The Neuropsychological Educational Approach to Cognitive Remediation (NEAR) Model: Practice Principles and Outcome Studies

Abstract

NEAR is an evidence based approach to cognitive remediation which was specifically developed for use with psychiatric patients. NEAR emphasizes the fact that cognitive remediation is essentially a learning activity and therefore instructional techniques incorporate basic educational principles that have been shown to enhance learning. Rather than using a fixed software package, NEAR uses a variety of exercises, which are chosen based on whether they meet the criteria to both address neuropsychological deficits and be motivating and engaging. The theory behind the NEAR program, practice principles and outcome studies are reviewed.

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The Neuropsychological Educational Approach to Cognitive Remediation
(NEAR) Model: Practice Principles and Outcome Studies
ALICE MEDALIA a; BRYAN FREILICH b
a Columbia University Medical Center, New York, New York, USA b Montefiore Medical Center, Albert Einstein
College of Medicine, Bronx, New York, USA
Online Publication Date: 01 April 2008
To cite this Article MEDALIA, ALICE and FREILICH, BRYAN(2008)'The Neuropsychological Educational Approach to Cognitive
Remediation (NEAR) Model: Practice Principles and Outcome Studies',American Journal of Psychiatric Rehabilitation,11:2,123 —
143
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The Neuropsychological Educational
Approach to Cognitive Remediation
(NEAR) Model: Practice Principles
and Outcome Studies
Alice Medalia
Columbia University Medical Center,
New York, New York, USA
Bryan Freilich
Montefiore Medical Center, Albert Einstein College
of Medicine, Bronx, New York, USA
NEAR is an evidence based approach to cognitive remediation which was
specifically developed for use with psychiatric patients. NEAR emphasizes
the fact that cognitive remediation is essentially a learning activity and there-
fore instructional techniques incorporate basic educational principles that
have been shown to enhance learning. Rather than using a fixed software
package, NEAR uses a variety of exercises, which are chosen based on
whether they meet the criteria to both address neuropsychological deficits
and be motivating and engaging. The theory behind the NEAR program, prac-
tice principles and outcome studies are reviewed.
Cognitive impairment is now recognized as a debilitating and
frequently occurring symptom in many psychiatric conditions.
These deficits, which commonly present as problems in attention,
memory, and executive functioning, have been found in patients
with schizophrenia, depression, substance abuse, and bipolar
disorder (Fioravanti, Carlone, Vitale, Cinti, & Claire, 2005; Fleming,
Address correspondence to Alice Medalia, PhD, 180 Fort Washington Avenue HP234,
New York, NY 10032, USA. E-mail: am2938@columbia.edu
123
American Journal of Psychiatric Rehabilitation, 11: 123–143
Taylor & Francis Group, LLC #2008
ISSN: 1548-7768 print=1548-7776 online
DOI: 10.1080/15487760801963660
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Blasey, & Schatzberg, 2004; Quraishi & Frangou, 2002). Studies
have consistently demonstrated that individuals with psychotic
illnesses score significantly below normal control subjects on
cognitive tests (Fleming et al., 2004; Heinrichs & Zakzanis, 1998), with
milder deficits present in individuals with affective disorders without
psychosis (Hill, Keshavan, Thase, & Sweeney, 2004; Schatzberg,
Posener, DeBattista, Kalehzan, Rothschild, & Shear, 2000). These def-
icits are persistent and not simply related to the episode of illness
(Heaton, Gladsjo, Palmer, Kuck, Marcotte, & Jeste, 2001; Olley, Malhi,
Mitchell, Batchelor, Lagopoulos, & Austin, 2005). Thus, even when
the person is psychiatrically stable, cognitive impairment remains
evident. Cognitive impairment in psychiatric disorders has also been
shown to negatively impact multiple aspects of daily functioning
such as treatment response, employment status, social relationships,
living status, and community functioning (Green, 1996; Green, Kern,
Braff, & Mintz, 2000; Revheim & Medalia, 2004). Recognition of this
significant impact on functional outcome has fueled an interest in
developing efficacious treatments to enhance cognition.
Cognitive remediation refers to behavioral-based training
techniques given to improve cognitive functioning. Clients are
given exercises with the expectation that there will be improve-
ments in attention, memory, and problem-solving, and that these
improvements will translate into greater competency at negotiating
real world challenges. At the most basic level, cognitive remedia-
tion is a learning activity, and as such it is important to consider
the factors that influence learning. Ideally, a theory of learning
informs evidenced-based practices that are designed to treat cogni-
tive impairment. The Neuropsychological Educational Approach
to Cognitive Remediation (NEAR; Medalia, Revheim, & Herlands,
2002) is an evidenced-based approach to cognitive remediation that
utilizes a set of carefully crafted instructional techniques that reflect
an understanding of how people learn best.
