Practical Implementation of INT



Fig. 2.1
Diagram of INT (Roder et al. 2008a; with kind permission of Beltz Verlag)



The sequence of the four treatment areas was established using the following criteria:



  • Increase in the level of difficulty of therapy content


  • Increase in the emotional stress caused by therapy content


  • Gradual reduction of the amount of therapeutic structuring in the course of treatment

In other words: INT begins with less complex and affectively non-emphasized neurocognitive content in a highly structured group setting and ends with complex, potentially emotional stressful content in interactive exercises in a less structured environment.

The schematic diagram of INT also clarifies the characteristics of a bottom-up and top-down approach: the subject matter of the largely basic first module is implicitly addressed again in the more complex modules following it. In this way, previously handled intervention areas are reinforced by the effect of positive feedback.



2.1.4 Didactic Structure of the INT Modules


Each of the four treatment areas starts with a neurocognitive section. Only then does the social-cognitive section of that module begins, alternating with further neurocognitive exercises. All four INT modules and each intervention unit for all 11 neurocognitive and social-cognitive functional areas within these treatment areas follow the same didactic structure. This structure comprises two therapy components: introductory sessions and follow-up sessions. The follow-up sessions are further subdivided into the components of compensation, restitution, and in vivo exercises/independent exercises. Table 2.1 provides an overview of INT’s didactic structure with the individual therapy components :


Table 2.1
Therapy components and therapy materials of the four INT modules







































Therapy components

Materials

Introductory session

Self-perception of the subjective experience of resources and deficits and optimization possibilities in everyday life

Case vignettes

Education specific to the treatment area for improving insight into problems/resources and deficits

Information sheets

Worksheets

Follow-up sessions

Compensation: The development of coping strategies and interactive application in a group setting

Worksheets

Information sheets

Film materials

Restitution: Repeated practice, also using computer-based exercises according to the principle of “errorless learning ” in order to habituate learned skills

Written cards

Depicted stimuli

Computer program

In vivo exercises: Encouraging transference to everyday life and generalization to other functional areas

Worksheets

Introductory Sessions

Each intervention unit for the 11 cognitive MATRICS functional areas starts with an introduction. The purpose of the introduction is to increase and standardize participant knowledge. The introductory sessions also promote self-perception of everyday resources and difficulties. INT focuses not only on cognitive functional deficits, but also on individual cognitive strengths (resources). Pointing out (new) possibilities of coping with everyday difficulties by using of one’s own resources helps build up motivation, especially when supported by a complimentary relationship with the therapist. In addition , patients assess the difficulty of the exercises individually, which also promotes motivation. Possible key questions for the individual assessment of exercises include:


Examples of Key Questions





  • Did I find the exercise easy?


  • Was the exercise fun?


  • Why?

or



  • Did I find the exercise hard?


  • Was it too difficult?


  • Did I not like the exercise?

Various therapy materials are available, such as case vignettes, information sheets, and worksheets (Sect. 2.1.5). In addition, it is possible in the neurocognitive section of each module to do a computer-based exercise after introducing the basic topic. The experiences the patients make there of their own deficits and resources can then be used as a starting point for further group elaboration of the cognitive functional area. Clearly structured and easily comprehensible computer exercises have the advantage of being largely free of social stress, so that even patients with pronounced negative symptoms are enabled. Another advantage is the possibility of comparing the results before and after the implementation of compensation strategies. Yet it should be kept in mind that less capable patients often cannot immediately implement compensation strategies they have learned. In order to avoid negative experiences, it is advisable only to compare results that have been improved by repeated practice (habituation ) with those of the introductory sessions. It is therefore the responsibility of the therapist to judge how appropriate this method might be in the introductory sessions.

To sum up, the goal of the introductory sessions is that the patients know which basic cognitive skills will be focused on in the next sessions, how they experience these skills in their everyday lives, and how they try – if at all – to avoid related difficulties. It is also important that patients become aware of their own cognitive capabilities in everyday, practical situations. Moreover, encouraging motivation and the ability to change is of central importance in this phase of therapy, as it is essential in order to guarantee active group participation when developing new coping strategies. Again, particular emphasis is placed on discussing the participants’ resources in the respective functional areas, as this is especially necessary when beginning treatment with a patient with schizophrenia (Sect. 2.5). As a rule, an emphasis on resources helps ensure relationship-forming and motivation.

Follow-Up Sessions

After the introductory sessions, INT follow-up sessions include various therapy components for each area-specific intervention: a compensation component, a restitution component, in vivo exercises, and independent exercises

Compensation

Personal strategies for coping with cognitive deficits in everyday life have already been compiled in the introductory sessions. These sessions also encouraged a positive frame of mind oriented towards solving these problems. Building on this, the group now looks for further coping strategies and supplements existing approaches. These coping strategies must always be concretely formulated and relevant to everyday activities. The second step is to adapt the (now summarized and documented) coping strategies to the individual person. Each group participant assesses which coping strategy is right for him/her and which strategies seem applicable. Using a problem-solving model, individual advantages and disadvantages are discussed, and feared difficulties are anticipated. Finally, the participants try out the new coping strategies in interactive exercises. The regular use of role play in this intervention component supports the implicit learning of the patients. Such interactive exercises make it possible for the patients to have their first experiences with applying learned strategies in a reality-simulating environment. Feedback and discussions with other group members also promote self-reflection about one’s own conduct. In the process, the patients are encouraged to employ arguments supported by facts and to avoid assumptions and suspicions. Ongoing motivation-building, positive reinforcement, coaching on the basis of actual coping experiences – all are prerequisites for ensuring active patient participation and for improving expectations of self-efficacy. The goal of INT’s compensation component is that the patients trust themselves to actively apply the coping skills they have learned. The therapy materials available for this will be described in detail in the next section.

Restitution

The term “restitution” designates the recovery of a function by practice. This repeated practice follows the principle of “practice makes perfect”. With this learning principle, it is possible to make demonstrable improvements in the cognitive functioning of patients with schizophrenia in the trained areas. However, the criticism often arises that associated improvements are not stable after completion of the treatment. INT differs in this respect from other classic cognitive remediation approaches. In the latter, a patient often has to solve abstract problems with increasing difficulty and speed, usually without assistance. INT’s restitution component is primarily focused on the practical rehearsal of coping strategies for various tasks. One approach to strategy learning is used in the process. New strategies are consolidated and made automatic by repeated practice. Another difference from conventional training is that about half of the INT exercises take place in a group setting, where the focus is on connecting back to everyday life . For example, exercises for improving vigilance are put in the context of the participants’ places of work, with all their specific demands and difficulties. In INT, participants work at computers separately or in groups for a maximum of 30 min. After this amount of time, concentration usually declines steadily, even with stable outpatients. To sum up, the overriding goal of INT’s restitution component is the repeated application and consolidation of new coping strategies.

In Vivo Exercises and Independent Exercises

Finally, each intervention unit concludes with in vivo exercises and independent exercises. If possible, the group accompanies the individual participant during in vivo exercises in real situations. In addition, patients apply coping strategies, which have already been individualized and rehearsed in the group, in independent exercises within their actual social environment. The next group session then starts with a detailed debriefing with regard to the exercise’s level of success, emotional stress, conditions specific to the situation, and existing/feared difficulties in the application of coping strategies. The goal is to support the patients’ application of newly learned coping strategies in their everyday lives.


2.1.5 Therapy Materials


This therapy manual contains an ample amount of therapy materials (on the attached CD-ROM) for each of the four treatment areas. These are listed separately in Chap. 6 and can be found on the CD-ROM. Table 2.1 provides an overview of the different types of materials used. The following types of therapy materials are employed in INT’s educational introductory sections and compensatory sections:


Case Vignettes

Representative short stories are available to help introduce the topic of a specific treatment area. These short narratives describe individual cognitive deficits and resources using the everyday experiences of the protagonist, who is named Peter. Group reading and discussion of the short stories introduce the patients to the topic without directly invoking the often stressful, emotionally charged everyday lives of the patients themselves. The group discusses Peter’s experiences, not their own. Only later do the patients report on their own everyday experiences. These may coincide with or differ from those described in the short story.


Information Sheets

These contain information about therapy content for the purpose of optimizing and standardizing the knowledge of the participants. They also include summaries of possible strategies for coping with cognitive deficits. These coping strategies can be individually supplemented by exploring their particular relevance to each group participant’s everyday life.


Worksheets

Worksheets contain definitions of terms and explanatory models of cognitive functions and their relevance to everyday life. They serve as the foundation for both group exercises and independent exercises. Worksheets promote the active participation of the patients. They also help individualize general information: patients document the cognitive difficulties they have experienced in concrete, everyday situations and reflect on the success of their application. Goals discussed in the group and the success of their application are also recorded on worksheets. Vignettes, information sheets, and worksheets are all included on CD-ROM.


Standardized Written Cards

Words, sentences, and short texts written on cards serve as language-based stimuli for group exercises. The practical part of this manual (Sect. 2.3) contains specific and detailed instructions on the use of written cards in each exercise. These therapy materials are also on CD-ROM.


Visual Stimuli

The social-cognitive sections of the four INT modules contain a wealth of visually depicted stimuli, all of which are included in PDF format on CD-ROM. These can be projected (CD e-Materials) or printed out (CD Materials). In addition, the treatment also utilizes cards printed with various designs (card-sorting exercise) as used in the first IPT module (Roder et al. 1988, 2008a, 2010). This interactive card-sorting task for the targeted promotion of group processes is available on paper. Furthermore, the set of pictures of facial affects created by Paul Eckman represent valuable visual stimuli for INT (Ekman and Friesen 1976).


Film Material

In the social-cognitive part of the INT modules, selections from commercially available films are also utilized. For copyright reasons, these films have to be acquired by the users themselves. Films that have hitherto proved effective in INT groups are listed in the practical manual sections (Sect. 2.3).


Computer Program

A computer program is available for the neurocognitive intervention section of the four INT modules. INT uses the CogPack program distributed by the Marker Software company (Olbrich 1996, 1998, 1999). Due to license reasons, this program is not included in the manual and should be acquired by the users themselves (www.​markersoftware.​com). CogPack provides exercises for all six neurocognitive MATRICS dimensions. Each exercise follows the principle of “errorless learning ” (Kern et al. 2002, 2003, 2005): in order to avoid patient error as much as possible during the exercise, it always begins with the simplest difficulty level and only moves to the next level when 80–90 % of the tasks have been solved correctly. This has the goal of minimizing errors, which can be experienced as emotionally stressful. It also promotes an individualized, automatic response to newly learned skills. After each individual task is completed, the CogPack program provides immediate performance feedback (is the solution right or wrong, what would have been the right answer, completion speed, etc.). This direct program feedback is therapeutically useful for promoting realistic self-perception and self-evaluation of capabilities in the target area. Practical descriptions of independent and group CogPack exercises can be found in Sect. 2.3.



2.2 Therapeutic Infrastructure



2.2.1 General Conditions


INT group implementation is subject to several general conditions. Particular institutional conditions, a differential indication for participation in INT, risks of group formation, and therapist requirements will be described in detail later in Chap. 3. We will focus here on general conditions. Before patient recruitment can even begin, infrastructural clarifications must first be made with respect to available rooms. Also, equipment such as computers, computer programs, projectors, and treatment materials may also need to be organized or acquired.


Room Conditions

INT involves group exercises and computer-based exercises. Accordingly, group sessions take place both in a standard group room (preferably with circular or semicircular seating) and in a nearby computer room. In the computer room, one computer with keyboard and mouse is required for each patient and the primary therapist. The standard therapy room should also be equipped with a computer (Fig. 2.2). INT sessions generally take 90 min with an additional break. Within one session, we recommend that no longer than 30 min be spent uninterrupted at a computer. After that, patient concentration and motivation abate markedly. Accordingly, the group switches back and forth between the therapy room and the computer room at least once in the course of a therapy session.

A322679_1_En_2_Fig2_HTML.gif


Fig. 2.2
Required materials and rooms (Müller and Roder 2010; with kind permission of Karger Publishers)


Computers

Computer-requirements are modest insofar as the program used, CogPack (Sect. 2.1.5), can be installed with systems using Windows 95. Other computer-based therapy materials are in PDF format. Older, fairly obsolete computers are usually sufficient.


Computer Programs

CogPack is distributed by Marker Software. Further information, also about obtaining a user license, is available on the company’s homepage: www.​markersoftware.​com.


Projectors

Group exercises involve the use of an ample amount of visually depicted stimuli and film excerpts. These are projected on a screen by a computer with a digital projector. Both the group room and the computer room should have a projector. Alternately, a projector can be transported back and forth between the two rooms.


Flip Charts

In group interactions and discussions, the flip chart is an indispensable aid for compiling discussion contributions clearly. Furthermore, it is possible to update therapy content recorded there once again at a later time.


Therapy and Group Materials

All therapy materials can be found, with three exceptions, on the enclosed CD-ROM.



  • For copyright reasons, we cannot include commercially distributed films, scenes from which are used for therapeutic purposes. These films have to be obtained by the therapists themselves. A list of films that have proved effective can be found in Sect. 2.3 (Description of the Four INT Modules).


  • The second exception are the tried-and-tested cards printed with four different designs (IPT card-sorting exercise) and the series of pictures for social perception from the Integrated Psychological Therapy program (IPT, 1st and 2nd modules; Roder et al. 1988, 2002, 2008a, 2010). The easily distinguishable designs of the IPT card-sorting exercise vary in the colors, shapes, numbers, and days of the week depicted on them. A set consists of 230 different cards. IPT’s two standardized series of pictures for social perception each contain 40 standardized pictures (degree of complexity, emotional stress, basic emotion depicted, etc.). These IPT materials can be obtained from the author (roder@sunrise.ch).


