Cognitive remediation (CIRCuiTS, CRT)

1. Introduction

Version followed: King's College London Cognitive Remediation Therapy (CRT) as described in the 2007 randomised trial (Wykes, Reeder et al.) and CIRCuiTS (Computerised Interactive Remediation of Cognition – a Training for Schizophrenia) as described by its developers in Reeder et al. 2016 and 2017, and in the ECLIPSE programme (Wykes et al., NIHR 2024); core ingredients follow the 2020 expert working group white paper (Bowie et al.). NEAR and CRT for anorexia nervosa are given briefly. Sources include NICE NG181 (guideline status); the Routledge page (bibliographic record and contents of Wykes & Reeder, 2005); King's College London event pages (training); the 2017 trial's declaration (CIRCuiTS ownership); the repository record of the Bowie et al. citation; and the Columbia profile and a secondary description (NEAR session structure). The 2005 CRT book text, the CIRCuiTS manual and Medalia's NEAR therapist guide are not drawn on here, so session-level detail from them stays marked [uncertain].

What it is. Cognitive remediation (CR) is a structured, therapist-delivered training of thinking skills (attention, memory, executive functions such as flexibility and planning) for people whose cognitive difficulties limit everyday functioning, chiefly people with schizophrenia and other psychoses. The Cognitive Remediation Experts Workshop (CREW, Florence 2010) definition, as cited by its developers, describes it as "a behavioural training-based intervention to improve cognitive processes" with the aim of durable benefits on community functioning. [source: Reeder et al. 2017; Bowie et al. 2020]
How change is thought to happen. Change comes from four combined ingredients: (1) a trained therapist who facilitates; (2) repeated, graded cognitive exercise (massed practice); (3) learning and monitoring efficient problem-solving strategies, i.e. metacognition, knowing and regulating one's own thinking; and (4) deliberate procedures that carry gains into daily life and personal goals. Computer training alone is not regarded as CR. [source: Bowie et al. 2020]
CRT (paper-and-pencil). Developed from the Delahunty and Morice programme and refined at King's College London by Til Wykes and Clare Reeder. A therapist works one-to-one through graded tasks in three modules (cognitive flexibility, working memory, planning), teaching "strategic information processing" in an errorless-learning environment and linking strategies to real-life goals. [source: Wykes et al. 2007; Tchanturia et al. 2007 for the Delahunty and Morice origin]
CIRCuiTS (computerised, therapist-supported). A web-based programme from the same King's College group, built around a metacognitive model: users estimate task difficulty, choose strategies, then rate how useful the strategies were; the therapist develops strategies with the person and bridges them to real goals. It can be used one-to-one, in small groups, or for independent homework. Tasks have up to 15 difficulty levels with automatic adjustment designed to keep success high; the therapist can change the order of work, repeat or skip tasks, and follow progress remotely through the user's profile. The intellectual property is jointly owned by Til Wykes, Clare Reeder and King's College London; the software was built by the company Spika. [source: Reeder et al. 2016; Reeder et al. 2017 incl. declaration of interest; NIHR Evidence 2024; Italian CIRCuiTS study, PMC6853079]
Who delivers it; regulation. CR is not itself a regulated profession. In the King's College trials therapists were trained, supervised graduate or assistant psychologists; King's College London's own CRT workshop is aimed at people with a psychology degree or equivalent plus experience of working with psychosis. In an Italian CIRCuiTS study, psychiatric rehabilitation technicians delivered it after training by a psychiatrist who had trained at King's College London. The expert group requires therapists who understand cognition, how deficits show in mental disorders and how cognition affects daily functioning, and recommends structured training or mentorship otherwise. In the UK, practitioner psychologists are registered with the HCPC; whether occupational therapists (HCPC) and mental health nurses (NMC) routinely deliver CR in services was not verified [uncertain]. A trained psychotherapist can deliver CR after programme-specific training, under supervision. [source: Wykes et al. 2007; Reeder et al. 2017; KCL CRT training page 2018; PMC6853079; NIHR PGfAR 2024; Bowie et al. 2020]
Evidence and guideline status (attributed). NICE guideline NG181, Rehabilitation for adults with complex psychosis (19 August 2020), recommendation 1.8.13, in the section on engagement in community activities including leisure, education and work: "Consider providing a cognitive remediation intervention alongside vocational rehabilitation services." NG181 defines cognitive remediation as a manualised intervention to improve cognitive function. NIHR Evidence (October 2024) reports that NICE does not recommend CR for early psychosis. NICE CG178 (2014) did not recommend it routinely, which commentators noted [source: NICE NG181; NIHR Evidence 2024; Taylor & Perera 2015; exact CG178 wording: uncertain]. SIGN 131 is quoted as saying CR "may improve cognitive outcomes" with limited evidence of transfer to social functioning [source: Taylor & Perera 2015]. In the ECLIPSE trial in early psychosis, one-to-one and group CIRCuiTS improved goal attainment and global cognition against usual care at the end of therapy, independent use did not, and benefits had faded by 6 months; both therapist formats were judged likely cost-effective [source: NIHR Evidence 2024; NIHR PGfAR 2024].

