Cognitive remediation therapy of working memory in addictive disorders: An individualized, tailored, and recovery-oriented approach

KEYWORDS:

• Addiction
• clinical outcome
• cognitive remediation therapy
• recovery
• relapse
• self-regulation
• training
• working memory

1. Working memory impairments in addictive disorders

Substance use disorders (SUD) constitute a major public health problem. Despite the availability of psychological and pharmacological interventions, SUD are still commonly associated with chronic courses, frequent relapses, and social negative consequences [1–5]. Consequently, developing innovative and complementary evidence-based therapeutic strategies to prevent or reduce the personal, social, and economic burden associated with addictions is of paramount importance.

Neurocognitive impairments in addiction have gained much attention in recent years as both determinants and consequences of drug use. Nevertheless, regardless of whether these impairments are considered primary or secondary to SUD, they constitute relevant transdiagnostic targets for treatment [6,7]. More specifically, many individuals with SUD present neurocognitive deficits across a wide range of functions, including planning, attention, memory, response inhibition, emotion recognition, and decision making [8–10]. In particular, several core executive functions, such as working memory (the ability to maintain and manipulate limited amounts of information to serve current goals), are frequently impaired in SUD [11]. Such impairments have been linked to poor self-regulation and decision making [12], which are hallmarks of addictive disorders.

Crucially, working memory impairments could interfere with patients’ daily life activities and social inclusion (e.g. managing finance, interacting with others, finding or holding a job) and impact on key clinical variables (e.g. attendance at sessions, compliance with medications, dropout rates, low willingness to change, relapse rate) [13]. For instance, such impairments may prevent patients from accurately appraising high-risk situations in daily life and fully assimilating and applying information or techniques provided in the course of therapy. This may, in turn, result in greater difficulties in preventing relapse and/or attaining meaningful personal goals. However, despite their relevance, working memory impairments are not yet a specific target of addiction treatment. By providing structured cognitive exercises and skills training, cognitive remediation therapy constitutes a promising approach to decrease working memory impairments and improve clinical and functional outcomes in patients with addictive disorders. Although working memory training has been examined in various clinical and nonclinical samples, including addiction-related disorders, controversies regarding its efficacy remain [14]. Therefore, our aim is to underline the limitations of cognitive remediation therapy as it is commonly implemented and to provide relevant avenues for improving its efficacy in patients with addictive disorders.

2. What is cognitive remediation therapy of working memory and is it efficacious?

Cognitive remediation therapy is generally defined as ‘a behavioral–training based intervention that aims to improve cognitive processes (attention, memory, executive function, social cognition, or metacognition) with the goal of durability and generalization’ [15,p.472]. Through intensive and structured cognitive exercises, this therapy ultimately aims to improve cognitive abilities by capitalizing on neuroplasticity and prompting modification of dysfunctional neural systems [16].

Working memory remediation promotes intense training (often called ‘drills’) with progressively difficult visual and/or verbal exercises to improve information maintenance, manipulation, and updating of content in short-term memory. Training is typically done by using standardized computerized programs such as CogMed [17]. Although recent reviews support the overall efficacy of working memory training in persons with SUD to improve the targeted function [although see 18], results are mixed regarding the transfer to untrained tasks and the generalization to clinical and functional outcomes [13,19]. Thus, whether these improvements in working memory can translate to meaningful longer term functional or clinical outcomes, such as improving social functioning, attaining personal goals, or preventing relapse, remains unclear [19].

3. How can the efficacy of cognitive remediation therapy in patients with addictive disorders be improved?

Beyond the methodological concerns in numerous studies that examined the efficacy of working memory training [see 14], we want to draw attention to three issues that might explain why most current cognitive rehabilitation programs of working memory in addiction are likely to have a poor impact, if any, on functional or clinical outcomes. We contend that resolving these issues will improve the efficacy of cognitive remediation therapy that targets working memory impairments (or other cognitive processes frequently impaired in addictive disorders), thereby fostering the translation of findings from experimental research to relevant clinical applications.

