Des outils de thérapie cognitivo-comportementale pour la remédiation cognitive

Abstract

Le programme de remédiation cognitive pour la schizophrénie ou un trouble associé (RECOS) s’appuie sur plusieurs techniques et outils développés par l’approche cognitivo-comportementale. L’évaluation des répercussions fonctionnelles (ERF) permet tout d’abord de saisir l’impact cognitif, comportemental et émotionnel des déficits cognitifs mesurés par une évaluation neuropsychologique détaillée. Au terme de l’évaluation, chaque participant est invité à fixer des objectifs concrets susceptibles d’améliorer sa qualité de vie. Durant les exercices d’entraînement cognitif, il est encouragé à analyser les résultats obtenus au regard des stratégies qu’il a lui-même déployées. Ce travail de « restructuration métacognitive » est fondamental car il lui permet d’identifier les raisons de ses échecs et de générer des stratégies alternatives afin de répondre précisément aux exigences de la tâche. Avec l’aide de son thérapeute, chaque participant visera finalement à transférer ses nouvelles compétences dans son lieu de vie afin d’atteindre l’objectif fixé. The Cognitive Remediation Program for Schizophrenia and other related disorders (RECOS) aims to improve participants’ skills in one or more cognitive areas in a specific and personalized way. It is based on theoretical principles derived not only from the fields of cognitive psychology, neuropsychology and educational psychology, but also from the cognitive behavioral approach. The program begins with an evaluation phase using psychopathological scales and neuropsychological tests. The evaluation of the functional repercussions then allows us to understand the cognitive, behavioral and emotional impact of measured cognitive deficits. Each participant is then asked to set concrete goals likely to improve their quality of life. Before starting the cognitive training, a session of psychoeducation emphasizes the importance of treating cognitive difficulties to promote independence and increase the chances of social and professional reintegration. The remedial phase itself is designed to improve the deficit skills while promoting the transfer and generalization of skills learned in therapy to everyday life. The objectives set at the beginning of the program and the clinical benefits of cognitive work and cognitive remediation are evaluated at the end of fourteen weeks of cognitive training. Besides the desire to measure progress observed with psychopathological scales, the RECOS program borrows concepts of empathy, positive reinforcement and collaborative relationships from cognitive behavioral therapy. From a neurocognitive point of view, the RECOS program develops the ability to change personal thought processes since each participant is requested to analyze performance against strategies they have themselves deployed. This work of “metacognitive restructuring” is important because patients tend to think that they have no control over their difficulties. They commonly consider that their failures are simply due to the fact that they suffer from schizophrenia. This sense of “learned helplessness” suggests that the drop in performance is due to repeated failures and the subjective impression that the situation is not controllable. On the contrary, the patient must understand that their successes are due to the conscious and systematic use of relevant problem-solving strategies and that their failures are due to strategies which are ineffective or inappropriate for the situation. Their sense of self-efficacy and motivation is then increased on a long-term basis. Therefore, the therapist's role is to help each participant to identify the strategies used, compare them with results and restructure these metacognitive processes to achieve the desired result. Based on our understanding, this work includes three metacognitive restructuring phases. The first stage of self-assessment is based on the techniques of “current and retrospective introspection” and work and observation by the therapist. The second step is to analyze the results in light of the chosen strategies. When the result is satisfactory, the therapist positively encourages the participant by underlining the relevance of the strategies used. If this is not the case, they are asked to generate and apply new strategies for problem solving. The results obtained with these alternative strategies ultimately determine their future use. This restructuring work is fundamental because it allows everyone to identify the reasons for their failures and to seek alternative solutions to respond appropriately to the requirements of the task. The therapist then helps each participant transfer these newly-acquired skills to their own environment to achieve their set goals. Thus, the RECOS therapy program aims to understand changes in the cognitive and metacognitive processes in each individual patient. The great heterogeneity of clinical and cognitive manifestations of schizophrenia prompted us to develop specific training modules and to work on a one-to-one basis. This personalized work is defined in terms of true functional analysis. As proposed by cognitive behavioral therapy, the results obtained after the phase of cognitive remediation are evaluated using an experimental approach with dedicated psychopathological tools and standardized tests. Due to the common use of techniques and a clinical approach based on functional objectives, cognitive remediation offered by the RECOS program seems to be able to integrate tried and tested cognitive-behavioral techniques in the field of psychosis.