The International Journal of Psychosocial Rehabilitation

  Efficacy of Social Skills Training among Persons with Schizophrenia

Praful P. Kapse
Development Officer
 Mental Health Initiative
Sir Ratan Tata Trust
Email: pkapse@tatatrusts.org

Dr. B. P. Nirmala
Associate Professor
Department of Psychiatric Social Work
National Institute of Mental Health and Neuro Sciences
Bangaluru.




Citation:
Kapse PP & Nirmala BP. (2015)   Efficacy of Social Skills Training among Persons with Schizophrenia.
International Journal of Psychosocial Rehabilitation. Vol 20 (1) 45-50


Abstract
Background: Person with schizophrenia have the deterioration of personal, family, and social life. The illness leads to many disabilities in terms of interpersonal skills, communication skills, coping skills, dealing with emotions, self-care, self-control, occupational skills. Impairments in social functioning are among the most debilitating and treatment refractory aspects of schizophrenia (Bellack et al., 2007).

Materials and Methods: The study aimed to know social skills deficits among persons with schizophrenia and to check the efficacy of the social skills training programme. A total number of 12 persons with schizophrenia, who were availing day care rehabilitation services, were selected randomly for the social skills training programme. The researcher adopted quasi experimental design without control, and interview and observer rating method used to collect data.

Major Finding:  Significant amount of deficits were found in self care, instrumental skills, communication skills, impulse control and social functions of the participants. The post social skills training programme there was significant improvement reported in social skills of the participants, repeated measures shows (F1.65,18.15)=93.26, p=26 significant level of change in social skills in post1 and post2 test. 

Conclusion: The present study reported the efficacy of social skills training in improving social skills among persons with schizophrenia who are availing day care rehabilitation facility. The model of social skills training programme were found to be effective and can be applied for larger practice in rehabilitation centres in India. 

Key Words: Social Skills Training, Schizophrenia, Rehabilitation


Introduction:
 It is perhaps commonplace to state to human being as social animals, nevertheless it is true. A substantial portion of human lives spent in interactions with one another moreover, the nature quality, and quantity of those interaction have a tremendous impact on behaviour, mood, and the adequacy of adjustment. Faulty interpersonal relationship patterns have unfailingly been associated with a wide variety of behavioural- psychological dysfunction ranging from simple loneliness to schizophrenia.

Schizophrenia is a clinical syndrome of variable, but severely disruptive, the psychopathology which involves disturbance in cognition, emotion, perception, and other aspects of behaviour. The expression of these manifestations varies across patients and over time, however the effect of the illness is always stark and is usually long lasting.

"Inexpressive faces, blank looks, monotone and monosyllabic speech, few gestures, seeming lack of interest in the world and other people, inability to feel pleasure or act spontaneously."

An estimated 25% of people with schizophrenia have "the deficit syndrome", marked by "severe and persistent negative symptoms." These negative symptoms are related to the individuals inability to socialize, and are connected to the cognitive deficits seen in many patients. These negative symptoms are also the markers for any schizophrenia spectrum disorder (such as schizoptypal personality, and schizoid personality), as well as early markers for full schizophrenia prior to the first psychotic break.

Not only are these negative symptoms common and detrimental, little is available for treatment. Most antipsychotic medications work mainly on positive symptoms, and patients with mostly negative symptoms are often deemed "treatment resistant".

The term “skills”- in contrast to the term “abilities” – implies that they are predominantly based on learning experiences. Thus, social skills training utilizes behaviour therapy principles and techniques for teaching individuals to communicate their emotions and requests so that they are more likely to achieve their goals and meet their needs for affiliative relationships and roles required for independent living.

Social skills are interpersonal behaviours that are normative and/or socially sanctioned. They include such things as dress and behaviour codes, roles about what to say and not to say, and stylistic guidelines about the expression of affect, social reinforcement interpersonal distance and so on and so forth. Whether they have never learned social skills or have lost them, most people with schizophrenia have marked skill deficits. These deficits make it difficult for many clients to establish and maintain social relationship, to fulfil social roles or to have their needs met.

In various studies social skills training has found moderately to strongly effective in increasing skill acquisition and reducing psychiatric symptoms. (Melody Nichols Dilk). Skills training are effective for virtually every area of role functioning for persons with severe psychiatric disabilities (Dion and Anthony 1987).

Three models of social skills training, all of which involve role playing by the patient and modelling, prompting, feedback, and reinforcement by the therapist. Many patients can benefit from the basic training model. For patients functioning at a higher level, the problem-solving model provides general strategies for dealing with a variety of social situations. (Robert P. Liberman et al.1985). Despite of these many studies, there are very less number of studies found in Indian context. Beliefs and understanding of mental illness is itself a taboo in India. Persons with mental illness perceive as possessed by black magic and other supernatural powers, so the Stigma, discrimination, hostility is attached with person with mental illness. It often found that family members and society is avoids the abilities of these population and does not give chance to their abilities. In this context the purpose of this study is to find out the effectiveness of social skills training among persons with schizophrenia availing day care rehabilitation services. 

