Bellack et al. (2004) define social skills as the ‘interpersonal behaviours that are ­normative and/or socially sanctioned. They include such things as dress and behaviour codes, rules about what to say and not to say, and stylistic guidelines about the expression of affect, social reinforcement, interpersonal distance, and so forth’ (p.3).

There are core skills (interactional skills, interpreting skills and responding and sending skills) used in this process, but a person’s success in the application of these skills is determined by their ability to use them appropriately in specific social contexts. For this reason, Bellack et al. (2004) identify that whenever a professional provides social skills training, it is essential to be aware of the specific context in which the person wants to use those skills. Wherever possible, social skills training exercises, whether in a group or individual context, should be personalised to a specific situation in which a person would like to communicate more effectively.

As skills are developed, the next step is to develop a sense of confidence in the ­ability to transfer these skills to real-life situations. To achieve this, a person needs to develop a sense of mastery over these skills by applying them in simulated and safe real-life (such as with family or friends) situations. During this process it is useful to identify and ­celebrate any positive gains made while providing clear feedback about how to improve.

When considering the goals for treatment with a person, it is important to consider the stage of their illness, their premorbid social functioning (if relevant) and their individual goals for therapy. In general, people in the early stages of an illness are more likely to have more intact social skills than someone with a longer history.

Once the goal of improving social skills has been identified by the person, the process of engaging and addressing the issues are the same as with any other treatment goal. Start by completing an assessment of the person’s current social functioning and identify their specific goals for therapy. The goal attainment scale (GAS see below) offers a useful tool to identify specific, measurable consumer goals. Importantly this tool gives the therapist and consumer the opportunity to clearly record and evaluate the desired outcomes from participating in therapy. Following this process consider the most appropriate intervention method (group or individual) to develop the required skills and/or confidence. Provide the intervention and evaluate the treatment outcomes. It is always useful to have one maintenance/­follow up session after the evaluation session to review the application of the skills learnt.

In the example provided above, the initial step is to accurately determine which social skills and in what contexts Sam feels most and least confident, negotiating which context he would like to work on most. A useful framework you might like to use to guide this process is the brief solution focused therapy framework (see below) discussed by George et al. (1990) and Sharry et al. (2001).

Useful topics to explore with Sam

• In what contexts is Sam most likely to be using his social skills – at home, with friends, looking for work?
  
• In which contexts does Sam feel most confident and least confident?
  
• Which social context does Sam want to work on most?
  
• Is Sam confident in initiating, maintaining and ending a conversation?
  
• How confident is Sam following conversations with people he knows well and/or strangers?
  
• Does Sam feel he can accurately read the emotional expressions of people he knows well? Does Sam feel he can accurately read the emotional expressions of people he does not know?
  
• Is Sam confident in being assertive when he would like to be?
  
• What are the specific skills required for the context you are working on with Sam?

A desire to return to work is a common goal, particularly for those in the early stages of an illness. In order to achieve this, addressing social functioning specifically related to the work setting is important. The Work Related Self-Efficacy Scale (Waghorn et al., 2005), described below, could be used for this. Items pertaining to work-related social skills include: ­co-operate closely with people helping you prepare for work, use your social network to identify job opportunities, ask an employer (in person or by telephone) for information about a job, participate appropriately in a job interview, ask relevant questions during a job interview, request urgent leave from the supervisor, check instructions with the ­supervisor, decline a request to work overtime, request a change of hours or days of ­working, resolve a conflict with a colleague, resolve a conflict with a superior, decline a request to exchange duties of work days, help to instruct or demonstrate a task to a new colleague, co-operate with other workers to perform a group task, and follow directions without resistance.

For Sam, in addition to the core social skills, you should explore work-related social skills.

• How confident is Sam about participating in interviews?
  
• How confident is Sam about negotiating common workplace interactions, e.g. shift times, days off, overtime, holidays?
  
• How confident is Sam in meeting the dress and personal presentation standards of the workplace?
  
• Can Sam confidently discuss work-related tasks with his supervisor, e.g. seeking help with tasks, checking instructions?
  
• How confident is Sam when negotiating job tasks with co-workers, e.g. seeking help, delegating tasks, taking instructions?
  
• Are there social skill requirements that are specific to Sam’s workplace?
  
• Does Sam want to/feel comfortable disclosing his mental illness with his boss?

Useful tools and resources for social skills training

As with all other assessments, it is important to have a clear reason (e.g. relates to a specific goal) for completing an assessment with a person.

