Social Cognition & Interaction Training for Psychosis

1. SCIT March 2, 2017 Social Cognition & Interaction Training for psychosis David L. Roberts, Ph.D. University of Texas Health Science Center at San Antonio

2. How are social cognition and neurocognition related? Hierarchical model: Social cognition is built upon neurocognition SCIT does not use this model. Social Cognition Neurocognition Brenner et al., 1992

3. How are social cognition and neurocognition related? Semi-independent model Neurocognition Social cognition SCIT uses this model.

4. Social cognition vs. Neurocognition • Social cognition = Making guesses about ambiguous information • e.g., others’ thoughts and feelings • Interpretation • Neurocognition = Manipulating objective information • e.g., numbers, images, words Fiske & Taylor, 2008

5. Two causes ofsocial cognitive dysfunction • Deficit = Diminished ability to process social information • EG: Inability to generate mental state representations • Bias = Distorted use of social information processing • EG: Always interpreting ambiguous information in the same way (e.g., hostility bias) • Any person may have either or both

6. People with Deficit: • “Jokes go over my head.” • “I can’t keep up with conversations.” • “I can’t think of anything to say.” • People with Bias: • “I always say the wrong thing and look stupid.” • “Everybody has an agenda.” • “People are out to get me.”

7. Bias vs. DeficitTreatment implications Bias • Develop insight into distortions, provide adaptive heuristics • Cf: Cognitive therapy Deficit • Remediate or compensate for deficit • Cf: Neurocognitive remediation We try to do both in SCIT.

8. SCIT Principles • Make adaptive social thinking feel fluid and fun, not laborious • Fundamental uncertainty of others’ thoughts and feelings rather than getting the right answer • Avoid jumping to conclusions through awareness of own biases and emotions, and accurate communication of confidence.

9. SCIT Key Techniques • Normalization & collaborative discovery rather than didactics or drill-and-repeat • Discussion of videos, photographs, events in lives of clients and therapists • Learn/practice a method of social thinking • Never 100% sure of thoughts/feelings • “Guesses” & uncertainty statements • Spotting & identifying with Mary/Eddie/Bill

10. Group Format • Number of clients: • 4 to 12 • Number of group leaders: • 2 (optimally), but can be conducted with one therapist • Two provides opportunity for modeling of interaction, self-disclosure, “checking it out” with others’, etc.

11. Intervention Format • Group intervention - 20-24 weekly sessions • Flexibility • 2 sessions per week; individual sessions, etc. • Fits easily into most clinics’ programming and resource structure. • 2 group leaders (ideally)

12. SCIT Treatment Phases • Phase 1: Emotions • Sessions 1-7 • Phase 2: Figuring out situations • Sessions 8-15 • Phase 3: Applying skills to real life • Sessions 16-20

13. Session Organization • Check-in (5 minutes) • Review previous session (1-2 minutes) • Review homework (5 minutes) • Set agenda for session (1-2 minutes) • Cover new material (35-40 minutes) • Assign new homework (5 minutes)

14. Involvement of “Practice Partners” • We encourage clients to identify someone (family, friend, staff) to liaise with therapists conducting SCIT. • Assists the client in: • Rehearsing activities from sessions • Generalizing skills • Completing homework/practice

15. Phase I:Emotions Domains addressed: - Emotion perception - Emotion self-awareness - Overconfidence

16. Session 5:Guessing People’s Emotions

17. In the next slide:What is the best guess? Look at the person’s face • What emotion clues do you see? • What do you feel like when your face looks like this? • What is the best guess about how the person is feeling? • How sure are you that your guess is right?

19. What is our guess? She is probably feeling ________. Happy Sad Afraid Angry Surprised No Emotion How sure are we? 100% Totally sure. No doubt. 75% Very sure. 50% Kind of sure. 25% Not very sure. 0% Just a guess.

20. What is the best guess? Look at the person on the next slide. • What emotion clues do you see? • What do you feel like when your face looks like this? • What is the best guess about how the person is feeling? • How sure are you that your guess is right?