Materials and Methods
The study aimed to know social skills deficits among persons with schizophrenia and to check the efficacy of the social skills training programme. The objective stated for study was to study the socio-demographic profile of the participants. 1) To assess the social skills deficits among participants. 2) To design social skills training program to address social skills deficits. 3) To study the efficacy of social skills training program. For present study researcher hypothesized that there will be significant improvement in social skills of the participants who undergo social skills training. 

A total number of 12 persons with schizophrenia, who were availing day care rehabilitation services, were selected randomly for the social skills training programme. The researcher adopted quasi experimental design without control. The interview and standardised instruments were used to collect data. Semi-structured interview schedule used to collect socio-demographic details of the participants, Social Adaptive Functioning Evaluation (SAFE) by Harvey et.al 1997 an observer rated scale used to measure social skills of the participants, Social Skills Checklist were used to check social behaviour and functioning over past month.

Results
Demographic
Demographic results shows that majority of the participants (66.7%) belongs to age group of 31 to 40 years. Majority of the participants (83.3%) were male. Highest number of participants (33.3%) reported to studied up to high school and very few (16.7%) studied up to graduation and above. All the participants belong to Hindu religion. Majority of the participants (91.7%)   were never married. And equal number of participants (41.7%) belongs to Nuclear and joint family.

Social Skills Deficits

Majority of the participants reported deficits in instrumental skills. Many of the respondents had difficulty in self care activities. 50% of the participants had moderate level of impairment in impulse control. Regarding conversation skills 66.7% participants had severe impairment.
Majority of the participants reported deficits in social functions.
 
Post Intervention Results
Social skills training in current study the mean total score of the participants during pre, post1 and post2 were 38.33, 22, and 5.75 respectively pair wise comparison shows significant level change F = 93.26, p<0.01 and the social skills training reported effect size 0.895. The study adopted repeated measures of ANOVA were obtained to see effects of intervention there was significant effect of social skills training on social adaptive functioning, F (1.65, 18.15) = 93.26, p=.05 These results show that there was significant change in social skills of participants after social skills training. The study also finds the improvement in social skills is significant at linear level (F=127.75,p<0.001) and quadratic trend found to be non-significant (F=0.001, p>0.05), which indicates the improvement in social skills at each post SST assessment. In the present study, the social skills training analysis shows that various skills have improved in the participants after social skills training. The efficacy can be seen from the differences in the means score, significant level and effect size. The social skills training effect on the various domain namely instrumental skills, self care, impulse control and social function shows significant improvement. There was a decreased mean score in these domains. The effect size shows a large effect on the above four domains.

Discussion
In present study regarding socio-demographic profile of the participants following results were observed majority of the participants were in age group 31 to 40 years, majority of them were male, all participants belong to Hindu religion, majority of them were never married and equal number of participants was in nuclear and joint family. The similar age group were widely studied in other studies related to social skills. This could be because of adulthood in which persons from this age group are most expected to work and earn money so in this way majority of the participants were from this age group the similar studies (William H. et al, 2009) reported older adults with schizophrenia use more services than any other diagnostic elderly group within community mental health organizations (Bartels, Miles, Dain, & Smyer, 1996; Cuffel, Jeste, & Halpain, 1996).and male member accessing the treatment and other allied services is commonly seen in India, the cultural and socio-cultural beliefs may influence accessibility of the services.

The present study intends to help in understanding the social skills deficits among persons with schizophrenia who are availing day care rehabilitation services. The present study shows among persons who are availing day care rehabilitation facility has significant level of social skills deficits in pre-training (M=38.33, SD=16.38). These deficits include instrumental and self care skills, impulse control, and social function skills. The similar level of deficits had been found widely (Harvey et al., 1997).

In another study the prevalence of social skill deficits in schizophrenia was examined by comparing patients assessed over a 1 year period with a group of non-patient controls recruited from the community. Social skills were assessed using a role play test and were considered deficient when they were below the range of the control sample. Approximately 50% of the patients were consistently unskilled over the one year, whereas 11% were consistently skilled. Deficits in specific social skills were relative rare. Consistent deficits were present for only one of six specific skills 14% of the patients was consistently less appropriate in their conversation. (Kim T. Mueser et al., 1991) This finding found to be similar with current study, the deficits in conversational skills found significant (M = 2.53, SD = .79) which is high among other skills.

