The aim of this study was to assess the efficacy of Goal Management Training on the organization of ADL in a person with schizophrenia who had difficulties with these activities. During the rehabilitation program, G. O. showed clear progress in his ability to apply the GM in an autonomous manner. Results from the cognitive assessment revealed improvements in planning and verbal automatic response inhibition. The efficacy of the intervention was also demonstrated based on specific gains obtained on the trained laboratory proofreading task and the trained meal preparation activity. Furthermore, generalization of the GMT effects was observed on both the nontrained laboratory (grouping) and nontrained everyday (meeting preparation) tasks. Finally, G. O. reported an improvement in self-esteem following the rehabilitation.
Cognitive assessment showed that GMT had a beneficial effect on two planning tasks and an inhibition task. On the Tower of London (TOL), a task that assesses the capacity to analyze and elaborate possible solutions to a new problem, a decrease of the subsequent execution time, and the number of the moves to reach the solution were observed. These results could be explained by a more fully formed plan, which resulted in improved accuracy. On the 6 Elements Test, G. O. had to attempt to do 6 simple subtasks within a limited time period, while at the same time respecting a number of rules. The goal was to apply an effective strategy, that is, engage in time management throughout the 6 subtasks and initiate task switching in order to complete the first items. After the rehabilitation, G. O. was able to organize the rules in order to perform all the subtasks efficiently. Finally, on the Hayling test, which assesses the ability to inhibit a strongly cued automatic response and to find an unrelated one, the number of errors greatly decreased. Before the rehabilitation, the observed deficit of response suppression could be due to the persisting use of routine semantic schema and a decrease in strategy use [33
]. This observation could also be related to G. O.'s poor performance on the TOL at prerehabilitation where he showed an inability to inhibit an inappropriate move that was very strongly triggered by the context [34
]. Thus, these results suggest that GMT improved G. O.'s ability to inhibit schemas induced by the context. Finally, the score on the errand test was impaired after rehabilitation. This may be due to the fact that, for this task, it was too difficult for G. O. to keep all the instructions in mind (i.e., make a plan and identify alternatives approaches).
Regarding the everyday paper-and-pencil tasks, proofreading and grouping, improved performance on these tasks were also associated with GMT. Indeed, G. O. read the instructions and performed the tasks more slowly and made fewer omissions. These results could indicate that GMT increased G. O.'s care and attention to the tasks, which in turn reduced errors. These results replicate those observed in Levine et al. [16
], furthermore suggesting the specificity of the effects of GMT on these tasks. The beneficial effect was observed on the task (proofreading) that was incorporated into training, as well as on the task (grouping) that was not specifically addressed by the intervention. This result indicates that there was a generalization of the training effects to the laboratory tasks. On the contrary, no change was observed on the room layout task that was incorporated into training. Here, G. O. expressed difficulties in listing the substeps in order to formulate a plan.
Beneficial effects of GMT were also demonstrated qualitatively and quantitatively on two ADL assessed in a real setting: meal preparation and meeting preparation. A considerable decrease of errors (omission, addition, and inversionsubstitution) was observed, and G. O. was less dependent on the examiners. Moreover, the analysis of errors provided evidence of the different mechanisms underlying the GMT effects. First, the reduction of context neglect errors and the more frequent consultation of the instructions and rules indicated that G. O. took the contextual information more into account. This could indicate that there was an improvement in his ability to analyze and deal with the environment, the first step of problem resolution [23
]. This step has been compensated by GM strategy, which taught G. O. to direct his attention toward pertinent information and inhibit inappropriate responses. A less redundant consultation of the recipe in the meal preparation task and of the guest list in the meeting preparation task might also suggest that G. O. was able to better structure his interaction with information. Additionally, this context information processing enabled G. O. to revise an initial plan in the face of the external contingencies. For instance, in the meeting preparation task, G. O. removed the name card and material of the guest who withdrew from the meeting. Second, G. O. demonstrated that he was able to monitor ongoing actions, for instance in the meal preparation task where he controlled the cooking time of cake. Third, G. O. often used the checking step of GM strategy, allowing him to reduce the number of errors. This was particularly clear during the meeting preparation task, where he checked and monitored his actions very actively by reading the rules and by orally reciting them. Finally, he spontaneously made commentaries about actions that he was doing or that he had to do, which could be a sign of organization and verbal self-regulation [35
On the whole, these findings suggest specific effects of GMT on targeted processes: context information processing, ongoing response monitoring, checking, and verbal self-regulation. It is unlikely that these effects are due to mere practice on the tasks without having learned a specific strategy [13
]. Moreover, on the control task that involved divided attention, the pattern of performance remained impaired indicating no general effect of GMT. The absence of improvement on different cognitive functions (flexibility, and attentional functions) that were impaired at prerehabilitation also demonstrates the specificity of GMT in our study.