  • The Pictures of Facial Affect (PFA) compiled and standardized by Ekman and Friesen (1976) are also not included. Each of the 110 electronically available black-and-white photographs represents either one basic emotion or a lack of affective expression (© Paul Ekman 1993). This visual material can be obtained on the Internet (www.​paulekman.​com).

Since INT includes several different worksheets and information sheets, it is advisable to hand out a labeled binder or transparent folder to each patient at the outset. The worksheets and information sheets are collected here. At the conclusion of INT, the whole binder then represents an individualized handout, which can be used even after the treatment is over.


2.3 Treatment Areas A–D for Neurocognition and Social Cognition


Each cognitive target area of the four INT modules is organized using the same didactic structure (Table 2.1). Introductory sessions contain area-specific instruction with the specific intention of promoting self-perception of cognitive resources and deficits. Follow-up sessions begin with a compensation component, which is followed by a restitution component. Finally, participants perform in vivo exercises/independent exercises. The various intervention techniques employed will now be described in detail for the intervention components of Module A. For the subsequent modules (B-D), the reader will find only short descriptions with references to Module A.


2.3.1 INT Module A


Module A aims to intervene in two neurocognitive target areas: speed of information processing and attention/vigilance . In the introductory sessions, the first topic is speed of information processing, which is put in connection with attention activation (alertness). The target area of attention and vigilance (concentration) is then introduced. In the ensuing compensation and restitution components, the two neurocognitive target areas are handled together owing to overlapping content. In addition, Module A provides the patients with a general introduction to INT as well as a framework for them to become acquainted with each other.


2.3.1.1 Neurocognitive Intervention Area: Speed of Information Processing and Attention/Vigilance



Module A: Neurocognitive Intervention Area: Speed of Information Processing and Attention/Vigilance



I.

Overview of therapy content and getting acquainted



  • Getting acquainted


  • Establishing group rules

 

II.

Speed of information processing and attention/vigilance

1.

Introduction



  • Speed of information processing



    • Definition: speed of information processing


    • Self-perception in the target area


    • Resource-oriented, individual cognitive profile: comparison of subjective assessment with objective test results in computer and group exercises


    • Connection with everyday life and self: case vignette


  • Attention/vigilance



    • Definition: attention/vigilance


    • Self-perception in the target area: overarching theme: understimulation


    • Reference to everyday life and self: case vignette


    • Factors influencing performance: alertness, medication, interests and motivation, mood, daily rhythm (education concerning homogenization of knowledge)

 

2.

Compensation



  • Learning and individualizing coping strategies: speed of information processing and attention/vigilance


  • Coping strategies for maintaining vigilance


  • Area-specific coping strategies:



    • Recreation


    • Difficulties in reading


    • Quality of sleep and lifestyle


    • Vocation


    • Concept-formation: mood and concentration

 

3.

Restitution



  • Habituation of learned coping strategies:



    • Repetition of computer exercises


    • Repetition of group exercises

 

4.

In vivo exercises and independent exercises



  • Transfer of individualized coping strategies to concrete, everyday situations

 

 

I. Overview of Therapy Content and Getting Acquainted


Tips





  • Infrastructure: group therapy room, flip chart


  • Therapy materials: CD Information Sheet 1


  • Didactics: highly structured group discussion

Therapy Content

The patients are informed about the content of the therapy, the materials and formats used, and the organization and sequence of the sessions. This information should be kept concise to avoid overtaxing the patients. An example of a short introduction to INT is found on CD Information Sheet 1 on the enclosed CD-ROM. Additions made by participants or therapists should also be noted on CD Information Sheet 1. As a rule, there are always patients who want to know what INT actually means. If this has not already been explained with each patient in the individual admission interview, therapists should briefly explain the concept of INT using simple language and avoiding technical terms.


Introduction Example

INT stands for Integrated Neurocognitive Therapy . The term “cognitive” stands for different functions that are important for thinking. The term “neuro” means the relationship of these mental functions to the brain. The brain is where mental functions like memory (“I’m trying to remember something”) take place. Finally, the term “integrated” has to do with combining, discussing, and exercising the various mental functions within the therapy program, since different mental functions influence each other.

In groups with outpatients and day-care patients, stigmatization experienced by persons suffering from schizophrenia is often a topic of discussion. For this reasons, we use the neutral terms “course” and “(course) participant” instead of “(psycho) therapy group ” and “patient”.

Getting Acquainted

In an ice-breaking round, the participants and the team of therapists introduce each other. Also, the therapists inquire about the patients’ experiences and expectations concerning group therapy and compile them neutrally. Every experienced therapist has their own preferred method in such ice-breaking sessions . Let us use the ball method as an example. The primary therapist throws a ball to a patient and asks: “May I ask what your name is? I’d also like to know about your hobbies and interests.” The participant answers this, throws the ball to another participant, and asks the same questions. This procedure is appropriate for uniform groups with mild symptoms and average to high performance levels. With other group configurations, a highly structured process is preferable. In this case, the therapists might ask the participants questions one by one. Such questions could include: “I’d also like to know what you expect from this course”, or “Is there something in particular you are afraid of?”

Establishing Group Rules

Group rules concerning the formal workflow of the treatment sessions must also be defined. The following group rules have previously been tried and tested in INT groups. However, they can also be supplemented with other rules introduced by the therapists or the group.


Group Rules





  • No obligation to speak: Each participant is allowed the possibility of taking a time out (and telling the therapist this) and of being passive during an exercise (i.e., attending without active participation).


  • Mistakes are allowed: The group should be established as a protected space where mistakes are expressly permitted during exercises. We learn from our mistakes.


  • Mutual support: Participants mutually support each other; only relevant, constructive criticism is allowed, not personal reproaches.


  • Self-imposed participant discretion: Participants’ ideas and personal contributions are not to be communicated outside the group, but remain in the group room.


  • ……

This formal introduction to group therapy is especially important in the psychotherapeutic treatment of patients with schizophrenia. It has the following goals: building up a sustainable group relationship between the participants, forming a supportive, complementary relationship with the therapists, supporting therapy motivation, and creating an atmosphere that is as anxiety-free as possible. This allows the patients to engage themselves with the group and the subject matter.

II. Speed of Information Processing and Attention/Vigilance


Tips





  • Infrastructure: group therapy and computer rooms, flip chart, digital projector


  • Therapy materials: CD Information Sheets 2–5, CD Worksheets 1–5, CD Vignettes 1–3


  • Card-sorting exercises: IPT (CD Materials 1), speed (CD Materials 2a–l), concentration and alertness (CD Materials 3a–b)


  • CogPack: speed: VISUMOTOR, UFOs, FALLINGSTARS, BALL, STOP, REACTION


  • Attention/vigilance: PIECE-WORK, SEQUENCE, SCAN


  • Didactics: highly structured group discussions, individual computer exercises


2.3.1.1.1 Introductory Sessions


2.3.1.1.1.1 Speed of Information Processing

Definition of the Target Area: Speed of Information Processing

The concept of the neurocognitive function “speed of information processing” is described in an introductory way using simple, easily comprehensive language.

Speed is defined as our individual pace in the intake and processing of information and in the resulting reaction.

Examples from everyday life are used for clarification:



  • How quickly do I take care of my everyday tasks?


  • How quickly do I understand what someone else says to me?


  • How quickly do I react when a traffic light changes from red to green?


  • How quickly can I work or read? etc.

Concerning the processing of recreational or vocational tasks, the distinction is already made between “accuracy” (attention, concentration) and “speed”:



  • Those who work very quickly, or even hastily, are more prone to error.


  • On the other hand, those who work very precisely and exactly are slower as a result, but probably make fewer errors.

Promoting Self-Perception in the Cognitive Target Area

After this, the participants take turns reporting on how they subjectively assess their own speed as defined above and which situations they see their performance as weak or strong. Their statements are recorded on the flip chart. In addition, each participant receives CD Worksheet 1 (“How fast am I?”). Only the questions on that sheet are answered at this point. There are also two questions on the worksheet concerning comparison with others (“I am generally faster than others”) and satisfaction (“I am satisfied with my speed”). These questions are an opportunity to address social components and the subjective evaluation of performance, both of which are decisive stress factors. The group discusses the questions on the worksheet to extend self-perception to these topic areas. At this point, CD Worksheet 1 serves only as a first stocktaking of individual self-assessment. The connection to patients’ everyday lives is later deepened when they have their first experiences with the computer exercises and discuss the case vignettes.

In addition to instructing the participants about the specific topic, the sessions introducing speed of information processing also serve to build up group motivation and cohesion. Factors that should be taken into consideration include potentially inflated mistrust due to persisting positive symptoms , reduced interest and level of activation caused by negative symptoms , and individual participants’ inexperience with groups, which can induce anxiety. Depending on the composition of the group, it is advisable not to divulge assessments from the worksheets of participants who exhibit excessive mistrust. Instead, the content should be discussed generally using statistics without specifying concrete assessments.

Computer Exercises

In the introduction to information processing speed, participants already move between the group and computer rooms. This is an exception to INT’s general didactic approach when introducing a new cognitive intervention unit. It is done for three reasons:



  • The participants are introduced to the CogPack program and learn its operation. Basic computer knowledge is taught, helping inexperienced participants become less anxious dealing with computers.


  • CogPack’s simple, highly structured and goal-oriented exercises help reduce anxiety-ridden expectations of being in a group in a way that is relatively free of social and emotional stress.


  • Objective, immediately reported test results can be compared with previously recorded subjective assessments of patient capabilities in the cognitive target area.

The following CogPack exercises have proved effective: The VISUMOTOR exercise is especially suitable for showing participants how to use the program and the computer mouse. The ease of the exercise helps reduce the fears of inexperienced participants. The exercises UFOs, FALLINGSTARS, or BALL are also recommended, as they are designed as games and tend to activate participants and promote motivation. These and other exercises will be described in detail in the restitution section below. The program’s direct feedback after each exercise (e.g., improvements in the second half compared to the first half of the exercise, or improvements in the second round compared to the first based on comparative values) is a key element for promoting adequate self-perception. From a psychotherapeutic point of view, giving the participants positive reinforcement for their test performances is also indispensible. For example, patients should receive praise and acknowledgment simply for engaging in the exercises and carrying them through to the end. If they have difficulties processing the exercises or experience stress, therapists support the patients and help solve the exercise to avoid overstraining them.

After this computer exercise, which is usually kept short, participants then return to the group room. Self-perception is promoted by briefly reflecting on individual experiences. Therapists should register the participants’ experiences in an approving and encouraging way.

Questions are discussed such as: “Did I find myself fast or slow?”, “Did I try to be as fast as possible?”, “What was easy for me?”, “Where did I have difficulties?” Patients are generally apt to make self-assessments at this point (“I was too slow”, “I reacted too quickly”, or “I was faster than average in the computer exercise”).

As a basic therapeutic rule, self-deprecation should be positively connoted according to the principle of reinforcement (“Those who work too quickly are prone to error”). Self-deprecating participants should also be reminded of possibilities for improvement (“Speed can be trained”). The functional relationship between pace and accuracy in the everyday lives of the participants thus becomes a key topic. The range of possibilities is marked by two extremes: “I’m fast but still free of error” and “I’m considered slow, and I also tend to make mistakes”.

The results of the computer exercises, which have now been discussed, are then compared with previously recorded subjective performance assessments (CD Worksheet 1). It should be taken into account that the computer-based results were obtained in laboratory-like conditions within the protected space of the therapy group. This performance thus cannot be compared directly with everyday performance, in which additional interactional and contextual demands are in play. For this reason, the next step is to read the first case vignette with the group.

Case Vignette

One or more group participants read CD Vignette 1 paragraph by paragraph. After every section, the participants summarize the main ideas. The therapists direct their focus on the relationship between speed and alertness (“It was only because Peter was so alert that he could brake his bike in time”). After reading the case vignette, a group discussion is held with the following objectives:



  • Self-reference: The participants identify themselves with particular aspects of the story (“The same thing happens to me”) or distance themselves from them (“That’s usually harder/easier for me”).


  • Reference to everyday life: Participants should identify and name concrete situations from their lives that they have experienced in a similar or contrary way to the case vignette’s protagonist, Peter. At the end, the group should reach a common conclusion and find a title for the example situations. This can then serve as a guideline for subsequent discussion.


2.3.1.1.1.2 Attention/Vigilance

Attention/vigilance, the second neurocognitive target area of Module A, was already discussed in the introduction to the first target area, speed of information processing (e.g., “Those who work too quickly make more mistakes and vice versa”). To avoid thematic overlap, we first introduce the neurocognitive functional area of attention/vigilance. Then factors influencing speed of information processing and attention/vigilance are discussed as a group.

Definition of the Target Area Attention /Vigilance

The neurocognitive function “attention” is defined briefly and in a generally understandable way. In the process, therapists should point out the distinction between attention activation (i.e., temporary power of concentration) and long-lasting maintenance of attention (vigilance):


Introduction Example

Attention is basically being able to concentrate on what is essential while having a conversation, working, or solving a task. Among other things, this requires that we hear and understand conversations, that we carry out activities at work, or that we perform tasks in a goal-directed way. For example: when we are having a conversation, we have to activate our attention as soon as someone speaks to us. If it is a longer conversation, we have to be able to hold our attention for a longer time.

