Running head: THE IMPACT OF SOCIAL SKILLS TRAINING 1

The Impact of Social Skills Training on Social Functioning in Individuals with

Schizophrenia: A Systematic Review

Vanessa Russell, Harley Kvenvold, and Anna Houston

University of Utah
THE IMPACT OF SOCIAL SKILLS TRAINING 2

Schizophrenia is a complex disorder with many contributing factors and symptoms

(Velhorst et al., 2017). Factors associated with schizophrenia are neurocognitive deficits,

particularly those processes occurring in frontal cortical areas. These deficits contribute to

impairments in executive functioning and social cognition; both of which play critical roles in

being able to perform social tasks, such as relating to others, communicating appropriately, and

recognizing social cues (Brown, 2005; Sestini et al., 2016). As a result, social functioning- the

ability to operate within an environment to establish relationships, live independently, pursue

employment or educational pursuits, and participate in social settings- is hindered.

There are two symptoms of schizophrenia, negative and positive, which impact

socialization. Negative symptoms include a lack of emotional expressions, disinterest in social

participation, and decreased drive to engage in activities. Positive symptoms include

hallucinations, delusions, and disorganized behaviors (Brown, 2005). Along with the

neurocognitive deficits present in schizophrenia, these symptoms contribute to deficits in social

functioning as they also impact communication skills, attention, and comprehension of social

situations necessary for living independently, maintaining employment, building relationships,

and being involved in a community (Velhorst et al., 2017).

Social Skills Training (SST) is a form of psychosocial rehabilitation, which has

commonly been used as an intervention for people who have schizophrenia since its origin in the

1980’s (Turner et al., 2018). It is based on behavioral therapy and learning principles, which

utilize role-playing, modeling, positive and constructive feedback, problem-solving practices,

goal setting, homework, and positive reinforcement (Kopelowicz, Liberman, & Zarate, 2006).

SST often takes place in a group setting with a therapist guiding the session. Its objective is to

facilitate skills that enable an individual to effectively communicate their needs, to understand
THE IMPACT OF SOCIAL SKILLS TRAINING 3

their emotions, and to increase social participation; thus improving their relationships, their

community interactions, and their ability to live independently (Kopelowicz et al., 2006).

Another common treatment for individuals with schizophrenia is medication. Although

medications are successful in decreasing positive symptoms, their ability to improve negative

symptoms, which have the greatest impact on social function, has not been supported by research

(U. Singh, B. Singh, & Sweta, 2018). However, SST has been shown to decrease both positive

and negative symptoms, as well as improve social cognition for people who have schizophrenia

(Kopelowicz, Liberman, & Zarate, 2006; Sestini et al., 2016; U. Singh et al., 2018).

Occupational therapists strive to help individuals perform daily tasks and activities, and

thereby live fulfilling and meaningful lives. To do so, social functioning must be addressed

because it impacts many occupations, including individual, community and family roles,

relationships, employment, and daily activities (Brown, 2005; Kopelowicz, Liberman, & Zarate,

2006). Social functioning is also a contributing factor to several outcomes described in the

Occupational Therapy Practice Framework (OTPF). These outcomes include: enhancement of

occupational performance, health and wellness, quality of life, participation, role competence,

and well-being (OTPF, 2014). For occupational therapists working with individuals who have

schizophrenia, it is important to know what intervention is the most appropriate to increase social

functioning. SST is a commonly used intervention that has been used for many years. Some

research has suggested that it can improve symptoms and produce cognitive changes

(Kopelowicz, Liberman, & Zarate, 2006; Sestini et al., 2016; U. Singh et al., 2018). What needs

to be addressed is whether or not these changes impact social functioning. The aim of this

systematic review is to assess the effectiveness of social skills training to improve social

functioning among individuals with schizophrenia.

THE IMPACT OF SOCIAL SKILLS TRAINING 4

Methods

This systematic review was conducted by three occupational therapy students at the

University of Utah as part of a Research Methods group project. Databases searched were

PubMed and PsychInfo, with search terms “schizophrenia”, “adults”, and “Social Skills

Training”. Inclusion and exclusion criteria ensured studies had a high quality design and were

applicable to the population, intervention, and outcome measures in question. Studies included

were quantitative with an evidence level of I, II, or III, published after the year 2000, with

participants having a diagnosis of a schizophrenia spectrum disorder. Interventions had to

include a form of SST and social functioning had to be a primary outcome measure. Studies were

excluded if they did not meet the inclusion criteria, and if they were systematic reviews or meta-

analyses.

