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ORIGINAL ARTICLE
Year : 2014  |  Volume : 41  |  Issue : 3  |  Page : 156-161

Efficacy of social skill training in patient with chronic schizophrenia: An interventional study


1 Department of Psychiatry, KLE University's J. N. Medical College, Belgaum, Karnataka, India
2 Department of Social Work, Karnataka University, Dharwad, Karnataka, India

Date of Web Publication19-Sep-2014

Correspondence Address:
Sateesh R Koujalgi
Department of Psychiatry, KLE University's J. N. Medical College, Nehru Nagar, Belgaum - 590 010, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-5009.141201

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  Abstract 

Background: Patients with schizophrenia often have social skills deficits. Social skill training (SST) is a structured learning oriented approach for patient with schizophrenia. Effectiveness of SST improves communication, which achieves patient's goals in social situations. Aim: The aim of this study is to assess the efficacy of SST in patient with schizophrenia. Materials and Methods: A total of 65 patients with chronic schizophrenia participated in the study, 34 in experimental and 31 as a control group. This was cross-sectional interventional study. The patients were diagnosed as having schizophrenia (all types) disorders using International Classification of Disease 10 (ICD-10), classification of mental and behavioral disorders, ICD-10 diagnostic criteria for research criteria. Patient with more than 2 years duration of illness were included in the study groups. Positive and Negative Syndrome Scale was used to rule out predominant positive symptoms. Scale for the Assessment of Negative Symptoms (SANS), and social adaptive functioning evaluation (SAFE) were used to measure the efficacy of SST in schizophrenia patient. All participants were examined on SANS, and SAFE on pre- and post-test design. Data were analyzed using Statistical pakage for social sciences SPSS 17 version. P < 0.005 was considered as statistically significance. Results: The pre-and post-intervention score of SAFE of the control group did not show significant differences (P = 0.053). There was a significant difference between the pre- and post-intervention SAFE scores in the experimental group were noted (P < 0.002). The result indicated no significant decrease in SANS score in the experimental group compared to the control group (P = 0.072). However, results indicated significant improvement in alogia, apathy, and anhedonia (P = 0.007, P = 0.030, P = 0.025. Conclusion: SST is effective in improving social skills of patients with schizophrenia. SST is effective in alogia, apathy and anhodonia, but not other domains of negative symptoms.

Keywords: Chronic schizophrenia, social skill training, social competence


How to cite this article:
Koujalgi SR, Patil SR, Nayak RB, Chate SS, Patil NM. Efficacy of social skill training in patient with chronic schizophrenia: An interventional study. J Sci Soc 2014;41:156-61

How to cite this URL:
Koujalgi SR, Patil SR, Nayak RB, Chate SS, Patil NM. Efficacy of social skill training in patient with chronic schizophrenia: An interventional study. J Sci Soc [serial online] 2014 [cited 2020 Mar 28];41:156-61. Available from: http://www.jscisociety.com/text.asp?2014/41/3/156/141201


  Introduction Top


Patient with schizophrenia have impaired cognition, affect, and behavior. Social disabilities are pervasive and persistent in this disorder and generally result in skills deficits. [1] Moreover, research documented that the having poor social skills will precipitate stresses which produce maladaptive and disruptive outcomes in patient with schizophrenia. [2],[3]

Patient with schizophrenia go through severe social and economic impairment. Illness induces functional impairment, which would last mostly throughout their life span. [4] The impairment or loss of function in individuals with schizophrenia may prevent them from taking part in various societal events. Social skills are considered as an important factor for the patient with schizophrenia to participate in community events. Thus, role of rehabilitation arises and which is important to resume their functions in the society. Social skill training (SST) is one of the important modes of treatment for clinicians, and social workers during rehabilitation. [5] Social functioning deficits are seen in many mental illnesses, and one among that is schizophrenia disorder. A social deficit includes difficulty in establishing, and maintaining relationships, inability resume or perform a role, which is assigned to patient with schizophrenia. There are also deficits in self-care skills and taking part in recreational activities. [5] Neuroleptic drugs help in clinical improvement, but may not help in improving role behaviors, interpersonal, and social skills. [6]