To illustrate this, examples of deficits and resources are taken from everyday life:



  • How many mistakes do I tend to make when I perform tasks?


  • How exactly do I usually work or attend to things?


  • How well can I concentrate on everyday tasks, e.g., reading a newspaper article or a letter, listening to a conversation, housekeeping, paying attention to traffic?

Therapists can also refer back to the experiences made with previously completed computer exercises.


Key Question





  • During the computer exercises, did I make more mistakes in the second half than in the first? (Refer to the feedback given by the program upon completion of a round of tasks)

Promoting Self-Perception in the Cognitive Target Area

After this, participants take turns reporting on how they subjectively assess their own ability to concentrate and which situations they see their performance as weak or strong. Participants’ statements regarding concrete situations are recorded on the flip chart. In addition, each participant fills out CD Worksheet 2 (“How well can I concentrate?”). The didactic approach is the same as that of the intervention unit on speed of information processing (see above). Also, therapists should point out the distinction between the short-term focusing of attention and longer-lasting power of concentration under low levels of stimulation.

Case Vignette

The group now reads the case vignettes paragraph by paragraph (CD Vignettes 2 and 3). In terms of content, these are a continuation of CD Vignette 1. CD Vignette 3 focuses on the theme of vocational rehabilitation. The protagonist Peter is confronted with the difficulty of having to maintain his power of concentration for a longer period of time.

After reading CD Vignette 2, a group discussion is held with the following goals:



  • Self-reference: Participants identify themselves with particular aspects of the story (“The same thing happens to me”) or distance themselves from them (“That’s usually harder/easier for me”).


  • Reference to everyday life: The group compares the vignettes to situations from everyday life. Finally, a common conclusion and title for the example situations are found.

Only then is CD Vignette 3 read. This vignette introduces competitive work as a concrete target area when coping with difficulties in vigilance . Asking the participants about similar or contrary experiences reestablishes the connection to their everyday lives. In CD Vignette 3, factors affecting one’s powers of vigilance (interest, states like boredom) are also addressed for the first time. The still highly structured group discussion is also centered on factors that influence one’s power of concentration.


Examples of Key Questions





  • Is my power of concentration always the same?


  • What does my ability to concentrate depend on?


  • Can you give both a positive example of when you could concentrate well and a negative example? Can you describe these situations exactly?

Participants’ everyday experiences concerning this cognitive target area are compiled on the flip chart and analyzed. The objective is a more discerning view of possible influences on attentional performance.


Examples of Key Questions





  • What was my mood in this situation?


  • Did this activity interest and motivate me, or did it bore me?


  • Did it demand too much or too little of me?


  • Did I feel tired or awake?


  • How was my daily rhythm at this time?

Factors Influencing Performance in the Target Areas

While promoting self-reference and reference to everyday life as described above, participants often make the justified objection during group discussion that their cognitive performance in the target areas depends on numerous factors (e.g., mood, fatigue, medication). Thus, the next step is for the therapists to explore various influential factors that the participants experience in everyday activities. The aim is to establish an explicit connection between pace/attentional performance and the factors of alertness, daily rhythm, mood, medication, sleep, and lifestyle.

The Influence of Alertness

With a view to INT’s strict resource-orientation, the term “alertness” is used instead of “fatigue”. For illustration, the alertness graph of a co-therapist or a participant – from waking in the morning to falling asleep at night – is shown on the flip chart as a model. This demonstrates the relationship between alertness and individual speed and attentional performance in the course of a day, Following this, each participant plots his or her average personal alertness graph on CD Worksheet 3 (“Alertness and speed/attention”). This should be confined to an average workday or the weekend. The worksheet can also be filled out as an independent exercise. However, this is only to be recommended for participants who are already highly motivated and active. The completed CD Worksheet 3 serves as a foundation for self-reference and reference to everyday life.

These questions are guidelines for the therapists for promoting participant self-reflection:



  • When and where do I experience fatigue, sluggishness, and difficulty paying attention in my everyday life?


  • When and where do I not?

In this way, the participant’s subjective everyday experiences of personal strengths and weaknesses with respect to alertness, speed, and concentration are explored with the group and supplemented by CD Worksheet 3. In conclusion, performances in the target function, now felt as relevant to everyday experience, are compared with and contrasted to previous self-assessments of performance. In the process, the therapists stress the situation-specific resources of each participant and positively reinforce them. Finally, therapists draw attention to the cognitive performance profile of each participant – each characterized by individual strengths and weaknesses – according to the motto “Nobody is perfect!”

Now the topic of maintaining attention (concentration ) over a long time period is discussed. Therapists should point out the differences between maintaining attention and speed of information processing or attention activation (“Before we wanted to be as alert and fast as possible during an activity. Now we are talking about keeping as alert as possible over a longer time period – at work for example – while making as few mistakes as possible”). Examples such as the following can be used for demonstration purposes:


In the Cockpit

A pilot is flying with his co-pilots and 100 passengers from Frankfurt over the Atlantic to New York. Flying time is 9 h. After starting, the pilots activate the autopilot, a kind of computer program for flying the airplane according to a preset route. We might think that the pilots have nothing more to do until landing in America. They could read a newspaper or sleep. There is also no variety during the trip. Flying high over the clouds, the pilots see almost nothing but white clouds and the blue sky above. There is no sensory stimulation. It is boring. Unfortunately, the pilots can’t sleep, because they are responsible for over 100 passengers as well as the flight attendants. If something should happen (the airplane could experience wind turbulence, for example), the pilots have to react as quickly as possible and take control of the plane from the autopilot. In other words, they must always remain alert and capable of reacting very quickly, as we discussed on the topic of speed. They have to be able to maintain their alertness and attention from over 10 h, even when it is actually boring and nothing is happening. This is what we will talk about now.

In addition, the therapists can refer back to CD Vignettes 2 and 3 at this point. Again, the goal is to anchor the connection between alertness and sustained attention (vigilance) in the participants’ everyday lives.


Examples of Key Questions





  • In my everyday life, where does sustained attention play an important role? At work? In recreational activities? When I’m alone?


  • Am I usually good at this?


  • And do I feel alert and ready in the process?

The Influence of Medication

Patients often mention the negative side effects of neuroleptics as an influence on concentration and speed. Therapists should discuss patients’ subjective experiences concerning such side effects on neurocognition in an approving and transparent way. To promote pharmacological compliance, patients should be reminded of the benefits of neuroleptic medication for coping with symptoms. They should also be reminded of positive experiences with new-generation neuroleptics. For this, easily comprehensible models and metaphors are best, such as are used in various psychoeducational approaches (see overview in Bäuml and Pitschel-Walz 2008). The island model created by Bäuml and his colleagues (Bäuml et al. 2010) for describing the dopamine hypothesis is provided here in an abbreviated form as an example:


Island Model for the Dopamine Hypothesis

Our brain contains a large amount of water. We can imagine the nerve cells in our brain as islands in an ocean that are in contact with each other. Thus, if we think or talk, the messages (information) are brought from one island to the next on boats (neurotransmitters, messengers). These boats land on different ports (receptors) on each island, and the cargo (message) is unloaded. The problem is that, if there is too much dopamine secretion under stress, too many boats are in transit, and the islands are overwhelmed with messages. The task of the neuroleptics is to block these island ports, reducing how many boats can land and thereby stopping the flood of messages. Older medications sometimes block too many ports, which with time gives us the feeling of being dulled. So newer medications purposely do not block all the ports. In this way, they assist communication, which we then experience as normal.

For illustration, a diagram of the island model is shown on the flip chart during the presentation.

If a patient’s pharmacological noncompliance becomes a problem, the physician in charge should be contacted. The overriding goal is to point out the supportive effect of INT and comparable methods in re-attaining better cognitive performance. Psychotherapy – in conjunction with sociotherapeutic measures and medication – is a cornerstone of a successful multi-professional treatment.

The Influence of Interest and Motivation

The effect of interest and motivation on sustained attention is also an issue. In order to promote self-perception, the following resource-activating exercise can be carried out. A doctor’s waiting room is simulated, complete with current newspapers and magazines on various subjects lying on the table. The participants should take a newspaper or magazine and browse through it. The aim is to activate the participants and to clarify the relationship between individual interests and attention.


Examples of Key Questions





  • What attracts my attention?


  • Where does my attention linger?


  • What attracts my interest?


  • What excites me?


  • What motivates me? What excites me?

The Influence of Mood

The topic of mood foreshadows the social-cognitive aspects of emotion perception as addressed in INT Module A (Sect. 2.3.1.2). The therapists point out that mood or disposition affects attention. Moods themselves depend on the processing of internal and external stimuli. Not only our thoughts and feelings (including those directed towards the past or future) affect our mood; body perception does so too (“I feel sick/I have a headache”). By the same token, excessive or insufficient stimulation can lead to stress or apathy and boredom. To illustrate the connection between cognitive performance and mood, CD Information Sheet 2 (“Performance and mood”) is distributed. The worksheet shows the influence of individual mood and the associated level of activation or excitement on (cognitive) performance. Highly chronic patients usually require extensive explanation of the activation graph.

The therapists call attention to the interaction between one’s internal level of activation, feelings, or moods and cognitive performance. This INT intervention unit focuses initially on the lower (left) area of the activation graph on the worksheet, where the level of activation is too low to yield favorable cognitive-emotional coping. The goal is to explore states of mood that not only affect concentration negatively (during monotonous tasks in the workplace, for example) but can also detract from positive activities in leisure time. The first overriding topic is thus vigilance during understimulation. In almost every group constellation, there are participants who exhibit a generally high level of activation, who are anxious and distrustful, and who tend to become nervous when exposed to an overstimulating situation. Accordingly, these participants, due to increased distractibility, often experience attention and concentration problems even during activities that actually interest and motivate them. Should a participant have such an experience of increased activation and stress, this is acknowledged with the observation that the group will reflect more deeply on the topic of distractibility and overstimulation in the last part of INT (Sect. 2.1). To avoid this situation, it is important that the patients can have positive experiences in this early phase of INT without much stress.

Recognizing the functional relationship between mood, activation, and cognitive performance is a key prerequisite for making a connection to the participant’s everyday lives. The therapists again use the flip chart to record the everyday experiences discussed by the participants.

Finally, the focus is shifted to daily rhythm as another factor that affects attention. Daily rhythm depends on our individual lifestyle and how we structure our day. In this discussion, therapists can have recourse to the individual alertness graphs that each participant has already recorded on CD Worksheet 2. Attentional performance changes during the day are similar to those of alertness (e.g., “In the morning after waking I can’t read a book, but I can in the evening”). When introducing this topic, therapists should also point out positive examples associated with experiences of success. For example, daily rhythm is determined to a great extent by quality of sleep (e.g., “When I don’t sleep much, sometimes I hardly understand what people say to me” but “When I sleep well, sometimes I feel like I could take on anything”). A person’s lifestyle manifests itself in his or her daily rhythm. Eating habits and the consumption of stimulants such as coffee, cigarettes, alcohol, and illegal drugs have an enduring effect on one’s power of concentration. Participants’ experiences in this regard are discussed and documented. Even if the consumption of alcohol and cannabis is not INT’s primary focus of intervention, participants should be given time to discuss the issue if necessary so they can elaborate on the pros and cons of such consumption. The goal of this is reduction of consumption or abstinence. Chapter 3 includes tips on how to deal with patients for whom drug or alcohol abuse is a vital issue.


2.3.1.1.2 Compensation

The objective of compensation is to develop new coping strategies. The foundation for this is the concrete connection to patients’ everyday lives and experiences that was made in the cognitive target area of speed of information processing. The next step is to individualize these strategies.

Coping Strategies for Improving Speed and Attention Activation

On CD Worksheet 3, which was already used in the introductory sessions, the participants noted their own coping strategies for improving alertness, speed, and attention. (3rd question: “What can I change in order to be more alert, faster, and more attentive?”). These strategies are now neutrally compiled and recorded on the flip chart. Only then does the group discuss these suggestions and assess them for their own use in concrete situations.


Examples of Key Questions





  • Which strategy is promising and why?


  • Which strategy improves my speed and attentional performance?


  • Which strategies am I confident enough to try out in a certain situation?


  • Which strategy suits me and which doesn’t?

Supplementing this, each participant receives CD Information Sheet 3 (“How do I have more speed and concentration”). This sheet lists strategies for the direct improvement of speed and preventative measures for indirect improvement. It also links speed with concentration, although the latter is discussed in the next intervention unit.


Repeated Practice

This signifies the habituation of an activity until it becomes a routine. Simple exercises are carried out in the group for demonstration purposes. For example, one participant is asked to recite the alphabet or the numbers 1–50 as quickly as possible, while the other participants monitor how intelligible the letters or numbers are articulated and measure the time required. This exercise is repeated to demonstrate the effect of practice. The level of difficulty can be increased by saying the letters or numbers in reverse. Every round is followed by a feedback session. First the active participants are allowed to speak, then the observers, and finally the therapists. Another way to illustrate the effect of practice is by using the IPT card-sorting exercise (Roder et al. 1988, 2002, 2008a, 2010): each of the 230 cards has a design with four criteria: shape (round, triangular, or rectangular), color (blue, yellow, or red), number, and either no additional criterion or the name of a day of the week. None of the cards is identical to another. The enclosed CD-ROM includes examples of IPT cards (CD Materials 1). The task is to sort the cards as quickly as possible according to a certain criterion, e.g., all cards with a blue design (Fig. 2.3). When the time is stopped, other members of the group check to see whether mistakes have arisen during the sorting process. This exercise’s level of difficulty can be varied by the number of cards or criteria to be sorted. In cases of low group cohesion or less capable participants, the exercise can be introduced briefly at the beginning before determining the target person. The participants are then asked how difficult the exercise is on a scale between 1 and 6, where 6 is the highest level of difficulty. Participants who assign it a low number are preferable for the exercise. As in all the following exercises, this exercise also concludes with a discussion of the strategy’s everyday relevance.

