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Cognitive training of self-

initiation of semantic encoding
strategies in schizophrenia: A
pilot study
ab ac
Synthia Guimond & Martin Lepage
a
Douglas Mental Health University Institute, Montreal,
Canada
b
Department of Psychology, McGill University,
Click for updates Montreal, Canada
c
Department of Psychiatry, McGill University,
Montreal, Canada
Published online: 06 Jul 2015.

To cite this article: Synthia Guimond & Martin Lepage (2015): Cognitive
training of self-initiation of semantic encoding strategies in schizophrenia: A
pilot study, Neuropsychological Rehabilitation: An International Journal, DOI:
10.1080/09602011.2015.1045526

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 Neuropsychological Rehabilitation, 2015
http://dx.doi.org/10.1080/09602011.2015.1045526

Cognitive training of self-initiation of semantic

encoding strategies in schizophrenia: A pilot study

Synthia Guimond1,2 and Martin Lepage1,3

1
Douglas Mental Health University Institute, Montreal, Canada
2
Department of Psychology, McGill University, Montreal, Canada
3
Department of Psychiatry, McGill University, Montreal, Canada
Downloaded by [New York University] at 01:52 11 July 2015

(Received 20 January 2015; accepted 22 April 2015)

Available cognitive remediation interventions have a significant but relatively

small to moderate impact on episodic memory in schizophrenia. The present
study aimed to evaluate the efficacy and feasibility of a brief novel episodic
memory training targeting the self-initiation of semantic encoding strategies.
To select patients with such deficits, 28 participants with schizophrenia per-
formed our Semantic Encoding Memory Task (SEMT) that provides a
measure of self-initiated semantic encoding strategies. This task identified a
deficit in 13 participants who were then offered two 60-minute training sessions
one week apart. After the training, patients performed an alternate version of
the SEMT. The CVLT-II (a standardised measure of semantic encoding strat-
egies) and the BVMT-R (a control spatial memory task) were used to quantify
memory pre- and post-training. After the training, participants were signifi-
cantly better at self-initiating semantic encoding strategies in the SEMT
(p ¼ .004) and in the CVLT-II (p ¼ .002). No significant differences were
found in the BVMT-R. The current study demonstrates that a brief and specific

Correspondence should be addressed to Martin Lepage, Douglas Institute, Frank B. Common

Pavilion, Room F-1143, 6875, boulevard LaSalle, Montreal (Quebec), H4H 1R3. E-mail:
martin.lepage@mcgill.ca
This work was funded by a James McGill Professorship to ML. SG was supported by a Vanier
Graduate Scholarship from CIHR. We would like to thank Karyne Anselmo for her help with
the recruitment and baseline clinical evaluations of patients, Laurence-Bergeron Gagnon for
her help with the data collection, Lauri Tuominen for comments on an earlier version of this
manuscript, and Maike Storks for proofreading the manuscript.
No potential conflict of interest was reported by the authors.
This work was funded by a James McGill Professorship from McGill University to M.L.
Supplementary content is available via the Supplementary tab on the article’s online page
(http://dx.doi.org/10.1080/09602011.2015.1045526).

# 2015 Taylor & Francis

 2 GUIMOND AND LEPAGE

training in memory strategies can help patients to improve a deficient memory

process in schizophrenia. Future studies will need to test this intervention
further using a randomised controlled trial, and to explore its functional impact.

Keywords: Schizophrenia; Memory training; Semantic encoding strategies;