22. What is our guess? He is probably feeling ________. Happy Sad Afraid Angry Surprised No Emotion How sure are we? 100% Totally sure. No doubt. 75% Very sure. 50% Kind of sure. 25% Not very sure. 0% Just a guess.

23. Session 6: Improving Emotion Guesses “You are about to see 6 photographs of Vince. They were taken quickly, one-after-the-other, just as Vince began to feel an emotion. For each picture guess what emotion he is feeling. Also, say how sure you are in your answer, from 0 (just guessing) to 100 (completely certain).”

24. 1 Happy Sad Afraid Angry Surprised Ashamed

25. 2 Happy Sad Afraid Angry Surprised Ashamed

26. 3 Happy Sad Afraid Angry Surprised Ashamed

27. 4 Happy Sad Afraid Angry Surprised Ashamed

28. 5 Happy Sad Afraid Angry Surprised Ashamed

29. 6 Happy Sad Afraid Angry Surprised Ashamed

30. Session 7:Suspicious Feelings • Primary goal • Provide a healthy way to think about suspicious feelings • They are not bad or crazy • They can have a range of causes • They can be useful or harmful • So we need to think carefully when we experience them • Techniques • Group discussion, clinician self-disclosure • Video vignettes (2, 3, 4) • Summarize on Emotion Poster

31. Other people Past behavior (lying, cheating, stealing) Current behavior (unusual for context, uncharacteristic, aggressive, etc.) Situation Dangerous (dark alley late at night) Unfamiliar (new city, new neighborhood, new group of people) Internal states Stress Anxiety Lack of sleep Symptoms of mental illness (hearing voices, feel like others can read your mind) Feeling self-conscious (appearance, outsider status, made a mistake) Past experiences (just saw a scary movie, was previously mugged in this neighborhood) Discussion: Causes of suspicious feelings

32. Phase II:Figuring out Situations Domains addressed: - Theory of Mind - Social perception - Attributional bias - Overconfidence

33. Phase II Overview Session 8: Jumping to Conclusions How to avoid jumping to conclusions: Sessions 9-10: Think up Other Guesses Sessions 11-13: Separate Facts from Guesses Sessions 14-15: Gather More Evidence

34. 3 Strategies to avoid JTC

35. Avoid Jumping to Conclusions by Thinking up other Guesses • A silly but easy way to remember the 3 styles of jumping to conclusions is these 3 characters: • Blaming Bill blames others • My-fault Mary blames self • Easy Eddie blames bad luck / situation • Avoid JTC by looking at social situations from all three perspectives

36. When they get into a small car accident, how does each character • Look? • Act? • Think? • Feel?

37. Blaming Bill

39. Blaming Bill • Thoughts: Blames someone else, even if it’s his fault. “You stopped too fast!” • Feelings: Angry, suspicious • Actions: Angry facial expression. Glares and points his finger. Says things like, “This is all your fault!” • Lets try acting like Blaming Bill

40. My-fault Mary

42. My-fault Mary • Thoughts: Always blames herself, even when it’s somebody else’s fault. “I should have noticed you running the red light.” • Feelings: Sad, upset with herself • Actions: Sad facial expression. Looks down, shakes head, head in hand. Says things like, “I’m so stupid, I always mess up everything!” • Lets try acting like My-fault Mary

43. Easy Eddie

45. Easy Eddie • Thoughts: Always blames bad luck. Never blames others or himself, even when he should. “It’s too bad the light turned red at just the wrong time.” • Feelings: Tries to feel relaxed and calm • Actions: Shrugs his shoulders, cocks his head, raises his eyebrows, raises his palms. Says things like, “Oh well, I guess it’s just bad luck.” • Lets try acting like Easy Eddie

46. Spotting the characters in pictures

47. Spotting the characters in pictures

48. Phase III:Checking It Out Domains addressed: - Integration of skills - Generalization to day-to- day life

49. Checking-It-Out

50. SCIT in First Episode Psychosis