A review and critique of social skills training with schizophrenic patients

Narrative-Derived Indices of Metacognition among People with Schizophrenia: Associations with Self-Reported and Performance-Based Social Functioning

Metacognitive functioning-which broadly encompasses the mental processes involved in thinking about the thinking of one's self and the thinking of others-is often impaired among individuals living with schizophrenia and may contribute to difficulties in social and interpersonal functioning. Although the majority of studies assessing metacognition among individuals with schizophrenia use standardized, laboratory-based measurements, an increasing number of studies have measured metacognitive capacity using natural language produced by individuals living with mental illness. At the same time, less is known about how language-derived indices of metacognitive function relate to key social outcomes among people with schizophrenia. The primary objective of this study was to employ a validated language coding system (the Metacognition Assessment Scale, Abbreviated; MAS-A) to assess metacognitive functioning from the spoken life narratives of individuals with schizophrenia (n = 32) and community controls (n = 15). Among individuals with schizophrenia, we also examined the associations between language-derived metacognition and measures of self-reported and performance-based social functioning. Our results suggest that most aspects of metacognition in our sample were not significantly diminished in people with schizophrenia compared to community controls. Unexpectedly, the MAS-A subscale related to one's ability to master psychological difficulties was rated higher among individuals with schizophrenia. Further, our results suggest that among people with schizophrenia, higher metacognitive functioning in the domain of self-reflectivity was associated with poorer self-reported social functioning, while a greater metacognitive awareness of other individuals' minds was associated with better scores on aspects of performance-based social functioning. Collectively, these results underscore the utility of assessing metacognitive functioning via life-story narratives to understand social outcomes and highlight possible aspects of resiliency among individuals who have experienced a serious mental illness.

Cycles of reform in the history of psychosis treatment in the United States

The history of psychosis treatment follows a series of four cycles of reform which provide a framework for understanding mental health services in the United States. The first three cycles of reform promoted the view that early treatment of mental disorders would reduce chronic impairment and disability. The Moral Treatment era (early 1800's to 1890) featured freestanding asylums, the Mental Hygiene movement (1890 to World War II) introduced psychiatric hospitals and clinics, and the Community Mental Health Reform period (World War II to late 1970's) produced community mental health centers. None of these approaches succeeded in achieving the disability-prevention goals of early treatment of psychosis. The fourth cycle, the Community Support Reform era (late 1970's to the present) shifted the focus to caring for those already disabled by a mental disorder within their communities and using natural support systems. This shift embraced a broader social welfare framework and included additional services and supports, such as housing, case management, and education. Psychosis became more central during the current Community Support Reform era partly because individuals with psychosis continued to have disabling life experiences despite efforts at reform. Some degree of recovery from psychosis is possible, and individuals with serious impairment may move towards social integration and community participation. Early intervention for young people with psychosis focuses on reducing the negative sequelae of psychosis and promotes recovery-oriented changes in service delivery. The role of social control, the involvement of service users and their families, and the balance between psychosocial and biomedical treatments play an important role in this history. This paper describes the reform cycles, their political and policy contexts, and what influenced its successes and shortcomings.

Social decision making in severe alcohol use disorder: Scoping review and experimental perspectives

BACKGROUND

Patients with severe alcohol use disorder (SAUD) demonstrate multifaceted impairments in social cognition abilities, including emotional decoding or Theory of Mind. Such impairments are associated with real-life interpersonal difficulties, which in turn could contribute to the persistence of SAUD. However, little is known regarding how patients with SAUD make decisions in a social context and this literature has not been comprehensively reviewed.

OBJECTIVES

The main aim of this paper was to conduct the first review specifically focusing on social decision-making abilities in SAUD. Following PRISMA guidelines for scoping reviews, we describe existing knowledge regarding the difficulties experienced by patients with SAUD during social interactions. Our second objective was to propose perspectives for future research, based on the shortcomings identified in the available literature.

DESIGN

We searched three online databases (PubMed, PsycINFO, and Scopus) and identified 14 papers using behavioral tasks to assess social decision making in patients with SAUD.

RESULTS

Included studies assessed social decision making through three paradigms: (1) economic games (four papers), (2) moral dilemmas (four papers), and (3) interpersonal problem-solving (six papers). Results indicated that patients with SAUD behave differently from controls in all three paradigms.

CONCLUSIONS

Previous studies suggested large-scale social decision-making impairments or biases in SAUD. However, in light of the limited number of studies available and of the restricted set of processes measured, we call for the extension of this field through more ecologically relevant and model-based paradigms in order to elucidate the underlying mechanisms of these effects.

