Metacognitive Training for Psychosis (MCT)

fifth volume, version 5.0

Steffen Moritz

Steffen Moritz Todd S. Woodward Caroline Stevens Marit Hauschildt Metacognition Study Group1
VanHam Campus Press 2010 last revision: December 2013 The MCT modules can be obtained at no cost via: www.uke.de/mkt. Contact: moritz@uke.de (Prof. Steffen Moritz, Hamburg)

The Metacognition Study Group consists of the people credited in the acknowledgement.

Acknowledgements The recent revision of the Metacognitive Training program for Psychosis (MCT) would not have been possible without the efforts of many people. First, we thank Julia Aghotor, Birgit Hottenrott, Ruth Veckenstedt, Rebecca Kpper, Lena Jelinek, Christiane Schmidt, Florian Scheu and Sabine Sperber for compiling most of the new exercises, as well as Tessa Constable, Sarah Randjbar and Jana Volkert for proof-reading preliminary versions of the present manual. Suggestions for improvement by Kerry Ross, Philippa Garety and Daniel Freeman on Module 2 have been picked up with thanks. The new layout has been created by Andrea Dunker. On behalf of all translators, we thank Ricarda Weil, Vivien Braun and Franziska Fliegner for orchestrating the integration of new material and suggesting valuable improvements. Finally, as always, thanks goes to our patients2 and the increasing number of clinicians utilizing the MCT, whose feedback has been essential for improving the bandwidth and efficacy of the MCT. Publication on current findings Reviews summarizing the encouraging findings on the efficacy of the metacognitive training program have been published in the Current Opinion in Psychiatry (Moritz & Woodward, 2007; Moritz, Vitzthum, Randjbar, Veckenstedt, & Woodward, 2010). You can download these and other article at www.uke.de/mct. Donations We are all too aware of the troubling financial situation in many psychiatric hospitals. Therefore, it remains our goal to provide the metacognitive training program (MCT) free of charge. However, research is very costly in terms of both time and financial resources. If you would like to support us in our effort to disseminate the MCT, we would be very grateful for donations. We will continue to support and help everyone, irrespective of their financial contribution. We guarantee that all donations will be used for the further development of the MCT (future tasks include the translation of the MCT into other languages or the creation of new graphics). By request, we can send you a donation receipt. Donations should be made payable to the following account: Pay To: Universittsklinikum Hamburg-Eppendorf Bank (sort code): Hamburger Sparkasse (200 505 50) Account Number: 1234363636 Account title (this is crucial to ensure that your donation reaches us): 0470/001 - Metacognition IBAN: DE54200505501234363636 BIC/Swift: HASPDEHHXXX

We are aware that some participants of the MCT are neither inpatients nor outpatients. The term patient is used in this manual to refer generally to people diagnosed with mental illness who are in treatment, and is not intended to degrade or stigmatise any person with a mental illness.

Introduction Why cognitive training for schizophrenia? Schizophrenia is a complex psychiatric disorder. Its core symptoms are delusions and hallucinations. The past decade has witnessed a shift in our thinking about, and particularly the treatment of, schizophrenia. Psychopharmacological treatment with neuroleptics still represents the primary therapeutic approach. However, the formerly deep-rooted reservation against psychotherapy for schizophrenia is now being increasingly questioned. In view of the high numbers of patients who show little or no response to neuroleptics or who discontinue treatment because of side-effects and lack of insight (Byerly, Nakonezny, & Lescouflair, 2007; Elkis, 2007; Voruganti, Baker, & Awad, 2008), research on complementary psychotherapeutic and cognitive treatment strategies is gaining importance. Cognitive-behavioral treatment, in particular, has proven to be a useful complementary approach to psychopharmacology (Wykes, Steel, Everitt, & Tarrier, 2008). The present metacognitive3 training program is based on the theoretical foundations of the cognitive-behavioral model of schizophrenia, but employs a somewhat different therapeutic approach. The metacognitive training program is comprised of eight modules targeting common cognitive errors and problem solving biases in schizophrenia. These errors and biases may, on their own, or in combination, culminate in the formation of false beliefs to the point of delusions (Freeman, 2007; Moritz & Woodward, 2007; Moritz, Vitzthum, Randjbar, Veckenstedt, & Woodward, 2010). The aim of the sessions is to raise the participants awareness of these distortions and to prompt them to critically reflect on, complement, and change their current repertoire of problem solving skills. Since psychosis is not a sudden and instantaneous incident, but is instead often preceded by a gradual change in the appraisal of ones cognitions and social environment (e.g., Klosterktter, 1992), enhancing metacognitive competence may act prophylactically on psychotic breakdown. Homework that is handed to the participants at the end of each session is intended to aid with this process. Each module begins with psychoeducational elements and normalizing: by means of many examples and exercises the respective domain is introduced (e.g., jumping to conclusions) and the fallibility of human cognition discussed and illustrated. In a second step, pathological extremes of each cognitive bias are highlighted: participants are shown how exaggerations of (normal) thinking biases lead to problems in daily life and may sometimes even culminate in delusions. This is illustrated with case examples of people with psychosis, providing the opportunity for group participants to exchange their own experiences if they feel so inclined. Patients learn to detect and defuse "cognitive traps". Dysfunctional coping strategies (e.g., avoidance, thought suppression) are also brought to attention in this context, along with means of replacing them with more helpful strategies. Potential contributors to the development and maintenance of delusions are attributional distortions (module 1), a jumping to conclusions bias (module 2 and 7), a bias against disconfirmatory evidence (module 3), deficits in theory of mind (module 4 and 6), overconfidence in memory errors (module 5) and depressive cognitive patterns (module 8).
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Metacognition can be described as thinking about one's own thinking, and involves the ability to select appropriate responses to environmental and social challenges/problems. It also encompasses the way we appraise and weigh information and how we cope with cognitive limitations.

Despite good empirical evidence for the validity of these accounts, some of them remain subject to ongoing scientific debate (e.g., Freeman, 2007). The modules are administered within the framework of a group intervention program. The main purpose of metacognitive training is to change the cognitive infrastructure of delusional ideation. In recent MCT versions we have emphasized the relationship between thinking styles, delusions and psychosis. Before that, we were concerned that a confrontational and symptom-oriented approach could overstrain participants; however, this concern has proven to be largely unfounded. Nevertheless, it is recommended that individual delusional themes are addressed in one-to-one therapeutic sessions (see for example our Individualized MCT program (MCT+) at www.uke.de/mkt_plus; Moritz, Veckenstedt, Randjbar, & Vitzthum, 2010). Metacognitive training materials can be adapted for this purpose. With their interactive and entertaining character, the sessions aim to capture the participants attention and exert a sustained impact. To meet this goal, we have also refrained from incorporating any drill & practice tasks. Basic cognitive dysfunctions (e.g., attentional problems) are not specifically targeted, because these deficits are common across different psychiatric populations, and it remains unclear whether they represent specific vulnerability factors of psychosis. Since most aspects of the program are self-explanatory, the manual is kept fairly short and thus allows for individual variation in training implementation. However, for this reason, reading the following sections cannot substitute for an in-depth study of the underlying theoretical concepts. The present program is available in many languages and can be downloaded free of charge via the following link: http://www.uke.de/mkt The metacognitive training program consists of the following materials: 16 PowerPoint presentations in PDF format (two parallel cycles each consisting of 8 modules) Manual 6 handouts with homework (modules 2 and 7 as well as 4 and 6 share the same handouts) one yellow and one red card for each participant video clips Before introducing the modules, some basic prerequisites need to be addressed.

Number of modules and frequency of sessions

The program consists of two parallel cycles each comprising eight modules. An administration mode of two modules per week is recommended (one module per session). Thus, most inpatients can complete a full cycle during a one month (hospital) stay. Outpatients and day patients receiving prolonged treatment should attend two cycles in order to deepen and sustain training success. The parallel versions are identical in terms of their rationale. However, the introduction and exercises differ, so that participants attending both cycles in sequence are not presented the same material twice.

Group size The group size ranges from 3 to 10 participants. Duration of sessions Each session should last between 45 and 60 minutes.

Opening of session
Although not mandatory, it is a good idea to start each new session with a brief discussion about the previous module and to go through the homework from the last session. In addition, there should be a short introduction round for new participants as well as a brief introduction to the program (for details see section Introducing the program to participants). End of each session Even if the exercises are not completed by the end of the session (which is likely to be the case), the practitioner should skip forward to the final slides. These describe the relevance of the tasks to daily life as well as to psychosis and summarize the learning objectives. Finally, leaflets with homework are handed out. Every participant receives a yellow and a red card at the end of his or her first session (see website) along with instructions on how to use them. The yellow card raises three fundamental questions, which the participants should consult when necessary, for example, when feeling offended or insulted: 1. What is the evidence? 2. Are there alternative views? 3. Even if it's like that...am I over-reacting? These questions should prompt participants to re-consider the available evidence before drawing hasty, false and perhaps consequential decisions. The red card is an emergency card. The patients are encouraged to write down telephone numbers of persons and institutions that can be contacted when help is needed. Arrangement of room A quiet room with sufficient chairs and the opportunity to project the slides onto a white wall or screen is required. Necessary technical equipment A video projector and a computer/laptop equipped with Adobe Acrobat reader (free download) are required. The slides are to be displayed in the full screen mode of Adobe Acrobat. Alternative: multiple computer screens if no projector is available Professional background of trainer The trainers are preferably psychologists or psychiatrists who have long-term experience with schizophrenia spectrum disorder patients. Psychiatric nurses and occupational therapists specialized in psychiatric disorders may also be eligible. Ideally, trainers are familiar with moderating group sessions. Dealing with psychotic symptoms during sessions If a group member displays severe psychotic symptoms during sessions, these should neither be supported nor challenged in front of others. Individual delusional ideas should be addressed in face-to-face sessions with the respective therapist. However, patients who are

distanced from their delusions may talk about similar experiences during exercises addressing common delusional themes (e.g., Module 1, scenario A friend is talking behind your back; Module 5, false memories; Module 6, scenario in which two men appear to be angry about a third man). Additionally, the slides entitled Why are we doing this? (at the start of the module) and What does this have to do with psychosis (at the end) may provide room for further individual reflections. Rules for group members On the MCT website, you can download a slide that lists important group rules (e.g., respect the opinion of other members). It is a good idea to print this out and mount it onto a wall, where it is visible for all group members. Refer to the rules from time to time, for example, when conflicts arise. Advice for trainers when presenting video clips Via the following link http://www.uke.de/mct_videos you can find video clips that correspond to the topics of the different modules- please look at possible video clips beforehand and choose carefully. Some clips are only available in German, English and French. Others have no sound and can therefore be used in any language version. Some movie clips contain language that may not be appropriate for all audiences and across all cultures. Please carefully pre-screen videos that you wish to use. After the video presentation, discuss with patients how the video was relevant to the specific topic of the module. Alternatively, you may do a roleplay or discuss individual experiences of patients. Clearly, you may also just proceed with the other exercises. Introducing the program to participants Metacognitive training is an open program. Patients can enter at any point during the cycle. Any new participant should be informed what the program is about preferably by experienced participants with the help of the trainer. At first, the term metacognition has to be introduced: meta is Greek for about and cognition refers to higher mental processes such as attention, memory and problem-solving. Thus metacognition means thinking about the way we think, or thinking about our own thinking. The aim of the program is to learn more about human cognition, and how we can shape it to optimize problem solving. At the heart of the program are thinking styles that may contribute to the development of delusions, and it is emphasized that not all patients will display all of these thinking biases concurrently. The relationship between the learning objectives and daily life/illness has to be pointed out regularly. For this purpose, each module includes several slides emphasizing its practical relevance (e.g., slides: Why are we doing this?; How jumping to conclusions [or other bias] promotes misinterpretations during psychosis examples; What does this have to do with psychosis?). The transfer of the learning objectives to daily life clearly represents the foremost goal of the training. Inclusion and exclusion criteria 1. Patients with schizophrenia and schizophrenia spectrum disorders are the primary target group. The program is also suitable for patients with other diagnoses, who currently or in the past have displayed psychotic symptoms (particularly delusions, ideas of reference, hallucinations). 2. Patients should be able to attend the duration of a session. For highly distractible patients, the training sessions may be too stressful. Nevertheless, participation should be attempted.

