Social Skills Training To Improve Functioning In Schizophrenia Patients: A Literature Review

PICO Question

Discuss About The Practice In Published Studies Using ATLAS.

The practice of nursing generally refers to a right that is granted by the state, with the aim of protecting individuals who require care. Nursing professionals promote and provide care services that most often involves service users, and their carers and family members in the process of decision making, thereby facilitating the process of making informed choices about the proposed treatment and care plan. The question regarding what establishes proper nursing knowledge is crucial for nurses to consider due to several reasons (Cheraghi, Jasper and Vaismoradi 2014).

Nursing are expected to use range of knowledge in their practice, including theoretical and practical knowledge that helps them identify several interventions that should be central to their practice (Westra et al. 2015). Schizophrenia is a major mental disorder, primarily characterized by a range of psychotic symptoms where the affected individual often loses touch with reality and suffers from perceptional impairments that affect the expression of realities (Hüfner, Frajo-Apor and Hofer 2015). Nursing management of the condition involves recognition of the disorder, establishment of support and rapport, maximization of the patient’s level of functioning, assessment of the symptoms and medical history, followed by conducting an evaluation. The research project will elaborate on increasing nursing knowledge on a particular form of non-therapeutic intervention for schizophrenia.

This specialized framework is used for formulating a research question that facilitates conduction of the literature review and adds to the body of knowledge. The PICO question for the project was as follows:

Do social skills training improve functioning in schizophrenia patients, when compared to their usual standard treatment?

P (Population/problem)	Schizophrenia patients
I (Intervention)	Social skills training
C (Comparison)	Usual care
O (Outcome)	Improved functioning

Table 1: PICO framework

Social skills training refers to a kind of psychotherapy approach that works with the aim of aiding people to advance their social skills and competence. A single-blind randomized controlled trial was conducted among veteran and non-veteran schizophrenia consumers in an outpatient clinic and combined social skills training with cognitive behavioural therapy in the intervention group (CBSST) (Granholm et al. 2013). Following the 36 week session of the therapy, significant positive results were obtained in the functional trajectories of the patients, over time. The training program was also associated with better improvements in the pessimistic attitudes of the patients. Similar findings were obtained in another RCT that randomly assigned patients with schizophrenia and schizoaffective disorder to a CBSST group and a control group (Granholm et al. 2014). Negative symptoms, defeatist performance insolences, functionality, and amotivation were found to significantly improve among the patients in the CBSST group. This indicates that social skills training, in combination with CBT acted as an effective nursing intervention for improving the reduced functioning and negative symptoms that are commonly reported by schizophrenia patients.

A preliminary study was also conducted with the aim of improving social competence and functioning among patients suffering from schizophrenia (Rus-Calafell et al. 2013). 31 patients were randomly assigned to the treatment group of social skills training and the control group following which their post-intervention outcomes were assessed. The SST patients reported improvements in their social discomfort, psychopathology, social withdrawal, interpersonal communication and social cognition. Another study compared the effects of computerized cognitive remediation, in combination with SST among schizophrenic individuals (Kurtz et al. 2015). Upon comparing the outcome, the intervention was found to bring about noteworthy advances in attention, empathy and working memory. However, no significant differences were observed in psychosocial skills or functioning. The feasibility and efficacy of a social training program, based on neuroplasticity was also evaluated in another study (Nahum et al. 2014). Schizophrenia patients who completed the online social program/game were found to demonstrate large improvements in their working memory, social functioning and social cognition. Thus, this literature review provides evidence regarding the effectiveness of social skills training programs and the need for implementing it as a major form of nursing intervention to reduce schizophrenia related symptoms.

