ORIGINAL ARTICLE
Predicting Attention-Shaping Response in People
With Schizophrenia
Danielle M. Beaudette, MS,* James M. Gold, PhD,† James Waltz, PhD,† Judy L. Thompson, PhD,‡
Lindsay Cherneski, MA,‡ Victoria Martin, MA,‡ Brian Monteiro, MA,‡
Lisa N. Cruz, MA,‡ and Steven M. Silverstein, PhD‡
Abstract: People with schizophrenia often experience attentional impairments
that hinder learning during psychological interventions. Attention shaping is a
behavioral technique that improves attentiveness in this population. Because rein-
forcement learning (RL) is thought to be the mechanism by which attention shap-
ing operates, we investigated if preshaping RL performance predicted level of
response to attention shaping in people with schizophrenia. Contrary to hypoth-
eses, a steeper attentiveness growth curve was predicted by less intact pretreat-
ment RL ability and lower baseline attentiveness, accounting for 59% of the
variance. Moreover, baseline attentiveness accounted for over 13 times more var-
iance in response to attention shaping than did RL ability. Results suggest atten-
tion shaping is most effective for lower-functioning patients, and those high in RL
ability may already be close to ceiling in terms of their response to reinforcers.
Attention shaping may not be a primarily RL-driven intervention, and other
mechanisms of its effects should be considered.
Key Words: Schizophrenia, reinforcement learning, attention shaping, behavioral
intervention
(J Nerv Ment Dis 2021;209: 203–207)
S evere attentional impairments in people with schizophrenia have
been noted since the first descriptions of the disorder. These deficits
usually begin before the onset of the illness (Fusar-Poli et al., 2012),
worsen as the illness progresses, and continue even after a psychotic ep-
isode has remitted (Medalia and Choi, 2009). Research shows that de-
gree of attentional impairment in this population is inversely related to
social and vocational functioning and quality of life (Addington and
Addington, 2000; Oie et al., 2011). Because sustained attention is es-
sential for learning, this deficit also severely limits one's ability to ben-
efit from psychosocial treatments (e.g., skills training, supported
employment; Green, 1996; Green et al., 2000). Thus, treating attentional
deficits in schizophrenia is critical to enhancing treatment outcomes.
For patients with the most severe attentional deficits, the technique
of attention shaping has demonstrated success in improving attentiveness
and learning of material taught in psychiatric rehabilitation groups
(Silverstein et al., 2001, 2005, 2009, 2014). Attention shaping was devel-
oped as a form of operant conditioning, with attentiveness as the target
behavior. It involves systematic and differential reinforcement of suc-
cessive approximations toward socially appropriate levels of attentive
behavior. Attention shaping has been incorporated into group therapy
programs to accelerate acquisition of posthospital community reentry
skills (Silverstein et al. 2005), social skills (Silverstein et al. 2009,
2014), and social cognition (Combs et al. 2008) for those with serious
*Indiana University–Purdue University Indianapolis, Indianapolis, Indiana; †Maryland
Psychiatric Research Center, University of Maryland, Catonsville, Maryland; and
‡Rutgers University, Behavioral Health Care, Piscataway Township, New Jersey.
Send reprint requests to Danielle M. Beaudette, MS, Indiana University–Purdue
University at Indianapolis, 402 N Blackford Street, LD 126X, Indianapolis, IN
46202. E‐mail: dbeaudet@iu.edu.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0022-3018/21/20903–0203
DOI: 10.1097/NMD.0000000000001286
The Journal of Nervous and Mental Disease • Volume 209, Number 3, March 2021
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
mental illness. Multiple studies (Silverstein et al. 2009, 2014) have in-
vestigated the effects of adding attention shaping to the University of
California, Los Angeles (UCLA) Basic Conversations Skills Module
(BCSM; Liberman and Wallace, 1990). Silverstein et al. (2009) found
that patients who received the BCSM augmented with attention shaping
demonstrated higher levels of skills acquisition than patients who
underwent the standard BCSM without attention shaping. Moreover,
change in attentiveness was associated with amount of skills acquired.
Silverstein et al. (2014) replicated these results and further demon-
strated that greater improvements in attention during the social skills
training intervention increased patients' abilities to generalize skills to
novel social situations.