The purpose of this article is to review the treatment principles
and theoretical basis behind NEAR, discuss how these principles
are applied to clinical practice, and provide a review of studies that
have examined the efficacy of NEAR in psychiatric populations.
Although this article offers a review of the NEAR model and its
basic principles, it is not intended to be a comprehensive tutorial
on how to initiate and run a NEAR program. Readers interested
in this objective are advised to contact the authors of this article
and review the NEAR manual (Medalia et al., 2002)
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TREATMENT PRINCIPLES OF NEAR
NEAR is guided by certain beliefs and goals, and is based upon
a theoretical foundation that informs the interventions and
procedures used. In this section, we discuss the goals of NEAR
and the theoretical foundations and influences that form its
underpinnings.
Theoretical Foundations: Learning and Motivation
in Psychotic Disorders
Cognitive remediation for psychiatric patients has largely had
its roots in neuropsychology because neuropsychologists were
so instrumental in identifying the cognitive impairment and
functional consequences in severe and persistent mental illness.
Neuropsychology provides a basic background for understanding
the nature of the cognitive deficits that need to be targeted, and
informs the neurophysiological and neuroanatomical framework
with which to consider the deficits.
When the psychiatric field turned to neuropsychologists to
devise treatments for cognitive impairment, inspiration was taken
from the work being done by neuropsychologists with brain injured
patients (Ben-Yishay & Diller, 1993; Sohlberg & Mateer, 2001).
NEAR appreciates in particular the holistic approach to remedia-
tion advocated by Ben Yishay and Dillar (1993), which recognizes
the multiple influences on learning.
Indeed NEAR, while grounded in neuropsychology, also recog-
nizes that a detailed understanding of how people learn is essential
to crafting a program that is, after all, a learning activity. When
clients are given tasks to improve attention, they are learning to
attend better. If they are given tasks to improve memory, they are
learning to remember better. The question then arises: what will
help people learn best? This is a question that has been considered
extensively by educational psychologists, who used to view
learning as a direct corollary of ability, but now appreciate the role
of instructional factors and motivation. In the pre-World War II
educational era (and in most cognitive remediation programs
today), learning activities were largely drill and practice exercises,
that varied mostly in difficulty, with the greatest difficulty being
reserved for the highest ability (Zimmerman, 2001). While student
ability is important for learning, it does not fully account for
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learning. Research indicates that in fact, motivation, ability, and
instructional factors interact to produce greater learning and
persistence of learning behaviors (Bandura, 1997; Schunk, 1995).
Students with higher abilities do learn more, and that can in turn
motivate them to continue learning. However, instructors who
make learning activities engaging and appropriate to the student’s
ability and interests are more likely to have students who are moti-
vated to learn. Considerable research has identified the processes
whereby motivation affects learning (Schunk, 1995; Wigfield &
Eccles, 2002) and this informs the NEAR approach.
Another influence of neuropsychology is the appreciation of the
hierarchy of cognitive functions, whereby, attention is most basic
and problem solving is more complex. A purely neuropsychologi-
cal approach isolates neuropsychological skills in a hierarchical
progression, starting with attention, and only later providing
exercises to improve problem solving. This reflects the belief that
problem solving cannot proceed smoothly unless attention and
other component skills are in place. For example, in attention reme-
diation, the ability to focus, encode, rapidly process and respond,
maintain vigilance, and avoid distraction from competing stimuli
may be isolated for remediation. While NEAR incorporates some
of these exercises which focus on more discrete cognitive skills,
NEAR exercises favor a top-down approach to remediation. As
opposed to a bottom-up approach in which deficits are remediated
in a stepwise, hierarchical progression, NEAR training tasks
incorporate several skills at once in a contextualized format. We
have found that this approach not only elicits several types of
responses in concert, thus simulating real life cognitive tasks, but
also allows for more flexibility in designing tasks that are engaging
and intrinsically rewarding.
Thus, while neuropsychology provides a background for
understanding the nature of the cognitive deficits we target, it does
not inform us about how skills are best learned and what factors
influence recovery. It is in this regard that rehabilitation psychology
as well as behavior, learning, educational, and self-determination
theories have had a major influence on NEAR.
Rehabilitation psychology is a specialty area of practice that
emphasizes an integrated approach to the patient, appreciating
the complex interaction of cognitive, emotional, and environmental
variables in the recovery process (Frank & Elliott, 2000). From this
perspective, cognitive deficits are not seen simply as a manifestation
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of neuropsychological dysfunction, but rather social-cognitive
dysfunction. Rehabilitation psychology favors a more interactive,
learning process approach to cognitive remediation over the formal
didactic exercises used in a purely cognition-oriented program.