Episodic memory

INTRODUCTION
When a person goes to the grocery store and attempts to remember a list of
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items to buy, he will naturally regroup in his memory the items in different
categories (e.g., fruits, vegetables, meat . . . ). This ability to spontaneously
use the semantic information to form a relation between items and thus facili-
tate their subsequent recognition or recall is referred to as the self-initiation of
semantic encoding strategies. Individuals with schizophrenia have difficulties
initiating such strategies. Indeed, previous studies have demonstrated that
patients use less semantic clustering than healthy controls when they are
asked to recall a list of words (Brébion, David, Jones, & Pilowsky, 2004;
Gsottschneider et al., 2011; Hazlett et al., 2000). However, when individuals
with schizophrenia were specifically trained to regroup the words in cat-
egories during the encoding of the list, or if the names of the categories
were provided just before the encoding, they were able to increase their
number of semantic clusterings (Chan et al., 2000; Fiszdon, Choi, Bryson,
& Bell, 2006).
It is now well established that patients with schizophrenia have episodic
memory impairments (Achim & Lepage, 2005; Danion, Huron, Vidailhet,
& Berna 2007; Lepage, 2007), and greater difficulties with associative or rela-
tional memory than with item memory (Lepage et al., 2006). As recently
suggested by Bonner-Jackson and Barch (2011), this specific deficit to form
and recall associations between items in schizophrenia could therefore in
part be driven by a deficit to self-initiate efficient semantic encoding
strategies.
Memory deficits in schizophrenia are related to poor community function-
ing and diminished psychosocial skills (Evans et al., 2004; Green, Kern,
Braff, & Mintz, 2000). To date, pharmacological intervention trials have
not demonstrated any clear positive impact on memory performance in
schizophrenia (Genevsky, Garrett, Alexander, & Vinogradov, 2010; Minzen-
berg & Carter, 2012). Hence, there is a great need to develop complementary
non-pharmacological approaches to improve memory functions in schizo-
phrenia. Cognitive remediation therapy is the most common intervention
used to improve cognition in schizophrenia and has a significant but relatively
 ENCODING STRATEGIES TRAINING IN SCHIZOPHRENIA 3

small to moderate impact on episodic memory (McGurk, Twamley, Sitzer,

McHugo, & Mueser, 2007; Wykes, Huddy, Cellard, McGurk, & Czobor,
2011). When strategy use is explicitly taught in this cognitive therapy,
better functioning outcomes are achieved (Wykes et al., 2011). Therefore,
it could be beneficial to tailor those strategies to individuals according to
their impairments in specific cognitive domains, such as episodic memory.
This pilot study sought to improve the self-initiation of semantic encoding
strategies in people with schizophrenia. Our goal was to develop a semantic
encoding strategies training and to evaluate its efficacy to improve associative
episodic memory in schizophrenia. To accomplish this, participants with
enduring schizophrenia and an established deficit in self-initiation of semantic
encoding strategies were first selected. Then training, consisting of two 60-
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minute weekly sessions on semantic encoding strategies, was provided. In

these sessions, participants practised different computerised exercises on
how to make semantic links between items to memorise. It was hypothesised
that this training would significantly increase memory performance in the con-
dition where self-initiation of semantic encoding strategies was needed in our
Semantic Encoding Memory Task (SEMT) and in the California Verbal Learn-
ing Test (CVLT-II), a standardised measure of semantic encoding strategies A
spatial memory task (Brief Visuospatial Memory Test–Revised; BVMT-R)
was administered to examine the specificity of the training and it was hypoth-
esised that performance on this task would not be influenced by such a training.

METHOD

Design
This study used an uncontrolled design recommended to evaluate initial effi-
cacy and feasibility of novel interventions with patients (Mueser & Drake,
2005). The cognitive intervention developed in the current study specifically
targeted individuals with schizophrenia having difficulties self-initiating
semantic encoding strategies. The intervention was delivered individually
by one of the authors (S.G.) and supervised by a licensed neuropsychologist
(M.L.). The sessions took place in a quiet room at the Douglas Mental Health
University Institute, Montreal, QC, Canada.

Study participants
Participants were recruited via advertisements, from different outpatient
units at the Douglas Mental Health University Institute, Montreal, QC,
Canada, and from external and community-based mental health clinics. We
excluded individuals with (1) a lifetime history of medical or neurological con-
ditions that have been shown to affect cognition, (2) a family history of
 4 GUIMOND AND LEPAGE

hereditary neurological disorders (e.g., Huntington’s disease), (3) a diagnosis

of substance dependence (current or within the past three months), (4) presence
of depression or Parkinsonism. From the 28 individuals with enduring schizo-
phrenia recruited, 13 with deficits to self-initiate semantic encoding strategies
were selected for the training (see Measures section below). One participant
dropped out prior to study completion, due to admission to an intensive reha-
bilitation programme. Only participants who completed the training (n ¼ 12)
were included in the analyses. Information on current medication was obtained
via self-report and corroborated when necessary with the treating psychiatrist.
Antipsychotic doses were converted to chlorpromazine equivalents according
to the literature (Jensen & Regier, 2010; Leucht et al., 2014; Woods, 2003). The
study was approved by the Douglas Mental Health University Institute’s
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Research Ethics Board and all participants provided informed written consent.

