a foundation for recovery success. · a foundation for recovery success. 216.504.6428 samhsa 2011...

A foundation for recovery success.www.cetcleveland.org

216.504.6428SAMHSA 2011 Science and Service Award Winner

For people with schizophrenia and related cognitive disorders

CET Improves•Processingspeed

•Cognition/thinking(attention,memory,problemsolving)

•SocialCognition (theabilitytointeractwiselywithothers)

•Meaningfulroles(e.g.,employment)

•Self-managementofmentalhealth& physicalhealth

•Adjustmenttoandacceptanceofdisability

(see page 3 for a detailed list of positive outcomes)

CET | COGNITIVE ENHANCEMENT THERAPYAn overview of the Evidence-Based Practice

2 – CET Overview | www.cetcleveland.org

INTRODUCTIONBRAIN, MIND & SOCIAL CONTEXTCognitiveEnhancementTherapy(CET)isaSubstanceAbuseandMentalHealthServiceAdministrationrecognizedevidence-basedpracticethathelpspeoplewithschizophreniaandrelatedcognitivedisordersimprovetheirprocessingspeed,cognition(attention,memory,andproblemsolving),andsocialcognition(theabilitytointeractwiselywithothers).Researchstronglysuggeststhatimpairmentsinthesementalcapacitiescontributetofunctionaldisabilityinpeoplewithschizophrenia.CETrehabilitatesthesecapacitiesand,thus,maximizessuccessinallactivitiesofrecovery.Asaresult,CETparticipantsincreasetheirpotentialtoengageinmeaningfulsocialrolesandtoliveindependent,self-determined,andsatisfyinglivesinthecommunity.

Evidence-based practice CEThasbeenproveneffectiveinastudyfundedbytheNationalInstituteonMentalHealth(NIMH).TheresultswerepublishedinThe Archives of General Psychiatryin2004,apeer-reviewedacademicjournal.Additionalresultsfromananalysisofthreeyearsofdatafromthisstudywerepublishedin2006(see“Sources”onpage8).Belowareafewfactsabouttheoriginalstudy:• Two-yearstudy• Ages18to55• N=121peoplewithschizophreniaandschizoaffectivedisorderwhometcriteriaforcognitivedisability

• RandomizedparticipationintheexperimentalCETgroup(n=67)andacontrolgroup—EnrichedSupportiveTherapy(EST)(n=54)

• Outcomesevaluatedat12and24months

A neurodevelopmental interventionResearchshowsthatthehumanbraindevelopsininfancy,childhood,andadolescenceinthecontextofinterpersonal(social)relationshipswithfamilymembers,friends,caregivers,andteachers,amongothers.Inaddition,braindevelopmentandpersonalitydevelopmentcontinueinadulthoodandthroughoutlifeinthecontextofrelationshipswithotheradults.

Researchalsoshowsthatthebrainhasanaturalcapacitytorepairdevelopmentaldelaysandtrauma.Thisiscalledneuroplasticity.Thishealingactivityismorelikelytooccurwheninterventionsinducepeopletousetheirbrains.CETisdesignedtodothis.

A neurodevelopmental disorderCETviewsschizophreniaasaneurodevelopmentaldisorder.Thismeansthatsomepartsofthebrainhavenotyetcompletelydeveloped.Forinstance,researchconductedwithfunctionalmagnetic-resonanceimaging(fMRI)hasidentifiedreducedactivityintheprefrontalcortexofpeoplewithschizophreniaandrelateddisorders.Theprefrontalcortexisthecenterforattention,workingmemory,judgment,anddecisionmaking.Ithelpseachofustransformemotionsintothoughtsandwise,appropriateactions.Italsohelpsusregulateandeditemotionsandthoughts.Impairmentsin

cognitionandsocialcognitionamongpeoplewithschizophreniaappeartobestronglycorrelatedwithdelaysinneurodevelopment.

Structured activities that exercise the brain & mindCETprovidesholistic,structuredactivitiestohelppeoplewithschizophreniaandrelatedmentalillnessesjump-startneurodevelopment,cognitivedevelopment,andsocialcognition.TherapistsinCETarecalledCoaches,becausetheyaretrainedtohelppeoplefunctionbetter.Coachesaretrainedtorespectfullychallengeandsupportparticipants,tonoticeandreflectuponthefeelingsandthoughtsoftheselfandothersandtoexecutespeechandactionsthatareappropriate,wise,andeffective.TheseinterventionsoccurineveryCETsessionandincludethefollowing:• Computer-basedexercises/interactivesoftware• Group-basedinteractions• Individual(one-on-one)coachingsessionswitheachCETparticipant

(For more detailed information, see “Components of CET” on page 5.)