2. Framework

CR is a time-limited programme with a front-loaded assessment and engagement phase, a long massed-practice phase in which strategy work and transfer run throughout, and a planned ending. Phase labels below are a practical synthesis of the developers' descriptions; CIRCuiTS itself presents a five-stage "metacognitive journey": introduction, goals, strategies, daily life, achievements. [source: Reeder et al. 2016; synthesis for phase grouping]

Format and dose (as published)

CRT trial: 40 face-to-face one-to-one sessions, at least three a week, about 12 weeks (mean 36.9 received). [source: Wykes et al. 2007]
CIRCuiTS trial: up to 40 sessions of up to an hour, at least three a week over at most 12 weeks; completers averaged about 45 minutes and roughly 5 tasks per session; therapists also allocated independent sessions. [source: Reeder et al. 2017]
CIRCuiTS feasibility work: 20–40 sessions, several a week, up to 12 weeks; service users differed in preferring shorter-and-more-frequent or longer-and-fewer sessions. [source: Reeder et al. 2016]
ECLIPSE: up to 42 sessions; one-to-one about twice weekly; groups of up to four, three times a week for 12 weeks; independent arm with up to 30 minutes of therapist access weekly. [source: NIHR Evidence 2024; NIHR PGfAR 2024]
Expert group: usually at least about 20 hours, 40 or more common, two to three sessions a week preferred. [source: Bowie et al. 2020]

Phase A – Referral, assessment and engagement (about sessions 1–3)

Goals: confirm suitability (clinically stable enough to attend and concentrate; cognitive difficulties linked to everyday problems); build a strengths-and-difficulties profile from cognitive testing and early task performance; explain the rationale; set collaborative real-world goals. [source: Bowie et al. 2020; Reeder et al. 2017; ECLIPSE recruited clinically stable people]
Move on when: the person understands the rationale, has at least one personally meaningful goal broken into small steps, and has completed early tasks with high success. [synthesis]

Phase B – Massed practice with strategy development (bulk of sessions)

Goals: graded practice of attention, memory and executive tasks at a level that keeps success high; identify, try, record and rate strategies; review goals regularly. In CIRCuiTS, abstract tasks dominate early and more complex real-life "exercises" (work, social situations, cooking, shopping, travelling) are added gradually. In CRT, tasks move through the flexibility, working memory and planning modules, graded from extremely easy to easy. [source: Reeder et al. 2016; Reeder et al. 2017; Wykes et al. 2007]
Move on (raise difficulty) when: performance is consistently highly successful; adaptive software examples step up after consecutive high scores and down after low scores. [source: Reeder et al. 2017; Bowie et al. 2020]

Phase C – Transfer and daily life (runs alongside B, emphasised in the second half)

Goals: apply strategies to the person's goals in vivo (e.g. shopping, job applications, recipes, using diaries or lists); link with vocational or skills programmes where available. [source: Wykes et al. 2007; Reeder et al. 2016; Bowie et al. 2020]

Phase D – Ending, consolidation and maintenance (last 2–4 sessions)

Goals: review achievements and the personal strategy set; plan continued use; consider maintenance sessions. Wykes recommends longer therapy time and periodic maintenance sessions, and suggests starting individually, then group, then independent practice. In CRT for anorexia, therapist and patient exchange reflective letters at the end. [source: NIHR Evidence 2024; Tchanturia et al. 2007]

