Research

Cognitive remediation may promote recovery, but work is needed to fit these interventions within existing treatment program structures

Many individuals who engage with substance use disorder treatment services experience cognitive impairments, which can undermine treatment and negatively impact long-term recovery. Cognitive remediation interventions that improve memory and other key cognitive functions have been shown to improve treatment and functional outcomes, yet implementation of these interventions is limited. This research examines staff impressions of cognitive remediation implemented in their clinic and explores barriers and facilitators of its sustained use.

WHAT PROBLEM DOES THIS STUDY ADDRESS?

Cognitive impairment is highly prevalent among individuals, with studies showing rates ranging from 30-80% of patients. Cognitive impairment can be a risk factor for substance use disorder, and prolonged substance use can also negatively impact cognitive functioning and patient’s ability to benefit from treatments that require intact cognitive abilities.

Cognitive remediation interventions have been shown to improve cognitive functioning, including executive functioning – referring to a set of skills important for behavioral control and essential for addiction recovery (e.g., inhibiting behavioral responses to drug cues, implementing newly learned coping skills) and improve quality of life. However, uptake and sustained use of these interventions within substance use clinics is limited. Understanding and overcoming barriers to the implementation of cognitive remediation interventions could improve access and sustained use of these interventions within substance use treatment settings. This research highlights staff impressions before and after embedding a cognitive remediation intervention in their treatment setting, and highlights barriers and facilitators to its long-term use.

HOW WAS THIS STUDY CONDUCTED?

This study was a pre and post evaluation of 8 treatment staff members’ impressions of a cognitive remediation intervention implemented within a non-profit residential treatment center in Australia. Specifically, using semi-structured interviews, the researchers evaluated staff impressions of a cognitive remediation intervention as implemented primarily by members of the research team before the intervention started and again 6 months after it was implemented. The interviews focused on what the staff knew about the intervention, their impressions of the intervention overall, their recall of patients’ impressions of its acceptability and effectiveness, and perceived barriers and facilitators to the implementation and sustainability of the intervention long term.

The 8 staff interviews conducted before and after the intervention represented over half of the treatment staff. Recruitment ceased when it was clear to the researchers that they were not obtaining any new information during the interviews. Two of the participants in the second interview were not included in the first; all of the other participants were the same.

The intervention used in the study was the Neuropsychological and Educational Approach to Remediation (NEAR) intervention, which was delivered over 3 group sessions per week for the duration of patients’ stay (up to 3 months). Prior to the implementation of the intervention, the study staff provided the treatment center staff with information about the intervention over the course of 4 weekly staff meetings. The initial staff interviews took place after these informational sessions and before the intervention was implemented, and then again 6 months later. Staff were also invited to participate in the implementation of the intervention; only one staff member agreed, joined the study team, and received training. Implementation of the intervention also occurred at a time when the clinic was undergoing significant changes (e.g., start of a withdrawal management program, merging of other programs, changes in management and staffing). The research team did not provide detailed information about the study participants – i.e., treatment program staff.

Figure 1. Cognitive remediation game example taken from Hamzah and Khairil, 2017

WHAT DID THIS STUDY FIND?

Interviews before the intervention was implemented.

The study team found that interviewed staff were positive about the intervention overall and optimistic about its potential to offer patients something that had not yet been offered to them. Prior to the implementation, some staff commented on the perceived efficacy of the intervention, stating it could be useful for memory and other executive functions. Staff also raised feasibility and implementation concerns. For example, the lack of staff awareness about what the intervention, how it should be delivered, and how to complement the intervention for patients were among the potential limits to is efficacy and implementation. They also raised concerns about tailoring the intervention for patients with different cognitive abilities and educational backgrounds. Despite information about the intervention and trainings being provided, staff did not comment on these trainings or share why they did not participate. Staff also commented on the added “burden” of implementing a new intervention in relation to other clinic operations.

Interviews after the intervention was implemented.

Staff impressions in the second interview, 6 months post-implementation by the study staff, were described as “overwhelmingly positive,” with everyone sharing something of perceived benefit to patients in the clinic. The staff noted examples of patients identifying specific, measurable, and observable changes they noticed, including improved memory, and how pleased they were with the progress. Staff also commented on the fact that cognitive changes were more observable early on, whereas other indicators of recovery from substance use might take longer to observe. All staff members interviewed said they would like to see the intervention continued.

WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?

Previous studies have demonstrated that cognitive remediation interventions can be efficacious for patients, including those with substance use disorder. As with many promising or evidence-based interventions, there is often a research-practice gap wherein interventions that are potentially or demonstrably efficacious are not implemented effectively or are not sustainable over time. The results of this study suggest that cognitive remediation intervention within a residential treatment clinic is acceptable to clinic staff, who also noted observable benefits for patients in terms of their self-reported satisfaction with the intervention and improved cognitive functioning and memory.

Additional research of this kind could support future implementation efforts. In particular, additional research that more closely examines barriers to implementation and follow through by clinic staff, even in situations like the current study where positive impressions of the intervention did not directly translate into adoption of the intervention or implementation of it by members of the staff, could be particularly beneficial. Without staff support, the long-term feasibility and sustainability of cognitive remediation interventions are low.

LIMITATIONS
  1. Implementation concerns are largely site specific, and this study focused on perceptions of feasibility and acceptability at one residential treatment site.
  2. The authors note that significant changes were taking place to the structure of the clinics, staff, and clinic operations at the time of the study. This could have significantly impacted the delivery of the intervention as well as impressions of the intervention among the study staff.
  3. The study evaluated perceptions of the intervention and implementation as delivered by study staff and one clinic staff volunteer. Impressions of the intervention might differ if delivered by clinic staff.
  4. Staff members’ reported lack of understanding of the specific elements of the cognitive remediation intervention might limit their perceptions of its feasibility, acceptability, and efficacy.
  5. Information on the efficacy of cognitive remediation was limited to clinic staff members’ anecdotal reports of interactions with patients who participated in the intervention. Further research might include staff perspectives who also had more direct exposure to the intervention or hands on participation with its delivery.
  6. The interviewers did not specifically ask about organizational barriers to participating in the intervention or the study.

BOTTOM LINE

The results of this qualitative study suggest that a cognitive remediation intervention delivered during residential substance use disorder treatment is acceptable to patients and clinic staff and is believed to be beneficial to patients. However, limited participation by staff and delivery of the intervention almost entirely by the study team (rather than program staff), coupled with lack of clinic update of the intervention, suggest that more research and development may be needed to make these interventions sustainable within clinics over the long term.

  • For individuals and families seeking recovery: Many individuals in substance use treatment experience cognitive difficulties, which include difficulties with memory, concentration, decision making, and impulse control. Cognitive remediation interventions could help with training the brain to improve overall cognitive functioning and might also promote better functioning and recovery long term.
  • For treatment professionals and treatment systems: Cognitive remediation interventions have been shown to be efficacious and, in this study, acceptable to clinic staff and desirable to patients. Cognitive remediation interventions could help with substance use disorder recovery, but also other critical areas of functioning and overall quality of life. In order to be implemented and sustainable within clinics, it could be useful if these efforts were supported with staff training and protected time to learn and creatively problem-solve implementation challenges. Further research into the factors that could facilitate the adoption and use of these interventions in both inpatient and outpatient settings could be beneficial.
  • For scientists: The cognitive remediation intervention in this study was delivered by study staff and at a time when the clinic was undergoing considerable organizational changes. Further research under more optimal or stable circumstances could be beneficial. It could also be helpful to gain perspective on the feasibility and acceptability of this intervention within residential care from staff who were more involved with the implementation and delivery of the intervention in the clinic. Development and evaluation of automated or other stand-alone interventions that could be implemented in clinics without requiring ongoing staff support – delivered with online, mobile, or other technology-based platforms – could promote adoption, implementation, and sustainability.
  • For policy makers: Cognitive remediation interventions represent a promising line of intervention development but with limited information on their sustainability. Support for further implementation research could improve update and sustainability of these interventions to support cognitive functioning and potentially substance use disorder treatment and recovery. In addition, support for further research to examine the effectiveness of these interventions, and when they are most effectively delivered (e.g., during or immediately after detoxification, during or post residential treatment, etc.) could prove beneficial.

CITATIONS

Allan, J., Thompson, A., Meumann, N., & Medalia (2021). Implementing cognitive remediation in substance use treatment: The impact of staff perceptions. Journal of Substance Abuse Treatment, 124, 108310. DOI: 10.1016/j.jsat.2021.108310

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