A holistic interventionCognition/thinkingandsocialcognition(theabilitytointeractwiselywithothers)aresocloselyrelatedthatitseemsinaccuratetoseparatethetwo.However,weseparatethemforconceptualreasons—tohelpyoumakethedistinctionbetweentheinternalprocessofperceiving,feeling,andthinkingandtheexternalprocessofusingfeelings,thoughts,andperceptionstointeractwiselywithotherpeople.Cognitionandsocialcognitionaresocloselyrelatedthattheyinfluenceandsupporteachother.Forexample,CETchallengesparticipantstopayattention(acognitivecapacity)sotheycanunderstandpeoplebetter(asocial-cognitivecapacity).Thisisimportantbecausewhenparticipantsunderstandotherpeoplebetter,itiseasierforthemtopayattention.ThisiswhyCETaddressesbothcognitionandsocialcognitionsimultaneously.

NOT BEHAVIORAL THERAPYCETisdifferentfromotherpsychotherapeutictechniquessuchasCognitiveBehavioralTherapy(CBT)thatfocusonhelpingpeoplechangethecontentoftheirthoughtsandbehaviors(e.g.,tochangenegativeideasabouttheselfintopositiveones;tochangeasocialbehaviorintofriendlyinteractions).

Instead,asCETfocusesontheinternalmentalprocess,itnaturallyaddressesthesocialcontent(speechandactions)thatarisesspontaneouslyamongparticipantsinthemoment,intheroomwherethecomputer-based,group-based,andone-on-onetherapeuticworkofCETistakingplace.CETparticipantsdonotbecomemorecompetentinformulatingspecifickindsofthoughtsandactions;rather,theybecomemorecompetentindealingwiselyandeffectivelywithawiderangeofpossibilitiesintheever-changingspontaneousworldofsocialinteractionsathome,work,school,andinthecommunity.

CET is not behavioral therapy. Nor does it focus on teaching “skills”. CET helps individuals develop and enhance the mental capacities that produce the awareness for self-directed social interactions that are wise, appropriate, and effective.

(continued on page 3)

CET Overview | www.cetcleveland.org – 3

TRANSFORMING TREATMENTCurrenttreatmentsforschizophreniaincludeacombinationofmedication,psychologicalcounseling,andgroup-basedinterventionssuchassocial-skillstraining,illness-management,andfamilypsychoeducation,amongothers.Sometreatmentplansalsoincludeemployment.Manyinterventionsteachindividualsdailylivingskillstoenhancetheirperformanceofdailylivingtasks.Yet,thesetreatmentsoftenfallshort,becausetheydonotaddresstheunderlyingneurodevelopmentalandcognitiveimpairmentsthatinhibitrecovery.

Incontrast,CEThelpsindividualsenhancethementalcapacitiesthatproduceawarenessandwisesocialinteractionsthatsupporttheminall aspects oftheirtreatmentplansandtheirrecoveryjourneys,whicharelifelongandconstantlychanging.CETisnotdesignedtoreplaceothertreatmentsthatfocusonsymptomcontrol,relapseprevention,andpracticallivingskills.Rather,CETisdesignedtocomplementthem.

Adjustment to disabilityPerhapsthemostuniqueaspectofCETisthespecialattentionitgivestohelpingparticipantsadjusttoandaccepttheirdisabilities.InthefirstfewweeksofCET,participantslearnagreatdealabouttheirimpairments

frompsychoeducationalpresentationsanddiscussionsandfromtheirexperienceswiththecomputer-basedcognitiveexercises.Thisunderstandingfacilitatesapersonalprocessofadjustingtodisability,thestagesofwhichincludethefollowing:• Shock • Anger• Denial • Grief• Bargaining • Acceptance

Throughthisprocess,participantslearnthattheyare nota“schizophrenic”or“mentallyill”—thatthedisorderdoesnotdefinetheirentirepersonorself.Rather,participantslearnthattheyhaveanillness—thattheynotonlyhavelimitationsbutalsostrengths,talents,skills,interests,andmuchmore.Goingthroughthisprocessofself-discoveryandself-acceptancehelpsparticipantscopewithstigmaandtobecomerealisticallyhopefulabouttheirrecovery.

A HOLISTIC APPROACHThecreatorsofCEThaveintentionallyusedtheoryandresearchfrommultipleprofessionaldisciplinestoarriveattheneurodevelopmentalapproachtorehabilitation.TheydevelopedCETbecausetheywerewitnessingthelimitationsofotherbiopsychosocialtreatmentsintheirclinicalpracticesandwerereadingaboutthelimitations

Researchshowsthatafter12months,individualsinCETattainsignificantimprovementinthementalcapacitieslistedbelow.Participantsalsomaintaintheseimprovementsat36monthsandcontinuetodevelopthemovertime.

I. Processing speedProcessingspeedisacognitivecapacitythatisapre-requisiteforalllearning.Peoplewithschizophreniaandrelatedcognitivedisordersfrequentlyexperienceimpaired(orslow)processingspeed.

