Yonago Acta medica 2007;50:69–80

Cognitive Remediation for Schizophrenia
Tamiko Mogami
Department of Fundamental Nursing, School of Health Science, Tottori University Faculty of
Medicine, Yonago 683-8053 Japan

The importance of treatment of cognitive impairments of people with schizophrenia
has long been established. Among many pharmaceutical and non-pharmaceutical approaches, cognitive remediation offers one of the best promises for the rehabilitation of
cognitive impairments of schizophrenia. The purpose of this paper is to introduce one
such approach, the Neuropsychological Educational Approach to Remediation (NEAR).
NEAR has been utilized as a leading treatment model for cognitive impairments ofschizophrenia. Cognitive remediation including NEAR is administered within a framework of psychiatric rehabilitation program. Cognitive remediation is most effectively
administered when the rehabilitation goals in the social and domain are clarified. Social
functions associated with the cognitive impairments of schizophrenia are discussed in
the specific categories of independent living skills, vocational skills and social problemsolving. Highlights of various models of cognitive remediation are presented to illustrate
the unique features of NEAR. In the theoretical framework of NEAR, intrinsic motivation, personalization and contextualization are the central concepts, and the patients are
regarded as learners aiming for independent living. In order to provide a clinical overview, specific treatment issues, staff training and patient characteristics are discussed.
A summary of the NEAR outcome studies with a diverse psychiatric population is presented to demonstrate its effectiveness. Functional measures associated with cognitive
impairments are presented to suggest directions for future studies.
Key words: cognitive function; functional outcome; psychiatric rehabilitation; remediation;schizophrenia

forced the reduction of government funding forthe patient care, the trend for shorter hospitalization emerged. It is now widely accepted that psychiatric treatment focuses on stabilization of acute
symptoms and discharge into community living.
Similarly, the movement toward deinstitutionalization of psychiatric patients is becoming common in Japan. More people with severe psychiatric illnesses such as schizophrenia are expected
to live in their communities, rather than to remain
institutionalized.
Integration of people with schizophrenia into
communities has become possible due to the ef-

Schizophrenia
Schizophrenia is a chronic, severe and debilitating
psychiatric illness. Epidemiological data indicatethat approximately 1% of population develops
schizophrenia during their life time. Impairmentsin the regulation of affect, perception, cognitionand social functioning have been associated withschizophrenia. Due to the chronicity and pervasive function impairments, schizophrenia often
requires intensive and long-term treatment. However, since the United States health-care reform

Abbreviations: CRS, Cognitive Remediation Specialist; NEAR, Neuropsychological Educational Approach to Remediation

69

T. Mogami

Table 1. Cognitive functions associated with social functions of schizophrenia
Social function
Independent living skills
Vocational function
Employment status
Social problem-solving
Social behavior
General social function

Cognitive function

Study

Executive functioning
Attention, verbal memory
Verbal learning and memory, executive functioning,overall intelligence
Executive functioning
Overall intelligence, attention, executive functioning
Cognitive flexibility
Working memory

fectiveness of atypical neuroleptics such as clozapine, risperidone and olanzapine. Atypical neuroleptics are primarily known for their effective suppression of positive and negative symptoms withfewer side effects. However, medication alone is
not effective in alleviating cognitive impairment,
which is the core feature of schizophrenic symptoms (Nakagome et al., 2007). The prevalenceof cognitive impairments for schizophrenia is
fairly high ranging from 50% to 80%, depending
on severity of illness (Goldberg and Gold, 1995).
A decline in cognitive function in schizophrenia
occurs near the onset of illness, and remains stable for the remainder of the course of the illness(Russell et al., 1997).
Cognitive impairment refers to problems in
the areas of cognition such as attention, memory,and problem-solving. Cognitive function is categorized into basic functions and executive functions. Executive functions refer to the higherorder thinking that require complex manipulationof information. Studies have shown that executivefunctioning is a predictor of prognosis for schizophrenia (Jaeger and Douglas, 1992; Green, 1996;
Wykes et al., 1999). In particular, executive functioning has been associated with social functions(McGurk and Mueser, 2004). However, caution isnecessary in the interpretation of the association
between social and executive functioning, which
is not a unidimensional ability. As the executivefunction entails the ability needed for complex
cognitive tasks such as problem-solving, planningand organization, it should be noted that currently

Penades et al., 2003
Bryson and Bell, 2003
McGurk et al., 2005
Spaulding et al., 1999
Zanello et al., 2006
Wykes et al., 1999
Bora et al., 2006

available research findings may not provide sufficient evidence to determine which aspect of executive function is associated with social functions.