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Fig. 2.3
IPT card-sorting exercise (Integrated Psychological Therapy, IPT, 1st Module; Roder et al. 1988, 2008a, 2010; with kind permission of Beltz Verlag)


Preventing Distraction

In this context, this means directing one’s attention to the task at hand (attention control) and repeatedly bringing the goal to mind. Various strategies are practiced in the group. These include self-verbalization (“My task during this activity is…”; “I want to concentrate on this task now”), noting the goal or content of the activity, and conscious physical tension and relaxation (making fists or tightening the arm muscles, followed by repeated deep breathing and relaxation of the muscles).


Having a Short Break

Here we are primarily concerned with the conscious organization of a break within the working process and the subdivision of the task into intermediate steps and subgoals. Participants can make autosuggestions like “I may now take time out, relax, and stop thinking about the task” or “I want to relax now” in the process of performing the above exercises. For example, number series or IPT sorting cards can be used: “After I have counted or sorted 20 units, I will allow myself a short break, breathe deeply, and shake my arms before I proceed counting”. The focus is on the overall process of counting. Properly placed breaks (between two rounds of computer exercises, for example) help sustain a consistently high speed of processing and ultimately lead more quickly to the final goal. The following section, “Coping strategies for maintaining attention/vigilance” contains a more detailed overview of the function of breaks in personally relevant domains such as work, recreation, and while reading.


Self-Motivation

Following the principle of self-reinforcement, rewards for completed tasks are already planned beforehand: one may occupy oneself with something pleasant after the activity, treat oneself to something, or simply rest and do nothing. The aspect of self-determination – that we “may” do something, not “must” – is crucial. It can also help promote motivation if an activity is understood as a competition with oneself (“I want to be better than last time”). Light-hearted competition with others, as practiced in the following exercise, can also be motivating. The interaction-promoting card-sorting exercise “Speed” (CD Materials 2a–l) consists of 96 cards each with different faces, colors, and numbers of faces. The faces express schematically depicted emotions, which can also be used as a preparation for the social-cognitive part of the module (“Which emotions are shown?”). In addition, there is one card with the game rules to be shown to the group (Fig. 2.4). If the group is very large, it can be split in half and the exercise carried out simultaneously by both therapists in two smaller groups. In this case, the cards are printed out twice. Each participant receives one stack of concealed cards. One randomly selected card from the whole group is placed face-up in the middle. The aim is to place one’s own cards on the play deck in the middle as quickly as possible according to certain criteria (either the same color, same face, or same number of faces as the card on the play deck; see game rules). Whichever card currently lies on top of the play deck is the deciding factor (so that the game criterion can change constantly during the exercise). To prevent sensory overload, every player initially reveals only two cards. Only when these are played does the player reveal two more cards from his or her pile. The biggest difficulty of this usually highly activating exercise is the interaction of the players. All participants reveal their cards simultaneously; whoever is faster and places a card first determines which playing card is in the middle. The first to place all of his or her cards wins. This exercise also involves risks: it can be too challenging for less capable and socially more reserved participants. Such participants are therefore aided by the therapists (prompting, playing along in teams of two, etc.).

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Fig. 2.4
Card-sorting exercise: “Speed”


Reducing Anxiety

This strategy should be discussed last. The strategies above may seem indirectly to indicate excessive respect towards anxiety-inducing activities. Amending this, we can now encourage participants to break down a complex, seemingly difficult activity and always to begin with the easiest level of difficulty. In INT, this approach is followed particularly in the computer exercises. The error rate is reduced by this approach, providing more experiences of success and thus reducing anxiety. It should also be noted that paranoid-delusional distortions are not the focus of this intervention. Yet standardized cognitive restructuring is still possible: what causes the anxiety, which automatic assessments follow from this, and which alternative assessments are possible, each of which result in different consequences in thinking, feeling, and behavior? If this cannot be appropriately handled in the group because of excessive distrust, it can be discussed in additional one-on-one talks or be delegated to the therapist responsible for individual treatment.


Increasing Alertness by Motivation and Interest in the Activity to Be Completed

The relationship between alertness and speed has already been discussed in detail. The target area of motivation and interest is introduced in the following intervention area. Therapists should therefore point out that a solution-oriented attitude often increases one’s interest in the activity. The basis for this is the participants’ insight into their own deficits and resources and related problems in the cognitive target area. Repeated emphasis of individual resources can be a particularly motivating factor in this process.


Sufficient Rest

A balanced daily routine, based on a weekly structure and regular sleeping habits, can be a positive condition for speed in reasoning.

If necessary, CD Information Sheet 3 can be supplemented with additional strategies. Finally, the coping strategies are individualized. Each participant assesses which strategies he or she would like to try out and which he or she does not feel confident about or considers unlikely to succeed. The aim of this intervention is to create an individual coping repertoire for each participant. These strategies are discussed again and again in the course of the treatment and are repeatedly applied, since speed is also related to other mental functions. As a result, there will continue to be a need to apply these coping strategies.

Coping Strategies for Maintaining Attention/Vigilance

The overarching theme is the maintenance of attentional performance with little sensory stimulation. In contrast, the treatment focus of Module D is coping with stress caused by overstimulation. In the following section, individually applied strategies for maintaining attention – both successful and not so successful – are elicited and summarized on the flip chart. This is done with reference to everyday situations already recorded on the flip chart in the introductory section. Again, this procedure is resource-oriented.


Examples of Key Questions





  • In the situation described, what did I try to do to maintain my concentration?


  • For what reasons and in which situations could I concentrate especially well? Can you tell us the trick you used to do it?

Area-Specific Coping Strategies

The strategies can be subdivided into these basic rehabilitation domains: vocational (“Sometimes my work is boring. Then my thoughts drift and I need a break. After that my concentration is better again”), recreational (“I’m very motivated during longer activities that are meaningful to me, like sorting my extensive CD collection” or “Even when reading an interesting book, I could only concentrate for three pages at most, so I don’t read anymore”), and residential (“When cleaning my apartment, I get tired quickly. Then I lie down and continue cleaning the next day”). The therapists first listen to and record participant contributions neutrally. These contributions are supplemented with the aid of the aforementioned CD Information Sheet 2 (“How do I become faster and more concentrated?”). The coping strategies are now discussed in the group, individualized, and a concrete connection to everyday life is promoted.


Examples of Key Questions





  • We have summarized all the strategies we have mentioned for improving concentration and assigned some to the vocational domain, others to the recreational or residential domains. Which of these strategies do you think are promising for your own everyday life? Can you tell us why?

In the subsequent discussion, the therapists consciously encourage the use of arguments instead of assertions and assumptions.

Coping During Recreation

Incorporating the sphere of recreation supports a more discerning identification of resources and factors that influence concentration. These resources and factors can differ from those of the work sphere. Participants often mention concentration problems while reading a longer text or a book as an example from their free time. Using this problem point, the following will illustrate how to introduce new strategies for coping with concentration deficits and how to encourage practicing those strategies.

Concentration Problems While Reading

This intervention is optional and should only be introduced in the case of reading difficulties. First, the reading habits and needs of the participants are elaborated with a focus on resources.


Examples of Key Questions





  • Do I like to read?


  • What do I like to read?


  • When and where do I like to read best?


  • How much do I read in one sitting?


  • What function does reading have for me? Or: Why don’t I read?

Reading interests and functions can vary considerably. Individual experiences should be discussed (e.g., “I like to read detective novels”, “I have to read textbooks for my education”, or “I read to fall asleep”), including reasons for not reading (e.g., “I’ve never read a book. That’s not for me”, or “I don’t read because I can’t concentrate. My thoughts wander, and, at the end of a page, I can’t remember what I just read”). Participants who claim to have no difficulties reading can act as a model and resource for the others. The group searches for possible reading strategies and both supplements and discusses these using CD Information Sheet 3 (“How do I have more speed and concentration?”). As a rule, group contributions can be assigned to three categories:



  • Prevent distraction: self-verbalizations about attention control, reading out loud, taking notes on content, choosing an interesting text, etc.


  • Set subgoals and reduce self-expectations: plan to read one chapter or one section, take a break, etc.


  • Memorize the content: active processing of content (highlight or underline central statements of the text, take notes and write summaries, summarize the content in one’s own words, repeat key passages etc.)

The group then practices the strategies it has found using short texts from periodicals or available books (implicit learning). The goal of this intervention is to improve reading ability and to reduce associated fears of failure.

Sleep Quality and Lifestyle

In the following step, ideas already discussed in the introductory section regarding quality of sleep and lifestyle are further elaborated. Using CD Information Sheet 4 (“Quality of sleep and lifestyle”), the group focuses on sleep hygiene and nutrition as potentially helpful coping strategies and risk factors for the power of concentration. The group reads the text section by section and discusses each point separately. The information sheet serves as an orientation aid. The initial goal of this intervention is to get the participants to look at their own life and sleeping habits critically and objectively. The next step is to promote appreciation of why an irregular daily routine and excessive consumption of stimulants are problematic. Finally, therapists encourage behavioral changes to reduce these risk factors. Participants can make concrete changes in their everyday lives in small steps in the form of independent exercises (see below: Independent Exercise). It is the responsibility of the therapists to prevent patients from having excessively high or stressful expectations of change (e.g., “I won’t smoke any more starting tomorrow!”). These should be substituted with realistic goals (e.g., “Starting tomorrow, I’ll try not to smoke before going to bed.”). If individual goals concerning the topic areas discussed have already been introduced at this point (e.g., abstinence from or reduction of cigarette/alcohol consumption), these goals are noted and supported by the therapists. However, the focus here is on self-perception and willingness to change. The therapist may need to point out that they will concentrate on the concrete realization of individual goals in the “Problem Solving” section of Module C.

Coping Strategies During Work

A lot of rehabilitation effort is centered on the vocational domain, so work should be treated as a separate topic. Building upon the coping strategies already collected by the participants, various types of breaks and distraction strategies for increasing vigilance are introduced on CD Information Sheet 5 (“How can I concentrate better at work?”). The same group exercises are carried out, slightly modified, as in the previous intervention unit. However, they differ with respect to their aim: the focus is not on speed, but concentration (i.e., the number of errors). Again, implicit learning is stressed. This is achieved by involving active experiences and interactive practice. The following exercises are possible:


Reciting a Number Series or the Alphabet

A participant is asked to recite the numbers 1 to 200 or the alphabet as correctly as possible, while the other participants monitor articulation and possible mistakes. Time is not measured. Instead, breaks, subgoals, self-verbalizations, and other previously mentioned strategies are deliberately applied. The level of difficulty can be increased by saying the letters or numbers in reverse. The round is immediately followed by a feedback session. First the active participants are allowed to speak, then the observers, and finally the therapists.


Card-Sorting Exercise

This is a modification of the IPT card-sorting exercise (Roder et al. 1988, 2008a, 2010). Each participant receives 10–20 cards. Each card is characterized by four criteria: shape (round, triangular, or rectangular), color (blue, yellow, or red), number, and either no additional criterion or the name of a day of the week. Each participant now sorts his or her card pile according to a given criterion (“Please sort out all cards with a red shape”). Individualized strategies to improve concentration and reduce errors can be practiced again (e.g., self-verbalizations like “What is the task at hand? According to which criteria do I have to sort the cards?”). Each participant then monitors whether his or her neighbor has sorted the cards correctly. The level of difficulty of this exercise can be increased gradually by adding additional sorting criteria and more cards. However, the participants should have as successful an experience as possible so that the challenge boosts motivation, not stress.


Distraction Strategies

The two exercises which have just been described are also used for trying out the distraction strategies contained on CD Information Sheet 5. In contrast to the speed exercises promoting attention activation, conscious and deliberate distraction now serves as a strategy for increasing attention when confronted with a monotonous activity with little sensory stimulation.

The experiences of the participants are compiled and their difficulties are analyzed. Therapists encourage the use of existing resources. The discussion should also address participants’ particular work situations or employment programs.


Examples of Key Questions





  • Did I use to take breaks consciously during work?


  • How often and how long did I require breaks to be so I could recoup and concentrate better?


  • Which distraction strategies for improving concentration would I like to try out during work?


  • What difficulties do I expect?

Card-Sorting Exercise for Mood and Concentration

At the end of the compensation section of this intervention unit, direct reference is made to the social-cognitive components of Module A (Sect. 2.3.1.2) by linking concentration and mood. This also reintroduces the topics of alertness and speed/attention (CD Worksheet 3), cognitive performance and mood (CD Information Sheet 2), and related participant experiences. The group now performs the card-sorting exercise “Mood and Concentration”. A total of 29 cards are found on the enclosed CD-ROM (CD Materials 3a and 3b). On the 27 smaller cards are concepts concerning emotional states. On the two large cards are printed the two polar opposites “Alert and Concentrated” and “Tired and Distracted”. These latter two cards are either attached to the flip chart or are each assigned to one of the two therapists. In the latter case, one therapist is considered alert, the other tired. The cards indicating emotional states are distributed among the participants. The participants now take turns assigning the cards to one of the alertness poles. The currently active participant should also justify his or her assignment with an argument based on everyday experiences. Cards for which no consensus is found in the ensuing group discussion and cannot be assigned unambiguously to one of the alertness poles are placed between the two large cards. The point of the exercise is not group consensus but to encourage the formation of understandable arguments based on patients’ own experiences (Fig. 2.5).