II. Cognition/Thinking, including the following:• Motivation,initiative,andenergy• Attention/concentration • Problemsolving• Workingmemory • Cognitiveflexibility• Verbalmemory • Mentalstamina

III. Social Cognition (the ability to interact wisely with others)• Perspective-taking(ofselfandothers)• Gistfulthinking(i.e.,understandingthethemesandmeaningsofverbalandnon-verbalmessagesandavoidingdigressionsaboutunimportantdetails)

• Motivationalaccount(i.e.,givingaclearaccountofone’sownactionsandtheactionsofothers)

• “Thinkingonyourfeet”/Problemsolving• Abstract,activethinkingvs.concretepassivethinking

• Roleflexibility• Fun/senseofhumor• Recognitionandappreciationofspontaneity,especiallyinsocialsituations

• Recognitionandappreciationofthejoyofachievingpersonalgoalsoftheselfandothers

IV. Meaningful roles CETisdesignedtohelpparticipantseventuallybecomesocializedintomeaningfuladultrolesthattheyidentifyasgoalsintheirrecoveryplans.Theserolesoftenincludethefollowing:• Friend• Spouse• Parent• Student

VI. Self-management of mental health and physical health Thisincludeslearningtoknowandtorespondeffec-tivelytoone’sownsubjectivecuesofdistress.EarlyoninCET,thepsychoeducationaltalksfocusonhelpingindividualsrecognizethesignsofstressthatcouldleadtoanexacerbationoftheillnessortopoorperformance.

VII. Adjustment to and acceptance of disabilitySee“TransformingTreatment”sectionabove.

POSITIVE OUTCOMES OF CET

• Employee(volunteerexperiencesandpart-timeorfull-timeemployment)



inpublishedresearch.Theywantedtoknowwhatwasbehindorbeneaththesymptoms(whatwasproducingthelimitations)sotheycouldhelppeoplemovebeyondthem.CETisbuiltupontheory,research,andpracticefromthefollowing:• Cognitivepsychology • Psychologyofdisability• Developmental • Socialpsychology psychology • Socialwork• Neurophysiology • Sociology• Neuropsychology • Vocational• Psychiatry rehabilitation

Traumatic brain-injury researchCETisalsoinspiredbyrehabilitationprogramsforpatientswithtraumaticbraininjury.Theseprogramsaredesignedtoutilizethebrain’sneuroplasticitytostimulatehealingandtoencourageparticipantsto

compensate forimpairments.Researchshowsthattheseprogramsrehabilitatesectorsofthebrainthatsupportcognitionandsocialcognition.AmongtheprogramsutilizedbyCETarethosedevelopedbythefollowing:• YehudaBen-Yishay,Ph.D.,andcolleaguesatNewYorkUniversity:cognitivetrainingandpsychosocialcognitiveremediation

• OdieBracy,Ph.D.,ofPsychologicalSoftwareServices,Indianapolis:computersoftwaredevelopedforuseintherehabilitationoftraumaticbraininjury

• H.D.Brenner,Ph.D.,ofSwitzerland:IntegratedPsychologicalTherapy(IPT)—cognitiverehabilitationmethodsthatintegrateexercisesforbasiccognitionwithsocialinteractionsforsocialproblem-solving

• WilliamSpaulding,Ph.D.,oftheUniversityofNebraska:IPT

SOCIALIZATION & SOCIAL ROLESThereisabeliefamongmanyprovidersofmentalhealthservicesthatpeoplewithschizophreniaandrelatedmentalillnessesexperienceimpairmentsinsocialcognitionandsocialinteractionaftertheonsetoftheirfirstpsychiatricepisode.Somealsobelievethereisaregressiontoanearlierstageofpsychologicaldevelopment.However,researchsuggeststhat“high-riskchildrenwhoeventuallydevelopschizophrenia”simplyfailtodeveloptheirabilitytointeractwiselywithothersatthesamerateandwiththesameamountofsuccessastheirpeerswhoarenotat-risk(seeHogarty&Flesher1999in“Sources”onpage8).Asaresult,peoplewithmentalillnessareoftensocializedintolimitedrolesinlife,suchastheroleofanunderemployedorunemployedpatient.

CETintentionallychallengesserviceprovidersandCETparticipantstouseaninterpersonalprocesscalledsecondary socializationtohelpparticipantsenhancetheirsocialcognitionand,thus,expandtheiropportunitiesforachievingsocialrolesthattheyhaveidentifiedaspartoftheirrecoveryplans.

SOCIALIZATIONSocialcognitionistheabilitytointeractwiselywithothers.Socializationistheprocessoflearningfromotherpeople(e.g.,parents,othercaregivers,relatives,peers,etc.)theinformalrulesofinteractingwiselyandeffectively.Itisalsotheprocessbywhichindividualslearntonegotiatethevariousrolestheyplaythroughoutlife,suchaschild,sibling,student,groupmember,adult,spouse,parent,andemployee,amongothers.Socializationtakesplaceacrossthelifespan.Therearebasicallytwokindsofsocialization,whicharebrieflydescribedbelow.