Assessments

• The Adaptive Behaviour Assessment Scale (ABAS) is a standardised questionnaire which is a useful tool for assessing a person’s general adaptive skills and includes a specific item relating to social skills. It provides an overall awareness of a person’s functioning. Three domains of adaptive behaviour are assessed: conceptual skills, ­social skills and practical skills. The ABAS takes approximately 45 minutes to complete.
  
• Another tool which is particularly useful is the Work-Related Self-Efficacy Scale (WSS-37) (Waghorn et al., 2005). This 37-item scale measures self-efficacy in four relevant activity domains: vocational service access and career planning, job acquisition, work-related social skills, and general work skills. The WSS-37 was developed in a 12-month longitudinal survey of people diagnosed with schizophrenia or schizoaffective disorder. The results from this indicated validity of both a four-factor structure differentiating four core skill domains and a single factor representing total work-related self-efficacy. The WSES-37 is a self-report measure with confidence rated on an 11-point scale (from 0 = no confidence to 100 = total confidence) (Waghorn et al., 2007). Harris et al. (2010) reported on the WSS-37 reliability and validity with individuals with schizophrenia and schizoaffective disorder and recommended its use in supported education programmes.
  
• The brief solution focused therapy approach focuses on what clients want to achieve through therapy rather than on their problems. George et al. (1990) outline a number of techniques that can be used in therapy that guides clients down this path. Examples of these tools include the ‘miracle question’ which asks clients to describe, in detail, what their life will be like when all their problems have gone, scaling questions, exception-seeking questions and coping questions. A key to this approach is agreeing with the client to keep the discussion in each session ‘problem free’.
  
• It is recommended that if you have not already done so, you consider the presence of co-morbidities such as anxiety or depression, which may significantly affect a person’s social skills. The Depression Anxiety Stress Scale (DASS) is a useful screening tool for this (Lovibond & Lovibond, 1995).
  
• The Goal Attainment Scale (GAS) is a useful tool to track the progress Sam makes as he engages in therapy (Kiresuk & Sherman, 1968; Lloyd, 1986). The GAS is a five-point scale created by an individual with the support of a practitioner to record the ­potential outcomes for a goal (see Tables 11.1 and 11.2). This scale provides an indicator for overachieving and underachieving for a goal and a method for measuring the degree of success in achieving the goal. Once a goal has been identified with a client, the practitioner should discuss how they would now feel if they achieved more than they hoped or less than they hoped before recording this as shown in Table 11.2.

Table 11.1 Goal Attainment Scale.

Table 11.2 Example of Goal Attainment Scale.

Resources

There are scores of resources available relating to this area but the following provide a good starting point.

• Bellack et al. (2004) is a useful detailed text outlining treatment approaches for social skills training in schizophrenia.
  
• Kingsep and Nathan (ND) have produced a useful and detailed treatment manual for group therapy through the Western Australian Department of Health Centre for Clinical Interventions.
  
• The US Department of Veterans Affairs has some useful training video clips that can be accessed without cost from their website at: http://www.mirecc.va.gov/visn5/training/sst/section1/sst_video_section1.asp.

Individual sessions

Session 1

Conversation starters

Develop phrases that Sam could use for each topic when in conversation with someone. Sam should write these phrases down before practising them in a role-play situation with the practitioner. Some examples might include, for someone who is known: ‘Hi, how’s it going?’ or ‘Hello, I haven’t seen you for a while. What have you been up to?’; for someone who is unknown, this might be: ‘Hello, my name is Sam, what’s your name?’.

Dealing with difficult questions

Discuss and plan phrases that Sam could use to answer questions that might be uncomfortable. An example might include Sam being asked by another group member to share personal information about his diagnosis and treatment; he might respond with a general answer and redirect the conversation using a question: ‘It’s still up in the air – hey, did you see the … last night on TV/news?’.

Session 2

Maintaining a conversation

Discuss and practise techniques that Sam could use to keep a conversation going, for example, active listening skills, using open-ended questions, how to make chit-chat using neutral topics like the weather or recent activities.

Finishing a conversation

Discuss and practise socially acceptable ways in which Sam could end a conversation if he wanted to, for example, looking at his watch before making an excuse that he had to be somewhere or by saying: ‘thanks for saying hello, do you mind if I go and catch some of the other people?’

Session 3

Reading body language

Use popular magazines or films (with the sound muted) to identify the emotions displayed in the person’s body language. It is good to start with films like comedies or sit-coms where emotions are overacted before moving on to scenes from dramas.