3. Guiding principles

Therapist facilitation is essential. You are the active ingredient; never hand over software without a therapeutic relationship and coaching. [source: Bowie et al. 2020; NIHR Evidence 2024]
Errorless learning. Keep tasks easy enough that the person rarely fails; mistakes are prevented rather than corrected afterwards. [source: Wykes et al. 2007]
Graded difficulty with high success. Increase difficulty only when performance is consistently successful; step back after a run of low scores. [source: Reeder et al. 2017; Bowie et al. 2020]
Massed practice. Many repetitions build mastery and give material for strategy work; aim for regular sessions several times a week. [source: Bowie et al. 2020; Reeder et al. 2017]
Strategy over score. The point is learning efficient, personal ways of thinking, not winning the task. [source: Wykes et al. 2007; Bowie et al. 2020]
Metacognition. Help the person know their own strengths and difficulties, plan, monitor and review their thinking. [source: Reeder et al. 2016]
Scaffolding. Give enough support (prompts, suggested strategies) for success, then withdraw it as competence grows. [source: Reeder et al. 2017; Bowie et al. 2020]
Individualisation. Tailor tasks, strategies and goals to the person's profile and life. [source: Wykes et al. 2007; Reeder et al. 2016]
Collaboration and goal focus. Goals are set together, tied to community functioning and broken into measurable short steps; review them regularly. [source: Bowie et al. 2020; Reeder et al. 2016]
Transfer is planned, not hoped for. Every session links task strategies to daily life. [source: Wykes et al. 2007; Reeder et al. 2017]
Intrinsic motivation. Praise process (effort, trying a strategy) more than performance; make the work interesting and personally relevant; give choice. [source: Bowie et al. 2020; Medalia's NEAR via Wikipedia]
Whole-person formulation of performance. Consider non-cognitive influences such as mood, sleep, medication effects, beliefs and environment. [source: Reeder et al. 2016]
Thinking style, not thought content (anorexia adaptation). In CRT for anorexia nervosa the work deliberately avoids food, weight and emotions and targets how the person thinks. [source: Tchanturia et al. 2007]
Fidelity and supervision. Work to the manual, keep session records, and take regular supervision; the trials used weekly supervision and a CRT fidelity scale. [source: Wykes et al. 2007; Reeder et al. 2017]

4. Intervention inventory

The inventory follows the course of a programme. Task materials (CRT task sheets, CIRCuiTS software) are licensed by their developers and are not reproduced; tasks are described by type only. All example language is illustrative unless quoted. [source for section: Wykes et al. 2007; Reeder et al. 2016, 2017; Bowie et al. 2020; NIHR 2024]

4.1 Referral and suitability check

Purpose / when: Before starting; decide whether CR fits now. ECLIPSE recruited clinically stable people within Early Intervention services; for complex psychosis, NICE NG181 (rec. 1.8.13) advises considering CR alongside vocational rehabilitation, so check whether vocational support can run in parallel. [source: NIHR PGfAR 2024; NICE NG181]
Steps: (1) Ask the care team what everyday problems seem cognitive (losing track at work, forgetting appointments, trouble planning meals or journeys). (2) Check current stability, acute symptoms and risk with the care coordinator or psychiatrist. (3) Check practical capacity to attend several sessions a week for about 12 weeks, and any sensory or literacy limits that affect task choice. (4) Agree who holds overall care and how you will feed back. [synthesis based on the cited trial formats]
Example language (illustrative): "Many people find that concentration or memory gets in the way of things they want to do. This programme trains those skills and helps you use them in your own life. It means meeting two or three times a week for about three months."
Watch for: acute relapse, high distress or new risk (postpone and liaise); expectations that CR will cure symptoms; practical barriers that will later look like non-adherence.

4.2 Cognitive assessment and strengths-and-difficulties profile

Purpose / when: At baseline and end; to inform goals and task selection. [source: Bowie et al. 2020]
Steps: (1) Use standard neuropsychological measures available in your service (the trials used, for example, digit span for working memory, a card-sorting test for flexibility and a behavioural planning battery), administered only by those qualified to use them. (2) Add early CR task performance as a working profile; CIRCuiTS uses its tasks to identify strengths, difficulties and factors affecting performance. (3) Share the profile in plain language, starting with strengths. (4) Repeat at the end to review change. [source: Wykes et al. 2007; Reeder et al. 2017; Bowie et al. 2020]
Example language (illustrative): "Your memory for things you see looks like a strength. Switching between two things at once seems harder. That gives us a place to start."
Watch for: the person reading results as a verdict on intelligence; test anxiety; using scores rather than daily-life examples to set goals.

4.3 Orientation and rationale

Purpose / when: Sessions 1–2, and whenever motivation dips. The expert group asks therapists to deliver the orientation and explain each exercise before training. [source: Bowie et al. 2020]
Steps: (1) Explain the idea: thinking skills can be trained through practice plus better strategies, and the aim is life goals, not test scores. (2) Explain the format: easy tasks first, gradual steps up, strategy talk every session, practice between sessions. (3) Demonstrate one task together. (4) Invite questions and concerns (e.g. "is this school?").
Example language (illustrative): "We start with tasks that feel easy on purpose. The aim is not to catch you out but to practise good ways of thinking until they become habits."
Watch for: feeling patronised by easy tasks (explain errorless learning); worries about being judged; fatigue in the first session.

4.4 Collaborative goal setting

Purpose / when: Early, then reviewed regularly. Goals link cognition to community functioning; ECLIPSE used personal social goals measured with the Goal Attainment Scale. [source: Bowie et al. 2020; Reeder et al. 2016; NIHR PGfAR 2024]
Steps: (1) Ask what the person wants to be able to do in the next months (work, study, cooking, travel, friendships). (2) Identify which thinking skills each goal needs. (3) Break each goal into measurable short-term steps. (4) Record goals and review them at set points, adjusting as needed. Goals can be restorative (rebuild a skill), rehabilitative (work around a difficulty) or habilitative (learn something new). [source: Bowie et al. 2020]
Example language (illustrative): "You'd like to cook a meal for your sister. What part of that is hardest: remembering the steps, keeping track of timing, or getting started?"
Watch for: goals that are too large or set by others; no clear link between goal and cognition; goals forgotten after week 2 (put them on each session record).