Primary socialization Inchildhood,individualslearntheconcreterulesofthephysicalworldandinterpersonalrelationshipswithinstructionanddisciplineofparentsandotheradultswhomustsetlimitsforthem(e.g.,“do”and“don’t”,“right”and“wrong”).Thisiscalledprimary socialization.Primarysocializationisverydirectiveandisparticularlywell-suitedforthemindsofchildren,whopossessthefollowingmentalcapacities,amongothers:• Concretethinking(e.g.,attentiontomanyspecificdetails)

• Verbatimmemory(e.g.,memoryofmanyspecificdetails)

Secondary socializationInadolescenceandyoungadulthood,thesocializationprocessbeginstochange.Individualslearnhowtodetect,evaluate,test,andutilizetheunwrittenandoftenunspokenrulesofsocialinteractionswithpeersandadults.Thisknowledgeisgainedthroughtrial,error,andsuccess.Inotherwords,individualslearnwhatisright(acceptable)andwrong(unacceptableorinappropriate)actionsinmanydifferentsocialsettingswithfeedbackfrommanydifferentpeople.Thisiscalledsecondary socialization.Itistheprocessthatadultsusetosocializeeachotherthroughoutlife.Secondarysocializationrequiresindividualstoutilizesocial-cognitivecapacitiessuccessfully(foralist,see“PositiveOutcomes”sectiononpage3).

Not “getting it”Withsecondarysocialization,peopleexpecteachothertogetthe gist(i.e.,themes,mainideas)oftheirinteractionsandnotgetstuckonordistractedbydetails.Inotherwords,peopleexpecteachother“togetit”,andtogetitquickly.Individualswhodonotappear“togetit”areoftenexcludedfromsocialnetworksratherquicklyandarenotsocializedintoadultroles.In

INTRODUCTION continued


addition,individualswhorelyuponverbatimmemoryandconcretethinkingforlearningareat-riskofmissingthegistofsocialsituationsand,therefore,areat-riskofnotbeingsocializedintoadultroles.Thisappearstobethecasewithmanypeoplewhoarevulnerabletoschizophreniaandrelatedmentalillnesses.

Transition from primary to secondary socialization Thefirstdebilitatingepisodeofmentalillnesstypicallycomesduringatimewhenayoungpersonisattemptingtonegotiatethemovefromprimarysocialization(e.g.,thepredictablestructureoffamilyandschool)tosecondarysocialization(i.e.,themorespontaneous,unstructuredinteractionsofautonomousadultrelationships).Thetriggersthatleadtoafirstepisodemightincludethefollowing:• Thefirsttimeawayfromhomeatcollegeor inthemilitary

• Thechallengeofgettingandmaintainingemployment

• Startingacareer• Negotiatingnumerousfriendships,romanticrelationships,andworkenvironments

SOCIAL ROLES & SCHIZOPHRENIAThereisanunderstandabletemptationforhealthandhumanserviceprovidersandfamilymemberstoutilizeprimarysocializationwithpeoplewhohaveimpairedcognitionandsocialcognition.Unfortunately,caregiverswhorelyuponprimarysocializationtendtobedirectiveandto“dofor”thepeopletheyaretryingtohelp(seeFloerschin“Source”onpage8).Thisapproachdeniesthemthebenefitsofsecondarysocializationandself-directed,wiseactions.Asaresult,peoplewithmentalillnessoftengetsocializedintotheroleofapatientanddonotdevelopthecapacitiestoparticipateinmanylife-roles,includingthefollowing:friend,spouse,parent,student,employee.

COMPONENTS OF CET“THE GIST” OF CETCETusestheprocessofsecondarysocializationtohelppeoplewithschizophreniaandrelatedmentalillnessesrecovertheabilitytocontinueneurodevelopmentandthedevelopmentofcognitionandsocialcognition.CETplacesemphasisupon“unrehearsedbutclinicallyguided”real-lifeinterpersonalexperiences.Thisenablesparticipantstoattainage-appropriatesocial-cognitivecapacitiesandachievements(seeHogarty&Flesher1999in“Sources”onpage8).

ByexposingCETparticipantstothemorechallengingdemandsofsecondarysocialization,CETcoaches/therapistshelpparticipantsexercisetheirbrainsandenhancetheircapacitiesfortheadultrolestowhichtheyaspire.CETcoachesrefrainfromrespondingtoparticipantswiththedirectiveapproachofprimarysocialization.Instead,theyrespondtoparticipantsasadults.