This allows for the social emotional as well as the cognitive needs
of the patient to be addressed and promotes a smooth interplay
of cognitive and emotional variables in everyday functioning.
NEAR is intended to be used within the context of a rehabilitation
program that offers patients training in the educational, vocational,
social, and independent living skills that they require. NEAR
provides the focus on cognitive functioning, but it does so with
an appreciation of the social-emotional context in which cognition
functions.
Behavior and learning theories provide us with an under-
standing of the process of learning. Drawing from the extensive
literature in these fields, NEAR incorporates several concepts that
have been found to promote learning and task engagement. For
example, errorless learning (Kern, Liberman, Kopelowicz, Mintz,
& Green, 2002; O’Carroll, Russell, Lawrie, & Johnstone, 1999),
which refers to the careful titration of difficulty level so that the
learner does not have to resort to trial-and-error learning, is an
important aspect to consider in all NEAR activities. This is so the
learner experiences success and has a positive experience with
increasing challenge. Generalization (i.e., the transfer of a learned
skill or behavior to other situations besides the one where the train-
ing occurred) is another concept that is derived from learning theory
and is critical to NEAR.Within the remediation exercises, target
behaviors need to be paired with multiple cues, ideally in various
contexts, so that the behavior will be elicited in multiple settings.
Educational psychology has made significant contributions to
our understanding of how people learn, the conditions under
which they learn optimally, and the best strategies for effective
teaching. Educational psychology has proven that people learn
the most, learn the fastest, and retain the knowledge longest when
they are excited and motivated to learn (Cordova & Lepper, 1996;
Kinzie, Sullivan, & Berdel, 1992; Terrell & Rendulic, 1996). This
excitement about learning is called intrinsic motivation. Intrinsic
motivation is the motivation to do an activity because performance
of that activity is in and of itself rewarding. It is the inherent incli-
nation to explore, learn, seek challenge, and test one’s abilities. In
contrast, some tasks are engaged in primarily for their extrinsic
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value, for example monetary gain, fame, and other indicators of
worth. Goal contents can be viewed on a continuum with extrinsic
and intrinsic pursuits being endpoints, and most tasks having a
relative salience in one direction or another. Research has shown
that when people are pressured through the use of incentives,
deadlines, and authoritarian commentary, they are less likely to
be intrinsically motivated, and as a result, less likely to learn and=or
perform to the best of their ability (Deci, Koestner, & Ryan, 1999).
Intrinsic motivation has other benefits besides increasing learning.
It is also associated with increased levels of autonomy, self-
determination, and a sense of well-being (Ryan & Deci, 2000). People
who are intrinsically motivated to get well are more likely to adhere
to treatment recommendations (Williams et al., 2006; Williams,
McGregor, Zeldman, Freedman, & Deci, 2004; Zeldman, Ryan, &
Fiscella, 2004). Because apathy, anhedonia and avolition are frequent
symptoms in the severely mentally ill, and these motivational
problems compromise engagement in treatment, it is important to
use teaching techniques that will increase intrinsic motivation.
Intrinsic motivation and task engagement occur when the tasks
are contextualized, personalized, and allow for learner control
(Cordova & Lepper, 1996). Contextualization means that rather
than presenting material in the abstract it is put in a context
whereby the practical utility and link to everyday life activities
are obvious to the patient. Personalization refers to the tailoring
of a learning activity to coincide with topics of high interest value
for the patient. For example, if the person likes to drive, they are
more likely to like a problem-solving task that has them negotiating
the problems that arise when driving cross-country, than doing
a task which teaches the abstract principles of problem solving.
Learner control refers to the provision of choices within the learn-
ing activity, in order to foster self-determination. For example, in
memory training, this occurs when the patient can choose task
features like difficulty level or presence of additional auditory cues
when doing a visual memory exercise.
Self-determination theory is an approach to personality and
motivation that examines how the interplay of social-contextual
conditions and innate psychological needs fosters constructive
development, well-being, happiness, and optimal functioning
(Ryan & Deci, 2000). Self-determination literally refers to those
factorsthatdeterminetheoutcome=development of the self. Accord-
ing to this theory, optimal development of the self occurs when
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people are intrinsically motivated, self-regulating, and when their
basic psychological needs are met. The basic psychological needs
are identified as competence, autonomy, and relatedness. When these
basic psychological needs are met, people become more intrinsically
motivated, and they learn more. NEAR has identified instructional
techniques to enhance opportunities to meet the basic needs for
competency, autonomy, and relatedness so that clients will be more
intrinsically motivated to improve cognitive functioning.
