Social Skills Training for Schizophrenia: A Step-by-Step Guide
337
Social Skills Training for Schizophrenia: A Step-by-Step Guide
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Overview
Product Details
| ISBN-13: | 9781462513963 |
|---|---|
| Publisher: | Guilford Publications, Inc. |
| Publication date: | 07/29/2013 |
| Sold by: | Barnes & Noble |
| Format: | eBook |
| Pages: | 337 |
| File size: | 2 MB |
About the Author
Kim T. Mueser, PhD, is Executive Director of the Center for Psychiatric Rehabilitation and Professor in the Department of Occupational Therapy at Boston University. Dr. Mueser's clinical and research interests include psychiatric rehabilitation for persons with severe mental illnesses, intervention for co-occurring psychiatric and substance use disorders, and the treatment of posttraumatic stress disorder. He has served on numerous editorial boards, has published many journal articles and book chapters, and has coauthored over 10 books. His book The Complete Family Guide to Schizophrenia (with Susan Gingerich) received the National Alliance on Mental Illness NYC Metro Ken Book Award.
Susan Gingerich, MSW, is a full-time trainer and consultant based in Narberth, Pennsylvania.
Julie Agresta, MSS, MEd, is a licensed social worker in private practice in Cheltenham, Pennsylvania.
Read an Excerpt
Social Skills Training for Schizophrenia
A Step-by-Step GuideThe Guilford Press
Copyright © 2004 The Guilford PressAll right reserved.
ISBN: 1-57230-846-X
Chapter One
Schizophrenia and Social SkillsIf asked to define schizophrenia or explain it, you would probably refer to hallucinations and delusions, the prototypical symptoms. But stop and form an image of a typical patient with schizophrenia. In imagining specific clients and what they are like, you likely think about their appearance and behavior. Even when florid symptomatology is controlled by medication, most individuals with schizophrenia seem a little different or "off center."
It may be difficult to follow their train of thought in a conversation. They may even say some things that sound slightly odd or unrelated to the topic. The person's face and voice may be unusually inexpressive, and he or she may avoid looking at you during the conversation. In fact, you may feel that the person is not really listening to you. Overall, you are apt to feel a little uncomfortable.
Critical factors that lead to your unease can be subsumed under the rubric of social skills deficits. Social skills are interpersonal behaviors that are normative and/or socially sanctioned. They include such things as dress and behavior codes, rules about what to say and not to say, and stylistic guidelines about the expression of affect, social reinforcement,interpersonal distance, and so forth. Whether they have never learned social skills or have lost them, most people with schizophrenia have marked skill deficits. These deficits make it difficult for many clients to establish and maintain social relationships, to fulfill social roles (e.g., worker, spouse), or to have their needs met.
In this chapter, we present an overview of the behavioral model of social skills and how the model applies to schizophrenia. We describe the specific behaviors that constitute social skills and then discuss other factors that interfere with social behavior in schizophrenia, especially information-processing deficits. We then describe some social situations that are especially difficult for clients with schizophrenia.
THE BEHAVIORAL MODEL OF SOCIAL SKILLS
Definition of Social Skills
Many definitions of social skills have been developed, but most specific definitions fail to account for the broad array of social behaviors.
Rather than providing a single, global definition of social skill, we prefer a situation-specific conception of social skills. The overriding factor is effectiveness of behavior in social interactions. However, determination of effectiveness depends on the context of the interaction (e.g., returning a faulty appliance, introducing oneself to a prospective date, expressing appreciation to a friend) and, given any context, the parameters of the specific situation (e.g., expression of anger to a spouse, to an employer, or to a stranger). (Hersen & Bellack, 1976, p. 562)
More specifically, social skills involve the
ability to express both positive and negative feelings in the interpersonal context without suffering consequent loss of social reinforcement. Such skill is demonstrated in a large variety of interpersonal contexts .. and it involves the coordinated delivery of appropriate verbal and nonverbal responses. In addition, the socially skilled individual is attuned to realities of the situation and is aware when he is likely to be reinforced for his efforts. (Hersen & Bellack, 1976, p. 562)
Two aspects of this definition warrant special mention. First, socially skilled behavior is situationally specific. Few, if any, aspects of interpersonal behavior are universally or invariably appropriate (or inappropriate). Both cultural and situational factors determine social norms. For example, in U.S. society, kissing is sanctioned within families and between lovers, but not between casual acquaintances or in the office. Direct expression of anger is more acceptable within families and toward referees at sporting events than toward an employer. The socially skilled individual must know when, where, and in what form different behaviors are sanctioned. Thus, social skill involves the ability to perceive and analyze subtle cues that define the situation as well as the presence of a repertoire of appropriate responses.