Measures
All participants were assessed at baseline with the Structured Clinical Inter-
view for DSM-IV (First, Spitzer, Gibbon, & Williams, 1998) to confirm their
diagnosis and with the Wechsler Abbreviated Scale of Intelligence (WASI)
(Hays, Reas, & Shaw, 2002) to confirm that their IQ was greater than 70.
Clinical symptoms were assessed using the Scale for the Assessment of Nega-
tive Symptoms (SANS; Andreasen, 1984a) and the Scale for the Assessment
of Positive Symptoms (SAPS; Andreasen, 1984b). The Hamilton Anxiety
Scale (HAS; Riskind, Beck, Brown, & Steer, 1987) and the Calgary
Depression Scale (CDS; Addington, Addington, & Maticka-Tyndale, 1993)
were also administered to all participants. All these clinical assessments
were performed by research staff not involved with the current intervention.
All participants completed the first five trials of the California Verbal
Learning Test (CVLT- II; List A or B) to assess objectively their use of
semantic clustering (Delis, Kramer, Kaplan, & Ober, 1987). Importantly,
only the first five trials were administered to the participants to prevent
prompting the use of semantic encoding strategies with the name of the cat-
egories. The Brief Visuospatial Memory Test–Revised (BVMT-R) was used
as a control for the practice effect, as well as a discriminant measure of the
training specificity (Benedict, Schretlen, Groninger, Dobraski, & Sphritz,
1996). To assess the memory control beliefs of the participants pre- and
post-training, the three subscales (Present Ability, Potential Improvement,
and Effort Utility) of the Memory Controllability Inventory (MCI) were
administered (Lachman, Bandura, Weaver, & Elliott, 1995).
Following these tests, participants completed the Semantic Encoding
Memory Task (SEMT). Figure 1 illustrates the different components of this
associative episodic memory task that we developed to target the self-
initiation of semantic encoding strategies. Participants were instructed to
 ENCODING STRATEGIES TRAINING IN SCHIZOPHRENIA 5

Figure 1. Semantic Encoding Memory Task (SEMT) was created to assess deficit in self-initiation of
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semantic encoding strategies in associative episodic memory.

remember 128 pairs of items. For half of the trials, they had to determine
whether or not both objects were from the same category (indicated by the
cue “Category?”) by pressing 1 if the objects were from one category and
2 if the objects were from two different categories. For the other half of the
trials, they had to determine which object was bigger in real life (indicated
by the cue “Bigger?”) by pressing 1 if it was the first object of the pair or 2
if it was the second object. Half of the pairs belonged to the same category
and the other half belonged to different categories. All conditions were
pseudo-randomised in six different versions of the task and counterbalanced
across participants, and time of measures (pre- and post-training). The con-
dition targeting self-initiation of semantic encoding strategies was created
when both objects were from the same semantic category and the orienting
question was about the size (Bigger?). Indeed, in this condition, participants
were not explicitly cued to use the semantic information, but could benefit
from self-initiating semantic encoding strategies to encode both objects of
the pair. After the encoding task, participants were asked to perform a
forced-choice recognition task. They had to determine which of the four
objects (all presented as a second object in the encoding task) was the one
paired with the first object appearing on the left side of the screen (see
Figure 1). The participants also filled out a Subjective Strategies Encoding
questionnaire at the end of the task to investigate at which level they used
self-initiation of semantic encoding strategies. This questionnaire asked
how much participants thought they used three different encoding strategies
(repetition, visualisation, and semantic strategies; see Supplementary
Material 1). In order not to influence or prompt the participants to use a
specific strategy, they were told that all these strategies were helpful and
could have been used during the encoding task.
We started with the assumption that participants who were able to self-
initiate semantic encoding strategies during the associative episodic
 6 GUIMOND AND LEPAGE