Goals of NEAR
The goals of NEAR are as follows: (1) to provide a positive learning
experience to each and every client; (2) to promote independent
learning skills; (3) to promote a positive attitude about learning;
(4) to improve those neuropsychological (cognitive) functions that
have been identified as sufficiently impaired to hamper functional
outcome; (5) to promote awareness about learning style, learning
strengths and weaknesses; (6) to promote a sense of competence
and confidence in one’s ability to acquire skills; (7) to promote
awareness of how social-emotional context affects cognitive
functioning; and (8) to promote optimal cognitive functioning in
different social contexts.
These goals are highly interrelated, for example, we do not believe
that much improvement in cognitive functions will occur unless the
person develops awareness about the malleability of their cognitive
skills (Dweck, 2006), a sense of competence, and a positive attitude
about learning. Likewise, we do not think that there is much value
in improving a cognitive skill without appreciating the social-
emotional context in which it is used. In accordance with functional
outcome models proposed by others (Brekke, Kay, Lee, & Green,
2005), we believe that it is important for treatment to not only
address issues related to cognition, but issues related to psychosocial
functioning as well. In this regard, we have found that NEAR works
best when it is integrated with other psychosocial rehabilitation
strategies such as social skills training, social cognition training,
and vocational training. Finally, the ultimate goal of NEAR is for
the client to be an independent learner, to not need the program,
and to be able to continue the learning process in mainstream edu-
cational and social settings. Recently a client explained how NEAR
was helping him, ‘‘I am getting better at doing tasks, but even if I
do not always get it right, I now know I can learn.’’
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NEAR—FROM THEORY TO PRACTICE
NEAR Setting and Program Structure
NEAR has been implemented around the world in experimental
and clinical settings. The range of treatment settings has included
research labs, acute and chronic inpatient psychiatric units,
continuing day treatment and intensive psychiatric rehabilitation
programs, forensic settings, psychiatric residences, vocational
rehabilitation programs, supportive housing, and generic out-
patient programs. To date, thousands of patients have been treated
with this approach because it has been so widely implemented in
community-based, public sector settings. In addition, clinical trials
are now underway investigating the effectiveness of NEAR in
special populations such as individuals with Attention Deficit
Hyperactivity Disorder (ADHD), substance abuse disorders, and
early Alzheimer’s disease (AD).
In general, NEAR is conducted in groups consisting of six to ten
clients. Although NEAR has been adapted for use in the individual
training of special populations (ADHD, AD), a group format is pre-
ferred for people with psychotic and affective disorders. In a group,
there is often a sense of community that develops among clients
who occupy the same space and are engaged in the same highly-
valued activity. The sense of relatedness established among group
members satisfies an important psychological need identified
by self-determination theory, and promotes increased intrinsic
motivation and task engagement (Ryan & Deci, 2000). Furthermore,
in a group, there are also opportunities for peer leadership.
Ideally, NEAR sessions should be conducted two to three days a
week in 45-minute to one-hour time intervals. We have found that
when sessions are held less frequently, clients do not make signifi-
cant gains. For every three sessions of NEAR, two should involve
clients performing cognitive activities, usually on the computer,
and a third entails a verbal session in which clients meet as a group,
practice social skills, and discuss how the individual exercises they
are working on in NEAR relate to real world activities.
In terms of staffing, it is beneficial to have one person designated
to run the NEAR program, and that the person has the time allotted
to do only that. In general, a staff commitment of 20 hours will
suffice to handle a case load of 30, assuming six clients are seen
at a time. Generally, clinicians providing NEAR should have at
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least a Master’s degree in a mental health field. If multiple clinicians
run the NEAR groups, it is all the more important for one person
who is trained in NEAR to be the identified program leader.
New training is required before running NEAR groups. This is a
formal training program that is taught by a NEAR specialist with
the help of a manual. The clinician will need to acquire knowledge
about how people learn, specific instructional techniques, the
cognitive deficits common in the persistently mentally ill, and the
ways these deficits impact on daily life. The theoretical basis for
the work needs to be learned and the interface between cognitive
rehabilitation and other treatment modalities has to be understood.
In addition to acquiring the relevant knowledge base, the NEAR
clinician will need to spend about 15 hours getting familiar with
the software and other learning activities before starting to see
clients. The programs can be complicated and it requires time to
become familiar with all the different ways they can be used to
remediate cognition.