Social functions of schizophrenia
Social functions of schizophrenia have been
extensively studied (Allen, 1990; Mueser et al.,
1995; Penn et al., 1995) and their definitions instudies on schizophrenia have been varied. Social
functions examined in relation to cognitive functions of schizophrenia include broad areas such as
independent living skills (Delahunty et al., 1993;
Harvey et al., 1997; Wykes, 1994), vocational
skills or employment status (McGurk et al., 2005)
and social problem solving (Yamashita et al.,2005; Zanello et al., 2006). Some studies usedmeasures of social functions that incorporated
several of these areas (Penades et al., 2003; Ryuet al., 2006). It stands to reason that cognitive impairments are associated with deficits in the broad
range of functions. Although an extensive review
has been provided (Green, 1996), more recent
findings for the areas of cognitive functioning associated with social functions are summarized inTable 1. As Green (1996) pointed out, it is evident
that the improvement of social function is a strong
factor in sustaining independent living for people
with schizophrenia. Cognitive remediation aims
to rehabilitate impaired cognitive functions,which in turn will affect the overall functions of
the individual that enable independent living.
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Cognitive remediation for schizophrenia

Fig. 1. Cognitive remediation
in a psychiatricrehabilitation
program.

Models of rehabilitation for people with chronic
psychiatric illness that emphasize community
living have been long since established. Representative models include Assertive Community
Treatment (Test and Stein, 1976), Choose-GetKeep model (Danley et al., 1992) and Intensive
Psychiatric Rehabilitation Treatment (Lamberti
et al., 1998). These rehabilitation programs
emphasize a multi-disciplinary approach, skills
acquisition, independent living, consumer advocacy and behavioral intervention in combination
with pharmaceutical treatment. They often offer
cognitive remediation as a part of their services,
as the overall goal of the rehabilitation model forindependent living is congruent with the rehabilitation philosophy of cognitive remediation. A
conceptual model for the placement of cognitive
remediation in a psychiatric rehabilitation program is presented in Fig. 1.

Models of rehabilitation
for people with schizophrenia
Deinstitutionalization of people with schizophrenia necessitates rehabilitation models that enable
them to acquire skills for independent living. Rehabilitation programs provide skills training andtreatment which encompass the goal of independent living. Rehabilitation programs for people
with chronic psychiatric illness include independent living skills training, vocational training,social skills training and cognitive remediation.
Cognitive remediation is often provided
in conjunction with vocational programs for its
congruency in treatment focus (Bell et al., 2001).
Researchers demonstrated that improvement ofcognitive functions was related to improvement ofvocational functions (McGurk and Mueser, 2004).
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T. Mogami

Table 2. Models of cognitive remediation
Model (author)

Modality

Description

Frequency

NEAR (Medalia) Group
2 wk
			
			
IPT (Brenner)
Group
3 wk
			
			
			
CRT (Delahunty) Individual 1-h daily 40 d						
CET (Hogarty)
Group								TSWP (McGurk) Group,
individual

Computer-assisted sessions and a verbal group are administered.
Acquisition and contextualization of cognitive skills are emphasized.
Structured sessions are administered to improve cognitive andsocial skills. The sessions are offered in 5 subgroups of cognitive differentiation, social perception, verbal communication,social skills, and interpersonal problem-solving.
Paper-and-pencil sessions are administered to improve executive functioning. The model consists of three modules including
cognitive flexibility, working memory, and planning.
Computer-assisted sessions and group exercises are administeredto improve social cognition. The model consists of cognitiveand social rehabilitation phases.
Computer-assisted sessions and supportive employment program
are combined.

