Clinical Psychologist shares her experience of delivering Cognitive Remediation Therapy...

...and witnessing its benefits

by Dr Rumina Taylor, CIRCuiTS Veteran & Prinicipal Clinical Psychologist at South London & Maudsley NHS Foundation Trust

1. What is your training background?

I completed an undergraduate degree in psychology and then went on to complete a Doctorate in Clinical Psychology after working as an assistant psychologist. I am a practicing clinical psychologist working within the NHS and private sector. I also enjoy research and have some academic time although it’s only a small part of my role. I have always been interested in more severe and enduring presentations and completed a post-graduate diploma in Cognitive Behavioural Therapy for Psychosis after my doctoral training. I now work within an NHS national specialist psychosis and bipolar disorder service.

2. What was your main reason to train and work in mental health?

I have always been fascinated in why we do the things we do. I remember being a teenager and wondering why people fall in love and why some people were more affected by things in the world whereas others didn’t seem to be. My interest in mental health was heavily influenced by my father who suffered with anxiety and depression. I was confused at the episodic nature of his symptoms and how his distress would come and go. It impacted not only his wellbeing but also our family. I felt I could offer little support at the time; to be honest I didn’t really get what was going on and was therefore motivated to understand more about human feelings and behaviour and the drivers. A career in psychology was particularly appealing due to the multifaceted nature of the profession. That’s something I still enjoy and still get excited about.

3. How did you become aware of the impact that cognitive difficulties have on the recovery prospects of people with mental health conditions?

I started to first understand cognitive difficulties when I was working as an assistant psychologist. My role involved clinical work with service users with a diagnosis of schizophrenia and working with their care team. This included working closely with support workers as service users engaged with supported employment. I was able to see first-hand the impact of cognitive difficulties. For example, appointments were often missed as they were forgotten. I worked with one client who was at risk of losing her job as she found it hard to remember work shifts and would forget or mix up customer orders. Service users also shared their personal difficulties with their thinking skills. Many described avoiding opening their post as they found it challenging to maintain concentration on all the detail, and to plan and then recall what actions needed to be taken as a result. Sadly, they had also received negative feedback from others. People often viewed them as stupid or that they lacked motivation, when in fact it was their cognition holding them back. It made me start to reflect on my own cognitive abilities and how I take these for granted.

4. When did you start using Cognitive Remediation Therapy (CRT)?

My introduction to CRT was as an assistant psychologist working on a research programme investigating the impact of therapy on outcomes such as cognition and real-world functioning. My role was as a therapist delivering one-to-one CRT to service users with psychosis. There was also emphasis on using therapy skills outside of sessions. I particularly enjoyed working collaboratively with clients and their support network to think about how cognitive strategies could be encouraged, supported, and used for everyday goals and tasks. This also translated to my own life. I started to recognise all the tools and strategies I use to support my own cognition and that of others, such as using scaffolding with my children. Over the years I have tweaked my own toolbox and have a much better view on what supports my cognition so I can give myself the best chance of successfully achieving goals.

5. How did you train in CRT?

I initially trained in CRT using the paper and pencil version (showing my age here)! It was intensive face-to-face training which covered the theory, evidence base, and how to deliver therapy. This included the importance of assessment and formulation driven work that was tailored to the client’s goals. It involved lots of practice with fellow trainees and we also had an opportunity to practice our new skills with experts by experience which was a great. Over the years I worked with many service users using the face-to-face package. There were so many manuals to lug around! During this time CIRCuiTS was designed and built, and I then completed training to use the software. I gained a deeper understanding of metacognition to ensure long lasting cognitive and functional benefits to clients.

6. Can you describe a success and a challenge in using CRT in your clinical work?

In terms of success, there is still one service user I worked with using CRT that has stayed with me at the forefront of my memory. This client was experiencing difficulties with her memory at work. CRT was particularly beneficial in identifying areas of cognitive strength (the ability to multi-task) and areas of need (working memory). Therapy allowed my client to develop effective cognitive strategies for supporting her memory but also provided a really good understanding of why we have cognition and what memory, attention and executive functioning are used for. The bit of the work I particularly enjoyed and that seemed beneficial, was working alongside my client in the café and seeing her implement the strategies she had developed. They were effective and made such a difference to her work performance. At first, she had some concerns about using cognitive tools at work, but we were able to normalise her worries by visiting restaurants and observing other strategies people used. For example, when ordering food and drinks many staff repeat back your order to you. A great strategy for supporting working memory! This client went on to study a catering course.

I think where I have found CRT challenging to implement has been with clients with ongoing distressing positive symptoms. Some clients have found their voices telling them not to attend sessions or their voices have become distracting during sessions which has made engagement with therapy difficult. Similarly, when clients are unsure of or report no cognitive difficulties, it has been hard to think about how to implement CRT. It has been helpful to work collaboratively with clients and problem solve ways forward together. For some, engaging in Cognitive Behavioural Therapy (CBT) alongside CRT has been a beneficial way to manage voice distress. Trying some CIRCuiTS tasks and “assessing” cognition together has also been a helpful way to identify strengths and weaknesses.

CRT was my first real experience of delivering psychological therapy and it showed me the importance of accessing regular supervision and using it effectively.

7. Have you used other CRT programmes before CIRCuiTS?

I used the paper and pencil version as discussed before (seriously those manuals were so heavy).

8. What is your favourite CIRCuiTS task? Why?

It’s hard to choose just one! I think Find the Middle is probably my favourite. I don’t think people should underestimate this task and its applicability and importance to everyday life! I think learning to scan effectively and approaching the task in a steady, organised fashion are such key strategies. For example, my daughter is learning to read, and right to left scanning, using a finger or ruler for guidance, and moving line by line have been crucial for her success. Similarly, in my CBT work with clients, behavioural experiments are more effective when clients scan the whole environment so they can get an accurate picture of what might be going on.

9. What do you think is a key therapist skill for delivering CIRCuiTS effectively to clients?

As with any therapy, a CRT therapist needs to have those core therapeutic skills such as warmth, genuineness, the ability to work collaboratively with clients, and empathy. You also need to be able to effectively engage clients and be able to set goals together to focus on in therapy. Using technology can be challenging for us all at times so the ability to recognise this and support clients where necessary is key. It’s important for us as therapists to feel confident with any technology we are using so I would recommend being prepared for sessions, problem solving any issues in advance, and not being afraid to have a practice with CIRCuiTS. We can all benefit! Delivering CRT should be guided by a formulation and accessing regular supervision is necessary. Lastly, it’s important to remember CIRCuiTS isn’t about just doing the tasks and getting them right. The development of metacognitive knowledge, awareness, and transfer to real life functioning are crucial alongside a toolbox of cognitive strategies.

10. If you could be granted a wish to improve mental health, what would it be?

Can I have three? For me it would be around access, experience, and outcomes. I wish there was more and equal access to mental health care and preventative mental health care. I wish people would have an excellent experience with mental health services. Finally, I wish care would be focused on outcomes that matter to service users, their friends and family, and that they are fully supported to achieve these.

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