memory task would have similar performance when both objects to memorise
were from the same category irrespective of the encoding question (“Cat-
egory?” or “Bigger?”). Hence, the selection of the patients to whom training
would be offered was based on their recognition performance in these two
conditions. To be selected for training, a participant needed to show a
decrease in performance (of at least 10%) when the encoding cue was
“Bigger?” compared to when the encoding cue was “Category?”.
Alternate versions of the CVLT-II, the BVMT-R, and the SEMT were
administered after the training, as well as the same subscales of the MCI,
and the subjective strategies encoding questionnaire. Finally, participants
were asked about their satisfaction with the training to evaluate the feasibility
and the acceptance of the intervention (see Supplementary Material 2 online).
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Training
We developed a training adapted to a selective memory deficit often experi-
enced by individuals with schizophrenia. It focuses specifically on the elabor-
ation of self-initiation of relevant semantic encoding strategies. The training
consisted of two 1-hour training sessions. At the beginning of the first session,
a meta-memory presentation introducing the objective of the training was
given to the participants. The presentation was first shown to the participants
alone in front of the computer. After this, the trainer briefly discussed with the
patient to ascertain that he or she completely understood the presentation. In
the first part of the training session, we explicitly taught the participants how
to use the semantic information related to different stimuli to organise infor-
mation by grouping items together more easily. They first practised with a
task with explicit instructions and cues to help them to categorise different
items. The self-initiation conceptually means that, by themselves, the patients
need to be able to initiate appropriate and efficient strategies related to the
material they have to encode. Therefore, four different exercises were
created to make participants practise these strategies using different types
of stimuli (visual, auditory, verbal and non-verbal). For example, patients
needed to memorise pictures of objects in different rooms, food verbally
ordered by people in a restaurant, grocery lists, and word pairs. At the end
of both sessions, some time was allocated for a bridging activity during
which we asked for feedback about the activities and discussed with the par-
ticipants the usefulness of applying efficient semantic encoding strategies in
their daily life. After the first session, participants were asked to find an
example in their daily life where they could use the strategies they learned
to improve their memory as homework, and we discussed this example at
the end of the second training session. The details about the presentation
and the exercises used for the training sessions can be found online in
Supplementary Material 3.
 ENCODING STRATEGIES TRAINING IN SCHIZOPHRENIA 7

Statistical analysis
To first evaluate the performance of participants during the encoding of the
SEMT depending on the time of measure (pre- vs. post-training) and of the
orientation question (Bigger? vs. Category?), and their interaction, a 2 × 2
repeated measures analysis of variance (ANOVA) was performed. Because
of a technical problem, two participants had incomplete recorded responses
for the encoding task and were then excluded for this specific analysis
only. A 2 × 2 × 2 repeated measures ANOVA was performed on the
performance on the SEMT recognition with the time of measure, pre-
vs. post-training, the orientation question, Bigger? vs. Category?, and the
semantic relatedness, not semantically related (NSR) vs. semantically
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related (SR), as factors. Planned paired t-test comparisons were then con-
ducted to determine precise differences between pre- and post-training on
the SEMT recognition task performance using a Bonferroni correction
(critical p-value ¼ .013). Participants’ subjective evaluation of their use
of semantic encoding strategies for the SR conditions after having com-
pleted the recognition task of the SEMT before and after the training
was also investigated using paired t-tests and Bonferroni correction (critical
p-value ¼ .025). Differences pre- and post-training for the CVLT- II Trials
1–5 corrected total and Semantic Clustering (Chance-Adjusted) Trials 1–5,
the BVMT-R delayed recall and recognition index, and the three subscales
of the MCI were assessed using paired t-test comparisons and Bonferroni
correction (critical p-value ¼ .007). Considering the small sample size,
we also included a standardised mean effect size (Cohen d’) to all the
pre- and post-training t-tests. All analyses were conducted using SPSS
version 20 (SPSS, Chicago, IL, USA).

RESULTS

Clinical and demographic data

Table 1 presents the clinical and demographic data of participants who were
included in and excluded from the training. Patients who were included in the
training had higher depression scores on the CDS, but did not significantly
differ on any other variables.