Second, social competence involves the maximization of reinforcement. Marriage, friendship, sexual gratification, employment, service (e.g., in stores, restaurants), and personal rights are all powerful sources of reinforcement that hinge on social skills. The unskilled individual is apt to fail in most or all of these spheres and, consequently, experience anxiety, frustration, and isolation, all of which are especially problematic for people with schizophrenia. Thus, social skills deficits may increase the risk of relapse, whereas enhanced social competence may decrease that risk.
Social Skills and Social Behavior
The following discussion elaborates the elements of the social skills model depicted in Table 1.1. First, interpersonal behavior is based on a distinct set of skills. The term skill is used to emphasize that social competence is based on a set of learned performance abilities, rather than traits, needs, or other intrapsychic processes. Conversely, poor social behavior is often the result of social skills deficits. Basic aspects of social behavior are learned in childhood, while more complex behavioral repertoires, such as dating and job interview skills, are acquired in adolescence and young adulthood. It appears as if some elements of social competence, such as the facial expression of affect, are not learned, but are genetically "hard wired" at birth. Nevertheless, research suggests that virtually all social behaviors are learnable; that is, they can be modified by experience or training.
As indicated in Table 1.1, social dysfunction results from three circumstances: when the individual does not know how to perform appropriately, when he or she does not use skills in his or her repertoire when they are called for, or when appropriate behavior is undermined by socially inappropriate behavior. The first of these circumstances is especially common in schizophrenia. Individuals with schizophrenia fail to learn appropriate social behaviors for three reasons. First, children who otherwise seem normal but who later develop schizophrenia in adulthood seem to have subtle attention deficits in childhood. These deficits interfere with the development of appropriate social relationships and the acquisition of social skills. Second, schizophrenia often strikes first in late adolescence or young adulthood, a critical period for mastery of adult social roles and skills, such as dating and sexual behaviors, work-related skills, and the ability to form and maintain adult relationships.
Many individuals with schizophrenia gradually develop isolated lives, punctuated by lengthy periods in psychiatric hospitals or in community residences. Such events remove clients from their normal peer group, provide few opportunities to engage in age-appropriate social roles, and limit social contacts to mental health staff and other severely ill clients. Under such circumstances, clients do not have an opportunity to acquire and practice appropriate adult roles. Moreover, skills mastered earlier in life may be lost because of disuse or lack of reinforcement by the environment.
Other Factors That Affect Social Functioning
Why might a person not use behaviors that are still in his or her repertoire, as suggested by item 3b in Table 1.1? As indicated in Table 1.2, a number of factors can be expected to influence social behavior in schizophrenia in addition to social skills per se (Bellack & Mueser, 1993).
Psychotic Symptoms
It should not be surprising that an individual hearing highly intrusive voices, or feeling jeopardized by malevolent forces, would be unable to focus on social interactions. Clients can be expected to have difficulty fulfilling social roles and behaving in a socially appropriate manner at the height of acute exacerbations.
However, research indicates that clients with schizophrenia have marked deficits in social competence even when psychotic symptoms are under control; conversely, many clients can learn more effective ways of interacting even when they have persistent symptoms. Psychotic symptoms may have a limiting effect on social performance, but they do not explain the bulk of social disability in this population.
Motivational Factors
Many individuals with schizophrenia actively avoid social interactions and appear to have little motivation to develop social relationships. Several factors seem to be involved in this pattern. First, most chronic clients have a history of social failure, rejection, and criticism. As a result, they learn that it may be safer to minimize social interactions than to risk further failure or censure. Second, most clients are engaged in a lifelong struggle to find an equilibrium in which they can control their symptoms, limit their experience of negative affect, and maintain the best possible quality of life. Although at one level they may desire to have improved social relationships and undertake more demanding social roles, venturing out into the social environment may pose an unmanageable threat.
Affective States
As indicated earlier, social interaction is often very anxiety provoking to individuals with schizophrenia which leads to avoidance. Moreover, clients frequently seek to escape from social interactions initiated by others. Research from our laboratory has shown that clients are particularly sensitive to conflict and criticism and will withdraw from potential conflict situations even when they are being taken advantage of or unjustly accused of things they have not done (Bellack, Mueser, Wade, Sayers, & Morrison, 1992).