4.5 Graded task practice in an errorless-learning environment

Purpose / when: Every session; the core of massed practice. CRT tasks are graded from extremely easy to easy so that errors are avoided. [source: Wykes et al. 2007]
Steps: (1) Choose a task level the person will almost certainly succeed at. (2) Before starting, make sure instructions are understood; give a model or example if needed. (3) Prevent errors by prompting at points where mistakes are likely, rather than waiting for failure. (4) Repeat the task type with small variations. (5) Step up one level only after consistent success. [source: Wykes et al. 2007; steps 2–3 synthesis]
Example language (illustrative): "Before you start, tell me what the rule is in your own words. Good. If you feel unsure halfway through, stop and check with me."
Watch for: repeated errors (drop a level, add support); boredom (vary task, increase pace); the person guessing rather than using a strategy.

4.6 CRT module: cognitive flexibility

Purpose / when: For difficulty shifting between ideas or rules; the module practises engaging, disengaging and re-engaging with a cognitive set, or switching between two sets. [source: Wykes et al. 2007]
Steps: (1) Start with a task with one simple rule. (2) Introduce a second rule and practise alternating on cue. (3) Ask what helps the switch (saying the current rule, marking the switch point). (4) Increase the number of switches and reduce cues gradually. (5) Link to a life example where switching is needed. [steps synthesis on the published module description]
Example language (illustrative): "When the rule changes, what could you do to remind yourself which rule you are on now?"
Watch for: perseveration on the old rule; frustration at switches; strategies that work in session but not outside.

4.7 CRT module: working memory

Purpose / when: For difficulty holding and using information; the module practises holding two sets of information at once and transforming what is held. [source: Wykes et al. 2007]
Steps: (1) Begin with a short amount of information to hold. (2) Teach strategies such as grouping items, rehearsing, or linking items into a picture or story. (3) Add a transformation (reorder, combine) once holding is reliable. (4) Ask which strategy worked best and when it could be used (phone numbers, instructions, shopping). [steps and strategy examples synthesis]
Example language (illustrative): "That was a lot to keep in mind. What could you do with the items to make them easier to hold?"
Watch for: overload (reduce amount); anxiety rising with load; reliance on one strategy that doesn't suit all tasks.

4.8 CRT module: planning

Purpose / when: For difficulty organising steps toward a goal; the module practises planning a sequence of moves using sub-goals and organising information. [source: Wykes et al. 2007]
Steps: (1) Present a simple goal-directed task. (2) Ask the person to state the goal and plan before acting. (3) Break into sub-goals and write them down. (4) Act, then compare outcome with plan. (5) Transfer the plan-do-review approach to a real task (a journey, a meal, an errand). [source: plan, implement, review approach in Reeder et al. 2016; remaining steps synthesis]
Example language (illustrative): "Before you begin, what's the end point? What's the first small step that gets you nearer to it?"
Watch for: impulsive starts (pause and plan aloud); rigid plans that can't adapt; skipping the review.

4.9 CIRCuiTS pre-task metacognitive step

Purpose / when: Before every CIRCuiTS task; builds awareness and planning. Users estimate difficulty and duration and identify strategies before starting. [source: Reeder et al. 2016]
Steps: (1) Ask the person to estimate how hard the task will be and how long it will take. (2) Ask which strategy they will use; offer one if they cannot yet generate one. (3) Make sure the strategy is recorded. [source: Reeder et al. 2016; Bowie et al. 2020 on offering strategies]
Example language (illustrative): "How tricky do you think this one will be? What could help you with it?"
Watch for: consistent over- or under-estimation (useful metacognitive information); "no idea" answers (offer two choices).

4.10 CIRCuiTS post-task review and strategy rating

Purpose / when: After every task; closes the metacognitive loop. Users see their score, rate actual difficulty and how useful their strategies were. [source: Reeder et al. 2016]
Steps: (1) Look at the result together. (2) Compare estimated and actual difficulty. (3) Rate the strategy's usefulness. (4) Decide whether to keep, adapt or replace it. (5) Ask where else it could help.
Example language (illustrative): "It was easier than you expected. Was that the strategy, or something else?"
Watch for: attributing success to luck and failure to oneself (reframe toward strategy); rushing past the review.