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Fig. 2.5
Card-sorting exercise: mood and concentration

To make more use of group dynamics, the exercise can alternatively be carried out by splitting the group into two halves. One half of the group gets the “Alert and Concentrated” card, the other the “Tired and Distracted” card. To assist the participants in their assessment of the cards, the therapists begin by updating the connection between the two poles of alertness and the internal activation level (excitement, arousal) with the help of CD Worksheet 2 and CD Information Sheet 3. The two groups then determine which activation level corresponds to their pole of alertness. The cards are sorted and distributed randomly. The task of both groups is to discuss which cards do not belong to their activation level and to exchange them with the other group. If the entire group is in agreement, the emotions are read aloud. The group then discusses whether the assignment seems realistic. The aim of this exercise is that the participants assign equivalent internal activation levels to different emotions. In this phase of INT, patient self-reference remains limited to motivational feeling states that tend to accompany understimulation, such as boredom, loss of motivation, listlessness, disinterest, apathy, dejection, lack of energy. In order to promote self-perception of such moods and willingness to change, it is important to emphasize positive moods. The participants should learn that increased internal excitation (arousal) and concentration need not only be associated with negative emotions, but is also linked to positive feeling states like hope, interest, joy, challenge, motivation etc.

If the group already has a high level of cohesion and contains motivated, resourceful participants, the following variation is possible: the emotional states written on the cards can initially be represented nonverbally by one participant or two participants simultaneously. The other group members cannot see the term being depicted. Then the group determines the level of activation being expressed and tries to assign the feeling that has been shown to tiredness or alertness. A distinction is made in the process between the levels of description, perception, and interpretation.


Examples of Key Questions





  • Which facial expressions , gestures , and behavior patterns are being shown?


  • When I see such behavior patterns, which expressions of emotion do I generally perceive?


  • When I or others feel such an emotion, do I tend to feel excited (high activation) or not?


  • Is this expression of emotion (and the associated level of activation) related more to tiredness or to alertness?

Summing up, this exercise pursues two goals:

1.

Sensitizing the participants to the distinction between subjectively experienced emotions and objective, visible observations of associated behavior and linking these emotions to concentration, and

 

2.

Preparing participants for the social-cognitive content of Module A (Sect. 2.3.1.2), emotion perception.

 


2.3.1.1.3 Restitution

Repeated Practice in the Area of Speed of Information Processing

In this target area, the restitution section comprises above all the repetition of computer-based exercises, which have already been worked on briefly in the introductory sessions. The card-sorting exercises (CD Materials 1, 2a–l) described above can also be repeated to create a more relaxed atmosphere. The restitution section serves to rehearse the coping strategies developed in the compensation section to the point of habituation. When preparing an exercise, each participant should fill out CD Worksheet 4 (“My helpful strategies for …”) individually.

Computer-Based Exercises

The method always follows the principles of “errorless learning ”: participants begin with the exercise level that is simplest for them in order to keep the amount of errors low and maximize their experience of success. Only when the participant has mastered this basic level does he or she proceed to the next level. At least 80 % of the tasks within an exercise should be solved correctly to be successful. In the following speed exercises, it is sometimes impossible to measure performance. In such cases, performance should be assessed by a therapist. Because the tasks are done individually, both the pace and the number of processed tasks vary among the participants. After some have finished all the available tasks, others have not come any further than the first two levels of difficulty. For this reason, therapists should positively reinforce slower participants constantly. If necessary, they should be given temporary individual assistance in working out the tasks. Before the participants begin working at their computers, the primary therapist demonstrates the exercise at his or her computer while a digital projector displays the image on a screen. The trial run contained in every CogPack exercise lends itself to this. Therapists should select exercises that are relevant on the problems under focus. Both the severity of the participants’ cognitive impairments and their resources should determine the difficulty level of the exercises and how many should be undertaken. The following CogPack exercises have proven effective:


VISUMOTOR

It is recommended that therapists start with this CogPack exercise, as it is especially suitable for introducing the group to the program. The first two sub-exercises are relatively easy to master. This helps to reduce anxiety and gives the participants a feeling of success. The easiest exercise is exercise a (Follow the Road). Following this, exercises b (Steer the Raft, easy) and c (Steer the Raft, hard) should be done. Because of their higher level of difficulty, exercises d and e (Follow a Target slow/fast) are optional and recommended only for especially capable participants.


UFOs

This classic reaction speed exercise is highly stimulating because of the moving stimuli and game-like approach. The following tasks are recommended: a (slow large UFOs), b (small fast UFOs), and c (hypers). The level of difficulty increases from a to c. Task d (ultras) is not appropriate since performing this task correctly can be very difficult depending on the display quality. In e (permanently adaptive UFOs), the program adjusts the difficulty level to the previous performance of the participant.


FALLINGSTARS

This exercise has a structure similar to the UFO exercise above. The level of difficulty increases gradually from a (easy) to b (intermediate) to c (hard). The “hard” exercise requires some practice to master. In d (adaptive), the program adjusts the difficulty level to the previous performance of the participant.


BALL

As an alternative to UFO, the equally activating BALL exercises can be utilized. The level of difficulty increases from task a to task f, and exercises with or without sound can be selected.


STOP

Here, the user must click on a clock at a given time. There are three levels of difficulty. An analog clock (a-c) or a digital clock (d-f) can be selected.


REACTION

Five reaction exercises are recommended (a-e). In these, the reaction time for correct clicking is measured in addition to the number of errors. This task helps clarify the connection between speed and number of errors.

Usually, not all of the exercises listed above are carried out. After a maximum of 30 min, the group returns to the group room. The group then discusses their experiences with the exercises in a feedback session. In this session, therapists direct the group’s attention to the coping strategies that were involved. Difficulties and successful experiences that arose in the course of repeated practice are also addressed.


Examples of Key Questions





  • What strategies did I employ? Which were helpful and which not? Could I apply the strategies immediately or did I need repeated practice?


  • How did I experience the exercises? Did I improve with time or not? What is the reason for this?


  • Did I profit sufficiently from repeated practice or do I need more practice?

The therapists have actively accompanied the individual exercises and have already given feedback (as positive as possible) on performance. They now structure the discussion in such a way that the participants assess their own performance as adequately as possible. For this purpose, therapists can remind the group of the self-assessments they made about speed of information processing, using CD Worksheet 1 as a reference.


Examples of Key Questions





  • Did my speed improve during the last few sessions?


  • Do I assess my speed exactly the same now as I did when we began this topic?

Each participant makes a note of any changes on CD Worksheet 1 and corrects previous self-assessments if necessary.

Repeated Practice in the Area of Maintaining Attention/Vigilance

The restitution section on vigilance is divided between the repetition of CogPack exercises in the computer room and the aforementioned card-sorting exercises in the group therapy room. The aim is to practice to the point of habituation strategies offered by participants and those on CD Information Sheets 2–5 and CD Worksheet 3 for improving vigilance.

Card-Sorting Exercises

The card-sorting exercises described above (CD Materials 1, 3a–b) are now repeated. The following is a possible variation of the IPT card-sorting exercise (CD Materials 1) (described in Roder et al. 2010): every participant and both therapists receive 6–8 IPT cards each (CD Materials 1) which they spread face up on the table. The co-therapist or one of the participants now has the task of selecting one of the displayed cards. With a group size of eight participants and two therapists, 60 or 80 cards are used. The co-therapist or selected participant notes the card’s features on a sheet of paper in such a way that the other players cannot see it. The task of the rest of the group is to find out what the target card is by asking specific questions about its features. The participant who selected the cards may only answer with “yes” or “no”. Most groups soon think of turning over cards that have been ruled out to reduce the card selection. The exercise’s difficulty level can be increased if the group has to avoid “no” answers or they must first determine which person is sitting in front of the target card.

Computer-Based Exercises

The CogPack program contains various vigilance exercises . The following have proved effective in INT:


PIECE-WORK

Various sorting tasks simulate the kind of sensory understimulation that is characteristic of work on an assembly line. The amount of understimulation can be varied by changing the speed of the conveyor belt. This option can help promote self-perception in the following way: 1. each participant selects the speed they are most comfortable with, and 2. the speed that causes the most discomfort. The participant then practices under both conditions. Exercises (a-d) (high/low fences and large/small blocks) differ only with respect to the stimuli presented, not in terms of the level of difficulty. Exercise e (tiles) contains model blocks that are difficult to distinguish. Accordingly, this exercise is only used towards the end of the intervention.


SEQUENCE

This exercise is similar in structure to the Continuous Performance Test (MATRICS Assessment, Inc. 2006). Feedback is given only after the exercise is completed. A total of 19 SEQUENCE exercises of about 3 min duration are available. Exercise a “numbers” is recommended to start with, since it requires the lowest skill level. Besides this, these exercises have also proved effective: b and c (numbers), d (alphabet), and e-h with sequences of days of the week, months, seasons, and dates. In addition, exercise i (traffic lights) contain figural stimuli.


SCAN

These exercises differ from the two mentioned above. Here, the duration of the exercise depends on the working pace of the participants. The time needed for completion is measured. Errors are penalized with penalty seconds. The host of stimuli that must be processed tests the participants’ power of vigilance. Tasks a-h differ with respect to the target stimuli.

In working out these exercises, participants habituate the coping strategies that were individualized in the compensation section. Self-perception is also promoted. The direct feedback given by CogPack after each exercise sequence is an initial didactic means to this end: was there an increase or a decrease in performance from the first to the second half of the exercise sequence?

After a computer exercise session, generally 30 min long, participants engage in self-perception by reflecting on individual experiences in the group room.


Examples of Key Questions





  • Did I find the exercise easy or difficult?


  • Was the exercise monotonous and boring?


  • Did I become fatigued and increasingly less concentrated during the exercise?

Therapists then recall the factors influencing concentration discussed in the compensation section of this module.


Examples of Key Questions





  • What made the exercises boring?


  • When were they interesting?


  • Why was I (not) interested, motivated, enthusiastic?


  • How was my mood during the exercises?

Finally, experiences with practiced coping strategies are discussed.


Examples of Key Questions





  • Could I concentrate on the task until the end?


  • What helped me do this? What did I try out?


  • Were the strategies we discussed helpful? Did they give me additional stress or perhaps motivate me?

Group discussions of the exercises are also always focused on resources. Participants’ strengths are stressed more than their deficits. Especially the PIECE-WORK exercises, with a duration of 15 min, is borderline over-demanding for some participants. It is important for such participants to have the option of not working through the exercise to the end. Instead, the shorter SCAN or SEQUENCE exercises can be done. The difficulties of some participants may be attributable to impairments of selective attention in conjunction with the experience of stress. If so, Module D should be consulted. Finally, each participant should amends his or her current self-assessment of concentration on CD Worksheet 2.


2.3.1.1.4 In Vivo Exercises and Independent Exercises

One important goal the in this first intervention unit of Module A has been boosting participants’ motivation to participate actively and to promote group cohesion. For this reason, carrying out in vivo and independent exercises at this stage of the INT process is considered optional. Participants should consider which of the strategies and experiences discussed in the group they can also use in their own everyday lives. To aid this process, each member of the group fills out CD Worksheet 5 (independent exercise). Therapists describe the topic of the independent exercise and introduce the concrete situation to be expected. They also suggest the strategy to be employed. Feared or expected difficulties are also anticipated. After experiencing the target situation concretely, the participants can note any difficulties that arose. If independent exercises are assigned, they should be discussed in the following session. Difficulties and are addressed as well as successes. If group cohesion is already high, the group should also motivate participants who initially refused to do independent exercises at the next opportunity. However, the intensity and frequency of independent exercises should always be adapted to group composition and participant motivation and performance.

As supplements or alternatives to independent exercises, in vivo exercises are provided. In these, the participant tries to apply new coping strategies for improving speed or attention/vigilance in a real, on site situation. However, this intervention depends on the composition of the group, on local conditions, and not the least on the time resources of the therapists and participants. In vivo exercises demand considerable time in preparation, execution, and subsequent discussion. For example, if there are facilities for occupational therapy in the immediate vicinity, the group can accompany the participant concerned into his or her protected workplace. There the participant can apply coping strategies on site and observing participants can learn by example. In vivo exercises are also possible in the recreational and residential spheres. The group can go on a short excursion, for instance. Before any of these joint activities, the patients involved should fill out CD Worksheet 4 (“My helpful strategies for…”). This helps the participant become more focused on the approaching task. Each in vivo exercise concludes with a debriefing session.


2.3.1.2 Social-Cognitive Intervention Area: Emotion Perception



Module A: Social-Cognitive Intervention Area: Emotion Perception



1.

Introduction



  • Definition: emotion perception


  • Self-perception in the target area


  • Filter model


  • Resource-oriented individual profile in the target area


  • Connection to self and everyday life: case vignette


  • Definition and functions of basic emotions

 

2.

Compensation



  • Learning coping strategies for emotion-decoding in 3 stages: facial perception, facial expressions and gestures, emotion sequences


  • Personal expression of emotion in group exercises


  • Emotional concept formation

 

3.

Restitution



  • Habituation of learned coping strategies in repeated group exercises

 

4.