Because NEAR provides a framework for working with clients,
and is a treatment approach rather than solely a fixed set of treat-
ment exercises, it has been used in conjunction with other more
neuropsychologically-oriented programs, such as neurocognitive
enhancement therapy (NET; Bell, Bryson, Greig, Corcoran, &
Wexler, 2001) or CogPack (Geibel-Jakobs & Olbrich, 1998). NET
and CogPack are cognitive remediation programs that use one
software package, and they can thus be easily combined with the
NEAR program. NEAR provides a way of structuring sessions,
an instructional framework for working with clients, and can use
a range of training exercises, which may also include NET or
CogPack or other computer or non-computer-based exercises.
NEAR Program Activities
Not all NEAR activities involve the computer, but the vast majority
do. Building a software library is thus key to making the NEAR
program a success. Unlike many cognitive remediation approaches
that use only one or two specific software programs, NEAR incor-
porates a range of program activities that target different skills and
offer a variety of opportunities for contextualization and personali-
zation. In addition, having a variety of software programs ensures
that there is a sufficient range of difficulty, content, and activity to
meet the varied needs of clients.
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In building a software library, the clinician must pay attention to
the cognitive areas targeted by a particular program, always
keeping in mind the types of deficits typical of individuals with
psychiatric illness. Because the major areas of cognitive impairment
that are targeted for treatment involve processes related to atten-
tion, memory, and problem solving, software programs should be
analyzed for opportunities to address these needs.
It is also important to consider some of the previously
mentioned concepts from behavior, learning, educational, and self-
determination theories when selecting software and program
activities. Thus, program activities should be engaging, enjoyable,
and challenging but not frustrating (i.e., errorless learning). They
should feature a diverse range of sensory stimuli, provide immedi-
ate feedback and positive reinforcement, and offer a range of
difficulty that can be controlled by the participant (i.e., learner
control). In addition, they should be personal and relevant to the par-
ticipant (i.e., personalization) and put in a context whereby the prac-
tical utility and link to everyday life activities is clear (i.e.,
contextualization). Without these features, it is less likely that the
client will be intrinsically motivated or engaged in treatment and,
as a result, less likely that they will learn or benefit from cognitive
remediation.
An extensive list of programs with which we have had success is
available in the NEAR manual (Medalia et al., 2002). However, it is
important to appreciate that the list of software is not fixed because
there is a constant incorporation of newly developed software that
has been reviewed and deemed appropriate from an educational
and neuropsychological perspective. Review of software is an
ongoing aspect of program development that clients and clinicians
jointly participate in. Ordering, trying and reviewing new programs
is an example of an enactive learning activity which NEAR uses to
promote problem solving, critical thinking, organization of thoughts,
insight into cognitive skill level, and control of the learning process.
As important as the software is to the NEAR program, it is not
the defining feature.
A common assumption is that exposing clients to the educational
software used in NEAR will improve cognition. This misses the
essential element of NEAR: it is a theory-based instructional
approach. Indeed, it has been shown that using NEAR educational
software without the NEAR instructional approach only impacted
engagement and task performance (Bellack, Dickinson, Morris, &
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Tenhula, 2005), suggesting that the instructional approach may be
key to impacting more distal outcomes.
NEAR Interventions
NEAR sessions look deceptively simple to run. The visitor will see
clients waiting outside the door for the session to start. They come
into a room, quietly pick up their work folders, choose a software
program from a box of discs, sit down at a computer and start up
their chosen activity. The clinician is there, perhaps greeting people,
perhaps reminding someone that today they will show them a new
activity, perhaps just sitting at a table watching the whole process.
Each client works at their own pace on programs they have chosen
to work on—programs chosen from the list of activities they have
been shown how to use by the clinician or peer leader. If they are
working on a task that remediates basic cognitive skills like
attention or working memory, they will work on at least two tasks
during the session. If they are working on a complex task, they
may stay on that task the whole session. Clients who have been
attending the group for some weeks are highly focused and
engaged in their work. Newer clients are less independent, work
in a focused manner for briefer periods, and may require more staff
intervention. Five minutes before the session ends, the clinician
announces it is time to finish up. Clients sign out of their activities,
take out their folders, write what they have done that day, put
everything away, and leave.
The job of the clinician in NEAR sessions varies from assessing,
to instructing, to observing. Much of the time clients work indepen-
dently, but the clinician is always there, carefully but unobtrusively
monitoring their progress, and ready to facilitate a more positive
learning experience if there are indications that the client needs
help or guidance. The clinician watches closely how clients perform
tasks and considers what about their performance of the task
indicates how they will be successful or unsuccessful in meeting
their rehabilitation goals. Each session is intended to provide a
positive learning experience, and the clinician intervenes as
necessary to achieve this goal.
