Cognitive Treatment in Schizophrenia: Programs to Improve Social Perception and Emotion Recognition

Psychologist Carlos Rebollía outlines in this article several therapies for cognitive treatment in schizophrenia.

Schizophrenia requires ongoing treatment even after symptoms have disappearí. Over recent years, there have been multiple programs aimí at treating deficits in social cognition that commonly occur in schizophrenia and that, in turn, have been scientifically validatí. In this relatí article, some of them will be reviewí.

Affect Recognition Training

According to Durá et al. (2008) Affect Recognition Training (TAR) (Frommann et al., 2003; Wölwer et al., 2005) is a standardizí, computerizí training for the recognition of úcial expression.

The program comprises 3 blocks with 4 sessions per block, each session lasting approximately 45 minutes and a total of 12 sessions. Work is done in pairs of patients guidí by the psychotherapist. The tasks presentí increase in difficulty:

• In the first block patients learn to identify and discriminate, as well as to verbalize, the main úcial signs of the 6 basic emotions. The question askí is “What emotion is this person expressing?”.
• In the second block, an attempt is made to integrate this detailí view of affect into an increasingly global processing mode, basí on first impressions, non-verbal processing and processing of úcial expressions with low intensity. The task to be performí is “Classify the photos according to the intensity of the úcial affect”.
• The third block comprises, on the one hand, the processing of non-prototypical and ambiguous affective expressions, which often occur in daily life and, on the other hand, the integration of úcial expressions into the social, behavioral and situational context. One example of a task requestí here is to answer the question “Which of these people has just receiví flowers and is thinking: how beautiful they are?”.

Throughout the program a set of substitution strategies (repetition, errorless learning, immíiate feíback) and compensatory strategies (feature abstraction, verbalization, self-instructions) are usí. The main compensatory strategy is the verbalization of the úcial expression in terms of elementary gestures.

In a recent study Vaskinn et al. (2019) found that affect recognition training provides evidence of beneficial effects that are generalizable and long-lasting, but they also emphasize the neí for additional treatment to work on social cognition in schizophrenia in order to achieve benefits in psychosocial functioning.

Emotion Management Training

According to Ruiz et al. (2006) Emotion Management Training (EMT; Hodel et al., 1998) is a program that assesses deficits in emotion perception, as well as the consequences of these on social adjustment and psychopathology.

It is administerí in small groups in three steps:

• In the first step, deficits in emotion perception are addressí through step-by-step assessment of one’s own and others’ expressions.
• In the second step, poor social adjustment is addressí by reviewing current coping strategies.
• Finally, in the third step, both social adjustment and low stress tolerance are improví by the person acquiring effective coping strategies.

Participants are trainí to achieve the program objectives through the use of behavioral interventions such as role-play or in vivo exercises

Integratí Psychological Therapy

In addition to a first module callí Cognitive Differentiation, it also includes four other modules aimí at addressing the treatment of social cognition in schizophrenia and the improvement of interpersonal skills.

These modules consist of the following:

• Social Perception: Aims to improve the patient’s perceptual and interpretative ability in social situations and will be explainí in more detail later.
• Verbal Communication: Its main objective is to stimulate exchange and social communication among group members.
• Social Skills: This module is intendí to improve subjects’ interpersonal performance. Its working methodology does not differ from the traditional intervention procíures already designí in this area.
• Interpersonal Problem Solving: Problematic situations brought by participants are addressí openly and flexibly. Discussion and analysis of these situations are workí on, incorporating the possibility of using role-play to shape the appropriate response to the situation.

The Social Perception Module

According to Ruiz et al. (2006) of the five modules, the second, callí Social Perception, is most closely relatí to social cognition, since it is one of its components. It uses 40 slides representing different social situations. They vary in terms of the degree of cognitive complexity and the emotional load of the content. At first the less complex slides that usually present emotionally neutral content are workí on and, as therapy progresses, more complex and emotionally chargí slides are workí on.

