Dealing with multiple cognitive (Mcog) deficits offers the possibility of improving a broader range of outcomes for a larger group of individuals. Both CBTp and CAT attempt to deal with cognitive problems in different ways. CAT uses supports in the environment to bypass formal neurocognitive deficits and cue and sequence functional behaviors.28
CBT seeks to identify and alter emotional processes, information-processing deficits, and reasoning and appraisal biases that contribute to the formation and maintenance of positive symptoms and functional problems.20
The integration of treatment primarily aimed at reducing positive symptoms, and improving insight with another designed-to-cue behavior in the home is a novel multimodal approach that we have called Mcog.29
There are both theoretical and practical reasons to integrate these treatments. On a theoretical level, Frith30
has proposed a neuropsychological model of schizophrenia that may be best addressed by an integrated therapy such as Mcog. According to Frith,30
negative symptoms and associated functional impairments arise from deficits in the mechanisms underlying generation of “willed” action. CAT supports are thought to function as an ancillary frontal lobe system such that intentions-to-perform (agreed upon) actions and the sequence of actions do not need to be generated by the person.28
While there are deficits in “willed” action, the mechanisms underlying stimulus-driven action (actions which are cued by stimuli in the environment) are intact.30
These latter mechanisms are used in CAT to promote desired behavior. Complex behaviors can be accomplished within this system as long as they are appropriately specified by the environment.30
Also, included in Frith's model is the notion that positive symptoms such as delusions and hallucinations arise out of problems in self-monitoring in which the individual is not aware of the sense of effort or intention that accompanies thought or willed action and has difficulties in understanding and monitoring the intentions of others.30
These monitoring deficits lead individuals to view actions and thoughts as arising from outside of themselves and to misrepresent the intentions of others. CBTp addresses these cognitive problems by purposefully engaging with the patient to examine and process emotions, thoughts, and evidence surrounding specific people and events. An integrated Mcog model allows the mechanisms described by Frith30
that maintain the positive and negative symptoms of the disorder and the functional consequences of these symptoms to be addressed.
From a more practical standpoint, both CBTp and CAT are designed to customize treatments to the needs of the individual. CBTp accomplishes this by developing an individual problem list collaboratively with the consumer, developing an individual case formulation regarding how symptoms are formed and maintained, and customizing homework to deal with a specific aspect of the problems identified.20
CAT accomplishes this by assessing cognition, functional skills, overt behavior, and environmental triggers and customizing the environment and supports based upon these dimensions.28
Because these treatments address different aspects of cognitive processing, CAT and CBTp should be complementary.
Based upon the models underlying CAT and CBTp and published data on effect sizes, it follows that here are certain difficulties that may be addressed more rapidly or thoroughly by CBTp or CAT. CAT has few strategies to deal with positive symptoms and poor insight and does not improve these symptoms. CBTp may have more trouble in addressing behavioral deficits, formal neuropsychological deficits, and problems with community functioning, although strategies have been designed within CBTp to address these problems. CAT may get people moving and reinforce increased involvement. CAT may get the individual to engage in behaviors that allow him/her to think about the veracity of his/her delusional thoughts. However, without techniques from CBTp, the processing and integration of these gains to modify self-defeating thoughts or delusional thoughts may not be accomplished. CAT is able to produce change in functional outcomes early, and while this change is maintained during treatment, there is some evidence that improvement in functional outcome may begin to decline following the cessation of home visits.23
With respect to CBTp, there is evidence from a number of studies of sustained changes and even gains being made following the end of treatment.7
The integration of CAT and CBTp could potentially improve effects on symptoms and functional outcomes and allow individuals to maintain more of these gains after treatment.
Moreover, Mcog provides the therapist with specific intervention approaches to address each identified problem depending upon the factors that contribute to the problem (eg, person is not walking outside due to hallucinations that the client is concerned will worsen outside, the delusional thought that people outside are trying to kill the patient, cognitive deficits that cause the individual to become easily lost, apathy that prevents the person from initiating walking although this is a stated goal). Because different individuals may demonstrate the same problematic behavior for different underlying reasons, Mcog treatment is customized to the client's needs. A client who is in denial of having an illness may not be helped to take medication by a psychoeducational approach and supports such as alarms and pill containers but may respond better to CBTp approaches that would allow exploration of the meaning of being labeled as “ill” and understanding the effects of medication from the perspective of the client.20
A client who accepts their need for medication but regularly forgets to take their evening dose of medication leading to an exacerbation in psychosis may be more likely to benefit from an approach using environmental supports to cue medication taking in the evening.23
A client may not take the bus because they are easily lost due to planning and memory deficits. Another client may not be willing to ride the bus because of their notion that people on the bus mean them harm. A third client may have both difficulties. For such clients, the willingness to take the bus can be addressed by guided discovery and homework in CBTp. However, the client may continue to demonstrate the effects of planning and memory problems on difficult routes. These later issues could be addressed utilizing CAT supports. Having both CBTp and CAT at their disposal allows the therapist to respond most effectively to the problem.
There are specific ways in which integration of CAT and CBTp could be accomplished. Homework assignments are regularly assigned in CBTp.31
Mcog therapists could furnish the supplies necessary to do specific assignments and set up cues to increase the likelihood that homework would be completed. For example, an Mcog therapist could provide a diary with a pen attached that would easily fit in a pocket to increase its use in the client's everyday environment. In addition, an Mcog therapist could add “put your voice diary in your pocket” to the patient's reminder list for behaviors to do each morning. Moreover, the Mcog therapist can provide supports to reinforce the work in CBTp. For example, the Mcog therapist could provide a recorder and headphones such that auditory tapes of therapeutic sessions exploring the evidence for delusional beliefs may be utilized in the very situations in which individuals have the greatest trouble coping (eg, riding the bus, standing in line). In addition, some of the work done in CBTp sessions (eg, pie charts for delusional conviction) could be placed by an Mcog therapist and the client on the wall near where the problem beliefs typically occurs (eg, by the television if the client is bothered by messages coming from the television). This may allow a client to hold on to gains made in the session in the settings that are most difficult. An Mcog therapist could discuss feelings and thoughts associated with environmental supports and their effects on behavior. This may allow processing of self-defeating attitudes that get in the way of functioning. While it is possible that opportunities for functioning provided in CAT alone may reduce distress surrounding delusions without utilizing CBT to process these issues, it is possible that many individuals with schizophrenia would have trouble integrating the new information in a manner that changes behavior in the longer term. By processing behavioral changes and their impact on the individual, it is possible that treatment gains may be better able to be maintained.
With respect to resources, CAT is a comprehensive in-home treatment. CBT has also previously been conducted on home visits.32,33
It is possible that combining CAT with CBT into one in-home treatment would allow a broader focused therapy without greatly increasing economic burden. Of course, this depends upon the specific level of training of therapist performing treatment. Duration of Mcog sessions might be longer (10–15 min) than either CBTp or CAT sessions alone to allow time to follow the structure of a traditional CBTp session, review and suggest homework, and train and establish supports. However, travel time to and from the individual's home and reimbursement for travel expenses would be the same. Particularly, for those with negative symptoms, cognitive deficits, and poverty who may find frequent visits to clinic burdensome, home visits may make therapy more regularly available. In addition, for individuals with more ambivalence, home visits may be initially able to promote engagement in therapy that would not have been possible if the client had to come into clinic to receive intervention.