Kaplan + Sadock's Synopsis of Psychiatry, 11e

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Chapter 28: Psychotherapies

Social Skills Rehabilitation Social dysfunction is a defining characteristic of schizophre- nia. People with the illness have difficulty fulfilling social roles, such as worker, spouse, and friend, and have difficulty meeting their needs when social interaction is required (e.g., negotiating with merchants, requesting assistance to solve problems). Social dysfunction is semi-independent of symptomatology and plays an important role in the course and outcome of the illness. As shown in Table 28.12-1, social competence is based on three component skills: (1) social perception, or receiving skills; (2) social cognition, or processing skills; and (3) behavioral response, or expressive skills. Social perception is the ability to read or decode social inputs accurately. This includes accurate detection of affect cues, such as facial expressions and nuances of voice, gesture, and body posture, as well as verbal content and contextual information. Social cognition involves effective analysis of the social stimulus, integration of current information with historical information, and planning an effective response. This domain is also referred to as social problem solving. Methods The primary modality of social skills training is role play of simulated conversations. The trainer first provides instructions on how to perform the skill and then models the behavior to demonstrate how it is performed. After identifying a relevant social situation in which the skill might be used, the patient

▲▲ 28.12 Psychiatric

Rehabilitation Psychiatric rehabilitation denotes a wide range of interventions designed to help people with disabilities caused by mental ill- ness improve their functioning and quality of life by enabling them to acquire the skills and supports needed to be success- ful in usual adult roles and in the environments of their choice. Normative adult roles include living independently, attending school, working in competitive jobs, relating to family, having friends, and having intimate relationships. Psychiatric reha- bilitation emphasizes independence rather than reliance on professionals, community integration rather than isolation in segregated settings for persons with disabilities, and patient preferences rather than professional goals. Vocational Rehabilitation Impairment of vocational role performance is a common compli- cation related to schizophrenia. Studies across the United States show that less than 15 percent of patients with severe mental illnesses, such as schizophrenia, are employed. Nevertheless, studies also show that competitive employment is a primary goal for 50 to 75 percent of patients with schizophrenia. Because of patient interests and historical factors, vocational rehabilitation has always been a centerpiece of psychiatric rehabilitation. Antonio is a 45-year-old man who has been a client of a mental health agency for more than 10 years. He attended the rehabilitative day treatment program until it was converted to a supported employ- ment program. His case manager encouraged him to think about the possibility of working part time. Antonio told his case manager that he could not work because of his schizophrenia and because he was helping to raise his two kids and needed to be home at 3 P.M., when they returned from school every day. The case manager explained to Antonio that getting a job does not necessarily mean working 40 hours a week and that lots of people in the agency’s supported employment program were working in part-time jobs, even jobs that only require a few hours a week. Antonio agreed to meet one of the employment specialists to discuss the possibility of work. Over the next couple of weeks, the employment specialist met with Antonio several times, read his clinical record, and talked with his case manager and psychiatrist. The employment specialist learned that Antonio loved to drive his car. He also learned that Antonio had attendance problems in past jobs because he felt unappreciated. The employment specialist found Antonio to be a sociable and likable person. Antonio told the employment specialist that he was willing to do any job. He did not have one specific job in mind. After discuss- ing options with Antonio and with the team, the employment spe- cialist suggested a job at Meals on Wheels as a driver for the lunch delivery. Antonio was hired and loved it right from the start. Absen- teeism was never a problem, because he liked driving around and knew that people were counting on him for their meals. The hours were perfect (10 A.M. to 2 P.M.), so he could be at home when his kids returned from school. He became good friends with the other workers. He told his case manager that it was wonderful to be bring- ing home a paycheck again. And best of all, he said, was that his kids saw him going to work just like their friends’ dads. (Courtesy of Robert E. Drake, M.D., Ph.D., and Alan S. Bellack, Ph.D.)

Table 28.12-1 Components of Social Skill

Expressive behaviors Speech content

Paralinguistic features Voice volume Speech rate Pitch Intonation

Nonverbal behaviors Eye contact (gaze) Posture Facial expression Proxemics Kinesics Receptive skills (social perception) Attention to and interpretation of relevant cues Emotion recognition Processing skills Analysis of the situation demands Incorporation of relevant contextual information Social problem solving Interactive behaviors Response timing Use of social reinforcers Turn taking Situational factors Social “intelligence” (knowledge of social mores and the demands of the specific situation)