After initial searches were completed by all three occupational therapy students,

duplicates were removed, and the titles and abstracts were screened for conformity to inclusion

and exclusion criteria. Additional screening was done by the students reviewing the full text

articles to further ensure inclusion and exclusion criteria were met. Reviewers then organized the

individual studies’ sample of participants, design method and variables, assessments and

outcome measures, and results. The risk of bias assessments were done for each study using the

PEDro scale.

Results

Eleven studies met the criteria for our systematic review (Figure 1). Levels of evidence

ranged from I to III, with the majority falling under the Level I category. Table 1 shows detailed

information on each of the studies’ sample of participants, design method and variables,
THE IMPACT OF SOCIAL SKILLS TRAINING 5

assessments and outcome measures, and results included in this systematic review. Level of bias

among the studies varied greatly, with PEDro scale ratings ranging from two to eight (Table 2).

Each study implemented different types of interventions using an SST program. The SST

programs consisted of group therapy sessions, with some studies implementing supplemental

individual sessions. Most of the sessions occurred more than once weekly. Six of the studies

reviewed included a cognitive approach to their SST interventions; these studies showed

improvement in overall social functioning. However, specific outcome measures and

assessments varied greatly among the studies, making it difficult to analyze what specific aspects

of the interventions improved areas of social functioning. These areas ranged from conversation

and assertiveness skills to social perception and insight.

Four other studies compared traditional SST without a cognitive approach to alternative

interventions and had varying results. A study by Roder, et al. (2002) compared Integrative

Psychological Therapy (IPT) to SST and Bucci, et al. (2013) compared Neurocognitive

Individualized Training (NIT) to SST. Both studies found that the alternative treatment groups

improved more than the SST groups. Ng and Cheung (2006) showed no change for either

intervention group, SST or supportive group discussion. The fourth study by Singh, et al. (2018)

had no comparison group and showed no improvement in social functioning using SST.

One study by Inchausti, et al. (2017) explored the social outcomes of Metacognition-

Oriented Social Skills Training (MOSST) compared to a conventional method of SST.. They

found that those in the MOSST group had statistically significant improvement on the Social and

Occupational Functioning Assessment Scale (SOFAS) and Personal and Social Performance

Scale (PSP) over the group that implemented SST alone.

Discussion
THE IMPACT OF SOCIAL SKILLS TRAINING 6

Schizophrenia is a complicated disorder that impacts a person’s overall functioning

(Velhorst et al., 2017). The nature of this condition affects social cognition and leads to negative

symptoms, causing individuals with schizophrenia to be withdrawn and disinterested in social

participation (Brown, 2005; Sestini et al., 2016). SST is a common intervention method used

with people who have schizophrenia in order to increase their ability to function in society. This

systematic review assessed studies evaluating the effect SST has on social function in adults with

schizophrenia. The studies that were eligible for our systematic review included quantitative

studies published from the year 2000 on that were a level of evidence of III or lower.

The review demonstrated the variety of types of SST. Many of the studies indicated that

combining SST with another form of therapy, especially cognitive or metacognitive, shows a

greater improvement in social functioning than SST alone. However, when attempting to delve

deeper into which type of cognitive therapy combined with SST is the most effective in

improving social function, there were not enough studies performed using replicated outcome

measures for us to come to a conclusion about which intervention is best to use in practice.

While it appears from the studies we reviewed that SST does indeed improve social

functioning in individuals with schizophrenia, the next logical step for future research is to

determine if there is one type of SST that is most effective, as well as to standardize outcome

measures and interventions. For this reason, we have classified the use of SST in individuals

with schizophrenia with the intent to improve social function as a Level A Class IIa strength of

recommendation, because while it is reasonable to implement SST interventions when working

with individuals with schizophrenia, additional studies with a stronger focus are needed to

determine what types of interventions are most effective.

THE IMPACT OF SOCIAL SKILLS TRAINING 7

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Figure 1
 THE IMPACT OF SOCIAL SKILLS TRAINING 11

