Mind to Function

Written by Wieteke Idzerda, Occupational Therapist, CRT Therapist

For many people experiencing psychosis and other severe mental health challenges, recovery extends far beyond symptom reduction. While mental health services have become increasingly skilled at addressing symptoms, cognitive difficulties such as challenges with attention, memory, planning, problem-solving, and cognitive flexibility often remain unaddressed despite their significant impact on daily life.

These cognitive difficulties can affect a person’s ability to maintain employment, pursue education, manage a household, sustain relationships, and participate meaningfully in their community. As Occupational Therapists and mental health clinicians, we see these impacts every day.

The evidence supporting Cognitive Remediation Therapy (CRT) continues to grow, demonstrating improvements in cognitive functioning and, importantly, enhanced functional outcomes when cognitive gains are linked to meaningful real-world activities (Medalia & Choi, 2009; Wykes et al., 2011). Yet access to CRT remains limited, particularly for people living in rural and regional communities.

Over the past several years, I have had the opportunity to support the implementation of CRT within a rural community mental health setting in Aotearoa New Zealand. This experience has reinforced an important lesson: effective cognitive rehabilitation is possible in rural communities when services are willing to think differently about access, partnerships, and recovery.

The Rural Challenge

Rural mental health services face unique barriers. Large geographical catchments, limited specialist workforces, travel requirements, and resource constraints can make it difficult to provide evidence-based rehabilitation interventions consistently.

Historically, domestically and internationally, many cognitive rehabilitation programmes have been delivered in specialist centres or group settings located within urban environments. For many of the people we work alongside, attending weekly sessions can involve significant travel, time away from family, and additional financial costs.

This raises an important question:

If cognition is a key determinant of recovery, should access to cognitive rehabilitation depend on where a person lives?

I would argue that it should not.

Developing a Hybrid CRT Model

To address these challenges – which was largely instigated by the travel and face to face restrictions during covid lockdown periods in 2022 – we adopted a hybrid approach combining individual CRT sessions with remote learning opportunities.

The model was intentionally flexible and recovery-focused. Individual sessions allowed clinicians to build therapeutic relationships, complete assessments, develop metacognitive awareness, and tailor interventions to each person’s goals. Between sessions, participants engaged in remote cognitive exercises and strategy practice within their own environments.

Rather than viewing technology as the intervention itself, we used technology as a vehicle to improve access.

The result was a model that reduced travel barriers while allowing people to practise cognitive strategies in the environments where they would ultimately need to use them.

This shift was particularly valuable for people working towards goals such as returning to study, gaining employment, improving independent living skills, or increasing community participation.

The Importance of Occupation and Meaning

One of the most important lessons from implementation was that CRT is most effective when cognitive exercises are connected to meaningful occupations.

Improving attention scores alone is unlikely to transform someone’s life. However, improving attention so a person can complete a training course, manage appointments, maintain employment, or reconnect with their community can be life-changing.

As Occupational Therapists, we are uniquely positioned to bridge this gap between cognitive rehabilitation and everyday functioning. CRT should never become a collection of computer-based exercises disconnected from a person’s aspirations and recovery goals.

The most powerful conversations often occurred when participants began recognising how cognitive strategies could help them navigate challenges they encountered in their daily lives.

Community Partnerships

Perhaps the most significant factor in the success of our implementation was the use of community partnerships.

Cognitive gains need opportunities for application. Without opportunities to practise and refine strategies in real-world settings, improvements may remain largely theoretical.

Partnerships with non government organisations  and vocational services created pathways for people to apply newly developed cognitive skills within meaningful contexts.

For some individuals, this meant participating in community programmes / groups and strengthening social connections. For others, it meant preparing for employment, developing workplace routines, or building confidence to pursue vocational goals.

These partnerships transformed CRT from a clinic-based intervention into a broader rehabilitation pathway.

In many cases, the most meaningful outcomes occurred not within the therapy room, but within community settings, volunteer roles, and everyday life.

What We Learned

Several lessons emerged throughout implementation.

1. Start small and build capability

Successful implementation required workforce development, supervision, and protected time. Beginning with a small number of clinicians and whaiora allowed confidence and expertise to develop gradually.

2. Flexibility is essential

Rural services cannot simply replicate urban models. Adaptation is often necessary, and flexibility should be viewed as a strength rather than a compromise.

3. Technology improves access but does not replace relationships

The therapeutic relationship remained central to engagement and success. Technology enabled access, but it was not the intervention.

4. Recovery goals drive engagement

Participants were most engaged when CRT was linked directly to goals that mattered to them, such as employment, education, independent living, or community participation.

5. Collaboration creates sustainability (I cant stress this enough)

Partnerships across health, NGO, and vocational sectors strengthened outcomes and increased opportunities for real-world application of cognitive strategies.

Looking Forward

With time, I believe there is significant opportunity to embed cognitive rehabilitation such as CRT more firmly within routine practice.

Rural communities should not be excluded from evidence-based interventions because of geography. Through innovative service design, workforce development, telehealth solutions, and strong community partnerships, CRT can become a realistic and sustainable component of community mental health care.

If cognition influences a person’s ability to participate in daily life, pursue meaningful roles, and achieve their recovery goals, then addressing cognition is not optional—it is fundamental.

References

Medalia, A., & Choi, J. (2009). Cognitive remediation in schizophrenia. Neuropsychology Review, 19(3), 353–364.

Wykes, T., Huddy, V., Cellard, C., McGurk, S. R., & Czobor, P. (2011). A meta-analysis of cognitive remediation for schizophrenia: Methodology and effect sizes. American Journal of Psychiatry, 168(5), 472–485.

McGurk, S. R., Twamley, E. W., Sitzer, D. I., McHugo, G. J., & Mueser, K. T. (2007). A meta-analysis of cognitive remediation in schizophrenia. American Journal of Psychiatry, 164(12), 1791–1802).