Adoption and dissemination of social skills training in Japan: a decade of experience (1988-1997)

Psychiatric rehabilitation has been slow to develop in Japan, in part because of traditional stigma against community-based treatment of the seriously mentally ill and a prevailing biological approach to schizophrenia. In the past decade, however, rehabilitation methods have been introduced, spearheaded by social skills training. The rapid dissemination of social skills training in Japan has been promoted by the publication of a national newsletter, the development of a Japanese Social Skills Training Association, reimbursement of social skills training by the national health insurance, and an active schedule of workshops, seminars, lectures and training programs. Research on social skills training has paralleled its development as a clinical modality. When skills training has been delivered with fidelity, it has been possible to measure the acquisition of skills by persons with schizophrenia. A role-play test has been validated after its cultural adaptation to Japan and correlations have been found between scores on the social skills role-play test and cognitive functioning of persons with schizophrenia, lending credence to the hypothesis that neurocognitive dysfunction may play a role in social and occupational adjustment of persons with schizophrenia.     

Prediction of social skill acquisition in schizophrenic and major affective disorder patients from memory and symptomatology

Memory and symptomatology were examined as predictors of social skill acquisition in psychiatric inpatients participating in a social skills training program. Poor memory was related to pretreatment social skill impairments and slower rates of skill improvement during the intervention for patients with schizophrenia or schizoaffective disorder, but not affective disorder. Symptomatology was not consistently related to pretreatment social skill or changes in skill for either schizophrenic or affective disorder patients. The results suggest that cognitive deficits in schizophrenia are associated with impairments in social skill and that such deficits may limit the rate of skill acquisition and clinical response to social skills training interventions.     

The psychosocial treatment of schizophrenia: an update

OBJECTIVE: The authors sought to update the randomized controlled trial literature of psychosocial treatments for schizophrenia. METHOD: Computerized literature searches were conducted to identify randomized controlled trials of various psychosocial interventions, with emphasis on studies published since a previous review of psychosocial treatments for schizophrenia in 1996. RESULTS: Family therapy and assertive community treatment have clear effects on the prevention of psychotic relapse and rehospitalization. However, these treatments have no consistent effects on other outcome measures (e.g., pervasive positive and negative symptoms, overall social functioning, and ability to obtain competitive employment). Social skills training improves social skills but has no clear effects on relapse prevention, psychopathology, or employment status. Supportive employment programs that use the place-and-train vocational model have important effects on obtaining competitive employment. Some studies have shown improvements in delusions and hallucinations following cognitive behavior therapy. Preliminary research indicates that personal therapy may improve social functioning. CONCLUSIONS: Relatively simple, long-term psychoeducational family therapy should be available to the majority of persons suffering from schizophrenia. Assertive community training programs ought to be offered to patients with frequent relapses and hospitalizations, especially if they have limited family support. Patients with schizophrenia can clearly improve their social competence with social skills training, which may translate into a more adaptive functioning in the community. For patients interested in working, rapid placement with ongoing support offers the best opportunity for maintaining a regular job in the community. Cognitive behavior therapy may benefit the large number of patients who continue to experience disabling psychotic symptoms despite optimal pharmacological treatment.     

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.     

Attention shaping: a reward-based learning method to enhance skills training outcomes in schizophrenia

Disturbances in sustained attention commonly interfere with the ability of persons with schizophrenia to benefit from evidence-based psychosocial treatments. Cognitive remediation interventions have thus far demonstrated minimal effects on attention, as have medications. There is thus a gap between the existence of effective psychosocial treatments and patients' ability to effectively engage in and benefit from them. We report on the results of a multisite study of attention shaping (AS), a behavioral intervention for improving attentiveness and learning of social skills among highly distractible schizophrenia patients. Patients with chronic schizophrenia who were refractory to skills training were assigned to receive either the UCLA Basic Conversation Skills Module (BCSM) augmented with AS (n = 47) or in the standard format (n = 35). AS, a reward-based learning procedure, was employed to facilitate patients' meeting clearly defined and individualized attentiveness and participation goals during each session of a social skills training group. Primary outcome measures were observational ratings of attentiveness in each session and pre- and post-BCSM ratings of social skill and symptoms. Patients receiving social skills training augmented with AS demonstrated significantly more attentiveness in group sessions and higher levels of skill acquisition; moreover, significant relationships were found between changes in attentiveness and amount of skills acquired. Changes in attentiveness were unrelated to level or change in antipsychotic medication dose. AS is an effective example of supported cognition, in that cognitive abilities are improved within the environmental context where the patient is experiencing difficulty, leading to gains in both attention and functional outcome.     