A Meta-Analysis of Social Skills Training and Related Interventions for Psychosis

Objective

Evidence suggests that social skills training (SST) is an efficacious intervention for negative symptoms in psychosis, whereas evidence of efficacy in other psychosis symptom domains is limited. The current article reports a comprehensive meta-analytic review of the evidence for SST across relevant outcome measures, control comparisons, and follow-up assessments. The secondary aim of this study was to identify and investigate the efficacy of SST subtypes.

Methods

A systematic literature search identified 27 randomized controlled trials including N = 1437 participants. Trials assessing SST against active controls, treatment-as-usual (TAU), and waiting list control were included. Risk of bias was assessed using the Cochrane risk of bias assessment tool. A series of 70 meta-analytic comparisons provided effect sizes in Hedges' g. Heterogeneity and publication bias were assessed.

Results

SST demonstrated superiority over TAU (g = 0.3), active controls (g = 0.2-0.3), and comparators pooled (g = 0.2-0.3) for negative symptoms, and over TAU (g = 0.4) and comparators pooled (g = 0.3) for general psychopathology. Superiority was indicated in a proportion of comparisons for all symptoms pooled and social outcome measures. SST subtype comparisons were underpowered, although social-cognitive approaches demonstrated superiority vs comparators pooled. SST treatment effects were maintained at proportion of follow-up comparisons.

Conclusions

SST demonstrates a magnitude of effect for negative symptoms similar to those commonly reported for cognitive-behavioral therapy (CBT) for positive symptoms, although unlike CBT, SST is not routinely recommended in treatment guidelines for psychological intervention. SST may have potential for wider implementation. Further stringent effectiveness research alongside wider pilot implementation of SST in community mental health teams is warranted.

Assertiveness Training for Clients with a Psychiatric Illness: A Pilot Study

The current literature documents a need for assertiveness training for clients with a psychiatric illness, in order to address this need, a programme was designed and implemented to provide clients with practical techniques to enable them to communicate in a more effective, assertive manner. The frames of reference for the programme were the model of human occupation and social teaming theory. Data were collected over a 2-year period from 33 clients with a psychiatric illness who participated in a 7-week training programme. The investigation incorporated a prospective one-group, pre-test/post-test design. The Rathus assertiveness schedule and the Rosenberg self-esteem scale were used to measure changes in assertiveness and self-esteem. A t-test analysis of the pre-test and post-test scores attained by group participants on both scales indicated a statistically significant increase in their level of assertive behaviour and self-esteem. A brief review of the pertinent literature and a description of the assertiveness training programme are provided. Programme evaluation results and recommendations for further research are also discussed.

Teaching Social Communication Skills Through Human-Agent Interaction

There are a large number of computer-based systems that aim to train and improve social skills. However, most of these do not resemble the training regimens used by human instructors. In this article, we propose a computer-based training system that follows the procedure of social skills training (SST), a well-established method to decrease human anxiety and discomfort in social interaction, and acquire social skills. We attempt to automate the process of SST by developing a dialogue system named the automated social skills trainer , which teaches social communication skills through human-agent interaction. The system includes a virtual avatar that recognizes user speech and language information and gives feedback to users. Its design is based on conventional SST performed by human participants, including defining target skills, modeling, role-play, feedback, reinforcement, and homework. We performed a series of three experiments investigating (1) the advantages of using computer-based training systems compared to human-human interaction (HHI) by subjectively evaluating nervousness, ease of talking, and ability to talk well; (2) the relationship between speech language features and human social skills; and (3) the effect of computer-based training using our proposed system. Results of our first experiment show that interaction with an avatar decreases nervousness and increases the user's subjective impression of his or her ability to talk well compared to interaction with an unfamiliar person. The experimental evaluation measuring the relationship between social skill and speech and language features shows that these features have a relationship with social skills. Finally, experiments measuring the effect of performing SST with the proposed application show that participants significantly improve their skill, as assessed by separate evaluators, by using the system for 50 minutes. A user survey also shows that the users thought our system is useful and easy to use, and that interaction with the avatar felt similar to HHI.

Video feedback in CBT supervision: review and illustration of two specific techniques

There is now expert consensus that directly observing the work of trainee therapists vs. relying upon self-report of sessions, is critical to providing the accurate feedback required to attain a range of competencies. In spite of this expert consensus however, and the broadly positive attitudes towards video review among supervisees, video feedback methods remain under-utilized in clinical supervision. This paper outlines some of the weaknesses that affect feedback based solely on self-report methods, before introducing some of the specific benefits that video feedback methods can offer the training and supervision context. It is argued that video feedback methods fit seamlessly into CBT supervision providing direct, accessible, effective, efficient and accurate observation of the learning situation, and optimizing the chances for accurate self-reflections and planning further improvements in performance. To demonstrate the utility of video feedback techniques to CBT supervision, two specific video feedback techniques are introduced and described: the Give-me-5 technique and the I-spy technique. Case examples of CBT supervision using the two techniques are provided and explored, and guidance as to the supervision contexts in which each of the two techniques are suitable, individually, and in tandem, are outlined. Finally, best practice guidelines for the use of video feedback techniques in supervision are outlined.

