Kaplan + Sadock's Synopsis of Psychiatry, 11e

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Chapter 28: Psychotherapies

Social Skills Training The negative symptoms in patients with schizophrenia consti- tute behavioral deficits that go beyond difficulties with asser- tiveness. These patients have inadequate expressive behaviors and inappropriate stimulus control of their social behaviors (i.e., they do not pick up social cues). Similarly, patients with depres- sion often experience a lack of social reinforcement because of a lack of social skills, and social skills training has been found to be efficacious for depression. Patients with social phobia similarly often have not acquired adolescents’ social skills. In fact, their social defensive behaviors (e.g., avoiding eye con- tact, making brief statements, and minimizing self-disclosure) increase the probability of the rejection that they fear. Social skills training programs for patients with schizophre- nia cover skills in the following areas: conversation, conflict management, assertiveness, community living, friendship and dating, work and vocation, and medication management. Each of these skills has several components. For example, assertive- ness skills include making requests, refusing requests, making complaints, responding to complaints, expressing unpleasant feelings, asking for information, making apologies, express- ing fear, and refusing alcohol and street drugs. Each compo- nent involves specific steps. For example, conflict management includes skills in negotiating, compromising, tactful disagree- ing, responding to untrue accusations, and leaving overly stress- ful situations. A situation in which conflict management skills might be used is when the patient and a friend decide to go to a movie and their choice of movie differs. Negotiating and compromising, for example, involves the following steps: 1. Explain one’s viewpoint briefly. At his initial appointment, Phillip described very serious symp- toms of obsessive-compulsive disorder (OCD). He was 23 years old and living at home because he was no longer able to work or go to school. His days were consumed with behaviors related to check- ing, repeating, and hoarding. Phillip was unable to throw away anything—he saved junk mail, used tissues and napkins, old papers and magazines, and any kind of receipt for fear that he might lose something important. Phillip spent many hours checking his trash, his car, and his home to be sure that he had not thrown away any- thing important. He also checked everything he wrote (e.g., checks, school exams and papers, letters and e-mails) to be sure that he had not made a mistake, and he read and reread books, magazines, and articles to be sure he understood the written material adequately. Phillip worried constantly that he had done something wrong and would disappoint his parents. He was also depressed because he was unable to function well in life, and he had tremendous social anxiety that had plagued him for many years, making it difficult to make and keep friends. By the end of Phillip’s second session, his therapist was begin- ning to get a good idea of the general nature and severity of his symptoms and some of the maintaining factors. However, to plan the treatment in more detail and to get a better idea of how the symptoms occurred during his daily life, she asked Phillip to keep daily records over the next week using a form that she had prepared 2. Listen to the other person’s viewpoint. 3. Repeat the other person’s viewpoint. 4. Suggest a compromise.

for him. The form had a place for recording the amount of time he spent doing rituals each morning, afternoon, and evening, as well as another place to record more details about at least one episode of rituals each day (e.g., what was happening before, during, and after the rituals; see Table 28.8-2). Phillip’s therapist determined that his difficulties with obses- sions, rituals, depression, and social fears reflected a core fear of negative evaluation. Phillip was overly concerned with making mis- takes, being imperfect, and disappointing others. Even as a child, Phillip was concerned about not doing well enough, and he had difficulty making friends for fear that others would not like him. His parents, who were highly anxious, provided much adulation when Phillip did things well (e.g., learned to ride a bike, got good grades in school), and they spent much time instructing him about how to improve his performance when an activity or grade was not perfect. As Phillip took on more responsibility at school and with part-time work, he became more concerned about doing things right. He learned that going back and checking his work relieved his anxiety. He also learned that saving his papers for future checking reassured him that he would be able to fix any unrecognized mistakes at a later time. His parents helped him to reduce his anxiety him when he was uncertain about his work by reassuring him that he was doing okay. As Phillip progressed from elementary school to junior high school to high school, his workload and anxiety gradually increased, but he was able to manage things with some moderate checking and saving. When he began attending college, however, the workload increased extensively, and he found himself doing even more check- ing and hoarding to reduce his fears about making mistakes. Phillip began to feel that these behaviors were getting out of control, but he could not stop them. He had to check and recheck to be sure that he was not making mistakes. The cycle of anxiety S ritual S reduced anxiety was so powerfully reinforcing that he could not stop. He needed help to break this cycle and to address his persistent fear of negative evaluation. Phillip’s therapist decided to begin treatment with a course of exposure and response prevention (ERP) to get his obsessions and rit- uals under control and begin to address his core fear of making mis- takes and being evaluated negatively. Given that Phillip’s depression had grown from the disability associated with his OCD, the therapist expected that a successful course of ERP might also help to reduce his depressive symptoms. ERP for Phillip began with a home visit, where the therapist helped him to complete common daily activities with adherence to his RP plan, which included the following:   No more checking: After eating, leave the table immediately without inspecting your plate and the surrounding areas (includ- ing under the table and chair) for lost items. Leave the restroom immediately after using it, without checking the toilet, trash, and sink for lost items. When leaving the car, no more checking of seats, floors, and windows. Write everything (papers, checks, etc.) only once; no checking to be sure that letters and words are correct.   No more repeating: No more rereading books. No staring repeat- edly at items to ensure that nothing is lost.   No more saving. Throw tissues away immediately after using. Discard trash and junk mail immediately. Do not look into the trash can for lost items. Phillip’s parents also were asked to stop reassuring him and to discontinue doing rituals for him. This was a very difficult session for Phillip and his family, but they understood the logic of ERP, and they were willing to try anything. For the next 3 weeks, Phillip and his therapist met three times a week to conduct in vivo exposure sessions that helped him to face his core fears. For many of these sessions, Phillip was asked