Although attention shaping has been successful in increasing at-
tention and learning for those with schizophrenia, it is resource inten-
sive (i.e., it requires a second staff member to deliver in-group
reinforcement) and time-consuming (i.e., it can increase the number
of group sessions required to complete all exercises in a treatment man-
ual). It would be beneficial to establish a screening tool to determine
which patients would benefit most from this intervention. Given atten-
tion shaping's foundation in operant conditioning, reinforcement learn-
ing (RL)—or the extent to which learning rate is modulated by the
positive and negative consequences of behaviors/choices—is thought
to be the mechanism through which attention shaping works. Therefore,
the current study sought to determine if response to attention shaping
can be predicted by a computerized measure of RL. There were two
study hypotheses: a) those with more intact RL ability at baseline would
improve their attention more throughout the intervention (i.e., would be
more responsive to the intervention), and b) baseline RL ability would
predict attention shaping outcome over and above a person's general
cognitive ability and his or her ability to pay attention at baseline.
METHODS
Study Design and Participants
This research was carried out in accordance with the latest ver-
sion of the Declaration of Helsinki. It was approved by the Institutional
Review Board at Rutgers University, and all participants underwent a
thorough informed consent process before being enrolled in the study.
Our sample was recruited from a partial hospitalization treatment pro-
gram. Participants were between 18 and 55 years old and had a diagno-
sis of schizophrenia or schizoaffective disorder according to the
Structured Clinical Interview for the DSM-IV (First et al., 2007). Exclu-
sion criteria included a) substance use disorder in the past 6 months, b)
history of medical illness that influences the function of the central nervous
system (e.g., uncontrolled diabetes, untreated hypertension), c) diagnosis of
autism spectrum or pervasive developmental disorder, and d) history of
a neurological disorder or head injury with loss of consciousness.
Subjects participated in the UCLA BCSM (Liberman and
Wallace, 1990) augmented with an attention shaping intervention.
The BCSM (Liberman and Wallace, 1990) is a manualized, social skills
training program that teaches five major skills using a structured,
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Beaudette et al. The Journal of Nervous and Mental Disease • Volume 209, Number 3, March 2021
repetitive format. Attention shaping involves the application of differ-
ential reinforcement to sequentially reward closer and closer approxi-
mations to a target behavior while decreasing reinforcement for
versions of the behavior that are farther from this target. The desired be-
havior is undivided attention throughout group therapy sessions, and
participants begin with an attention goal they can already achieve
(e.g., 2 minutes of continuous attention), set based on a baseline assess-
ment during the first two sessions (see below). As part of the attention-
shaping intervention, monetary reinforcement is given as participants
reach their attentional goals. Once a participant meets his or her goal
for two consecutive sessions, the goal is raised to the next step on the
prespecified hierarchy (e.g., 3 minutes of continuous attention), and
the previous goal is no longer reinforced.
Eight rounds of the program were completed with approximately
six participants per group. The groups met twice weekly for 1 hour over
4 months. Before beginning the intervention, participants were assessed
using selected measures of intelligence, cognition, and RL (see below
for description of measures). Participant attentiveness during each ther-
apy session was also rated using an observational assessment measure
(described below).
Measures
Attention
During each session, a noninteractive observer rated each partic-
ipant on operationalized attentiveness criteria (see Silverstein et al.,
2009 for details). These criteria included behaviors that showed the par-
ticipant was paying attention (e.g., head up, eyes open, looking at the
focus of the group such as the leader) and/or participating (responding
to questions within 5 seconds, responses are relevant, and participates
in role-plays). Behaviors that indicated lack of attention included mak-
ing irrelevant comments or interrupting others, arguing, staring off (into
space, at the floor, etc.), getting out of one's chair, or leaving the group.
The rater observed each participant for 10 consecutive seconds during
each minute and then coded each minute (interval sampled) for each
participant as “meeting attentiveness criteria” or not. In this way, each
subject was measured on how many minutes he or she paid attention
during every group session. Reliability of attention ratings was initially
established using a set of “gold standard” video recordings requiring all
potential attention raters to achieve a 95% level of agreement. Rerating
of at least two full session recordings occurred every 6 months to guard
against rater drift. From these ratings, two attention measures were
computed: a) the mean of the total minutes of attention over the first
two sessions (before the use of attention shaping procedures) was com-
puted as a baseline measure of attention, and b) the slope or change in
total minutes of attention over all group sessions corrected for the
first-order autoregressive component was computed as an outcome
measure for attention shaping.
