Social Skills Training for Veterans with Schizophrenia Changes Lives for Better

by U.S. Medicine

September 6, 2012

By Annette M. Boyle

BALTIMORE– For many veterans with schizophrenia, deficits in social skills commonly associated with the disorder can make maintaining relationships and achieving personal goals extremely challenging. The VA’s Social Skills Training (SST) program helps these veterans acquire the skills they need to effectively engage in social interactions, set and reach goals and take critical steps on the road to recovery.


Richard W. Goldberg, PhD

“The social skills training program makes evidence-based psychosocial treatment accessible to veterans with schizophrenia. Through the program, they learn how to communicate more effectively, integrate more actively into society and adopt roles and goals that relate to living a meaningful life,” said Richard W. Goldberg, PhD, director of the VA Psychosocial Rehabilitation Training Program at the VA Maryland Healthcare System in Baltimore and associate professor at the University of Maryland School of Medicine.

The VISN 5 Mental Illness Research, Education and Clinical Center (MIRECC) oversees implementation of social skills training programs across the VA health system. The program is co-facilitated by the VSIN 22 MIRECC in Los Angeles.

Since 2008, 465 clinicians and some peer-support technicians have gone through the two-day training and six-month follow-up consultation that enables them to establish and operate SST programs in sites across the country. As each clinician typically runs several groups of six to eight patients, hundreds of veterans have had the opportunity to participate.

Goldberg’s group provides ongoing consultation to clinicians to assist with implementing the programs in a variety of settings. Groups operate within Psychosocial Rehabilitation and Recovery Centers (PRRC), as well as inpatient and outpatient clinic settings.

“We help clinicians focus on getting buy-in from program directors and building SST into existing programming. Our ability to implement the training across the country speaks to the VA’s commitment from the top down to assure that veterans have access to effective treatments for schizophrenia,” Goldberg said.

Recovery Through New Ways of Interaction

“Recovery is possible, even after diagnosis of a severe mental illness such as schizophrenia,” said Goldberg. “Recovery is about skills and support for roles and goals. The SST program gives veterans the support and teaches them the skills they need to learn new ways of interacting with others and new approaches to life management.”

This approach is in keeping with the National Consensus Statement on Mental Health Recovery: “Mental-health recovery is a journey of healing and transformation enabling a person with a mental-health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential.”

A group-based behavioral intervention, SST teaches expressive and receptive skills, starting with listening and letting speakers know they are being heard. Through very structured role-play, group participants learn how to communicate their feelings, make requests, assert themselves, engage in conversation and manage conflict in the contexts of friendships, dating, vocational and work settings, health maintenance and alcohol- and drug-related challenges.

Social Skills Training for Veterans with Schizophrenia Changes Lives for Better

Stress Reduction

In addition to helping individuals with schizophrenia reach their goals, the coping skills and social competence learned through SST have been shown to provide protection against stress and correlate with high levels of life satisfaction.

While the VA’s SST classes are quite structured, the duration of participation in the classes is highly variable. Unlike some other evidence-based therapies that have a set number of sessions, SST can work for veterans who are in an inpatient setting for just a week or for those who participate in outpatient groups for three months or longer.

Clinicians regularly check with participants to see if the program is continuing to work for them. Many cycle in and out of SST as they need skills at particular times to reach their goals, according to Goldberg. Others may be referred for SST from vocational programs, clinics and recovery centers.

Veteran satisfaction with the program has been very high. Since the program began surveying participants, over 90% have reported that they were pleased with the program and would recommend it to others.

1.  Kopelowicz A, Liberman RP, Zarate R. Recent advances in social skills training for schizophrenia. Schizophr Bull. 2006 Oct;32 Suppl 1:S12-23. Epub 2006 Aug 2. Review. PubMed PMID: 16885207; PubMed Central PMCID: PMC2632540.

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Social Skills Training for Veterans with Schizophrenia Changes Lives for Better

 “What’s wonderful about the classes is the opportunity to repeatedly practice the skills and to highlight the essential components through a multistep process,” said Goldberg. The six-step process works to teach and consolidate the skills immediately:

  1. Clinicians model the behavior, while group participants observe.
  2. Group members practice the skill in a role-playing format.
  3. The group and clinician provide positive feedback to members.
  4. Class members repeat the role-play.
  5. The clinician breaks down the skill into its smallest components for practice.
  6. The group role-plays again to solidify the skill.

“By working on a single skill in a role-play and practicing it three times, veterans see instant improvement is social skills they can use in other situations beyond the class. It’s not about symptom management but about learning how to communicate more effectively. That third time practicing the skill allows the veteran to ‘knock it out of the park.’ Each skill learned has a longterm effect on self-esteem, functional outcomes and social interactions,” Goldberg noted.

VA Social Skills Training for Serious Mental Illness

GROUP SESSION SEQUENCE
1. Review homework
2. Give a rationale for the skill
3. Briefly have members share a relevant experience or rationale
4. Explain the steps of the skill
5. Model the skill; review the model
6. Have a group member role-play
7. Give feedback
8. Have the member role play again
9. Solicit feedback from the group
10. Repeat role-play again and provide feedback
11. Repeat Steps 6-10 with each other group member
12. Give out homework

To effectively transfer skills learned in class to the life situations important to the veteran, clinicians work with each group participant to select goals such as obtaining a job, dating, getting along better with others in a residence, managing relationships with family or maintaining health. The goals provide a rationale for learning the skills, so veterans can see that the classes are relevant and helpful.

“One veteran we worked with had trouble getting a job,” Goldberg recounted. “We worked on the skills he needed and on generalizing them out of the group and into a vocational context. Practicing the new skills with his goal in mind ultimately enabled him to be successful in obtaining and maintaining employment.”

The positive results seen by SST are not simply anecdotal, however. Reviews of more than 50 studies document significant improvements in a wide range of behaviors and knowledge as the result of SST for individuals with schizophrenia across multiple settings, according to an article in Schizophrenia Bulletin. Further, those gains lasted for at least two years, the maximum duration studied.


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