Working memory dysfunctions predict social problem solving skills in schizophrenia

The current study aimed to examine the contribution of neurocognition and social cognition to components of social problem solving. Sixty-seven inpatients with schizophrenia and 31 healthy controls were administrated batteries of neurocognitive tests, emotion perception tests, and the Chinese Assessment of Interpersonal Problem Solving Skills (CAIPSS). MANOVAs were conducted to investigate the domains in which patients with schizophrenia showed impairments. Correlations were used to determine which impaired domains were associated with social problem solving, and multiple regression analyses were conducted to compare the relative contribution of neurocognitive and social cognitive functioning to components of social problem solving. Compared with healthy controls, patients with schizophrenia performed significantly worse in sustained attention, working memory, negative emotion, intention identification and all components of the CAIPSS. Specifically, sustained attention, working memory and negative emotion identification were found to correlate with social problem solving and 1-back accuracy significantly predicted the poor performance in social problem solving. Among the dysfunctions in schizophrenia, working memory contributed most to deficits in social problem solving in patients with schizophrenia. This finding provides support for targeting working memory in the development of future social problem solving rehabilitation interventions.

Social Skills Training for Schizophrenic Patients

Deficiencies in social skills are a major problem in the rehabilitation of schizophrenic patients. To adapt to community life, schizophrenic patients must meet certain minimum levels of socially acceptable behaviour. Over the last two decades, social skills training procedures have been used to systematically teach these behaviours. Procedures typically used in social skills training include instructions/coaching, modelling, behavioural rehearsal and role play, feedback and reinforcement, and homework assignments. These and other procedures are discussed in this review. In addition, the outcome of social skills training for the schizophrenic patient is discussed with reference to short- and long-term changes in social behaviour.

Social cognition and social functioning in nonclinical paranoia

INTRODUCTION

Persons with nonclinical paranoia show many of the same biases as those with clinical paranoia, suggesting that paranoia exists on a continuum. However, little is known about the various social cognitive processes found in paranoia and how these relate to social functioning and social behaviours in general. This study will examine performance on emotion perception and attributional style measures and their relationship to social functioning, social problem solving, and social skill. A key element in this study will be the incorporation of ambiguity in the perception of emotional expressions and the assignment of attributional blame, which appears to be an important, yet neglected, construct in paranoia.

METHODS

Twenty-six persons with high levels of nonclinical paranoia and 31 persons with low levels of paranoia completed measures of emotion perception, attributional style, social functioning, and social problem solving. Salient and subtle emotional expressions were used to examine how ambiguity impacts emotion perception in paranoia.

RESULTS

The group high in nonclinical paranoia showed reduced accuracy for subtle negative emotional expressions and showed more perceived hostility and blame for ambiguous social situations as compared to the group low in nonclinical paranoia. Also, the high nonclinical paranoia group reported less social engagement, fewer social contacts, and more problems in social perception and social skill than the group low in nonclinical paranoia.

CONCLUSION

Social cognitive and social functioning biases are found in persons with high levels of nonclinical paranoia. Possible mechanisms of these biases and relevance for treatment approaches are discussed.

Memory functioning and negative symptoms as differential predictors of social problem solving skills in schizophrenia

BACKGROUND

Neurocognition in general, and memory functioning in particular, as well as symptoms have all been shown to be related to social problem solving (SPS) in schizophrenia. However, few studies have directly compared the relative contribution of neurocognition vs. psychiatric symptoms to the components of SPS.

METHOD

Sixty outpatients (aged 21-65) who met DSM-IV criteria for schizophrenia or schizoaffective disorder were administered a broad battery of memory tests and assessed for severity of positive and negative symptoms as part of a baseline assessment of a study of psychiatric rehabilitation. Multiple regression analyses were used to examine the contribution of memory functioning vs. symptoms on receiving, processing, and sending skill areas of social problem solving ability.

RESULTS

An index of verbal learning was the strongest predictor of processing skills whereas negative symptoms were the strongest predictor of sending skills. Positive symptoms were not related to any of the three skill areas of social problem solving.

CONCLUSIONS

Memory functioning and psychiatric symptoms differentially predict selected areas of social problem solving ability in persons with schizophrenia. Consistent with other reports, positive symptoms were not related to social problem solving. Consideration of both neurocognition and negative symptoms may be important to the development of rehabilitation interventions in this area of functioning.