Reinforcement Learning
The Gains vs. Loss Avoidance Test (Gold et al., 2012) is a com-
puterized measure of RL. In each trial, participants are presented pairs
of pictures and are asked to choose the “better” picture. After making
a choice, participants are given one of four types of feedback: “Win
$0.05!,” “Not a winner. Try again!,” “Keep your money!,” or “Lose
$0.05!” The “better” picture is explained as the one most likely to earn
$0.05 or allow them to keep the money they already have. In this way,
participants learn which is the “better” picture through trial and error.
Four different stimulus pairs are presented. Two pairs involved potential
gain; if the correct item was selected, participants received the “Win
$0.05!” feedback; if the incorrect item was selected, they saw “Not a
winner, Try again!” The correct response was reinforced on 90% of tri-
als in one pair and on 80% of trials in the other pair. Two other pairs in-
volved learning to avoid losses; in these pairs, choosing the correct
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Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
picture received the feedback “Keep your money!,” whereas selection
of the incorrect picture resulted in the feedback “Lose!” Again, better
responses to the loss-avoiding pairs were reinforced on 90% of trials
in one pair and on 80% of trials in the other pair. Thus, success in the
task requires two types of learning: gain driven and loss avoidance. This
task yields four subscale RL scores, one for each stimulus pair. A com-
posite learning score denoting one's overall ability to learn from predic-
tion errors is also calculated from the four stimulus pairs. The task took
about 30 minutes to complete and was administered at baseline.
Intelligence and Cognition
The Wechsler Abbreviated Scale of Intelligence, Second Edition
(WASI-II; Wechsler, 2011), is a measure of intelligence designed for in-
dividuals 6 to 90 years of age. It consists of four subtests: vocabulary,
similarities, block design, and matrix reasoning. Subtest scores can be
combined to create a Full-Scale IQ-4 Subtests composite score. The
WASI-II was standardized using a large, representative sample from
the United States, and psychometric data suggest excellent internal con-
sistency and test-retest reliability, as well as high convergent validity
with the Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV;
Wechsler, 2008, 2011). In this study, IQ scores were collected at base-
line to better understand the cognitive functioning of our sample and
to determine if this variable impacted how much participants gained
from the attention shaping intervention.
The MATRICS Consensus Cognitive Battery (MCCB; Nuechterlein
et al., 2008) is a neuropsychological assessment that measures working
memory, attention/vigilance, verbal learning and memory, visual learn-
ing and memory, speed of processing, reasoning and problem solving,
and social cognition. To summarize a person's overall cognitive ability,
the MCCB produces an age- and sex-corrected global cognition T-
score. The assessments making up the battery have excellent psycho-
metric properties, small practice effects, no ceiling effects, and strong
relationships with social functioning (Nuechterlein et al., 2008). In
the current study, the MCCB was completed at baseline. Composite
scores and the attention/vigilance subscale scores were used to under-
stand baseline cognitive functioning of our sample and determine if
these variables affected one's ability to benefit from the attention shap-
ing intervention.
Analytic Plan
Analyses were run using IBM SPSS Statistics for Windows, Ver-
sion 25.0. First, we computed descriptive statistics including demo-
graphic information and average level of education, IQ, and cognitive
functioning to assess the representativeness of our sample. Next, we
ran correlation and regression analyses to test the main hypotheses.
These analyses were conducted in two parts. First, participants who
attended at least 50% of all group session were included in the analyses
(n = 40). Next, analyses were repeated to include participants who
attended at least 25% of sessions (n = 47). This procedure was imple-
mented to determine if results vary based on how many attention shap-
ing sessions participants had.
RESULTS
Forty-nine people diagnosed with schizophrenia or schizoaffective
disorder completed the study. Table 1 outlines descriptive statistics of the fi-
nal sample, including demographic information and cognitive functioning.
To test our first hypothesis, we performed correlation analyses to
determine associations between RL scores and slope of attentiveness
over the course of the intervention. We also tested correlations between
slope of attentiveness and measures of baseline cognitive functioning
(IQ and MCCB scores). Because the corrected slope of attentiveness
yielded nonnormally distributed data, Spearman's Rho correlations
were used. Results of these analyses are outlined in Table 2. For the first
set of analyses (n = 40), only one stimulus pair yielded an RL subscore
© 2020 Wolters Kluwer Health, Inc. All rights reserved.