CET, Cognitive Enhancement Therapy; CRT, Cognitive Remediation Therapy; d, days; IPT, Integrated Psychological Therapy; NEAR, Neuropsychological Educational Approach to Remediation; TSWP, Thinking Skills for Work Program, The; wk,
week. (Table 2 was partially adapted with permission from Treatment of cognitive dysfunction in psychiatric disorders, byMedalia and Lim, Journal of Psychiatric Practice, volume 10, pages 17–25. Copyright© 2004 by the Lippincott, Williams andWilkins. All rights reserved.)

cognitive remediation included the issue of motivation and social functions. Avolition is a prominent symptom of schizophrenia and interfereswith the treatment compliance. Impairments insocial function is another characteristic of schizophrenia. Therefore, a model of cognitive remediation that addresses impairments in motivationand social function is expected to best serve theneeds of people with schizophrenia. Among existing models of cognitive remediation, one model
addresses these features: the Neuropsychological
Educational Approach to Remediation (NEAR).

Cognitive remediation
Several models of cognitive remediation are available. Representative models of cognitive remediation are summarized in Table 2. The featuresof the models of cognitive remediation vary, depending on their treatment context and theoreticalfoundation. While some models emphasize drill
practice of isolated cognitive skills (Delahunty
et al., 1993), others are offered in conjunction
with vocational training (McGurk et al., 2007).
However, it is becoming more common for cognitive remediation to be offered with or as a partof vocational rehabilitation program (Bell et al.,2001). The movement toward the inclusion of a
vocational approach is consistent with the deinstitutionalization of psychiatry.
Originally developed for the rehabilitationof brain injury, cognitive remediation needed tobe tailored to address the unique characteristics
of schizophrenia. The central characteristics ofschizophrenia associated with the induction of

NEAR
Theoretical foundation
NEAR is theoretically based on neuropsychology, educational psychology, learning theory andcognitive psychology. In NEAR, the process ofrehabilitation is viewed as the learning process
for a person with psychiatric illness. Thus in theframework of NEAR, the patient receiving treat72

Cognitive remediation for schizophrenia

is highly valued for effective learning to occur.
Therefore, efforts are made to enhance the intrinsic motivation of the patient. The strategies to enhance intrinsic motivation include the clarificationof the target cognitive functions, and overall rehabilitation goals. Additionally, the theme of tasks
may be tailored to meet the patient’s interests. In
sum, patient participation is facilitated by theirmotivation for rehabilitation and learning, and notby the external demand for treatment compliance.

ment may be referred to as a learner or a student,with the implication that the participant is engaged in learning. The theoretical foundation of
NEAR emphasizes motivation, social aspect of
rehabilitation such as personalization, and contextualization.
Intrinsic motivation for treatment
The role of motivation in learning and acquisitionof novel skills has been extensively discussed in
the field of educational psychology (Kage, 1994;
Ryan and Connell, 1989; Vallerland and Bissonette, 1992). The importance of motivation is not
limited to educational context, as motivation has
been associated with the treatment complianceof psychiatric patients (Pelletier et al., 1997). In
NEAR, the role of motivation may be regarded
as two-fold since the motivation is related to thetreatment compliance specific to NEAR, and totreatment compliance with the overall rehabilitation program. In psychological literature, motivation is categorized into extrinsic motivation andintrinsic motivation (Vallerland and Bissonette,
1992). Although some researchers question thevalidity of the dichotomized categorization of
intrinsic and extrinsic motivation (Kage, 1994;
Ryan and Connell, 1989), the category fits well inthe theoretical context of NEAR. Extrinsic motivation refers to a behavior that is motivated by external rewards such as monetary gain or praise by
an instructor or a therapist. It is expected that themaintenance of learned behavior is difficult withextrinsic motivation because the behavior tends tobe discontinued unless the external rewards arecontinued. Intrinsic motivation is observed in a
behavior that is motivated by internal factors suchas the sheer pleasure of mastering a task or enjoyment of an activity. In short, intrinsic motivation
is observed when an individual participates in theactivity due to internal and personal needs fromwithin, independent of external factors. Intrinsic
motivation is regarded as more effective in themaintenance of learned behaviors.
In NEAR, the role of intrinsic motivation