4.11 Building a personal strategy set (strategy coaching)

Purpose / when: Throughout; strategy use is the main metacognitive target. Therapist and user jointly develop a personalised, flexible set. [source: Reeder et al. 2016, 2017]
Steps: (1) Notice and name strategies the person already uses (many do not recognise them). (2) Identify inefficient ones. (3) Encourage self-generated strategies; suggest strategies when the person cannot yet generate them. (4) Record each strategy with when it helps. (5) Review the list regularly; in groups, share strategies. [source: Bowie et al. 2020]
Example language (illustrative): "You said the numbers out loud in pairs. That's a strategy. Let's write it down and call it 'pairing'."
Watch for: strategies that are generic rather than personal; a list that grows but is never used outside; dependence on the therapist's suggestions (start fading).

4.12 Scaffolding and difficulty titration

Purpose / when: Every session; keeps success high while challenge rises. Therapists add scaffolding so participants perform successfully and consistently; difficulty rises with highly successful performance. [source: Reeder et al. 2017]
Steps: (1) Start with high support (demonstrations, prompts, suggested strategies). (2) Reduce support step by step as success holds. (3) Raise task level when performance is consistently high; step down after repeated low scores (adaptive software uses accuracy thresholds). (4) Note on the session record what support was needed. [source: Bowie et al. 2020; Reeder et al. 2017]
Example language (illustrative): "Last time I gave you a hint at the start. Shall we try this one without it and see?"
Watch for: support never fading; difficulty jumps causing failure runs; the person avoiding harder levels.

4.13 Feedback and process-focused praise

Purpose / when: During and after tasks; supports intrinsic motivation and prevents negative self-attributions. [source: Bowie et al. 2020]
Steps: (1) Give feedback on accuracy and speed, trial by trial or after sets. (2) Praise engagement and trying new strategies more than scores. (3) After a low score, attribute to task and strategy, not ability.
Example language (illustrative): "I liked how you stopped and checked the rule before going on. That's exactly the habit we're building."
Watch for: praise that feels hollow or childish; the person fixating on scores.

4.14 From abstract tasks to real-life exercises (CIRCuiTS)

Purpose / when: Across the programme. Abstract tasks (neutral content such as numbers or shapes) target specific functions and dominate early; "exercises" are more complex, ecologically valid tasks drawing on several functions, especially executive, in five areas: work, social situations, cooking, shopping, travelling. They are introduced gradually. [source: Reeder et al. 2016, 2017]
Steps: (1) Build the programme in the administrator interface from tasks matched to the profile and goals. (2) Begin mainly with abstract tasks. (3) Introduce exercises from the life areas most relevant to the person's goals. (4) Ask how the strategy used in the abstract task applies in the exercise. [source: Reeder et al. 2016; step 4 synthesis]
Example language (illustrative): "This shopping task uses the same planning strategy you used on the shapes. Want to try it here?"
Watch for: exercises introduced before strategies are stable; life areas that are irrelevant or upsetting for this person.

4.15 Bridging and in vivo transfer

Purpose / when: Every session and between sessions; the step that turns cognitive gains into functioning. CRT therapists encouraged applying strategies to real-life goals such as shopping; CIRCuiTS therapists prompt links to everyday life and in vivo rehearsal. [source: Wykes et al. 2007; Reeder et al. 2016, 2017]
Steps: (1) End each task review by asking where the strategy could help this week. (2) Agree one small real-life try linked to a goal step. (3) Plan it concretely (when, where, which strategy, what aid such as a list or diary). (4) Review it next session. (5) Use role-play or staged real tasks when discussion alone is not enough. (6) Where possible, join up with vocational rehabilitation or skills training, which improves transfer. [source: Bowie et al. 2020; Reeder et al. 2016 on memory aids]
Example language (illustrative): "You used 'write it down in steps' today. Where in your week could that save you trouble? Let's pick one time and plan it."
Watch for: bridging done as an afterthought in the last minute; tries that are too big; negative symptoms reducing follow-through (ECLIPSE found negative symptoms reduced transfer to goals). [source: NIHR PGfAR 2024]

4.16 Independent (homework) sessions

Purpose / when: Between therapist sessions, once the person can work with low support; therapists allocate tasks for independent completion to support scaffolded learning and massed practice. [source: Reeder et al. 2017]
Steps: (1) Choose tasks already mastered with minimal support. (2) Agree when and where (online or offline install). (3) Review results and strategy ratings together next time. Note that independent use alone, with little therapist contact, showed no benefit over usual care in ECLIPSE. [source: Reeder et al. 2016; NIHR Evidence 2024]
Example language (illustrative): "Would you like to do two of these on your own before Thursday? We'll look at how they went together."
Watch for: low uptake (only a minority used independent sessions in the CIRCuiTS trial); practising without strategies; discouragement from unsupported failure. [source: Reeder et al. 2017]

4.17 Group format

Purpose / when: As an alternative to one-to-one; ECLIPSE ran groups of up to four with one therapist, with outcomes similar to one-to-one. [source: NIHR Evidence 2024]
Steps: (1) Each member works on their own programme. (2) The therapist circulates for pre- and post-task metacognitive questions. (3) Build in strategy-sharing time. (4) Adapt praise and feedback to members' different paces. [source: Bowie et al. 2020; steps 1–2 synthesis]
Example language (illustrative): "Sam found a neat trick for remembering the order. Sam, would you be willing to share it?"
Watch for: comparison and shame across differing levels; quieter members getting less coaching.