3. Present delusions and hallucinations do not constitute exclusion criteria, unless strong self-referential delusional misinterpretations occur. Manic patients showing inappropriate (antisocial, sexual, hostile) behavior may not be able to participate unless further symptom remission occurs. Otherwise, the group dynamics could be disrupted. 4. If a patient fails to attend a session, individual repetition is not necessary as the program is not set up in sequential stages: every module deals with a unique aspect of metacognition. Atmosphere 1. The training session should not be rushed. Completing all slides within one session is not required and is in fact almost impossible! Although the training is highly structured and has a clear focus on the exercises, lively discussion should be encouraged and participants should have enough time to exchange their views. Social interaction and exchange is a core factor for gaining self-awareness and changing behavior in everyday life. 2. Some patients feel uncomfortable speaking in front of others. These participants may be involved by posing simple yes/no questions or by asking them to participate with hand signals (e.g., Who else shares this opinion?; Is there anybody who has already made a decision?). Another option is to hand out red and green cards for the purpose of indicating yes and no, respectively. However, participants should not be forced to engage and the trainer should act in a non-patronizing/supportive manner. 3. From time to time, the trainer should highlight the basic rules of interpersonal engagement (e.g., listen to other people, show respect for different opinions), particularly when problematic communication patterns are observed. Each member should have the chance to actively take part and the discussion should not be dominated by one person only. A pattern of taking turns can be established so that each member receives the opportunity to contribute, or the trainer may appoint a particular participant to respond. 4. Create a friendly and preferably humorous atmosphere. The exercises should be entertaining, interactive and playful. Critical comments towards group members should be discouraged. In the following, we outline the target domains, basic tasks, and theoretical rationale for each module. This is followed by the objective of the module, as well as general and specific recommendations for administration.

Module 1: Attribution Blaming and Taking Credit Target domain: External-personal attribution for failure; monocausal inferences Basic task: In the first part of the module, participants are familiarized with extreme attributional styles and their possible social consequences (e.g., blaming others for failure may trigger interpersonal tensions). Participants are encouraged to come up with more objective and balanced explanations for each scenario (e.g., sharing success with others instead of self-praise only). In the second part, participants have to generate reasons for briefly described incidents; for example, why a friend has not called (negative), or why someone invited you for dinner (positive). Situational and personal factors should be taken into account. Please note that there are no clear-cut solutions for these exercises. Instead, a number of different possible explanations should be considered even if only one explanation seems valid at first (e.g., A friend is talking behind your back.; possible explanation: The person is not a true friend.; alternative interpretations: That person asked other people whether I was ill. He did not want to ask me directly since I could be upset or worried.; This is normal, we all gossip from time to time. This does not mean we are bad people.). The second task set incorporates a section on voice-hearing. The participants are confronted with several arguments as to why internal voices (voice-hearing) are in fact self-generated and not inserted from the outside. Material: The set-up of the second task set is analogous to the Internal, Personal, Situational Attribution Questionnaire (IPSAQ, Kinderman & Bentall, 1997). The contribution of photographers/artists is acknowledged at the end of the presentation. Theoretical background: Bentall, Kinderman and coworkers (Bentall, 1994; Bentall, Corcoran, Howard, Blackwood, & Kinderman, 2001; Bentall, Kaney, & Dewey, 1991; Kinderman & Bentall, 1996, 1997; Kinderman, Kaney, Morley, & Bentall, 1992) found that paranoid patients are biased towards blaming others for their failures (see also Janssen, Versmissen, Campo, Myin-Germeys, van Os, & Krabbendam, 2006). Conversely, patients attribute success preferably to themselves as opposed to others, although this style is less well confirmed by the literature (Garety & Freeman, 1999). The latter response pattern is called self-serving bias (externalization of blame, internalization of success) and to some degree also exists in healthy individuals (as folk wisdom tells us: The bad workman blames his tools.). However, the external attribution for failure seems to be pathologically pronounced in paranoid patients and is shifted towards the personalization of blame. In a recent study, we observed a variant of this pattern: acutely deluded patients attributed the source of both positive and negative events less frequently to themselves in comparison to controls. This suggests that patients may suffer from a perceived loss of control (Moritz, Woodward, Burlon, Braus, & Andresen, 2007). There is also mounting evidence for an increased tendency for monocausal inferences in the disorder (Randjbar, Veckenstedt, Vitzthum, Hottenrott, & Moritz, 2011). Objective of the module: Participants are encouraged to generate explanations for different situations by considering three possible sources (alone or in combination): oneself, others, or situational factors. The objective is not to lead participants to a definitive answer. Rather, different possibilities should be contemplated which helps to change dysfunctional attributional patterns (e.g., it is always my fault vs. it is always the others fault). Advantages and disadvantages of both a depressive attributional style (attributing failure to

oneself and success to luck/coincidence decreases self-esteem) and a self-serving bias (attributing failure to others and success to oneself may lead to social conflict as others may get upset if they are blamed without good reason) should be underlined. The primary focus of this module is to point out that multiple factors can lead to the same incident/scenario. As pointed out, this holds true even for situations where only one explanation seems possible at first. General advice: On slide 5 of the presentation, different explanations for an event should be collected. Subsequently, the answers are grouped according to three possible origins: oneself, others, or the situation. This classification should also be applied in the scenario on slide 9. On slide 12, more balanced responses should be put forward, ideally incorporating aspects of the aforementioned three possible causal sources. The responses on the last slide of the corresponding scenario serve as examples, and not as definite solutions. The opinions of group members may well deviate from these. On slides 14-23 of the presentation, participants should come up with potential consequences for different attribution styles. For the second part of the program, the trainer may create examples or can ask participants to share personal experiences of misinterpretations. However, it is important that the discussions do not become too person-specific. There are plenty of exercises, so long reflections on a single slide should be avoided. Once several alternatives have been put forward, the group may select the most plausible cause. For the section on voice-hearing, the trainer should adopt an open attitude. Participants should be encouraged to consider alternative attributions for voice-hearing, but should not be forced to a more rational explanation. Insight into the irrationality of voice-hearing is a gradual process which cannot be achieved in a single session. The aim of this section is to seed doubt regarding the authenticity of the voices, and to raise metacognitive awareness rather than to immediately convince participants of the counter-arguments. Specific advice (examples): Please note that some of the attributions below are mixtures of different sources. Following a brainstorming phase, please discuss the plausibility of each explanation.
Scenario Cycle A 1. Complaint Myself My arguments were convincing. Attribution Others The salesman is very fair. Coincidence/Circumstances - This is a common procedure in this shop. - I bought the item yesterday. I am just exercising my rights as a customer. - There was a short break between two presentations. - The door creaked and people got irritated and paused. Everybody at my work place was on holiday, except for me. Maybe in direct comparison I do not look as rested as them.

2. Silence

I am not dressed properly (unlikely but possible).

3. Looking rough

- I feel bad. - I am ill.

4. Fail an exam

- I did not study properly. - The exam did not match with my talents.

- They have nothing to talk about. - They are nosy and want to know who entered the room. - This person says that to many people, just a phrase. - This person wants to insult me. - The person wants to express concern. I was distracted by some noisy students in the hallway (possible but unlikely as single cause). - The invigilator was extremely strict.

Everyone failed the exam, it was very difficult.

5. Dinner

6. Freeway

I did him a favor (e.g., I helped him with his work). I drove too fast.

7. Winning a game

8. Scratch on the car finish

9. High blood pressure

- He is very generous. - He wants to apologize for something. The police officer is in a bad mood, he is just trying to bully me (unlikely). - I am an excellent player. - The other players did not - I cheated. know the game very well. - They let me win. I tried to unlock the door - The children from the and the keys slipped. neighborhood played a prank. - My neighbor does not like me. I did not follow the The doctor is a novice and doctors recommendations took the incorrect blood and did not take my pressure reading (unlikely). medication as prescribed.

- He has won the lottery (unlikely). - Its my birthday. This is a standard traffic control.

Luck, I just had good cards.

This can easily happen without any bad intention since cars have to park close to each other in this parking lot.

10. Refusal to help

I did not help her either when she asked me.

11. Present 12. To be regarded as stupid. 13. Baby

I helped her out. I made a big mistake. I am unfamiliar with handling babies and held it wrongly. I lied to or cheated on him.

- High blood pressure runs in my family. - The device is broken (unlikely). - Due to my anxiety the blood pressure was high at that time (e.g., so called "White Coat" blood pressure). - She generally does not help She is very busy at the moment. with these kinds of tasks. - She believes that I can manage on my own. She is a generous person. - Its my birthday. - I passed an exam. He wants to hurt me because - Misunderstanding between us. he is angry with me. - This was not meant literally. The baby was not fed on Babies just cry from time to time time. for no reason. He has very high moral standards which, from his perspective, I do not meet. attribution Others - She often talks about other people behind their backs. - It is only human to gossip a bit about other people, this is not necessarily a hostile act. A colleague from the company recommended me. She does not like unannounced visits. This is a misunderstanding, he heard a false rumor about me.

14. No respect

Scenario Cycle B 1.Talking behind your back

Myself I did something she despised.

Circumstances/chance My birthday is coming up, they are planning a surprise party.

2. Interview

3. Spontaneous visit

- I submitted a very good application. - I am very qualified. I have recently overstrained her hospitality. - I made an embarrassing slip of the tongue. - I made a good joke.

Every applicant has been invited.