WHO IS ELIGIBLE FOR CET CETisanevidence-basedpractice.Thismeansitiseffectiveforpeoplewhoresemblethosewhoparticipatedinthepublishedresearchstudy(seepage2).Therefore,serviceorganizationsofferCETtopeoplewhomeetspecificcriteria.WhileCETwasdesignedandtestedforpeoplewithschizophreniaandschizoaffectivedisorder,peoplewithotherdiagnoseswhoexpressaninterestinCETandmeetthecriteriaforcognitivedisabilitymayparticipate.ThereisinterestintestingCET’seffectivenesswithpeoplewhohaveotherdiagnoses.BelowarecriteriaforparticipantsinCET:• Individualswithschizophreniaandschizoaffectivedisorder(andotherrelatedmentaldisorders)whomeetcriteriaforcognitivedisability

• 18yearsofageorolder• Maleandfemale• Inrecoveryphaseoftreatment(notinacutephase)• Stablesymptoms• Medicationcompliant• Donothaveasubstanceusedisorder(SUD), orareabstinentifthereisanSUD

• IQ=80orabove• FluentinEnglishandabletoreadatafourth-gradelevel

CORE COMPONENTS OF CET

1. TIME-LIMITED• 1dayperweek• 48weeks• 3-1/2hoursperday/session• Computer-basedcognitiveexcercises(1hour)• Psychoeducationalgroup(1-1/2hours)• Individualcoachingsessionwitheachparticipant(.5to1hour)

2. SMALL GROUPS & PERSONALIZED ATTENTIONEnrollmentineachCETgroupisnolessthan8andnomorethan12participants.ThisenablesthetwoCETcoaches/therapiststoprovidepersonalizedattentiontoeachparticipant.Thesmallgroupsizeenablesparticipantstodevelopsupportivepeer-relationshipsandnetworks.

CET helps service providers, family members, and people with mental illness engage in a process of secondary socialization, which expands opportunities for more meaningful adult roles among people with mental illness.



3. CET COACH/THERAPIST CETcoachesaresocialworkers,mentalhealththerapists,orvocationalcounselorswhoaretrainedtohelpparticipantsenhancecognition,socialcognition,andothermentalcapacities,suchasprocessingspeed.Coachesareabstractthinkerswhoareabletorefrainfromusingtheprocessofprimarysocialization(seepage4)of“doingfor”clients.Instead,coacheschallengeclientstothinkforthemselvesratherthan“connectingthedots”forthem.Coachesengagewithparticipantsinaprocessofsecondarysocializationtohelpthemreflectupon,becomeawareof,andutilizetheirfeelings,thoughts,andperceptionstoplanandexecutewiseactionsthatgeteffectiveresults.Inotherwords,CETcoacheshelpbringoutthebestineachperson.

TherearetwocoachesineachCETgroup.Theyprovidegroupcoachingaswellasindividualizedone-on-onecoachingtoeachparticipantinseparatenon-groupsessions.Coachesguideparticipantsthroughtheprocessofutilizingcomputer-basedexercises,group-basedexercises,andone-on-oneinteractionstostimulatecognitionandsocialcognition.Coachesrespectfullychallengeincomplete,hard-to-understand,andinappropriatespeechandactionsasawaytohelpparticipantsbecomemoreawareofhowtheyarecomingacrossto(beingperceivedby)others.Coachessupportparticipantsthroughthedifficultfeelingsthatariseastheylearnnewwaysofthinkingandinteracting.Difficultfeelingsoftenincludefrustration,shame,fatigue,apathy,confusion,anddisappointment,amongothers.Coachesalsosupportparticipantsthroughpleasantexperiencesofjoyandpridethatcomewithaccomplishments.Theyalsoencourageeveryonetoenjoythehumorthatarisesspontaneouslyduringgroupactivities.

LikeCETparticipants,coacheslearntotoleratetheambiguityofspontaneoussocialinteractionsinCETgroupsandlearnthattherearenorightorwronganswers,justeffectiveandineffectivespeechandactions.

4. INDIVIDUALIZED ASSESSMENTBeforetheonsetofCET,coachesmeetindividuallywitheachparticipanttoassesshimorherforthefollowing:• Neuropsychologicalimpairments• Cognitiveimpairment• Social-cognitiveimpairment• Cognitivestyle(e.g.,unmotivated,disorganized,orrigidthinking)

5. INDIVIDUALIZED TREATMENT PLANNINGCETcoachescollaboratewitheachparticipanttohelphimorheridentifygoalsthatpertaintohisorhercognitivedevelopment.Together,theydevelopatreatmentplan.TheplanispostedintheroomwheretheCETgroupmeets(withtheparticipant’spermission)toserveasaconstantreminderofeachperson’sindividualgoals.

6. WORKING WITH A PARTNER EachCETparticipantworkswithanotherparticipantasapartnerduringthecomputerexercisesandthepsychoeducationalgroup.Thepartnershipsprovideparticipantswithasenseoffamiliarity,safety,trust,andbelonging.Thepartnershipsalsochallengeindividualstoexerciseattentivenessandlistening,tooffersupport,tocollaborate,andtoengageinnegotiationandconflictresolution.WhenCETparticipantsinteractone-on-onewithapartner,theyareabletoexperienceandprocessalimitednumberofsocialcues,whichminimizesanxietyandstress.Whentheyworkingroups,theyarechallengedtoprocessmultiplesocialcuessimultaneously.