4.18 Monitoring non-cognitive influences and liaising with the team

Purpose / when: Throughout; CIRCuiTS strategy work takes account of mood, sleep, medication effects, beliefs and environment. [source: Reeder et al. 2016]
Steps: (1) Briefly check sleep, mood, stress and side effects at session start. (2) If performance drops, consider these before raising support. (3) Pass concerns such as sedation, slowed thinking or new symptoms to the prescriber or care coordinator; never advise any change to medication. (4) Record what you passed on. [synthesis]
Example language (illustrative): "You seem more tired than usual. Has anything changed with sleep or with your tablets? It might be worth mentioning to your doctor; I can let the team know if you like."
Watch for: early warning signs of relapse; risk; side effects affecting attention.

4.19 Ending, consolidation and maintenance

Purpose / when: The last few sessions; consolidates learning and plans maintenance. [source: NIHR Evidence 2024; Reeder et al. 2016]
Steps: (1) Review the goal list and the strategy set together (CIRCuiTS ends on an "achievements" stage). (2) Repeat the baseline assessment where used. (3) Write down the strategies to keep using and where. (4) Plan follow-on: independent practice, linked vocational or skills support, or maintenance sessions as Wykes recommends. (5) Acknowledge feelings about ending; CIRCuiTS users reported relief, achievement and some sadness, which they felt able to manage. [source: Reeder et al. 2016; NIHR Evidence 2024]
Example language (illustrative): "Look at this list of strategies you've built. Which three will you carry with you?"
Watch for: gains fading (ECLIPSE benefits were not maintained at 6 months, so plan boosters); loss of structure after frequent sessions.

4.20 Therapist fidelity and supervision

Purpose / when: Throughout delivery. Trials used manuals, session records, task sheets, observation, weekly supervision and a CRT fidelity scale (Stenmark, 2006, modified) rated on recorded sessions. [source: Wykes et al. 2007; Reeder et al. 2017]
Steps: (1) Keep a record each session of tasks, levels, strategies and bridging. (2) Record sessions (with consent) for supervision. (3) Use a fidelity checklist in supervision. [source: Reeder et al. 2017]
Example language (illustrative, to a client): "With your agreement I'd like to record a session so my supervisor can help me make this work as well as possible for you."
Watch for: drift into general talking therapy or into unsupported drill.

4.21 Remote delivery

Purpose / when: When travel is a barrier. A separate study reported remote CIRCuiTS delivery as acceptable and convenient. In an Italian study, the first three weeks had three therapist-led sessions a week; after that one of the three weekly sessions was done independently at home, and about 30% of all sessions were completed from home; participants noted difficulties to discuss at the next meeting. [source: NIHR Evidence 2024; PMC6853079]
Steps: Agree device, connection and privacy; keep the same pre- and post-task structure and bridging; agree a crisis and contact plan with the team. [synthesis]
Example language (illustrative): "Let's check you can see the task and hear me clearly before we start."
Watch for: technical failures eroding motivation; less visibility of distress.

4.22 Other programmes in brief

NEAR (Neuropsychological and Educational Approach to Remediation; Alice Medalia, Columbia University). A model grounded in how people learn and designed to enhance intrinsic motivation to learn; it teaches clinicians to evaluate cognitive training programmes through neuropsychology, neuroplasticity and motivational theory. Columbia describes it as used with people diagnosed with schizophrenia, depression, bipolar disorder, ADHD and mild cognitive impairment, in psychiatric, educational, forensic and supportive housing settings. Session structure as a software vendor's blog describes it (secondary source): usually a group; the clinician opens by naming a shared goal about one cognitive skill; members practise that skill on printed or digital exercises (one workstation each) while the clinician supervises and helps; the group then discusses which strategies they used, which worked and what to refine; a bridging part uses hands-on, real-life activities (e.g. planning a dinner with friends, booking transport) to see which strategies transfer; sessions run about 90 minutes and can be shortened or lengthened; individual and video-based versions exist. The therapist guide, Cognitive Remediation for Psychological Disorders (Oxford University Press, Treatments That Work; 2009, 2nd edition 2017), is not drawn on here, so session frequency, group size and how activities are matched to each learner are [uncertain]. Example language (illustrative): "Today we're all working on keeping attention steady. Which of these activities looks most interesting to you?" Watch for: activities chosen by the therapist alone, which undermines the motivational design; bridging squeezed out by exercise time [synthesis]. [source: Columbia Psychiatry profile of Alice Medalia; Happyneuron blog "What is NEAR?" 2020; Wikipedia, Alice Medalia; Oxford Academic book page]
CRT for anorexia nervosa (Kate Tchanturia and colleagues, Maudsley/King's). Adapted the Delahunty and Morice set-shifting work to target thinking style (flexibility and "bigger picture" or global thinking) rather than food, weight or emotion. The early case series used ten 45-minute pencil-and-paper sessions alongside inpatient treatment; tasks included illusions, switching tasks and route-finding, with later additions such as summarising text into a headline and prioritising information. After each task the therapist asks the person to reflect on their thinking style and its links with daily life; small between-session behavioural experiments (e.g. taking a different route, changing a routine) were proposed; therapist and patient exchange reflective letters at the end. The stance is motivational and non-judgemental. Example language (illustrative): "What does that task tell you about how you tend to think? Where else do you notice that?" Watch for: excessive detail-focus and perfectionism on tasks; wanting more help applying skills to life. [source: Tchanturia et al. 2007] A resource pack for children and adolescents with eating disorders exists (second edition) [uncertain: not verified].