4. Laughing while talking

- Someone told a good joke at the same time. - The others are always very silly and laugh about nothing. - They drank too much alcohol.

- She had a party at her flat yesterday and the place looks messy. - She already has visitors. It is New Years Eve/carnival everybody is in a party mood.

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5. Driving home

I have given him a lift many times before.

- He cares about others. - He likes me.

We live very close to each other; it was just on his way.

6. Stood up

I told him the wrong time (possible but unlikely).

7. No post card

8. A car driving behind you

- He is forgetful. - He does not think I am important enough (unlikely). I never sent him a - He generally does not send postcard either. any postcards. - He took on too much, so he did not have time to send one. I drive in wiggly lines and The person thinks I am the police car is about to interesting and wants to stop me (possible but know where I live (unlikely). unlikely). I did not run fast enough to catch it. I helped him move into his flat. The bus driver is having a bad day. - He wants to know me better. - He loves wine and wants to show me his collection (possible but unlikely). I have placed an ad in the - He lives across the road and papers to sell my lost his key. He is waiting for apartment. The man is just the locksmith. killing time until the - His girlfriend is visiting official viewing starts. me; he is jealous and is spying on her (unlikely). - I cheated in the game. He is very sensitive and gets - I said bad things about easily insulted. him. - I am smart. - He always asks simple - I said something smart. questions. - He likes me and wants to raise my self-esteem.

He was held up, for example, his car broke down or he missed the bus. - The holiday is just too short. - The post card got lost in the mail (unlikely).

9. Bus drives off 10. Invitation for a drink

- This is pure coincidence, the other driver wants to get to the same place. - There is only one street in this area (e.g., freeway). The bus driver did not see me. - He only just moved in. - It is a house warming party.

11. Reading the paper

Next to my house is a corner store.

12. Unfair

This is a misunderstanding.

13. Smart

I saw the answer to his difficult question in a quiz show the night before.

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Module 2: Jumping to Conclusions I Target domains: Jumping to conclusions bias; bias against disconfirmatory evidence Basic task: Possible consequences of jumping to conclusions are illustrated using several examples at the start of the module. In the section jumping to conclusions in action urban legends the group discusses "urban legends"/modern false beliefs (e.g., Paul is dead legend in cycle A). Arguments for and against this belief should be collected, exchanged and evaluated for their plausibility. It should be made clear that legends of this kind have arisen due to jumping to conclusions, and are founded on dubious evidence. Thus, they are a good model for delusional ideas. The exercises of the first task set show common objects (e.g., a frog), which are displayed in decreasing degrees of fragmentation: new features are added in eight successive stages, until the entire object is eventually displayed. In alternating order, participants are asked to rate the plausibility of either self-generated or pre-specified interpretations. Participants should withhold their decision until sufficient evidence has been presented. For example, the first stage of the frog exercise strongly resembles a lemon, as only the contour of the frog is displayed. A hasty decision consequently would result in an error. In the second task set, picture puzzles are shown, which depending on the observers perspective, contain at least two different objects or scenes (e.g., the first picture of cycle B concurrently shows the profile of an old man and a street scene by night). Participants are asked to give their first impression of the picture, and then to change their perspective in order to find the alternative figure/scene. Material: Objects in the first task set are post-edited simple black and white drawings from a fairy tale book. The contribution of other photographers/artists is acknowledged at the end of the presentation. Theoretical background: We have previously used some stimuli from the first task set in a study on schizophrenia (Moritz & Woodward, 2006). In line with prior investigations (Woodward, Moritz, & Chen, 2006; Woodward, Moritz, Cuttler, & Whitman, 2006), schizophrenia patients exhibited a decreased ability to revise the ratings of incorrect interpretations. This response pattern has been termed bias against disconfirmatory evidence (Woodward et al., 2006). Even with emerging counter-evidence against interpretations that were only initially conclusive, patients cling to the obsolete option in comparison to both healthy and psychiatric controls. Finally, numerous findings suggest a jumping to conclusions data gathering bias in patients with schizophrenia (Van Dael, Versmissen, Janssen, Myin-Germeys, van Os, & Krabbendam, 2006; for reviews see Bell, Halligan, & Ellis, 2006; Fine Gardner, Craigie, & Gold, 2007; Garety & Freeman, 1999): patients draw hasty decisions, that means, judgments are made on the basis of incomplete evidence (for a variation of this account see Moritz & Woodward, 2004). Objective of the module: Participants are trained to avoid succumbing to first impressions, which may eventually prove to be wrong (first task set) or only reveal half truths (second task set). Things/situations can change over time, and increasing evidence often casts a different light on things. Therefore, alternative views and attitudes should not be dismissed prematurely. In our study, the pictures for the first task set did not elicit a jumping to conclusions pattern in schizophrenia patients (Moritz & Woodward, 2006), but the exercises are well suited to demonstrate disadvantages of such a response style which has been well

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confirmed in schizophrenia using other paradigms (Freeman et al., 2004; Garety, Hemsley, & Wessely, 1991; Peters & Garety, 2006). General advice: The pros and cons for a hasty vs. a cautious response style have to be pointed out at the outset: If the stakes are high and there is sufficient time, all available evidence should be considered before making a final decision. Consequences of a jumping to conclusions bias can be momentous at times and this is illustrated with several examples (e.g., medicine: false diagnoses etc.). Give participants the chance to relate their own experiences (e.g., during psychosis). Ask patients to denote their response confidence, for example, by raising their hands halfway to express doubt and fully to express high confidence. Patients should learn to reduce their confidence if the evidence is incomplete. In half of the exercises in the first task set participants have to come up with their own interpretations/ideas. For a better overview it is recommended that participants write these down on a flipchart or whiteboard (optional). The validity of each interpretation has to be reevaluated after each new fragment. Participants may raise their hands to indicate whether they have a new idea or have already made a decision. Discuss with participants, which particular features of a picture speak for or against an interpretation. In the picture puzzles of the second task set, the trainer has to ensure that all participants discover the different objects. If a patient cannot see both solutions, another participant may help by pointing at specific clues (e.g., in the first picture of the second task set in cycle B the dog on the street can also be seen as the old mans hand). Specific advice Example (frog, cycle B, second example): For this task, many participants prematurely decide for the response option lemon. On this occasion, the trainer may emphasize that seven more fragments are to follow. A lemon could probably be completed immediately afterwards and therefore represents a rather unlikely alternative. You may alternate between the first and second task set. There is no compulsory sequence.

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Module 3: Changing Beliefs Target domain: Bias against disconfirmatory evidence; jumping to conclusions bias Basic task: Following a brief introduction, the so-called confirmation bias is demonstrated through a short task. Three objects are presented (version A: three flowers; B: three kinds of fruits). Participants are asked to think of a higher level category that subsumes the presented objects by suggesting new objects for the category (superordinate categories: living beings, food). With yes/no answers the trainer provides feed-back as to whether or not the novel objects fit into the superordinate category. The presented objects mislead many to believe that the superordinate categories are flowers and fruits. Therefore, most people come up with objects that fit into these categories instead of trying out alternative hypotheses or critically testing their assumptions with other items. The confirmation bias is a powerful response bias, which occurs when people ignore sources of information (e.g., newspapers, certain TV programs, books) that do not match their pre-existing opinions and attitudes. Even if some group members are already familiar with the exercise or provide the correct solution, do not confirm the correct solution right away, but allow suggestions from other members. The main exercise consists of a series of three pictures shown in reversed order. The sequences of pictures gradually reveal an ambiguous plot (example from cycle B: man is leaning over a fence and is watching a barking dog; in the following two pictures it becomes clear that the man has just escaped from the dog over the fence). For each picture, participants are asked to rate the plausibility of four different interpretations. The correct interpretation is highlighted at the end of each trial. One of the four interpretations appears improbable on presentation of the first picture, but eventually proves true in most cases (in the example above: The man has just escaped from the barking dog.). Two of the other interpretations appear plausible on presentation of the first picture, but are eventually proven wrong (lures, e.g., The man is playing with his neighbors barking dog.; The man has just built a fence for his dog.). All exercises include at least one interpretation, which remains unlikely at all times. The examples comprise three different conditions presented in random order: revealedon-first (the most plausible interpretation upon presentation of the first picture is valid), revealed-on-second (story plot is revealed on presentation of the second picture), and revealed-on-third (story plot is revealed on presentation of the final picture). Material: Most of the picture sequences are inspired by the WAIS picture arrangement subtest. Theoretical background: Using these picture sequences, we repeatedly found that patients with schizophrenia exhibited a bias against disconfirmatory evidence (Woodward, Moritz, & Chen, 2006; Woodward, Moritz, Cuttler et al., 2006). Patients with schizophrenia were less able to revise ratings of incorrect interpretations on the revealed-on-second and revealed-onthird conditions. This pattern of results was particularly pronounced for patients with current paranoia symptoms in the revealed-on-third condition (Woodward et al., 2006). Another study suggests, however, that a bias against disconfirmatory evidence in schizophrenia may also occur in non-delusional schizophrenia patients (Moritz & Woodward, 2006). Objective of the module: Analogous to module 2 (Jumping to Conclusions I), it should be explained to the group that it is often important to withstand the (normal) tendency to stick to

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first impressions as this response bias fosters faulty decisions. It is therefore desirable to maintain an open mind. Specific advice: Beginning with slide 3, several questions are raised, which should be answered by different group members. For the picture sequences, participants should indicate their preferred interpretation after each picture is revealed (e.g., in descending order) and whether they have already ruled out certain ones, respectively. After several opinions have been put forward, other participants are asked to agree by show of hands (raising the hand halfway may indicate doubt). For each new picture, novel clues have to be detected followed by a re-evaluation of the interpretations. Participants who have prematurely decided on an incorrect interpretation should be brought to attention that although their interpretations might have been plausible at the beginning, the evidence has changed in the meantime. Emphasize the potential negative consequences of hasty decision-making for interpersonal contexts and delusion formation, since hasty decisions may prime misunderstanding and social conflict. Clues for detecting the correct interpretation
Task Cycle A 1 (fire) When the solution is clear: second or third picture Clues for determining the correct solution (examples): - The boy is praised by the adults. - If you look closely, you can see on the first picture that there is a hole in the roof of the neighboring house. However, this is a clue rather than a proof. It is not clear until the third picture that the man was unable to park properly because the adjacent cars did not use the appropriate parking spaces before. - The man is holding the telephone receiver. - The dough is falling on his head. It does not seem like he is wearing the dough on purpose (makes alternative 3 unlikely). - Tomatoes and salt in the foreground speak against alternative 4 (cake). Alternative 4 activates common prejudices against politicians that easily mislead participants to hasty and false decisions. - Because of the mans dress and his suspicious behav ior it is extremely unlikely that he is the womans bodyguard. - The guardian angel interpretation is absurd throughout. - There are no particular clues that the mans clothes are wet (makes alternative 4 unlikely). It is not entirely clear until the third picture that the boy should be gardening. However, the second picture makes this interpretation already very likely. To arrive at a definite solution, all three pictures have to be looked at. The man on the left is surprised to see that the other man enters the room as he has tried to open the door himself in vain. Apparently, the man to the left confused push with pull. - The man in the foreground has been restrained and struggles to free himself. - The other alternatives are absurd.

