Flipping treatment on its head: research supports strengths-based approach to cognition in first epi

Flipping treatment on its head: research supports strengths-based approach to cognition in first episode psychosis

26 August 2020

Traditional behavioural treatment for cognition in first episode psychosis could be flipped on its head, Orygen researchers have concluded in a paper that supports a strengths-based approach to therapy for cognitive functioning.

The paper, published in Clinical Psychology Review, proposes that taking a strengths-based approach may enhance wellbeing and recovery, and be more acceptable to young people than established behavioural treatments, which focus on improving areas of cognitive weakness.

Lead author, Orygen’s Associate Professor Kelly Allott, said the paper recognised the evidence for established practices but said that a more positive approach could be more engaging and effective.

“We wanted to flip it on its head and say ‘Can we do more? Can we look at this in a different way? Is there another way of addressing cognition that's more strengths-focused rather than deficit-focused?’” Associate Professor Allott said.

“We wanted to see if there was a way that would help the young person identify their strengths and use those strengths to achieve their goals, develop hope and positive identity formation.”

Cognition refers to thinking skills such as judgement, reasoning and memory. Cognition allows people to function and make sense of the world, to plan and execute tasks, and to communicate with others.(1,2)

Treating cognition is important in first episode psychosis because cognitive impairments are some of the first signs of psychotic illness, and cognitive difficulties have a big impact on work, study and social outcomes for young people.

“In first episode psychosis, cognitive impairment can manifest in a range of ways – from poor concentration and poor memory, to how quickly people can think – and in terms of what we call higher order cognitive functions – things like planning, organisation, problem-solving and being able to think flexibly,” Associate Professor Allott said.

There are two types of treatment for cognition in psychosis: behavioural treatments and pharmacological treatments (medicine), although research shows that pharmacological treatments are not particularly effective and may even worsen cognition.(3,4)

The most studied behavioural treatment is an approach called cognitive remediation.

“Cognitive remediation often involves practicing drills, usually computerised drills, where you're engaging with a computer or some kind of app to improve your cognitive performance,” Associate Professor Allott said.

“It's a highly intensive intervention – it usually requires two to three hours of training a week – and there is evidence that young people don’t engage with these interventions particularly well, which means they drop out of treatment or they don't start it in the first place.

“There is some research to suggest that, for some people, cognitive remediation might actually make them feel worse about themselves because there is a focus on deficits or what they’re not doing so well.”

The paper proposed working with young people and others to develop a cognitive strengths-based behavioural treatment that draws on positive psychology and self-determination theory.

“First we need to define what we mean by cognitive strengths – by conducting qualitative interviews with young people, clinicians and experts in the field – as well as more quantitative research where we might conduct surveys,” Associate Professor Allott said.

“The next step would be to validate – to explore whether the cognitive strengths that have been identified in the interviews and literature do actually have a flow-on effect to education, employment, and physical health outcomes.

“And then we would develop and trial specific treatments or interventions.”

Associate Professor Allott hoped this approach to further research would help to deliver a treatment that young people wanted to engage with.

“The development of treatment should be done, as much as possible, with service users themselves so that we're building something that's relevant to young people, that's meaningful to them, and that they’re more likely to engage with,” Associate Professor Allott said.

Associate Professor Allott receives funding from a Dame Kate Campbell Fellowship from The University of Melbourne, and funding from a National Health and Medical Research Council (NHMRC) Career Development Fellowship (APP1141207).

Orygen co-author Mario Alvarez-Jimenez was supported by an Investigator Grant (APP1177235) from the NHMRC.

The NHMRC had no role in the concept or writing of the manuscript, or the decision to submit the paper for publication.

  1. Unsworth C. Cognitive and perceptual dysfunction: a clinical reasoning approach to evaluation and intervention. F. A. Davis Company; 1999.
  2. Allott K. Staging of cognition in psychiatric illness. UK: Cambridge United Press; 2019.
  3. Keefe R, Bilder R, Davis S, Harvey P, Palmer B, Gold J. Neurocognitive effects of antipsychotic medications in patients with chronic schizophrenia in the CA TIE Trial. Archives of General Psychiatry. 2007 64(6), 633-M7.
  4. Kim E, Howes O, Turkheimer F, Kim B, Jeong J, Kim J ... Kwon J. The relationship between antipsychotic D2 occupancy and change in frontal metabolism and working memory: a dual [(ll)C]raclopride and [(18) F]FDG imaging study with aripiprazole. Psychopharmacology. 2013. 227(2), 221-229.
  5. Cognitive Remediation Experts Working Group. How is cognitive remediation training perceived by people with schizophrenia? A qualitative stud