CIRCuiTS – Instructions for Use

Introduction

CIRCuiTS (Cognitive Interactive Remediation of Cognition and Thinking Skills) is a digital cognitive remediation therapy (CRT) program delivered by a therapist and developed at King's College London.

Supported by independent sessions and homework, the therapy involves completing a journey of tasks which provide massed practice of cognitive/thinking skills, in an approach focused on developing metacognition, particularly strategy use. Recipients of the therapy ("clients") develop a set of personalised strategies to improve their cognitive performance and achieve their goals.

Intended Use

CIRCuiTS aims to improve clients' thinking (cognitive) skills, and to transfer cognitive gains to daily life to improve functioning and goal attainment.

CIRCuiTS uses therapeutic and pedagogical techniques such as errorless learning and massed practice to help people develop their cognitive skills whilst sustaining motivation and increasing independence. To improve task success and transfer of new skills to daily situations, the therapist and the CIRCuiTS program encourage clients to learn about their own thinking ("metacognition"). This includes, but is not limited to, goal setting, strategy use, and recognising personal strengths and difficulties.

Please read these instructions before using CIRCuiTS. You can refer to them at any time by clicking on the instruction book icon by the CE mark label.

Safety Information

Cautions

Pre-Use Requirements and Dependencies

CIRCuiTS is a web-based program and is accessed via a web-browser. This means the user must have access to either an internet-compatible device (e.g. computer, laptop, or tablet), and an internet connection. We do not recommend that CIRCuiTS is used on a mobile device.

We recommend that CIRCuiTS is used only on trusted internet/WiFi networks to ensure that the connection is secure. We recommend users do not use public or unsecured networks.

We also recommend that users log out after they have finished using CIRCuiTS.

Software Installation, Upgrade and Configuration

For the website to work as well as possible and display everything as it should be, we recommend that users use the most recent versions of device operating systems and internet browsers.

Step-by-Step Instructions

For clients

Your CIRCuiTS therapist will contact you directly and provide you with the web address and your login details for accessing CIRCuiTS. It is likely that you will meet with them before your first session, and they may ask you to provide more information about yourself and/or complete questionnaires. The information gathered is at the therapist's discretion and none is stored in CIRCuiTS.

In your first CIRCuiTS session, your therapist will guide you through logging in and starting your therapy journey, the steps for which are:

• 1. Go to the CIRCuiTS website provided to you.
• 2. Enter your User Code in the User Login tab.
• 3. Read the Introduction message presented to you.
• 4. Click the link at the end of the Introduction to read your privacy information.
• 5. Once in the Village, visit the Library by clicking the flashing Library building or the Info button. Here you can read books about, for example, using a mouse or touch screen, what to expect from CIRCuiTS, and how to do homework.
• 6. Start your therapy journey by returning to the Village (using the Village button) and enter your first task by pressing the other flashing building or the task link at the bottom.
• 7. After you complete each task, you will return to the Village where your next task will be loaded.
• 8. Your therapist will support you to complete tasks, progress through your therapy journey and monitor your progress. Visit the My Progress book in the Library at any time to review your task performance and thinking skills.

For therapists

A member of the CIRCuiTS team or a member of your organisation with administrative privileges will create a CIRCuiTS therapist account for you and will provide you directly with the relevant URL and your personal login details.

The steps for accessing CIRCuiTS for the first time are:

• 1. Go to the CIRCuiTS website provided to you.
• 2. Enter your Therapist Username and Password in the Therapist Login tab.
• 3. You will be asked to provide your details and to read and electronically agree to the CIRCuiTS Terms & Conditions and Data Processing Agreement, and you will be presented with a link to your privacy information.
• 4. Once logged in, the Therapist Guides on the left contain the information you should need, following your training, to refresh your memory of how to progress further into the website, how to use CIRCuiTS and the admin system, etc.

Troubleshooting & Frequently Asked Questions

If you cannot find the answer you are looking for here, the CIRCuiTS Library books (for clients) or the Therapist Guides (for therapists) are likely to answer most questions. Any further questions can be sent to the CIRCuiTS team at circuits@kcl.ac.uk.