Personalization and contextualization
It is important to personalize and contextualize tasks for effective learning to occur (Bender,
1986; Fishman, 1992), and in this instance, foreffective remediation of cognitive functions.
Personalization refers to the fact that a task ora learning environment is “customized” for theindividual. For example, in NEAR, individual
patient folders are prepared so that when a patient
arrives for the rehabilitation session, he or she cantake the folder and sign-in, just as they might at
a work setting. Inside the folder is their log forthe session record, in which they keep track of
the lesson activities. Moreover, individual lessonplans are prepared prior to the start of the rehabilitation which is analogous to the personalized
treatment plan. With the individualized lesson
plan, patients work on their unique menu whichtargets their cognitive impairments.
Contextualization is vital for effective cognitive remediation, and it’s one of the most distinguishing features of NEAR. Unlike some of theprevious models of cognitive remediation thatheavily relied on drill activities disconnected fromdaily cognitive functions, NEAR utilizes contextualized tasks. Cognitive function is rehabilitatedin a context that is as relevant to real life as possible in order to facilitate the process of transfer.
Transfer of the task from treatment room to a reallife setting is called bridging. In NEAR, bridging also occurs through more deliberate attempts,
such as a discussion on how learned skills may be
relevant to everyday functions.
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T. Mogami

Table 3. Neuropsychological Educational Approach to Remediation (NEAR) outcome studies
			
Choi and Medalia Medalia et al.
2005
2003

Study
Revheim et al.
2003

Medalia et al.
2001

Number of subjects* 48
1231
54
Subject age†
34.9 [–]
48.3 [–]– [18–55]
P‡ 36.4 [–]					
M‡ 33.6 [–]					
C‡ 39.0 [–]Symptom scale			
BPRS, SANSPANSSWork measure
WBI
Other functional scale			
QLS, ILS, SESSILS
Cognitive scale
MCT
CSI
WCST, WMS,
WAIS, WMS
			
CVLT, WAIS		Diagnosis
Schizophrenia Chronic psySchizophrenia,
Schizophrenia,
spectrum,chiatric illness,schizoaffective
schizoaffective
affective dissubstance abuse
disorderdisorderorder
Treatment facility
Community
Supportive
Inpatient
Inpatientintensive
housingrehabilitation
12 sessions
10 sessions
NEAR administration 26 sessions
2 wk for 1 yr
OutcomeCognitive function
+
+
0
+/0
Vocational function+
Other function			++/0Medalia et al.
2000
28
E‡ 33.0 [21–48],
C‡ 33.5 [21–45]
DPRS, SCL-90
WAIS, TOH
Schizophrenia,
affective disorder
Inpatient
6 sessions++“+” indicates significant improvement at post-intervention.
* Includes control group.
† Mean [range].
‡ P, Problem-solving group; M, Memory group; C, Control group; E, Experimental group.
BPRS, Brief Psychiatric Rating Scale; CVLT, California Verbal Learning Test; CSI, Cognitive Stability Index; DPRS,
Derogatis Psychatric Rating Scale; ILS, Independent Living Scale; MCT, Minnesota Clerical Test; PANSS, Positive and
Negative Symptom Scale; QLS, Quality of Life Scale; SCL-90, Symptom Checklist-90; SANS, Scale for the Assessmentof Negative Symptoms; SESS, Self-Efficacy Scale for Schizophrenia; TOH, Tower of Hanoi; WAIS, Wechsler Adult Intelligence Scale; WBI, Work Behavior Inventory; WCST, Wisconsin Card Sorting Test; wk, week; WMS, Wechsler Memory
Scale; yr, year.

ing are examined such as the most and the least
favorite subjects, learning styles (e.g., auditory,visual, tactile learner) and the most effective timeof day (e.g., day, evening, etc.). Assessment in theareas of cognitive impairment is provided by thepatient and the referral source. The informationfrom two sources is helpful in informing the treatment plan.
Evaluation at intake and discharge includes
measures of cognitive functions, social functions,and other biomarkers that may be relevant to thetreatment outcome of schizophrenia. (Refer toTable 3 for the measures that were previously
used in NEAR outcome studies.) Depending on