The Nonverbal Transmission of Intergroup Bias: A Model of Bias Contagion with Implications for Social Policy

Social and policy interventions over the last half-century have achieved laudable reductions in blatant discrimination. Yet members of devalued social groups continue to face subtle discrimination. In this article, we argue that decades of anti-discrimination interventions have failed to eliminate intergroup bias because such bias is contagious. We present a model of bias contagion in which intergroup bias is subtly communicated through nonverbal behavior. Exposure to such nonverbal bias "infects" observers with intergroup bias. The model we present details two means by which nonverbal bias can be expressed-either as a veridical index of intergroup bias or as a symptom of worry about appearing biased. Exposure to this nonverbal bias can increase perceivers' own intergroup biases through processes of implicit learning, informational influence, and normative influence. We identify critical moderators that may interfere with these processes and consequently propose several social and educational interventions based on these moderators.

Effectiveness of integrated psychological therapy (IPT) for schizophrenia patients: a research update

Standardized recovery criteria go beyond symptom remission and put special emphasis on personal and social functioning in residence, work, and leisure. Against this background, evidence-based integrated approaches combining cognitive remediation with social skills therapy show promise for improving functional recovery of schizophrenia patients. Over the past 30 years, research groups in 12 countries have evaluated integrated psychological therapy (IPT) in 36 independent studies. IPT is a group therapy program for schizophrenia patients. It combines neurocognitive and social cognitive interventions with social skills and problem-solving approaches. The aim of the present study was to update and integrate the growing amount of research data on the effectiveness of IPT. We quantitatively reviewed the results of these 36 studies, including 1601 schizophrenia patients, by means of a meta-analytic procedure. Patients undergoing IPT showed significantly greater improvement in all outcome variables (neurocognition, social cognition, psychosocial functioning, and negative symptoms) than those in the control groups (placebo-attention conditions and standard care). IPT patients maintained their mean positive effects during an average follow-up period of 8.1 months. They showed better effects on distal outcome measures when all 5 subprograms were integrated. This analysis summarizes the broad empirical evidence indicating that IPT is an effective rehabilitation approach for schizophrenia patients and is robust across a wide range of sample characteristics as well as treatment conditions. Moreover, the cognitive and social subprograms of IPT may work in a synergistic manner, thereby enhancing the transfer of therapy effects over time and improving functional recovery.

Reliability and validity of The Awareness of Social Inference Test (TASIT): A clinical test of social perception

PURPOSE

The Awareness of Social Inference Test (TASIT) is an audiovisual tool designed for the clinical assessment of social perception with alternate forms for re-testing. Part 1 assesses emotion recognition, Parts 2 and 3 assess the ability to interpret conversational remarks meant literally (i.e., sincere remarks and lies) or non-literally (i.e., sarcasm) as well as the ability to make judgments about the thoughts, intentions and feelings of speakers. This paper aims to examine TASIT's reliability and validity.

METHOD

Some 32 adults with severe, chronic brain injuries were administered Form A twice, one week apart. 38 adults with brain injuries were readministered alternate forms over a period of 5 - 26 weeks. Construct validity was examined in subsets of a sample of 116 adults with brain injuries by relating TASIT performance to standard tests of neuropsychological function and specific social perception measures.

RESULTS

Test-retest reliability ranged from 0.74 - 0.88. Alternate forms reliability ranged from 0.62 - 0.83. TASIT performance was associated with face perception, information processing speed and working memory. Socially relevant new learning and executive tasks were significantly associated with TASIT performance whereas non-social tasks showed little association. Social perception tasks such as Ekman photos and theory of mind stories were also associated.

CONCLUSIONS

TASIT has adequate psychometric properties as a clinical test of social perception. It is not overly prone to practice effects and is reliable for repeat administrations. Performance on TASIT is affected by information processing speed, working memory, new learning and executive functioning, but the uniquely social material that comprises the stimuli for TASIT will provide useful insights into the particular difficulties people with clinical conditions experience when interpreting complex social phenomena.

Social Skills Training with Chronic Schizophrenic Patients Living in Community Settings

Six patients meeting DSM III criteria for schizophrenia, residual phase who lived in community hostels underwent social skills training. The training programme utilized was “Stacking the Deck” developed by Foxx et al. which involves a structured board game incorporating modelling, behaviour and feedback. A multiple baseline across subject design was used to assess acquisition of targeted social behaviours in the training settings. Generalization of skills to a community setting was assessed by a structured interaction in the patients' homes at pre-treatment, post-treatment and follow-up. All subjects improved their social skills in the training setting, the improvement showed partial but weak generalization to the community setting, with some gains maintained to a three-month follow-up. Pre-treatment, post-treatment and follow-up measures of general social skills and psychiatric status indicated improvements for some of the subjects. The results suggest this approach has promise for achieving clinically significant change with chronic schizophrenic patients, but that strategies to enhance generalization of training effects are needed.

