Bridging the gap between extrinsic and intrinsic motivation in the cognitive remediation of schizophrenia.

An important development in cognitive remediation of schizophrenia is a focus on motivation. However, following a distinction between the concepts of intrinsic motivation (IM) and extrinsic motivation, discussions of IM-based methods have downplayed or misrepresented the role that extrinsic rewards can, and actually do, serve to promote positive treatment outcomes in cognitive remediation. Therefore, the purpose of this article is to explore the rationale for using techniques incorporating extrinsic rewards into cognitive treatment of people with schizophrenia. To do this, evidence is presented on each of the following points: (1) there is a long history of research demonstrating that delivery of extrinsic reward is associated with positive outcomes in both behavioral and cognitive rehabilitation; (2) basic human brain systems respond strongly to tangible rewards, and this can directly enhance attention, working memory, and other cognitive functions; (3) nearly all data on the negative effects of extrinsic reward on IM have come from studies of healthy children and adults in school or work settings who have adequate IM for target tasks; these findings do not generalize well to cognitive remediation settings for people with schizophrenia, who often have abnormally low levels of IM and low base rates of attentive behaviors; and (4) in real-world situations, cognitive remediation interventions already utilize a combination of intrinsic and extrinsic reinforcers. Future studies are needed to clarify state and trait factors responsible for individual differences in the extent to which extrinsic rewards are necessary to set the conditions under which IM can develop.