Schizophrenia Bulletin vol. 44 no. 3 pp.
472–474, 2018
doi:10.1093/schbul/sbx184
Advance Access publication January 5, 2018
COMMENTARY
Social Skills Training for Negative Symptoms of Schizophrenia
Eric Granholm*,1,2 and Philip D. Harvey3,4
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1
Department of Psychiatry, University of California, San Diego, San Diego, CA; 2Psychology Service, VA San Diego Healthcare System,
San Diego, CA; 3Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL;
4
Research Service, Bruce W. Carter VA Medical Center, Miami, FL
*To whom correspondence should be addressed; Department of Psychiatry, University of California, San Diego, 3350 La Jolla Village
Drive, San Diego, CA 92161, US; tel: 858-552-8585 x7563, fax: 858-642-6416, e-mail: egranholm@ucsd.edu
Negative symptoms of schizophrenia account for much of these trials receive medications. This new meta-analysis
the poor functional outcome in schizophrenia and are a of 27 clinical trials by Turner and colleagues goes fur-
significant unmet treatment need in a large proportion of ther to demonstrate significant medium effects on nega-
patients.1,2 Reduction in negative symptoms could result tive symptoms for SST relative to both standard care and
in improved engagement in vocational, independent liv- active controls, as well as durable effects up to a year after
ing, social and recreational activities. There is no doubt treatment ended.
that effective treatment of negative symptoms in schizo- Despite this evidence for efficacy, SST is not recom-
phrenia would have a profound effect on quality of life in mended in the UK NICE guidelines and is rarely deliv-
people with schizophrenia and their families, as well as ered in the United Kingdom.5 SST is recommended in
the mental health system and broader economy. Several US guidelines (eg, American Psychiatric Association6;
expert recommendations, such as the NIMH-MATRICS Patient Outcomes Research Team7), although not specif-
Consensus Statement on Negative Symptoms,2 call for ically for reducing negative symptoms. Despite decades
treatments for negative symptoms. of recommendations to deliver SST in the United States,
The meta-analysis by Turner and colleagues in this issue SST is still rarely delivered. As Turner and colleagues
reconfirms the efficacy of social skills training (SST) for point out, it is possible that a culture of individual cog-
improving social skills and reducing negative symptoms nitive-behavioral formulation-driven interventions may
in people with schizophrenia. Numerous clinical trials limit the availability of more behavioral group inter-
have shown that SST has large effects on improving social ventions in the United Kingdom. Cost-effective group
skills and medium effects on reducing negative symptoms therapy interventions are more common in community
and improving functioning in people with schizophre- mental health systems in the United States, but SST is
nia. For example, a meta-analysis of 19 clinical trials by still rarely delivered. SST is also recommended in the
Pfammatter and colleagues3 found large significant ben- Veterans Health Administration (VHA) system (eg,
efits for skills acquisition, and medium effects for social in the handbook for Psychosocial Rehabilitation and
functioning and general psychopathology. Another meta- Recovery Centers, or PRRCs, for Veterans with severe
analysis of 22 clinical trials by Kurtz and Mueser4 found mental illness), and the VHA provides a systematic roll-
very large effects for skill content mastery, moderate out program to train and certify providers in SST deliv-
effect sizes for negative symptoms and community func- ery. This program has been fairly successful in improving
tioning, and small effects on other symptoms and relapse. access to SST for Veterans with severe mental illness.
These consistently-replicated findings that SST improves VHA provides funding for providers, a systematic train-
social skills, negative symptoms and functioning relative ing and consultation program, and mandates delivery of
to standard care suggests that existing standard services SST, and these factors likely facilitate the success of SST
for schizophrenia can be improved by adding SST. As implementation in VHA.
Turner et al point out, these effects are in addition to any One of the barriers to implementation in the United
improvement in negative symptoms produced by phar- States is the availability of qualified providers, but this
macological treatments, because nearly all patients in may be a more important factor for implementation of
© The Author(s) 2018. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved.
