Social skills training: Alive and well?

Social skills training is one of the oldest and widely studied approaches to psychiatric rehabilitation, with a history dating back over 40 years. Social skills training involves the systematic teaching of interpersonal skills through the process of breaking complex behaviors into their constituent elements, demonstrating (modeling) those skills in role plays, engaging clients in role plays to practice those skills, providing positive and corrective feedback to improve performance, additional role play practice, and developing assignments to practice those skills in naturally occurring interactions in clients lives. With the roots of social skills training in conditioned reflex therapy (Salter, 1949), psychotherapy by reciprocal inhibition (Wolpe, 1958), and social learning theory (Bandura, 1969), social skills training was first packaged as “assertiveness training” for the general population, and was soon after applied to a broad range of clinical populations, including persons with severe mental illness (Mueser, 1998).

Although research on social skills training is voluminous, the findings have spurred more debate than consensus, and access to skills training programs varies greatly both within and across countries. Despite the debates about the nature and magnitude of the effects of social skills training on schizophrenia and other severe mental illnesses (Mueser & Penn, 2004; Pilling et al., 2002a), most reviews of research on skills training have converged on four general conclusions (Bellack, 2004; Benton & Schroeder, 1990; Corrigan, 1991; Dilk & Bond, 1996; Heinssen, Liberman, & Kopelowicz, 2000; Kopelowicz, Liberman, & Zarate, 2006; Wallace, 1998; Wallace et al., 1980). First, there is ample evidence that people with severe mental illness can learn new skills and maintain these gains over time. Second, the primary impact of social skills training is on improving social functioning and the quality of social relationships, with little or no impact on symptoms, relapse, and rehospitalizations. Third, some transfer of social skills occurs from the training setting to clients' day-to-day lives using the standard skills training methods of homework assignments and in vivo community practice. Fourth, cognitive impairment, especially poor memory, is related to a slower acquisition of skills in social skills training.

The importance of these effects needs to be understood in the context of the central role of impaired social functioning in schizophrenia. Poor social competence is one of the hallmarks of schizophrenia, and social skills are a strong marker of social functioning, quality of life, and community adjustment (Bellack, Morrison, Mueser, Wade, & Sayers, 1990; Bellack, Morrison, Wixted, & Mueser, 1990). Problems with social functioning are a risk factor for the development of schizophrenia (Zigler & Glick, 1986), and a deterioration in social drive and the quality of social relationships is one of the first signs of the onset of the disorder, typically preceding the emergence of psychotic symptoms by several years (Häfner et al., 2003). In addition, poor social competence is stable over time in the absence of treatment (Mueser, Bellack, Douglas, & Morrison, 1991), and is related to a worse course of illness (Erickson, Beiser, Iacono, Fleming, & Lin, 1989). Other than social skills training, no psychosocial treatments have been consistently shown to improve social functioning in schizophrenia. Furthermore, other established psychiatric rehabilitation approaches, such as supported employment (Bond, 2004), assertive community treatment (Phillips et al., 2001), family psychoeducation (Pilling et al., 2002b), cognitive-behavior therapy for psychosis (Zimmermann, Favrod, Trieu, & Pomini, 2005), and cognitive rehabilitation (Twamley, Jeste, & Bellack, 2003), have minimal or no impact on social functioning. These findings are consistent with Strauss and Carpenter's (1972) conceptualization of the outcome of schizophrenia as characterized by several semi-independent domains of functioning, and the general observation that the impact of psychiatric rehabilitation interventions tend to be domain-specific with little cross-over to other domains (Mueser, Drake, & Bond, 1997). Thus, while the magnitude and clinical significance of social skills training for schizophrenia remain unclear, skills training approaches are the most powerful rehabilitation technology currently available for addressing the stubborn social impairments that are so prominent in this disorder.

Progress in research on social skills training has led to a number of recent developments aimed at increasing its effectiveness and addressing other areas of functioning. Efforts to improve the generalizability of skills training have shown that targeted, in vivo practice of skills (Glynn et al., 2002), and systematically involving natural supports in helping clients use targeted social skills during their daily interactions (Tauber, Wallace, & Lecomte, 2000), can maximize treatment gains. To address the rate-limiting effects of cognitive impairment on learning social skills (Smith, Hull, Romanelli, Fertuck, & Weiss, 1999), some research has shown that combining cognitive rehabilitation with skills training improves outcomes (Hogarty et al., 2004; Roder, Mueller, Mueser, & Brenner, 2006; Silverstein et al., 2005). In addition, a growing number of programs have incorporated skills training to address a range of other domains related to social functioning, such as substance abuse (Bellack, Bennet, Gearon, Brown, & Yang, 2006), work (Tsang & Pearson, 2001), and HIV-risk reduction (Carey et al., 2004), and to meet the social needs of special populations, such as older persons with severe mental illness (Bartels et al., 2004). Finally, research is increasingly examining theoretical models of social competence, with a particular focus on the mediating role of social cognition in determining functional outcomes (Brekke, Kay, Lee, & Green, 2005; Mueser et al., 1996; Nienow, Docherty, Cohen, & Dinzeo, 2006; Sergi, Rassovsky, Nuechterlein, & Green, 2006). This research has also spawned efforts to develop training programs aimed at improving social cognition skills such as emotion recognition (Combs, Tosheva, Wannner, & Basso, 2006; Penn et al., 2005; Silver, Goodman, Knoll, & Isakov, 2004; Wölwer et al., 2005), which has the potential for amplifying the impact of social skills training.

Although social skills training enjoys growing empirical support, many clients do not have access to skills training programs, and many clinicians lack basic training in teaching social skills. There is a need to incorporate social skills training into the clinical training of all clinicians working with persons with severe mental illness, and to make skills training programs accessible to all clients who need them. Interpersonal relationships are an important dimension of quality of life, and are frequently cited in definitions of recovery (Liberman, Kopelowicz, Ventura, & Gutkind, 2002; Ralph, 2000). Social skills training is currently the most potent intervention for helping individuals develop more rewarding and meaningful relationships, and for promoting social integration into the community. Access to skills training programs for clients with severe mental illness should be viewed as a right, not a luxury, and the planning and provision of mental health services should attend to this right accordingly.