Clinicians receive specialized training to run the groups. There
are a number of instructional techniques which must be taught,
practiced, and then supervised before clinicians feel confident. This
can only be done with hands-on training sessions, and therefore
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NEAR, like dialectical behavior therapy, is taught with the aid of a
manual, but not solely by the manual. Because it is so challenging to
keep track of eight clients, each working on their own activities, the
help of a Peer Leader is most welcome. Peer Leaders are clients who
have completed the program, and made significant cognitive
change but still need to work on their social skills. Helping to run
groups is an excellent way to integrate their newfound cognitive
competence in a social setting. Peer Leaders show clients how to
do new activities, and they help if someone is encountering
difficulty. They receive feedback about their leadership skills, and
are actively mentored by the clinician.
NEAR EFFICACY STUDIES
Research on NEAR has addressed topics ranging from efficacy to
mechanisms of action, with the aim of better understanding what
predicts a positive response to cognitive remediation. A mixture
of randomized controlled trials and community-based outcome
studies have been used, reflecting the need to study NEAR both
in the laboratory, and as it is used in daily practice. Because the goal
of cognitive remediation is to improve cognitive functioning and
functional outcome, as opposed to training task performance, we
only consider studies where treatment efficacy has been defined
as a change in cognition as measured by an independent test, or
by evidence of functional change. Some of the measures of real
world functioning have included treatment compliance, inde-
pendent living skills, psychosocial functioning, psychiatric status,
and educational and occupational advancement. Unless otherwise
noted, raters determining outcomes of treatments were blind as to
whether subjects received NEAR or the control treatment. While
encouraging, the following results have several important metho-
dological limitations. For example, the well-controlled studies often
had small sample sizes, while the larger, community-based studies
frequently lacked control groups. In addition, only a few of the stu-
dies had follow-up assessments to evaluate whether improvements
persisted beyond treatment termination.
Improvement in Cognition
A multisite randomized waitlist control trial of NEAR in
schizophrenia was conducted with an Australian sample (Rogers
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& Redoblado-Hodge, 2006). Forty-one participants with a diagnosis
of schizophrenia=schizophreniform disorder between the ages
of 16 and 55 were randomly allocated into immediate treatment
or waitlist control groups. The treatment group received 20–30
sessions of NEAR in 15 weeks duration. Both groups received
standard treatment as usual. Following treatment, significant
improvements were found in the areas of attention, processing
speed, and delayed verbal memory in the treatment group
compared with the control group. These gains were sustained three
months after treatment ended.
Preliminary analysis from an ongoing randomized controlled trial
conducted by our group suggests that diagnosis may be a factor in
determining the pattern and degree to which clients benefit from
NEAR. In a sample of 32 psychiatric outpatients, half of whom
received 18 sessions of NEAR, we found that participantswith schizo-
phrenia spectrum but not affective spectrum disorders made signifi-
cant improvements following treatment on a measure of learning
and memory compared to similarly matched wait-listcontrol subjects.
In contrast, participants with affective spectrum but not schizophrenia
spectrum disorders showed significant gains on a measure of problem
solving and mental set shifting comparedto control subjects. This data
from a sample asyet too small to power a diagnosis by treatment inter-
action, suggests a potentially fruitful area for further research.
There is evidence from community based outcome studies that
NEAR can lead to improvements in cognition. Choi and Medalia
(2005) followed 48 outpatients with schizophrenia and affective spec-
trum disorders who took the Minnesota Clerical Test (MCT; Andrew,
Paterson, & Longstaff, 1979), before and after 26 sessions of NEAR.
The MCT is a measure of processing speed and sustained attention
that has also been used to determine skill level for clerical placement.
Thus it is both a proxy vocational functioning measure as well as a
neurocognitive test. As a group, the 48 clients showed significant
improvement on the MCT, indicating that 26 sessions of NEAR results
in improvement in processing speed and sustained attention.
A different community based outcomes study by Medalia
and colleagues (unpublished data) followed 26 outpatients with
persistent and severe psychiatric illness (schizophrenia and affec-
tive disorders), who were enrolled in an Intensive Psychiatric
Rehabilitation Treatment (IPRT) in New York City. It was found
that clients made significant improvements on measures of proces-
sing speed, working memory, immediate memory, and delayed
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memory after a total of 16 sessions of NEAR. For example, on a
measure of delayed verbal memory from the Repeatable Battery
for the Assessment of Neuropsychological Status (Randolph,
1998), the group improved .5 standard deviations.
A study by Medalia, Herlands, and Baginsky (2003) examined
the efficacy of NEAR in 12 subjects with mental illness referred
from a New York City-based supportive housing program for the
homeless. After six-months of NEAR, subjects made significant
improvements on measures of processing speed, reaction time,
and memory from a computerized cognitive test battery.