Questions about CIRCuiTS

What is CIRCuiTS and what is it for?

CIRCuiTS is a web-based form of cognitive remediation therapy (CRT), a psychological therapy for improving thinking skills such as concentration, planning and memory. It involves completing a 'Journey' of tasks which practice cognitive skills and metacognition (particularly strategy use) to aid the transfer of cognitive improvements to everyday life. It is delivered by a therapist and can incorporate homework and independent sessions.

What is cognitive remediation therapy (CRT)?

The Cognitive Remediation Expert Working Group define CRT as "An intervention targeting cognitive deficits using scientific principles of learning with the ultimate goal of improving functional outcomes. Its effectiveness is enhanced when provided in a context (formal or informal) that provides support and opportunity for extending everyday functioning."

What is metacognition?

Metacognition is "thinking about thinking". In essence, your metacognition is your knowledge and beliefs about your own thinking. It is also your ability to monitor and evaluate your thinking, and to control or regulate your cognitive and behavioural performance, for example by using strategies to aid the performance of activities. Developing metacognition is a defining feature of CIRCuiTS.

What is a CIRCuiTS 'Journey'?

A 'Journey' in CIRCuiTS is a pre-defined sequence of tasks that are presented to clients one-by-one to complete in the Village. There are two types of tasks:

• 'Abstract tasks' are simple and practice particular cognitive skills. They have neutral content (shapes, numbers, etc.) and are not directly based on real-life activities. They appear more frequently at the start of a journey, to help people acclimatise to using the program and practice cognitive skills.
• 'Exercises' are more complex and require multiple thinking skills. They are based on real-life activities related to work, cooking, shopping, travelling and social situations, thereby increasing transfer of cognitive skills to everyday life. Exercises appear more frequently as a client progresses through their therapy journey.

All tasks involve metacognitive elements, such as choosing, implementing, and evaluating strategies, predicting task demands beforehand, and reflecting on task demands and performance afterwards. A CIRCuiTS Journey also provides frequent tutorials and tips on evaluating your thinking skills and acknowledging your strengths and progress. To cater for varying confidence, needs or abilities of different clients, Standard and Advanced Journeys are available, bespoke journeys can be created, and any task in a journey can be reset or skipped.

Why have I been chosen to use this program?

Your doctor, another healthcare professional or a researcher may have recommended CIRCuiTS to you as you may be finding that your thinking skills are having a negative impact on your day-to-day life and wellbeing.

Who designed CIRCuiTS?

CIRCuiTS was designed and written by Professor Dame Til Wykes and Dr Clare Reeder at the Institute of Psychiatry, Psychology and Neuroscience at King's College London. The software was built and is hosted by SPIKA, London.

How long does the CIRCuiTS program take?

CIRCuiTS delivery is around 40 sessions with a therapist at a recommended frequency of 3 times a week, equating to roughly 12 weeks in total. This can include independent homework sessions. Some people work faster or slower than others and the pace can be tailored to each client, although 'massed practice' (frequent performance of tasks in high volume) is a contributing factor to CIRCuiTS' effectiveness.

Can CIRCuiTS be used on a tablet?

Yes, CIRCuiTS has been tested for use on the following tablet devices:

Make / Model	Operating system version	Browser
Apple iPad	iOS 13 or higher	Safari
Samsung Galaxy Tab series	Android 10 or higher	Google Chrome

As tablets and operating systems are regularly being replaced by newer versions, if you find a problem please feel free to report it to us on: circuits@kcl.ac.uk
CIRCuiTS provides both a client tutorial on using a touch screen (in the Library) and a therapist tutorial on delivering CIRCuiTS using a tablet (in the Therapist Guides).
CIRCuiTS can also be used on a laptop, desktop or Macbook.

Can CIRCuiTS be used on a mobile phone?

We do not recommend using CIRCuiTS on any mobile phone device. Mobile screens are too small to view and interact with the finer details of CIRCuiTS.

Who is supporting me throughout this process?