The Journal of Nervous and Mental Disease • Volume 209, Number 3, March 2021 Attention Shaping in Schizophrenia

Results were not in line with our initial hypotheses. First, most of the
TABLE 1. Descriptive Statistics of the Sample (N = 49) baseline measures of RL were not statistically related to attention shap-
ing outcome, even without controlling for multiple statistical tests. Pre-
Age, mean (SD) 41.3 (10.9) vious research testing associations between RL task scores and
Sex, % male 81.6% real-world variables have yielded mixed results (e.g., McCarthy et al.,
Race 2016; Treadway et al., 2015), suggesting that many real-world behav-
Caucasian 42.9% iors, even if occurring in the context of delivery of reinforcement, are
Black/African-American 42.9% determined by multiple factors, some or all of which may be more pre-
Asian 12.2% dictive than reward processing ability. In the current study, RL scores
Multiracial 2.0% from one stimulus pair were significantly correlated with change in at-
Ethnicity, % non-Hispanic 81.6% tention over time, but the direction of this relationship was in the oppo-
site direction of what was predicted: Poorer pretreatment performance
Years of education, mean (SD) 12.4 (1.8)
on the laboratory RL task was related to larger improvements in atten-
WASI FSIQ-4, mean (SD) 81.6 (18.0)
tiveness during the attention shaping intervention. This apparently par-
MCCB adoxical finding suggests that even patients who seem to have RL
Composite, mean (SD) 23.6 (16.0) deficits are sensitive to reward under conditions where rewards are
AttnVig, mean (SD) 32.0 (13.0) made salient and are consistently delivered for specific behaviors. This
Baseline Attn, mean (SD) 75.2 (23.5) conclusion fits with much data on strong treatment effects for social
learning–based milieu interventions for “treatment-refractory” patients
AttnVig indicates attention vigilance; Baseline Attn, average percentage of
with schizophrenia (Glynn and Mueser, 1986; Paul and Lentz, 1977;
session each participant paid attention to for over the first two group sessions;
MCCB, MATRICS Consensus Cognitive Battery; WASI FSIQ-4, Wechsler Ab- Silverstein et al., 2006). Moreover, people with intact baseline RL
breviated Scale of Intelligence Full Scale IQ-4 Subtest. may already be sensitive enough to social reinforcement that they do
not need additional external reinforcers to increase their attention spans
(i.e., they are close to their ceiling at baseline in terms of attentiveness in
that was significantly related to slope of attention (the gain/miss with group situations). Second, RL ability weakly accounted for additional
80% probability of best outcome pair). In the second set of analyses variance in attentiveness change over time over and above baseline at-
(n = 47), a second stimulus pair was significantly related to slope of atten- tention. Thus, results indicate that attention shaping should not be
tion (the loss/avoid with 90% probability of best outcome pair). For both viewed as a primarily RL-driven intervention.
sets of analyses, the direction of the association between the RL compos- In our sample, participant's IQ and baseline measures of cognitive
ite score and slope of attentiveness change over time was the opposite of functioning were unrelated to attention shaping response. Importantly,
the predicted direction and did not reach significance. Moreover, baseline
measures of cognitive functioning (IQ and MCCB scores) were unrelated
to slope of attention in both sets of analyses (Table 2).
To test our second hypothesis, we ran hierarchical linear regres- TABLE 2. Spearman's Rho Correlation Analyses
sion models to see if RL predicted slope of attention over and above the
Slope of Attention Slope of Attention
predictive ability of baseline attentiveness. Because IQ and MCCB
(n = 40) (n = 47)
scores were unrelated to slope of attention, these measures were ex-
cluded from regression models. For each regression model, the depen- RL stimulus pair
dent variable was the corrected slope of attention over the course of the Gain/miss pair (90%) 0.18 0.07
intervention, and baseline attentiveness (i.e., attentiveness during the p = 0.26 p = 0.64
first two group sessions, before the initiation of attention shaping proce- Gain/miss pair (80%) −0.35* −0.34*
dures) was included as a predictor in the first step of the model. We in-
p = 0.03 p = 0.02
cluded the RL subscore that was significantly associated with slope of
attention as a predictor in the second step of each model. In our first Loss/avoid pair (90%) −0.27 −0.30*
analysis (model 1, n = 40), the gain/miss with 80% probability of best p = 0.10 p = 0.04
outcome pair was included in the second step. The resulting model sig- Loss/avoid pair (80%) −0.07 −0.10
nificantly predicted slope of attention, accounting for 59% of the vari- p = 0.69 p = 0.51
ance, R2 = 0.59, F(2,37) = 26.40, p < 0.001 (Table 3). Results Composite RL Score −0.14 −0.22
revealed that at step 1, baseline attention significantly contributed to p = 38 p = 0.13
the model and accounted for 55% of the variance, R2 = 0.55, Measures of cognition
F(1,38) = 45.88, p < 0.001. Introducing the RL variable added an addi- WASI FSIQ-4 −0.19 −0.13
tional 4% of variance in slope of attention; however, this change in R2 p = 0.23 p = 0.38
only approached significance, F(1,37) = 3.68, p = 0.063. We ran two
MCCB composite −0.21 −0.14
subsequent regression analyses including the larger sample (n = 47):
one with the gain/miss with 80% probability of best outcome pair in- p = 0.21 p = 0.35
cluded in the second step (model 2), and one with the loss-avoid with MCCB AttnVig 0.03 0.73
90% probability of best outcome included (model 3). These analyses p = 0.86 p = 0.62
yielded similar results to those of model 1. Regression models were sig- Percentage for each stimulus pair refers to probability of best outcome. Sam-
nificant, but adding each RL subscore at step 2 did not add significant ple size differences refer to participants who attended at least 50% and 25% of
predictive value to either model (Table 3). sessions, respectively.