When patient with schizophrenia are equipped with good social skills, they handle stressful life events. They may also become more capable of solving problems and challenges, which arise in their routine life. Thus, stressors may not trigger to exacerbations or cause decompensation in patients with schizophrenia. [7] SST helps individuals to stabilize their illnesses, improve adherence to medication and psychosocial intervention. Indirectly, it helps in good prognosis and promote toward recovery. [8]

In a patient with schizophrenia diminished interpersonal, and social functioning are the predictors of relapse and rehospitalizations. This suggests that improving concurrent social skill may help in improving social functioning. Moreover, it may also result in good prognosis of illness. SST is evidence based element of a comprehensive approach to the rehabilitation of persons with serious mental illness. We aimed to study the effect of SST on patient with schizophrenia with predominant negative symptoms and accordingly to restore or enhance their social competence.


  Materials and methods Top


A total of 100 patients with schizophrenia (all types International Classification of Disease 10 diagnostic criteria for research) were randomly screened out with more than 2 years of illness, by using Positive and Negative Syndrome Scale to rule out positive symptoms. Those who score more on negative symptoms were included in the study. Hence, of 100 patients, we could get 83 patients with predominant negative symptoms, and such patients were included in the intervention. Hence, sample consisted of 83 patients diagnosed with persistent forms of schizophrenia living in the community of their respective residence. These patients were on medication, but currently in remission. All the 83 samples were randomly divided into two groups frothy-frothy two in each experimental and control group. Further experimental group participants were randomly divided into four groups comprising of eight-ten patients. Each participant in both groups was evaluated during the first session and at the end of 20 sessions to measure the efficacy of SST by using a pre- and post-test design. Both groups of patients were rated on Scale for the Assessment of Negative Symptoms (SANS) and social adaptive functioning evaluation (SAFE) before, and after the completion of intervention to evaluate the effectiveness of SST. The SAFE was used to measure client's ability to function in everyday social situation and SANS was to estimate the efficacy of SST on negative symptoms of schizophrenia. The independent variable was SST. The dependent variable consisted of 19 domains of SAFE and SANS scale. Pre- and post-design were evaluated by paired t-test by comparing with P < 0.05 as statistically significant value. SST sessions were configured utilizing SST for schizophrenia: A step-by-step guide (2 nd ed.) by Bellack et al. [2] Checked and confirmed The researcher conducted the SST in psychiatry outpatient department (OPD).

Three sessions were held in a week comprising 10 patient in each group. The sessions were lasted for 1.5-2 h over a period of 6 months in the same hospital OPD setup. In each session of the intervention phase, the initial 15 min were utilized for warming up and homework task, later 25 min were utilized for explanation, demonstration, and role-play; 40 min were utilized for introducing new skills and remaining 20 min were utilized for assigning homework.

The researcher took one session for all before starting the intervention to explain present research study design, aim and objective of research, what SST will be done, what the session consists of, what their is a role in the session and the benefit of the sessions. Before each session, the respondents were reminded that it was voluntary participation; therefore, people were free to drop the session at any point. Forty-one respondents were included in the experimental cohort, where they took part in SST in four groups and 42 respondents were recruited in the control group. Altogether, 83 patients were enrolled in the intervention study. Two respondents in the experimental group dropped out from the study before intervention, three because of medical illness. Two respondents in the experimental cohort withdrew because he refused to continue during the process of intervention. Three respondents in the control cohort withdrew due to relapse. Seven subjects in the control cohort were excluded from the study because they were unable to participate due to transportation scarcity and one other due to death. Hence, the statistics analysis included 34 respondents in experimental cohort and 31 respondents in the control cohort.

Respondent's conversations were observed at the close of each role-play. These instructed participants provided feedback as how distribution of scenes was demonstrated. The principal outcomes were thoroughly debated and provided positive reinforcement. The role-plays were accomplished in each intervention sessions. Respondents were provided positive reinforcement during the sessions as well as real life setting.

