Cognitive remediation grooms the brain in steps needed to meet goals
It can help mentally ill people develop order in their lives and problem-solve
The treatment has been around for 20 years but only now is gaining wider acceptance
Mental illness is "something you can live well with," one former patient says
During a chance meeting five years ago at Boston’s airport, Cheryl Gagne mentioned to a former psychiatrist of hers that she was bound for an Australian conference to deliver a keynote speech on mental illness recovery.
Confounded, the physician merely stared at Gagne. Probably, said Gagne, the doctor was recalling her former patient’s years of being psychologically crippled by alternate diagnoses of borderline personality disorder and bipolar disorder, and a succession of hospitalizations.
“Oh, the look on her face. I was poised and well put together. She couldn’t figure out whether I was having an episode or telling the truth,” Gagne recalled.
Bucking widely held expectations that the mentally ill are destined to lifelong dysfunction, Gagne, 52, has been thriving for many years. Her path to what she and others call recovery has relied on cognitive remediation, a roughly 20-year-old therapy that, its adherents say, is gaining wider acceptance.
Premised on the notion that routines help many with mental illness develop order in their everyday lives and succeed in their pursuits, cognitive remediation grooms the brain in the steps needed to meet such goals.
Boston University neuropsychologist Susan McGurk gives an example of how it works: A severely mentally ill person undertakes three to four months of thrice-weekly sessions using special software with repetitive exercises.
Those exercises may be aimed at helping him or her develop productive day-to-day routines; be better organized; pay better attention to directions; problem-solve with greater speed, accuracy and regularity; and so forth.
“Maybe they start out learning a shopping list of six items,” McGurk said. “And if they cannot remember all six items at first, we evaluate how they encode that list of things. What can they remember and not remember?”
Cognitive skills, she added, are not a gauge of a mentally ill person’s intellectual ability. When memorization isn’t sufficient, a mentally ill client is coached on writing down information he or she doesn’t readily retain.
“Trying to remember some instruction your boss gives by repeating it over and over again on your way back to your desk is not an effective tool in the workplace,” McGurk said. “We’re teaching people how to recognize what they should do before they’re in over their heads.”
In 2010, The Bridge New York, which provides mental health rehabilitation services, converted its outpatient program to a cognitive remediation model. That’s partly because the New York State Office of Mental Health, a main funder for The Bridge, began demanding that such programs seek to move many mental health clients into the social and economic mainstream, agency social worker Daniella Labate said.
“The aim is not to have people sitting around in a room doing nothing for the rest of their lives,” said Labate, who coordinates the agency’s cognitive remediation programs.
Cognitive remediation – not to be confused with cognitive behavioral therapy – first helped to treat schizophrenia and schizoaffective disorder. Increasingly, it’s being tested on those with depression, autism, anorexia nervosa, attention-deficit hyperactivity disorder and other conditions, said Alice Medalia, director of psychiatric rehabilitation at Columbia University Medical Center.
Nevertheless, even as some with mental illness who’ve benefited from cognitive remediation consider themselves recovered, experts add that recovery is a fluid notion. Also, cognitive remediation is not a guaranteed fix for everyone.
“Some would say recovery means you don’t have an illness at all anymore,” Medalia said. “Others will say it means managing your illness so that you live a gratifying life. … ‘Recovery’ means people are able to negotiate functional everyday tasks that are meaningful to them after their cognitive functioning has gotten better.”
Michele Ponist, 57, diagnosed with bipolar disorder and a client at The Bridge New York since 2007, has been doing cognitive remediation since 2011.
In one of two computer labs in the agency’s offices on Manhattan’s Upper West Side, Ponist recently showed her skill at computerized cognitive remediation drills with names such as “Brain Bender,” “Fripple House” and “Factory Deluxe.”
The drills approximate scavenger hunts and puzzles. They involve precise grouping of identical items such as “Fripple House’s” animated characters and graphics outlining work flow. The drills’ level of difficulty increases as clients get more and more correct answers.
Ponsit credits those drills and other cognitive remediation strategies for helping turn her life around. After more than a decade of not being employed, she spent a year in a $9-an-hour state-funded position as a peer counselor to clients in a separate residential program run by The Bridge.
Last month, funding for the program ran out. But Ponist is on target, social worker Labate said, to land her dream job of working in a corporate mailroom. Ponist has done similar work for The Bridge, which partners with companies willing to employ people with mental illness.
“I’m running into the higher-ups. I’m hobnobbing with them, giving them the mail and loving it,” Ponist said. “I accomplished that here at The Bridge. I know I can do that outside The Bridge.”
She added, “We discuss during group session what we’re learning through cognitive remediation and how what we’re learning applies to all areas of our daily lives.
“Maybe someone wants to date and doesn’t know how to do that. Well, it takes planning. You’ve got to have clean clothes; you’ve got to wash those clothes; you’ll need change for the laundromat. Cognitive remediation develops different skills, ones that involve memory, multitasking, organizing.”
For a population angling to be perceived as normal as possible, given what they struggle with mentally, hope is key, experts said.
“The no-hope message is the old paradigm, ” said Harvard’s Dr. Dost Ongur, a psychiatrist and clinical director of the schizophrenia and bipolar disorder programs at McLean Hospital in Boston. “… There’s a growing recognition of all the dynamic changes that take place in the brain, which shrinks in the early years of a psychotic disorder. What’s also being discovered is that positive interventions reverse that brain shrinkage.”
Indeed, cognitive remediation has been shown to reshape the brains of some mentally ill people positively, said Medalia, lead organizer of an annual conference on cognitive remediation in psychiatry in New York, hosted this month.
In 1998, many of her colleagues dismissed the merits of her first randomized controlled trial on the subject, said Medalia, who is also director of Columbia’s Lieber Recovery and Rehabilitation Clinic for Psychotic Disorders.
“The prevailing attitude was that people with schizophrenia couldn’t change … (or) anyone with brain disease,” she said
Just as those beliefs are being debunked, so, too, are many people’s views on mental illness, which “has to be looked at like other chronic diseases,” said Gagne, deputy project director at the Center for Social Innovation, a Boston organization that helps the mentally ill get access to appropriate social and health services.
“Some diabetics respond well to insulin, some don’t,” she said. “Some need to try out different medications. Some die very young of diabetes. The point, in terms of mental illness, is that it’s no longer enough to merely be focused on reducing the obvious symptoms. There also has to be a lot of focus around a person’s hopes and dreams and goals. It’s about helping people see that this illness is something you have. It also is something that you can live well with.”