In vivo exercises and independent exercises



  • Transfer of individualized coping strategies to concrete, everyday situations

 


Tips





  • Infrastructure: group therapy room, flip chart, projector


  • Therapy materials: CD Information Sheets 6–8, CD Worksheets 4–5, CD Vignette 4, Ekman pictures (CD Materials 4a–b), CD e-Materials 1–3; card-sorting exercise: emotional concepts (CD Materials 5a–h)


  • Didactics: highly structured group discussion


2.3.1.2.1 Introductory Sessions

Definition of the Target Area

The social-cognitive function of emotion perception has already been introduced in the neurocognitive intervention section of Module A. This intervention concerned the effect of mood on neurocognitive functioning. The present topic is recognizing the feelings and emotional states of other persons. First the concept of emotion perception should be defined.


Introduction Example

Our thoughts, actions, and bodily sensations are related to our feelings. For example, when we laugh, cry, or swear, we express our feelings in a way that is easy for others to recognize. It’s difficult not to express feelings. Every feeling or emotion we experience is characterized by certain modes of expression such as facial expressions, gestures, and behavior. These can be identified by others.

Therapists also point out the value of the skill of correctly perceiving the emotions of others.


Introduction Example

Being able to assess the emotions expressed in a conversation or in public provides a sense of security and helps in orientation. A person’s emotional expression can often be recognized even when that person says nothing or the other does not hear what is being said (nonverbal behavior). A gesture or facial expression is often worth a thousand words. From emotions, we recognize what attitude a person has towards another: Does the person have a positive or negative attitude? Does the person bear a grudge or is he/she friendly? On the other hand, a false interpretation of emotions often leads to uncertainty, fear, or to groundless distrust.

Optical Illusions (Optional)

As an option, optical illusions or tilted images can be used to introduce perception processes in a relaxed atmosphere. Numerous books and Internet sites contain an extensive amount of illustrations, which can be used by therapists. Figure 2.6 is one example of such an illustration.

A322679_1_En_2_Fig6_HTML.gif


Fig. 2.6
“Love or football, that is the question!”

Filter Model

One overriding didactic goal throughout the INT process is to make connections between the various intervention units as they follow in succession. A newly introduced intervention area thus always refers to directly preceding units. This promotes intrinsic motivation. Participants can understand why it is important to spend time (just now) on this intervention area.

Here, we review previously discussed factors influencing speed and attentional performance such as one’s current mood and emotional state. This is done in the light of a participant’s own experience and those of his or her intervention partners. For this purpose, the filter model of perception is introduced. This is available both for electronic presentation (CD e-Materials 1) and as an information sheet (CD Information Sheet 6) since it will be used again and again in subsequent intervention units (Fig. 2.7).

A322679_1_En_2_Fig7_HTML.gif


Fig. 2.7
Filter model : perception and memory (Müller and Roder 2012)

The filter model is used to illustrate basal perception processes. Perception with the five senses is discussed, and then the connection between perception and memory (an intervention of Module B) is established. Finally, therapists talk about various filters that affect information selection (selective perception is an intervention area of Module D). If filters shaped by attitude and personality are mentioned in the process, the participant is referred to the social-cognitive section of Module C. Using participants’ everyday examples, therapists relate the topic back to that of attention and interest as well as the level of alertness. The everyday examples of the group help to individualize the significance of emotions for perception and memory and to exemplify the filter modalities. Yet the primary topic is the effect of personally experienced emotions on perception. It is recommended that this subject matter be illustrated with simple examples:


Filtering Perception

A participant is asked whether she has already seen the person sitting next to her and has spoken to that person. This participant answers in the affirmative. The person is asked to maintain eye contact with the therapist who is speaking and not to look at the neighbor. The next question is whether the participant can describe in detail the shoes her neighbor is wearing.


Emotional Influences on Perception

A participant is asked whether he likes pizza. In case he says yes, the therapist asks what his favorite pizza is. The therapist then asks whether the participant can imagine the following: he is walking home this evening with a growling stomach. As he passes by a pizzeria, he can smell the wonderful aroma of pizza baking in real wood-fired oven. He yields to the aroma, goes in, and orders his favorite pizza. If the participant can imagine this, the therapist then asks about the emotions he might experience in such a situation. The scenario continues: unfortunately, one of the pizza ingredients was no longer fresh, and he winds up having to spend most of the night on the toilet. Finally, he walks past the pizzeria 1 week later (after the group session), again smelling the aroma of pizza from the wood-fired oven. The final question is then: “Did the smell of the pizza trigger the same emotions as it did last week?”

Promoting Self-Perception in the Cognitive Target Area

The group first focuses on recognizing the emotional expressions of others in social interaction. Within the structure of INT, this serves as the prerequisite for the social-cognitive functions, discussed later in Module B, of ToM and social perception. These functions build upon proficiency in adequate affect decoding. The therapists could introduce the subject in the following manner:


Introduction Example

We have dealt with the significance of emotions for perception and concentration. In social situations, when we meet other people, emotions are also being expressed constantly – emotions which we can perceive and recognize. Recognizing the emotions of others makes it possible for us to orient ourselves very quickly regarding how the other person is doing and how that person feels about us. The emotional involvement of our conversation partners and our own emotional involvement help us to recall these situations and experiences.

By linking affective activation with the power of memory, we have anticipated the intervention area of Module B (verbal and visual memory). The point here is to bring into focus participants’ self-perception of their ability to perceive emotion.

Participants are each asked how they assess their own ability to recognize emotions expressed by other people.


Examples of Key Questions





  • Do you consider it easy or difficult to recognize emotions expressed by others and to interpret them correctly?


  • In which concrete situations and under what conditions is it easier to do this?


  • What are the pros and cons of being immediately able to identify emotions?


  • When another person expresses an emotion, does this lead to uncertainties?

In addition, each participant fills out CD Worksheet 6 (“How well can I recognize the feelings of others?”), which is discussed according to the method described above.

Case Vignette

Participants take turns reading CD Vignette 5 paragraph by paragraph. In this short story, the protagonist Peter has a date with Manuela, a woman he likes. This story indirectly introduces the target area and demonstrates INT’s didactic questioning technique.


Discussion of Content

First the group summarizes and discusses the story section by section to promote understanding of its content. Also, therapists activate the participants by asking how they assess the chances for another encounter with Manuela (open-ended story).


Promoting Argumentation

Therapists encourage the formulation of arguments based on facts (e.g., Peter has good chances because Manuela came early to the meeting place and said goodbye with a warm handshake). Assertions and assumptions are scrutinized with the help of existing facts (cognitive conversation techniques; Socratic dialog).


Definition of the Target Area

The emotion expressed by Manuela in the story is discussed as a potential argumentation aid (“How do I recognize in Manuela’s face whether she is expressing pleasure, annoyance, or disgust?”)


Self-Reference

The participants are asked about their own experiences and how they deal with perceiving emotions. Positive and negative experiences are compared and possible influential factors are analyzed (“Are there situations and condition under which I succeed better in assessing emotions than in others? What does this depend on?”).


Reference to Everyday Life

The concern here is to sensitize patients to the relevance of the target area to coping with everyday life. Concretely experienced situations from individual everyday experience are described in detail.

Again, the flip chart is used to compile contributions to the discussion. Therapists should take care that the discussion is not limited to facial expressions and gestures, which are often mentioned first; the entire palette of human modes of expression emotions should be taken into consideration. If concrete emotions are mentioned, these can also be shown and expressed by the therapists and patients. However, expressing emotional states via facial expression and gestures or by modifying speech volume can be a potential stress factor for some participants. If there is a danger of this, therapists should structure the discussion to avoid this. The co-therapist or a participant with suitable resources can be used as a model. Participants with greater deficits (those with pronounced negative symptoms with increased flattening of emotions, for example) should always be supported in a playful group atmosphere and should be positively reinforced when they present something.

Definition of Basic Emotions

The aim of this intervention is to differentiate the concept of emotion, which has hitherto been treated non-specifically, and finally to categorize it. Together, the group defines basic, culturally independent emotions.


Examples of Key Questions





  • What basic emotions are expressed and experienced more or less the same in all cultures?


  • What effect do these emotions have on me?


  • Do I perceive them as pleasant or not?


  • How do I usually deal with them?

All emotions discussed in the group are collected and compiled on the flip chart. As a rule, a large number of emotion concepts can be complied in this way, far surpassing the amount of basic emotions defined in the literature. It is thus up to the therapists to lead the subsequent discussion with focused questioning such that these concepts are assigned to categories (e.g., the concept “fun” can be assigned to the general term “pleasure”, “disgruntled” to the general concept “anger”, “amazement” to “surprise”, or “depressed” to “grief”). These categories correspond to the basic emotions. The conceptualization of emotions described here will again be the subject of a card-sorting exercise in the following compensation section. The following basic emotions are target areas in the associated INT module “Emotion Recognition”:



  • pleasure


  • anger/rage


  • anxiety/fear


  • disgust


  • grief


  • surprise

The therapists also confirm other emotions such as shame or love, but they are not handled in the following compensation exercises (stage 1). In the first phase of this intervention unit, the stress level of the participants should be kept as low as possible. Feelings of shame and, for many participants, of love are often associated with unpleasant, stressful experiences. States of emotion are discussed, but stresses linked to them will be the subject of interventions in Module D (emotion regulation). The same is true of participants’ subjective experience of negative emotions like sadness or highly activating feelings like fear, rage, and anger. It should also be taken into account that even emotions that are positive per se like happiness can be perceived in a stressful way by the patients (“I can’t be happy anymore”, “I have a bad conscience when I’m happy”). Also, the basic emotion of surprise can have both positive and negative components (“It’s a pleasant surprise when someone invites me to a coffee” vs. “I don’t like to be surprised with an invitation to a drink. Then I don’t know what the other person wants from me in return”).

Function of Emotions

Some participants may comment that emotions are pointless because they often involve stress or pressure and are themselves perceived as such. Thus, it is necessary to focus also on the function of emotions. The ultimate purpose is to promote the recognition of emotions and, later in Module D, the regulation of emotions. Here are some possible guidelines:



  • Every emotion always has a certain function: When we experience a feeling ourselves or perceive the emotions of others, we obtain important information this way. Emotions are carriers of useful information.


  • Pleasure: Pleasure gives us a feeling of happiness. People like to communicate pleasure, and this can be contagious.


  • Anger: When we aren’t satisfied with ourselves, feel provoked by our environment, we signal this by showing anger. Everyone then immediately recognizes that something doesn’t suit us, and at the moment it’s best not to tangle with us. Anger and rage are also valves for releasing pressure.


  • Fear: This feeling warns us about danger and reminds us to be careful. Something that might happen may or may not be predictable (e.g., “A deer relies on its fear so that it will be careful and avoid becoming the prey of predators or hunters.”)


  • Disgust: Like fear, disgust can also warn us of danger. Disgust warns us not to come too close to certain things or not to eat what might be bad for us. Disgust is directed towards particular, concrete objects. It is caused by smell, taste, contact, or appearance.


  • Grief: With this we express the loss of a person close to us, not only when someone dies, but also when someone leaves us. Grief usually lasts a long time and helps us to process our longing for the lost person and our pain. We can also react with grief when we have not reached a goal. This feeling is shorter in duration, however.


  • Surprise: This feeling is a direct reaction to something unexpected that does not correspond to our experience. This can be experienced positively or negatively. If we are surprised, we are initially in shock before we attempt in our astonishment to classify the situation and react to it. With surprise, we signal that we did not expect what has happened and that our reaction to it will be spontaneous.

The discussion now centers on the relevance of these emotions to the everyday lives of the participants. Everyday experiences of each basic emotion are compiled in the group. The group also discusses how high their level of activation (internal excitation) was in these situations along with their degree of alertness and the emotion’s effects on concentration. Deciding what is “right” or “wrong” is not the focus. Instead, the aim is to promote the self-perception of emotions experienced in everyday life.


2.3.1.2.2 Compensation

In the compensation section, the group now works out techniques for recognizing emotions by means of facial expressions. In addition to facial expressions, gestures are also addressed as possible ways to express emotions. Finally, the group’s attention will be turned to sequences of emotion often experienced and observed in everyday life. Emotion decoding is split into three stages:

1.

affect decoding using facial perception,

 

2.

affect decoding using facial expressions and gestures, and

 

3.

emotional sequences.

 

A variety of pictorially represented stimuli exists for this purpose. This material is available in electronic form for presentation with a projector (CD e-Materials) or, for stage 1, should be acquired on the Internet. The goal of the compensation section is that each participant becomes acquainted with compensation strategies. Participants then practice applying the new affect-decoding techniques in the group context. Compensation then concludes with a card-sorting exercise on emotional concept formation, in which further emotions and other ways to express basic emotions are clarified.

Affect Decoding Stage 1: Facial Perception

Stage 1 focuses on the perception of the face when recognizing emotions. For illustration, individual images of facial expressions on the accompanying CD-ROM can be utilized (CD Materials 4a–b; pictures with emotions; stage 1).


Examples of Key Questions





  • From what facial features can we recognize a feeling being expressed?


  • How do the basic emotions we discussed differ with respect to these features? For example, how does fear differ from pleasure or grief?

The contributions are collected and supplemented with the tips on CD Information Sheet 7 (“How do I recognize the feelings of others?”). The group discusses various features of facial expressions for each of the six basic emotions: shape and position of the eyes, eyebrows, eyelids, nose, and mouth; lines in the corners of the mouth, on the nose, between the eyebrows, and on the forehead. The emotionally neutral face is also introduced as a reference point for differentiating expressions of emotion (CD Information Sheet 7). Each participant should be able to recognize and distinguish the basic emotions with the help of various features of facial expression.