Vocational outcomes of an integrated supported employment program for individuals with persistent and severe mental illness

We examined the effectiveness of an integrated supported employment (ISE) program, which augments Individual Placement & Support (IPS) with social skills training (SST) in helping individuals with SMI achieve and maintain employment. A total of 163 participants were randomly assigned to three vocational rehabilitation programs: ISE, IPS, and traditional vocational rehabilitation (TVR). After fifteen months of services, ISE participants had significantly higher employment rates (78.8%) and longer job tenures (23.84 weeks) when compared with IPS and TVR participants. IPS participants demonstrated better vocational outcomes than TVR participants. The findings suggested that ISE enhances the outcomes of supported employment, endorsing the value of SST in vocational rehabilitation.

Social/communication skills, cognition, and vocational functioning in schizophrenia

Deficits in social/communications skills have been documented in schizophrenia, but it is unclear how these deficits relate to cognitive deficits and to everyday functioning. In the current study, social/communication skills performance was measured in 29 schizophrenia patients with a history of good vocational functioning (GVF) and 26 with a history of poor vocational functioning (PVF) using a role-play-based social skills assessment, the Maryland Assessment of Social Competence (MASC). A battery of standard cognitive tasks was also administered. MASC-indexed social skills were significantly impaired in PVF relative to GVF patients (odds ratio = 3.61, P < .001). Although MASC social skills performance was significantly associated with cognitive performance in domains of verbal ability, processing speed, and memory, the MASC nevertheless remained an independent predictor of vocational functioning even after controlling for cognitive performance. Social/communications skills predict vocational functioning history independently of cognitive performance, and social skills measures should be considered for inclusion in test batteries designed to predict everyday functioning in schizophrenia.

Integrated psychological therapy (IPT) for schizophrenia: is it effective?

Against the background of evidence-based treatments for schizophrenia, nowadays the implementation of specific cognitive and behavioral interventions becomes more important in the standard care of these patients. Over the past 25 years, research groups in 9 countries have carried out 30 independent evaluations of Integrated Psychological Therapy (IPT), a group program that combines neurocognitive and social cognitive interventions with social skills approaches for schizophrenic patients. The aim of the present study was to evaluate the effectiveness of IPT under varying treatment and research conditions in academic and nonacademic sites. In a first step, all 30 published IPT studies with the participation of 1393 schizophrenic patients were included in the meta-analysis. In a second step, only high-quality studies (HQS) (7 studies including 362 patients) were selected and analyzed to check whether they confirmed the results of the first step. Positive mean effect sizes favoring IPT over control groups (placebo-attention conditions, standard care) were found for all dependent variables, including symptoms, psychosocial functioning, and neurocognition. Moreover, the superiority of IPT continued to increase during an average follow-up period of 8.1 months. IPT obtained similarly favorable effects across the different outcome domains, assessment formats (expert ratings, self-reports, and psychological tests), settings (inpatient vs outpatient and academic vs nonacademic), and phases of treatment (acute vs chronic). The HQS confirmed the results of the complete sample. The analysis indicates that IPT is an effective rehabilitation approach for schizophrenia that is robust across a wide range of patients and treatment conditions.

Attentional dysfunction, social perception, and social competence: what is the nature of the relationship?

The aim of this study was to examine the nature of the relationship between attentional dysfunction and social competence deficits in patients with schizophrenia. Attentional functioning, social perception, and social competence were assessed in 56 inpatients. Measures of vigilance and span of apprehension were administered to assess attentional functioning. Social perception was assessed with an audiovisual measure of affect recognition. Social competence was rated from a role-play task. Span of apprehension and auditory vigilance emerged as specific predictors of social competence. Affect recognition was tested as a mediator and a moderator of the relationship between attentional dysfunction and social competence. Affect recognition was found to moderate the relationship between span of apprehension and social competence.

Cognitive predictors of skill acquisition on social problem solving in patients with schizophrenia

The aim of the study was to evaluate the relationship between social problem solving ability, clinical features and cognitive functions, and determine the predictors of benefit from social problem solving training in 63 patients with schizophrenia. We administered Brief Psychiatric Rating Scale (BPRS), Wisconsin Card Sorting Test (WCST), Digit Span Test, Continuous Performance Test (CPT) and the Assessment of Interpersonal Problem Solving Skills (AIPSS). Only BPRS-positive symptoms subscale was negatively related to AIPSS on linear regression analysis. After the completion of the pretest, the patients were randomized to either problem solving training (n = 32) or control groups (n = 31). Patients in training group received 6 weeks problem solving training in-group modality, and those in control group were treated as usual. We readministered AIPSS at the end of 6 weeks. There were significant changes from pretest to posttest on AIPSS-total, AIPSS-receiving skills, and AIPSS-processing skills score in training group but not in control group. The number of correct answers in WCST and CPT hit rate were the predictors of post-training AIPSS scores in training group. Our findings suggest that skill acquisition on social problem solving is related with cognitive flexibility and sustained attention.