Improving recreational, residential, and vocational outcomes for patients with schizophrenia.

As Roder and colleagues propose, we have seen three eras in the development and refinement of social skills training for individuals with schizophrenia. In the 1960s, skills training relied on the use of operant conditioning, as exemplified by the token economy. Reinforcement contingencies succeeded in activating patients with negative symptoms and in improving their social behavior. Contemporary psychiatric rehabilitation can profit from the identification and use of reinforcers to motivate anergic individuals who lack insight to participate actively in community-based programs.During the second era, in the 1970s, social learning through modeling, coaching, role playing, and behavioral assignments was introduced into skills training. These techniques were used to improve nonverbal skills, such as eye contact, fluency of speech, gestures, and facial expression, as well as conversational skills, assertiveness, and emotional expressiveness.Intervention programs of the third and current era are incorporating cognitive methods into the skills training enterprise. For example, in the modules for training social and independent living skills developed and validated by Liberman and his colleagues at the University of California at Los Angeles (1), the deficits in attention, memory, and verbal learning often experienced by persons with schizophrenia are overcome by repetition, shaping of incremental behavioral improvements, video modeling, and feedback for galvanizing attention. Procedural learning techniques that do not rely on the brain capacities that mediate verbal awareness and insight are also used.In this month's Rehab Rounds column, Roder and his colleagues present another example of a skills training approach of the third era that includes elements of cognitive remediation. As autonomous offsprings of integrated psychological therapy (IPT), which was originally developed by Hans Brenner and Volker Roder and their colleagues at the University of Bern in Switzerland (2), the new programs address deficits in the residential, vocational, and recreational domains of community functioning. Overall, social skills training has been shown to be effective in the acquisition and maintenance of skills and their transfer to community life. Moreover, evidence is accumulating that structured and systematic skills training is more effective than other psychosocial treatments with which it has been compared, such as supportive group therapy and expressive modes of occupational therapy.     

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.     

Counter striking psychosis: Commercial video games as potential treatment in schizophrenia? A systematic review of neuroimaging studies

Schizophrenia is a severe, chronic, and strongly disabling neuropsychiatric disorder, characterized by cognitive decline, positive and negative symptoms. Positive symptoms respond well to antipsychotic medication and psycho-social interventions, in contrast to negative symptoms and neurocognitive impairments. Cognitive deficits have been linked to a poorer outcome and hence specific cognitive remediation therapies have been proposed. Their effectiveness is nowadays approved and neurobiological correlates have been reconfirmed by brain imaging studies. Interestingly, recent MRI work showed that commercial video games modified similar brain areas as these specialized training programs. If gray matter increases and functional brain modulations would translate in better cognitive and every day functioning, commercial video game training could be an enjoyable and economically interesting treatment option for patients with neuropsychiatric disorders. This systematic review summarizes advances in the area with emphasis on imaging studies dealing with brain changes upon video game training and contrasts them to conventional cognitive remediation. Moreover, we discuss potential challenges therapeutic video game development and research would have to face in future treatment of schizophrenia.     

Recent advances in social skills training for schizophrenia

Social skills training consists of learning activities utilizing behavioral techniques that enable persons with schizophrenia and other disabling mental disorders to acquire interpersonal disease management and independent living skills for improved functioning in their communities. A large and growing body of research supports the efficacy and effectiveness of social skills training for schizophrenia. When the type and frequency of training is linked to the phase of the disorder, patients can learn and retain a wide variety of social and independent living skills. Generalization of the skills for use in everyday life occurs when patients are provided with opportunities, encouragement, and reinforcement for practicing the skills in relevant situations. Recent advances in skills training include special adaptations and applications for improved generalization of training into the community, short-term stays in psychiatric inpatient units, dually diagnosed substance abusing mentally ill, minority groups, amplifying supported employment, treatment refractory schizophrenia, older adults, overcoming cognitive deficits, and negative symptoms as well as the inclusion of social skills training as part of multidimensional treatment and rehabilitation programs.     

Determinants of everyday outcomes in schizophrenia: The influences of cognitive impairment, functional capacity, and symptoms

Deficits in everyday living skills and social skills are associated with the pervasive disability seen in schizophrenia. Cognitive impairments are determinants of these skills deficits and it is known that positive and negative symptoms add to the influence of cognitive impairments for prediction of real-world outcomes. This study examined the relative importance of cognitive impairments measured with a neuropsychological battery, performance-based measures of social and everyday living skills, and positive and negative symptoms for the prediction of real-world outcomes in social and residential domains. In contrast to most previous studies, we examined the importance of individual symptoms, as well as total subscale scores, for predicting clinician rated outcomes in 194 older outpatients with schizophrenia. Symptoms were rated with the Positive and Negative Syndrome Scale; everyday living skills were measured by the UCSD Performance-based Skills Assessment; and social skills were measured with the Social Skills Performance Assessment. For prediction of real-world social outcomes, blunted affect and passive-apathetic social withdrawal accounted for all of the predicted variance, while social competence and cognitive impairments did not enter the final equation. For residential functioning, everyday living skills were the most important predictor, followed by lack of spontaneity. The positive symptoms of hallucinatory behavior and suspiciousness also predicted real-world residential outcomes. These results suggest that real-world disability is the product of a complex array of ability deficits and symptoms, indicating interventions will need to be carefully targeted. For social and everyday living outcomes, variance accounted for by the entire array of predictive variables was less than 40%, suggesting that other factors, such as social and cultural influences, are involved as well.     

Associations between social cognition,skills, and function and subclinical negative and positive symptoms in 22q11.2 deletion syndrome

Background

Identification of the early signs of schizophrenia would be a major achievement for the early intervention and prevention strategies in psychiatry. Social impairments are defining features of schizophrenia. Impairments of individual layers of social competencies are frequently described in individuals with 22q11.2 deletion syndrome (22q11.2DS), who have high risk of schizophrenia. It is unclear whether and to what extent social impairments associate with subclinical negative and positive symptoms in 22q11.2DS, and which layer of social impairments are more correlated with schizophrenia-related symptoms. The aims of this study were to conduct a comprehensive investigation of social impairments at three different levels (function, skill, and cognition) and their interrelationship and to determine to what degree the social impairments correlate to subclinical levels of negative and positive symptoms, respectively, in a young cohort of 22q11.2DS not diagnosed with schizophrenia.

Methods

The level of social impairment was addressed using questionnaires and objective measures of social functioning (The Adaptive Behavior Assessment System), skills (Social Responsiveness Scale), and cognition (The Awareness of Social Inference Test and CANTAB Emotional Recognition Task), and the presence of subclinical symptoms of schizophrenia were evaluated using the Structured Interview for Prodromal Syndromes in a cross-sectional case-control study of 29 cases and 29 controls, aged 12 to 25 years. Association between social impairment and negative and positive symptoms levels was examined in cases only.

Results

Subjects with 22q11.2DS were highly impaired in social function, social skills, and social cognition (p?≤?6.2?×?10^?9) relative to control peers and presented with more negative (p?=?5.8?×?10^?11) and positive (p?=?7.5?×?10^?4) symptoms. In particular, social functional and skill levels were highly associated with notably subclinical negative symptoms levels.

Conclusions

This study shows strong correlations between levels of social impairments and subclinical negative and positive symptoms. However, longitudinal studies are required to show if social impairments represent early disease manifestations. If parental or self-reporting suggests severe social impairment, it should advocate for clinical awareness not only to social deficits per se but also of potential subclinical psychosis symptoms.

     

Symptoms and neurocognition as rate limiters in skills training for psychotic patients.

OBJECTIVE: This study aimed to replicate findings that neurocognitive capacity in schizophrenia is more predictive of acquisition of social skills than are symptoms. METHOD: Thirty-two hospitalized patients with chronic psychotic disorders were randomly assigned to community reintegration skills training or supportive group therapy. Neurocognitive functioning was assessed before treatment, and symptoms and skill levels were measured before and after treatment. RESULTS: The skills training group showed significantly greater skill acquisition. In a regression model, skill acquisition was predicted by group membership and verbal memory capacity and not by symptoms. CONCLUSIONS: With methodological advances, the authors replicated findings regarding the importance of neurocognition in determining treatment outcome in schizophrenia.     

A randomized, controlled trial of cognitive behavioral social skills training for middle-aged and older outpatients with chronic schizophrenia

OBJECTIVE: The number of older patients with chronic schizophrenia is increasing. There is a need for empirically validated psychotherapy interventions for these patients. Cognitive behavioral social skills training teaches cognitive and behavioral coping techniques, social functioning skills, problem solving, and compensatory aids for neurocognitive impairments. The authors compared treatment as usual with the combination of treatment as usual plus cognitive behavioral social skills training. METHOD: The randomized, controlled trial included 76 middle-aged and older outpatients with chronic schizophrenia, who were assigned to either treatment as usual or combined treatment. Cognitive behavioral social skills training was administered over 24 weekly group sessions. Blind raters assessed social functioning, psychotic and depressive symptoms, cognitive insight, and skill mastery. RESULTS: After treatment, the patients receiving combined treatment performed social functioning activities significantly more frequently than the patients in treatment as usual, although general skill at social functioning activities did not differ significantly. Patients receiving cognitive behavioral social skills training achieved significantly greater cognitive insight, indicating more objectivity in reappraising psychotic symptoms, and demonstrated greater skill mastery. The overall group effect was not significant for symptoms, but the greater increase in cognitive insight with combined treatment was significantly correlated with greater reduction in positive symptoms. CONCLUSIONS: With cognitive behavioral social skills training, middle-aged and older outpatients with chronic schizophrenia learned coping skills, evaluated anomalous experiences with more objectivity (achieved greater cognitive insight), and improved social functioning. Additional research is needed to determine whether cognitive insight mediates psychotic symptom change in cognitive behavior therapy for psychosis.     

Social perception and early visual processing in schizophrenia

Persons with schizophrenia experience deficits in social cognition-the cognitive processes involved in how people perceive and interpret information about themselves, others, and social situations. These deficits may be related to the neurocognitive impairments often experienced by persons with schizophrenia. Our primary objective was to examine associations between social perception and early visual processing in schizophrenia. Our secondary objective was to examine whether outpatients with schizophrenia and healthy persons differ in social perception. Forty outpatients with schizophrenia and 30 healthy persons completed a measure of social perception (the Half-Profile of Nonverbal Sensitivity), visual masking procedures, and ratings of positive and negative symptoms. Within patients, performance on visual masking procedures was related to performance on the Half-Profile of Nonverbal Sensitivity. Patients with schizophrenia and the healthy persons differed significantly in their performance on the Half-Profile of Nonverbal Sensitivity, but this difference became nonsignificant when education was a covariate. These findings suggest that social perception in schizophrenia is related to very early aspects of visual processing.     

A review of cognitive training in schizophrenia

Empirically supported treatments for schizophrenia now include a variety of psychosocial interventions, such as social skills training, vocational rehabilitation, and psychotherapy. As awareness of the functional importance of neurocognitive impairments in schizophrenia has increased, interest in treatments to improve cognition has grown. We review the literature on cognitive training (CT), which has been studied in 17 published randomized, controlled trials to date. The differential effectiveness of noncomputerized and computer-assisted interventions, with and without strategy coaching, and an environmental adaptation intervention, is examined. We conclude that the different types of approaches, whether computer assisted or not, all have effective components that hold promise for improving cognitive performance, symptoms, and everyday functioning. Our recommendations for further research, including the use of functional outcome measures and long-term followup, highlight the importance of improving ecological validity in this area of treatment research.     

Neurocognitive and social cognitive predictors of interpersonal skill in schizophrenia

Social dysfunction is among the major criteria for receiving a diagnosis of schizophrenia, and research indicates that the impairments in social functioning experienced by individuals with schizophrenia are strongly related to deficits in interpersonal skills. In turn, these deficits in interpersonal skills have been linked to impairments in general cognitive abilities and impairments in social cognition. This study explored the relationship between neurocognition, social cognition, and interpersonal skills in 49 outpatients with schizophrenia and 44 non-clinical control participants. Results indicate that individuals with schizophrenia demonstrated impaired performance across several domains of neurocognitive and social cognitive functioning as well as interpersonal skills. In addition, among the participants with schizophrenia, social cognition significantly contributed unique variance to interpersonal skill beyond that of neurocognition. This pattern was not observed in the non-clinical control sample. These findings have implications for the treatment of the disorder and represent an important step in understanding the role of social cognition in schizophrenia.     