Table 1
Author/Date Sample Design/ Variables Assessments/Measures Findings
Bucci, et al. Outpatients age 18- Level of evidence: I Assessments completed at QLS Real-world
(2013). 60 years, diagnosis baseline, after 6 months of functioning: NIT group
of schizophrenia or Randomized clinical trial. intervention, 6 months post had significant
schizoaffective intervention completion. improvement in
disorder. DV: Cognitive performance and interpersonal skills but
real world functioning. Measures: no changes in
Total N= 58 Quality of Life Scale instrumental roles or
IV: Neurocognitive (QLS)- assess real-world intrapsychic
NIT- N=25; male Individualized Training (NIT); functioning. Subscales foundations. SSIT
N= 21, female Social Skills Individualized address interpersonal showed significant
N=4. Training (SSIT). relationships, instrumental improvement in
roles, intrapsychic instrumental roles but
SSIT- N= 33; male NIT- a computer assisted foundations, use of objects no significant changes
N=26, female N=7. cognitive rehabilitation program and participation in in interpersonal
that utilized 6 modules: activities. relationships or
“Attention and Concentration”, Continuous performance intrapsychic
“Verbal Memory”, “Memory for Test-AX (CPT-AX)- foundations.
faces”, “Logical thinking”, attention.
“Shopping” and “Day Planning”. Category Instances (CI)- NIT had improvement
Treatment was given in one hour verbal fluency. in attention at 6 and 12
individual sessions twice weekly months, and verbal
over six months. fluency only at 12
months. SSIT didn’t
SSIT- behavioral focused social have any changes in
skills intervention that used verbal fluency and
modeling, feedback, behavior performed worse on
rehearsal and problem solving attention measures.
exercises. Treatment was given in
group sessions for two hours over
six months with homework
assignments.

Chien, et al. Inpatients with a Level of Evidence: II Assessments completed Assertive and
(2003). diagnosis of before treatment, after the conversation skills of
schizophrenia. Non-randomized fourth and eighth the experimental group
longitudinal study treatments, and at follow showed greater
Total N= 78, male up one month after improvement than
N= 43, female N= DV: Social skills abilities treatment finished. control group at all
35. assessment periods.
IV: Social Skills Training (SST); Measures
N= 19 previous routine nursing care (treatment Interaction Anxiousness
social skills not specified). Scale.
training. Interpersonal
N= 59 no previous SST- One hour group therapy Communication
social skills sessions utilizing role-plays, Satisfaction Scale.
 THE IMPACT OF SOCIAL SKILLS TRAINING 12

training. feedback, demonstration, and The Assertive Skills Scale.

homework, twice weekly for four
weeks. Emphasis of training was
on assertive and conversation
skills.

Combs, et al. Inpatient adults Level of evidence: II Assessments completed SCIT had significant
(2007). with schizophrenia before and after treatment. improvement in social
spectrum disorder Quasi-experimental pre-test and Data on aggressive perceptions measures,
diagnosis. post-test design. incidents were collected for no significant
three months prior to and improvement in coping
SCIT: N=18 DV: Emotion and social following the groups. skills group.
Male = 67% perception, and social
Female = 33% relationships. Measures SCIT showed
Social perception improvement in self-
Coping Skills: N = IV: Social Cognition Interaction measures- Face Emotion reported social
10 Training (SCIT); Coping skills. Identification Test, Face relationships and
Males = 90% Emotion Discrimination significant reduction in
Females = 10% SCIT- One hour group sessions Test, Social Perception aggressive incidents. No
weekly for 18 weeks. Three Scale. improvement seen in
phases: emotion training, figuring Social Relationships- coping skills group.
out situations, and integration. Social Functioning Scale:
Social Engagement and
Coping skills- One hour group Interaction Subscales;
sessions weekly for 18 weeks. aggressive incidents on
Focused training on symptom ward.
management, problem-solving,
and relapse prevention skills.
Granholm, et Diagnosis of Level of evidence: I Assessments completed at CBSST had
al. (2014). schizophrenia n= baseline, 4.5 months mid significantly greater
117 or Randomized clinical trial. treatment, 9 months end of improvements over
schizoaffective treatment, 15 months and time for the primary
disorder n=32. DV: Functional outcomes 21 months. functioning outcomes
Capacity to (independent living skills, social (ILSS).
provide informed skills capacity, employment and Measures:
consent. educational activities), negative Independent Living Skills Both treatment groups
symptoms, defeatist attitudes. Survey (ILSS)- assess showed slight
Total N= 149 domains of functioning. improvements in social
Mean age= 41.6 IV: Cognitive behavioral social Maryland Assessment of competence.
yrs skills training (CBSST); Goal- Social Competence
Male= 70% Focused Supportive Contact (MASC)- performance CBSST required fewer
White= 58% (GFSC). based measure of social sessions.
skill capacity.
CBSST- a psychosocial
rehabilitation intervention in
schizophrenia targeting
functioning and negative
symptoms.
 THE IMPACT OF SOCIAL SKILLS TRAINING 13

GFSC- support group intervention

focused on working towards
functional goals.