Training outcomes

SEMT
Participants performed well during the encoding task before (mean ¼ 80%,
SD ¼ 10%) and after the training (mean ¼ 84%, SD ¼ 12%). The repeated
 8
TABLE 1
Demographic, neuropsychological and clinical data

GUIMOND AND LEPAGE

Included Excluded
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(n ¼ 13) (n ¼ 15)

Mean SD Range Mean SD Range p-value

Age 33.07 7.19 22–50 32.73 9.14 21–49 .27

Age of onset 22.46 4.92 18–32 21.6 5.65 15–35 .93
Duration of illness 10.61 4.85 4 –20 11.13 7.38 4 –31 .44
SAPS 15.23 9.31 0 –27 13.5 8.87 0 –25 .91
SANS (without attention) 21.69 7.9 6 –38 16.46 10.38 0 –38 .39
CDS 3.3 4.92 0 –13 2 1.85 0 –6 .003
HAS 5.5 6.4 0 –21 6.2 5.8 0 –17 .84
IQ 99.6 12.56 79–121 104.4 12.94 79–125 .88
Medication (mg chlorpromazine) 987.53 1319.9 10.7–4835 757.11 435.24 166.25–1711 .57
SEMT Recognition (%)
SR Bigger? 66.85 12.92 47–87 77.54 8.64 63–91 .01
SR Category? 79.23 11.67 60–97 75.33 12.28 47–94 .39
NSR Bigger? 41.42 18.13 13–81 42.27 16.32 16–72 .89
NSR Category? 37.75 13.21 16–53 37.47 14.11 22–75 .96
CVLT-II
Total trials 1 –5 46.77 12.22 17–59 47.33 8.89 34–62 .88
Semantic clustering 1–5 0.57 1.17 21.04–2.84 0.76 1.58 21.04–4.72 .73
(chance adjusted)
Downloaded by [New York University] at 01:52 11 July 2015

BVMT-R
Delayed recall 22.31 7.42 11–31 20.78 7.04 10–32 .59
Recognition 5.62 0.65 4 –6 5.50 0.85 3 –6 .69

ENCODING STRATEGIES TRAINING IN SCHIZOPHRENIA

MCI
Present ability 4.90 1.17 2.7–6.5 4.61 1.48 2.3–7 .57
Effort utility 5.54 1.65 1 –7 4.64 1.33 2.7–6.7 .12
Potential improvement 5.28 1.47 1 –6.7 4.75 1.57 2 –6.7 .30

Gender .27
Male n (%) 9 (69) 13 (87)
Female n (%) 4 (31) 2 (13)

Independent t-tests were performed to investigate between-group differences for all variables, except for the gender where a Kruskal-Wallis test was used.
Post-hoc correlations between medication and memory measures (SEMT, CVLT-II and BVMT-R) did not reveal any significant relationships between these
variables.
SAPS ¼ Scale for the Assessment of Positive Symptoms; SANS ¼ Scale for the Assessment of Negative Symptoms; CDS ¼ Calgary Depression Scale; HAS ¼
Hamilton Anxiety Scale; SEMT ¼ Semantic Encoding Memory Task; CVLT ¼ California Verbal Learning Test; BVMT-R ¼ Brief Visuospatial Memory Test –
Revised; MCI ¼ Memory Controllability Inventory.

9
 10 GUIMOND AND LEPAGE

measures ANOVA on the performance on the encoding task revealed a signifi-

cant difference between the questions asked, F(1, 9) ¼ 6.22, p ¼ .03, no sig-
nificant main effect of the time of measure, F(1, 9) ¼ 1.08, p ¼ .33, and no
significant interaction, F(1, 9) ¼ 0.00, p ¼ .99. Even if they correctly
answered the majority of the trials, participants seemed to have had better
accuracy when the question was “Category?” than when it was “Bigger?”.
The absence of a significant interaction confirms that this bias was present
to the same extent prior to and after the training. All participants performed
above the chance level for the forced-choice recognition task.
Figure 2 illustrates the percentage of correct answers for every condition of
the recognition task pre- and post-training. The repeated measures ANOVA
on recognition performance revealed a significant interaction between the
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orientation question and the time of measure, F(1, 11) ¼ 9.50, p ¼ .01.
Paired t-tests performed to investigate the pre- and post-training effect
showed a significant difference only in the targeted condition where partici-
pants had to self-initiate semantic encoding strategies (SR Bigger?), t(11) ¼
23.57, p ¼ .004, d ¼ 1.04. This is also concordant with the subjective report