Instruction techniques were used to transmit the dissimilarities among assertive passive and aggression style of conversation. In role-play exercises, respondents had an opportunity to provide feedback to each other regarding their performances in simulated arena. Few important factors were considered during the sessions, like therapist moved slowly so that the respondents were not overwhelmed by attempting to modify too many social skills at 1 time. In addition, therapist did not intensify the patients feeling of social incompetence. An additional precaution was considered that was to transfer of social skills from the sessions to real life situation.


  Results Top


The means of pre- and post-intervention affective flatting or blunting score in the control group was 23.13 ± 6.79 and 23.13 ± 6.79, respectively, no significant difference was found between the two groups (P = 0.781). The means of affective flattening or blunting scores in the experimental group was 22.53 ± 9.57 and 22.43 ± 9.51, respectively, and it was not significant (P = 0.744). The means of alogia scores in the control group was 15.93 ± 3.54 and 15.76 ± 3.71, respectively, no significant difference was noted between the two groups (P = 0.425).

The means of alogia scores in the experimental group was 15.13 ± 4.15 and 12.93 ± 4.09, respectively; it was significantly different between the two groups (P < 0.007). The means avolition/apathy score in the control group was 14.00 ± 3.97 and 14.00 ± 3.97, respectively, significant difference was not noted between the two groups (P = 0.195). The means of avolition/apathy scores in the experimental group was 12.53 ± 4.65 and 11.56 ± 4.50, respectively, significant differences was noted between the groups (P = 0.030). The means of anhedonia/asociality scores in the control group was 16.30 ± 3.95 and 16.26 ± 3.98, respectively, and significant difference was not noted between the groups (P = 0.091). The means of anhedonia/asociality scores in the experimental group was 14.13 ± 5.66 and 13.46 ± 5.36, respectively, and significant difference was noted between the experimental group (P = 0.025). The means of attention scores in the control group was 8.66 ± 1.80 and 8.16 ± 1.80, respectively, and significant differences were not noted between groups (P = 0.099). The means of attention scores in the experimental group was 7.63 ± 2.84 and 7.60 ± 2.79, respectively, and significant difference was not noted between the groups (P = 0.085). The mean and standard deviation (SD) of the pre- and post-intervention SANS scores (total) in the control group was 78.03 ± 15.39 and 77.83 ± 15.54, respectively, and significant difference was not noted between the groups (P = 0.264). The means of SANS scores (total) in the experimental group was 71.96 ± 25.05 and 68.16 ± 24.39, respectively, and significant difference was not noted between the groups (P = 0.072) [Table 1].
Table 1: Comparison of pre- and post-test means for SANS variables between the experimental group and the control
group baseline


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The mean and SD of the pre- and post-intervention SAFE scores (total) in the control group was 57.50 ± 7.85 and 57.68 ± 7.53, respectively. Significant difference was not noted between the groups (P = 0.053). The means of the pre- and post-intervention social adaptive functioning evaluation (SAFE) scores (total) in the experimental group 51.90 ± 13.49 and 48.46 ± 13.73, respectively. A significant difference was noted between the groups (P < 0.002) [Table 2].
Table 2: Diff erence between experimental and control
group characteristics on SAFE global scores


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  Discussion Top


Sociodemographic details of the study group were published in the other article. Individual with schizophrenia shows greater rates of social skill impairments. The impairment could be linked with poor premorbid learning abilities, resisted environmental stimulation, psychopathology, and the diminished skills due to prolonged or more number of hospitalizations.