4.23 The psychotherapist's role alongside a CR programme

Purpose / when: When you are not the CR therapist but work with the person. [source for rationale: Bowie et al. 2020 on supplemental activities]
Steps: (1) Recognise cognitive difficulties that block therapy or life goals and suggest referral to a CR programme via the care team. (2) Support informed choice: explain what CR involves (frequency, duration, therapist role) and what it can realistically offer. (3) With consent, agree with the CR therapist on the person's goals and strategies, so you can prompt the same strategies in your sessions (e.g. written summaries, plan-do-review). (4) Adapt your own therapy to the cognitive profile (shorter chunks, written aids, more repetition). (5) Integrate psychological work on beliefs about ability, low self-esteem or hopelessness that limit transfer. (6) Pass on changes in mental state or risk to the care team. [synthesis]
Example language (illustrative): "Your remediation therapist mentioned you've been using a checklist strategy. Could we use that here when we plan your week?"
Watch for: competing or confusing strategies across services; therapy load becoming too much alongside three CR sessions a week.

4.24 Training routes

The King's College trials trained graduate psychologists through theory, observation and supervised practice, with weekly supervision. [source: Wykes et al. 2007]
ECLIPSE developed an online e-learning programme for CIRCuiTS therapists and piloted it with volunteers from eight NHS trusts; it was feasible and acceptable but took longer than expected, and adaptations were being made. [source: NIHR PGfAR 2024]
The expert group recommends structured training or mentorship for clinicians lacking background in cognition. [source: Bowie et al. 2020]
Medalia runs training workshops for clinicians in cognitive remediation techniques and founded, and still directs, an annual conference on cognitive remediation in psychiatry, now hosted by Columbia. The founding year differs between sources (1996 per Wikipedia, 1998 per Columbia) [uncertain]. [source: Columbia Psychiatry profile; Wikipedia, Alice Medalia]
King's College London's Institute of Psychiatry, Psychology & Neuroscience has run a two-day intensive small-group CRT workshop (e.g. 13–14 June 2018, Dr Matteo Cella and Dr Rumina Taylor; up to 20 places; £500). It combined teaching, live demonstrations, video, group and pair work, role-play and practice on CRT tasks; covered the evidence, theory, a metacognitive model linking thinking skills to everyday living skills, core skills, assessment and formulation, therapist competences and fitting therapy into services; introduced both CIRCuiTS and the paper-and-pencil method; and aimed to let trainees begin therapy under appropriate supervision. Entry: a psychology degree or equivalent plus experience with psychosis. CIRCuiTS IP is jointly owned by Wykes, Reeder and King's College London, and a 2010 CIRCuiTS manual was published by King's College London; the Italian version was adapted with Spika, which supplied a translation manual. Current course dates and costs, and how services obtain CIRCuiTS access or a licence, were not found: contact the developers at King's College London [uncertain]. [source: KCL CRT training event pages (2018); Reeder et al. 2017, declaration of interest and references; PMC6853079]

5. Handling problems

Guidance below is marked [source] where it rests on the developers' or expert group's papers and [synthesis] where it is the guide's own practical advice.

