7. Picture Puzzles: Part 4, Ratio. Participants receive presented analogy questions where the participant has to determine the ratio or proportional relation of the items. Targeted skills include memory, creativity, and decision-making.
8. Mental Arithmetic: Part 2, Potpourri. Participants receive a hodgepodge of math problems, including number sequences and word problems. Targeted skills include reasoning and computation.
9. Visual/spatial. Participants are presented exercises that require them to think in 3 dimensions and see “hidden” areas behind folds or on the other sides of figures. Targeted skills include spatial perception, reasoning, and decision-making.
10. Reasoning. Participants receive problems that involve taking in information, processing the data, analyzing the options based on previous experiences, and coming up with a decision that is factual and rational. Targeted skills include reasoning and decision-making.
11. Memory Exercise, Listening. Participants are provided a reading selection. After the reading, there is 20-minute waiting period during which the participant is engaged in other exercises before returning to answer questions about the reading. Targeted skills include listening, retention, and memory.
12. Speed Training. Participants receive exercises that provide practice in gathering and processing information and making decisions based on the given information. Targeted skills include decision-making, speed, and concentration.
Preliminary results, optimism about good outcomes
In the past 12 months, 28 participants have completed the CRT program: 11 in the basic training class and 17 in the advanced class. Of those, 7 in the basic program and 11 in the advanced program showed significant improvement as measured by the pre- and post-training RBANS; 64% of the participants improved. The average pre-test score in the basic group was 63 and post-test score was 72 (t10 = 3.148, P < .05). The average advanced pre-test score in the advanced class was 75 and post-test score was 80 (t16 = 2.476, P < .05) (Figure 1).
Because this program was developed as a treatment intervention for psychiatric inpatients, not a research study, we did not establish a control group.
In addition to the overall increase in cognitive functioning, individual successes have been noted. One participant who experienced a psychotic break while pursuing a college degree in literature scored 73 on his initial RBANS, indicating moderate impairment. After completing the 12-week program, his RBANS score increased to 95 (Figure 2). One year after completing the CRT program without additional cognitive training, the participant achieved an RBANS score of 104. Since then, the patient has been observed reading the classics in Latin and Greek, as he did before his psychotic break, and has been noted to be making more eye contact and engaging in conversations.
Success also has been noted for participants who did not see an increase in their RBANS scores. One participant historically had shown little interest in any programming or classes, but attended every CRT class, participated, and asked for additional worksheets to take back to the unit. Based on this feedback, each session now includes a worksheet that participants can take back with them.
Further findings of success
Cognitive impairment can be a significant disability in patients with severe mental illness. Longer lengths of stay present an opportunity to provide a CRT program over 12 weeks. However, some increase in cognitive functioning, as measured by the RBANS, was seen with participants who would not or could not complete all 24 classes. In addition to increased cognitive functioning, clinicians have noted improvements in patients’ participation in treatment and self-esteem.
The program engaged patients who previously were uninvolved in activities, and provided a sense of purpose and hope for them. One participant stated that he felt better about himself and had a more optimistic outlook for the future.
This program offers the possibility for participants to clear the mental fog caused by their illness or medication. The exercises stimulate cognitive activity when the goal is not to get the correct answer, but to think about and talk about possible solutions.
CRT, we have found, can greatly increase the quality of life of people with severe mental illness.