Literature Review

During psychotic episodes of schizophrenia, patients experience a plethora of positive and negative symptoms. Some of the positive symptoms include hallucinations and delusions that result in irrational or unusual behaviour (Langdon, Connors and Connaughton 2014). Negative symptoms are those that result in anhedonia and the patients lose pleasure in activities that were earlier pleasurable, and also report social withdrawal symptoms. Social skills training (SST) have the primary objective of teaching individuals facing emotional problems about certain non-verbal and verbal behaviour that are encompassed by social interactions (Ottavi et al. 2013). SST is based on the prime assumption that when individuals improve their change selected behaviour or social skills, they are found to enhance their self-esteem, which in turn increases the likelihood of receiving favourable response from others (Kane 2013).

Another goal of SST is to improve the patient’s ability to function in daily social situations. Thus, SSTs assist the users to work on their specific functioning related issues (Mikami, Jia and Na 2014). Some of the common examples of appropriate social skills are maintaining eye contact during conversation, smiling while greeting person, shaking hands as a welcoming gesture, expressing opinions, perceiving feelings and empathy shown by others and demonstrating fitting emotional responses (Otero et al. 2014). Cognitive impairment is one of the major deficits of schizophrenia and includes problem solving capabilities, attention and working memory (Tonna et al. 2016). In addition to the psychotic symptoms, these deficits marketing the schizophrenia patients socially incompetent, and create hindrances in implementing nursing care plan. This can be attributed to the fact that a reduction in cognitive function signifies that it becomes extremely difficult for nurses to train these patients for improving their social competency. This establishes the relevance of the SST programs for treating schizophrenia symptoms and facilitating nursing practice.

The research project was based on a randomized control trial where 27 eligible participants were selected from the mental service of two general hospitals located in the district. The randomized control trial was conducted after obtaining informed consent from the participants, following providing them a clear description of the potential purpose and benefits of the research. Inclusion criteria were (1) patients aged more than 18 years, (2) DSM-V diagnosed schizophrenia and (3) sound state of mind to provide consent. The exclusion criteria comprised of (1) previous exposure to SST (2) any other psychotic disorder or substance abuse that might interfere with their participation. The patients were randomly assigned to the SST group and usual care group. SST was administered to 14 patients, and was conducted by two qualified clinical psychologist.

Tri-weekly sessions were held in the form of group therapy for two hours, for 6 months during the treatment phase, followed by monthly sessions during a follow-up period of 5 sessions. Participants in the usual care group were only administered the prescribed medications for treating schizophrenia associated symptoms. The SST regimen was formulated on their self-reported functioning, social competence, and positive and negative symptoms. Following implementation of the intervention, the primary and secondary outcomes were assessed with the help of several tools.

Relevance of the Topic

The Independent Living Skills Survey was used for assessing a range of functioning domains among the patients. This survey is based on a 51-item questionnaire that acts as a measure of essential functioning aspects such as clothing and appearance, possession, personal hygiene, living space, health and money maintenance, job seeking and recreational activities (Bal, Kim, Cheong and Lord 2015). The patients reported items as not performed (0), performed (1), not applicable. This was followed by calculating a composite score in the form of an average for the scores obtained against each functional domain (Ni et al. 2015). Another data collection tool was the Interaction Rating Scale Advanced (IRSA) that helped in measuring ability of the patients in resolving their interpersonal problems through different conversation scenarios (Anme et al. 2011). The patients were presented with the 92-item tool that assessed their basic social competence through five minutes observation of a social interaction with live confederates. Average scores were calculated for the 6 subscales that provided information on self-control, sensitivity, expressivity, assertiveness, regulation and responsiveness. The observable behaviour were scored on a five-point scale of 1 to 5, ranging from ‘not evident’ to ‘highly evident’.

Presence of positive and negative symptoms associated with schizophrenia were determined on the basis of the Positive and Negative Syndrome Scale (PANSS), specific for the disorder. This tool is based on a brief interview that required an estimated 45-50 minutes for its administration (Anderson et al. 2015). This was followed by rating the patients on a range of 1 to 7, on 30 symptoms that were reported by the care giver as well as the family members. Items in the positive scale included hallucinations, delusions, excitement, grandiosity, hostility, among others. Some of the items in the negative scale included emotional withdrawal, blunted effect, poor rapport, and apathy. Several general psychology items were also measured with the use of the scale such as, poor attention, depression, tension, disorientation, and mannerisms. The lowest score was 1 for each item and mean scores were calculated separately for the positive, negative and general psychopathology scale.

All interaction with the 27 schizophrenia patients in the intervention and usual care group was audio recorded, followed by its verbatim transcription and coding for condensing their responses. All survey scores and responses were condensed into emergent themes with the use of thematic analysis that was facilitated by the NVivo 10 software (Woods et al. 2016). The selected themes were perceived changes in social competence, perceived changes in social functioning and presence of positive and negative symptoms. All the themes comprised of a range of unique statements. These themes and subthemes were identified independently by two members of the research team (Vaismoradi, Turunen and Bondas 2013).

Before coding of the survey responses, there was an establishment of interrater reliability on the information presented in two independently coded surveys. 75% agreement was obtained for the survey statements. Assistance from a third investigator helped in independent review of the identified themes derived earlier. In instances when the responses did not fit well in the selected themes, novel categories were again created. Once all the responses by the patients were coded, the themes were again reviewed for ensuring their representativeness of the statements that were present in the scales or survey questionnaires.

Framework

2 patients from the control group and 1 patient from the social skills training intervention group were lost during the follow-up period. Thus, only 24 participants completed the entire research activity. The two groups failed to show any other significance in their dropout rates during the study and the intervention period.

Perceived changes in social competence

Thematic analysis of the participant responses suggested that all patients subjected to the social skills training program reported experiencing positive changes in their social competence associated with schizophrenia. 11 patients gave positive responses regarding demonstration of self-assertiveness, smiling, making eye contact, assertiveness, provide logical explanation of opinions, show appropriate gestures, and behave appropriately. 8 participants also responded in a way that suggested they were better able to gain control over their interpersonal relationships. Only 3 participants in the control group, receiving usual care testified social competence skills.

Perceived changes in social functioning

Of the 13 participants attending the social skills training, 9 of them stated that they could wash their clothes using proper detergents and store them separately after they were dried, in the last 30 days. Answers of 10 respondents suggested that they could bathe or shower properly, brush their teeth, comb their hair and also appeared clean in the past month. 9 participants were also successful in taking care of their personal possessions such as, their bed and room and could prepare simple food, and could manage money. Only 2 participants in the control group could report significant changes in their social functioning.

Positive and negative syndrome

Significant reductions were observed in the positive and negative symptoms. 10 participants in intervention group, reported less instances of experiencing hallucinations, delusions and hostility. Of them 8 participants were also found to report fewer events of emotional withdrawal, apathy and lack of spontaneity. Only 3 participants from the control group reported noteworthy reductions in schizophrenia associated symptoms.

Conclusion

Thus, it can be concluded that implementation of the social skills training among the schizophrenia patient was a successful research activity. SST acts as an effective psychosocial intervention that improves the functioning among schizophrenia patients. Functional recoveries were more substantial over time, in SST group than the control group. These findings replicated those of previously conducted RCTs and extend the evidence for improved nursing knowledge regarding schizophrenia management.

References

Anderson, A., Wilcox, M., Savitz, A., Chung, H., Li, Q., Salvadore, G., Wang, D., Nuamah, I., Riese, S. and Bilder, R., 2015. Sparse factors for the positive and negative syndrome scale: Which symptoms and stage of illness?. psychology Research, 225(3), pp.283-290.

Anme, T., Watanabe, T., Tokutake, K., Tomisaki, E., Mochizuki, Y., Tanaka, E., Wu, B., Nanba, M., Shinohara, R. and Sugisawa, Y., 2011. A Pilot Study of Social Competence Assessment Using Interaction Rating Scale Advanced. ISRN Pediatrics, 2011, pp.1-6.