Chinese version of the Assessment of Interpersonal Problem Solving Skills

The study consisted of three phases. In the first phase, we translated the Assessment of Interpersonal Problem Solving Skills (AIPSS) from English to Chinese (CAIPSS), studied the Chinese version's cultural relevance and re-edited the film. A qualified translator translated the package from English to Chinese. Another independent qualified translator backward-translated the materials. An expert panel with 14 experienced clinicians was formed to assess the cultural relevancy of the package. All of them stated that the Chinese version was more culturally relevant. Given the preceding, a culturally relevant CAIPSS was finally developed for use by Hong Kong clinicians. The second phase was to evaluate the reliability of the CAIPSS. Some 30 participants (16 males, 14 females) with schizophrenia were recruited for this study. Internal consistency, test-retest reliability and inter-rater reliability were studied. Results indicated good to excellent internal consistency, excellent inter-rater reliability, and good test-retest reliability. The third phase was the study of convergent validity with another group of 30 participants (13 males, 17 females) with schizophrenia. Results show that CAIPSS had good convergent validity with scales measuring similar constructs. To conclude, this assessment package is user-friendly with good psychometric properties. Local clinicians should feel comfortable using it as an integral part of their daily practice to examine their client's social skills.

Cognitive rehabilitation for schizophrenia and the putative role of motivation and expectancies

Cognitive rehabilitation (CR) approaches seek to enhance cognitive processes or to circumvent cognitive impairments in schizophrenia in an effort to improve functional outcome. In this review we examine the research findings on the 8 evidence-based approaches to cognitive remediation listed in the 2005 Training Grid Outlining Best Practices for Recovery and Improved Outcomes for People With Serious Mental Illness, developed by the American Psychological Association Committee for the Advancement of Professional Practice. Though the approaches vary widely in theoretical orientation and methods of intervention, the results are, for the most part, encouraging. Improvements in attention, memory, and executive functioning have been reported. However, many persons with schizophrenia are more impaired in real-world functioning than one would expect given the magnitude of their cognitive deficits. We may need to look beyond cognition to other targets such as motivation to identify the reasons that many persons with schizophrenia demonstrate such marked levels of disability. Although a number of current CR approaches address motivation to varying degrees, treating motivation as a primary target may be needed to maximize CR outcomes.

Cognitive functions related to interpersonal problem-solving skills in schizophrenic patients compared with healthy subjects

Subjects with schizophrenia have cognitive alterations. The functional consequences of these deficits need to be fully determined, in order to implement more effective rehabilitation programs for patients with schizophrenia. This research explores the relationships between cognitive functioning and social problem-solving skills in a group of 20 chronic schizophrenic patients compared with those found in a group of 20 healthy subjects. The following cognitive domains were evaluated: verbal memory (Rey Auditory-Verbal Test; RAVLT), visuo-spatial organization and visuo-spatial memory (Rey-Osterrieth complex figure test; RF), executive functioning (semantic verbal fluency test; VF, design fluency task; DF and Wisconsin Card Sorting Test; WCST), attention (d 2 cancellation test) and general intellectual ability (Standard Progressive Matrices of Raven; SPM). Social problem-solving skills were assessed with a video-based test; the Assessment of Interpersonal Problem-Solving Skills (AIPSS). As a group, patients performed significantly worse than control subjects on every cognitive variable and on AIPSS receiving, processing and sending constructs. Among schizophrenic patients, correlations between AIPSS constructs and neuropsychological tests were observed for VF, DF, d2 and SPM whilst these associations were not replicated in healthy subjects. However, in the whole sample, after adjusting for age, gender and education, SPM displayed significant associations with all three AIPSS constructs. Moreover, after taking SPM into account, neither diagnostic groups (patients versus control) nor cognitive variables, except d2, provided an additional contribution to AIPSS performance. Cognitive impaired performances, mainly frontal, have a deleterious effect on social problem-solving skills in the schizophrenic group. It is suggested that alterations in social problem-solving skills may reflect social anxiety and/or " theory of mind " impairment. These factors may explain the lack of association among healthy subjects. The results support the inclusion of cognitive remediation programs designed to enhance social skills for patients where a cognitive deficit is clearly ascertained.

Untangling social function and social cognition: a review of concepts and measurement

Over the past few decades, there has been increasing interest in the study of social impairment in schizophrenia. However, the concept of social functioning has been poorly defined in the literature. This article highlights the global and multi-factorial nature of social functioning and reviews the theoretical determinants of social dysfunction in schizophrenia. Emphasis is placed on outlining the social cognitive deficits that may occur. The study of social cognition appears particularly promising in elucidating our understanding of the development of social impairment in schizophrenia and has the potential to improve current psychosocial interventions. However, continued advances depend upon the existence of reliable and well-validated measures of social functioning and social cognition. A selection of measures are reviewed in this article in an attempt to highlight the importance of assessing multiple aspects of social functioning in schizophrenia and to assist researchers in the selection of appropriate measures. Future efforts should be directed towards the continued validation of social functioning and social cognitive measures and their adaptation for use in at-risk and early psychosis populations.

