Table 3 MCT+ therapy units

1. Case History Questionnaire

The patient’s case history including current problems and symptoms, as well as previous treatments, are gathered through a clinical interview. The patient’s level of motivation is evaluated and the importance of the therapeutic relationship is discussed.

With the use of worksheets, the therapist and patient identify the patient’s current problems, including delusions or hallucinations and to what extent the patient is certain of this belief. Interpersonal or coping difficulties resulting from the delusion/hallucination are identified.

2. Introduction to MCT+

Information about MCT+ and the main therapeutic strategies are discussed. A secondary goal is to develop an understanding of the patient’s problem areas and possible therapeutic targets.

An overview of the therapy program is provided and the patient’s goals are determined with help from therapy worksheets. Patients are asked to identify current or past symptoms and how distressed they are (have been) by these symptoms.

3. Case Formulation

An individual vulnerability-stress-model is created utilizing a “fire” metaphor. For patients with limited illness insight who may be overwhelmed by such a discussion or may be unable to accept explanations for their symptoms, this therapy unit can also be completed toward the end of the training.

Using therapy worksheets the “fire” metaphor is personalized. Vulnerability factors (e.g., genetic predisposition) are compared to wood or coals, while factors that contribute to a first psychotic episode (e.g., stress), are likened to a spark, which ignites the flames. Interventions, which help to reduce symptoms (e.g., psychotherapy), are the “fire extinguisher.”

4. Attributional Style

The goal is to help patients understand that complex social situations can rarely be attributed to one cause (i.e., mono-causal attributions), but are rather the outcome of many factors (myself, other people, circumstances). It is important to help patients gain insight to situations in which they themselves tend to make one-sided attributions, and how certain attributions (especially personalization and blame) reinforce delusions.

Using fictional and, if possible, personal real-life examples, patients are encouraged to identify multiple causes of events that may otherwise be attributed to psychosis-related factors (e.g., a strange smell means that I am being poisoned rather than the possibility that there was a chemical spill or I am in an unfamiliar area where smells may be new). A “card trick” exercise is used to illustrate that there are often simple explanations for strange experiences.

5. Decision Making

Jumping to conclusions can lead to suboptimal decisions, sometimes with dramatic consequences. Patients are encouraged to reflect on whether they currently, or in the past, have made decisions too hastily, and if their delusions were caused or strengthened by these “short-circuit” thinking patterns. Patients should learn to consider the pros and cons of making strong assumptions and to always be open to alternative explanations.

Patients are shown, for example, slides of line drawings in which the details of the figure become increasing clear with each slide. The patient is asked to indicate when they are certain that they know what is depicted. Early responses are often incorrect as not enough details are present to reach a clear decision.

6. Changing Beliefs

Being stubborn and inflexible at times is part of human nature and can actually be helpful to ensure a certain amount of stability so that we do not instantly question everything and everyone. However, being overly fixated can lead to problems too, especially if one’s convictions are wrong.

Pictures, which depict a story, are shown to the patient in reverse order (i.e., the last pictures is shown first). The patient is asked to indicate when they are certain that they know the correct beginning of the story. Often reaching a decision with incomplete information leads to an incorrect response.

7. Empathizing

“To err is human”, especially when it comes to assessing the motives of others. It is emphasized that we cannot infer what another person’s emotional state is from facial expressions or nonverbal signals alone. To become more certain about our interpretation, patients are encouraged to consult additional sources (e.g., contextual factors, previous knowledge of the person). Patients learn that social perceptions are often influenced by personal feelings and people often tend to confuse their inner emotional world with the outside world (e.g., when anxious, a patient may think: “Everybody is against me”). "Unwritten social rules” are also discussed with the patient. The relationship to delusions should be carefully clarified.

The patient is shown a series of pictures and is asked to guess how the person is feeling or what they are thinking. It is emphasized that it is often difficult to know how another person is feeling and that additional information should be sought to avoid making incorrect assumptions. The patient is asked to identify situations in which they were uncertain of how others were feeling.

8. Memory and Certainty of Judgment

The potential for memory biases are discussed and normalized. It is always important to consider the possibility that vague memories might be false, and therefore, should be investigated further by asking others or consulting documents as false memories can have potentially serious consequences (e.g., conflict).

Patients are briefly shown complex scenes with many objects and are then asked to identify which objects were present in the scene. It is discussed with the patient that, like all humans, their memory may not always be perfect and details are often added or omitted based on previous experiences or “common sense” (i.e., false memories).

9. Depression and Thinking

This unit focuses on improving self-perceptions and improving or maintaining social relationships with others. Depression is not “unavoidable” or innate, but tends to be promoted and maintained through certain thought distortions, which can be changed. Therapists help patients to become more aware of if and when they tend to have depressive thought distortions and how their personal depressive symptoms or delusions were intensified or perhaps caused by such thoughts. The extent to which psychosis has an effect on self-esteem is also discussed.

With the help of fictional and, if possible, personal real-life examples, patients are asked to identify alternative, more helpful thoughts for various situations when one might use “black and white thinking” or “should” statements (e.g., when receiving negative feedback from a boss).

10. Self-Esteem

Self-esteem is defined in MCT+ as something that one largely subjectively determines and actually has little to do with the opinions of others. The therapist carefully addresses the different influences that psychotic symptoms can have on one’s self-esteem (excitement and a feeling of being important versus anxiety and guilt), while also recognizing that these symptoms can also partially serve a social function. Using the metaphor of an “inner critic” and a “well-meaning companion,” it is carefully suggested that sometimes content from auditory hallucinations can reflect inner conflicts.

The patient is encouraged to identify personal strengths, especially in areas, which are often not noticed or thought of as self-evident. Concrete situations in which these strengths have been demonstrated are identified.

11. Dealing with the Diagnosis and Relapse Prevention

Based on information gained throughout the 6 weeks, patients are given information about their disorder and how to cope with the diagnosis in everyday life, especially regarding communication of information about the disorder in social situations. Patients are made aware of possible ways the disorder may progress. It can also be beneficial to involve relatives in this final session because they often recognize prodromal symptoms earlier on than patients.

An emergency plan is created in cooperation with the patient, which clarifies whom the patient should seek in case of a crisis (e.g., an institution that the patient trusts, a therapist). Stress reducing and coping strategies are discussed. It is also discussed with the patient in which situations revealing their diagnosis may be helpful or unhelpful.