Treatment
Administration of NEAR consists of an intake
interview and evaluation, a treatment phase and adischarge evaluation. A patient is usually referred
by a treating physician, to prompt the intake interview. Exclusion criteria for enrollment in NEAR
are a reading level lower than 4th grade, pervasive
developmental disability and substance abuse notin remission. The intake interview covers areasof information including primary diagnosis, onsetof illness, treatment history and educational andvocational history. Factors associated with learn74

Cognitive remediation for schizophrenia

the context in which NEAR is provided, a midterm evaluation or a follow-up evaluation may be
conducted to observe changes at a given stage of
rehabilitation.
Patients are typically enrolled in the treatment for a period of six months, although thetreatment phase may be extended. Outcome studies indicated improvements in functioning after
the enrollment of five weeks (Medalia et al., 2001)
to a year (Medalia et al., 2003). The treatment
phase is the core of NEAR where patients attend
three 1-hour sessions a week. The sessions are
conducted in a group format, with one or two Cognitive Remediation Specialists (CRSs), and two toa dozen patients. Patients work on individualized
tasks in a group format. Of the three sessions,
two sessions are the core sessions in which learning tasks are assigned using a PC and computer
software. Prior to the beginning of the treatment,
software is systematically reviewed by the CRS
for target cognitive areas, and the level of contextualization. An example of a computerized task isshown in Fig. 2. Computerized learning tasks are
selected to address the specific cognitive impairments for each patient. During a 1-hour session,
two to three tasks are assigned to a patient basedon individualized treatment plan. Patients whocomplete a 6-month period are usually discharged
to more challenging vocational skills training, assisted employment, an academic program, or assisted living of increased independence.
A discussion group is held once a week inorder to facilitate contextualization and socialization. In the discussion group, opinions that foster
the transference of learning to real life experiences are solicited. For instance, a patient may
share an experience of working on a simulated
filing task which targets cognitive functions ofattention, processing speed and decision-making.
A successful bridging or a transfer of the learning
experience has transpired if the patient is able tomention a similar incident in real life that requires
attention, processing speed and decision-making
such as the instance of working as a casher at astore. A CRS may lead the discussion in order toFig. 2. An example of a computerized task.
Note: The figure represents the simulated task of
a commercial long-distance truck driver. The patient isrequired to utilize cognitive functions while executing
tasks as the truck driver, such as making a travel plan
(planning), remembering to fasten the seat belt (memory),and deciding when to take a break (decision-making).
Failure to utilize appropriate cognitive functions will
result in a penalty such as an accident due to driving extensive hours without a break.

facilitate conversations. A variant of the discussion group may involve non-threatening exercisesthat involve simulated daily tasks that require
specific cognitive functions. Other suggested
activities during a discussion group may include
sharing an article from a periodical and identifying the main points as a group.
In addition to the primary objective of proving the transfer of learning, the discussion groupprovides an opportunity for the patients to interact with each other, who are otherwise engaged
in individual tasks during the two computerized
sessions. Through sharing opinions, group cohesiveness and the sense of belonging is developed
among the members. Learning takes place effectively in a socialized environment (Caspi, 2006).
With a sense of membership in a group that purports learning, patients’ motivation to learn isfurther developed. Moreover, participation in a
discussion group also provides opportunities topractice social skills.