Bal, V., Kim, S., Cheong, D. and Lord, C., 2015. Daily living skills in individuals with autism spectrum disorder from 2 to 21 years of age. Autism, 19(7), pp.774-784.

Cheraghi, M., Jasper, M. and Vaismoradi, M., 2014. Clinical nurses’ perceptions and expectations of the role of doctorally-prepared nurses: A qualitative study in Iran. Nurse Education in Practice, 14(1), pp.18-23.

Granholm, E., Holden, J., Link, P.C. and McQuaid, J.R., 2014. Randomized clinical trial of cognitive behavioral social skills training for schizophrenia: Improvement in functioning and experiential negative symptoms. Journal of consulting and clinical psychology, 82(6), p.1173.

Granholm, E., Holden, J., Link, P.C., McQuaid, J.R. and Jeste, D.V., 2013. Randomized controlled trial of cognitive behavioral social skills training for older consumers with schizophrenia: defeatist performance attitudes and functional outcome. The American Journal of Geriatric Psychiatry, 21(3), pp.251-262.

Hüfner, K., Frajo-Apor, B. and Hofer, A., 2015. Neurology Issues in Schizophrenia. Current Psychiatry Reports, 17(5), p.32.

Kane, J., 2013. Tools to Assess Negative Symptoms in Schizophrenia. The Journal of Clinical Psychiatry, 74(06), p.e12.

Kurtz, M.M., Mueser, K.T., Thime, W.R., Corbera, S. and Wexler, B.E., 2015. Social skills training and computer-assisted cognitive remediation in schizophrenia. Schizophrenia research, 162(1-3), pp.35-41.

Langdon, R., Connors, M. and Connaughton, E., 2014. Social cognition and social judgment in schizophrenia. Schizophrenia Research: Cognition, 1(4), pp.171-174.

Mikami, A., Jia, M. and Na, J., 2014. Social Skills Training. Child and Adolescent Psychiatric Clinics of North America, 23(4), pp.775-788.

Nahum, M., Fisher, M., Loewy, R., Poelke, G., Ventura, J., Nuechterlein, K.H., Hooker, C.I., Green, M.F., Merzenich, M.M. and Vinogradov, S., 2014. A novel, online social cognitive training program for young adults with schizophrenia: a pilot study. Schizophrenia Research: Cognition, 1(1), pp.e11-e19.

Ni, Q., García Hernando, A.B. and de la Cruz, I.P., 2015. The elderly’s independent living in smart homes: A characterization of activities and sensing infrastructure survey to facilitate services development. Sensors, 15(5), pp.11312-11362.

Otero, T., Schatz, R., Merrill, A. and Bellini, S., 2015. Social Skills Training for Youth with Autism Spectrum Disorders. Child and Adolescent Psychiatric Clinics of North America, 24(1), pp.99-115.

Ottavi, P., D’Alia, D., Lysaker, P., Kent, J., Popolo, R., Salvatore, G. and Dimaggio, G., 2013. Metacognition-Oriented Social Skills Training for Individuals with Long-Term Schizophrenia: Methodology and Clinical Illustration. Clinical Psychology & Psychotherapy, 21(5), pp.465-473.

Rus-Calafell, M., Gutiérrez-Maldonado, J., Ortega-Bravo, M., Ribas-Sabaté, J. and Caqueo-Urízar, A., 2013. A brief cognitive–behavioural social skills training for stabilised outpatients with schizophrenia: A preliminary study. Schizophrenia research, 143(2-3), pp.327-336.

Tonna, M., Ottoni, R., Paglia, F., Ossola, P., De Panfilis, C. and Marchesi, C., 2016. Obsessive–compulsive symptoms interact with disorganization in influencing social functioning in schizophrenia. Schizophrenia Research, 171(1-3), pp.35-41.

Vaismoradi, M., Turunen, H. and Bondas, T., 2013. Content analysis and thematic analysis: Implications for conducting a qualitative descriptive study. Nursing & health sciences, 15(3), pp.398-405.

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