7. COMPUTER-BASED COGNITIVE EXERCISESBeforetheformalgroupworkofCETbegins,CETparticipantsworkwithapeer-partneroncomputer-basedexercises.ThishelpsparticipantsacclimatetotheCETenvironment.CETusesavarietyofsoftwarethatchallengesparticipantstoexerciseandrehabilitatespecificcapacities,suchasattention,memory,processingspeed,sorting,categorizing,andpredicting,among others.Thesoftwarehasbeenobtainedfromtherehabilitationresearch,theory,andpracticeofmultipledisciplines.(For related information, see “A Holistic Approach” on page 4.)

8. SPECIFIC GROUP STRUCTUREManypeoplewithschizophreniaandrelatedcognitivedisabilitiestendtofeeloverwhelmedandthreatenedbyspontaneous,unpredictableinteractions.Therefore,thestructureofeachgroupsessionisintentionallysimilareachweek.Thisprovidesaframeworkofpredictability,whichprovidesanotherlevelofsafetyandtrust.Thegroupstructureisalsodesignedtoprovideanenvironmentthatencouragesandallowsforspontaneityandunpredictabilityofsocialinteraction.Belowisabriefoutlineofthegroupstructurethatfollowsasetagenda:• Welcomeback• Selectionofchairperson(encouragesleadershipandpeercollaborationamongparticipants)

• Eachmemberdiscusseshomeworkquestions(connectspsychoeducationaltalktoreallife).

• Psychoeducationaltalk&discussion(i.e.,curriculumtopics)(see#11)

• Group-basedcognitiveexercises(requiresparticipantstointeractwithapartnerinfrontofthewholegroup)

• Eachgroupmemberprovidesfeedbacktothepersonswhohavecompletedthecognitiveexercise.

• Readingofnexthomeworkassignment(connectspsychoeducationaltalktoreallife)

COMPONENTS OF CET continued


FAMILY CETCETstrivestointegratefamilymembersintotherecoveryprocess.Familymembersareinvitedtosomeofthemilestone-eventsthattakeplaceperiodicallyinCETgroup.Theyarealsoinvitedtograduation.Abriefmultiple-familygrouppsychoeducationalclassisavailableforfamilymembers.Thisgivesthemtheknowledge,awareness,andcapacitytounderstandthedisabilityandtoavoidthedirective“dofor”interactionsofprimarysocializationandtoengageinsecondarysocializationwhileinteractingwiththeirlovedones(seepage4).FamilymemberswhounderstandanduseCETconceptsandtechniquesareequippedtocompassionatelysupportandadvancerecovery.

POST-CETCETprovidesalibraryofgroup-basedexercisesandcomputer-basedexercisesforCETgraduateswhowishtocontinuetoenhancetheircognition,socialcognition,andmentalprocessingspeedinasemi-structuredenvironment.Unliketheregular48-weekCETcurriculum,thepost-CETcurriculumandgrouparelessstructuredandlessformal.Post-CETopportunitieshelpparticipantsmaintainandexpandtheircognitivecompetencies,aswellastheirpeer-networksofsupportandfriendships.

9. GROUP-BASED WORKAspartofthestructureoftheweeklyCETsession,participantsattendasocial-cognitivegroupthataddressesapsychoeducationalcurriculumwhichfocusesonadifferenttopic/lessoneachweek.Eachparticipanttakesturnschairingthediscussion.Thegroupworkencouragesparticipantstoengageinmanylearningactivities,someofwhicharelistedbelow:• Payattention(andmanagementaldrifting)• Beawareofandsensitivetochangingverbalandsocialcontexts—tofigureouthowtorespondappropriatelyinnewandcomplexsocialsituations

• Thinkandspeakgistfully(i.e.,identifyandarticulatethemesandavoiddigressionsaboutunimportantdetails)

• Takenotestopayattentionandtoorganize,analyze,andprioritizeinformation

• Giveandreceiverespectful,relevantfeedback• Workinteamsandnegotiatewithpeersandcoaches/therapists

• “Thinkonyourfeet”tosolveproblemsspontaneouslyassocialsituationschange

• Engageinhomeworkassignmentsaboutsocial-cognitionscenariosthatareincreasinglychallenging

• Exploreandunderstandthenatureofone’sownmentalillness

10. HOMEWORKAftertheweeklygroup,eachparticipantpreparesahomeworkassignmentindividuallywithaCETcoachinaseparate,one-on-onesession.Homeworkcomplementsthepsychoeducationalpresentationsanddiscussionsbyrequiringparticipantstoreflectuponandapplytotheirdailylivestheconceptstheylearnedduringthegroup.Duringthenextgroupsession(inthefollowingweek),eachparticipantisrequiredtoanswerthehomeworkquestionsinfrontoftheirpeersandcoaches,whoaskmostlyopen-endedquestionstohelpeachpersonreflectandelaborateuponhisorherpresentationspontaneously—inthemomentand

withoutrehearsal.Thisinteractionrequiresparticipantsto“thinkontheirfeet”,toprocessinformation“onthespot”,andtoexercisetheirbrains.Inthisway,participantslearntoholdseveralthoughtsandfeelingsintheirminds,tocompareandsynthesizetheirideas,andtoengageinspeechthatisrelevanttothesituation.