Both groups received 36 weekly

group therapy sessions for 2 hours
each in treatment phase, 12
booster sessions in follow up
period. Both were offered 30-50
min. individual goal setting
session at baseline, every 3
months after.
Granholm, et Age 42-74 yrs. Level of evidence: I Assessment of process and CBSST group
al. (2005) Diagnosis of symptoms at 3 months; performed social
schizophrenia Randomized controlled clinical assessment of symptoms, functioning activities
paranoid type N= trial. functioning and process at more frequently than
22, schizophrenia 6 months. usual treatment group.
undifferentiated DV: Social skills functioning
N=22, (primary), symptoms (secondary). Measures: CBSST had
schizophrenia ILSS significantly greater
disorganized type IV: CBSST; Treatment as usual UCSD Performance Based outcomes for ILSS, no
N=2, schizophrenia (TAU)- psychotropic Skills Assessment noted change in TAU
residual type N=2, medications, psychotherapy; (interview)- assesses social group.
schizoaffective functioning.
disorder N=28. CBSST- modified to meet needs Neither group showed
of older population such as changes in performing
CBSST N= 37, interpersonal loss. Included specific daily
male N= 26, completion of three functioning tasks.
female N= 11. modules:“thought-challenging
TAU N= 39, male module”, “asking for support
N= 30, female N= module” and “problem solving
9. module” over 24 weeks, with 2
hour group psychotherapy per
week, modules completed twice.

TAU- psychotropic medications,

psychotherapy; 82% took
psychotropic medications and
19% had psychotherapy.
Horan, et al. Adults with Level of Evidence: I Assessments done at pre Social cognition
(2009). schizophrenia and post treatment. showed significant
randomly assigned Randomized clinical trial improvement in the area
to cognitive skills Measures of facial affect
training program or DV: Social cognition, Facial Emotion perception for
control group. neurocognition. Identification Test. Cognitive Skills
Half- Profile of Nonverbal Training group, no
Cognitive Skills IV: Cognitive Social Skills Sensitivity (PONS). effect in control group
 THE IMPACT OF SOCIAL SKILLS TRAINING 14

Training Program: Training Program; Illness Self- The Awareness of Social and other measures of
N = 17 Management. Inference Test (TASIT). social cognition.

Illness self- Cognitive Social Skills Training There were no changes

management and Program- focused on emotional in either group for
relapse prevention and social perception, social measures of
skills (control): attribution, and theory of mind. neurocognition.
N = 17
Illness self-management- focused
on relapse prevention and illness
self-management.

Each group met for six weeks

with 2 sessions each week.

Inchausti, et al. Adults with Level of evidence: I Assessments completed at Statistically significant
(2017). diagnoses of baseline, 4 months later between group
Schizophrenia or Single-blind, randomized (post-treatment) and 6 differences at post
Schizoaffective controlled trial. months. treatment with large
Disorder effect sizes in favor of
DV: participants social, Measures MOSST on SOFAS and
MOSST: N = 36, occupational, and personal Social and Occupation PSP relative to SST.
males N = 20, functioning. Function Assessment Scale These remained
females N = 16 (SOFAS) and significant at follow-up.
IV: Metacognitive Oriented Personal and Social
SST: N = 33, Social Skills Training (MOSST); Performance Scale (PSP)-
Males N = 18, Social Skills Training (SST). psychosocial functioning.
females N =15
MOSST and SST focused on
conversation, assertiveness, and
conflict management skills.
Therapists in the MOSST group
stimulated metacognition during
sessions. Both groups consisted of
weekly 90 minute group therapy
sessions over 16 weeks.
Ng, R. M. K., Inpatients in a Level of evidence: I Assessments completed at There were no
& Cheung, M. psychiatric rehab baseline, week 8, and 6 significant differences
S. L. (2006). ward. Age 18-65. Single-center prospective rater- months post-treatment. or improvements
Diagnosis of masked randomized controlled between SST and
schizophrenia. clinical trial. Measures supportive discussion
Social Behavioral Schedule group for social
Total N = 36, male DV: social functioning, social (SBS) and Social outcomes.
N= 18, female skills, relapse. Functioning Scale (SFS)-
N=18, general social functioning.
IV: SST; supportive group RPT- behavioral measures
discussion. of social skills.
 THE IMPACT OF SOCIAL SKILLS TRAINING 15

SST- training in receiving,

processing and sending skills,
implemented behavioral
techniques (modeling, role-
playing, feedback, coaching,
prompting, homework).

Supportive group discussion-

group discussions about finances
and information about social
security.

