CLINICAL HANDBOOK OF SCHIZOPHRENIA

24. Social Skills Training 243The sequence, role play followed by feedback and reinforcement, is then repeateduntil the patient can perform the skill adequately. Generally, each patient should be engagedin at least three to four role plays of each behavior. There is a strong emphasis onbehavioral rehearsal and overlearning of a few specific and relatively narrow skills thatcan then be enacted relatively effortlessly. This serves to minimize the cognitive load fordecision making during stressful social interactions and increase the chances that the patientwill use the skills taught outside the clinic setting. In training, typically conducted insmall groups (up to eight patients), patients take turns role playing for three to four trialsat a time, and providing feedback and reinforcement to one another. Role plays should bedone in the most realistic manner possible. This means that facilitators should be familiarwith vocabulary that is most often used in the role-play situations. Asking for specificswhen developing role-play scenarios with group members is one way to gain this sort ofinformation.Handouts and written prompts are used to minimize demand on patients’ memoryand to maximize their success on the skill. The use of homework assignments is encouragedto maximize opportunities for generalization of newly acquired skills. Specific SSTcurricula have been developed for a variety of skills within the domains of conversation,assertiveness, conflict management, romantic relationships, medication management,HIV prevention, employment, and drug refusal skills. The general training model can beadapted and used to teach essentially any social skill.EVIDENCE SUPPORTING SSTSeveral parallel versions of SST have been developed, manualized, and evaluated. TheSST literature has not compared these clinical variations, but a number of common keyelements employed in the majority of randomized trials yielded positive results and aretherefore regarded as highly important, if not essential. As indicated earlier, training ischaracteristically conducted in small groups. The contents of training programs are organizedinto curricula, such as work-related skills, medication management (how to communicatewith health care providers), dating skills, and safe-sex skills. Training durationcan range from four to eight sessions for a very circumscribed skill, and up to 6 monthsto 2 years for a comprehensive skills training program. Regardless of duration, trainingsessions are typically held two to three times per week. Training is structured so as tominimize demands on neurocognitive capacity. Extensive use is made of audiovisual aids,with instructions presented in handouts and on flipcharts or whiteboards, as well asorally and on videotapes. Material is presented in brief units, with frequent repetition andreview, and patients are regularly asked to verbalize instructions and plan what they willsay before engaging in role play. An attempt is made to produce overlearning, so responsescan be elicited relatively effortlessly in the environment (i.e., with minimum demandon analytical and problem-solving skills). Individuals delivering SST are generallybachelor’s or master’s level clinical staff, and two therapists are employed whenever possible(one to direct the session, and the other to serve as role-play partner). Skills trainingis generally conducted on an outpatient basis, but it can be implemented in long-term inpatientsettings as well; acute admissions generally do not afford enough time for usefultraining. Given the challenge of generalization from training to in vivo application, SSTshould focus on skills that are currently relevant to the client’s life rather than skills thatmight one day be useful.Wide variability in methodology, outcome criteria, assessment instruments, and subjectpopulations in different trials make the SST literature somewhat difficult to review.