processing.

• Strategy Developing mental strategies for completing different tasks
• Drills Practice and repetition of cognitive exercises over many sessions until cognitive performance improves
• Hierarchy Progression in difficulty of exercises from basic to more complex
• Cueing Paying attention to external aids like sound or sight to boost cognitive performance
• Anchoring Linking cognitive exercises to "real world" behaviors
• Integration Pairing cognitive remediation therapy with additional schizophrenia treatments to help get the most out of treatment

• Concentration problems
• Memory issues
• Attention difficulties
• Issues with processing information
• Difficulty with problem-solving
• Difficulty with decision-making

“There are a variety of different ways in which cognitive issues can present themselves in people with schizophrenia,” says the adult and child psychiatrist Christine Crawford, MD, MPH, an assistant professor of psychiatry at Boston University School of Medicine in Massachusetts and an associate medical director at the National Alliance on Mental Illness (NAMI). “They suddenly forget what they were going to say, they could have thought blocking, be somewhat disorganized. It can be hard to engage in the planning that’s needed to get yourself together each day.”

As mentioned earlier, while antipsychotic medications are the gold standard for treating schizophrenia, they only affect positive (or psychotic) symptoms of schizophrenia, such as hallucinations and delusions, says Adrian Preda, MD, a professor of clinical psychiatry at the University of California in Irvine, who performs research on schizophrenia.

“Medications are very effective for positive symptoms, but they don't do much for negative symptoms, and they do close to nothing when it comes to cognitive deficits,” Dr. Preda explains. “We don’t have effective medical intervention for these other symptoms.”

If you or a loved one with schizophrenia is struggling with any of the symptoms listed above, it’s worth asking your mental health provider about cognitive remediation therapy.

“If you have trouble being able to do things you care about, you want to work better, or you're upset because your friends keep telling you you’re forgetting things, we can do something about it,” Medalia says.

• Bipolar disorders
• Depressive disorders
• Anorexia nervosa
• Attention deficit hyperactivity disorder (ADHD)

“Recommendations have the strongest evidence for efficacy based on the literature,” Keepers explains. “The evidence base for suggestions is much less robust, but still adequate for us to include as a particular treatment in the guidelines.”

• Improved attention span and memory
• Better cognition
• Better autonomy to be able to live more independently
• Enhanced communication and psychosocial skills
• Improved executive functioning, spanning from flexible thinking to following directions

“If you look across all the randomized controlled trials that are coming in, you see these small to moderate effects. You can really see nice changes both in cognition and functioning,” Medalia says.

Keepers agrees. “What’s hopeful about it is that engaging in this treatment seems to preserve the brain tissue, which is in the areas of the brain that are concerned with memory and cognitive skills,” he says.

Here’s what you should know before starting cognitive remediation therapy for schizophrenia.

What Is a Cognitive Remediation Therapy Session Like?

Cognitive remediation therapy includes a mixture of computerized games to work on skills like paying attention, retaining memories, and problem-solving, says Medalia. This is followed by group discussion to apply what participants learn in real-world settings.

When Medalia leads cognitive remediation therapy sessions, for example, small groups of four to six participants spend about an hour playing brain-training games on computers. The games can include tasks like dodging obstacles on a busy highway, fitting items into a suitcase, and matching and ordering shapes according to memory.

After that, groups spend another hour discussing strategies that can help make their daily lives easier, says Medalia. This can include using mnemonics to remember grocery lists, moving things around in the home to make it easier to find household items like keys or smartphones, or carrying a notebook and pen around at all times to make note of important things they need to remember.

“We call this a bridging group — it’s a discussion where we’re literally bridging what we’re working on on the computer to everyday life and [creating] strategies to have better memory and response times in everyday life,” she says.

But some CRT programs are completed individually and at home via software programs, Keepers notes.

The brain-training app Lumosity is an example of the types of exercises or drills participants work on repeatedly to bolster their cognitive functioning. Although apps like Lumosity are still being studied and are not a replacement for cognitive remediation therapy with a trained professional, they highlight the need for steady practice of cognitive skills.

How to Find a Cognitive Remediation Therapy Provider

It’s important to note that cognitive remediation therapy is a newer, more niche form of treatment, and as a result, it’s not yet available everywhere.

First, try to see if a mental health professional trained in this therapy is available in your region. It can help to ask your doctor, a local mental health center, or an organization like the National Alliance on Mental Illness for recommendations. Once you locate a professional trained in cognitive remediation therapy, you’ll work together to identify your goals and tailor your weekly training sessions to sharpen your cognitive skills.

Cognitive symptoms are very common and often disabling among people with schizophrenia. Although antipsychotic medication is an important part of schizophrenia treatment, it usually doesn’t improve cognitive symptoms.

Cognitive remediation therapy is currently the best available treatment for improving cognitive symptoms of schizophrenia. Research suggests it may help improve areas like attention and concentration, memory, processing speed, and problem-solving.

“Schizophrenia is a chronic condition, but we can make it such that by engaging in these types of therapies that the functional decline doesn’t have to be as intense and impairing,” Crawford says. “You can engage in therapy in a meaningful way and find strategies and tools that can be used to overcome some of the cognitive challenges people experience.”