Affect decoding techniques that have been learned are now practiced for the first time in the group. The pictures contained on the enclosed CD-ROM are especially suitable for this. Each picture shows a face expressing a basic emotion (CD Materials 4a–b; affect decoding stage 1; facial expressions ). These frequently used pictures by Ekman and Friesen (1976) have been standardized. Only those pictures are included that were assigned to one of the basic emotions in a standardization population with at least 70 % agreement. There is a total of 82 pictures (Fig. 2.8). These are subdivided into pictures with faces expressing either fear, anger, disgust, pleasure, grief, or surprise. Emotionally neutral faces are also depicted as control stimuli.

A322679_1_En_2_Fig8_HTML.gif


Fig. 2.8
Affect decoding stage 1: facial perception (Pictures of Facial Affect PFA; Ekman 1993; with kind permission of Paul Ekman Group; www.​paulekman.​com)

The purpose of this compensation section is for participants to apply emotion recognition techniques for the first time and to promote self-perception of skills in this cognitive functional area. In the restitution section following this, newly learned techniques are habituated via repeated practice. For this reason, initially only 1–2 pictures are used for each basic emotion. The pictures are presented with the projector. The group should identify the basic emotion being displayed using objectively identifiable features of facial expressions. Again, the goal is to compile objective facts of feeling perception and to separate speculations and hypotheses. Finally, the pictures of basic emotions are compared with each other. Features associated with different emotions are defined. For example, some participants often have difficulties distinguishing between fear and surprise or between anger and disgust.

Optionally, the participants can show the different basic emotions using their own facial expressions. Yet it is not recommended to request a participant directly to show a basic emotion. First, the connection should be made to participants’ everyday lives.


Examples of Key Questions





  • Is it easy for me to express my feelings in front of other people?


  • Do I generally feel well understood?


  • Do others react adequately to the feelings I express? For example, do they notice when I’m very happy about something?

Individual practice in emotional expression is supported (or provoked) by an external stimulus. A short, fictitious situation described by the primary therapist or a situation experienced by a participant can function as the stimulus. This didactic approach to promoting perception of one’s own affective states and those of others is very activating in the group context. However, it requires a high level of structuring by the therapists. Participants with pronounced negative symptoms often exhibit considerable deficits in this (affect flattening). They should be positively reinforced and protected from excessively negative assessments and interpretations by other participants (“The intensity of the expression of emotion varies from person to person and depends on the situation”). Then again, other participants show considerable deficits in affect decoding, leading to misinterpretations. In this case, therapists introduce the same emotion recognition techniques based on facial features that were used when processing the standardized pictures (CD Information Sheet 7: “How do I recognize the feelings of others?”).

Affect Decoding Stage 2: Facial Expressions and Gestures

Building upon the recognition of emotions using facial features, the task is now to identify facial expressions and gestures on a higher performance level. This primary intention of this intervention unit is to raise awareness of observable nonverbal behavior for emotion recognition. In a group discussion, therapists introduce gestures as further ways to express emotion (CD Information Sheet 8 “A gesture often says more than 1000 words”). The examples of gestures contained on CD Worksheet 8 and their meanings are discussed in the group and participant self-perception is promoted by asking about their own experiences. The information about gestures on CD Worksheet 8 is supplemented by participant comments. In addition, other emotional states are added to the basic emotions, shame and interest for example. This is followed by an exercise, the goal of which is recognizing and interpreting feelings using gestures and facial expressions.

For this, the nine photographs contained on the CD-ROM are used (CD e-Materials 2a–i). These black-and-white photographs show the gestures and facial expressions of a young woman for various emotional states (Fig. 2.9). In addition to the basic emotions, the emotional states of shame, interest, and physical pain are also depicted. An emotionally neutral image completes the series.

A322679_1_En_2_Fig9_HTML.jpg


Fig. 2.9
Affect decoding stage 2: facial expressions and gestures (Hodel 1998; with kind permission of B. Hodel)

This series of pictures was evaluated using 100 healthy test persons (Hodel 1998): 28 men and 72 women between the ages of 15 and 51. The photographs were assessed using a multiple-choice method with the aforementioned categories as possible options with the exception of the category “neutral”. Women tended to recognize the depicted target emotions somewhat better than men (exception: pleasure). Yet the difference was insignificant. Table 2.2 summarizes the results of correctly assessed emotions by the entire test population. The photograph with the emotionally neutral expression (CD e-Materials 2i) was clinically tested but not taken into account for analysis.


Table 2.2
Evaluation of the picture series “Affect decoding stage 2”: facial expressions and gestures (n = 100) (Hodel 1998)












































Image number

Target emotion

Correct assessments (%)

e-2a

Pleasure

98

e-2b

Fear

76

e-2c

Anger/rage

77

e-2d

Disgust

75

e-2e

Grief

90

e-2f

Interest

96

e-2g

Shame

73

e-2h

Physical pain

68

The photos of emotions expressed by gestures are handled using the same procedure as the pictures of facial expressions. The participants are asked to identify the depicted emotions by means of facial expressions and gestures. Argumentation based on facts (features visible on the image) is encouraged; spontaneous assumptions and assertions are called into question. Therapists also point out the harmony of gestures and facial expressions when identifying the target emotion so as to create an overall view of nonverbal, emotional expression. Often, it is only after combining gestures and facial expressions into a unified image that some participants can recognize the target emotion.

Again, the gesture and facial expression accompanying an emotion can optionally be acted out in a role play and then discussed. This can help reconnect with the everyday life of the patients. This process, along with the risks involved, was described above (Affect Decoding Stage 1: Facial Perception).

Affect Decoding Stage 3: Emotional Sequences

As a more complex stage of affect decoding, image sequences with changing emotional expressions are now analyzed instead of single pictures. This way, sequences of emotions can be addressed in the therapy. Such sequences are experienced often in everyday life and are more difficult to decode adequately than isolated facial expressions or gestures.


Examples of Key Questions





  • In everyday life, we are sometimes confronted with situations where the emotional states of our conversation partner changes in quick succession. For example, a person receives a gift. He or she first expresses surprise with their facial expression and gestures, followed by pleasure. After seeing the contents of the present, he or she might show annoyance. Have you observed such situations?


  • Have you yourself ever been surprised at first, then glad, but ultimately annoyed?


  • Recalling that situation, which of these emotions had the most impact on you and your conversation partner and has remained most in your memory?

The goal is again to establish a connection to the personal, everyday lives of the participants. CD Vignette 4 (“Rendezvous at a cafe”), which has already been discussed, can be used as an example of a possible sequence of emotions. It is important to point out to the group that this is not about stable states of emotion, such as long-lasting grief. The idea is rather that emotional states can change relatively quickly in connection with one’s thoughts, behavior, and body perception, even within a single situation. Individual experiences contributed by the participants are again summarized on the flip chart.

For this intervention unit, further didactic material is also available on the accompanying CD-ROM (CD e-Materials 3a–b: Emotion Perception Stage 3: Emotional Sequences). On each slide are 4 to 5 pictures of the same person with varying emotional expressions or no emotional expression. Each of these images is designated with a letter. The task is to put the pictures in the right order and to make an argument of why the suggested emotion sequence is the correct one.


Examples of Key Questions





  • Imagine the pictures you are looking at are snapshots from a film. We don’t know exactly what has taken place between the pictures in the film. Despite this, the pictures give us information with which we can get an idea how the film’s plot might unfold. Specifically, each picture expresses a certain emotion. Which?


  • Do you have a suggestion of which arrangement of pictures can explain the emotion sequence?


  • Do alternative emotion sequences exist?

Thus, each picture is first analyzed in isolation with respect to the affect expressed. Then possible sequences are considered. The aim is to put the pictures into a correct order – correct in the sense of the transition between two different emotions (CD e-Materials 3a: e.g., reflective, sad to happy, radiant). Every alternative ordering volunteered by the participants is first recorded neutrally. Only afterwards is the rationale given. Several plausible sequences are possible. As a rule, any sequence can also be reversed (CD e-Materials 3a: e.g., from happy, radiant to reflective, sad). When giving their arguments, the participants generally are already employing ToM skills (e.g., “The woman on the pictures had a good day and was very happy. But when she thought about something or something happened, she became reflective. Happiness disappeared from her face. Her expression was neutral at first, then becoming increasingly reflective and finally melancholy.”). This exercise thus also serves as an introduction to the concept of ToM and social perception, the social-cognitive target areas of Module B.

Emotional Concept Formation

As a final intervention in this target area, various ranges of emotion are introduced. Now the focus is on discriminating ranges of feeling with all their variations and nuances, which also manifest themselves in different concepts.

The card-sorting exercise “Terms of Emotion” is utilized for this purpose (CD Materials 5a–h). Affective concepts are listed on a total of 97 small cards. Eight general terms, each designating a different range of feelings, are on the green cards. The ranges of feeling included here are the basic emotions defined above: fear, pleasure, disgust, grief, surprise, and anger. These are supplemented with love and self-confidence. The rest of the 89 cards are white and each contains a subordinate term for one of the green cards (Fig. 2.10).

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Fig. 2.10
Card-sorting exercise: “Terms of Emotion”

The 97 cards are distributed randomly. Each participant lays the cards they have received face-up on the table.


Examples of Key Questions





  • Each of you has now received different cards. Do you notice anything? Do all the cards have the same color?


  • We have now placed all 8 of the green cards in the middle. On the green cards are all the basic emotions we have defined as well as a couple of others. Can the white cards be assigned to these basic emotions? If yes, can you explain this assignment?

The participants now take turns assigning one of their white cards with subordinate terms to one of the green cards and justifies this (e.g., “When I’m happy, I also feel pleasure” or “When I’m brave, I also have self-confidence”). If one subordinate term is assigned to two different general terms and both lines of reasoning are plausible, the white card in question is put between the associated green cards. Once again, it is the participant’s ability to make an argument which is at stake here, not a dichotomously right or wrong assessment. This card-sorting exercise is used again in Module C (Reasoning and Problem Solving).


2.3.1.2.3 Restitution

In the restitution section, newly learned strategies for affect decoding are now practiced repeatedly to the point of habituation. In terms of scope, stage 1 (affect decoding of facial expressions) takes up most of the restitution. However, for didactic reasons and to give variety to the sessions, therapists should continuously intersperse exercises from the 2nd stage (facial expressions and gestures) and 3rd stage (emotion sequences). Finally, each participant again assesses his or her current performance level with respect to emotion perception on CD Worksheet 6 (“How well can I recognize the feelings of others?”). Improvements in self-assessment compared to that made in the introductory section are discussed along with changes for the worse or stagnation. The latter are often an indication that the interventions are too demanding for those persons or that their motivation is not yet sufficient. Both situations should be addressed in one-on-one talks if required.


2.3.1.2.4 In Vivo Exercises and Independent Exercises

In social-cognitive target areas such as emotion perception, in vivo exercises often involve the risk of being too activating and too stressful for the participants. This is because they are based on social interaction. Thus, it is sometimes preferable to organize exercises on emotion perception so that participants experience them as passive observers. For example, the group can watch films together. The participants would then have the task of concentrating specifically on emotions expressed via facial expressions and gestures as well as identifying contradictions to the discussed text (“Nonverbal behavior never lies”). Such a joint activity requires thorough debriefing.

As an independent exercise, the participants can transfer such observer functions to their everyday lives. Prior to this, CD Worksheet 5 (independent exercise) should be filled out to prepare for the task. The subsequent discussion follows the formula described in the previous intervention unit.


2.3.2 INT Module B


The intervention focus in the neurocognitive target area of Module B is memory. More precisely, it deals with learning and memory as target functions, since learning and memorization techniques are practiced as coping strategies in the compensation section as well. As regards content, the topic is verbal and visual memory. In addition, prospective memory is introduced to supplement verbal learning and memory, particularly in the compensation section. Prospective memory is especially crucial for patients in order to lead independent lives. Module B falls back on content already addressed in Module A: the filter model describing the relationship between perception and memory and factors influencing cognitive performance, which act as filters.

The social-cognitive section of Module B contains interventions for the two target areas of social perception and theory of mind (ToM). Therapists refer back to the affect decoding techniques worked on in Module A for didactic purposes. Here, these techniques are put in the overarching context of social perception and adopting interpersonal perspectives (ToM). These interventions originated primarily from the subprogram “Social Perception” of Integrated Psychological Therapy (IPT) (Roder et al. 2008a, 2010).


2.3.2.1 Neurocognitive Intervention Area: Verbal and Visual Learning and Memory



Module B: Neurocognitive Intervention Area: Verbal and Visual Learning and Memory



1.

Introduction



  • Definition of the target area: verbal and visual memory


  • Types and contents of memory: prospective memory


  • Self-perception in the target area (cognitive profile)


  • Reference to everyday life and self: case vignette

 

2.

Compensation



  • Learning and individualizing coping strategies:



    • written memory aids


    • using the senses


    • memory tricks for enumerations


    • storing textual information


    • memory tricks for counting


    • following a conversation


    • memory tricks for keeping appointments


    • visual memory tricks

 

3.

Restitution



  • Habituation of learned coping strategies:



    • Repetition of group exercises


    • Computer Exercises

 

4.

In vivo exercises and independent exercises



  • Transfer of individualized coping strategies to concrete, everyday situations

 


Tips





  • Infrastructure: group therapy and computer rooms, flip chart, digital projector


  • Therapy materials: CD Information Sheets 6, 9–15, CD Worksheets 4–5, 7–10, CD Vignettes 5–8, CD Materials 6–8, CD e-Materials 4–5


  • CogPack: MEMORY, NEWorNOT, ARCHIVE, ONtheROAD, EYEWITNESS, ROUTE, ALPHA-BRAVO, CAR-SYMBOLS, INHABITANTS, READING


  • Didactics: structured group discussion, group exercises, computer exercises (individual and group)


2.3.2.1.1 Introductory Sessions

Definition of the Target Area: Verbal and Visual Memory

As an introduction, the neurocognitive function “memory” is described. Therapists first point out the relevance of memory not only for everyday coping and planning but also for forming identity through stored experiences:


Introduction Example

In everyday life, we need memory in order to make a mental note of names, telephone numbers, birthdays, faces, or objects so that they can be recalled later. Yet memory encompasses much more than this. In a nutshell, our memory determines everything we know. All the experiences that have formed our character are stored in our memory. Memory represents the identity of a human being. Do you remember the filter model that you received as a handout? Whatever is stored in our memory also determines how we perceive things and how we react to them.

CD Information Sheet 6 (Module A: filter model of perception) is briefly recapitulated in order to explain to the participants the connection between the function of memory and other cognitive functional areas. The factors influencing memory discussed in Module A (mood, emotions, alertness, medications, etc.) can be illustrated using simple examples.


Example Exercise

The participants are asked about an experience from the last 7 or 14 days that spontaneously comes to mind. As a rule, either particularly positive experiences (e.g., being invited to a good meal, the “right” team won in a football match) or particularly negative experiences (e.g., a fight, symptoms of illness) are mentioned. Based on these experiences, the group discusses the increase in memory performance in formative, emotion-triggering experiences.

Other influential factors such as alertness and daily rhythm or mood might also be briefly discussed. Yet depending on the group constellation, the negative effect of the consumption of substances like alcohol or cannabis on memory may be more relevant. The following questions might be used to expand on factors that affect memory:


Examples of Key Questions





  • Is it equally easy for you to remember things in the morning, during the day, and in the evening?


  • When you’re in a bad mood, can you remember things just as well as when you’re in a good mood?


  • Do you think it’s possible for someone who has consumed a lot of alcohol not to remember what happened anymore?

The objective is to increase awareness that these factors affect not only attention, but also the powers of perception and memory.

As a continuation of the filter model, the memory model (CD e-Materials 4) is introduced to the group (Fig. 2.11). In addition to illustrating the interdependence between perception and memory, therapists should subdivide the memory process into encoding/learning, storage, and retrieval. This structuring serves as a basis for resource promotion and memory performance in the following compensation section. The focus of Module B is on learning and storing memory content. The ability to recall is first discussed in detail in Module D during the intervention on working memory.

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Fig. 2.11
Explanatory model: memory

Types of Memory

Because of the different types of memory and the varying use of the term “memory” in everyday language, it is difficult to find a basic, generally comprehensible usage for the following interventions. Usually, every participant claims to know what the power of memory entails. But are the differently applied types and features of memory all identical? The point is not to communicate specialized psychological knowledge about memory, but to define a common language. This standardizes participant knowledge and prepares it for later interventions. With the help of CD Information Sheet 9 (memory), the previously introduced model of memory is made available to participants as a source of information. The handout also indicates the distinction between short-term and long-term memory. The information sheet is introduced briefly by the primary therapist, read jointly section by section, and finally summarized by the group. The following is a possible introduction to the information sheet:


Introduction Example

When we remember what we have experienced, seen, heard, felt, or learned, it matters whether it took place 5 s (short-term memory ) or 5 min (long-term memory ) ago. (Module D distinguishes these types of memory from working memory as a control center and ultra short-term memory). Short-term memory has less capacity and the retention period is hardly longer than 20 s. If we retain something in our memory for a longer time, this is achieved by long-term memory. Yet in both short and long-term memory, the object is to encode or learn information, to store it, and then later to retrieve it for use in everyday life.

The co-therapist reads a simple word list of 20 words. This exercise aims to activate the participants and to illustrate the limited storage capacity of short-term memory. Examples can be found on the enclosed CD-ROM (CD Materials 6a–b). However, memorization techniques will first be discussed later in the next compensation section. In order to prevent social anxieties or fears of failure, this exercise is carried out in a group setting and together with at least two other participants. The goal is to recall memorized terms following a short distraction (e.g., solving a simple calculation).

Memory Content

To prepare for the memorization techniques (memory tricks) given in the compensation section and to complete the memory model, different types of memory content are summarized. For this, CD Information Sheet 10 (“Types of memory content”) is available. For didactic purposes, a distinction is drawn between the following three categories of memory content (Table 2.3).


Table 2.3
Categories of memory content



















1.

Verbal learning and memory

Words

Numbers (number series)

Word lists

2.

Visual learning and memory

Faces, places, objects (visual and spatial-local memory)

3.

Prospective memory

Remembering future events that were agreed upon (appointments) or are fixed (e.g., birthdays)

Therapists then point out that memory content is stored as a network. A word, number, face, or place is compared with previously stored content and thereby acquires meaning.


Example

For example, if you hear the familiar word “tiger”, you immediately imagine something associated with it. You know that this is a really big and dangerous cat that lives in Asia. You can also make an internal image of this large cat since you have certainly already seen a tiger in a book, on TV, or in the zoo.

Promoting Self-Reference and Reference to Everyday Life in the Cognitive Target Area

Therapists relate the topic to patients’ individual lives using the same didactic means as in Module A. The participants are first asked how they asses their own ability to remember the content listed on CD Information Sheet 10 (“Types of memory content”). If possible, they should describe related concrete experiences from their everyday lives. Participants generally underestimate their own powers of memory. Participant accounts regarding concrete situations are recorded on the flip chart. In addition, each participant fills out CD Worksheet 7 (“How good is my memory?”).

Case Vignettes

The group now reads the case vignettes together paragraph by paragraph (CD Vignettes 5–8). CD Vignette 5 (“A day to forget”) summarizes various memory contents (forgetting names, telephone numbers, a shopping list). CD Vignettes 6 (“A telephone call for Daniel”) and 7 (“Yesterday at the Italian restaurant”) describe typical everyday situations in which short-term memory and retentivity are needed. Finally, CD Vignette 8 (“The forgotten doctor’s appointment ”) focuses on prospective memory. However, it is best not to read all four vignettes in one sitting. Most participants would not be able to absorb all the content at once. The first two vignettes can usually be read sequentially, however. CD Vignettes 7 and 8 can then be used to introduce the topic of coping strategies in the following compensation section.

After reading the CD Vignettes (7–8), a group discussion is held with the following goals:



  • Self-reference: Participants make a connection to their own, personally experienced memory resources and deficits. There may be disagreement with plot of the vignette (“That’s completely the opposite in my case”).


  • Reference to everyday life: Participants put the story in the context of their own experience and describe paradigmatic situations from their everyday lives.

The following questions are possible guidelines for therapists for structuring self-reflection on these two points:


Examples of Key Questions





  • What can I remember well in everyday life? Names, conversations, and telephone numbers or persons, faces, and places?


  • When and where do I have memory problems in everyday life?


  • Where do I generally need such skills?


  • Are there situations in everyday life in which my memory is especially good?


  • Do the moods and emotions we discussed in past sessions play a role in my power of memory?


  • What or whom do I remember especially well? What or whom especially poorly?

Other key questions on prospective memory:



  • Where in my everyday life do I require the ability to remember appointed times like doctor appointments or birthdays?


  • Is it easy for me to keep appointments?


  • What aids do I use to remember appointments?

The group now explores individual, subjective experiences of strengths and weaknesses associated with memory in everyday life. In the process, therapists should establish a link to the social-cognitive sections of this module. Perception and ensuing memory processes (encoding, storage, retrieval) should be put into concrete social contexts. As always in INT methodology, participant self-reflection is not reduced to disclosing personal deficits. Instead, resources are stressed. Therapists should also strive to make a participant’s individual resources useful for the whole group:


Examples of Key Questions





  • You have no difficulties with memory in this area. Can you tell us how you do that? Is there a memory trick you can reveal to us?


  • You said that you are very pleased with your power to remember this type of content. Is that always the case? What does it depend on?


2.3.2.1.2 Compensation

The goal of the introductory section was to find a common language for concepts of memory and to support the participants in relating the types and content of memory to their everyday lives. This introduction simultaneously prepared the group for finding coping strategies, which is the aim of this section.

Coping Strategies for Improving Memory

At the start of the session, the participants are asked which coping strategies, memorization techniques or memory tricks they know and already use in their everyday lives. Generally, participants repeat memory tricks already mentioned in the introductory sessions. As before, less promising examples are initially acknowledged without reservation. Each strategy mentioned is recorded on the flip chart together with the individually experienced situation in which the strategy was applied. This is followed by a group discussion focusing on the evidence of the strategies that were compiled. To prevent any participant from becoming insulted, statements such as “This strategy is useless” should be avoided. Instead, structured conversation elicits which of the strategies participants can imagine trying out, whether they think they are already capable of doing so, and what advantages they see in it. Several didactic supplements are available for this (CD Information Sheets 11–15b).

Written Memory Aids

As shown in the memory model (Fig. 2.11), the storage process begins with the encoding or learning of perceived information. The group’s first step towards optimizing memory performance is thus to discuss the function of understanding the information that is to be stored (“I must know and understand exactly what I should remember”). CD Information Sheet 11 (“Memory tricks: Inquire, repeat, and write down”) is used as a didactic tool for this purpose. The techniques of requesting and repeating information are explored as ways to complete or check the correctness of that information. Writing down information as an external memory aid is also stressed. In addition, it can be highly beneficial in the everyday life to reduce the amount of information, and only taking note of information that is important for achieving the objective.

To illustrate the advantages of this memory trick, the following role play can be performed (Fig. 2.12). It is not included on the CD-ROM since it should be adapted to regional conditions for the sake of the participants (excursion destination; train or bus connections).

A322679_1_En_2_Fig12_HTML.gif


Fig. 2.12
Memory exercise: inquire, repeat, and write down

Exercise: Inquire, Repeat, and Write Down


Content

The case vignette’s protagonist Peter has decided to go on an excursion tomorrow by train. He has already chosen a destination (from Bern to the Jungfraujoch, home to the highest restaurant of the Alps, and thus also called the “Top of Europe”). He called the train information office to inquire about the exact route and departure times (the highly complicated and long itinerary is taken from the official Swiss timetable). However, the person providing the information is under stress and reads him the information rather quickly.


Objective

In the role play, participants should try out asking for and writing down information.


Procedure



1.

First, one participant is chosen for the role of Peter. The co-therapist assumes the role of the information person. Both receive a written copy of their text.

 

2.

In the first run, Peter calls the information person without prior instruction or receiving a text. In the role of the information person, the co-therapist reads his or her text very quickly and then says goodbye, Peter will probably have stored little of the information.

 

3.

The group discusses what information is important for Peter to reach his destination safely.

 

4.

Starting with the 2nd run, participants practice how to interrupt the information person and how one can ask questions in order to write down the essential information regarding departure/changing times and platforms. Another participant can assume the role of the information person.

 

5.

Each role play is discussed by the group extensively. Feedback is given in this order: the active actor (Peter), the passive actor (information person), the other group members (of whom some may have been assigned observer roles with concrete functions), and finally the therapists.

 

For further practice of limiting and storing pertinent information, the enclosed CD-ROM contains materials with short texts of typical everyday conversations (CD Materials 7a–h):


Procedure

In this exercise, one participant reads the others a text, e.g., a conversation at the family doctor’s (Fig. 2.13). In the meantime, the others take notes. Then, with peer support, participants try to reproduce the most important information. At the end of each text, example questions are listed that aim at the essential content of the conversation.

A322679_1_En_2_Fig13_HTML.gif


Fig. 2.13
Conversation examples

Using the Senses as Memory Aids

Further memory aids can be summarized by the title “using the senses”. This concept is a useful didactic tool for helping the participants learn different memory strategies using a single keyword. Primary focus is placed on sight, hearing, and to a lesser extent on the touch. Yet smell and taste should also be integrated as further sensory modalities. The following is an example exercise that can serve as an introductory illustration of sensory modalities. It should be explained by the primary therapist as follows:


Introductory Exercise

Imagine you are in the waiting room of your family doctor and meet a middle-aged man. He is elegantly dressed, uses an intense-smelling aftershave, and gives you a firm salutatory handshake. During conversation, he offers you a delicious chocolate from a precious confectionery box. He has introduced himself to you as Mr. Barthuber-Stiegelmayer. After meeting him, you’d like to remember him. Of course, you’d also like to remember his name. To imprint this rather difficult name in your mind, you can make use of all five senses:

1.

Hearing: Repeat the name out loud or internally, or perhaps put it to a melody such as we often hear on the radio or in TV commercials.

 

2.

Sight: Write the name down and read it several times. You can also associate the name in a mental image with the elegant clothing or with physical attributes of the person concerned. Or imagine the name written elegantly on a chalkboard.

 

3.

Physical sensation: Associate the name with the firm handshake, which perhaps surprised you and hurt slightly.

 

4.

Smell: Associate the name with the person’s intense aftershave, which you didn’t like because it was too overpowering.

 

Sep 24, 2016 | Posted by in NEUROLOGY | Comments Off on Practical Implementation of INT

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