Manual TRC Grupal Inglés

Group Cognitive Remediation
Therapy for Adolescents

withAnorexia Nervosa
The Flexible Thinking Group
Zoe Maiden, Laura Baker, Dr. Jonathan Espie, Dr. Mima Simic and
Dr. Kate Tchanturia
Version 1: August 2014

Introduction
This manual is a modification of the Cognitive Remediation Therapy Manual for anorexia
nervosa developed by Tchanturia, Davies, Reeder and Wykes (2010). The original manual of
the Cognitive Remediation for Anorexia Nervosa is available to download from the following
website: http://www.national.slam.nhs.uk/wp-content/uploads/2014/04/Cognitive-
remediation-therapy-for-Anorexia-Nervosa-Kate-Tchantura.pdf).
The original protocol has been adapted for working with young people with anorexia nervosa
in a group setting. It has been developed within the day-patient Intensive Treatment
Programme (ITP), part of the Child and Adolescent Eating Disorder Service (CAEDS) at
Maudsley Hospital.
The manual includes a brief overview of how the group has developed over time, session
plans, exercises, feedback from young people, facilitators and supervisor.
Development of this Manual
In the early stages of cognitive remediation therapy (CRT) work with young people, we used
the adult group protocol. It was also originally a ‘closed’ group with 4 weekly sessions. After
several runs and a pilot study (Pretorius et al., 2012), with the use of qualitative feedback
from group participants (both young people and facilitators), we considered the following
issues:
1) The protocol needed age appropriate modifications to be engaging

2) More tasks were needed to help young people translate the skills into everyday life
3) A rolling group programme was required due to service demands
4) 8 session protocol would be more helpful, engaging and practical
In response to this, facilitators adapted some existing tasks in the adult protocol and added
enough novel exercises to run 8 sessions. These exercises were discussed at length between
the authors of this manual to ensure that they were in line with the principles of cognitive
remediation therapy.
Other CRT Developments
CRT for young people continues to progress. For example, we are investigating the cognitive
profiles of young people by completing systematic reviews of the literature (Lang et al
2014a,b) as well as collecting new cognitive profile data. We continue to evaluate our
Flexible Thinking group quantitatively with self-report measures (Cognitive Flexibility Scale
and Motivational Rulers). We also qualitatively assess group member’s feedback. The
method of collection has changed over time from questionnaires to semi-structured exit
interviews at the point of discharge from the programme.
~1~
A 10 session CRT individual protocol for young people with anorexia nervosa is also
available in the public domain. This was created by a Norwegian group www.rasp.no, which
was the first attempt to make CRT age appropriate for young people with eating disorders.
Other extensive unpublished work is being undertaken in Stanford by Dr Kara Fitzpatrick and
Prof James D. Lock (chapter 2014).
~2~
General Session Information and Structure
The group is called “The Flexible Thinking Group” in order to be more accessible to young
people. Sessions are 45 minutes long. The group is designed to be a rolling programme, so
that young people can join at any session and be able to participate.
It is designed to be facilitated by two members of multi-disciplinary staff. Facilitators take it

in turn to lead and participate in the exercises, thus modelling flexible thinking, curiosity and
anti-perfectionism. They are also aiming to be motivational, enthusiastic, interactive and
respondent to the needs of the young people in the group. Facilitators receive regular
supervision from Consultant Clinical Psychologist Dr. Kate Tchanturia, who developed the
adult individual and group manuals.
The group aims to explore different thinking styles, considering the pros and cons for each.
Sessions focus on three main skills:
1. Bigger Picture Thinking

2. Switching
3. Multi-tasking
Sessions 1 – 3 and 5 – 7 focus on one individual skill. Sessions 4 and 8 are summary
sessions:
Session 1:
Bigger Picture
Thinking
Session 8: Session 2:
Summary Switching
Session 7: Session 3:
Multi-tasking Multi-tasking
Session 4:
Session 6:
Motviational
Switching
Summary
Session 5:
Bigger Picture
Thinking
~3~
Session plans are followed, which all have a similar format:
Ice breaker 5 minutes
Review of Homework (if applicable) 5 minutes
Welcome new young people, explanation of why we do ‘Flexible Thinking’ 5 minutes

and introduction to today’s sessions
Exercise 1 followed by reflective discussions 10 minutes
Exercise 2 followed by reflective discussions 10 minutes
Reflective discussion of session/links with everyday life and homework setting 10 minutes
Ice-breakers
Initially, group facilitators observed that often young people’s minds were wondering and not
focussed on the group. Ice-breakers were introduced to address this difficulty, with the aim to
activate the young people and help them to be focussed on the present moment. Additionally,
the ice-breakers set a light-hearted and interactive atmosphere. The ice-breakers are designed
to include at least one of the targeted thinking skills. One or both facilitators participate in the
group activity, depending on the content of the ice-breaker.
Review of Homework
Reviewing the previous session’s homework and young people exchanging ideas is very
important. Weekly homework review motivates young people to complete the task between
sessions and can help to consolidate learning. Sometimes, young people do not complete their
homework. When this happens, facilitators can be curious about what got in the way. For
some homework tasks, it may be possible to think about them during the review and this is
encouraged.
Welcome New Young People and Introduction to Today’s Session
Due to the rolling nature of the programme, it is important to welcome any new young people
at the start of the group and give a brief explanation of why we think the group is important
(see Session plan 1). An introduction to today’s session is also important but it is also
essential to not give away too much information or the reflective discussions will become
more redundant.
Exercises
Tasks are designed to practice one or more of the flexible thinking skills or consolidate
learning. They aim to encourage interaction between group members within a light-hearted,
fun atmosphere. In addition, our creative games can help to increase self-confidence and self-
~4~
esteem, encouraging quieter young people to open up and communicate about things that are
not directly related to anorexia nervosa (AN). Although we make the sessions relevant to
recovery from the illness, the majority of the sessions do not feel like formal “therapy”,
which enables the adolescents who are more reluctant to change to engage in a group.
It is important for facilitators to emphasise that the aim of the exercises is not to “get them
right” or complete them perfectly. There is often more room for discussion if the task goes
wrong allowing more things for young people to learn.
Reflective Discussions of Exercises and Sessions
Facilitators ask questions to generate conversations about the exercise young people just
completed. Task reflections offer the opportunity to explore what they have learned, why
they think we have done the exercise and to relate the skills to real life, including recovering
from AN. The questions asked depend on the exercise/session being reflected on. Facilitators
also need to be responsive to the needs of the group of young people in front of them and so
further questions are asked based on knowledge of the group. Questions also vary relative to
the amount of prompting required by a group. Generally, questions fit into one of four
categories:
1. What did you think of the task?
2. Did you use or develop any strategies to help you complete the task?
3. What does this task tell us about the way our/your brain works?
4. How can we apply these skills to everyday life?
Homework Setting
Homework is a key tool for young people to relate the skills practiced in session to everyday
life. Individual challenges around being more ‘flexible’ in general, can be issued at any
session.
~5~
Brief Session Overview
Session 1: Bigger Picture Thinking
• Ice-breaker: Body-positioning game

• Script for today's session
• Exercise 1 and reflections: Complex figures task
• Exercise 2 and reflections: Blokus and/or Qwirkle
• Session reflections
• Homework setting: Complex figures task at home
Session 2: Switching
• Ice-breaker: Doing the opposite

• Exercise 1 and reflections: Illusions
• Exercise 2 and reflections: Stroop material
• Homework setting: Trying something new
Session 3: Multi-tasking
• Ice-breaker: Multi-coloured ball game