Improvement in Psychiatric Symptoms and
Psychosocial Functioning
Several randomized controlled treatment trials support a positive
effect of NEAR on psychiatric symptoms. A study by Medalia,
Dorn, and Watras-Gans (2000a) found that six sessions of NEAR
exercises led to significant improvements on both a self-report
measure of ability to cope with psychiatric symptoms and a rating
of global psychopathology provided by nurses.
Another randomized controlled trial with chronically ill
inpatients (Bark, Revheim, Huq, Khalderov, Ganz, & Medalia,
2003) reported that only the psychiatric inpatient group exposed
to a brief ten-session course of problem-solving training improved
significantly over time on the Positive, Negative, and General
Psychopathology Subscales of the Positive and Negative Symptoms
Scale (Kay, Fiszbein, & Opler, 1987; Lindenmayer, Bernstein-
Hyman, Grochowski, & Bark, 1995).
One randomized control trial and several community based
outcome studies have examined the impact of NEAR on measures
of psychosocial functioning. A multisite randomized waitlist control
trial conducted in Australia (Rogers & Redoblado-Hodge, 2006)
found that participants with schizophrenia exposed to 20–30
sessions of NEAR in 15 weeks duration made significant improve-
ments on the Social and Occupational Functioning Assessment
Scale (Goldman, Skodol, & Lave, 1992) relative to the control group.
Revheim, Kamnitzer, Casey, and Medalia (2001) examined
outcomes of 87 mixed-diagnosis outpatients enrolled in a NEAR
program at an inner city IPRT program. Using utilization as a
reflection of treatment engagement, they found that, of clients not
engaged in NEAR, 60%attended their scheduled IPRT programs;
136 A. Medalia and B. Freilich
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whereas, of clients who additionally received NEAR, 82%attended
regularly scheduled treatment programs. Furthermore, 88%of
IPRT clients who received NEAR completed all their IPRT goals,
whereas, of IPRT clients not receiving NEAR, only 5%completed
all their IPRT goals. Rates of psychiatric hospitalization were 10%
for NEAR participants and 22%for IPRT clients who did not attend
NEAR. These data suggest that participation in NEAR improves
overall treatment engagement, ability to accomplish treatment
goals, and ability to avoid rehospitalization.
Medalia et al. (2003), in their outcomes study of 27 clients with
severe and persistent mental illness referred for NEAR from a
supportive housing facility for the homeless, reported that, after six
months, 52%of these clients enrolled in an educational program to
get their GED and 22%started a vocational internship. None of these
clients had previously been successfully engaged in vocational=
educational services, suggesting that participation in the NEAR
program facilitated advancement in functional outcome.
Choi and Medalia (2005) examined the pre- and posttreatment
Work Behavior Inventory (WBI; Bryson, Bell, & Lysaker, 1997) scores
of 48 outpatients with schizophrenia and affective spectrum disorders
exposed to 26 hours of NEAR. The WBI is a 34-item supervisor-rated
scale that measures work-related behaviors that are essential for suc-
cessful employment. In this study, subjects were found to have signifi-
cantly improved work-related behaviors, regardless of the intensity of
their attendance. These results suggest that even erratic attendance at
NEAR can benefit work readiness behaviors.
Research on Mechanisms of Therapeutic Benefit
Does Motivation Really Matter?
NEAR is typically implemented in community-based settings, where,
unlike research settings, there is no financial compensation for attend-
ing treatment. Given the voluntary nature of attendance in these set-
tings, regular attendance can be considered a measure of intrinsic
motivation for treatment. Using this definition of motivation, two stu-
dies have found that motivation is indeed a powerful moderating vari-
able in treatment success (Choi & Medalia, 2005; Medalia &
Richardson, 2005). The treatment effect size for motivated clients
was .90 while unmotivated clients only showed minimal benefit of
treatment, as indicated by an effect size of .01; neuropsychological
functioning was the outcome measure.
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One problem with using attendance as a measure of intrinsic
motivation is that treatment intensity impacts outcome (Choi &
Medalia, 2005; Medalia & Richardson, 2005), so it becomes difficult
to disentangle the effect of intrinsic motivation and treatment
intensity. Satisfaction ratings, task enjoyment, and willingness to
persist in the program have also been used as measures of intrinsic
motivation, and were obtained in two studies ( Medalia, Revheim,
& Casey, 2001; Revheim et al, 2001) using ten-point Likert scales.
