Kaplan + Sadock's Synopsis of Psychiatry, 11e

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28.12 Psychiatric Rehabilitation

(3) acquisition or relearning of social and conversational skills, and (4) decreased social anxiety. Learning, however, is tedious or almost nonexistent when patients are floridly ill with positive symptoms and high levels of distractibility. Some findings limit the applicability of social skills training. It is more difficult to teach complex conversational skills than to teach briefer, more discrete verbal and nonverbal responses in social situations. Because complex behaviors are more critical for generating social support in the community, methods have been developed to improve the learning and durability of con- versational skills. These training methods, focusing on training in social skills and information-processing skills, are discussed below. Training in Social Perception Skills Recently, efforts have been made to develop strategies for train- ing patients in affect and social cue recognition. Patients with chronic psychotic disorders, such as schizophrenia, often have difficulty perceiving and interpreting the subtle affective and cognitive cues that are critical elements of communication. Social perception abilities are considered the first step in effec- tive interpersonal problem solving; difficulties in this area are likely to lead to a cascade of deficits in social behavior. Train- ing skills in social perception address these deficits and help provide a foundation for developing more specific social and coping skills. Despite attending several social gatherings, Matt felt apart from the rest of the group. He reported that these events seemed like “a jumble of sights and sounds.” His therapist, recognizing Matt’s difficulty with social perception, gave him a series of ques- tions designed to help him organize and give meaning to the social stimuli he encountered. For example, when Matt was confused about a conversation someone was having with him, he would ask himself, “What is this person’s short-term goal? At what level of disclosure should I be? Should I be talking now or listening?” Identifying the rules and goals of a particular social interaction provided a template for Matt to recognize, and react to, a greater variety of social cues, thus enhancing his behavioral repertoire. (Courtesy of Robert Paul Liberman, M.D., Alex Kopelowicz, M.D., and Thomas E. Smith, M.D.) Information-Processing Model of Training.  Meth- ods of training that follow a cognitive perspective teach patients to use a set of generative rules that can be adapted for use in various situations. For example, a six-step problem-solving strategy has developed as an outline for helping patients overcome interpersonal dilemmas: (1) adopt a problem-solving attitude, (2) identify the problem, (3) brainstorm alternative solutions, (4) evaluate solutions and pick one to implement, (5) plan the implementation and carry it out, and (6) evaluate the efficacy of the effort and, if inef- fective, choose another alternative. Although the step-wise, structured, linear process of problem solving occurs intui- tively, without conscious awareness in normal persons, it can be a useful interpersonal crutch to help cognitively impaired mental patients cope with the information needed to fill their social and personal needs.

engages in role play with the trainer. The trainer next provides feedback and positive reinforcement, which are followed by sug- gestions for how the response can be improved. The sequence of role play followed by feedback and reinforcement is repeated until the patient can perform the response adequately. Training is typically conducted in small groups (six to eight patients), in which case patients each practice role playing for three to four trials and provide feedback and reinforcement to one another. Teaching is tailored to the individual—for example, a highly impaired group member might simply practice saying “no” to a simple request, whereas a less cognitively impaired peer might learn to negotiate and compromise. Richard was a single white man first diagnosed with schizo- phrenia at age 22, when he was a freshman at college. He was hos- pitalized briefly but was unable to return to school and moved back home with his parents. He attended a day treatment program inter- mittently over the next 6 years, before he was referred for help with getting a job and dating. Richard had missed out on a critical period of adult develop- ment and had never learned dating skills or the social skills needed to get or maintain a job. He was appropriately groomed and did not present himself as a patient, but he seemed quite uncomfortable in social interactions. He scarcely made eye contact, staring at the floor when he spoke, and did not initiate conversation, responding to questions with brief answers. Richard was invited to participate in a social skills training group for 3 months with six other patients. The focus of the group was employment skills. Patients were taught critical social skills for getting and maintaining a job, such as how to participate in job interviews; how to approach a supervisor to understand how to do a job or for help with work-related problems; how and when to make requests or explain problems, such as getting to work late because of traffic or needing to leave early to go to a doctor’s appointment; and socializing with coworkers. Simultaneously, Richard was enrolled in a supported employment program and worked with a case manager to find a job as a computer support person. He found a 24-hour-per-week job at a small company and continued to attend the skills group, using the sessions to work on interpersonal issues at work, including engaging in casual conversation with coworkers and dealing with unreasonable requests from people. When the vocational skills group ended, Richard was sched- uled for a dating group with seven other male and female patients who had similar interests. This group focused on finding someone to date, dating etiquette, asking someone out (or being asked out), appropriate conversation for dates, sexual interactions, and safe sex practices. In addition to role play and discussion, the group shared ideas on how to meet people and what to do on dates. Richard responded well to treatment. He had maintained the computer job at follow-up, 6 months after he concluded the dat- ing skills group. His case manger also reported that he had a girl- friend, a woman whom he had met at his church group. He had also expressed an interest in enrolling in college classes at night. He was still living at home with his parents, but, for the first time, was seri- ously considering what he would need to do to move out. (Courtesy of Robert E. Drake, M.D., Ph.D., and Alan S. Bellack, Ph.D.) Goals In a treatment setting, there are four major goals of social skills training: (1) improved social skills in specific situations, (2) moderate generalization of acquired skills to similar situations,