• Exercise 1 and reflections: Drawing invisible circles and real infinity signs
• Exercise 2 and reflections: Memory tablet game
• Exercise 3 and reflections: Word-search and colouring in
• Homework setting: Multi-tasking in real life
Session 4: Summary
• Ice-breaker: Buzz
• Exercise 1 and reflections: Occupations Task
• Homework setting: Dream job worksheet
~6~
• Ice-breaker: Zip Zap Boing

• Exercise 1 and reflections: 'How to' text to an alien
• Exercise 2 and reflections: London Landmarks
• Homework setting: Difficult meal time worksheet
• Ice-breaker: Splat
• Exercise 1 and reflections: Illusion cards
• Exercise 2 and reflections: Hand tapping game
• Exercise 3 and reflections: Switching in Real Life
• Homework setting: Experiment with doing things differently
• Ice-breaker: Slap Clap Click Click

• Exercise 1 and reflections: Play-dough multi-task
• Exercise 2 and reflections: Fruit Ninja multi-task
• Homework setting: Pros and cons worksheet
Session 8: Summary
• Ice-breaker: Multi-coloured ball game

• Exercise 1 and reflections: Bigger Picture Squares Task
• Exercise 2 and reflections: Finer Detail Cars Task
• Exercise 3 and refelctions: Twisted Fairytale
• Skill summaries
• Homework setting: Flexible thinking mottos
~7~
Session 1 – Bigger Picture Thinking
Aim of the Session:
The aim of the session is encourage young people to practice thinking about the bigger
picture, rather than focussing on finer details. Relating the skills to real life is also essential
and should be done at every opportunity. Specifically, conversations about thinking styles
during meal times and thinking styles in regards to recovery can be helpful. It is also a chance
for young people and facilitators to explore the pros and cons of both thinking styles.
First 5 minutes - Icebreaker: Body Positioning Game (Message to the

Moon) (Facilitator 1)
Aim of Icebreaker:
To encourage group cohesion as communication is essential for the task to be achieved. All
young people (and sometimes facilitators depending on numbers) have to be involved, for
example, if we are asking them to spell “ITP”, this isn’t just done with three young people.
Bigger picture thinking is also needed.
Materials Required:
n/a
Task Instructions:
• As a team, young people are asked to form words using their bodies, whilst standing
up
• The words should be readable from a bird’s eye view
• All young people
• Five to six words, increasing in difficulty, should be used. We often ask them to spell
the same words in both lower case and capitalised. Examples of words we have used
previously are:
o itp
o ITP
o BRAIN
o Brain
o FLEXIBLE
o Flexible
o THINKING
o thinking
From 5th-10th minute - Introductory Script and Script for Today’s Session
(Facilitator 2):
~8~
This script is designed to give young people a general idea of what to expect from the
Flexible Thinking group and why we think it is helpful for young people with AN. It can
sometimes be helpful to repeat this script at the start of other sessions if there are new
members of the group.
“This group is to help young people think about their thinking styles. What we know from
our experience in the service is that young people with anorexia can become very rigid in
their thinking. This might mean that they focus on the finer details, especially in regards to
food, get very stuck in routines and find it difficult to make even small changes, for example
in their meal plan, where they sit at meal times, the order they eat their food in. Is this
something you can relate to?”
“We practice three main thinking skills in this group, Bigger Picture Thinking, Switching and
Multi-tasking. The group is like a ‘brain-gym’, similar to the games/apps you can download.
Some of the tasks may seem a bit ‘silly’ and ‘just for fun’ but they are all aiming to train
specific parts of your brain, to help you think more flexibly. It is important to think about
how these skills can then be applied to everyday life, including your eating difficulties. ”
“Today we are going to be looking at something called ‘bigger picture thinking’. This is the
ability to look at the wider perspective instead of getting stuck at looking at the finer details.
We think this is a useful thing to look at because although details can be important, keeping
the bigger picture in mind can keep us moving forward.”
From 10th-20th minute - Exercise 1: Complex Figures Task (Facilitator 1)
Aim of the Task:

The aim of the task is to encourage young people to practice thinking in terms of the bigger
picture, rather than focussing on the finer details of the image. Describing figures to
somebody else who has to draw them is difficult, especially if the tendency is to start with the
details. In the task reflection, the aim is for young people to compare their listening and
verbal skills and consider whether there is room for improvement.
Materials Required:
Per young person: 1 complex figures pack (set A or set B), clipboard, blank sheet of paper,
pen
Task Instructions:
• Split the young people into pairs
• Each person in the pair is given a different set of complex figures (see overleaf)
• Each person takes it in turns to describe one of the complex figures for their partner to
draw. For the first round, the ‘drawer’ is not allowed to ask questions and both the
describer and the drawer are asked to keep their images hidden from each other. No
further information is provided about how to draw the figures.
~9~
• When each person has described and drawn once, the exercise is repeated and the
‘drawer’ is given permission to ask questions.
• Once completed, everyone is asked to show their drawings to the rest of the group and
the original figures are revealed.
Questions for Task Reflections:
• What did you think of the task?

• Was it easier to be the describer or the drawer? Did anyone develop any strategies?
• Did you describe the finer details of the pictures or were you describing the bigger
picture?
• Does the task tell you anything about your thinking style?
From 20th-40th minute - Exercise 2: Blokus or Qwirkle (Facilitators 1 & 2)
Aim of the Task:

Blokus and Qwirkle are board games than can be easily purchased online. As well as
encouraging bigger picture thinking, young people are required to be generally flexible and
respond to the moves of other players.
Materials Required:
Blokus board game (4 players)
Qwirkle board game (between 2-6 players)
Task Instruction:
• Which game is played is dependent on the number of young people in the group.
Blokus must be played by 4 players.
• Usually, with a group of 8 young people, they are split into two groups, each with a
facilitator and a different game. It can be helpful to note which young people play
which game, in case they repeat the session at a later date.
• Blokus: consists of a board with 400 squares on it. Each player is represented by a
different colour and has 21shapes varying in size. Each player has to fit as many of
their pieces on the board as possible, each new piece must touch at least one other
piece of the same colour. This game requires bigger picture thinking from the
beginning. The game ends when all players are blocked from laying down any more
of their pieces.
~ 10 ~
• Qwirkle: often described as a pictorial version of scrabble. Each participant takes it in
turns to place tiles on the board, ensuring that these are either the same shape or
colour to the row of tiles they are adding to. You get extra points for being able to fit
tiles into more than one row, which is one way ‘Bigger Picture Thinking’ can be used
in this game. The overall aim of the game is to create as many ‘Qwirkles’ as possible,
for which the most points are awarded. This requires keeping the bigger picture in
mind. For example, young people must decide if they want to risk putting tiles down,
as their opponent may only need one tile to gain a ‘Qwirkle’. Further instructions on
scoring are provided with the game. If a group of young people are highly
competitive, Qwirkle can be a great option for encouraging them to work together,
rather than play against each other. Multi-tasking is also required in this game as
players are required to hold many rules in mind at once.
• How did everyone find the game? Was it hard or easy?