11. SPECIFIC CURRICULUMTheCETcurriculumcovers48weeksofCET’sduration.Eachsessionfocusesonadifferentpsychoeducationaltopic.Thiscontentprovidesafocalpointofdiscussionwithwhichtopractice,exercise,andmasterthecognitiveandsocial-cognitiveprocesses.Someexamplesofthepsychoeducationaltopicsinthecurriculumincludethefollowing:• RationaleforCET• Howthebrainworks• Attentionandmemory• Methodsfordealingwithcriticism• Howtotaketheperspectiveofothers• Howtoacceptandadjusttoadisability/impairment• Howtocopewithstigma• Howtoestablishmeaningfullife-roles

EachgroupmemberpassesmilestonesduringhisorherworkinCETbymakingpresentationswithoutnotes.Themilestoneeventsculminateinagraduationspeech.

12. GRADUATIONAttheendofCET’s48-weekcurriculumthereisaformalgraduationcelebrationthatisattendedbyCETparticipants,coaches,familymembers,andothersinvitedbythegraduates.Thepurposeoftheeventistopubliclyacknowledgethehardworkandaccomplishments.Atthecelebration,eachCETparticipantspeakspubliclyabouthisorherexperiencesandachievementsinCET.Itisanopportunitytopubliclydemonstratenewsocialcompetence.

ADDITIONAL COMPONENTS

Like CET participants, coaches learn to tolerate the ambiguity of spontaneous social interactions in CET groups.

ABOUT THE CCR | Center for Cognition and Recovery, LLC

NATIONAL TRAININGTheCenterforCognitionandRecovery(CCR)providestrainingandconsultationtocommunity-basedandinpatientmentalhealthandhumanserviceorganizationsthatwishtoprovideCognitiveEnhancementTherapy(CETCLEVELAND®)topeoplewithschizophreniaandrelatedmentalillnesses.

Training & Consultation Services• TrainingofCETCLEVELAND®coaches/therapists• OngoingconsultationforCETCLEVELAND®coaches/therapists• Educationofmentalhealthprofessionalsandstudents• CETCLEVELAND®FidelitytoModel• EvaluationResearch• Assistancewithgrantwritingandsubmission

AN EVIDENCE-BASED PRACTICECEThasbeendemonstratedtobeeffectiveinacontrolledstudyfundedbytheNationalInstituteonMentalHealth(NIMH)GrantMH-30750.TheresultswerepublishedinTheArchivesofGeneralPsychiatryin2004.CETimprovesprocessingspeed,cognition/thinking(attention,memory&problemsolving)andsocialcognition(theawarenesstointeractwiselywithothers)—threecapacitiesofthemindthatarethefoundationforsuccessinallactivitiesandoutcomesofrecovery.CETalsoenhancesmeaningfulrolesofpeoplewithmentalillness,includingemployment.SAMHSA(SubstanceAbuseandMentalHealthServicesAdministration)recognizedCETasanEvidencedBasedPracticein2012.

SAMHSA 2011 SCIENCE AND SERVICE AWARD SAMHSAselectedtheCCRasoneof11organizationsacrosstheUSAtoreceivetheagency’sprestigious2011ScienceandServiceAwardsforitsworkindisseminatingCET.Theseawardsrecognizeexemplaryimplementationofevidence-basedinterventionsshowntopreventand/ortreatmentalillnessesandsubstanceabuse.

EXPERIENCED TRAINERSCCRtrainersarelicensedprofessionalsinsocialwork,psychology,counselingandotherrelateddisciplines.TheyarealsoexperiencedCETcoaches/therapistswhohaveprovideddirectservicetoindividualsrecoveringfrommentalillnessandhaveaccumulatedthefollowingexperiencewithCETCLEVELAND®:• 14yearsprovidingCETCLEVELAND®• Morethan180CETCLEVELAND®groups• Over1,000CETCLEVELAND®graduates• Averagingan85to90%attendancerateoverthe48weeksofCETCLEVELAND®

• Averagingan85%graduationratewithanincreasedrateofvolunteerandpart-timeandfull-timeemploymentexperiences

Cognitive Enhancement Therapy (CET) was originally designed by Gerard Hogarty, MSW, Sam Flesher, Ph.D., Mary Carter, Ph.D., and Deborah Greenwald, Ph.D., at the University of Pittsburgh Medical Center, Western Psychiatric Institute and Clinic. Since 2000, CET has been conducted and refined at Mercy Behavioral Health in Pittsburgh, PA, by PLAN of Northeast Ohio and now by the Center for Cognition and Recovery. In 2006, the CCR was established to further the dissemination of CETCLEVELAND® as designed by Dr. Flesher. CETCLEVELAND® Programs have (as of October 2013) been established at 24 sites in 10 states with 8 to 10 additional sites in development in 5 states. This booklet was made possible with funding from the Margaret Clark Morgan Foundation, the William J. and Dorothy K. O’Neill Foundation, the Fairfax Foundation, and the Maltz Family Foundation. This booklet was written by the following: Samuel M. Flesher, PhD; Sharon M. Shumaker, LISW; Ray Gonzalez, LISW; & Paul M. Kubek, MA.