AttnVig indicates attention vigilance; MCCB, MATRICS Consensus Cogni-
tive Battery; WASI FSIQ-4, Wechsler Abbreviated Scale of Intelligence Full
DISCUSSION Scale IQ-4 Subtest.
The purpose of this study was to examine if RL ability can pre- *p < 0.05.
dict one's ability to benefit from an attention shaping intervention.

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Beaudette et al. The Journal of Nervous and Mental Disease • Volume 209, Number 3, March 2021

Next, the attention shaping intervention in this study took place only twice
TABLE 3. Summary of Hierarchical Regression Analyses for Variables a week. In other published studies of attention shaping (e.g., Silverstein
Predicting Slope of Attention
et al., 1998), sessions were held three to five times per week. Therefore,
it is unclear if our results would generalize to predicting treatment re-
Variable b t R R2 ΔR2
sponse under those more intensive reinforcement delivery conditions.
Model 1 (n = 40) Lastly, researchers have questioned the reliability of probabilistic
Step 1 0.74 0.55 0.55*** RL tasks (Baker et al., 2013), and the reliability of the specific task used
Baseline attention −0.01 −6.77*** in this study is not yet known. Therefore, this research is limited in that
Step 2 0.77 0.59 0.04+ the robustness of our findings cannot be currently estimated. However,
Baseline attention −0.01 −6.17*** test-retest reliability may not be a meaningful metric for tests involving
learning, as prior experience with the test may lead to insights about
RL gain/miss 80% score −0.24 −1.92+
how to approach the test that can affect subsequent scores. It may also
Model 2 (n = 47) be the case that even if low test-retest reliability is obtained, the test
Step 1 0.76 0.57 0.57*** could still be valid. That is, it may accurately measure the construct of
Baseline attention −0.01 −7.79*** interest, and variability in scores over time could be accounted for by spe-
Step 2 0.77 0.60 0.03 cific factors that are expected to affect learning (e.g., drug use, amount of
Baseline attention −0.01 −7.29*** sleep, fluctuations in attention, symptoms). This point has been noted in
RL gain/miss 80% score −0.21 −1.57 prior discussions of psychometric issues in interpreting data from patients
Model 3 (n = 47) with schizophrenia (Mathalon et al., 1993; Silverstein, 2008). In such
Step 1 0.76 0.57 0.57*** cases, reduced test-retest reliability can actually be associated with in-
Baseline attention −0.01 −7.79*** creases in validity (Mathalon et al., 1993; Silverstein, 2008; Willett, 1989).
Future research should consider other mechanisms involved in
Step 2 0.78 0.60 0.03+
attention shaping. A recent meta-analysis found that stronger therapeu-
Baseline attention −0.01 −7.46*** tic alliance in treatment for serious mental illness predicted greater
RL loss/avoid 90% score −0.26 −1.71+ treatment adherence and improvements in functioning across interven-
Percentage indicates the probability of best outcome. tions (Browne et al., 2019). Moreover, Beaudette et al. (2020) found
+
p < 0.10.
that clinician-rated alliance was associated with average attention dur-
ing a similar attention shaping intervention; alliance mediated the rela-
***p < 0.001.
tionship between negative symptoms and attention shaping outcome.