Feasibility of a skills training approach to reduce substance dependence among individuals with schizophrenia

A novel treatment for persons who have both schizophrenia and substance abuse was evaluated by incorporating cognitive-behavioral drug relapse prevention strategies into a skills training method originally developed to teach social and independent living skills to patients with schizophrenia. Thirty-four of 56 patients completed treatment and a three-month follow-up assessment. Participants learned substance abuse management skills and reported that they found the treatment relevant, useful, and satisfying, and their drug use decreased. Improvements were noted in medication adherence, psychiatric symptoms, and quality of life. This manual-driven therapy may play an important role in the treatment of substance abuse among patients with schizophrenia.     

The longitudinal relationship of clinical symptoms, cognitive functioning, and adaptive life in geriatric schizophrenia

Cognitive dysfunction is increasingly being recognized as a major contributor to the adaptive impairment seen in most patients with schizophrenia. Reported here is a prospective longitudinal evaluation of the relationship between cognitive and adaptive functioning in elderly patients with schizophrenia. It was hypothesized that baseline cognitive and negative, but not positive symptoms, would be predictive of cross-sectional impairment and longitudinal outcome. Subjects were 168 elderly patients with schizophrenia, free of major neurological disorders, who were residents of a long-term psychiatric facility. Subjects were assessed at baseline and again an average of 15months later. The PANSS was used to assess the severity of symptoms of schizophrenia. Cognitive symptoms were assessed using the components of the CERAD cognitive battery. Social and adaptive functioning was assessed using the SAFE scale. Spearman correlations were determined among clinical variables, and the rank ordering of prediction of SAFE scale scores at follow-up was determined using a stepwise regression procedure. At follow-up, adaptive life skills correlated with cognitive performance and negative symptoms (Spearman rho values 0. 41-0.57, all p values <0.0001), but not positive symptoms (r=0.09, n. s.). Among cognitive tasks, verbal learning and memory were most highly correlated with adaptive skills at follow-up. These results confirm and extend previous studies that indicate that cognitive impairments are predictive, both cross-sectionally and longitudinally, of adaptive life skills in persons with schizophrenia. Negative symptoms, but not positive symptoms, were correlated with impaired adaptive skills. Taken together, these results underscore the need to develop more effective treatments for cognitive and negative symptoms in schizophrenia.     

Negative symptoms and concordant impairments in attention in schizophrenia: Associations with social functioning, hope, self-esteem and internalized stigma

Research has suggested that negative symptoms in schizophrenia may be closely linked to impairments in schizophrenia. Research on the strength and nature of this association has been equivocal, however. One possible explanation is that there are two distinct groups of persons with negative symptoms: those with and those without attentional impairments. To examine this question we performed a cluster analysis on 99 adults with schizophrenia or schizoaffective disorder on the basis of their level of negative symptoms and performance on a continuous performance task. Four groups were found: low negative/relatively better attention (n = 31), low negative/relatively poor attention (n = 20), high negative/ relatively poor attention (n = 28), and high negative/relatively better attention (n = 20). To determine whether these groups differed meaningfully from one another, we next compared their performance on other assessments of positive symptoms, social function, self-esteem and stigma. A MANOVA found significant differences (Wilks' lambda F = 3.2; p < .01) with the high negative/poor attention group having poorer self esteem and greater acceptance of stigma than the other three groups and the high negative/relatively better attention group having higher levels of positive symptoms than the other groups. Implications for research and treatment are discussed.     

Conversation skills training of thought-disordered schizophrenic patients through attention focusing

An attention-focusing procedure was designed as discrete trials and multiple prompts with contingent social reinforcement to facilitate the acquisition of conversational skills in thought-disordered schizophrenia patients. Three patients with DSM-III-R diagnoses of schizophrenia completed a standard social skills training program and the attention-focusing procedure in multiple baseline experimental designs. While social skills training had little effect on the acquisition of skills, patients who completed the attention-focusing procedure significantly increased performance of conversational skills and showed some generalization of trained behaviors.