• Did anyone notice any strategies that worked well/didn’t work?
• What skills do we need to have to do this?
Last 5 minutes - Summary/Reflective Discussion and Homework Setting

(Facilitator 2)
Questions for Session Reflection:

• Do people feel they generally use bigger picture thinking or are you more focussed on
the finer details?
• What are the pros and cons of each skill? Which skill can help us in which situations?
Do we have any examples from our everyday lives?
• What about in relation to your eating difficulties?
Homework
Young people are given a new set of complex figures (set C) and asked to practice them with
someone at home. This is designed to encourage them to share the idea of bigger picture
thinking with those they spend a lot of time with (parents, siblings etc.). It can also be helpful
to use this task as a way of seeing how young people can communicate to their
parents/siblings and vice versa.
~ 11 ~
Geometric Figures – Set A
~ 12 ~
Geometric Figures – Set B
~ 13 ~
Geometric Figures Set C
~ 14 ~
Aim of the Session:
The aim of this session is to practice switching attention between two different forms of
information.
First 5 minutes – Ice breaker: Doing the Opposite (Facilitator 1)
Aim of Icebreaker:
Simple game to engage members of the group promoting a light-hearted atmosphere.
Materials Required:
n/a
Task Instructions:
• Young people are to do the opposite of what the facilitator says
• Some facilitators may find it helpful to have a list of pre-determined instructions
to read out, but this is not essential.
• Examples of instructions to use:
o walk in a circle clockwise
o sit down
o put your hands up
o stand up
o step to the left
o put your right hand out in front of you
o crouch down
From 5th-10th minute - Reflection on Homework (Facilitator 2):

Questions to ask about last weeks homework:
• Did anyone try the geometric shape task with their parents/siblings?
• How did it go? Was it easier with more practice?
• Have you learned anything from or about your parents/siblings?
From 10th-15th minute – Script for Today’s Session (Facilitator 1):

This is an opportunity to welcome any new members to the group. Ask the existing members
of the group to describe the group to the new people. Staff can then ‘fill in the gaps’ with the
welcoming script from session 1.
“Last week we looked and bigger picture and finer detail thinking. We have discussed the
benefits of using both, but how can we use both? We either need to be able to switch our
attention or our thinking style. This is what today’s session will focus on. Can anyone relate
what we did in the ice-breaker to this concept?”
~ 15 ~
From 15th-25th minute – Exercise 1: Illusions (Facilitator 2)
Aim of the Task:
For young people to practice switching how they look at an image and to explore the idea that
there may be more than one way to view an image and also situations in everyday life.
Materials Required:
Per young person: a selection of laminated illusions. We have gathered a collection of
illusions that we can use. Some of these are real life examples, which particularly engage the
young people. We have gained examples from various websites including
brainden.com/optical-illusions.html, www.moillusions.com and www.eyetricks.com. Our
(and the young peoples) favourite ‘frog’ illusion can be found at the following website:
http://www.boredpanda.com/body-art-illusions-johannes-stoetter/
Task Instructions:
• Each young person is given an illusion, face down, so that they cannot see it.
• Instructions are given that after a count of 3, they turn over the card and shout out the
first things that they see.
• A discussion then evolves about the illusion and what everyone can see.
• Young people are encouraged to be able to ‘switch’ from seeing one side of the
illusion to the other
• Repeat for 3 - 4 illusions

• What does this tell us about how our brains?
• When do we have to be able to switch the way we see things in real life?
From 25th-35th minute - Exercise 2 – Stroop (Facilitator 1)

Aim of the Task:
Similarly to the adult protocol, the following tasks aim to train young people to practice
switching their attention between different aspects of stimuli or between different rules,
quickly and accurately. They are designed to help young people to increase mental control
over what they focus their attention on and to increase how easily they can move between
ideas and tasks.
The task often evokes an interesting discussion about how our brains, and anorexia, can ‘play
tricks’ on us. We often talk about how it must feel to be told that what they are thinking about
food/calories/their shape or weight is wrong, not right, or inaccurate. We talk about how easy
it is to get involved in “anorexic conversations” and whether that is helpful or not, or whether
these kind of conversations in the dining room or around meal preparation can actually cause
more problems. We try to get the young people to the place where they can consider an
alternative way of thinking, and role play this in the sessions.
Materials Required:
Per pair: One set of hand-outs (see over-leaf)
~ 16 ~
Task Instructions:
• Young people are put into pairs and given a set of hand-outs.
• One member of the pair completes the stroop task whilst their partner says ‘switch’.
• When one hand out has been completed, the pair change roles.
• Complete for other hand-outs:
o Pictures: switch between saying what the picture is and the word that is
overlaid in the picture
o Colour: switch between saying what the word actually says and the colour the
word is written in
o
o Shapes: switch between saying the name of the shape and the word which the
shape is written in
o Number Boxes: switch between saying the word written in the box and the
number of words written in the box
o Compass directions: switch between where the arrow is pointing and saying
the opposite compass direction to where the arrow is pointing
o Clocks: switch between saying the times on the clock faces using 24 hour and
12 hour clocks.
Questions for Task Reflection:

• How did everyone find the task?
• Which stroop or switch task was the hardest?
• Did anyone develop any strategies that helped them switch quickly and accurately?
Last 10 minutes – Summary/Reflective Discussion and Homework Setting

(Facilitator 2)
Questions for Session Reflections:
• Do people feel they can use this skill?
• Do we have any examples from our everyday lives? When is it hard to be flexible?
Homework:
Brain storm on a flipchart what everyone likes to do in their spare time and everyone picks
something to try that they have not done before.
~ 17 ~
Stroop/Switching Pack
Pictures:
watch
vase pencil
table
mobile balloon
phone
telephone
book
umbrella chair
watering train Bus table

can
~ 18 ~
Colours:
~ 19 ~
Shapes:
~ 20 ~
Number Boxes
one four two four two three

three
one two four two
three
one two two
one
two three four one three two four
two four one three two
two one two
two
one two three one four two one
one three one four two one
one two one
one
~ 21 ~
Compass Directions
~ 22 ~
Clocks
11 12 1 11 12 1 11 12 1
10 2 10 2 10 2
9 3 9 3 9 3
8 4 8 8
7 5 4 4
6 7 6 5 7 6 5
11 12 1 11 12 1 11 12 1
10 2 10 2 10 2
9 3 9 3 9 3
8 4 8 4 8 4
7 6 5 7 6 5 7 6 5
11 12 1 11 12 1 11 12 1
10 2 10 2 10 2
9 3 9 3 9 3
8 4 8 4 8
7 5 7 5 4
6 6 7 6 5
11 12 1 11 12 1 11 12 1
10 2 10 2 10 2
9 3 9 3 9 3
8 4 8 8
7 5 4 4
6 7 6 5 7 6 5
11 12 1 11 12 1 11 12 1
10 2 10 2 10 2
9 3 9 3 9 3
8 4 8 4 8 4
7 6 5 7 6 5 7 6 5
11 12 1 11 12 1 11 12 1
10 2 10 2 10 2
9 3 9 3 9 3
8 4 8 4 8
7 5 7 5 4
6 6 7 6 5
~ 23 ~
Aim of the Session:
The aim of this session is to introduce the idea of multi-tasking and doing two (or more)
things at once. We also aim to generate discussion about multi-tasking at meal times; is this a
helpful or unhelpful skill to have?
First 5 minutes - Icebreaker – Multi-coloured ball game (Facilitator 1)
Aim of Task:
This is a fun and difficult game that requires concentration. It allows young people to practice
multi-tasking and switching. Generally, mistakes are made during this game, which is
modelled by the facilitators.
Materials Required:
Three different coloured balls (e.g. Red, Blue, Yellow)
Task Instructions:
• Young people and facilitators stand in a circle
• Throw the red ball between participants around the circle, in a certain order, so that
each member of the group is always throwing the ball to and catching from the same
person.
• Once a pattern is established, the facilitator asks that when a group member makes
eye contact with the person they are about to throw the ball to, they say the colour
“blue”.
• Once the group is used to this, introduce the blue ball, but group members must call it
“yellow” and throw two balls around the group simultaneously.
• A final yellow ball is introduced which they must call “red”. So all three balls are
thrown around the room, saying the colours which they are not.

• Did anyone try a new pastime?
• How did people find doing something different?
• What other areas of your life could you try and do something differently?