Low attendance and dropout. ECLIPSE reported substantial dropout (defined as missing six sessions: 38% in groups, 23% one-to-one). Response: agree session times that fit the person's routine; send reminders; offer the format preferences service users described (shorter and more frequent, or longer and less frequent); start one-to-one and move to group later as Wykes suggests; contact after a missed session without blame. [source: NIHR Evidence 2024; Reeder et al. 2016; synthesis for reminders and contact]
"This is pointless / childish" (resistance to easy tasks). Explain errorless learning and that early ease is deliberate; tie each task to a stated goal; offer choice of tasks; move faster through easy levels when success is consistent. [source: Wykes et al. 2007; Bowie et al. 2020; synthesis for wording]
Stuck: no progress on levels. Check non-cognitive factors (sleep, mood, side effects, stress); review whether the strategy fits the task; step down a level and re-scaffold; suggest a strategy outright if self-generation is not working. [source: Reeder et al. 2016; Bowie et al. 2020]
Stuck: good task scores, no change in daily life. Bridging is too thin. Spend more of each session on real-life application, set smaller in vivo tries, use role-play or staged tasks, and link with vocational or skills support. Negative symptoms reduce transfer; ECLIPSE authors suggest more sessions and better integration of skills into daily life. [source: Bowie et al. 2020; NIHR PGfAR 2024]
Overwhelm, frustration or fatigue in session. Stop the task; drop the level; shorten sessions or add breaks; return to a task the person masters for a success experience; praise effort. [synthesis drawing on errorless learning and process praise principles in Wykes et al. 2007; Bowie et al. 2020]
Negative self-attributions ("I'm stupid"). Attribute outcomes to task difficulty and strategy, not ability; point to recorded strategies and past successes; where self-esteem work is needed, involve the psychotherapist or integrate brief cognitive work. [source: Bowie et al. 2020 on attributions; synthesis for integration]
Non-adherence to independent sessions. Expect low uptake (a minority used them in the CIRCuiTS trial); keep independent tasks to mastered levels; review them in session so they count; do not rely on independent practice alone. [source: Reeder et al. 2017; NIHR Evidence 2024]
Over-reliance on the therapist. Fade prompts systematically; ask the person to state the strategy before you offer one; move toward group or independent formats near the end. [source: Reeder et al. 2017 on scaffolding; NIHR Evidence 2024 on sequencing; synthesis for fading steps]
Ruptures (feeling tested, judged or patronised). Name it, apologise for anything that felt demeaning, re-explain that the work is collaborative and goal-led, and give the person more control over task choice and pace. [synthesis]
Group problems (comparison, shame, dominance). Keep each member on their own programme; frame strategy sharing as swapping tips, not ranking; adjust praise to individual pace; check in privately with quieter members. [source: Bowie et al. 2020 on differing pace; synthesis for responses]
Relapse, rising symptoms or risk during the programme. Pause or slow CR; inform the care coordinator or psychiatrist the same day if risk is present; follow the team's crisis plan; resume when stable. Never advise on medication; pass on observed side effects to the prescriber. [synthesis; ECLIPSE reported adverse events similar across arms with no serious adverse events linked to therapy: NIHR Evidence 2024]
Gains fade after ending. ECLIPSE benefits were not seen at 6 months. Plan maintenance or booster sessions, continued independent practice of mastered tasks, and linked vocational or education support. [source: NIHR Evidence 2024; NIHR PGfAR 2024]
Service and implementation barriers. ECLIPSE authors call for a trained therapist, group or one-to-one delivery with team and training support, flexible leadership and protected time; commentators noted services may not prioritise CR until national guidance and audit include it. [source: NIHR PGfAR 2024; NIHR Evidence 2024]
Anorexia nervosa: detail focus and perfectionism. Patients gave excessive detail on figure tasks; the revised approach added global-thinking tasks (headlines, prioritising). Patients wanted more guidance applying skills, so build in between-session behavioural experiments and discuss them. Keep focus on thinking style, not food or weight, and coordinate with the eating disorder team on medical monitoring. [source: Tchanturia et al. 2007; synthesis for team coordination]
Remote sessions: lost connection or reduced visibility of distress. Agree a fallback phone number and what happens if the call drops; check privacy at the start; ask directly about mood more often. [synthesis]

Sources

Web sources:

Books and papers cited (book texts not drawn on unless stated):

Wykes, T. & Reeder, C. (2005). Cognitive Remediation Therapy for Schizophrenia: Theory and Practice. Routledge, 1st edn, 328 pp., ISBN 9781583919712. Bibliographic details and contents verified on the publisher page: Part III, "The process of therapy", has chapters on a theoretical model for CRT, the content and process of therapy, assessment and formulation, and case studies. The book text is not drawn on here, so no session techniques are attributed to it here; the CRT module descriptions rest on Wykes et al. 2007 [uncertain for book-level detail].
Medalia, A., Revheim, N. & Herlands, T. (2009). Cognitive Remediation for Psychological Disorders: Therapist Guide. Oxford University Press. [as cited on Wikipedia]
Medalia, A. & Revheim, N. (2002). Dealing with Cognitive Dysfunction Associated with Psychiatric Disabilities. OMH Press. [as cited on Wikipedia]
Delahunty, A. & Morice, R. (1993). Original cognitive remediation programme for schizophrenia. [as cited by Tchanturia et al. 2007; title uncertain: not verified]

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