2 (parking-space)

third picture

3 (pizza)

first picture

4 (speech)

third picture

5 (escape)

third picture

6 (fishing)

second or third picture

7 (pull/push)

third picture

8 (cowboy)

first picture

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9 (boat)

first or second picture

10 (crash)

third picture

11 (mannequin) Cycle B 1 (shark)

third picture

- The cat is floating away on the boat. - It does not look like the dogs caught a suspected thief. They are following the boat rather than the person. In the first picture, you can see a table in the background, but a definite decision for interpretation 3 is not yet possible. In the second picture, it could still be due to chance that the man came along with a table when the other man was already lying (perhaps drunk) on the ground. no particular clues.

second picture

2 (choir)

third picture; may be guessed after the second picture

3 (dog) 4 (washing) 5 (gun)

second picture first picture first picture

6 (umbrella)

second picture

7 (king) 8 (quarrel)

third picture second picture

9 (serenade)

first or second picture

10 (house)

the first (if you look very closely) or second picture

In the second picture, you see people running away. Footsteps in the sand are already visible in the first picture. - In the second picture, you can see that the man in the front row has red cheeks (may indicate shame or embarrassment). However, it is questionable whether a solid decision is justified at this stage. - In the first picture, the conductor listens to the choir. It could already be speculated that he is checking if the choir is singing in tune. The dog is in front of the fence, not surrounded by it (makes alternative 1 unlikely). - The sign suggests a Laundromat. - The woman is carrying a basket. - The gun is pointed at the man on the right. - The man has his hands raised. - The men are too old to play cops and robbers . - If the man on the left was giving back his gun, the other man would not offer money (makes alternatives 2 and 3 unlikely). - The girl seems to be soaked by water, not sweat. - The father seems amused rather than threatening. - Alternative 2 remains a possibility until the end (however, the averting gesture of the girl speaks against this). To make a definite decision, you have to see all three pictures. - In the second picture, the boy on the right is pointing to a toy car. - The same boy looks very angry. - The boy looks very angry. - It is late at night (moon) and probably too late to go to a band rehearsal (makes alternative 2 unlikely). - A classical guitar is more commonly used for a serenade than in a band. - The man has a bucket in his hand. - He does not seem to be watching anything (makes alternative 3 unlikely). - The house does not look dirty. It is also very unusual to clean the faade of ones house (makes alternative 1 unlikely).

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Module 4: To EmpathizeI Targeted domain: Theory of mind; emotion perception Basic task: At the beginning, participants are asked to identify basic human emotions and assign them to facial expressions. In order to bring home the point that faces are relevant clues for deducing a persons internal motives but do not provide definite proof, four pictures are presented showing an athlete, a psychologist, an actor and a serial killer. In this exercise, most people make incorrect assignments on the basis of facial expressions! Subsequently, we provide examples demonstrating that expressions and gestures may be interpreted differently depending on cultural background and age ("When in Rome, do as the Romans do"). Next, we present pictures displaying different facial expressions. Participants are asked to judge how the person in the picture might feel and to discuss the plausibility of the alternative interpretations. Afterwards, the correct answer is highlighted (often accompanied by the presentation of the complete picture). The third task set is similar to the task set presented in Module 3 (the third and fourth task set are not recommended anymore as they are too easy for many patients). Three pictures are shown successively and in reverse order. After each picture is displayed, participants should discuss which of the three options listed at the bottom of the slide provides the most logical continuation for the sequence. For example, in one of the exercises of part B a woman is shown taking a coin from her handbag. At this point, two of the three options to continue the sequence are plausible paying the parking meter, donation to musician although the smiling face of the woman provides a clue that the latter option is more plausible. The following slide disambiguates the scene further: the woman had listened to a musician. The point at which the correct storyline can be deciphered varies across exercises. For example, some exercises allow for a definite decision only after the third picture is displayed. In the last task group, four pictures are successively shown, with each picture increasingly disambiguating the scenario. Participants are encouraged to make a judgment about the intentions of one or a number of people using three alternatives. Material: Stimuli for the third task set have been made available by Sarfati, Hardy-Bayle, Besche and Widlocher (1997), the stimuli at the end have been generously provided by Martin Brne from Bochum/Germany (see Brne, 2003). The contribution of other photographers/artists is acknowledged at the end of the presentation. Theoretical background: Theory of mind deficits are well documented in schizophrenia patients (Sprong, Schothorst, Vos, Hox, & van Engeland, 2007). Schizophrenia patients have difficulties predicting the actions of others, which may contribute to delusional ideation (Mehl, Rief, Lllmann, Ziegler, Kesting, & Lincoln, 2010; Versmissen, Janssen, MyinGermeys, Mengelers, Campo, van Os, & Krabbendam, 2008). Problems with interpreting facial expressions are also well documented in schizophrenia (Phillips & David, 1995). For example, Sarfati et al. (1997) found that patients with schizophrenia, particularly those with formal thought disorder, display problems in tasks requiring situational understanding, presumably due to distraction by context-irrelevant features. Objective of the module: The first part of this module demonstrates that although facial expressions are very important for understanding the mental state and inner feelings of a person, they can also be misinterpreted quite easily. For instance, you cannot determine whether a person is an actor or a serial killer solely by examining their expression. In order to

17

adequately interpret a facial expression, it is important to consider other sources of information (e.g., context; personal background). Participants learn to consider a variety of contextual information rather than relying on single details. General advice: Patients should take context into account when deducing the most plausible interpretation. Stress the fallibility of first impressions, and emphasize the need to remain open-minded. Patients should learn to reduce confidence if evidence is insufficient (doubt can be expressed by hand-signs, see modules 2 and 3). Use examples to underline the relevance for daily life. Specific advice: The tasks described in this manual can be presented in any order. The trainer may wish to switch task sets depending on the participants performance level. Clues for detecting the correct interpretation: There are no particular cues for task set 1 and 2. The core learning objective is that facial expressions can be misleading and further information should be gathered before arriving at a strong conclusion. On the slide Basic Emotions in the first part of the module, the solutions can be deduced from the context rather than gestures (e.g., happiness = woman's bridal veil/wedding; anger = man clenching fist). As mentioned before, task sets 3 and 4 are deemed too easy for some participants and are no longer recommended.
Cycle A Task Set 3 1 (man hanging painting) Stage at which the solution is obvious: second picture; may be guessed after the first picture Clues for detecting the correct solution (examples): - In the first picture, the man could be putting his painting onto the easel but the portion of the painting he is working on is already complete in the first picture (makes alternative A less likely). - Alternative B is absurd right from the start. - In the second picture, the man is about to put a nail in the wall indicating that he intends to hang something up. - In the first picture, the woman is walking towards her babys crib. At this stage, her intention is unclear. All three alternatives are possible at this point. - However, she looks concerned, thus alternative B is unlikely at this point. - In the second picture, you can see that the woman is trying to put out a fire, making alternatives B and C unlikely. - Alternative A is unlikely from the beginning. - After the second picture it appears that the man is trying to get the watch, making alternatives A and B unlikely. However, alternative B can not be entirely discarded at this point. - At first, all three options are plausible. - After the second picture, it becomes clear that the woman is cooking, making alternatives B and C unlikely. - Alternative A is absurd from the beginning, since a clock cannot turn into a thermometer. - Alternative B can be guessed at the first picture, if you look closely and register the concerned facial expression. - The second picture indicates that the woman is cooking, making alternatives A and C unlikely.

2 (woman with baby)

second picture

3 (man with garbage can)

second or third picture

4 (woman with match)

second picture

5 (woman and clock)

second picture

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6 (woman wearing necklace)

first (if you look closely) or second picture

7 (boy with umbrella)

second or third picture

8 (man with wet boots)

first picture

9 (woman with basket)

second picture

10 (man and tree)

second picture

- The price tag in the first picture indicates that the woman is shopping for a necklace. - The second picture shows the woman interacting with the saleswoman displayed in option B, making alternatives A and C less likely. - Although C can not be entirely dismissed until the last picture, B is most likely. - All three pictures need to be displayed before a definite decision can be made. - Alternative C is unlikely from the start. - In the first picture it is unclear what the boy intends to do with the umbrella. - In the second picture we learn that the boy is too short to open the door unassisted. - Alternative B might plausibly follow after alternative A is completed. - Alternative A is ruled out from the onset because it is unlikely that a man would microwave his wet shoes. - Alternative C is also unlikely as the boots and the man are dry and in the bedroom. - At first, all three options are somewhat probable, however alternative A seems most likely. - In the second picture, the woman is standing next to the fireplace and has realized that she is out of fire wood (makes alternatives B and C unlikely). - At first all three options are somewhat plausible. - The second picture indicates that the man is planting a tree thus making alternative B the best option. Clues for detecting the correct solution (examples): - In the first picture, the man could be picking flowers but it looks like he is digging in the ground (makes alternative C less likely). - Alternative A seems absurd right from the start. - In the second picture, it is clear that the man is about to go fishing, ruling out alternatives A and C. - In the first picture, alternatives A and C are both plausible. Alternative B appears to be absurd. - Alternative A could be guessed after the first picture, if you look closely and notice the womans happy face. - In the second picture, you can see that the woman is enjoying the music, indicating that she will give the violinist some money. After the second picture it appears that the man is trying to get across the canyon, making alternative B unlikely and C absurd. - After the first picture, all three options are plausible. - After the second picture, it becomes clear that the man is hungry, making alternative A improbable. On close observation it becomes clear that the man is looking at only one cake (Alternative B is most likely). - Alternative C can not be entirely discarded, but seems less likely, since a baguette is not displayed in the shop window.