Figure 2. Percentage of correct answers on the recognition for the Semantic Encoding Memory Task
(SEMT) pre- and post-training. The results are presented separately for each condition: when both
objects were semantically related (SR) and the question during the encoding was Bigger?; when
both objects were semantically related (SR) and the question during the encoding was Category?;
when both objects were not semantically related (NSR) and the question during the encoding was
Bigger?; when both objects were not semantically related (NSR) and the question during the
encoding was Category? The dotted line represents the chance level of the percentage of correct
answers. The p-value and Cohen’s d are reported for every pre- and post-training comparison.
 ENCODING STRATEGIES TRAINING IN SCHIZOPHRENIA 11
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Figure 3. Subjective impression of the patients pre- and post-training regarding their level of self-
initiation of semantic encoding strategies when both objects were semantically related (SR) for
each orientation question during the encoding (Bigger? and Category?). The p-value and Cohen’s d
are reported for every pre- and post-training comparison.

that participants gave regarding their use of semantic encoding strategies.

Indeed, they reported they used semantic encoding strategies more often
for the targeted condition after the training, t(11) ¼ 2.75, p ¼ .02, d ¼
0.80 (see Figure 3).

CVLT-II, BVTM-R, and MCI

As shown in Figure 4, participants significantly increased the total of
words recalled for trials 1–5, t(11) ¼ 24.39, p ¼ .001, d ¼ 1.27, and
their number of semantic clustering, t(11) ¼ 24.14, p ¼ .002, d ¼ 1.20.
No significant improvements were reported on the BVMT-R for the
delayed recall, t(11) ¼ 1.07, p ¼ .31, d ¼ 0.31, or for the recognition,
t(11) ¼ 0.80, p ¼ .44, d ¼ 0.23. In addition, no significant pre- and post-train-
ing differences were found for the MCI, Present Ability: t(11) ¼ 20.65, p ¼
.53, d ¼ 0.19, Potential Improvement: t(11) ¼ 20.71, p ¼ .49, d ¼ 0.34, or
Effort Utility: t(11) ¼ 20.38, p ¼ .71, d ¼ 0.21.

Feasibility of the training

The descriptive comments about the satisfaction with the training gathered in
the questionnaire highlight that participants describe the training as interest-
ing, challenging, useful, feasible, and pleasant. Based on the answers on a
Likert scale with scores from 1 to 5 (where 1 ¼ not at all, 3 ¼ moderately,
and 5 ¼ very much), the majority of patients indicated that they enjoyed par-
ticipating in the training (mean ¼ 4.2, SD ¼ 0.63). Generally, participants
also reported a subjective improvement of their memory following the train-
ing (mean ¼ 3.4, SD ¼ 0.70), the belief that they are now better at using
 12 GUIMOND AND LEPAGE
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Figure 4. Pre- and post-training results for the California Verbal Learning Test (CVLT- II, the
objective measures of self-initiation of semantic encoding strategies) and the Brief Visuospatial
Memory Test–Revised (BVMT-R, the control spatial memory task). The p-value and Cohen’s d
are reported for every pre- and post-training comparison.

semantic encoding strategies (mean ¼ 3.7, SD ¼ 0.83), and that the training
may help them in their everyday life (mean ¼ 3.7, SD ¼ 0.95).