Every client who uses CIRCuiTS is assigned a therapist or therapists. All CIRCuiTS therapists are trained, qualified, and supervised healthcare professionals who will provide clients with support during the program. They will be clients' main source of support, and between sessions will be available for contact, monitor clients' progress and organise regular therapy sessions, according to their availability and/or that of their healthcare service or research team.

What happens if I don't like CIRCuiTS and want to try something different?

Using CIRCuiTS is voluntary and you may stop at any time. If you have concerns about the therapy or do not want to continue, please speak to your CIRCuiTS therapist(s). They can discuss this with you and help you decide on next steps. Other options may be offered by your healthcare service, and again your therapist(s) can talk these through with you.

Technical Issues

What happens if I forget my password?

If a client forgets their User Code, they should contact their CIRCuiTS therapist(s) who will be able to reset it and provide the client with their new login details.

If a therapist forgets their Username or Password, they should send an email to the secure circuits@kcl.ac.uk email and a member of the CIRCuiTS team with administrative privileges will reset one or both of them, as needed, and email the therapist their new login details.

I am having trouble logging in.

Check that you have correctly typed in the login details that were provided to you when your CIRCuiTS account was first created. Check also whether CAPS LOCK is on whilst typing your login details. Accessing the CIRCuiTS website may be compromised if your internet strength is not strong enough, or if planned maintenance is being carried out on the CIRCuiTS site. Therapists will have been made aware of routine maintenance.

What happens if I disconnect from CIRCuiTS part-way through a session?

Clients will be able to continue their therapy journey from where they left off, although progress is likely to be saved only from the last task, tutorial or tip completed. We apologise for any inconvenience this causes.

What happens if my device breaks down?

Because CIRCuiTS is a web-based program it is not dependent on the device you use to access it. This means that if your device (e.g. laptop or tablet) breaks, you can still access CIRCuiTS using the same website address on a different device.

Will using a different device or browser affect how CIRCuiTS works?

CIRCuiTS has been designed to work across a variety of different devices, including laptops, desktops, and tablets. Interacting with on-screen elements may be more challenging on touch screens, particularly smaller screens (e.g. tablets) where the website content will appear smaller. CIRCuiTS has not been tested for use on smartphones and we do not recommend its use on these devices.

Certain makes/models, operating systems and browsers are recommended for optimal CIRCuiTS performance when using a tablet (see above). On laptops and desktops, the program has been optimised for use in Google Chrome, Firefox or Microsoft Edge. It has also been tested on Safari on a Macbook. We cannot guarantee that CIRCuiTS will work optimally in other browsers.

For the website to work as well as possible and display everything as it should, we recommend that you use the most recent versions of device operating systems and internet browsers. If you are experiencing technical difficulties, try updating your device or browser, or clearing your browser's history or cache.

Questions about data and privacy

How does CIRCuiTS manage personal data?

CIRCuiTS is fully compliant with the current UK General Data Protection Regulation (GDPR). Users can read full information on how we manage their data and privacy at any time in the CIRCuiTS program. Clients can access this information in the Library, and therapists in the Therapist Guides. Please refer to those resources for questions relating, for example, to:

• How secure and private CIRCuiTS is
• What, how, where and for how long data is stored
• Who can see users' data
• Whether CIRCuiTS uses cookies

For all other data and privacy questions, or to request a copy of our Data and Privacy Policy, please email circuits@kcl.ac.uk.

How do I make sure my connection is secure?

We recommend that you use CIRCuiTS on trusted internet/WiFi networks, for example, your home broadband. Using a secure connection such as this means that the connection is encrypted by one or more security protocols - this means that it cannot be accessed by external third parties.

We recommend that you do not use public or unsecured networks.

We also recommend that you log out after you have finished what you are currently doing in CIRCuiTS.

Other

Where can I read more about CIRCuiTS and cognitive remediation (CRT)?

The following book is an essential resource on the background, theory, and delivery of CRT:

Wykes, T., & Reeder, C. (2005). Cognitive Remediation Therapy for Schizophrenia: Theory and Practice. Hove: Routledge.