Cycle B Task Set 3 1 (man with fishing line)

Stage at which the solution is obvious: second picture; may be guessed after the first picture

2 (woman with changed handbag)

second picture; could be guessed after the first picture

3 (man with rope)

second picture

4 (man with wallet)

second picture

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5 (man with bottle)

first picture

6 (man with ladder)

third picture

7 (man with broken glass)

third picture, can be guessed after the second picture

8 (man with fridge)

second picture, can be guessed after the first picture if you look closely

9 (man with dirty hand) 10 (man and sticks)

first picture second picture, may be guessed after the first picture

- Alternative A is likely from the beginning. - Alternative B is absurd right from the start. - Alternative C could imply that the man went crazy on the island but is unlikely. - The first picture indicates that the man is placing a note in a bottle. The man appears to be stranded (e.g., ripped up clothes), making alternatives B and C unlikely. - Alternative B is unlikely right from the start. - All three pictures are required to arrive at the correct conclusion as little information is conveyed in the first pictures. - To make a definite decision, you have to see all three pictures but alternative B is most likely from the start. - In the first picture it is unclear what the man is thinking. - If you look closely at the second picture you may realize that the man is thirsty. - Alternative C is absurd from the beginning. - Alternative A and B seem equally plausible after the first picture. - After the second picture it becomes clear that the man is annoyed because of the loud music from his neighbors house. Thus, alternative A is most plausible. From the onset, it is clear that the man wants to wash his hands, ruling out alternative A and C. - The second picture indicates that the man is camping, making alternative C the best option. - Alternative A is unlikely from the start. Clues for determining the correct solution (examples): - In the first picture, all three options are possible. - The second picture makes alternative C unlikely. - The third picture with the two boys calling over to the third boy makes alternative A possible but the presence of the hole in the ground makes alternative B the better option. - In the first picture, it is already likely that one of the men is trying to climb over the wall. - The second picture shows both men trying to climb the wall, making alternatives A and C unlikely. - In the second picture, it becomes clear that the boy is not wrapping a present or enjoying his birthday present, making alternatives A and B unlikely.

Cycle A Task Set 4 1 (three boys)

When the solution is obvious: fourth picture; may be guessed after the second picture

2 (two prisoners)

second picture, may be guessed after the first picture

3 (boy with box)

second picture

Cycle B Task Set 4 1 (two boys with tree)

third picture; may be guessed after the second picture second picture, can be guessed after the first picture

2 (boy with flower bush)

- In the first picture, all three options are possible. - The second picture makes alternative A improbable. - In the third picture it becomes clear that the boy will help his friend, making alternative B the best option. After the second picture it is possible to infer that the boy is playing a trick on his girlfriend (alternative C).

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3 (two boys and sweets stand)

third picture, may be guessed after the second picture

In the second picture it becomes plausible that the boys are up to something but it doesnt become clear that they want to rob the store until the third picture, making alternatives A and B unlikely.

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Module 5: Memory Target domain: Over-confidence in errors Basic task: Visual stimuli from the so-called Deese-Roediger-McDermott, or false memory paradigm, are presented (Roediger III & McDermott, 1995; Roediger III, Watson, McDermott, & Gallo, 2001). This material is known to induce false memories even in 5080% of healthy subjects. In cycle A, a typical beach scene is initially shown (e.g., children playing, people sunbathing, water) intentionally leaving out objects one would naturally expect on a beach (e.g., a ball, towels). Usually, participants later recall having seen these plausible but in fact missing objects. By means of the first two pictures as well as a brief description, participants are familiarized with the false memory effect. After that, participants are instructed to look at the following pictures carefully and to recall each item as vividly as possible in order to avoid the false memory effect. Each picture (display time: 15 to 30 seconds, depending on the performance level of the group) is followed by a recognition task in which participants have to decide whether an item had been displayed or not. Several tasks encourage a brainstorming on typical scenes (see General advice), which typically raises the probability of false memories. Material: Some of the pictures were drawn by Norman Rockwell (edited by Miller & Gazzaniga, 1998). Pictures marked with are used with kind permission of Geobra Brandsttter GmbH & Co. KG, Germany. Several pictures have been generously provided by Stefan Merz and Frank Burmeister. The contribution of other photographers/artists is acknowledged at the end of the presentation. Theoretical background: Patients with schizophrenia produce a large proportion of highconfident memory errors (Moritz & Woodward, 2002, 2005; Moritz, Woodward, Cuttler, Whitman, & Watson, 2004; Moritz, Woodward, & Ruff, 2003). While they are rather convinced about the authenticity of false recollections, patients are typically less confident in correct responses relative to healthy controls. This response pattern, along with a high number of memory errors, leads to a state called knowledge corruption: a large portion of what a subject believes to be factual (subjective knowledge) is corrupt or contaminated. There is evidence that vivid recall represents a good heuristic for differentiating correct from incorrect memories. In contrast, mere familiarity or weak and pale recollections are poor proof for authenticity (Reisberg, 2001). Importantly, patients with schizophrenia appear to have a less vivid recall relative to healthy participants (Bacon, Danion, Kauffmann-Muller, & Bruant, 2001; Danion, Rizzo, & Bruant, 1999; Huron et al., 1995). Memory judgments in patients are mostly based on familiarity and intuition (Weiss, Dodson, Goff, Schacter, & Heckers, 2002), making them susceptible to errors. The false memory effect (Roediger III & McDermott, 1995; Roediger III et al., 2001) is an impressive demonstration of how our memory can be tricked by priming effects, logical inference (e.g., it is reasonable to assume that people who sunbathe usually lie on towels) and confusion of past with current mnestic episodes. Objective of the module: Although in most investigations patients with schizophrenia did not differ from controls on accuracy in the Deese-Roediger McDermott paradigm (e.g., Huron & Danion, 2002), their conviction of these memory errors was disproportionately increased (Moritz, Woodward, & Rodriguez-Raecke, 2006). The present material elicits false memories

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in most persons (i.e., irrespective of psychopathological status), and is instructive to show that even memories believed to be hard facts can be pseudo-memories. Participants should understand the fallibility of human memory: our memory is constructive and does not work like, for example, a video recorder. One of the objectives of this module is to teach participants to doubt their memories, if a vivid recollection is not available. In this case, further proof is necessary, particularly for significant interpersonal situations (e.g., conflicts). General advice: The introduction slides should be administered in a very interactive fashion (for example, ask participants about personal mnemonic aids on the slide titled How can I memorize things better? in cycle A). In the course of the exercises on the false memory effect, participants have to learn that the occurrence of false memories is enhanced in situations with strong (prototypal) themes. For example, we may recall snippets from a recent quarrel/argument not actually said but somehow implied (subjective deduction), or had actually been mentioned in prior conflict situations. In these circumstances, it is crucial to verify our first impressions. In addition, participants are taught how to differentiate true from false memories (higher degree of vividness, remembering details). There are plenty of tasks. Do not bore participants with long discussions about single exercises. After each picture, discuss which items were presented (preferably by show of hands, or for example, red and green cards). Ask participants to rate their confidence (e.g., by raising hands: fully raised hand indicates confidence; if the hand is raised halfway this indicates some doubt) and whether they can recall specific details (e.g., color, location of object). After collecting and discussing the participants responses, the picture is shown again to verify judgments. In the brainstorming tasks, after the presentation of the corresponding picture but prior to recognition, participants are asked which objects irrespective of the just presented picture they would typically expect on a similar scene (e.g., classroom, pool). This enhances the false memory effect, as expectancies regarding objects typically seen in these contexts often edit the accurate mental image. Specific advice: none.

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Module 6: To Empathize II Target domains: Complex theory of mind/social cognition; need for closure Basic task: At the beginning, participants should talk about clues that aid to make a judgment about a person (e.g., language, gestures). Weaknesses and strengths of each criterion should be thoroughly discussed. Then, comic sequences are presented, for which participants are required to take the perspective of one of the protagonists and to deduce what the character may think about another person or certain event. There are two different variants available for this task: a standard administration procedure and a BADE-ized administration (for more information on the BADE, please refer to module 3). The standard version presents the comic sequences all at once. It is recommended that this version be used if the session is shorter than usual. For both variants, participants have to take the perspective of the characters displayed. In the BADE-ized administration most slides are presented in reverse sequential order, with the final picture within the comic being displayed first. Chronologically speaking, the last picture (or pictures) is (are) presented first, while the first picture(s) of the comic sequence remain covered. With each new picture, more context is provided about the story. It is recommended to ask the participants after the first presented picture(s) (that is, the last picture chronologically) if the presentation of more pictures of the comic sequence is still necessary or if the solution is already obvious. In fact, the true chain of events is often put in a completely different light by subsequent pictures. Clues for detecting the correct interpretation during the discussion of the standardized or BADE-ized slides can be found in the table below. For the majority of items in the standard as well as in the BADE-ized administration procedure, several interpretations remain possible until the end. In this case, participants should propose what additional information is required for a reliable judgment. Even if a sequence remains ambiguous, it should be discussed which interpretation is best supported by the available evidence. Material: Picture sequences were drawn by Britta Block, Mariana Ruiz-Villarreal and Christin Hoche. The contribution of other photographers/artists is acknowledged at the end of the presentation. Theoretical background: Patients with schizophrenia show difficulties with situations that require perspective-taking and empathizing with others (Frith, 2004; Sprong et al., 2007). A distorted perception of other peoples motives and actions may easily promote interpersonal problems. Theory of mind deficits are, however, observed in other psychiatric populations as well and their pathogenetic relevance for delusion-formation is subject to an ongoing controversy (Garety & Freeman, 1999). In addition, in some studies patients with schizophrenia showed an increased need for closure and certainty (Colbert & Peters, 2002): they have trouble tolerating open-ended episodes and ambiguity. Objective of the module: The participants are demonstrated the difference between their level of information as "omniscient viewer" and the facts available to the protagonists. For example, in one exercise of cycle A, a woman is confronted with bad news by her doctor. When she arrives late for work, her boss scolds her. From the final picture, we cannot really tell whether her boss is cold-hearted or simply unaware of the doctors visit; it could be

24

argued that the boss should have acted more considerately, since his employee likely looks devastated. Some of the comic scenes are unsatisfactory for persons with an increased need for closure. In many scenes as in real life definite explanations cannot be provided. Therefore, participants should propose what additional information is needed to ultimately verify one of the hypotheses. General advice: Let the participants take turns describing each picture of a sequence. Intervene if descriptions go beyond what is displayed in the picture. For the core tasks, participants should imagine themselves in the position of the presented characters. One of the overarching aims of the MCT is to seed doubt regarding hasty interpretations, and to persuade patients to attenuate their level of confidence and abstain from hasty decision-making when the evidence is incomplete. Therefore, from time to time ask participants to rate their confidence (e.g., by raising hands: a fully raised hand indicates a high degree of confidence; a halfway raised hand denotes some doubt). Clues for detecting the correct interpretation
Cycle A Standard Administration 1 (birthday) Since the grandma did not openly express her disgust for toffees, the little girl may well buy grandma toffees again for her next birthday. However, it is unlikely that the grandma will be delighted about the toffees. BADE-ized Administration From the first slides presented, it is difficult to decide what the girl would give her grandma for her next birthday. After uncovering the remaining picture of the comic sequence on which the grandma seems to be delighted to get toffees, it becomes likely that the girl would give her toffees again. The grandma doesnt like toffees, but does not show this openly to the girl. At this point it should become obvious that the group/participants possess more knowledge than the girl. From the first picture (hence, last chronological picture) it is difficult to decide if the boss is coldhearted or not. The second slide that becomes available shows the woman crying, indicating that she may have a legitimate reason for being late. The final slides revealed indicate that the woman is having health problems. It is not clear if her boss knew she had a doctors appointment before work or health problems, so one cannot be certain if he is cold-hearted. Conversely, if the woman is periodically late for work, the boss frustration would be understandable. On the other hand, in the last chronological picture the boss may see that the woman has been crying and in this case, his reaction could be considered a bit too harsh.