3.1. First issue: taking into account the heterogeneity and interindividual differences in cognitive impairments

Although the issue of the heterogeneity and interindividual differences in cognitive impairments in addiction has rarely been specifically addressed, recent data underlined the extreme variability of such impairments in patients with addictive disorders. For instance, in alcohol use disorder, some patients fully recover from their cognitive impairments after alcohol detoxification, others still present neurocognitive impairments after 1 year of abstinence, and others may have permanent impairments [10]. In particular, one study stressed that after 2–3 weeks of alcohol detoxification, only half of the patients who exhibited impairments in working memory at the beginning of detoxification spontaneously recovered [20]. Cognitive remediation therapy studies have, however, largely ignored these interindividual differences. Indeed, in most of these studies, the same standardized remediation program is administered to all patients without taking into account their specific cognitive profile. It is thus crucial to first profile cognitive functioning with a theoretically grounded assessment battery that allows one to appraise the nature and heterogeneity of cognitive impairments (as well as the preserved capacities) in patients with addictive disorders and then to provide individualized and tailored cognitive remediation therapy [9]. Taking into account both the heterogeneity and interindividual differences in cognitive impairments is likely to have a heuristic value that can further determine both the content and type of cognitive remediation that should be delivered (second issue). This consideration also stresses the need to provide this kind of therapy in recovery-oriented services (third issue) to maximize its efficacy.

3.2. Second issue: providing training skills in cognitive training programs to improve generalization to daily life

Most studies in the field of addiction relied on computerized cognitive training programs to improve patients’ working memory from the assumption that improving performances on a given cognitive task would lead to beneficial effects on clinical outcomes and everyday functioning. However, recent reviews and meta-analyses that examined the efficacy of working memory training revealed the absence of transfer to untrained tasks or to participants’ daily life [14; but see 21]. Consequently, the sole use of computerized cognitive training for improving working memory is debatable. However, in clear contrast to the traditional drill approach in which learning is based only on repeating laboratory tasks that become gradually more difficult, a drill associated with a strategic approach (e.g. compensatory strategies) in which the objective is to teach the explicit use of a specific strategy constitutes a relevant therapeutic alternative. For instance, Duval et al. [22] successfully administered a tailored remediation program to a patient with marked working memory deficits due to a cerebral tumor. The program included intensive and graduated exercises that enable the patient to acquire specific strategies (e.g. using verbal and visual encoding) to improve working memory and an ecological section that included analyses of scenarios and simulations of reallife situations, which aims to transfer the strategies learned to everyday life. Adding a strategic approach to traditional cognitive training is all the more important given that it was shown to improve functional outcomes in schizophrenia in contrast to a drill approach alone [15].

3.3. Third issue: providing cognitive remediation therapy in recovery-oriented services

Recovery has been defined as ‘a personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/or roles’ and ‘a way of living a satisfying, hopeful, and contributing life even within the limitations caused by illness’ [23,p.15]. Recovery-oriented mental health services have the potential to support autonomy, competence, and relatedness, three pillars of the self-determination theory associated with better outcomes in SUD [24], and to support patients’ engagement in meaningful activities and roles. Accordingly, and in congruence with the recommended ‘sustained-recovery management’ approach of addictive disorders, social targets are fully considered in the treatment of patients with SUD regardless of their patterns of substance use [25]. Thus, promoting cognitive remediation therapy in accordance with patients’ views and goals, as well as specific cognitive training needs from a recovery-oriented perspective, has the potential to improve the transfer of such therapeutic intervention to real life and to promote recovery processes.

4. Conclusion

Although this research is still in its infancy [26], increasing evidence suggests that patients with addictive disorders may benefit from cognitive remediation therapy of working memory (or other cognitive processes). Nevertheless, controversies regarding its efficacy have emerged. In this context, our aim here was to question the uniform application of standardized intense cognitive training to all patients. Instead, we advocate the necessity of first appraising the nature and heterogeneity of cognitive impairments to ultimately identify which processes should be the focus of remediation therapy and then developing individualized and tailored treatment. From this perspective, cognitive remediation programs should include strategic and recovery-oriented training to improve generalization to daily life, which requires identification of difficulties in everyday tasks, activities, and situations that prevent the individual from attaining specific goals or fulfilling meaningful personal and social roles. Indeed, the ultimate goal of cognitive remediation therapy should not be to improve cognitive performance in a given test per se, but above all to generalize improvements to long-lasting applications in patients’ daily lives. Finally, patients with addictive disorders vary not only in their cognitive functioning, but also in many other psychological (e.g. symptoms, goals, motivations, coping capacities) and environmental factors (e.g. familial, educational, social) in a context of frequent elevated comorbidity [27]. Consequently, cognitive remediation therapy should be integrated with other treatments in a holistic and tailored approach to adequately respond to the specific needs of the individual patient, to improve the durability of benefits, and to generalize to clinical and functional outcomes [13]. Further research is warranted to determine the additive or synergic effect of adjunct treatment such as cognitive remediation therapy in addiction clinical care.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgments

The authors would like to thank Barbara Every, ELS, of BioMedical Editor, for English language editing.

Additional information

Funding

This paper was not funded.