The pre- and post-intervention score of SAFE of the control group did not showed significant differences. This outcome may be because the control group did not receive the SST. A significant difference between the pre-and post-intervention SAFE scores in the experimental group was noted and possibility for this outcome may be the effect of the SST on schizophrenia disorder, but same was not seen in the control group. Social skills in the experimental group after SST was superior to that before training, this findings support previous studies. [9],[10],[11] This difference may be attributed to the fact that first, SST consisted of explanation, instruction, modeling, role-playing and feedback and reinforcement techniques. Second, intervention were designed in accordance with clinical requirement of the respondents and moreover, majority of them participated in the group therapy were motivated to learn. Perhaps, the behavioral rehearsal obtained in the skill intervention sessions serves the purpose of repetition, which might have helped in acquiring social skills. Third, therapist provided an opportunity for the patient to acquire and practice new skills; moreover, competence practice between interventions is needed in order to generalize social skill into real life setting. Therefore, all the respondents were regularly provided homework assignment to utilize the acquired particular skill during the session with family members/friends before step into the next session. Fourth, that all respondents were community living residents of their respective places. It is a well-known fact that social interaction is often contaminated in the hospital setting. As a result, such a protected and restricted environment may not be greater helpful to the patients. Glynn et al. [12] in their study pointed out that SST is more effective in those who reside in the community and they show significantly greater or quicker improvement rather institutional/hospital based skill training or closed indoor patient. Fifth, individual with schizophrenia disorder who were less attentionally impaired were able to acquire social skills. Sixth, less chronic patients may have benefited more from the SST. These respondents might have adequate verbal memory wherein they recall of words from the word list which may be a stronger factor and may have benefited from SST. Auslander and Jeste [13] suggested that physical health, memory, and social functioning are the good treatment response factors. Mueser et al. [14] illustrated that verbal memory is one of the strongest predictor of improvements of SST for schizophrenic patient. A study done by Spaulding et al. [15] revealed that patient whose scores adequately on verbal learning test, were more likely to improve on the interpersonal problem solving skills. It may be apparent that verbal memory may be an indicator of better acquisition and performance of social skills. Seventh, continuous and planned systematic feedback might have benefited experimental group. During the process of feedback, experimental group might have learned reading cues from the social environment about their interpersonal behavior; such issues were addressed in the therapy. Green [16] concluded that verbal memory and attention influences the competence. In this study, patients participated in the intervention group were schizophrenic patient who lacked social skills due to psychiatric syndrome. Hence, social skill with more repeated instruction on multiple areas results an improvement in SAFE scores in the experimental group.

The result indicated no significant decrease in SANS score in the experimental group compared to the control group (P = 0.072). This study findings could be due to a number of factors. However, result indicated significant improvement in alogia, apathy, and anhedonia (P = 0.007, P = 0.030, P = 0.025), but not in other domains of SANS. First, SST may be beneficial over a longer period of training, which may reduce the severity of disability among the schizophrenia sample population. An approximate amount of time is difficult to estimate; however, previous research studies has been carried out over the period of few months and even extended up to 2 years of duration. Overall, studies suggest that a longer period of time may be required for the beneficial effect of SST on schizophrenia patients. Second, patient's chronicity and disability due, which patients did not get the benefit from SST. Third, that schizophrenia is a severely debilitating and continuous/chronic mental illness which pervasively decline psychosocial functioning, and learning abilities. Hence, the present study group patients did not shown improvement. Holmes [17] have reported that symptoms like hallucinations, delusions, bizarre thoughts which may last for a longer period, consequences of which patient may become poorer in learning new skills. National Institute of Mental Health (NIMH) [18] that reports schizophrenic patients may have unusual thought process, disorganized thinking and difficult in organizing their own thoughts and connecting them logically, which perhaps may be the reason for the current study results. Fourth, that negative symptoms such as blunted effect, apathy amotivation, and diminished drive may cause distraction in learning new skills. Depersonalization, derealization, and somatic symptoms are seen and may have reached to delusion proportions, which have hampered the acquisition of social skills in the present study population. Fifth, reason may be individual acceptance of mental illness. NIMH [18] reports that the majority of patient with schizophrenia were unaware of their psychotic illness; therefore, they may have poor coping behavior. Owing to poor insight patient with schizophrenia become noncompliant to the treatment, poor functioning and which may cause poorer prognosis of illness. It is obvious that one who denies about their mental illness may not accept treatment because they feel treatment is not required. Hence, therefore teaching social skill acquisition and improvement becomes very difficult. Sixth, it could be the preoccupation with systematized delusions/hallucinations to a particular theme, which may not be in accordance with the pattern. Such a pattern may have restricted the SST benefit. The analysis showed a significant difference between the two groups across some domains of SANS such as alogia, avolition, and asociality. It appears SST may have some effect on negative symptoms. The possible reason may be first, that the present study used a role-play measure of social skills. Once the skill was demonstrated the patient was instructed to try to copy the therapist behavior; a short role-play interaction. This is a prominent domain of SST. Talking or viewing required behavior is less likely to impart the target skill to the patient. Second, learning abilities of this study group were contributed to significance difference. As part of SST social perception training was given to the experimental group, wherein overt response skill and expressive elements, which consists of verbal and nonverbal response parameters which involves communication messages to another group person. A significant difference was observed between the two groups on the asociality measures. A program developed by Wallace [19] was used, which basically improves the information processing skills of schizophrenia population. In this program, patients were taught to perceive and process incoming stimuli rightly and subsequently pass the effective verbal and nonverbal measures. Moreover, during this patients were taught to elicit various alternatives options and devise them in an appropriate way.