75

T. Mogami

required to receive extensive training in NEAR
before they start working as a CRS (Medalia etal., 2002b). The training acclimates the professionals to literature on cognitive impairment inschizophrenia, theoretical foundations of NEAR,
and logistical aspects of NEAR administration.
The training consists of didactic and experiential
components. Experiential components offer opportunities for the trainees to try computerized
exercises and to practice verbal intervention.
Although NEAR uses computerized exercises, the role of verbal intervention by CRSs is
critical in facilitating the process of rehabilitation.
Verbal intervention by a CRS aims to provide feedback for patient progress. The primary goal of the
feedback is not to provide answers to the tasks, but
to help the patient to increase awareness on how
their cognitive functioning works. An example ofan effective feedback by a CRS is “I see that you
are struggling with the task. Which part of it dothink you is most challenging?” and not “I see thatyou are struggling with the task. Let me give youan answer.” Moreover, effective feedback focuseson the process of how their cognition functions,and not on whether they have the right answer orhave achieved a certain task level. An example isillustrated in the contrast between effective feedback, “Could you tell me how you solved the taskdifferently this time?” with less effective feedback,“I’m impressed that you solved the task this time.”
Effective feedback is immediate, specific, and wellinformed. While in the beginning, a CRS’ urge isto provide solutions to the tasks for the patients, itis critical to observe the patients as they work on
learning tasks. Through careful observation, CRSs
are able to identify the characteristics of theirtask approach (e.g., haphazard versus orderly), thepattern of errors (e.g., not following instructions,
missing details, running out of time) and how
they complete one task and start the next one (e.g.,
abruptly ending a task after being frustrated overa difficult problem). These observations undoubtedly inform the feedback. The points of observation and well-informed feedback are grounded in
the theoretical foundation of NEAR.

NEAR outcome studies
NEAR has been conducted with diverse clinicalpopulations. Studies have shown improvements
in cognitive functions such as attention (Choi and
Medalia, 2005), problem-solving (Medalia et al.,2000) and other areas of functioning related tosocial functions such as employment readiness(Choi and Medalia,2005), and independent living
skills (Medalia et al., 2001, 2002a). Improvements in psychiatric symptoms associated with
NEAR included the changes in Brief PsychiatricRating Scale, Scale for the Assessment of Negative Symptoms (Revheim et al., 2003), Positive
and Negative Symptom Scale (Bark et al., 2003),
Symptoms Checklist 90-R and Derogatis Psychiatric Rating Scale (Medalia et al., 2000). Reduction in recidivism is another critical marker ofeffectiveness of NEAR (Revheim et al., 2001).
Attainment of rehabilitation goals such as employment and enrollment in schools have also
been reported (Medalia et al., 2003). Details of
the outcome studies are summarized in Table 3.

Application of NEAR
NEAR has been effectively applied at psychiatric institutions (Bark et al., 2003), at vocational
rehabilitation facilities (Revheim et al., 2001),
and at housing settlements (Medalia et al., 2003).
The first attempt to disseminate NEAR in Japanis in the early stage of implementation at Tottori
University Faculty of Medicine. Specific issues
pertaining to the application of NEAR in Japan,
consisting of staff training and patient characteristics, are discussed below.
CRS training
Candidates for CRS may hold a range of professional disciplines. Previous CRSs have included
psychiatrists, nurses, social workers, psychologists
and occupational therapists. Professionals are76

Cognitive remediation for schizophrenia

chotherapy, competence in basic group facilitation
skills is instrumental in effective facilitation of
NEAR. Effective group facilitation skills will
enhance social aspect of learning. An inclusionof brief training on group facilitation skills in the
CRS training workshop may be helpful.

Treatment issues associated with systematic differences
Systematic differences between Japan and theUnited States, where NEAR was originally developed, affect the application of NEAR in Japan.
One treatment issue relates to the technology literacy rate of the patients. Contrary to Japan, computer use is far more common in the United States
where NEAR was developed (Ono and Zavodny,2005). Regardless of age or socioeconomic status, patients generally have not rejected participation in NEAR due to their apprehension of computer skills in the United States. However, someof lower functioning patients, patients with fewer
years of education, and older patients are expected to be reluctant to participate in NEAR due totheir perceived apprehension of computer skills
in Japan. A few candidates for CRS themselves
may feel intimidated that NEAR uses computers.
Remedies for the fear of computers involve simple
tactics. It is critical that patients are assured that
there is no requirement for computer literacy prior
to beginning the rehabilitation sessions. For thepatients who have never used a computer, small
steps may be taken to familiarize them with its
basic operation. They may be guided as to how
to turn on the computer and using the right- andleft-click of the mouse. These small steps may bepracticed until the patient feels sufficiently confident about basic computer operation.
The other treatment issue is related to thesystematic differences in the training of mental
health professionals in the United States and Japan. In Japan, training for treatment in groupmodality is required for limited disciplines, whilegroup facilitation is a common clinical skill
across disciplines in the United States. It is possible that many professionals outside of the fieldof psychology have never facilitated group treatment prior to their work as a CRS. In NEAR,
both computerized sessions and discussion sessions are conducted in a group format. Althougha CRS does not need to be an expert in group psy-