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472
Social Skills Training for Negative Symptoms
more complex treatments like cognitive-behavioral ther- In addition, by participating in pleasurable social
apy (CBT) rather than SST. CBT interventions typically activities and learning that activities can be enjoyed
involve individual therapy and a formulation-driven and successfully completed can also challenge defeat-
approach (ie, generating hypotheses about how early ist thoughts like, “Why bother, it won’t be fun,”
childhood/formative experiences lead to core beliefs, which may contribute to amotivation and antici-
conditional assumptions, compensatory strategies, and patory anhedonia. Beck and colleagues9 proposed
schema that impact cognitive, emotional and behav- that dysfunctional attitudes can influence function-
ioral reactions), which may be more difficult to imple- ing in schizophrenia directly or through their impact
ment in community mental health settings in the United on emotions and motivation. Several studies have
States, where workloads are high and highly-educated found that defeatist performance beliefs (eg, “Why
providers with training in CBT are rare. SST, in con- try, I always fail”) and social disinterest attitudes
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trast, is a skills-based group therapy, which is easier to (eg, “I’m better off alone”) are endorsed more strongly
train, and more accessible to frontline clinicians in the by consumers with schizophrenia than healthy controls
United States. As such, more providers may be avail- and are associated with negative symptoms and poor
able to deliver SST relative to more complex psychoso- functioning, even after accounting for depression.10
cial interventions. Implementation research is needed Changing these dysfunctional beliefs through posi-
to identify the providers who can deliver SST with high tive experiences with skills practice or directly through
fidelity, facilitators and barriers to implementation, and CBT interventions targeting these beliefs may lead to
the organizational strategies and policy approaches that increased motivation to engage in goal-directed behav-
can promote delivery and fidelity in typical community iors. SST in a group context also involves weekly social
mental health systems. contact with providers and peers in social interactions
The Turner et al meta-analysis showed that SST can outside the home, which may bolster social interest
improve negative symptoms, but was not able to show and improve attitudes about others. This is a critical
why. They found some evidence of greater benefit for issue, because deficits in social motivation, indexed by
SST interventions that included social-cognition train- 2 negative symptoms, active and passive social avoid-
ing, but comparisons among subtypes of SST interven- ance, have been found to predict over 20% of the vari-
tions were underpowered. For generic SST, there is no ance in social outcomes in people with schizophrenia.11
clear theoretical model to explain why negative symp- Increasing motivation through regular reinforcing
toms should improve. SST was not initially conceptual- experiences may be the first step toward achievement
ized as a treatment for negative symptoms. SST is based of broader functional goals.
on social learning theory involving modeling, behavioral Thus, there are a number of candidate mechanisms
practice, shaping and reinforcement principles, which are by which SST may improve negative symptoms in schiz-
applied to train basic communication and other func- ophrenia. Future research is needed to identify the
tioning skills, not to treat negative symptoms, per se. The mechanism(s) of change in SST associated with improve-
primary target of SST is social competence, including ments in negative symptoms. The impact of SST on
expressive, receptive, conversational, and assertiveness negative symptoms could be strengthened if the change
communication skills and, to some extent, everyday liv- mechanisms are identified. A better understanding of the
ing and illness self-management (eg, medication adher- mechanism(s) may also help convince policy and program
ence) skills.8 However, SST also involves a strong goal decision makers to implement SST if a clear rationale
setting component, including breaking long-term recov- can be provided as to why SST could improve negative
ery goals down into short-term goals and goal steps that symptoms and functional outcome in people with schizo-
can be accomplished each day by using skills to take phrenia their programs.
action toward improving functioning in the community.
It is possible that this recovery goal focus and behav- Acknowledgment
ioral activation related to using skills and taking action
toward goals in the real world leads to improvement in The authors have declared that there are no conflicts of
negative symptoms. Focusing on positive goals (adding interest in relation to the subject of this study.
living, learning, working and socializing activities into
life) may motivate action and engagement in society
more than goals focused on elimination of symptoms References
and life problems. Behavioral activation can also reduce
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