2 (bad news)

It is hard to decide if the boss is cold-hearted or not. Given the circumstances, one may easily be led to believe that the boss is overreacting. However, it is important to point out that the boss, unlike us, does not appear to know why the lady was late for work. We do not know if the lady is periodically late for work, making the boss frustration understandable, or if this is an isolated incident, indicating that the boss is perhaps overreacting.

25

3 (accident) The man presumably smells of alcohol. The police officer will most likely believe that the accident has happened because the man was drunk. This is not necessarily wrong but we do not know for sure whether a sober person could have prevented the accident. As the road is rather straight, this may be an indication that the man carries the main responsibility because he might have had enough time to stop the car.

4 (bank)

5 (sailing)

6 (icecream van)

7 (sausage)

Given the information from the first presented slide (last chronological picture), it is difficult to deduce what the police officer is thinking. We can derive that the driver is disorientated, but we dont know whether this is only due to the car accident. As more slides are presented, the participant becomes aware that deer were crossing the road prior to the accident. With the concluding information of the first chronological picture, it is clear that the man had been drinking alcohol. It is important to remember that the group has more information than the police officer; however, it is possible that the police officer smells the alcohol, leading him to think intoxication caused the accident, but the true situation is more complex. The bank clerk does not know that the boy has Based on the information in the first presented just bought a toy pistol. Whether the employee picture (last chronological slide) the participant will be fearful depends on a number of factors may conclude that the bank employee could be (e.g., does the boy look unpredictable, does the frightened by the gun. The boy may also appear as toy gun look real, is the bank employee a fearful a small man. On the remaining slides the person?). participants are informed that the gun is a toy but the bank clerk may not perceive this. Whether the employee will be fearful depends on a number of other factors that we cannot ultimately evaluate (e.g., does the boy look unpredictable, does the toy gun look real, is the bank employee a fearful person?). Although father and son have not heard the In the first presented picture (last chronological warning message, they have probably noticed the slide) father and son look as if they are ready to go weather change (amassing clouds) and may for boating, however, on a closer look one may notice this reason have decided against the boating trip. that the weather conditions may not be optimal However, in this case, they might have reverted (amassing clouds). The third chronological slide long before. may assist the participants in concluding that father and son should not go boating, but it is important to remember that they did not hear the warning message. With the additional information of the first two chronological slides we know that the weather condition has changed. It is likely that father and son have also noticed that the weather has changed for the worse and decided against boating. However, in this case, they might have cancelled the trip long before. They may also have noticed that the beach seems quite deserted, and this may also persuade them not to go boating. The boy does not know that the girl has seen the No BADE-ized administration available. ice-cream truck at the church and may therefore think that she last saw it at the park (when he last saw her). As the boy is apparently very hungry, the mother No BADE-ized administration available. may falsely accuse him of having eaten all of the sausages by himself.

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8 (neighbor)

A man is repeatedly unable to start his car No BADE-ized administration available. because of a dead car battery. In view of the quarrel with his neighbor from downstairs, who has complained about the loud music (pictures 12), he may think that the neighbor has entered the car and turned the lights on to drain the battery. However, as his battery ran out again in picture 4 at a different location, it might occur to him that he himself left the lights on because of negligence (perhaps the car owner was somewhat absent-minded because of the argument with his neighbor). Standard Administration It is important to understand that the people in the caf did not see the boy with the saw. Therefore, the people will most likely assume that the chair cracked because of the mans weight. However, the chair would have probably broken even with a lighter person. One cannot really tell whether the woman will take the mans words as mere information, advice or patronizing behavior. Several interpretations are possible. Perhaps the man does not notice that the woman is on the phone and may therefore attribute her comments to himself. This is supported by the fact that he directly poses his question without trying to catch her attention first. In this case, he might be upset. Alternatively, he may think that the woman should attend to her duties instead of making personal calls. BADE-ized Administration No BADE-ized administration available.

Cycle B 1 (big man)

2 (car)

No BADE-ized administration available.

3 (library)

Based on the second slide of the comic sequence, one could infer that the man does not realize that the woman is on the phone as he has just asked her a direct question. It is possible that the man thinks the woman is replying to him. On the other hand he might think that she should be working instead of chatting on the phone. When the remaining slide is revealed, it seems probable that the woman was in the middle of a phone conversation and was not responding to the mans question. This comic sequence allows different interpretations. It is important to emphasize that the participants have more information than the man. 4 (footIn picture 1, foreigners are apparently learning the In the first presented slide (last slide ball) language of their host country. The content of the chronologically) the park ranger is likely thinking curriculum seems very easy (see grammar on that the football players are blatantly disregarding blackboard), so it is reasonable to assume that the park rules by playing on the grass. By revealing their vocabulary is still poor. Therefore, they the rest of the slides it becomes apparent to the might not figure out what the sign in the park participants that the football players are foreigners means. The park ranger in turn may think that the with a poor vocabulary. We get to know that the boys are disobeying the rules on purpose. content of the curriculum is very easy (see grammar Prejudices against foreigners may also play a role. on blackboard). Nevertheless, this information is It should also be discussed if the presence of a not available to the park ranger, so his opinion of sign on the lawn represents sufficient indication to the situation should not change. refrain from playing football per se. 5 (gallery) A man enters an art gallery. He might mistakenly Based on the information given in the first slide think that the two other people are talking about presented (last slide chronologically), it seems him. Alternatively, the two visitors may complain plausible to think that the two people in the gallery that the man obstructs their sight. are talking about the man in front of the cat painting. When the remaining slides are presented, it becomes clear to the participants that the men were previously discussing the cat painting, but the man may retain the idea that they are talking about him as he entered the room later.

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6 (sick)

The mother will only believe the boy is ill if the boy has put the thermometer in a (hot) cup and then shook the thermometer down to a plausible fever temperature (not displayed!). Otherwise, the thermometer will read too high and the mother will figure out that the boy is just pretending to be ill.

7 (house)

A man has obviously forgotten the key to his house and now climbs through his own window. The ambler may mistake him for a burglar. Alternatively, he may know the man (perhaps as a neighbor), or the owner of the house could have explained the situation to him (e.g., the owners gesture in the second picture might be interpreted in this way).

8 (twins)

The man probably thinks that Lisa (the woman he called on the phone) is sitting in the caf, although she told him that she had something else to do. As he does not speak to her with her first (Christian) name, it might be assumed that he does not know her well and therefore might not even know of her twin sister.

In the first slide presented (last slide chronologically), it looks like the mother is confused by her sons condition and perhaps concerned. The third chronological slide shows the boy sticking the thermometer into a hot cup, trying to make it seem like he has a fever. This information puts the story in a different light. Possibly, it is obvious to the mother that her son is pretending to be ill if the temperature is extremely high. In this case the mother would probably be angry. The first two slides of the comic show the preceding course of events but do not give additional information. In the first slide shown (i.e., the last slide chronologically) it looks like the man is breaking into the house. It is not until the second chronological slide that it becomes clear to the participants that the man had forgotten his house key and is not a burglar. At this point it is important to remind the participants that the man with the dog does not have the same knowledge as the participants and therefore may believe the other man is breaking into the house. This is only true assuming that the man with the dog does not know the man climbing through the window. The man probably thinks that Lisa (the woman he called on the phone) is sitting in the caf, although she told him that she had something else to do. It is not until the remaining slide is shown (first slide chronologically) that it becomes clear that the woman sitting in the caf is Lisas twin sister called Karin. As he does not address her by her first name, it might be assumed that he does not know her well, and therefore might not even know of her twin sister.

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Module 7: Jumping to Conclusions II Target domains: Jumping to conclusions bias; liberal acceptance Basic task: The participants are shown a number of paintings. Their task is to deduce the correct title of each picture from four options. Whereas for some paintings the solution is rather obvious, for others it only becomes clear upon thorough contemplation. For some paintings it can even be questioned whether the correct title fits. In analogy to module 2, the introduction deals with jumping to conclusions and presents a popular urban legend/conspiracy theory (example from cycle A: Marlboro is owned by the Ku-Klux-Klan?). Arguments for and against this belief should again be collected, exchanged and evaluated for their plausibility. It should be made clear that legends of this kind have arisen due to jumping to conclusions and are based on dubious evidence. Thus, they serve as a good model for delusional ideas. Materials: Classical and modern paintings; two pictures are taken from different editions of the Thematic Apperception Test (TAT). Theoretical background: In previous studies, patients with schizophrenia have displayed a liberal acceptance bias for hypotheses (Moritz & Woodward, 2004, 2005; Woodward, Moritz, Cuttler et al., 2006). Relative to controls, patients gave higher plausibility ratings for absurd or improbable alternatives, indicating that patients adopt less stringent criteria for decisionmaking (this account is a variant of the jumping to conclusions approach by Garety et al., 1991). Further, not all available evidence is considered (see also module 2, Bell et al., 2006; Garety & Freeman, 1999) and patients do not weigh information adequately (Glckner & Moritz, 2009). Objective of the module: Participants should learn that it is pivotal to invest sufficient time on the solution of complex problems. Sometimes certain features justify clear-cut decisions, which with superficial exploration would go unnoticed. General advice: The details that speak for or against a certain title should be discussed in the group. The participants attention has to be directed towards information yet unrecognized (see further details below). After having discussed all details, the participants should evaluate the title option again. In this module, it is helpful for participants to use red and green cards to express consent. The disadvantages of hasty decision-making can be demonstrated best when asking participants to make an assessment right after the initial presentation of the picture and then again after discussing the details. Like in previous modules, ask participants to rate their level of confidence (e.g., by show of hands: raise hand fully in case of high confidence and raise it halfway in case of doubt). If there are certain parties in the group favoring different titles, the trainer may encourage and moderate an open discussion.