Again, this is the opportunity to welcome new members to the group and ask for input from
other members to describe the group’s content and purpose. Once this has been completed,
the following script may be used to introduce this session.
“Last week we looked at switching from one thing to another which can be tricky, but
sometimes we need to hold 2 things in mind at the same time which can be even harder -
~ 24 ~
multi-tasking. This week we will look at this skill and think about when we can use it in our
everyday lives. ”
From 15th-20th minute - Exercise 1 – Drawing ‘invisible’ circles and

drawing real infinity signs (Facilitator 2)
Aim of the Task:
Simple and novel exercises to generate a conversation about the difficulties multi-tasking can
cause.
Materials Required:
For each young person: two pens, two pieces of paper
Task Instructions:
• Young people are instructed to draw ‘invisible’ circles going forward using their right
finger.
• Then they are asked to draw ‘invisible’ circles going backwards, using their left finger
• Now challenged to do both at the same time.
• After a few minutes of practicing, young people are given two pieces of blank paper
and two pens
• First, they are asked to draw an infinity sign with their dominant hand
• Following this, they are asked to draw an infinity sign with their left hand
• Then do both at the same time in the same direction
• Then do both at the same time in the opposite direction

• What does this tell us about how our brains deal with managing two things at once?
From 20th – 30th minute – Exercise 2 - Memory Tablet Game (Facilitator 1)

Aim of the Task:
A novel task designed to practice multi-tasking in a different way; listening and playing a
game. We are fortunate enough to have resources to use portable computerised tablets for the
group tasks. However, any alternative individual game/task (e.g. word search, spot the
difference etc.), would be acceptable.
Materials Required:
For facilitator: list of words (see example)
Per young person: portable computerised tablet or individual game/task, blank piece of paper
and a pen
Task Instructions:
• Give each young person a tablet and tell them to play whatever game they want
out of the selection available (examples are fruit ninja, temple run, candy crush)
• After a few minutes, facilitator starts reading out a list of 30 random words, which
the young people are asked to remember
• After the list of words has been read out, ask the young people to write down what
they can remember
~ 25 ~
• How did everyone find it?
• Was it hard or easy? When did it get harder?
• When do we have to do this in everyday life?
From 30th–35th minute – Exercise 3 – Word Search and Colouring in

(Facilitator 2)
Aim of the Task:
This task is designed to practice multi-tasking in a novel way.
Materials Required:
Per young person: worksheet with a small word search on one side of the page and a small
colouring in image on the other (see overleaf)
Task Instructions:
• Young people are asked to complete both tasks at the same time (one with each hand)

• Which task did you find easier?
• Did anyone feel under more pressure to get one side ‘right’ more than the other?
Last 10 minutes – Summary/Reflections on Session and Homework

(Facilitator 1)
• What skills have we used in today’s tasks?
• Do we have any examples from our everyday lives? When is it hard to multi-task?
• Is being able to multi-task at meal times helpful or unhelpful?
Homework
From the ideas that have already been generated, each young person chooses a specific every
day example of ‘multi-tasking’ to practice. Young people should be encouraged to practice
multi-tasking at meal times, but are able to choose a non-food related example. Facilitators
make a note of what each young person chooses
~ 26 ~
Word Search and Colouring in Task
~ 27 ~
Session 4: Summary of Skills Learnt
Aim of the Session:
This session summarises and consolidates the skills learnt in the previous sessions. It’s also
an opportunity to increase motivation to experiment with different thinking skills.
First 5 minutes – Ice Breaker - Buzz (Facilitator 1)

Aim of the Task:
Fun adaptation of the popular childhood maths game ‘Buzz’. The game has switching and
multi-tasking components and requires concentration.
Materials Required:
n/a
Task Instructions:
• Young people and facilitators stand in a circle
• Begin to count, in turn, to 30
• Once this has been completed, begin counting to 30 again, replacing multiples of
three with the word ‘buzz’.
• For the next round, multiples of 5 are replaced with a clap. As the previous rule for
multiples of 3 remains, some numbers will require a “Buzz-clap” e.g. 15
• For the final round, multiples of 4 are replaced with a stamp. Again, the previous rules
for multiples of 3 and multiples of 4 are in place. Therefore, the last time should
correctly sound like this:
“One” “Two” “Buzz” *Stamp* *Clap* “Buzz” “Seven” *Stamp* “Buzz” *Clap*
“Eleven” “*Buzz-Stamp*” “Thirteen” “Fourteen” “*Buzz-Clap*” *Stamp*
“Seventeen” “Buzz” “Nineteen” *Clap-Stamp* “Buzz” “Twenty Two” “Twenty
Three” “*Buzz-Stamp*” *Clap* “Twenty Six” “Buzz” *Stamp* “Twenty Nine”
“*Buzz-Clap*”
From 5th-10th minute – Reflection on Homework (Facilitator 1)

• Did anyone practice multi-tasking this week?
• Did you notice anything? Did it become easier with practice?
From 10th – 15th minute - Today’s Session Script (Facilitator 1):

“We thought we would spend today reflecting on what we have learnt from the Flexible
Thinking Group so far and how the skills may be useful in everyday life. Can anyone tell me
what thinking skills we have been practicing?”
~ 28 ~
From 15th-40th minute - Exercise 1 - Occupations Task (Facilitator 2)
Aim of the Task:
There is a similar task in the adult protocol, however it has been adapted. It allows young
people to explore the idea of ‘Flexible Thinking’ and how this may be useful in future life. It
also revisits the idea of Bigger Picture and Finer Detail thinking. This continuum was chosen
due to qualitative feedback that this is the most helpful skill in the group. The overall aim is
for young people to realise the value of all different styles of thinking and that most
occupations require a combination. We also want this session to be motivational by asking
young people what thinking styles are needed in their dream job. We also want them to
acknowledge the thinking style of ‘anorexia’.
Materials Required:
For facilitator: Blu tack, flip chart with the continuum below drawn, and pen
Per young person: ‘Random’ job flashcard and a ‘fun’ job flashcard (see overleaf)
Task Instructions:
• “Today’s task is going to explore what type of thinking styles are used by different
people.
• “We are going to look at different jobs and think about what skills the person doing
them would need and plot them on this axis.”
• Firstly, give each young person a ‘random’ job flashcard
• Each young person takes it in turn to plot their ‘random’ job on the axis, whilst giving
an explanation for their reasons (see examples overleaf)
• Group discussion is encouraged, with facilitators asking if others agree and also
giving their own opinions. At the end, occupations should be scattered across the axis.
~ 29 ~
• Next, give each young person a ‘fun’ job. Again, group discussion is encouraged (see
examples overleaf)
• Following this, ask each young person to write their own ‘dream job’ on to the axis.
• The group are then asked to plot ‘anorexia’ and their ‘ideal therapist’ onto the axis.
Usually, young people are able to see that anorexia is very rigid and very finer detail
focussed; more so than any other occupation they have plotted.
• Finally, they are asked to think about where they would put themselves currently on
the axis, but they are not asked to share this.

