Social Skills Training for Negative Symptoms of Schizophrenia

Negative symptoms of schizophrenia account for much of the poor functional outcome in schizophrenia and are a significant unmet treatment need in a large proportion of patients.^1,2 Reduction in negative symptoms could result in improved engagement in vocational, independent living, social and recreational activities. There is no doubt that effective treatment of negative symptoms in schizophrenia would have a profound effect on quality of life in people with schizophrenia and their families, as well as the mental health system and broader economy. Several expert recommendations, such as the NIMH-MATRICS Consensus Statement on Negative Symptoms,² call for treatments for negative symptoms.

The meta-analysis by Turner and colleagues in this issue reconfirms the efficacy of social skills training (SST) for improving social skills and reducing negative symptoms in people with schizophrenia. Numerous clinical trials have shown that SST has large effects on improving social skills and medium effects on reducing negative symptoms and improving functioning in people with schizophrenia. For example, a meta-analysis of 19 clinical trials by Pfammatter and colleagues³ found large significant benefits for skills acquisition, and medium effects for social functioning and general psychopathology. Another meta-analysis of 22 clinical trials by Kurtz and Mueser⁴ found very large effects for skill content mastery, moderate effect sizes for negative symptoms and community functioning, and small effects on other symptoms and relapse. These consistently-replicated findings that SST improves social skills, negative symptoms and functioning relative to standard care suggests that existing standard services for schizophrenia can be improved by adding SST. As Turner et al point out, these effects are in addition to any improvement in negative symptoms produced by pharmacological treatments, because nearly all patients in these trials receive medications. This new meta-analysis of 27 clinical trials by Turner and colleagues goes further to demonstrate significant medium effects on negative symptoms for SST relative to both standard care and active controls, as well as durable effects up to a year after treatment ended.

Despite this evidence for efficacy, SST is not recommended in the UK NICE guidelines and is rarely delivered in the United Kingdom.⁵ SST is recommended in US guidelines (eg, American Psychiatric Association⁶; Patient Outcomes Research Team⁷), although not specifically for reducing negative symptoms. Despite decades of recommendations to deliver SST in the United States, SST is still rarely delivered. As Turner and colleagues point out, it is possible that a culture of individual cognitive-behavioral formulation-driven interventions may limit the availability of more behavioral group interventions in the United Kingdom. Cost-effective group therapy interventions are more common in community mental health systems in the United States, but SST is still rarely delivered. SST is also recommended in the Veterans Health Administration (VHA) system (eg, in the handbook for Psychosocial Rehabilitation and Recovery Centers, or PRRCs, for Veterans with severe mental illness), and the VHA provides a systematic roll-out program to train and certify providers in SST delivery. This program has been fairly successful in improving access to SST for Veterans with severe mental illness. VHA provides funding for providers, a systematic training and consultation program, and mandates delivery of SST, and these factors likely facilitate the success of SST implementation in VHA.

One of the barriers to implementation in the United States is the availability of qualified providers, but this may be a more important factor for implementation of more complex treatments like cognitive-behavioral therapy (CBT) rather than SST. CBT interventions typically involve individual therapy and a formulation-driven approach (ie, generating hypotheses about how early childhood/formative experiences lead to core beliefs, conditional assumptions, compensatory strategies, and schema that impact cognitive, emotional and behavioral reactions), which may be more difficult to implement in community mental health settings in the United States, where workloads are high and highly-educated providers with training in CBT are rare. SST, in contrast, is a skills-based group therapy, which is easier to train, and more accessible to frontline clinicians in the United States. As such, more providers may be available to deliver SST relative to more complex psychosocial interventions. Implementation research is needed to identify the providers who can deliver SST with high fidelity, facilitators and barriers to implementation, and the organizational strategies and policy approaches that can promote delivery and fidelity in typical community mental health systems.

The Turner et al meta-analysis showed that SST can improve negative symptoms, but was not able to show why. They found some evidence of greater benefit for SST interventions that included social-cognition training, but comparisons among subtypes of SST interventions were underpowered. For generic SST, there is no clear theoretical model to explain why negative symptoms should improve. SST was not initially conceptualized as a treatment for negative symptoms. SST is based on social learning theory involving modeling, behavioral practice, shaping and reinforcement principles, which are applied to train basic communication and other functioning skills, not to treat negative symptoms, per se. The primary target of SST is social competence, including expressive, receptive, conversational, and assertiveness communication skills and, to some extent, everyday living and illness self-management (eg, medication adherence) skills.⁸ However, SST also involves a strong goal setting component, including breaking long-term recovery goals down into short-term goals and goal steps that can be accomplished each day by using skills to take action toward improving functioning in the community. It is possible that this recovery goal focus and behavioral activation related to using skills and taking action toward goals in the real world leads to improvement in negative symptoms. Focusing on positive goals (adding living, learning, working and socializing activities into life) may motivate action and engagement in society more than goals focused on elimination of symptoms and life problems. Behavioral activation can also reduce depression and anhedonia and increase motivation and social engagement, which may explain the positive findings for improvements in general psychopathology in the Turner et al. meta-analysis.

In addition, by participating in pleasurable social activities and learning that activities can be enjoyed and successfully completed can also challenge defeatist thoughts like, “Why bother, it won’t be fun,” which may contribute to amotivation and anticipatory anhedonia. Beck and colleagues⁹ proposed that dysfunctional attitudes can influence functioning in schizophrenia directly or through their impact on emotions and motivation. Several studies have found that defeatist performance beliefs (eg, “Why try, I always fail”) and social disinterest attitudes (eg, “I’m better off alone”) are endorsed more strongly by consumers with schizophrenia than healthy controls and are associated with negative symptoms and poor functioning, even after accounting for depression.¹⁰ Changing these dysfunctional beliefs through positive experiences with skills practice or directly through CBT interventions targeting these beliefs may lead to increased motivation to engage in goal-directed behaviors. SST in a group context also involves weekly social contact with providers and peers in social interactions outside the home, which may bolster social interest and improve attitudes about others. This is a critical issue, because deficits in social motivation, indexed by 2 negative symptoms, active and passive social avoidance, have been found to predict over 20% of the variance in social outcomes in people with schizophrenia.¹¹ Increasing motivation through regular reinforcing experiences may be the first step toward achievement of broader functional goals.

Thus, there are a number of candidate mechanisms by which SST may improve negative symptoms in schizophrenia. Future research is needed to identify the mechanism(s) of change in SST associated with improvements in negative symptoms. The impact of SST on negative symptoms could be strengthened if the change mechanisms are identified. A better understanding of the mechanism(s) may also help convince policy and program decision makers to implement SST if a clear rationale can be provided as to why SST could improve negative symptoms and functional outcome in people with schizophrenia their programs.