Skills Training to Enhance Vocational Outcomes in Veterans With Serious Mental Illness
Phase: NA
Conditions: Schizophrenia, Bipolar Disorder, Psychotic Disorders
Sponsor: Minneapolis Veterans Affairs Medical Center

Skills Training to Enhance Vocational Outcomes in Veterans with Serious Mental Illness 
July 10, 2020 
NCT02663349 
 
Background and Rationale:  Schizophrenia and bipolar disorder are profoundly disabling 
illnesses. Only 15% and 24% of individuals with these conditions are competitively employed, as 
compared to nearly 70% of healthy individuals(1).  Vocational rehabilitation programs such as supported 
employment have proliferated in recent years to facilitate work placement of individuals with serious 
mental illness.  These programs have successfully placed individuals, typically doubling employment 
rates(2).  However, maintenance of employment is dependent upon being able to successfully integrate 
into one’s work setting.  This can present a significant challenge to individuals with serious mental 
illness, as they typically exhibit impairment in their ability to accurately perceive and understand social 
exchanges(1, 3, 4).  Thus, in addition to work skills, these individuals are also likely to need assistance 
developing skills to manage the social demands of work.  To enhance vocational outcomes, integration 
of psychological interventions with vocational programs has been recommended(5). 
 
Social cognition is the ability to accurately perceive and understand the social world and 
encompasses emotion recognition, interpretation of social exchanges (Theory of Mind), and inference of 
motivations (Attribution Bias).  Social cognitive deficits are associated with functional disability and have 
been found to be unique predictors of community(6-8) and work functioning(9, 10).  The impact of social 
cognition on functional outcomes is direct and indirect.  Bell and colleagues found that the relationship 
between social cognition and work performance was mediated by social discomfort, suggesting that 
difficulty understanding social interactions led to discomfort around co-workers, and ultimately, 
affected job performance(9).  Similarly, Brekke et al. noted that social cognition contributed to poor role 
functioning both directly and through social competence and perceived social support(7).  Individuals 
with poor social cognitive ability functioned less effectively because they were less able to respond 
skillfully in social interactions and to perceive and access support from others.  Given its strength as a 
predictor and proximity to functioning, social cognition has become an intervention target(11). 
 
Results of recent studies suggest that social cognitive abilities are modifiable in both 
schizophrenia(12) and bipolar disorder(13).  Presently, the most established intervention is Social Cognitive 
Intervention Training (SCIT), a 12-week group intervention in which participants learn strategies to 
enhance emotion recognition and to assess the accuracy of their interpretation of social interactions(14).  
SCIT’s ultimate goal is for training to transfer beyond the social cognitive training targets to more distal 
outcomes such as enhanced role functioning.  The first full scale clinical trial of SCIT’s efficacy found that 
the impact of training generalized beyond social cognitive performance and resulted in increased 
skillfulness in social interactions(15).   
To enhance transfer of training gains to functional outcomes, two pilot studies have paired 
participants with a social mentor to facilitate completion of homework and to ensure that skills are 
practiced outside of treatment (supported SCIT).  Both studies reported improvements not only in social 
cognition but also in social relatedness(16) and community functioning(17).  The proposed study will 
extend this work by being the first to examine the impact of supported SCIT on work role functioning.  
When other types of skills training have been paired with work, a synergistic effect has been noted, with 
greater(18, 19) and more sustained(20) treatment gains observed, presumably because work offered 
opportunities to practice skills.   
Specific Aim 1:  This study will assess the feasibility of providing supported SCIT to individuals 
with serious mental illness who are engaged in work activity or school (i.e., competitive employment, 
hospital based compensated work therapy placement, volunteer work, school).  One 2-hour group-
based skills training sessions will be offered weekly.  The group training will be supplemented with 
individual sessions with a group co-facilitator to complete homework tailored to the work setting. 

Hypothesis 1.  Supported SCIT will be completed by 75% of enrolled veterans, a rate comparable to non-
supported SCIT offered to non-veterans(21).  Completion will be defined as attendance at 80% or more of 
group and individual sessions. 
Specific Aim 2:  This study will assess the impact of supported SCIT on social cognitive 
intervention targets as well as functional outcomes.   
Hypothesis 2.  Recipients of supported SCIT are expected to demonstrate performance gains on 
measures of social cognition, perceived social support, social competence, social comfort, and work 
performance post-intervention. 
Specific Aim 3:  This study will assess durability of intervention-induced change.  
Hypothesis 3:  Recipients of supported SCIT are expected to sustain gains in social cognitive and 
functional domains during a 3-month follow-up period. 
Methods: 
               Study Design.  An open-trial pilot study will be conducted in which participants attend 
12 weeks of supported SCIT.   
 
 
Participant Inclusion/Exclusion Criteria.  Participants will be individuals, ages 18-70, 
with a DSM-5 diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder who are engaged 
in work activity.  In addition, participants must be clinically stable, defined as no psychiatric 
hospitalizations and no changes in antipsychotic or mood stabilizing medication in the 4 weeks prior to 
study enrollment, and participants must be able to participate appropriately in a group-based activity, as 
judged by no recent history of disruptive behavior in groups and no history of unprovoked aggression 
toward others.  Participants will be excluded if they have met criteria for substance abuse in the last 
month or substance dependence in the last 6 months, if they are not fluent enough in English to 
understand testing procedures, if they have premorbid IQ less than 70, or if they do not have the 
capacity to give informed consent. 
 
 
Participant Recruitment.   Patients will be recruited from the Minneapolis VAHCS.  A 
study investigator or a Master’s level study staff person will meet with mental health staff to provide 
information about the study and to request that information be provided to appropriate patients.  We 
will also post advertisements describing the study at the VAHCS.  In addition, with a waiver of consent 
for screening and a waiver of HIPAA authorization for screening purposes, the investigators will request 
a list of patients treated at the Minneapolis VAHCS who have a chart diagnosis and are within the age of 
participants eligible for this study.  These individuals will be sent an IRB-approved letter that describes 
the study and that offers them the opportunity to indicate whether they would like to hear more about 
the study.  Participants who do not respond to research staff within two weeks of receipt of the letter 
will receive a follow up phone call from research staff asking them if they would like additional 
information about the study.  When a prospective participant expresses interest in the study, research 
staff will further describe the study to him/her.  If the participant continues to be interested, a brief 
eligibility screening will take place.  If the participant appears to be appropriate, the participant will be 
asked to provide consent for a diagnostic interview.  If the potential participant appears appropriate for 
the study, he or she will be given the opportunity to complete the protocol and provided with a consent 
form. The consent form will contain a detailed description of all study procedures, as well as possible 
risks and benefits.  Dr. Nienow, another study investigator, or a Master’s level study staff member will 
review the content of the form with the participant and respond to any questions or concerns.  To 
ensure comprehension of the information provided in the informed consent forms, participants will be 
asked to answer questions about the information on the consent form.  Indicators that a participant 
cannot currently comprehend meaningfully the content of the consent form will include:  1) the 
potential participant has severe formal thought disorder that does not allow him or her to ask 
understandable questions or to paraphrase the basic points in the consent form; 2) the potential 

participant is unable to maintain attention to the description of the consent form long enough to 
perceive the individual basic points in the consent form; 3) the potential participant cannot ask 
questions or respond sufficiently to indicate agreement due to catatonia; or 4) the potential participant 
expresses delusions related to the research protocol that significantly distort his or her basic 
understanding of the research.  In contrast, some indicators that the potential participant can provide 
meaningful consent will include: 1) ability to pay attention well enough to read the form or have it read 
and described to him/her; 2) ability to paraphrase the basic points in the consent form; and 3) ability to 
ask reasonable questions about the research and associated treatment conditions.   
               Study Intervention.  The intervention will consist of one 2-hour, small group training 
session and 30-minutes of individualized supported practice of skills with a treatment facilitator weekly.  
Dr. Nienow and bachelor and master’s level assistants will offer the intervention.  The Social Cognitive 
Intervention Training (SCIT) will be described as a relationship skills class.  The class will consist of a 
combination of lecture, demonstrations, and role-play activities.  Participants will learn skills to facilitate 
emotion recognition.  They will also learn strategies to assist with perspective taking and assessing the 
accuracy of attributions about social situations.   
Assessment.  See Table 1 for all assessment measures.  Participant diagnosis will be  
established with a SCID diagnostic interview.  In addition, to establish eligibility, structured interviews 
will be conducted to obtain participant demographics, medical, and psychiatric history.  In addition, the 
Wechsler Test of Adult Reading will be administered to obtain an estimate of pre-morbid IQ.  Baseline, 
post-intervention (3-month), and follow up (6-month) assessments will measure social cognitive training 
targets, functional outcomes, and potentially confounding variables such as symptom severity with 
instruments previously used with this patient population.  Social cognitive domains will be assessed with 
the Bell-Lysaker Emotion Recognition Task, the Ambiguous Intentions and Hostility Scale, the Facial 
Emotion Identification Test, and The Awareness of Social Inference Task.  Social competence, 
community functioning, perceived social support at work, and social comfort at work, will be assessed 
with the Social Skills Performance Assessment, the Mentoring and Communication Support Scale, the 
First Episode Social Functioning Scale, the Vocational Efficacy in Trauma Survivors Scale, and the 
Mentoring and Communication Support Scale.  Potential confounds, symptom severity and outside 
treatment hours, will be assessed with the Brief Psychiatric Rating Scale and the treatment update 
interview.   
Statistical Analysis:    Descriptive statistics, including means, standard deviations, and measures 
of frequency will be used to describe the sample as well as uptake and engagement in treatment.  
Repeated measure ANOVAs and paired sample t-tests will be used to test for the effects of Time on 
social cognitive and functional outcome variables.  Magnitude of within group change with treatment 
will be measured with Cohen’s d.   
 
 
 
 
 
 
 
 
 
 
 
 
 

References 
 
1. 
Lahera G, Herrera S, Reinares M, Benito A, Rullas M, Gonzalez-Cases J, et al. Hostile 
attributions in bipolar disorder and schizophrenia contribute to poor social functioning. 
Acta Psychiatr Scand. 2015;131(6):472-82. 
2. 
Hoffmann H, Jackel D, Glauser S, Mueser KT, Kupper Z. Long-term effectiveness of 
supported employment: 5-year follow-up of a randomized controlled trial. Am J Psychiatry. 
2014;171(11):1183-90. 
3. 
Samame C, Martino DJ, Strejilevich SA. An individual task meta-analysis of social 
cognition in euthymic bipolar disorders. J Affect Disord. 2015;173:146-53. 
4. 
Thaler NS, Allen DN, Sutton GP, Vertinski M, Ringdahl EN. Differential impairment of 
social cognition factors in bipolar disorder with and without psychotic features and 
schizophrenia. J Psychiatr Res. 2013;47(12):2004-10. 
5. 
Tsang HW, Leung AY, Chung RC, Bell M, Cheung WM. Review on vocational 
predictors: a systematic review of predictors of vocational outcomes among individuals 
with schizophrenia: an update since 1998. Aust N Z J Psychiatry. 2010;44(6):495-504. 
6. 
Martinez-Dominguez S, Penades R, Segura B, Gonzalez-Rodriguez A, Catalan R. 
Influence of social cognition on daily functioning in schizophrenia: study of incremental 
validity and mediational effects. Psychiatry Res. 2015;225(3):374-80. 
7. 
Brekke J, Kay DD, Lee KS, Green MF. Biosocial pathways to functional outcome in 
schizophrenia. Schizophr Res. 2005;80(2-3):213-25. 
8. 
Fett AK, Viechtbauer W, Dominguez MD, Penn DL, van Os J, Krabbendam L. The 
relationship between neurocognition and social cognition with functional outcomes in 
schizophrenia: a meta-analysis. Neurosci Biobehav Rev. 2011;35(3):573-88. 
9. 
Bell M, Tsang HW, Greig TC, Bryson GJ. Neurocognition, social cognition, perceived 
social discomfort, and vocational outcomes in schizophrenia. Schizophr Bull. 
2009;35(4):738-47. 
10. 
Lo P, Siu AM. Social cognition and work performance of persons with schizophrenia 
in a Chinese population. Work. 2015;50(4):629-36. 
11. 
Kern RS, Glynn SM, Horan WP, Marder SR. Psychosocial treatments to promote 
functional recovery in schizophrenia. Schizophr Bull. 2009;35(2):347-61. 
12. 
Fiszdon JM, Reddy LF. Review of social cognitive treatments for psychosis. Clin 
Psychol Rev. 2012;32(8):724-40. 
13. 
Lahera G, Benito A, Montes JM, Fernandez-Liria A, Olbert CM, Penn DL. Social 
cognition and interaction training (SCIT) for outpatients with bipolar disorder. J Affect 
Disord. 2013;146(1):132-6. 
14. 
Penn DL, Roberts DL, Combs D, Sterne A. Best practices: The development of the 
Social Cognition and Interaction Training program for schizophrenia spectrum disorders. 
Psychiatr Serv. 2007;58(4):449-51. 
15. 
Roberts DL, Combs DR, Willoughby M, Mintz J, Gibson C, Rupp B, et al. A randomized, 
controlled trial of Social Cognition and Interaction Training (SCIT) for outpatients with 
schizophrenia spectrum disorders. Br J Clin Psychol. 2014;53(3):281-98. 
16. 
Tas C, Danaci AE, Cubukcuoglu Z, Brune M. Impact of family involvement on social 
cognition training in clinically stable outpatients with schizophrenia -- a randomized pilot 
study. Psychiatry Res. 2012;195(1-2):32-8. 

17. 
Hasson-Ohayon I, Mashiach-Eizenberg M, Avidan M, Roberts DL, Roe D. Social 
cognition and interaction training: preliminary results of an RCT in a community setting in 
Israel. Psychiatr Serv. 2014;65(4):555-8. 
18. 
Bell M, Bryson G, Greig T, Corcoran C, Wexler BE. Neurocognitive enhancement 
therapy with work therapy: effects on neuropsychological test performance. Arch Gen 
Psychiatry. 2001;58(8):763-8. 
19. 
McGurk SR, Mueser KT, Pascaris A. Cognitive training and supported employment 
for persons with severe mental illness: one-year results from a randomized controlled trial. 
Schizophr Bull. 2005;31(4):898-909. 
20. 
Bell MD, Zito W, Greig T, Wexler BE. Neurocognitive enhancement therapy with 
vocational services: work outcomes at two-year follow-up. Schizophr Res. 2008;105(1-
3):18-29. 
21. 
Bartholomeusz CF, Allott K, Killackey E, Liu P, Wood SJ, Thompson A. Social 
cognition training as an intervention for improving functional outcome in first-episode 
psychosis: a feasibility study. Early Interv Psychiatry. 2013;7(4):421-6.