• What does this tell us about the different thinking styles we have learnt about?
Last 5 minutes – Homework Setting (Facilitator 1)

Issue each young person with a ‘My dream job’ worksheet to complete.
‘Random’ Job Flashcards
Brain English
Judge
Surgeon Teacher
Head Fiction
Architect
Chef Author
TV
Artist
Producer
~ 30 ~
‘Fun’ Job Flashcards
Simon Cowell Andy Murrey Alan Sugar
One Direction
Beyonce's Nigella
Extreme Fan
Stylist Lawson
(Directioner)
The Prime
Prince William
Minister
Anorexia and Therapist Flashcards
Ideal
Anorexia
Therapist
~ 31 ~
My Dream Job Homework Sheet
~ 32 ~
Aim of Session:
This session aims to revisit the concept of bigger picture thinking and allow practice of using
this skill again, with different exercises. The homework task is designed to make young
people think about how the skills they are practicing in session can help with their eating
difficulties.
First 5 minutes - Ice Breaker – Zip Zap Boing (Facilitator 1)

Aim of Icebreaker:
Fun game to engage young people in the group. Requires concentration.
Materials Required:
n/a
Task Instructions:
• Whole group stands in a circle
• Saying the word ‘Zip’ aloud is passed around the circle in one direction by one player
pointing to another player and saying ‘zip’
• At any time, any player can say ‘zap’ to the person pointing at them, which leads to
the travelling ‘zip’ changing direction
• A third rule may be introduced where any person receiving a ‘zip’ or ‘zap’ may
choose to shout ‘boing’ and point at someone anywhere in the circle. That person then
restarts the ‘zip’ going in the direction of their choice.
From 5th-10th minute – Reflection on Homework (Facilitator 2)

• Did everyone complete the ‘dream job’ worksheet?
• Did anyone have any other thoughts about it that we did not talk about last week?
• Did anyone come up with any good ideas how they can practice the thinking skills
that they need for their dream job?
From 10-15th minute – Script for Today’s Session (Facilitator 1)

“Today we’re going to re-visit the idea of ‘Bigger Picture thinking’ Sometimes it can be
helpful to think about your life like a film. There are the swooping wide angle shots and the
intimate detailed close ups, with different aspects of your life having different focal lengths.
On a day to day basis our attention is often focussed on the finer details, e.g. how we are
going to get from A to B and B to C. This can be a good thing sometimes as it gets things
~ 33 ~
done. However, sometimes it is really important to take a step back. It is very easy to get
wrapped up in the little steps without ever thinking about where you’re really heading. We
think this is important to think about when talking about anorexia. It’s rare that everything is
fine one day and then they next day people get stuck in rituals, or eating in a certain way or at
a certain time, but it’s often not until you’re stuck in a pattern or rut that you realise it’s gone
too far and unpicking it gets harder and harder. If your life feels like you are constantly
running on a treadmill but you never really get anywhere, you might find it hard to see
beyond the present moment. But the problem with that is, if you stay caught up in the details,
seeing the reason for changing small behaviours can be impossible. By taking a mental step
back, you can start to think about how making small incremental changes can start to help
you move forward.”
From 15th – 30th minute - Exercise 1 – ‘How to’ Text to an Alien (Facilitator
2)
Aim of the Task:
This task aims to practice communicating an idea in a brief way. The tendency for a lot of
young people is to go into a lot of detail when explaining something, but sometimes this can
be impractical in our everyday lives. This task can help young people to think about the main
points of what needs to be explained and hence brings awareness of the bigger picture.
Materials Required:
Per pair: “How To” Flashcard
Task Instructions:
• Put young people into pairs and give each pair a flash card with a different task on it
• “Imagine that you are sending a text to an alien, explaining the task that is written on
the flashcard in front of you. Try not to let the other pairs know what you are doing.”
• When the young people have finished, ask them to now explain the task in 10 words
• When they have done that, ask them to explain it in 3words.
• Ask each team to say their three words and see if the rest of the group can guess what
the task is

• Was it hard or easy?
From 30th – 40th minute - Exercise 2 – London Landmarks (Facilitator 1)

Aim of Task:
Again, this task aims for young people to be able to practice describing something in terms of
the bigger picture.
Materials required:
Per young person: a different “London Landmark” sheet (see overleaf)
Task Instructions:
~ 34 ~
• Each young person is given a picture of a London landmark
• They are asked to describe the landmark to the rest of the group using only 3 words.
• They are not allowed to use the words at the bottom of the picture.
• The rest of the group has to guess what they are describing


(Facilitator 2)
• Do people feel they generally use bigger picture thinking or are you more focussed on the
finer details?
• What are the pros and cons of each skill? Which skill can help us in which situations? Do we
have any examples from our everyday lives?
• What about in relation to your eating difficulties?
Homework:
‘Think about a difficult meal time’ worksheet (if they find meal time too difficult at this
stage, think about another challenging time). The work sheet asks young people to firstly
observe the type of thinking style they used during this difficult meal time and then to
consider alternative thinking styles that may have helped them. The worksheet also asks them
to consider what would help them to implement different thinking styles and what may be
difficult about this. Young people are then asked to try to implement different thinking styles
at their next difficult meal time.
~ 35 ~
‘How to’ Flashcards
How to plan
How to make a
an event on
cup of tea
Facebook
How to plan How to order

an outfit for a a drink at
party Starbucks
~ 36 ~
London Landmarks - 1
St Pauls Cathedral
Church – Old - White
~ 37 ~
Big Ben
Clock – Tall - Time

~ 38 ~
London Eye
Big – Thames - Wheel
~ 39 ~
London Zoo
Animals – Cage - Walk
~ 40 ~
The Gherkin
Tall – Shape -
Vegetable
~ 41 ~
The Shard
Glass – High – New
~ 42 ~
Tower Bridge
Thames – Open - Old
~ 43 ~
Harrods
Shop–Expensive-
Knightsbridge
~ 44 ~
‘Difficult Meal Time’ Worksheet
Detail Focused Thinking
Bigger Picture Thinking
Think about a difficult meal time…
What thinking style/s do you notice that you use during difficult meal times?
(e.g. Focused or stuck on details? Rigid thinking? Other thinking styles?)
What thinking styles might be more helpful to use at these times?
(e.g. Standing back and looking at the bigger picture? Flexible thinking? Other
thinking styles?)
What could I do to help me use these helpful thinking styles during difficult
meal times?
What might be difficult when trying to use these helpful thinking styles during
difficult meal times?
What can I do it this happens?
Now let’s give it a go…
~ 45 ~
Aim of Session:
To revisit the idea of switching. Exercises aim to practice switching attention from one thing
to another; and to notice the rules that we follow and our opinions.
First 5 minutes – Ice Breaker - Splat (Facilitator 1):

Aim of Icebreaker:
Fun drama game to practice switching and engage young people in the group. Requires
concentration and improves reaction times.
Materials Required:
n/a
Task Instructions:
• Young people and facilitators stand in a circle and shoot at each other with imaginary
guns.
• One person stands in the middle of the circle and shoots at someone standing in the
circle whilst saying ‘splat!’
• The person who has been ‘splat’ at, must duck to avoid getting shot.
• The players on either side of the shot person must shout ‘splat’ and shoot at each
other.
• One of the following then occurs:
o The shot person fails to duck in time so is shot and is then out
o The last of the players on either side of the shot person to say ‘splat’ is out
o Shot player ducked in time and both shooters said ‘splat’ simultaneously. No-
one is out and the play continues
• If someone accidently shoots or ducks when they are not supposed to, they are also
out.
• Once a player is out they have to sit out of the game. The players next to them now
have a different player next to them and must react to them being shot.
• When only two players remain, they must stand back-to-back in the centre of the
circle.
• The person in the middle of the circle now starts to say things that sound similar to
‘splat’ eg. ‘split’ ‘splodge’ ‘slop’ etc. On each of these words the two remaining
players take a step forward. Only when the person says ‘splat’ can they turn around
and ‘splat’ each other.
From 5th-10th minute – Homework Reflection (Facilitator 2):

• How was the experiment?
• Were you able to notice what thinking style you were using?
~ 46 ~
• Was it a helpful thinking style for this situation? If not, were you able to choose a
more helpful thinking style?
• What have you learned from this experiment?
From 10th-15th minute – Script for Today’s Session (Facilitator 1)