A large amount of research studies have done regarding social skills training. Social skills training (SST) involves the use of standard behavioural skills training procedures to develop social competencies, and has been used for over three decades in an attempt to remediate poor social skills in schizophrenia patients (Halford & Hayes, 1991). Implicit in the use of SST is the assumption that poor social skills inhibit the development of supportive social networks and decrease patients coping with stressors, and consequently patient’s quality of life & prognosis deteriorate (Anthony & Liberman, 1986; Trower, Brgent, & Argyle, 1978; Wallace, Boone, Donohue, & Foy, 1985). Consistent with this assumption low levels of social skills co vary with social isolation, and poor community functioning (Bellack et al. Halford & Hayes, 1995).  

The literature dealing with social skills training of schizophrenia patients indicates that topographical features and self-reports of anxiety and discomfort can be changed for the better functioning by social skills training. Unfortunately, these changes do not occur for every patient and, when they do occur, often do not generalize to new situations. Research must be directed to determining the interaction between patient characteristics and training procedures as they affect outcome. The scope of the procedures must also be expanded if meaningful changes in patients' quality of life are to be effected. (Charles J. Wallace, Connie J. Nelson, Robert Paul Liberman et al., 1980).

In line of these finding current study adopts social skills training for persons with schizophrenia. Social skills training found to be effective in many previous studies, the efficacy of social skills training and day hospital treatment for 20 chronic schizophrenia patients in a 12-week day hospital program and 44 patients in the same program supplemented by comprehensive social skills training. Patient who completed treatment showed improvement immediately following treatment, during the six month post treatment they maintained gains ( Alan S. Bellack, et al. 1984).

In present study social skills training among schizophrenia patient found to be useful in improving overall social skills. The mean difference in pre-SST and post SST significantly shown improvement, pre SST overall (M = 38.33, SD = 16.38) which was considerably improved in post1 SST (M = 22, SD = 12.96) and further in post 2 SST shown significant improvement (M = 7.58, SD = 9.23). Similar significant improvement were reported in many studies in a study of twenty-eight schizophrenic male patients, diagnosed by the Present State Examination and Catego criteria, and from families high on “expressed emotion,” were randomly assigned to either intensive social skills training or holistic health therapy. A multidimensional evaluation was conducted before and after 9 weeks of inpatient treatment and for 24 months in the community. Patients exposed to social skills training evidenced significantly greater acquisition, generalization, and durability of social skills and their social  adjustment in the community was rated as better by significant others; and they experienced fewer relapses and rehospitalisation (Charles J Wallace et al., 2002).

Efficacy of Social Skills
In line of the searching efficacy of social skills training in current study the mean total score of the participants during pre, post1 and post2 were 38.33, 22, and 5.75 respectively pair wise comparison shows significant level change F = 93.26, p<0.01 and the social skills training reported effect size 0.895. Which is large effect among previous similar other studies.  For between-group studies, the overall effect size was medium at post test (d. = .40, n = 58, z = 9.18, p < .001) and large at follow-up (d = .56, n = 14, z = 5.34, p < .01). For within-group studies, the overall effect size was also medium at post test (d. = .48, n = 9, z = 7.59, p < .01), but small at follow up (d. = .30, n = 4, z = 2.37, p < .05). Thus, the overall post test effect size for the within-group studies was similar to that for the between-group studies, whereas the overall follow-up effect size was smaller for the within-group studies than the corresponding statistic for the between-group studies. The study adopted repeated measures of ANOVA were obtained to see effects of intervention there was significant effect of social skills training on social adaptive functioning, F (1.65, 18.15) = 93.26, p=.05 These results show that there was significant change in social skills of participants after social skills training. The study also finds the improvement in social skills is significant at linear level (F=127.75,p<0.001) and quadratic trend found to be non-significant (F=0.001, p>0.05). Which indicates the improvement in social skills at each post SST assessment.

Conclusion
Efficacy of social skills training among persons with schizophrenia was studied in present study. The social skills deficits have been widely found to be obstacle in recovery of persons with mental illness.  Many individuals with schizophrenia gradually develop isolated lives, punctuated by lengthy periods in psychiatric hospitals or in community residence. Such events remove clients from their normal peer group, provide few opportunities to engage in appropriate social roles, and limit social contacts to mental health staff and other severely ill clients. Under such circumstances, clients do not have an opportunity to acquire and practice appropriate adult roles. Moreover, skills mastered earlier in life may be lost because of disuse or lack of reinforcement by the environment.

Several studies have reported social skills deficits interfere with the development of appropriate social relationship and the acquisition of social skills. Schizophrenia often strikes first in late adolescence or young adulthood, a critical period for mastery of adult social roles and skills, such as dating and sexual behaviours, work related skills, and the ability to form and maintain adult relationships. (Bellack & Muser, 1993)

The present study was reported the efficacy of social skills training in improving social skills among persons with schizophrenia who are availing day care rehabilitation facility. Several similar studies also widely reported the efficacy of social skills training (Benton et al., 1990).The model of social skills training programme were found to be effective and can be applied for larger practice in rehabilitation centres in India.


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