28.12 Psychiatric Rehabilitation
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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.
(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.
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,
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.