“Today we are going to revisit the skill of ‘switching’. This can apply to many different
things including the rules that we abide by, the behaviours we engage in, how we see things
and the opinions we have.”
From 15th-25th minute - 13.55 - Exercise 1 – Illusions (Facilitator 2)

Aim of Task:
Generate conversation about how our brain can sometimes ‘trick’ us into seeing something
that is not there and how we can apply this to AN and other difficulties.
Materials Required:
Illusion cards: “50 optical illusions” by Usborne Activities, available to purchase online.
Task Instructions:
• “Let’s look at our abilities to be flexible and switch the way we see things”
• Split young people into pairs/groups and give them a selection of 5-6 illusion cards
• Ask them to work through the illusions in their pair/group and to think about how
‘switching’ or ‘rule changing’ is being used. The ‘answer’ to the illusion is on the
back of the card.
• Each pair/group to pick their favourite and present to the rest of the group

• Were some illusions easier to figure out than others?
~ 47 ~
• What does this tell us about how our brains work?
• Are there any real-life situations this can be applied to?
From 25th-35th minute - Exercise 2 - Hand tapping game (Facilitator 1)

Aim of Task:
The aim of the task is to practice switching between different rules, quickly and accurately.
Materials Required:
n/a
Task Instructions:
• Young people and facilitators sit in a circle, either on the floor or around a table
• Everyone places their left hand on the floor
• Everyone places their right hand over the left hand of the person next to them, on the
floor. Hence, everyone should have a hand from each neighbour in between their own
hands.
• The lead facilitator chooses the direction (e.g. clockwise) for a single tap on the floor
to be ‘passed’ around the circle (the tap travels in the order of the hands placed on the
floor)
• A single tap indicates for play to continue to the next hand.
• After a few minutes and when the tap is being passed at speed, a new rule is added;
two taps of the same hand signals a change in direction of the ‘tap’.
• Again, after a few minutes and the play is at speed, a new rule is added; three taps of
same hand leads to the next hand ‘missing a go’.
• To see the game in action, please see the link below:
http://www.youtube.com/watch?v=DHMxfA2OivI
Questions for Task Reflection

• When do we have to do this in everyday life?
From 35th- 45th minute – Exercise 3 - “Switching in real life” (Facilitator 2)
Aim of Task:
Qualitative feedback from young people indicated that they wanted sessions to relate more to
real life. This exercise aims to do that, by practicing switching from one opinion to an
alternative. This also practices theory of mind. Difficult but helpful conversations can often
arise during this task.
Materials required:
List of pre-determined real-life situations (see overleaf)
Task Instructions:
~ 48 ~
• “Being able to ‘switch’ your attention from one thing to another or ‘switching’ your
view of a situation can be helpful in real life. I’m going to read out statements and can
you tell me what an alternative would be”
• If young people struggle to come up with an alternative, it can be useful to ask them
to think about what they would say to a friend if they came to them with this
difficulty.

• Does this exercise help people to think about how they can use switching in everyday
life?
• Can anyone think of any other examples?
Last 5 minutes - Homework (Facilitator 1)

Hand out list of experiments. The following script can be helpful to explain the benefit of
trying something new:
“We all have habits and routines to some extent. Doing things in a certain way or order, at a
particular time and keeping things in a certain place, can be very helpful in our everyday
lives. They allow us to function on ‘autopilot’ and get things done. However, people who
struggle to think flexibly can become very stuck in their routines and there can be negatives
to this. Rigid thinking can get in the way of trying something new, finding out there is a
better way to do something and disruptions to routines can make people very distressed.
Quite often people don’t realise that their habits are a problem until something new arises
which they feel they cannot do. For example have a spontaneous meal out with friends, or
enjoy a particular food at a special occasion because it’s not on the meal plan etc. This
homework is designed to help you to start thinking about the routines you are stuck in. Some
tasks are fairly ‘easy’ such as changing your profile picture on Facebook, others are more
difficult such as trying a new snack. There is also space for you to add in your own ideas. Try
to complete as many challenges as you can by our next session.”
We find it is helpful to add an element of competition to see who can try to do the most
things differently by the next session.
Switching in Real-Life Exercise
1. My mum is trying to make me fat

2. Looking in the mirror at the parts of me I dislike
3. Everyone’s looking at me
4. No one likes me
5. Focussing on the calories in the food I’m eating
6. I am fat
7. I’ll never have a romantic relationship
8. I’m going to fail all of my exams
~ 49 ~
Homework – List of experiments
~ 50 ~
~ 51 ~
Aim of Session:
This session aims to revisit the skill of multi-tasking and practice it.
First 5 minutes – Icebreaker Slap Clap Click Click (Facilitator 1)

Aim of Icebreaker:
To engage young people in the group as it requires concentration. Contains elements of
switching, multi-tasking and being flexible in general by having to respond to the previous
player’s answer.
Materials Required:
n/a
Task Instructions:
• This is a word association game that is played whilst sat down in a circle
• Facilitators start off by setting a steady rhythm: slapping both hands on knees, clap,
clicking their right hand (on its own) and clicking their left hand (on its own).
• On each click a word is said. The first click is the word said by the previous person on
their second click.
• The second click is the ‘new’ word that is freely associated with the word on the first
click.
• For example if the person starting the game says “hot” the next person in the circle
would say “hot” on the first click and perhaps free associate with this to be “sun” on
the second click. The next player might say “Sun, Sand” and so on.
• As an interesting ‘switch’ we then ask young people to complete the task again but
this time the word on the second click is not at all related to the first word.

Questions to ask about last weeks homework
• Did anyone try any of the suggestions on the list?
• How did people find doing something different? Did anything bad happen?
• Will you continue to do this thing differently or will you go back to the way you
were doing it?
• What other areas of your life could you try and do something differently?
From 10th – 15th minute – Script for Today’s Session (Facilitator 1):
~ 52 ~
“Last week we looked at switching from one thing to another which can be tricky, but
sometimes we need to hold 2 things in mind at the same time which is even harder - multi-
tasking. This week we will look at this ability and think about when we can use it in our
everyday lives.”
From 15th – 25th minute - Exercise 1 – Play dough multi-task (Facilitator 2)

Aim of Task:
To practice multi-tasking by having to follow instructions and do something else at the same
time.
Materials Required:
Facilitator: list of pre-determined instructions (see-overleaf)
Each young person: play-dough (enough to make something out of)
Task Instructions:
• Young people are asked to start walking around the room
• “Make a model of a cat, as detailed as possible (whiskers, eyes, nose, tail, ears, fur),
whilst listening and following my directions”
• The instructions, read out by a facilitator, are designed to increase in difficulty

• How did you find the task? What was the most difficult instruction to follow?
• Which task were you most focussed on? What was more important to you; making a
‘good’ cat or following the instructions correctly?
• What does this tell us about how our brains deal with managing two things at once?
From 25th-25th minute – Exercise 2 – Fruit Ninja multi-task (Facilitator 1)

Aim of Task:
To practice multi-tasking through listening and playing a game.
Materials Needed:
Facilitator: song ‘Diamond’ by Rihanna and a way to play this to the whole group
Each young person: portable computerised tablet with the game ‘Fruit Ninja’ downloaded OR
any other game/task e.g. word-search, cross-word, Sudoku, spot the difference etc.
Task Instructions:
• Each young person is given a portable computerised tablet and instructed to play Fruit
Ninja (or given alternative activity)
• After everyone has been playing for a few minutes, the following instructions are
given “I’m now going to play a song. I want you to carry on playing Fruit Ninja but
count how many times Rihanna sings or says the word ‘Diamond’”.
• Play the song
• When the song is finished, ask everyone for their guesses (the correct answer is 37)
• To continue to practice multi-tasking, young people can continue to play the fruit-
ninja game during the questions for task reflection.
~ 53 ~
• How did everyone find it? Was it hard or easy? When did it get harder?
• Did people who were more accurate with their guess do well in the game?
• Did people who were less accurate with their guess do well in the game?