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Specific advice
Picture # Cycle A picture 1 English title Courtship Clues for detecting the correct interpretation The following speak for B: The womans facial expression is rather coquettish and sensual; the man has brought her a gift (flower); the mans devotional posture. The reading Mortar and pestle indicate a chemist, who might study a new formula (speaks chemist for C). The fact that he is absorbed in reading, that the bottle is closed and that no glass is on the table argues against B. The style of dress does not indicate a monk (speaks against A). The poor poet The number of books shown in the picture indicates a poet (alternative C) rather than a servant (alternative A). The way he holds his hand may indicate that he is in the act of writing poetry (alternative C). Even though he is living in apparent poverty, the diverse belongings (particularly books) argue against the poorhouse interpretation. The admonition The following speaks for D: The girl seems to feel guilty; the older womans threatening gesture; the focus is on the girl (not on the boy). The boy does not have any shoes in his hands (makes alternative C implausible). The visit The mans attention is visibly focused on the bird at the window, for which he lifts his gaze (option A). Since the man is not looking at the book, option B is implausible. Hunting accident The red nose of the man makes option B plausible. The scared face of the man also makes option A plausible; however, clothing, shotgun and the tumbling man support option D. The Cossack-letter One of the men at the table is holding a pen in his hand (speaks for B). The men are not arm wrestling; the Cossacks seem to be in a cheerful mood and apparently do not prepare for a battle (makes alternative D implausible). The spectacles Adults and children try on eyeglasses (tested by reading the newspaper); the salesman bearded man offers glasses out of his case to a woman (argues for D). The children are not in the focus of the picture and adults are in the majority (argues against A). The entering man is only a background figure (C is therefore not plausible). In order to illustrate a scholar, one might have depicted him at a writing table with books, instead of putting him in such a social environment. The water seller of The man in front is wearing ragged clothes; the liquid in the glass is clear; Sevilla even white wine is more yellowish and the glass would be emptier if it was wine-tasting (argues against C). The widower The gentleman dressed in black is certainly looking at the ladies passing by. The gentleman does not interact with the ladies (thus option A is implausible). The sitting man takes a fairly central position in the painting (makes option B implausible). The pedicure The man visibly attends to the feet/toe nails of the woman. No doctors bag or instruments (scalpel) are visible (thus option B and C are implausible). The fruit thieves The kids or little men have apparently picked fruits from the tree, as there are some fruits at the bottom of the tree and one boy is still in the tree; the old man banishes them with a whip. Evening prayer The hands of both persons are folded and their heads bent down. It is sunset. No gravestones or priest are displayed (hence option C is implausible). The Hedger option (D) does not fit with the peaceful atmosphere of the painting. Awaiting the The mother and one of her children are looking (wishfully?) at the ocean. fishing boat Boats at the skyline, meager clothing of the mother and children argue for a poor fishermans family (alternative B). Furthermore there is no luggage for a journey and the child is bare-foot (argues against D). If the scene had described a promenade, the painter would have likely illustrated the scene more dynamically. There is no specific hint for a grieving widow (but no definite proof against option C). Boy with violin Most interpretations go far beyond the visible. In fact, the boy is the famous violin player Yehudi Menuhin as a child before an upcoming concert.

picture 2

picture 3

picture 4

picture 5

picture 6

picture 7

picture 8

picture 9

picture 10

picture 11 picture 12

picture 13

picture 14

picture 15

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picture 16

The love letter

picture 17

picture 18

picture 19

No one is moving furniture (makes alternative C implausible); the pictures atmosphere is sunny and peaceful; a topographer would likely have more professional tools (makes alternative D implausible). Land tax The coin is an important element of the picture (argues for C). It is unlikely that a buccaneer gives money to a nobleman (argues against D). A and B are possible but less plausible than C. Another argument against A is that it is doubtful that a theme like corruption was openly depicted in medieval times. To ask for a dance There is a dancing couple pictured in the background of the painting. The man bows to a woman, which argues for C. In addition, the group seems to appreciate his presence. The two women in the back of the table are not necessarily gossiping about him, the noise level in the room could be a reason why they are so close. Everyone seems to be drinking alcohol, not only the man to the right (beer mugs on the table; speaks against A). The drama There is a big crowd watching a scene happening on stage; there is no screen (makes alternative C implausible). It is unlikely that so many people witness a crime and would not intervene (makes alternative A implausible). The crowd is sitting in the dark, whereas the scene is illuminated just like in theatres.

Cycle B picture 1

Sad message

picture 2

Soup in the monastery The war Why did I marry him?

picture 3

picture 4

picture 5

Childrens games

picture 6

Cheater with the diamond ace Two men contemplating the moon Rest at the edge of the woods Feeding rabbits Mother at the cradle

picture 7

picture 8 picture 9

picture 10

The woman is crying; the soldier has brought her a hat and a coat (presumably belonging to her fallen husband); there is a letter on her lap (speaks for D). The baby is not looking ill; the little boy is looking at the uniformed man and not the baby (makes alternative B implausible). The following speaks for C: A boy with a (soup) bowl is leaving the monastery; there are people in the background who are presumably eating; the nun in the background has a soup kettle in front of her. The door is perhaps too unimpressive for a church (speaks against C). The sword, the torch and the dead bodies on the ground hint towards option A. There is no indication for the annunciation of the arrival of Jesus Christ (option B is implausible). Option C and D rely on peripheral details. The couple is apparently on a ship (porthole in the background), they are probably on their honeymoon trip (argues for B). The man is lying on the bed with clothes on, perhaps being crapulous. A bottle lies on the table next to him (also argues for B). The woman is too young to be the mans mother (argues against alternative D). There are no clues for murder (e.g., a pistol) or suicide (argues against alternative A and C). In the past, a red ribbon, as worn by the woman, indicated that she has (just) married (another hint for alternative B). There are no sales booths and food visible (therefore option B and C are implausible). The games (exercise, dancing, etc.) indicate option D. In favor of option A is the initially apparent chaos, which is however contradicted by the playing people. The red drink renders some plausibility to option C, but leaves too many questions open. Option D seems plausible because of the ladys look; however the card behind the mans back (ace of diamond) is in favor of option B. The moon is an essential element of the picture (speaks for B). There are no tombstones or vampires (argues against alternative A and C). Moreover, the scene appears to be peaceful. The atmosphere suggests night-time (argues against alternative D). The women brought a big basket along; people do not seem to be agitated; no specific clues for an injury (D). The children are feeding the rabbits; no specific clues for Easter (D). Last meal (A) would be a macabre title and does not catch the rather peaceful mood of the picture. The child is sleeping peacefully and doesnt appear to be seriously ill or dying (healthy coloring; argues against alternative A and B). The mother is just sitting at the cradle, her chin is resting on her hand and her lips seem closed, which makes singing unlikely (argues for D but against C).

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picture 11

Dressing

picture 12

Ironing women Land of cockaigne The juggler Lunch

picture 13

picture 14

picture 15

picture 16

Girl drinking wine, with two suitors

picture 17

Lady with opera glasses

There are clothes lying on a chair in the background; the standing woman is fixing the young mans collar, who is kneeling in front of her, wearing underclothes in the fashion of that time (speaks for C and against A). The atmosphere is rather friendly, the two ladies are looking neither angry nor accusatory, but seem cheerful (argues against D). The position is uncommon for a massage (makes B implausible). There is no body to be reanimated (makes alternative B implausible); the woman on the right side is ironing a dress; the other woman seems to be tired from work, she is yawning. The flail in the picture might argue for alternative A. Food lying all around and animals with cutlery stuck in their bodies argue for B. The beheaded chicken is too small to justify the pictures title. There are no special hints for food poisoning (alternative D). The mans equipment (e.g., dog and hoop) indicates a juggler, rather than a sorcerer (alternative A) or an itinerant preacher (alternative C). Alternative B might also be possible. The lowered heads make option A and B initially plausible, however, nobody looks mournful (therefore option A is impossible). One of the people is eating already, thats why option B seems implausible. Nobody seems to speak (thus option D is implausible). Since most of the people are eating, option C is correct. The woman, holding a glass of wine, seems to be flattered, slightly amused and smiles, perhaps she has just received a compliment (argues for A). The presence of the second man and the fact that the woman does not look at the man argues against alternative B. The woman takes centre stage in the picture, which further argues against C. Furthermore, there are no lavish foods visible on the table, as one would expect if D was true. The woman holds an opera glass but no mask (argues against alternative A). There are no specific clues for alternative C.

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Module 8: Self-Esteem & Mood Target domains: Negative cognitive schemata, low self-esteem Basic task: First, the group lists typical symptoms of depression. Following this, therapeutic possibilities for depression and negative cognitive patterns are discussed. The subsequent exercises target depressive cognitive schemata. In cooperation with participants, the trainer explains how distorted cognitive schemata can be replaced with more realistic and helpful ones. The module also targets dysfunctional coping strategies often adopted by people with psychological problems. For example, people with schizophrenia have a tendency to appraise common intrusions as extremely negative (e.g., intensive negative thoughts and images) and to react with a heightened level of fear (Morrison, 2001). These thoughts are subsequently strengthened by enhanced vigilance and an attempt to suppress them. A feeling of alienation from ones mental processes may take place, sometimes resulting in subjectively permeable ego-boundaries (made thoughts) and hallucinations. Participants shall learn that such thoughts may be bothersome but are relatively benign. They will also learn that thought suppression counter-intuitively enhances the presence and the impact of negative thoughts. Instead, it is recommended to observe ones own thoughts from a detached perspective without interfering, like watching a storm outside or a tiger in a zoo. Finally, some techniques are provided which, when used regularly, help alter negative self-schemata and raise ones mood. Materials: Some examples have been inspired by cognitive-behavioral textbooks (e.g., Beck, 1976) and case stories. The contribution of photographers/artists is acknowledged at the end of the presentation. Theoretical background: Many patients with schizophrenia display low self-esteem (Freeman et al., 1998; Moritz, Veckenstedt, Randjbar, Vitzthum, Karow, & Lincoln, 2010). Rates of depression and suicide are very high in this population (Buckley, Miller, Lehrer, & Castle, 2009). There is a continued debate as to whether paranoid ideation is a dysfunctional coping strategy to raise self-esteem (Adler, 1914/1929; Bentall et al., 2001; Kinderman & Bentall, 1996), for example, by enhancing ones subjective importance during persecutory delusions (e.g., heroic fight against evil spirits: the more enemies, the more honor) and creating a new fantastic purpose in life (Moritz, Werner, & Von Collani, 2006). It is not the intention of the program to raise self-esteem to unrealistic heights (therefore, we did not incorporate positive thinking phrases like I am a special person which may well be reasonable for non-psychotic patients), but rather to foster a realistic sense of self. Objective of the module: Participants are introduced to dysfunctional thinking styles which may contribute to the formation and maintenance of depression and low self-esteem. It should be emphasized that with regular training these cognitive styles can be corrected. General advice: This module differs from other parts of the MCT as no conventional tasks with correct versus incorrect response options are provided. It is crucial that the trainer is familiar with the cognitive-behavioral model of depression which underlies this module. Specific advice: Some of the slides contain questions, where the participants are asked to come up with more helpful and rational interpretations, before possible response options are revealed.

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References Adler, A. (1914/1929). Melancholia and paranoia. In A. Adler (Ed.), The practice and theory of individual psychology. London: Routledge & Kegan Paul Ltd. Bacon, E., Danion, J. M., Kauffmann-Muller, F., & Bruant, A. (2001). Consciousness in schizophrenia: a metacognitive approach to semantic memory. Consciousness and Cognition, 10, 473-484. Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York: Meridian. Bentall, R. P. (1994). Cognitive biases and abnormal beliefs: towards a model of persecutory delusions. In A. S. David & J. Cutting (Eds.), The neuropsychology of schizophrenia (pp. 337-360). Erlbaum: London. Bentall, R. P., Corcoran, R., Howard, R., Blackwood, N., & Kinderman, P. (2001). Persecutory delusions: a review and theoretical integration. Clinical Psychology Review, 21, 1143-1192. Bentall, R. P., Kaney, S., & Dewey, M. E. (1991). Paranoia and social reasoning: an attribution theory analysis. British Journal of Clinical Psychology, 30, 13-23. Brne, M. (2003). Theory of mind and the role of IQ in chronic disorganized schizophrenia. Schizophrenia Research, 60, 57-64. Buckley, P. F., Miller, B. J., Lehrer, D. S., & Castle, D. J. (2009). Psychiatric comorbidities and schizophrenia. Schizophrenia Bulletin, 35, 383-402. Byerly, M. J., Nakonezny, P. A., & Lescouflair, E. (2007). Antipsychotic medication adherence in schizophrenia. Psychiatric Clinics of North America, 30, 437-452. Colbert, S. M., & Peters, E. R. (2002). Need for closure and jumping-to-conclusions in delusion-prone individuals. Journal of Nervous and Mental Disease, 190, 27-31. Danion, J.-M., Rizzo, L., & Bruant, A. (1999). Functional mechanisms underlying impaired recognition memory and conscious awareness in patients with schizophrenia. Archives of General Psychiatry, 56, 639-644. Elkis, H. (2007). Treatment-resistant schizophrenia. Psychiatric Clinics of North America, 30, 511-533. Fine, C., Gardner, M., Craigie, J., & Gold, I. (2007). Hopping, skipping or jumping to conclusions? Clarifying the role of the JTC bias in delusions. Cognitive Neuropsychiatry, 12, 46-77. Freeman, D., Garety, P., Fowler, D., Kuipers, E., Dunn, G., Bebbington, P., & Hadley, C. (1998). The London-East Anglia randomized controlled trial of cognitive-behaviour therapy for psychosis. IV: Self-esteem and persecutory delusions. British Journal of Clinical Psychology, 37, 415-430. Freeman, D., Garety, P. A., Fowler, D., Kuipers, E., Bebbington, P. E., & Dunn, G. (2004). Why do people with delusions fail to choose more realistic explanations for their experiences? An empirical investigation. Journal of Consulting and Clinical Psychology, 72, 671-680. Freeman, D. (2007). Suspicious minds: the psychology of persecutory delusions. Clinical Psychology Review, 27, 425-457. Frith, C. D. (2004). Schizophrenia and theory of mind. Psychological Medicine, 34, 385-389. Garety, P. A., Hemsley, D. R., & Wessely, S. (1991). Reasoning in deluded schizophrenic and paranoid patients. Biases in performance on a probabilistic interference task. Journal of Nervous and Mental Disease, 179, 194-201. Glckner, A., & Moritz, S. (2009). A fine-grained analysis of the jumping-to-conclusions bias in schizophrenia: Data-gathering, response confidence, and information integration. Judgment and Decision Making, 4, 587-600.

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Huron, C., & Danion, J.-M. (2002). Impairment of constructive memory in schizophrenia. International Clinical Psychopharmacology, 17, 127-133. Huron, C., Danion, J.-M., Giacomoni, F., Greng, D., Robert, P., & Rizzo, L. (1995). Impairment of recognition memory with, but not without, conscious recollection in schizophrenia. American Journal of Psychiatry, 152, 1737-1742. Kinderman, P., & Bentall, R. P. (1996). Self-discrepancies and persecutory delusions: evidence for a model of paranoid ideation. Journal of Abnormal Psychology, 105, 106-113. Kinderman, P., & Bentall, R. P. (1997). Causal attributions in paranoia and depression: internal, personal, and situational attributions for negative events. Journal of Abnormal Psychology, 106, 341-345. Kinderman, P., Kaney, S., Morley, S., & Bentall, R. P. (1992). Paranoia and the defensive attributional style: deluded and depressed patients' attributions about their own attributions. British Journal of Medical Psychology, 65, 371-383. Klosterktter J. (1992). The meaning of basic symptoms for the genesis of the schizophrenic nuclear syndrome. Japanese Journal of Psychiatry and Neurology, 46, 609-630. Miller, M. B., & Gazzaniga, M. S. (1998). Creating false memories for visual scenes. Neuropsychologia, 36, 513-520. Mehl, S., Rief, W., Lllmann, E., Ziegler, M., Kesting, M.-L., & Lincoln, T. M. (2010). Are theory of mind deficits in understanding intentions of others associated with persecutory delusions? Journal of Nervous and Mental Disease, 198, 516-519. Moritz, S., Veckenstedt, R., Randjbar S., & Vitzthum, F. (2010). MKT+: Individualisiertes Metakognitives Therapieprogramm fr Menschen mit Psychose. [MCT+: Individualized metacognitive therapy for people with psychosis]. Heidelberg: Springer; see also www.uke.de/mkt_plus Moritz, S., Veckenstedt, R., Randjbar, S., Vitzthum, F., Karow, A., & Lincoln, T. M. (2010). Course and determinants of self-esteem in people diagnosed with schizophrenia during psychiatric treatment. Psychosis, 2, 144-153. Moritz, S., Werner, R., & von Collani, G. (2006). The inferiority complex in paranoia readdressed: a study with the Implicit Association Test. Cognitive Neuropsychiatry, 11, 402-435. Moritz, S., & Woodward, T. S. (2002). Memory confidence and false memories in schizophrenia. Journal of Nervous and Mental Disease, 190, 641-643. Moritz, S., & Woodward, T. S. (2004). Plausibility judgment in schizophrenic patients: evidence for a liberal acceptance bias. German Journal of Psychiatry, 7, 66-74. Moritz, S., & Woodward, T. S. (2005). Jumping to conclusions in delusional and nondelusional schizophrenic patients. British Journal of Clinical Psychology, 44, 193207. Moritz, S., & Woodward, T. S. (2006). A generalized bias against disconfirmatory evidence in schizophrenia. Psychiatry Research, 142, 157-165. Moritz, S., & Woodward, T. S. (2007). Metacognitive training in schizophrenia: from basic research to knowledge translation and intervention. Current Opinion in Psychiatry, 20, 619-625. Moritz, S., Vitzthum, F., Randjbar, S., Veckenstedt, R., & Woodward, T. S. (2010). Detecting and defusing cognitive traps: Metacognitive intervention in schizophrenia. Current Opinion in Psychiatry, 23, 561-569. Moritz, S., Woodward, T. S., Burlon, M., Braus, D., & Andresen, B. (2007). Attributional style in schizophrenia: Evidence for a decreased sense of self-causation in currently paranoid patients. Cognitive Therapy and Research, 31, 371-383.

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Moritz, S., Woodward, T. S., Cuttler, C., Whitman, J. C., & Watson, J. M. (2004). False memories in schizophrenia. Neuropsychology, 18, 276-283. Moritz, S., Woodward, T. S., & Rodriguez-Raecke, R. (2006). Patients with schizophrenia do not produce more false memories than controls but are more confident in them. Psychological Medicine, 36, 659-667. Moritz, S., Woodward, T. S., & Ruff, C. (2003). Source monitoring and memory confidence in schizophrenia. Psychological Medicine, 33, 131-139. Morrison, A. P. (2001). The interpretation of intrusions in psychosis: an integrative cognitive approach to hallucinations and delusions. Behavioural and Cognitive Psychotherapy, 29, 257-276. Peters, E., & Garety, P. (2006). Cognitive functioning in delusions: a longitudinal analysis. Behaviour Research and Therapy, 44, 481-514. Phillips, M. L., & David, A. S. (1995). Facial processing in schizophrenia and delusional misidentification: cognitive neuropsychiatric approaches. Schizophrenia Research, 17, 109-114. Randjbar, S., Veckenstedt, R., Vitzthum, F., Hottenrott, B., & Moritz, S. (2011). Attributional biases in paranoid schizophrenia: Further evidence for a decreased sense of selfcausation in paranoia. Psychosis, 3, 74-85. Reisberg, D. (2001). Cognition. New York: WW Norton & Co. Roediger III, H. L., & McDermott, K. B. (1995). Creating false memories: remembering words not presented in lists. Journal of Experimental Psychology: Learning, Memory, and Cognition, 21, 803-814. Roediger III, H. L., Watson, J. M., McDermott, K. B., & Gallo, D. A. (2001). Factors that determine false recall: a multiple regression analysis. Psychonomic Bulletin and Review, 8, 385-407. Sarfati, Y., Hardy-Bayle, M. C., Besche, C., & Widlocher, D. (1997). Attribution of intentions to others in people with schizophrenia: a non-verbal exploration with comic strips. Schizophrenia Research, 25, 199-209. Sprong, M., Schothorst, P., Vos, E., Hox, J., & van Engeland, H. (2007). Theory of mind in schizophrenia: meta-analysis. British Journal of Psychiatry, 191, 5-13. Versmissen, D., Janssen, I., Myin-Germeys, I., Mengelers, R., Campo, J., van Os, J., & Krabbendam, L. (2008). Evidence for a relationship between mentalising deficits and paranoia over the psychosis continuum. Schizophrenia Research, 99, 103-110. Voruganti, L. P., Baker, L. K., & Awad, A. G. (2008). New generation antipsychotic drugs and compliance behaviour. Current Opinion in Psychiatry, 21, 133-139. Weiss, A. P., Dodson, C. S., Goff, D. C., Schacter, D. L., & Heckers, S. (2002). Intact suppression of increased false recognition in schizophrenia. American Journal of Psychiatry, 159, 1506-1513. Woodward, T. S., Moritz, S., & Chen, E. Y. (2006). The contribution of a cognitive bias against disconfirmatory evidence (BADE) to delusions: a study in an Asian sample with first episode schizophrenia spectrum disorders. Schizophrenia Research, 83, 297298. Woodward, T. S., Moritz, S., Cuttler, C., & Whitman, J. C. (2006). The contribution of a cognitive bias against disconfirmatory evidence (BADE) to delusions in schizophrenia. Journal of Clinical and Experimental Neuropsychology, 28, 605-617. Woodward, T. S., Moritz, S., Cuttler, C. C., & Whitman, J. (2004). A generalized cognitive deficit in integrating disconfirmatory evidence underlies delusion maintenance in schizophrenia. Schizophrenia Research, 67, 79.

36

Wykes, T., Steel, C., Everitt, B., & Tarrier, N. (2008). Cognitive behavior therapy for schizophrenia: effect sizes, clinical models, and methodological rigor. Schizophrenia Bulletin, 34, 523-537.

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