DISCUSSION
The aim of this study was to evaluate the efficacy of a novel memory training
targeting specific deficits in semantic encoding strategies in individuals with
enduring schizophrenia. The current results suggest that patients may improve
the self-initiation of semantic encoding strategies following this specific train-
ing. The participants clearly improved their performance in the condition of
the SEMT where self-initiation of semantic encoding strategies was
needed, and in the CVLT-II measures. The effect seems to be generalised
to different measures involving the same encoding strategies. As expected,
no significant pre- and post-training differences were observed for the
 ENCODING STRATEGIES TRAINING IN SCHIZOPHRENIA 13

control task (BVMT-R), and for the conditions of the SEMT where self-
initiation of semantic encoding strategies was not needed. The positive
effect of the training observed only on targeted self-initiation of semantic
encoding strategies in patients suggests a good specificity of our intervention.
Medalia, Revheim, and Casey (2000) studied the impact of cognitive reme-
diation therapy on memory disorders in schizophrenia and failed to show any sig-
nificant improvement on memory performance after the training. In this study,
there was no a priori selection of the participants based on their memory capacity.
Moreover, during the training sessions, they had to perform several activities
implicating different types of memory and strategies (working memory, short-
term memory, episodic memory, and spatial and verbal memory). This study,
as well as the majority of others using cognitive training (see Twamley, Jeste,
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& Bellack, 2003), did not target a specific memory process. We believe that
the use of a one-size-fits-all approach, which is a typical method for improving
memory deficits in schizophrenia, is unlikely to be the most efficient intervention
with this population. There are many individual differences with regard to faulty
episodic memory processes in schizophrenia (Brazo, Ilongo, & Dollfus, 2013;
Turetsky et al., 2002) and it could be beneficial to develop a training that
focuses on specific strategies to effectively memorise information in a given
context. In line with this, Pillet et al. (2014) observed that individuals with
schizophrenia, who benefited most from cognitive remediation therapy, seem
to be those with a lower initial level of memory. Targeting patients with
memory deficit before the therapy could thus be an efficient approach. It is
also possible that individuals with less difficulty with memory could benefit
more from interventions adapted to their need and focusing on the different cog-
nitive deficits that they experience. In the current study, we developed an associ-
ative episodic memory task to target individuals with schizophrenia with
difficulty self-initiating adequate semantic encoding strategies. As Bonner-
Jackson and Barch (2011) suggested, it seems that deficits in self-initiation of
semantic encoding strategies can affect the associative episodic memory per-
formance in some patients. The fact that less than half of our initial sample
showed this deficit supports the need to consider individual differences
between patients in the development of cognitive interventions. In the current
study, we observed clear positive improvements after the training in the mnemo-
nic process targeted in only two 1-hour training sessions. An approach focusing
on the tangible deficit that patients with schizophrenia are experiencing could
thus be more efficient than actual interventions that aim to improve general cog-
nition or memory.
Another goal of the current study was to provide some evidence for the
feasibility of a specific training targeting the improvement of self-initiation
of semantic encoding strategies with individuals with enduring schizophrenia.
The overall attendance rate of completers (12/13) and the feedback received
can be seen as two positive indicators of the feasibility of the training. The
 14 GUIMOND AND LEPAGE

present results suggest thus that the proposed training is feasible and accep-
table to the patients.
This pilot study has nonetheless some limitations that need to be men-
tioned. The small size of our sample may have led to Type 2 errors in the
results. Nonetheless, we still observed significant effects with large effect
sizes on our measures of interest. As mentioned earlier, this study did not
include a control group, and it is possible that the observed effects were
due to variables other than the training itself. The aim of this study was to
evaluate the impact and the feasibility of new memory training, but we
decided to include a control task assessing the specificity of the intervention.
The fact that our participants only improved their performance on the targeted
tasks and conditions, and not on the control task, may increase the confidence
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that the observed changes in performance are related to the specific training.
We tried to reduce as much as possible the possibility of prompting semantic
encoding strategies in our measures of interest. However, the absence of a
control group limits the conclusion that can be drawn from this study and,
as such, other explanations for the findings are possible. Future research is
needed to examine the relative efficacy of the proposed encoding strategies
training compared to another type of intervention in a randomised controlled
trial and to examine its impact on real-life functioning.
To summarise, this study investigated the impact and the feasibility of a
new approach regarding memory intervention in schizophrenia. Training
schizophrenia patients to improve their self-initiation of semantic encoding
strategies seems to improve their performance on related episodic memory
tasks where these strategies were needed. Taking into account individual
differences and focusing on the current deficit that patients with schizo-
phrenia present could therefore be an efficient way to develop new cognitive
treatments. Further randomised and controlled studies using this approach
with individuals with schizophrenia are needed, and should therefore be
encouraged.

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