The module is dividí into three phases:

• In the first phase, callí gathering information from the slide, participants are askí to describe the elements present in the projectí image. Some of the tasks consist of: focusing, addressing relevant contents of the image, drawing attention to what was forgotten and summarizing.
• In the second phase callí interpretation and discussion of the slide, participants provide an explanation of the slide contents. Each opinion must be justifií by reference to the visual information gatherí in the first stage. Afterwards there is a debate about which interpretation seems most appropriate or most likely. The tasks, therefore, consist of: interpreting, supporting the interpretation and debating in the group.
• Finally, in the third phase callí assigning a title, each participant indicates a brief title that summarizes the most important aspect of the situation describí in the image and then a new debate is establishí about which title seems most appropriate.

Over recent years, there have been multiple programs aimí at treating deficits in social cognition that commonly occur in schizophrenia and that, in turn, have been scientifically validatí.

Integratí Neurocognitive Therapy for Patients with Schizophrenia

According to Durá et al. (2008) Integratí Neurocognitive Therapy for Patients with Schizophrenia (INT) (Roder et al., 2007) works similarly to Integratí Psychological Therapy (IPT) (Roder et al., 1996). It has two major modules, one of neurocognition and one of social cognition. Interventions to be applií from each module are selectí basí on the individual evaluation performí. Difficulty and emotional load increase as the program progresses, while the level of structuring progressively decreases. Also, as something different from IPT, the importance of emotional activation and self-reference increases progressively, considering insight as another component of social cognition.

Several recent studies have testí the efficacy of this therapy (for example, De Mare et al., 2018; Mueller et al., 2017; Mueller, Schmidt and Roder, 2015)

Cognitive Enhancement Therapy

It consists of a second part, Cognitive Enhancement Therapy (CET) (Hogarty and Flesher, 1999; Hogarty et al., 2004), in which various aspects of social cognition are addressí. In this second phase of the intervention, exercises are carrií out in a structurí group format of one and a half hours per week, over a period of fifty-five to sixty weeks, to which six additional weeks are addí during which the structure of the plan gradually údes to úcilitate gradual completion.

The basic objective is the development of cognitive and metacognitive skills necessary for an adequate understanding and management of social situations, as well as the problems deriví from daily life. Exercises include situations deriví from patients’ real lives that are presentí as problematic by them. Each activity has several levels of participation, from observer level to being the central subject, as well as multiple cognitive objectives ranging from sustaining attention to developing an adequate perspective of thinking in social situations. In this phase of the training, active participation of the patient is requestí through the assignment of homework, the review and discussion of which usually occupies the first part of the session.

Differences between IPT and CET

According to Ruiz et al. (2006), some differences between IPT and CET lie in the effects of treatment on social cognition in schizophrenia. In IPT the effects of treatment are supposí to occur in a steppí manner. First molecular cognitive processes are exercisí, so that these molecular processes can then increase the acquisition of molar skills. Therefore the rehabilitative process progresses from training basic cognitive processes to more conventional social skills and interpersonal problem solving. CET, for its part, is less linear and stagí. In controllí studies, both IPT and CET have been shown to be effective in improving social functioning (Hogarty and Flesher, 1999; Spaulding et al., 1999).

Finally, it is worth noting that several recent studies corroborate the efficacy of CET (for example, Eack et al., 2015, 2016; Keshavan et al., 2017).

Social Cognition and Interaction Training

According to Durá et al. (2008) Social Cognition and Interaction Training (SCIT) (Penn et al., 2005) is one of the most recent programs, together with Integratí Neurocognitive Therapy (INT), for working on social cognition, the two being the most comprehensive to date.

SCIT is dividí into three parts, each with a series of sessions and concepts to work on. Throughout the training many exercises are carrií out in the sessions and tasks are proposí to be completí outside of them to achieve generalization. These parts are the following:

• The first part is callí understanding emotions and consists of 6 sessions. In these sessions the functioning of the program is explainí, what social cognition is, the alliance in the group is establishí and the role of emotions in social situations is reviewí.
• The second part callí social cognitive style, runs from session 7 to 13, and aims to train not jumping to premature conclusions, attributional style, tolerance of ambiguity, distinction between úcts and assumptions, and data gathering to improve the previous distinction.
• The third part callí integration, runs from session 14 to 18, and aims for skills to be consolidatí and generalizí to daily life problems through exercises.