Environmental Factors
Three aspects of the environment often make it difficult for clients with schizophrenia to use their social skills effectively. First, as their skills tend to be limited, their performance is often odd or imperfect in some way. Unfortunately, many people are not tolerant of idiosyncrasies or social errors and tend to be unsympathetic, impatient, or overtly critical. As a result, clients are not reinforced for their efforts and, in some circumstances, may receive a critical or hostile response. Hence, they tend to become wary of engaging in social interactions.
Second, many clients are unemployed and live in harsh economic circumstances. They do not have the resources to participate in social recreational activities that they might otherwise be able to succeed in and enjoy. Finally, many clients are isolated and do not have good social networks. The illness is stigmatizing, leading others to avoid them. In addition, repeated exacerbations and periods in the hospital disrupt relationships and gradually remove clients from the social environment. Friendships generally develop from the workplace or school, hobbies, volunteer activities, child rearing, and other activities that individuals with schizophrenia often do not participate in. As a result, social contacts for many clients are limited to other clients, mental health staff, and/or family members.
Neurobiological Factors
Several significant neurobiological factors affect social behavior in schizophrenia. The illness is characterized by significant deficits in information processing: the multiple abilities necessary for thinking, learning, and remembering (Green, Kern, Braff, & Mintz, 2000). People with schizophrenia tend to have a variety of problems with attention. They cannot process information as rapidly as others. They have difficulty discriminating important from unimportant stimuli, such as what the interpersonal partner is saying versus voices coming from another conversation or the TV. They have problems with concentrating, focusing attention, sustaining attention over time, or focusing in difficult conditions such as when under stress or when presented with a highly complex task. Thus, they may have great difficulty in attending to what someone is saying if the person speaks rapidly or presents a lot of complex information, if there are distractions (e.g., other conversations going on in the background), if the other person is angry and increasing their level of stress or anxiety, or if the person is providing confusing cues (e.g., subtlety or sarcasm).
Clients with schizophrenia also frequently have problems with memory, especially with short-term verbal memory (e.g., what someone said or told them to do) (Mueser, Bellack, Douglas, & Wade, 1991) and working memory (e.g., ability to retain information on line while making a decision or solving a problem). The problem does not seem to be one of forgetting as much as difficulty in initial learning or accessing information that has been learned (e.g., as when you cannot remember a name). Individuals with schizophrenia often seem forgetful or distracted, and they may be accused of not paying attention or not caring about important things. In fact, the real problem may be that the information is not presented in a way that adjusts for their attention problems (e.g., slowly, clearly, and with repetition) or that they simply cannot remember what they did hear unless they are provided with reminders or prompts.
A third important information-processing deficit involves higher-level or complex information processing. People with schizophrenia have trouble in problem solving, in part because they have difficulty in drawing abstractions or deducing relationships between events. A related problem involves the ability to draw connections between current and past experience. Whether it is because they cannot recall past experience, cannot determine when past experience is relevant, or because they simply cannot integrate the diverse processes of memory, attention, and analysis of multiple pieces of information, these individuals have difficulty in learning from experience. They also are unable to effectively organize mental efforts, such as initiating and maintaining a plan of action. As a result, their reasoning and problem solving often seem to be disorganized or even random.
These various problems are not extreme, such as the memory impairment in Alzheimer's disease, but they can nevertheless disrupt social behavior and the ability to fulfill social roles. The fact that these deficits cause significant problems without their being very noticeable to other people sometimes adds to their negative effects, as family members and others in contact with such clients often get frustrated and angry with them when they fail to respond or do things that they appeared to understand (e.g., requests for favors, directions for taking medications). As indicated earlier, disability is often mistaken for laziness, disrespect, and other undesirable personal attributes.
Continues...
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Table of Contents
I. Principles, Format, and Techniques for Social Skills Training of Clients with Schizophrenia1. Schizophrenia and Social Skills
2. Social Skills Training as an Evidence-Based Practice
3. Assessment of Social Skills
4. Teaching Social Skills
5. Starting a Skills Group
6. Using Curricula for Social Skills Training Groups
7. Tailoring Skills for Individual Needs
8. Troubleshooting: Common Problems and Challenging Clients
9. Working with Clients Who Abuse Drugs and Alcohol
10. Reducing Relapse by Creating a Supportive Environment
11. Parting Tips for Social Skills Trainers
II. Steps for Teaching Specific Social Skills: Curricular Skill Sheets
Appendix A. Materials Useful to Group Leaders
Appendix B. Materials Related to Assessment
Interviews
Practitioners working with mentally ill individuals in inpatient settings, group homes, community mental health centers, special education classes, and other settings.