CONTACT INFORMATIONRayGonzalez,ACSW,LISW-SCenterforCognitionandRecovery,LLC3659S.GreenRoad,Suite308Beachwood,OH44122216-504-6428rgonzalez@cetcleveland.orgwww.cetcleveland.org

SOURCESThisbookletwascreatedwithreferencetothesourceslistedbelowandwithreferencetothepracticeexperi-encesofCCR’sCETcoaches/therapistsandtrainers.

GerardE.HogartyandSamuelFlesher(1999).DevelopmentalTheoryforaCognitiveEnhancementTherapyofSchizophrenia.Schizophrenia Bulletin,25(4),p677-692.

GerardE.HogartyandSamuelFlesher(1999).Practiceprinciplesofcognitiveenhancementtherapyforschizophrenia.Schizophrenia Bulletin,25(4),p693-708.

GerardE.Hogarty,MSW;SamuelFlesher,Ph.D.;et.al.(2004).CognitiveEnhancementTherapyforSchizophrenia.Archives of General Psychiatry,v61,p866-876.

GerardE.Hogarty,MSW;DeborahP.Greenwald,PhD;andShaunM.Eack,MSW(2006).DurabilityandMechanismofEffectsofCognitiveEnhancementTherapy.Psychiatric Services,57,December,p1751-1757.

PlannedLifetimeAssistanceNetworkofNortheastOhio(2004).SamuelFlesher,Ph.D.andSharonShumaker,ACSW,LISW(ed).CognitiveEnhancementTherapyCoachesManual.PLANofNortheastOhio.

GerardHogarty,MSW,andDeborahP.Greenwald,Ph.D.(2006).CognitiveEnhancementTherapy:TheTrainingManual.Pittsburgh.

JerryFloerschandJeffreyLonghofer(2004).“PsychodynamicCasemanagement,”inPsychodynamic Social Work,p350-369,editedbyJerroldBrandell.NewYork:ColumbiaUniversityPress.

ADDITIONAL ARTICLESEack,S.M.;Hogarty,G.E.;Cho,R.Y.;Prasad,K.M.R.;Greenwald,D.P.;Hogarty,S.S.;Keshavan,M.S.(2010).Neuroprotectiveeffectsofcognitiveenhancementtherapyagainstgraymatterlossinearlyschizo-phrenia:resultsfroma2-yearrandomizedcontrolledtrial.Arch of Gen Psychiatry, 67,E1-E9.

Eack,S.M.;Greenwald,D.P.;Hogarty,S.S.;Keshavan,M.S.(2010).One-yeardurabilityoftheeffectsofcognitiveenhancementtherapyonfunctionaloutcomeinearlyschizophrenia.Schizophrenia Research. 210-216.

Eack,S.M.;Greenwald,D.P.;Hogarty,S.S.;Cooley,M.N.;DiBarry,A.L.;Montrose,D.M.;&Keshavan,M.S.(2009).Cognitiveenhancementtherapyforearly-courseschizophrenia:Effectsofatwo-yearrandomizedcontrolledtrial.Psychiatric Services, 60,1468-1476

EackS,HogartyG,GreenwaldD,HogartyS,KeshavanM.EffectsofcognitiveenhancementtherapyonemploymentoutcomesinearlySchizophrenia:resultsfroma2-yearrandomizedtrial.Research on Social Work Practice, 21(1),pp.32-42

WykesT;HuddyV;CellardC;McGurkSR;CzoborP(2011)Meta-analysisofCognitiveRemediationforSchizophrenia:MethodologyandEffectSizes.Am J Psychiatry. 2011; 168(5):472-85(ISSN:1535-7228)

CCR_OCT2013_2500 The Center for Cognition and Recovery, LLC. is a subsidiary of Jewish Family Service Association of Cleveland.

1. Pittsburgh, PA2. Akron, OH3. Beachwood, OH4. Cincinnati, OH5. Northfield, OH6. Dallas, TX7. Morgantown, WV8. Washington, PA9. Philadelphia, PA10. St. Louis, MO11. Louisville, KY

12. LACDMH, CA13. Pomona, CA14. Wilmington, DE15. Kalamazoo, MI16. Inglewood, CA17. Beaumont, TX18. Buffalo, NY19. Cleveland, OH20. Houston, TX21. Terrell, TX22. Galveston, TX

A. Philadelphia, PAB. Portland, ORC. Seattle, WAD. Brick, NJE. Atlanta, GAF. Toledo, OHG. Chardon, OHH. Erie, PA

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