Participants in NEAR report high average levels (nine) of enjoy-
ment of the activities and desire to continue in the program. This
level of enjoyment suggests that intrinsic motivation is a factor
in attendance at the program, and by attending, the benefit of
treatment intensity is accrued.
Is it the Engaging Software that Promotes a Positive
Effect or the Specific Nature of the Task?
A randomized controlled study by Medalia, Dorn, and Watras-
Gans (2000a) found that acutely ill, mixed-diagnosis patients on a
psychiatric unit improve more on problem-solving, if they are
exposed to six hours of an engaging problem-solving activity than
if they are exposed to six hours of an engaging cognitive activity
that does not require problem solving.
Two other randomized controlled studies support the hypothesis
that cognitive remediation activities must not only be engaging, but
also neuropsychologically relevant to the deficit being remediated.
Medalia and colleagues (2001) found that inpatients with chronic
schizophrenia or schizoaffective disorder improved more on
problem solving if they were exposed to problem solving software
than to software that focused on memory. Similarly, a randomized
controlled study by Medalia, Revheim, and Casey (2000b) found
that these same inpatients with chronic schizophrenia or schizo-
affective disorder only improved in memory, if they were exposed
to memory remediation, not problem-solving remediation.
Is the Beneficial Effect Due to Extra Time with a
Clinician Performing Learning Activities or to the
Specific Nature of the Learning Activity?
A randomized controlled study by Medalia, Aluma, Tryon, and
Merriam (1998) examined whether individuals in a state hospital
were more likely to benefit from attention training than watching
National Geographic videos. Fifty-four participants with chronic
138 A. Medalia and B. Freilich
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schizophrenia, half of whom were randomized to complete 18
sessions of attention remediation, participated in the study. It
was found that subjects that received the attention training made
significantly more improvement on measures of sustained attention
and reaction time compared to the control group that watched
video documentaries for 18 sessions, thus providing support that
it is not the extra learning time that matters, but the specific nature
of the learning activity.
Do Treatment Variables Impact a Positive Response?
Medalia and Richardson (2005), in an attempt to determine what fac-
tors determine a good response to cognitive remediation interventions,
analyzed the data from three separate studies comprising a total of 117
clients who participated in NEAR. The authors divided the samples
into participants who showed or did not show reliable improvement
from baseline to posttest on a number of neuropsychological and
functional measures. It was found that treatment variables such as
treatment intensity (i.e., the spacing of sessions) and therapist qualifi-
cations were important moderating factors in determining which
clients benefited from NEAR. In addition, while certain patient factors
such as motivation for treatment and baseline sets of work habits were
also found to be important treatment moderators, there was no
evidence that illness factors such as diagnosis, acuity, or most factors
of symptom profile were significant variables that differentiated
clients’ responses to cognitive remediation.
SUMMARY
NEAR is an evidenced-based approach to cognitive remediation that
differs from most other rehabilitative models of treatment in its
emphasis on how people learn best. Influenced by various theories
in the fields of psychology and education, NEAR strives not only to
help improve specific cognitive functions but also to help each person
be the best learner they can be. Intrinsic motivation is recognized as
essential for the learning process, both to make someone a good lear-
ner and to enhance effectiveness of the specific cognitive exercises.
Educational psychology has indicated aspects of learning activities
that promote intrinsic motivation, for example, contextualization,
personalization, and choice. Self-determination theory indicates other
ways to promote intrinsic motivation for learning, namely, by
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fostering a sense of belonging to a group that values learning,
by providing opportunities to gain a sense of competence, and by
encouraging autonomous functioning in learning environments.
In addition, NEAR differs from other cognitive rehabilitative
models in its ability to not only address issues related to neurocog-
nition, but issues related to psychosocial functioning as well. NEAR
is designed to be conducted in a group format and though the
bulk of sessions entail clients performing cognitive activities on
computers, a third of sessions involve clients meeting as a group,
practicing social skills, and discussing how the individual exercises
they are working on relate to real world activities. Furthermore, the
NEAR model encourages the appointment of Peer Leaders, who are
clients that have completed the program and made significant
cognitive change but still need to work on their social skills.
The NEAR model has been refined by many years’ experience
working with psychiatric populations in multimodal rehabilitation
programs in diverse communities. Although the bulk of our
research has been conducted with psychiatric subjects, particularly
individuals with schizophrenia, clinical trials are now underway
investigating the efficacy of NEAR in special populations such as
individuals with ADHD, substance abuse disorders, and early
AD. As the defining feature of NEAR is not the software programs
used or even the cognitive areas targeted for remediation, but
rather the emphasis on instruction and how people learn best, we
are optimistic that NEAR will have utility in the treatment of a
range of conditions in which cognitive impairment is evident.
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