(Facilitator 2)
• Brain storm on the flip chart how we can use multi-tasking in everyday life
• When is it hard to multi-task?
Homework:
“Next time we will be thinking about what we have learned so far in flexible thinking. To
start thinking about it we want you to complete the ‘Pros and Cons’ of Flexible Thinking
Worksheet”
List of Pre-Determined Instructions

Walk round in a circle anti-clockwise
Walk round in a circle clockwise
Stop walking and stand on one leg
Walk around the room
Hop in a circle
Sit down on a chair
If your birthday is in the first half of the year stand by the window. If your birthday is
in the second half of the year stand by the door
Walk around the room
Line up in height order without speaking to each other
Walk in a circle anti-clockwise
Get into groups of 4
Get into groups of 3
Get into pairs
Line up in order of birthdays – (i.e. those born in January at the front, December at the
back)
~ 54 ~
Pros and Cons of Flexible Thinking Homework
Flexible Thinking
Bigger Picture Thinking
Pros Cons
Finer Detail Thinking
Pros Cons
Flexible Thinking
Pros Cons
Rigid Thinking
Pros Cons
~ 55 ~
Session 8: Summary of Skills Learnt
First 5 minutes – Ice breaker – Multi-coloured ball game (Facilitator 1)
See description in session 3.

“Today is a ‘round up’ session for those of you who have been to the group quite a bit and an
‘introduction’ for those of you who are a bit newer. We are going to practice all of the skills
that this group targets and think about how these can apply to everyday life. We’ve already
done multi-tasking and switching in the ice breaker!”
From 10th-15th minute – Exercise 1 - Bigger Picture Squares Task

(Facilitator 2)
Aim of Task:
The aim of this task is for young people to use both bigger picture thinking and finer detail
thinking. They will need to be able to switch between both in order to get the correct answer.
Materials Required:
Per young person: laminated ‘square’ hand out (see overleaf)
Task Instructions:
• Give each young person in the group a print out of ‘the square’
• Give them a few minutes to count how many squares they can see
• Have a group discussion about the number of squares (the correct answer is 40)

• How did people find the task?
• Is it easy to see the bigger picture?
From 15th-20th minute – Exercise 2 – Finer Detail Cars Task (Facilitator 1)

Aim of Task:
This is the only task that practices ‘finer detail’ thinking. It’s an opportunity to demonstrate to
young people how good they are at this. Generally, they find the correct answer a lot quicker
than the facilitators and enjoy doing so. This generates an interesting conversation.
Materials Needed:
Per young person: Car spot the difference hand-out (taken from the book ‘Left brain/right
brain; 50 puzzles to change the way you think’ which is available to purchase from
www.puzzlesociety.com). The print out is of nine images of the same car, but only two are
actually identical. Alternatively, any difficult spot the difference may be used.
Task Instructions:
• Give each young person in the group a print out of the ‘car’ task
~ 56 ~
• Give them a few minutes to find the ones that match. The correct answer can be found
in the back of the book.

• How did people find the task?
• Was it easier or harder than the squares task?
• What does this tell us about your brain/anorexia?
From 20th-30th minute – Exercise 3 – Twisted Fairy Tale (Facilitator 2)

Aim of Task:
The aim of this task is to demonstrate that young people are able to ‘switch’ a story that they
have been told all their lives. This task also practices bigger picture thinking, as young people
are only given a few minutes to tell the basic outline of a story that they could relay in great
detail.
Materials Required:
Per pair: blank paper and a pen
Task Instructions:
• Split young people into pairs and ask them to write the basic outline of a fairy tale of
their choice. If they cannot think of one, give a well-known example, for example
Cinderella, Little Red Riding Hood, Sleeping Beauty, Snow White and the Seven
Dwarves.
• Ask each pair to read their outline to the rest of the group
• Then ask each group to ‘twist’ the fairy tale and tell it from the point of view of the
villain. “I want you to make me feel really, really sorry for them”
• Each pair then reads out their ‘twisted fairy tale’

• How did people find this task?
• Is it something you’ve ever considered before?
• If you’re able to ‘switch’ something you have been familiar with for most of your life,
do people feel more confident in being able to switch other things?
From 30th-40th minute - Skill Summaries (Facilitator 1)

Aim of Task:
To utilise what each person has thought about for homework (the pros and cons of flexible
thinking) and work as a team to complete a mini-presentation.
Materials Needed:
Per group: blank paper and pens
Task Instructions:
• Split young people up into groups: “Bigger Picture” “Multi-tasking” and “Switching”.
It is often useful to pair young people who are newer to the group with those who
have been in a lot of sessions.
~ 57 ~
• Each group is given 5 minutes to discuss how they can use their assigned skill in
everyday life (including the pros and cons they will have thought about for
homework)
• Each group presents their skill back to the whole group (maximum of one minute)
Last 5 minutes – Homework – Flexible Thinking Motto (Facilitator 2)

Sheet with ‘Flexible Thinking’ mottos are given to the group. They are asked to think of their
own flexible thinking motto and bring it with them next week.
‘How Many Squares?’ Task
~ 58 ~
Flexible Thinking Moto Homework
~ 59 ~
~ 60 ~
Alternative Exercises
Occasionally, young people can be in the group for more than 8 sessions. We have therefore
created a set of ‘back-up’ exercises that we replace some of the standard exercises with. This
is with the aim that the same skills are practiced but the group is still engaging for the young
person. For ease of use, we have split these into the different thinking styles.
It is also worth noting that for many of the exercises already discussed, they can be made
novel again by changing a small element. For example, using different geometric figures or
illusions.
Bigger Picture Thinking/Finer Detail: Where’s Wally?
Aim of Task:
This is a well-known childhood puzzle. The task aims for young people to practice focussing
on relevant information amongst irrelevant stimulus.
Materials Required:
Per young person: pack of 4-5 ‘Where’s Wally?”. These can be obtained by typing ‘Where’s
Wally?’ into any internet search engine.
Task Instructions:
• Young people are given a pack of ‘Where’s Wally?’ puzzles

• Instructions are given to find Wally and for young people to put their hand up when
they have found him.
• When all young people have found Wally in one picture, the group moves on to the
next puzzle.

• Where you using bigger picture or finer detail thinking?
• Do you find this task easier than thinking about the bigger picture?
• What does that tell us about your brain?
Switching: One, Two, Three

Aim of Task:
Aim is to practice switching whilst enhancing communication skills. Also promotes alertness
as this task requires concentration. To enhance communication skills, this gets young people
thinking and alert as this task cannot be done successfully without full concentration.
Materials Required:
~ 61 ~
n/a
Task Instructions:
• Young people are put into pairs and given the following instructions:
• “Turn to face each other. Start counting from one to three between yourselves, taking
it in turn to say each number. Do this over and over again as quickly as you can.”
• When young people have got the hang this, give the next instructions
• “Instead of saying the number "one", clap your hands - but still say "two" and "three"”
• Once this has been mastered, the next rule is introduced
• “Now bend your knees instead of saying “three”. Don’t forget you still need to clap
your hands for “one”.”
• The final exercise should look and sound like this:
A: "One" (Claps hands)
B: "Two"
A: "Three" (Bends knees)
B: "One" (Claps hands)
A: "Two"
B: "Three" (Bends knees)

• Can you tell me how this task uses ‘switching’?
• Did anyone develop any useful strategies to keep the rules in mind?
Multi-tasking: Snap
Aim of Task:
To practice having a conversation whilst doing something else; a skill we all need in
everyday life.
Materials Required:
Per pair: pack of cards
Task Instructions:
• Split young people into pairs and give each a pack of cards
• Instruct them to start playing the popular childhood game ‘snap’ where the aim is to
collect all of your players cards.
• After a few minutes of this, ask them to continue playing whilst having a conversation
about the last film they saw in the cinema.