Thus, it seems that one's ability to form a strong alliance with treatment
staff may determine attention shaping success. Relatedly, one's level of
engagement with treatment (i.e., participation in services) greatly influ-
ences therapeutic and functional outcomes (Dixon et al., 2016) and
baseline attention/vigilance as measured by the MCCB did not influ- should also be considered as a potential predictor of attention shaping
ence one's ability to benefit from attention shaping during the group in- response. Research suggests client factors such as better insight, less
tervention. Although these results may seem counterintuitive, they perceived stigma, and a higher sense of mastery are associated with
align with our conclusion that attention shaping benefits even the ability to form a strong therapeutic alliance (Beaudette et al., 2020;
lowest-functioning patients. That is, our participants exhibited below Browne et al., 2019). Sense of mastery itself may be a particularly im-
average IQ and MCCB scores compared with other schizophrenia sam- portant mechanism through which attention shaping operates. Errorless
ples (August et al., 2012) yet still exhibited attentional gains. In a pre- learning, as seen in attention shaping, is thought to lead to recovery by
vious investigation of attention shaping (Silverstein et al., 2014), continuously promoting goal setting, control, and mastery, thereby
patients who showed the greatest shaping response did not differ from strengthening positive self-beliefs in the individual (Grant et al., 2018).
nonresponders on any demographic or clinical variables. Silverstein Similarly, goal attainment leads to improved sense of self (Clarke et al.,
et al. (2014) concluded that patients should not be excluded from atten- 2009) and better therapeutic outcomes for people with serious mental ill-
tion shaping interventions based on clinical or demographic character- ness (Michalak and Holtforth, 2006). In this way, patients high in
istics. Our results extend these findings, as IQ and baseline cognitive self-esteem and mastery may be at an advantage when it comes to
functioning did not affect one's ability to benefit from attention shap- goal-based interventions like attention shaping. Alternatively, attention
ing. Thus, patients should not be excluded from this intervention based shaping may be best suited for those low in mastery because its error-
on low cognitive functioning. less learning design directly targets and improves this domain. Either
Key limitations of this study should be considered. First, because way, future research exploring these constructs may elucidate the pri-
of a relatively small sample (N = 49), lack of power to detect true rela- mary processes through which attention shaping works. Assessing fac-
tionships is a concern. Relatedly, our sample was mostly male and ex- tors such as working alliance, self-esteem, and sense of mastery at
hibited below average cognitive functioning compared with other baseline may help better identify patients best suited for an attention
schizophrenia samples (August et al., 2012). Thus, restrictions in the shaping intervention.
representativeness of our sample should be considered when interpret-
ing results. Our procedure of only analyzing data from participants who
attended a minimum percentage of group sessions is also potentially CONCLUSIONS
problematic. Missing many sessions or discontinuing treatment pre- Although attention shaping has been shown to successfully in-
maturely may be indicative of, or related to having, extreme atten- crease learning during psychological interventions for people with
tional impairments relevant for the success of this intervention. schizophrenia (Silverstein et al., 2001, 2014), it is a resource- and
Excluding these participants may inadvertently exclude a subset of time-intensive process. Thus, establishing a screening tool to determine
the lowest-functioning people with schizophrenia and therefore con- which patients would benefit most from attention shaping is crucial for
found results. However, given that findings were consistent across anal- efficiently and practically delivering this intervention in treatment pro-
yses of data from those who attended at least 50% (n = 40) and at least grams. The current study tested baseline RL ability as a predictor of at-
25% (n = 47) of group sessions, this limitation is likely not a concern. tention shaping response in those with schizophrenia. Contrary to

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The Journal of Nervous and Mental Disease • Volume 209, Number 3, March 2021
hypotheses, we found that less intact pretreatment RL ability and lower
baseline attentiveness predicted participants' attention shaping re-
sponse. These results suggest that attention shaping is most effective
for lower-functioning patients, and those high in RL ability may already
be at their maximum in terms of their response to reinforcers. We con-
clude that attention shaping may not be a primarily RL-driven interven-
tion, and other factors should be considered. Specifically, strength of
one's working alliance with treatment staff, one's self-esteem, and one's
sense of mastery seem to be promising predictors of treatment response.
DISCLOSURE
This work was supported by the National Institutes of Mental
Health, Clinical and Computational Studies of Dopamine Function in
Schizophrenia (grant number 2R01 MH080066-06A1). Principal inves-
tigator: James M. Gold; site principal investigator at Rutgers: Steven
M. Silverstein.
The authors declare no conflict of interest.
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