Factor structure of essential social skills to be salespersons in retail market: implications for psychiatric rehabilitation

This study continued the effort to apply social skills training to increase vocational outcomes of people with severe mental illness. We planned to identify factor structure of essential social skills necessary for mental health consumers who have a vocational preference to work as salesperson in retail market. Exploratory factor analysis of the results of a 26-item questionnaire survey suggested a five-factor solution: social skills when interacting with customers, problem-solving skills, knowledge and attitudes, flexibility, and skills for conflict prevention, which accounted for 65.1% of the total variance. With the factor solution, we developed a job-specific social skills training program (JSST) to help consumers who want to be salespersons. The structure and session design followed the basic format of a typical social skills training program. The way this JSST is to be used with the work-related social skills training model previously developed by the corresponding author to produce better vocational outcomes of consumers is suggested.

No contexto da travessia para o ambiente de trabalho: treinamento de habilidades sociais com universitários

Com base nos atuais desafios inerentes à inserção no mercado de trabalho e a crescente valorização da competência para as relações interpessoais nesse contexto, descreve-se um programa de treinamento de habilidades sociais conduzido em um grupo formado por dez universitários em fase final de graduação na área de ciências exatas. O programa, com delineamento A-B-A, teve uma duração de trinta e seis horas, em duas sessões semanais de aproximadamente duas horas cada e foi planejado em módulos teórico e prático, que ocorriam em uma mesma sessão. A avaliação da intervenção foi realizada por meio da aplicação de um inventário tipo auto-relato (IHS-Del-Prette) antes e depois da intervenção e da avaliação por pares ao final do programa. Os resultados indicaram diferenças significativas (teste de Wilcoxon) entre os escores pré e pós-intervenção para a maioria dos participantes e avaliações positivas dos colegas com relação a tais mudanças.

A mutual-aid group for psychiatric rehabilitation of mental ex-patients in Hong Kong

BACKGROUND

Mutual-aid group and self-directed group are recognized as important interventions for anti-oppression of disadvantaged groups in our society.

METHOD

In this paper, the writer describes a mutual-aid group implemented in a psychiatric half-way house in Hong Kong. Members in this group were free to set their own agenda for discussion and to invite guest speakers. In terms of various stages of this group, the writer discusses how different group activities facilitated the development of mutual-aid and self-directed natures of mental ex-patients.

RESULTS

The findings show that this group can have an impact on the wider community and aid in improving the self-image of mental ex-patients and the perception of them as contributing positively to that community, hence lessening negative stereotypes.

Applying social skills training in the context of vocational rehabilitation for people with schizophrenia

This paper describes a model for the conceptualization of social skills necessary for the vocational success of people with schizophrenia. Based on this model, a two-part measure was developed and validated to assess social skills necessary for job search and tenure. The measure consists of a 10-item self-administered checklist and a role-play exercise. The self-administered checklist measures clients' perceived competence in handling work-related social situations. The role-play exercise assesses the social skills necessary for job acquisition and maintenance in two simulated situations (participating in a simulated job interview and requesting urgent leave from work). Furthermore, a social skills training module has been designed, which enhances vocational outcome and fills a gap in the existing, commonly used modules. A pilot study shows that the training module together with appropriate professional support afterward is effective in enhancing the social competence and vocational outcomes of persons with schizophrenia. Implications for cross-cultural applications are discussed.

Neurocognitive and social functioning in schizophrenia: a 2.5 year follow-up study

In our previous study we demonstrated that, in 80 schizophrenia subjects, verbal ability, verbal memory and executive functioning were significantly associated with social problem solving. The objective of this present study was to assess the longitudinal stability of the relationship between social and neurocognitive functioning in schizophrenia. This 2.5 year longitudinal cohort study re-assessed community functioning, social problem solving and symptoms in 65 of the 80 original subjects to determine the predictive ability of neurocognitive functioning. Neurocognition was not re-assessed at this follow-up. Positive and negative symptoms were assessed with the Positive and Negative Syndrome Scale. Social functioning was assessed using the Social Functioning Scale, the Quality of Life Scale, and the Assessment of Interpersonal Problem-Solving Skills (AIPSS). Verbal ability, verbal memory and vigilance were significant predictors of social problem solving as assessed by the AIPSS. Results suggest that the association between neurocognition and social functioning remains consistent over time.