• When did it become harder?
• When do we need to be able to do this in everyday life? When is it most difficult?
Summary: Mind-Maps
~ 62 ~
Aim of Task:
As with all other summary tasks, the aim is to consolidate what has been learned in previous
sessions and how they apply to everyday life.
Materials Required:
Per young person: blank paper and pens
Task Instructions:
• Young people are given a blank piece of paper and a pen and asked to write ‘Flexible
Thinking’ in the middle
• They are then asked to write words/phrases they relate to the flexibility group. This
can include what they have learned about themselves.
• Young people are asked to share their mind maps with the rest of the group
• Reflective discussions are had about individual and/or group themes.
Example:
~ 63 ~
Feedback
To date, the Flexible Thinking group has been attended by 101 young people, who received
treatment in ITP. ITP is a day patient programme for young people with anorexia nervosa or
eating disorder not otherwise specified restrictive type, first set up in September 2010. It is
for young people who require more intensive input than outpatient treatment and is an
alternative to an inpatient admission.
Up to 8 young people per day attend ITP, which is run from Monday to Friday. If young
people attend full time they receive 10 hours of education. Each young person also has two
weekly family reviews and one weekly session of individual therapy. In addition, young
people attend various therapeutic groups based on dialectical behaviour therapy (DBT),
cognitive behavioural therapy (CBT), mindfulness, motivational interviewing (MI)
mentalization based art psychotherapy and CRT principles.
The ‘Flexible Thinking’ group currently takes place at 13:30 on a Monday afternoon, straight
after lunch.
Quantitative outcomes of the group are measured by the Cognitive Flexibility Scale (CFS)
and two motivational rulers; importance to change and ability to change. An alternative
measure, currently used in the adult team, is the deflex. Due to positive qualitative feedback
from young people, the group is seen as an important part of the group programme. We
continue to use the feedback to adapt the group.
We have recently started conducting ‘exit interviews’ with young people when they are
discharged from ITP. To date, 4 out of 14 young people have named “Flexible Thinking” as
one of the most helpful groups.
The following quotes are from young people regarding the group. Please note that names
have been changed to protect anonymity.
Jess, aged 17:

“Flexible thinking is my favourite group. It helps in a way that’s fun and not patronising. It doesn’t
tell you what to do but let’s you figure things out for yourself. It helps you with rigidity that you
didn’t even know you had.”
Dianne, aged 15:

“The flexible thinking group helped me to notice when I was being detail focussed and rigid
in life. It made me think about why I have to do things in a certain way and then challenge
this”
Samantha, aged 14:

“I liked that it wasn’t too intense. I could think without being overwhelmed.”
~ 64 ~
Freya, aged 17:
“I liked learning new skills but I would like the group to be more specific to eating and
anorexia”
~ 65 ~
References:
Fitzpatrick, K., & Lock, J. (2014) Cognitive Remediation with Children and Adolescents
(Chapter 8) in the book edited K.Tchanturia Cognitive Remediation for Eating and Weight
Disorders. Routledge.
Lang, K., & Tchanturia, K. (2014). A systematic review of central coherence in children and
adolescents with Anorexia Nervosa. Journal of Child and Adolescent Behavior
Lang, K., Stahl, D., Treasure, J., & Tchanturia, K. (2014). Set Shifting Abilities in Children and
Adolescents with Anorexia Nervosa: An exploratory Systematic Review and Meta-Analysis.
International Journal of Eating Disorders, 47, 394-399.
Pretorius, N., Dimmer, M., Power, E., Eisler, I., Simic, M., & Tchanturia, K. (2012). Evaluation of a
Cognitive Remediation Therapy Group for Adolescents with Anorexia Nervosa: Pilot study.
European Eating Disorder Review, 20, 321-325.
Pretorius, N., Espie, J., & Simic, M. (2014). Evaluation of a cognitive remediation therapy group for
adolescents with anorexia nervosa in a day patient setting (Chapter 9) in the book edited K.
Tchanturia Cognitive Remediation for Eating and Weight Disorders. Routledge.
Wood, L., Al-Khairulla, H., & Lask, B. (2011). Group cognitive remediation therapy for
adolescents with anorexia nervosa. Clinical Child Psychology and Psychiatry, 16, 225-231.
Tchanturia, K., & Lock J. (2010). Cognitive Remediation Therapy (CRT) for Eating
Disorders: Development, Refinement and Future Directions. In R.A.H. Adan and W.H. Kaye
(eds.), Behavioural Neurobiology of Eating Disorders, Current Topics in Behavioural
Neurosciences 6. Berlin: Springer-Verlag.
www.rasp.no –adaptation of CRT by Norwegian group
~ 66 ~

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Group Cognitive Remediation

Therapy for Adolescents

Version 1: August 2014

Development of this Manual

1) The protocol needed age appropriate modifications to be engaging

Other CRT Developments

It is designed to be facilitated by two members of multi-disciplinary staff. Facilitators take it

1. Bigger Picture Thinking

Ice breaker 5 minutes

Review of Homework (if applicable) 5 minutes

Welcome new young people, explanation of why we do ‘Flexible Thinking’ 5 minutes

Exercise 1 followed by reflective discussions 10 minutes

Exercise 2 followed by reflective discussions 10 minutes

Welcome New Young People and Introduction to Today’s Session

Reflective Discussions of Exercises and Sessions

1. What did you think of the task?

4. How can we apply these skills to everyday life?

• Ice-breaker: Body-positioning game

• Ice-breaker: Doing the opposite

• Ice-breaker: Multi-coloured ball game

• Ice-breaker: Zip Zap Boing

• Ice-breaker: Slap Clap Click Click

• Ice-breaker: Multi-coloured ball game

Aim of the Session:

First 5 minutes - Icebreaker: Body Positioning Game (Message to the

From 10th-20th minute - Exercise 1: Complex Figures Task (Facilitator 1)

Aim of the Task:

Questions for Task Reflections:

• What did you think of the task?

From 20th-40th minute - Exercise 2: Blokus or Qwirkle (Facilitators 1 & 2)

Aim of the Task:

Questions for Task Reflections:

• How did everyone find the game? Was it hard or easy?

Last 5 minutes - Summary/Reflective Discussion and Homework Setting

Questions for Session Reflection:

First 5 minutes – Ice breaker: Doing the Opposite (Facilitator 1)

From 5th-10th minute - Reflection on Homework (Facilitator 2):

From 10th-15th minute – Script for Today’s Session (Facilitator 1):

Questions for Task Reflections:

From 25th-35th minute - Exercise 2 – Stroop (Facilitator 1)

Questions for Task Reflection:

Last 10 minutes – Summary/Reflective Discussion and Homework Setting

watering train Bus table

one four two four two three

two three four one three two four

two four one three two

two one two

one two three one four two one

one three one four two one

one two one

First 5 minutes - Icebreaker – Multi-coloured ball game (Facilitator 1)

From 5th-10th minute - Reflection on Homework (Facilitator 2):

Questions to ask about last weeks homework:

From 10th-15th minute – Script for Today’s Session (Facilitator 1):

From 15th-20th minute - Exercise 1 – Drawing ‘invisible’ circles and

Questions for Task Reflections:

From 20th – 30th minute – Exercise 2 - Memory Tablet Game (Facilitator 1)

From 30th–35th minute – Exercise 3 – Word Search and Colouring in

Questions for Task Reflection: