A group cognitive-behavioral and process-oriented approach to treating the social impairment and negative symptoms associated with chronic mental illness.

Social impairment is widely believed to play a major role in the pathogenesis as well as the course of chronic mental illness.1–3 Some researchers, for example, view social dysfunction as the “most debilitating and refractory aspect of psychopathology” for the chronically mentally ill.4 Numerous investigations have also demonstrated clear overlaps in the expression of negative symptoms (such as diminished emotional range, insufficient social drive, social withdrawal, and poverty of speech) and those symptoms that are markers for social impairment.4,5 Moreover, social skills deficits not only seem to persist over time, but also are more resistant to treatment when they are secondary to negative symptoms.6,7 Behavioral and cognitive-behavioral treatment (CBT) approaches to social skills training are used extensively in treating the social impairments found in people with severe mental illness.4,6,8–12 Many studies appear to demonstrate that by learning social cue recognition, appropriate behavioral responses, and how to generate alternative solutions to interpersonal problems, the individual can develop significantly enhanced overall social competence,1,2,13 which is also assumed to provide positive long-term generalizable effects. However, treatment outcome studies reveal that enhancing specific cognitive-behavioral social skills components does not necessarily lead to enhanced interpersonal relationships outside of the treatment setting.1,6,14,15 These studies have shown that for people diagnosed with schizophrenia, the treatment effects of current CBT models of social skills training are notably inconsistent with respect to generalization and impact on relapse rates.l6–19 For example, more recent findings by Penn and Mueser17 show that while behavioral skills may be enhanced by social skills training, improvement in symptoms and community functioning are less prominent. Moreover, many investigators have found that cognition skills training has little effect on psychiatric relapse,16,17,20 since between 35% and 50% of community service–connected people with a chronic mental illness relapse within a year and between 68% and 85% relapse within 5 years of a psychiatric hospitalization.21–26 A review of the literature also reveals that negative symptoms (estimated to affect between 30% and 60% of people with chronic mental illnesses27) significantly interfere with social learning and thus lead to further resistance to standard cognitive-behavioral social skills training.7,28 Unsuccessful interpersonal interactions, poor coping skills, and high relapse rates reflect the adverse impact of negative symptomatology on social functioning and its relationship to social skills learning for the chronically mentally ill. Mueser et al.,5 for example, found that negative symptoms were highly associated with poor social functioning and quality of life in chronically mentally ill populations. Although the presence of negative symptoms in schizophrenia and schizoaffective disorders is widely accepted as a significant barrier to pharmacological and psychological treatments,6,7,27 current cognitive-behavioral social skills training models generally do not target actively the goal of negative symptom reduction. It then seems likely that CBT social skills training outcomes are mixed in part because current models do not adequately examine how to motivate group members so that skills learned in training can be internalized and integrated into modifiable social models, which could then be used outside of the treatment environment. The abilities to internalize social skills, interpret instances of related knowledge, and integrate new information should lead to positive long-term generalizable improvement in overall social functioning and quality of life. The establishment of social skills training treatments that focus on the active facilitation of engaged relationships among group members should create viable models of social interactions while actively targeting negative symptom reduction. Many studies show that the facilitation of group process (through means such as altruism, group cohesiveness, self-disclosure, and instillation of hope) leads to enhanced interactions and engagement among group participants. Yalom29 also found that for people with severe and persistent mental illnesses, emergence of group process factors was followed by long-term positive effects that improved overall social functioning. Although many CBT social skills training models do not actively explore how and to what extent group process factors should be fostered, an important modification of standard social skills training models may be the active inclusion of interpersonal group process strategies to facilitate motivation for learning and interpersonal connections between group members. This approach should, in practice, reduce negative symptomatology and significantly improve social skills acquisition. The present study assesses the efficacy of Interactive-Behavioral Training (IBT),30 an approach to social skills training with a combined focus on cognitive-behavioral techniques (such as instruction, modeling, and behavioral rehearsal) and group process strategies. The IBT format directly facilitates therapeutic group process and uses established cognitive-behavioral strategies. The blending of cognitive-behavioral and group process interventions is therefore postulated to increase motivation for learning, improve social skills acquisition, and enhance overall social competence. It appears, then, that IBT should improve the effectiveness of current social skills training models, inasmuch as therapeutic group process itself reduces negative symptoms by increasing motivation for social learning. Through the use of cognitive-behavioral and interpersonal group process strategies, group members may learn to participate fully and to act as vehicles for social learning by serving as clarifiers of affect, reality testers, and interpersonal behavioral and problem-solving models. Thus, the combination of cognitive-behavioral and interpersonal group process strategies29,31 may offer the most comprehensive and dynamic social skills treatment package. The application of cognitive-behavioral social skills techniques with group process strategies may then fill the current gap in outcome research between social skills and social competence. Preliminary data32 comparing the efficacy of IBT with standard social skills training33 suggest that IBT training results in positive changes in psychiatric symptoms and social functioning. Clinical observations also provide encouragement for further examination of the IBT model. The following hypotheses were tested: IBT will increase the overall social competence of people with chronic schizophrenia and schizoaffective disorders. IBT will improve the negative symptoms that are often associated with poor treatment outcome for people diagnosed with schizophrenia or schizoaffective disorder. IBT will facilitate the emergence of those therapeutic group process factors found to enhance social competence in people with chronic schizophrenia and schizoaffective disorders.