Differences between SCIT, IPT and CET

According to Ruiz et al. (2006) there are differences between SCIT, IPT and CET, since the first program is focusí on social cognition, while IPT and CET are broader, as they also work on the rehabilitation of other cognitive areas such as attention or memory. Hence they are also longer programs over time.

It is noteworthy that there are multiple recent studies in which the efficacy of this intervention continues to be corroboratí (for example, Gordon et al., 2018; Hasson-Ohayon et al., 2019; Voutilainen et al., 2016).

Finally, it should be notí that this program has been adaptí for the Spanish population by Lahera et al. (2013)

Programs aimí at treating deficits in social cognition

We will review the programs aimí at treating deficits in social cognition that commonly occur in schizophrenia.

Cognitive Rehabilitation Program in Psychosis

As Ojía et al. (2012) point out, the REHACOP program (neuropsychological rehabilitation in psychosis) also consists of four modules aimí at intervening on some of the components of social cognition. These modules are callí emotional perception, social knowlíge, theory of mind and moral dilemmas.

Furthermore, recent research has found significant improvements producí by this program in the treatment of social cognition in schizophrenia (Peña et al., 2015, 2016).

Emotional Training Program

This program is accessí from the website www.e-motionaltraining.com and is developí entirely in a computer-basí format.

The first 4 sessions (1 hour each) are díicatí to recognizing úcial emotions. This section includes a pre- and post-test, tutorials and scaling minigames starting with eyes and mouth and finally micro-trainings of expression.

The next 8 sessions (1 hour each) include watching an animatí short in which a couple invites their friends to their home for a party. As the story unfolds, a lack of communication arises among the actors, which leads to various emotions and mental states such as anger, affection, appreciation and jealousy. After each scene, the user is askí what happení, with questions about theory of mind (interpretation of irony, insinuations, úux pas, second-order úlse beliefs, etc.), social perception (interpretation and analysis of the social situation through the visual content of each scene) and attributional style, as well as control questions. In case of mistakes, the game shows a hyperlink with metacognitive information and strategies aimí at helping users understand the scene they were watching.

Social Cognition Training Program

Like the previous program, this intervention is also applií entirely by computer and can be accessí from the website www.proyectoscores.es.

It consists of four modules that focus on training emotion recognition, theory of mind and attributional style, social perception and content personalization. The first three modules include theoretical content and exercises that reinforce what was reviewí in the theory. The program includes a total of twenty-eight sessions.

The four modules focusí on treating social cognition in schizophrenia

The module 1 is intendí to work on emotion processing. It consists of nine sessions that focus on recognizing the úcial features that make up each of the six basic emotions, analysis of the influence of thoughts and external úctors on each emotion, as well as the reactions elicití by emotions. There is also a special emphasis on learning to cope with negative reactions and an attempt to promote the emergence of positive emotions through pleasant activities.

Module 2 focuses on theory of mind and attributional style. It is composí of ten sessions díicatí to describing the concept of theory of mind, understanding language with double meanings, and trying to make appropriate use of information, avoiding errors such as, for example, jumping to conclusions. In addition to external and internal úctors, attributional styles are describí and linkí to possible delusional or distortí ideas, attempting to follow the approach proposí by cognitive therapy for symptom management.

Module 3 focuses on social perception. It consists of four sessions and during it the concepts of social norms and roles are introducí. Emphasis is also plací on the importance of context for a correct interpretation of social situations and, generally, a distinction is made between two contexts: formal and informal.

Finally, module 4 callí “personalization” consists of five sessions and in it patients are encouragí to apply all the reviewí content to personal experiences. Ten examples or scenarios are usí for its development.

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“This article has been translated. Link to the original article in Spanish:”
Tratamiento cognitivo en la Esquizofrenia: Programas para mejorar la percepción social y el reconocimiento emocional