Both groups received intervention

for eight weeks, two sessions per
week, 1.5-2 hours each.
Roder, et al. Adults with Level of evidence: II Assessments completed at All groups showed
(2002). schizoaffective baseline, post-treatment, 3 improvements in social
disorder or Experimental pre-test and post- months post-treatment, 1 functioning that
schizophrenia. test design. year post-treatment. continued to increase at
DV: Cognitive and social 1 year post-treatment
Total N= 105 abilities, and psychopathology. Measures assessment.
Residential Global Assessment of
Functioning: IV: Specific cognitive SST for Functioning Scale (GAF)-
N = 21 residential, vocational, and assess general level of
Mean age=33.1 recreational functioning; psychosocial role
Integrated Psychological Therapy functioning.
Vocational (IPT). Social Interview Schedule
Functioning: (SIS)- assess psychosocial
N = 23 Specific cognitive social skills adjustment and social
Mean age = 33.4 training- cognitive and emotional behavior.
skills training, decisions making Disability Assessment
Recreational skills, implementation of skills, Schedule (DAS-M)- assess
Functioning: cognitive behavioral techniques. social impairment. ,
N = 29 Intentionality Rating Scale
Mean age = 35.5 IPT- general social skills training (InSka) Subscale 6- assess
and problem-solving training. social behavior.
Integrated
Psychological Each group received 3 months in
Therapy (control): the treatment phase that consisted
N = 32 of two 90-minute group sessions
Mean age 31.2 and one individual session
weekly. There was also an
aftercare phase lasting 3 months
with a weekly group session and
biweekly individual session.

Rus-Calafell, Diagnosis of Level of evidence: I Assessments at pre-test and SST group improved
et al. (2012). schizophrenia or post-test, 6 month follow significantly from pre
 THE IMPACT OF SOCIAL SKILLS TRAINING 16

schizoaffective Randomized controlled trial up. to post test on social

disorder age 18-55 cognition, and social
years. DV: cognitive performance, Measures skills, no changes
clinical symptomatology, social Assertion inventory (AI)- among the TAU group.
Total N= 32 cognition, and psychosocial assess discomfort and SST group improved in
females. functioning. response probability. positive-self statement,
Social interaction self- but improvement was
TAU N = 18 IV: CBSST; TAU statement test (SISST)- not maintained at
positive and negative follow-up, no changes
SST N = 13 CBSST- Group therapy with a statement questionnaire. seen in TAU group.
user manual including slide- Simulated social SST improved on
shows from sessions and activities interaction test (SSIT)- degree of social
between groups. Seven blocks social interaction skills. discomfort, withdrawal
(social perception, social Social Functioning Scale and interpersonal
information processing, (SFS). communication when
responding and sending skills, SF-36 Health Survey- compared with control.
affiliative skills, instrumental role assess health dimensions.
skills, interactional skills,
behavior governed by social
norms) with two sessions per
block, as well as a beginning and
ending session. There were 16
total sessions, two per week.

TAU- individual sessions

psychiatrist, social worker, and
psychologist.
Singh, et al. Inpatients ages 21- Level of evidence: III Assessments completed at Significant
(2018). 40 years, diagnosis pre and post test. improvements on both
of schizophrenia Quasi-experimental design pre measures of socio-
. and post test (one group). Measures: occupational
Male N= 20, no Self-created social skills functioning after SST.
females. DV: Socio-occupational checklist. Specifically,
functioning Socio-occupational improvement in ADL’s,
functioning scale (SOFS)- conversational skills,
IV: SST- focus on behavioral socio-occupational social perceptions,
skills in areas of ADL’s, functioning scale social engagement,
communication and interpersonal money management,
skills, and vocational training, skills for work and
utilized a three phase therapeutic participation in leisure
module: initial phase consisted of activities.
psycho education; middle phase
included training in life balance
skills, social skills, and
occupational therapy treatment;
terminal phase consisted of post
assessment and feedback from
participants.
THE IMPACT OF SOCIAL SKILLS TRAINING 17

16 group and individual sessions

for 60-90 min over 3 months.
 THE IMPACT OF SOCIAL SKILLS TRAINING 18

Table 2: Risk of Bias PEDro Scale

Outcomes
Blinding Between-
Blinding Blinding from Intention
Random Concealed Baseline of group Point
of of >85% to treat
allocation allocation similarity participant compariso measures
Study, year s
therapists assessors participant analysis
ns
s
Bucci, et al.
X X X X X
(2013).
Chien, et al.
X X
(2003).
Combs, et al.
X X X
(2007).
Granholm, et
X X X X X X X
al. (2014).
Granholm, et
X X X X X X
al. (2005).
Horan, et al.
X X X X X
(2009).
Inchausti, et al.
X X X X X
(2017).
Ng, R.M., et al.
X X X X X X X X
(2006).
Roder, et al.
X ? X X
(2002).
Rus-Calafell, et
X X X X X
al. (2012).
Singh, et al.
X X
(2018).
X- met, blank- not met, ?- not specified