Group modalities are often used in conjunction with other intervention, such as medication and SST. Group therapy resulted in an increase in the emotional communication, free-time activities and social interaction and resulted in reduction in anhedonia. The group process was found to assist clients with self-discloser, awareness of oneself and his problem, opportunity to interact with others, increase self-esteem and enhance social functioning outside the group.

In this study, severity of social deficits decreased, there was an improvement in level of social functioning over 20 sessions. This input is seen to be contributed; therefore an SST treatment option is very important when dealing with cases of schizophrenia with predominant negative symptoms. Such interventions may indirectly decreases symptoms thus further improves the quality of social life. Establishment of SST in the community will help to improve the quality of social life in this population. Evidence suggest that generalizability of SST from therapeutic setting to real life situation is not clear and weaker, hence further research is needed to address assessment of generalizability in real life situation and also the factor affecting the transferring of new learned skills from therapeutic setting to real life situation. Including family members in SST may benefit. The other area required to examine is whether demographic characteristics, setting, environmental/social factors, length of training, also affect the acquisition and adopting social competence in the community.


  Conclusion Top


The SST is helpful in improving social adaptive functions. It is also helpful in improving some negative symptoms such as alogia, apathy, and anhodania.

 
  References Top

1.Bellack AS, Morrison RL, Wixted JT, Mueser KT. An analysis of social competence in schizophrenia. Br J Psychiatry 1990;156:809-18.  Back to cited text no. 1
    
2.Bellack AS, Mueser KT, Gingerich S, Agresta J. Social Skill Training for Schizophrenia: A Step-by-Step Guide. New York: The Guilford Press; 1997.  Back to cited text no. 2
    
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4.Mueser KT, McGurk SR. Schizophrenia. Lancet 2004;363:2063-72.  Back to cited text no. 4
    
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12.Glynn SM, Marder SR, Liberman RP, Blair K, Wirshing WC, Wirshing DA, et al. Supplementing clinic-based skills training with manual-based community support sessions: Effects on social adjustment of patients with schizophrenia. Am J Psychiatry 2002;159:829-37.  Back to cited text no. 12
    
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[PUBMED]    
17.Holmes DS. Abnormal Psychology. 4 th ed. Massachusetts: Allyn and Bacon; 2001.  Back to cited text no. 17
    
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19.Wallace CJ. The social skills training project of the mental health clinical research center for the study of schizophrenia. In: Curran JP, Monti PM, editors. Social Skills Training: A Practical Handbook for Assessment and Treatment. New York: Guilford Press; 1982. p. 57-89.  Back to cited text no. 19
    



 
 
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