Is using a computer or tablet a lot bad for me?

Excessive screen use at night, particularly when looking at a bright screen in a dark room, is not recommended. Instead, we recommend you use the program at some point during the day or evening, and not too close to bedtime.

When using CIRCuiTS we recommend that you take regular breaks and do not sit in front of the screen for multiple hours at a time. Making sure you sit with good posture and getting up occasionally is also good.

What if I disclose something that puts me or others at risk?

If your therapist is concerned about your or another person's safety, they will discuss this with you. However, they may also have a professional obligation to let other healthcare professionals know, depending on the situation.

Is CIRCuiTS only available in UK English?

No, CIRCuiTS is also available in a range of other languages including French, Spanish, Italian, Danish, Dutch, Finnish, and US English. The program can be translated into other languages and adapted to fit different religious or cultural requirements, and you can direct queries about this to circuits@kcl.ac.uk.

Technical Specifications

CIRCuiTS is digital therapy program hosted as a website. It is made up of a 'front-end' client- and therapist-facing website and a 'back-end' website for therapists and administrators. CIRCuiTS is hosted by SPIKA Ltd. using a secure, UK-based cloud platform (Amazon Web Services).

Labelling & Packaging

Icons are shown with respective description:

• CE mark - developed in compliance with Directive 93/42/EEC for Class I medical devices. Made in United Kingdom.
• Instructions for Use
• Full registered name and registered address of legal manufacturer.
• Reference name of device/software
• Version no. of device/software

Regulatory Information

CIRCuiTS has been developed under the control of the Kings Digital Therapies Quality Management System in compliance with the Medical Devices Directive 93/42/EEC for Class I medical devices.

Accessibility Statement

This accessibility statement applies to the CIRCuiTS therapy web software www.circuitstherapy.com.

We want as many people as possible to be able to use this website. For example:

• You should be able to zoom in up to 150% without the text spilling off the screen. We recommend that you use a screen size no smaller than 8 inches/20cm.
• It is possible to change the device orientation from horizontal to vertical to make it easier to view the content.
• Most of our information is provided as HTML documents

We've also made the software text as simple as possible to understand.
If you have a disability, search AbilityNet for "how to" guides to make your device easier to use.

How accessible this web application is

We know some parts of the software are not fully accessible:

• the text will not reflow in a single column when you change the size of the browser window
• you cannot modify the line height or spacing of text
• it is not compatible with using a screen reader.

Feedback and contact information

If you need information on this website in a different format:

• email circuits@kcl.ac.uk
• call 020 7848 5040

We aim to respond in 5 working days.

Reporting accessibility problems with this website

We're always looking to improve the accessibility of this web application. If you find any problems not listed on this page or think we're not meeting accessibility requirements, please contact us on circuits@kcl.ac.uk. This helps us improve.

Technical information about this website's accessibility

CIRCuiTS is committed to making its website accessible.

Compliance status

This website is partially compliant with the Web Content Accessibility Guidelines version 2.1 A standard, due to 'the non-compliances and exemptions' listed below.

Non-accessible content

The content listed below is non-accessible for the following reasons.

Non-compliance with the accessibility regulations

• Images do not have a text alternative, so people using a screen reader cannot access the information.
• This software is not compatible with screen readers.
• The audio clips do not have captions.
• The contrast levels in the software cannot be altered.
• The software cannot be navigated solely by keyboard.

When we publish new content we'll endeavour to make it meet accessibility standards.

Disproportionate burden

Navigation and accessing information

• It's not possible for users to change text size without some of the content overlapping.
• It is not possible to use the software navigating only using a keyboard.

We've assessed the cost of fixing these issues. We believe that doing so now would be a disproportionate burden within the meaning of the accessibility regulations. We will make another assessment in about 5 years.

Content that's not within the scope of the accessibility regulations

PDFs and other documents

Our few remaining PDFs are essential to providing our services. Within five years we will replace these with accessible PDFs or HTML documents.

Preparation of this accessibility statement

This statement was prepared on 1st March 2023.