Functional improvements related tocognitive remediation outcomes
Researchers have examined different areas offunctions associated with cognitive remediationand cognitive functions (Green, 1996;McGurk
and Mueser, 2004). Although social function as
an expansive concept has been associated withcognitive functions in the past (Green, 1996), thissection further categorizes social functions into
independent living skills, vocational skills, social problem-solving, social behavior and generalsocial function. Scales relevant to each area arelisted as potential outcome measures for cognitive
remediation.
Independent living skills
Enhanced independent living skills have been associated with the increase of cognitive functions(Delahunty et al., 1993; Penades et al., 2002).
Measures for independent living skills consist of
surveys. Surveys are either self-reported or reported by a third party such as the patient’s family and/or treatment staff (e.g., Life Skills Profile,
Rosen et al., 1987). Some scales that measuresocial function as an overarching domain such as
the Social Functioning Scale (Birchwood et al.,1990) also include subscales for independent living skills.
Vocational skills
Enhanced vocational skills have been associatedwith an increase of cognitive functions (Bryson
and Bell, 2003; McGurk and Mueser, 2004). Vocational skills have traditionally been measured
77T. Mogami

Conclusion: A model of cognitive remediation,
NEAR, has been introduced as a new model ofrehabilitation for schizophrenia. Although NEAR
directly aims for the improvement of cognitive
functions, improvements in independent living
skills, vocational skills and interpersonal skills
are reported. The application of NEAR in Japanrequires some modifications in order to address
uniqueness of staff and patient characteristics.
Future studies on NEAR may examine the effectiveness of NEAR through multi-faceted perspectives, including cognitive, and other functions that
capture the individual’s ability for independentfunctioning in the community.

by scales (e.g., Social Adjustment Scale, Schooler
et al., 1979; Work Behavior Inventory, Lysaker etal., 1993), or more indirectly by vocational goals
attainment or vocational status at the completionof cognitive remediation. It should be noted thatsystematic measures of vocational skills target
basic job skills and employment readiness suchas punctuality and greetings, and not specific vocational skills such as typing. The attainment ofbasic job skills such as punctuality and greetings
are related to improvement in cognitive functions.
Social problem-solving
It should be noted that impairments in social
problem-solving have been viewed as the central
features of symptoms of schizophrenia. It has
been indicated that enhanced social problem-solving is associated with the increase of cognitive
functions (Zanell et al., 2006). Social problemsolving skills are measured by surveys, or by behavior rating. Behavior rating involves analysis ofrole-play behaviors (Assessment of Interpersonal
Problem-Solving Skills, Donahoe et al., 1990;
Social Problem-Solving Assessment Battery, Bellack, 1990) and responses to stories involving hypothetical social problems (Means-Ends Problem
Solving Procedure, Platt and Spivack, 1975).
The review of functional measures showsranges of areas that may be examined in assessing the outcome of NEAR. However, it should be
noted that the review does not contain the measures that were developed in Japan. Many of theabove measures have been translated for Japaneseusers with variable psychometric properties (e.g.,
Social Functioning Scale, Means-Ends ProblemSolving Procedure). In selecting an outcome
measure, it is imperative to confirm that a measure has been properly back-translated, and appropriate standardization data is available. Selectionof an outcome measure for NEAR will also beaffected by the type of patient population and thetreatment context.

Acknowledgments: I would like to thank Professor
Kazuyuki Nakagome for his informative comments on
the previous version of this article. (Professor Kazuyuki
Nakagome, Division of Neuropsychiatry, Department ofMultidisciplinary Internal Medicine, School of Medicine,
Tottori University Faculty of Medicine)
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Received September 21, 2007;accepted November 9, 2007
Corresponding author: Tamiko Mogami, PhD

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