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Chapter 28: Psychotherapies
Social Skills Training
The negative symptoms in patients with schizophrenia consti-
tute behavioral deficits that go beyond difficulties with asser-
tiveness. These patients have inadequate expressive behaviors
and inappropriate stimulus control of their social behaviors (i.e.,
they do not pick up social cues). Similarly, patients with depres-
sion often experience a lack of social reinforcement because of
a lack of social skills, and social skills training has been found
to be efficacious for depression. Patients with social phobia
similarly often have not acquired adolescents’ social skills. In
fact, their social defensive behaviors (e.g., avoiding eye con-
tact, making brief statements, and minimizing self-disclosure)
increase the probability of the rejection that they fear.
Social skills training programs for patients with schizophre-
nia cover skills in the following areas: conversation, conflict
management, assertiveness, community living, friendship and
dating, work and vocation, and medication management. Each
of these skills has several components. For example, assertive-
ness skills include making requests, refusing requests, making
complaints, responding to complaints, expressing unpleasant
feelings, asking for information, making apologies, express-
ing fear, and refusing alcohol and street drugs. Each compo-
nent involves specific steps. For example, conflict management
includes skills in negotiating, compromising, tactful disagree-
ing, responding to untrue accusations, and leaving overly stress-
ful situations. A situation in which conflict management skills
might be used is when the patient and a friend decide to go to a
movie and their choice of movie differs.
Negotiating and compromising, for example, involves the
following steps:
1. Explain one’s viewpoint briefly.
2. Listen to the other person’s viewpoint.
3. Repeat the other person’s viewpoint.
4. Suggest a compromise.
At his initial appointment, Phillip described very serious symp-
toms of obsessive-compulsive disorder (OCD). He was 23 years old
and living at home because he was no longer able to work or go to
school. His days were consumed with behaviors related to check-
ing, repeating, and hoarding. Phillip was unable to throw away
anything—he saved junk mail, used tissues and napkins, old papers
and magazines, and any kind of receipt for fear that he might lose
something important. Phillip spent many hours checking his trash,
his car, and his home to be sure that he had not thrown away any-
thing important. He also checked everything he wrote (e.g., checks,
school exams and papers, letters and e-mails) to be sure that he had
not made a mistake, and he read and reread books, magazines, and
articles to be sure he understood the written material adequately.
Phillip worried constantly that he had done something wrong and
would disappoint his parents. He was also depressed because he
was unable to function well in life, and he had tremendous social
anxiety that had plagued him for many years, making it difficult to
make and keep friends.
By the end of Phillip’s second session, his therapist was begin-
ning to get a good idea of the general nature and severity of his
symptoms and some of the maintaining factors. However, to plan
the treatment in more detail and to get a better idea of how the
symptoms occurred during his daily life, she asked Phillip to keep
daily records over the next week using a form that she had prepared
for him. The form had a place for recording the amount of time he
spent doing rituals each morning, afternoon, and evening, as well
as another place to record more details about at least one episode of
rituals each day (e.g., what was happening before, during, and after
the rituals; see Table 28.8-2).
Phillip’s therapist determined that his difficulties with obses-
sions, rituals, depression, and social fears reflected a core fear of
negative evaluation. Phillip was overly concerned with making mis-
takes, being imperfect, and disappointing others. Even as a child,
Phillip was concerned about not doing well enough, and he had
difficulty making friends for fear that others would not like him. His
parents, who were highly anxious, provided much adulation when
Phillip did things well (e.g., learned to ride a bike, got good grades
in school), and they spent much time instructing him about how to
improve his performance when an activity or grade was not perfect.
As Phillip took on more responsibility at school and with part-time
work, he became more concerned about doing things right. He
learned that going back and checking his work relieved his anxiety.
He also learned that saving his papers for future checking reassured
him that he would be able to fix any unrecognized mistakes at a later
time. His parents helped him to reduce his anxiety him when he was
uncertain about his work by reassuring him that he was doing okay.
As Phillip progressed from elementary school to junior high school
to high school, his workload and anxiety gradually increased, but
he was able to manage things with some moderate checking and
saving. When he began attending college, however, the workload
increased extensively, and he found himself doing even more check-
ing and hoarding to reduce his fears about making mistakes. Phillip
began to feel that these behaviors were getting out of control, but he
could not stop them. He had to check and recheck to be sure that he
was not making mistakes. The cycle of anxiety
S
ritual
S
reduced
anxiety was so powerfully reinforcing that he could not stop. He
needed help to break this cycle and to address his persistent fear of
negative evaluation.
Phillip’s therapist decided to begin treatment with a course of
exposure and response prevention (ERP) to get his obsessions and rit-
uals under control and begin to address his core fear of making mis-
takes and being evaluated negatively. Given that Phillip’s depression
had grown from the disability associated with his OCD, the therapist
expected that a successful course of ERP might also help to reduce
his depressive symptoms. ERP for Phillip began with a home visit,
where the therapist helped him to complete common daily activities
with adherence to his RP plan, which included the following:
No more checking: After eating, leave the table immediately
without inspecting your plate and the surrounding areas (includ-
ing under the table and chair) for lost items. Leave the restroom
immediately after using it, without checking the toilet, trash, and
sink for lost items. When leaving the car, no more checking of
seats, floors, and windows. Write everything (papers, checks,
etc.) only once; no checking to be sure that letters and words are
correct.
No more repeating: No more rereading books. No staring repeat-
edly at items to ensure that nothing is lost.
No more saving. Throw tissues away immediately after using.
Discard trash and junk mail immediately. Do not look into the
trash can for lost items.
Phillip’s parents also were asked to stop reassuring him and to
discontinue doing rituals for him. This was a very difficult session
for Phillip and his family, but they understood the logic of ERP, and
they were willing to try anything.
For the next 3 weeks, Phillip and his therapist met three times
a week to conduct in vivo exposure sessions that helped him to
face his core fears. For many of these sessions, Phillip was asked