Psychosocial treatments in schizophrenia: a review of the past 20 years

Pharmacotherapy can improve some of the symptoms of schizophrenia but has limited effect on the social impairments that characterize the disorder and limit functioning and quality of life. Through computerized literature searches and bibliographies of published reports we identified peer reviewed studies of group, family, and individual therapy with schizophrenia and schizoaffective disorder patients. We identified 70 studies: 26 on group therapy, 18 on family therapy, and 11 on individual therapy. Additionally, treatment models were compared in 4 studies and combined in 11 others. Controls were included in 61 and all studies included medication. Benefits in symptoms as well as social and vocational functioning were associated with psychosocial treatments. Family therapy demonstrated the most promising findings and traditional social skills treatment yielded the least robust results. Adjunctive psychosocial treatments augment the benefits of pharmacotherapy and enhance functioning in psychotic disorders. Although these positive results have led to increased enthusiasm about psychosocial treatments for schizophrenia, questions remain about comparative benefits of specific treatment methods and additional benefits of multiple treatments.

Development of clinical methods for utilization review in psychiatric day treatment

When a time-limited day treatment program was reconfigured to serve individuals with long-standing psychotic disorders, the number of treatment episodes exceeding six months rose to 70%. To justify this concentration of resources, the program needed methods to identify individuals for whom sustained treatment was appropriate. This report describes development of utilization review methods adapted to publicly funded day treatment of individuals with serious mental illness and training of clinicians in new documentation skills. Data from three years of operation suggest that symptom severity is not a reliable indicator of medical necessity in day treatment. As expected with a clinically based system, a composite measure of benefit and medical necessity indicators weighted toward functioning in living, learning, working, and socializing environments predicted physician reviewer denial of continued day treatment, but length of stay did not.

An empirical method for assessing social problem solving in schizophrenia

The development of a multimethod social problem-solving battery for schizophrenia is described. The battery is unique in that empirical methods were used throughout its development. The battery includes components that tap skills for response generation and response evaluation. The behavioral components of social problem solving are assessed in an extended role-play format. Individuals with schizophrenia and bipolar disorder, as well as nonpatient controls, completed the social problem-solving battery and cognitive measures. Subjects in the schizophrenia group performed more poorly than controls on measures of the ability to generate and evaluate response alternatives, as well as on the role-play test. The two patient groups did not differ in performance on any of the social problem-solving components. Appropriateness of affect was the most powerful predictor of problem-solving effectiveness.

Psychosocial rehabilitation in schizophrenia: beginnings in acute hospitalization

Schizophrenic patients discharged from acute inpatient settings are often unprepared to function outside the hospital, leading to recidivism and frequent rehospitalization. Social skills training programs addressing this need have hitherto only been developed for use in outpatient or long-term inpatient settings. We describe the development of a social skills training program for application in a short-term acute inpatient unit. Nursing coordinates the program, which is designed for a 3 to 4 week hospitalization and is delivered in an open group setting. The training program emphasizes communication skills, problem solving, affect identification, needs recognition, and social relatedness. The program uses group discussions, writing tasks, physical activity, education, role-play, feed-back, and assignments. Goals include assessment of individual deficits, inculcation of awareness that life-objectives can be identified and achieved, assistance with transition to postdischarge living situation or outpatient treatment program, and development of awareness of one's roles and responsibilities. The evolution and present structure of the program are described and four representative lessons are detailed.

Social skills training and negative symptoms

Schizophrenic patients with severe negative symptoms may have an impaired capacity to benefit from social skills training (SST), and their negative symptoms may show little change as a result of SST. The present study, employing a multiple-baseline design across-behaviors with three patients who had prominent negative schizophrenic symptoms, combined nonverbal skills training with the Stacking the Deck social skills game. Further, the study examined changes in both social skills (assessed using role-play and conversation tests) and negative symptoms. Depression, extrapyramidal side effects, and positive symptoms were also monitored. Modest improvements in social skills and negative symptoms were achieved. There was little evidence of a training effect. The unstable baselines may have contributed to this finding. It is important for further research to employ comprehensive patient-assessment procedures.

Social skills training in adult psychiatric populations: a meta-analysis

A meta-analysis was conducted on 73 studies of social skills training in four adult psychiatric populations: developmentally disabled, psychotic, nonpsychotic, and legal offenders. Findings from this analysis showed that patients participating in social skills training programs broadened their repertoire of skills, continued to demonstrate these skills several months after treatment, and showed diminished psychiatric symptoms related to social dysfunctions. Although results from an ANCOVA comparing effect sizes across the four populations (with design quality as a covariate) were nonsignificant, consistent trends suggested that social skills training had the greatest effect on developmentally disabled groups and the least effect on offender groups. In addition, social skills training was found to be relatively more effective in outpatient than inpatient settings.