Generalization of GMT effects to other real-life contexts was manifested as improvement was observed on the meeting preparation task, a task that was not targeted during the cognitive rehabilitation program. Several issues can account for this effect. GMT is conceived as a top-down strategy, which can engage different behaviors and be applied to various contexts that need plan formulation. Moreover, generalization of learnt strategies was built into the intervention. Indeed, G. O. learnt how to apply GMT in contexts other than the target activity (i.e., meal preparation), such as domestic chores and different situations as illustrated in homework exercises. Finally, psychoeducation given before the training was very important in order for G. O. to become aware of the cognitive mechanisms involved in various ADL.
G. O.'s self-esteem also improved after the intervention. For instance, before the rehabilitation, G. O. expressed lack of self-confidence about the completion of ADL. The implementation of the GM strategy in his daily-life enabled him to directly improve his self-confidence. On the contrary, results regarding clinical symptoms (the latter were not severe to begin with) did not show any significant improvement after the rehabilitation.
One key factor in the success of GMT was no doubt related to G. O.'s high level of motivation throughout the rehabilitation program (based on comments made by G. O. and the fact that he attended all the sessions). Motivation and rehabilitation engagement were in part promoted through the personalization of the rehabilitation goal and material, training of ADL, and verbal encouragement from the therapist. Indeed, according to Medalia et al. [5
], intrinsic motivation (desire to engage in an activity because it is inherently interesting and engaging) is an essential factor to consider as in a learning environment it could be associated with greater learning, higher self-esteem and a sense of well-being, and greater engagement.
Some negative results following the application of GMT on the ADL deserve further comment. First, the beneficial effects of the GMT did not generalize to the washing activity. This might be related to the fact that this task was familiar to G. O. Indeed, he washed clothes once a week and he was used to doing it without sorting out according to temperature and color of clothes. This routine action relied thus on schema that specified in detail how the behavior should be carried out. In order to improve or change the behavior, G. O. had to reject the existing schema and create a new schema [23
]. Limited impact of GMT on the washing task could be explained by G. O.'s difficulty in inhibiting the routine schema. It might be more difficult to spontaneously transfer training effects to routine actions, in contrast to new and nonroutine actions (such as the meeting preparation task), as new skills can be more easily and quickly incorporated [38
]. Second, goal definition and splitting up of a task in substeps remained difficult steps to carry out by himself. In particular, G. O. had difficulty in mentally simulating the real execution of an action plan, which could be related to an observed defective ability in action sequencing, that is, detecting boundaries in large action units, such as macrosteps, and setting priorities among the events with regard to the stated goal. These difficulties could indicate a disturbance in causal connections between the component actions to represent a plan as a coherent and structured sequence of goal-related events [39
]. Consequently, the increased amount of fragmentized actions could have overloaded G. O.'s working memory capacity during the execution and monitoring of actions in ADL. GMT aimed to remediate these difficulties by teaching G. O. to define the main goal and to sequence the main goal into substeps by selecting the most appropriate steps for achieving the goal. G. O. also learnt to estimate and manage the time for the articulation of action plans. Moreover, when the steps of an activity were defined on a sheet of paper, G. O. could be guided by their automatic execution and monitoring (by following and crossing out each completed step on a sheet), decreasing the demands on working memory, and the intervention of voluntary control. Third, purposeless actions increased on the meal preparation task indicating that hyperactivity was still present in G. O. This could be related to his high level of anxiety that did not change after the rehabilitation and was predominant in his symptomatology. Finally, the caregiver's responses on the PROFINTEG questionnaire regarding G. O.'s daily functioning did not indicate a substantial decrease in difficulties, unlike G. O.'s responses. It should be noted that it was difficult for the caregiver to perceive everyday changes, as he only had brief contacts with G. O. mainly due to time constraints.
Regarding the two-year followup, the durability of the beneficial effects was largely evident in that the beneficial effects of the cognitive rehabilitation program were still present. Indeed, G. O. still had fewer difficulties in the realization of everyday activities at followup. Additionally, G. O. expressed being more self-confident and autonomous—crucial goals of a rehabilitation program. However, it is important to note that a few rehabilitation sessions aimed at refreshing acquisition would have been necessary in order to favor a better internalization of the 5 GMT steps.
Several limitations can be mentioned. First, blind assessments were not carried out. However, this was not feasible as G. O.'s assessments were carried out as part of a cognitive rehabilitation program. We considered filming G. O. while performing the various tasks, but he did not approve of this. Nevertheless, all assessments were always conducted by two judges. Second, there was a lack of stability of performances on the proofreading and room layout tasks at pre- and postrehabilitation.
Beneficial results from the different types of measures support evidence of the efficacy of GMT to structure goal-directed behavior in a person with schizophrenia. They suggest that GMT is a promising technique for the rehabilitation of everyday executive difficulties in this population. Future directions could be to analyze the effects of individual GMT steps with multiple baseline protocols (i.e., assessment after each step) and to use of a multiple case study design in order to determine the cognitive and functional profiles of those persons with schizophrenia who are susceptible (or not) to benefit from GMT (in its entirety or for specific steps).