Implementation of social skills training for patients with psychotic syndromes at the regional social Borgo Roccabascerana

Introduction

Numerous scientific evidences show that the critical factors that determine the discomfort of the patient with psychotic syndromes can be summarized in the definition “social skills deficit”. These compromise the ability of an individual to fulfill with personal satisfaction the main roles expected from him in a defined social environment, to establish interpersonal relationships, to communicate effectively, to express his feelings, to take care of himself and his their living environment, to positively involve themselves in recreational and leisure activities. The possible causes of social disability in people with psychiatric pathologies are numerous. Some decompensate before they have been able to fully develop social skills. Others have grown up in environments without valid models, others have acquired good skills and then lose them with the disease and the consequent social withdrawal. One of the psychoeducational interventions recognized as effective by the literature, for the development and enhancement of social skills in psychiatric patients, is a path of Social Skills Training which refers in particular to the model of Bellack and Mueser (2003). It is a rehabilitation intervention, which is based on the theories of social learning, aimed at increasing the patients’ more functional strategies and correcting the attitudes that hinder the recovery or learning of the skill. The basic assumption is that all social behaviors can be learned, therefore, they can be modified with experience and training. Social Skills Training is recommended by the World Health Organization as one of the key elements in health and wellness projects. This model is based on a bio-psycho-social approach to mental illness, centered on the ‘promotion’ of health understood as the development of human potential. Difficulties in social skills can increase the risk of relapse, while improved social competence can decrease that risk. Social competence and coping behaviors offer protection against stress-induced relapses by improving the quality of life. When individuals are able to behave more appropriately, such as to be able to face stressful events and daily difficulties, they are more capable of solving problems. SST can help stabilize the disease in treated subjects, improve their adherence to drug and psychosocial treatment, and promote progress towards recovery. This is because it is a technique that allows patients to become active subjects in the management of their disease. We present the results of a study on the implementation of Social Skills Training for patients with psychotic syndromes at the Borgo Sociale Regionale Roccabascerana, accredited by the Campania Region as a Habitat for Individualized Rehabilitation Therapeutic Projects with Health Budget (PTRI) and authorized and accredited by the Territorial area of ​​and social services such as Housing; Evidence-based psychosocial rehabilitation interventions are provided for people with psychiatric disabilities, aimed at maintaining the skills possessed and the reacquisition of others in view of the subsequent return to their home, family insertion or to a home with various degrees of support.

Target

The objective is to detect the usefulness and effectiveness of Social Skills Training (SST), a cognitive-behavioral intervention for psychosocial rehabilitation, on adaptive social functions and personal and social functioning of a group of patients with psychotic syndromes at the regional social village of Roccabascerana. In particular, we want to evaluate the improvements that allow the individual to enhance social skills that allow them to effectively manage different situations, be they personal, family or social, and the ability of an individual to fulfill the main roles with personal satisfaction. expected from him in a defined social context.

Materials and Methods

Sample examined

10 male users were involved in the intervention of group social skills, with psychotic syndromes with an average age of 49 years. The inclusion criteria were: (1) aged between 18 and 65; (2) diagnosis of depressive syndrome with psychotic features, bipolar disorder with psychotic features and schizophrenic syndromes; (3) attend residential or day hospital treatment and the ability to give informed consent. The exclusion criteria were: (1) primary diagnosis of mental retardation; (2) dementia or organic brain disorders. The intervention was carried out in biweekly meetings lasting 90 minutes for one year. Patients, at the time of inclusion in the study, were in a phase of clinical stability and continued to take drug therapy. The sessions were conducted by a Psychiatric Rehabilitation Technician and a Psychologist. The “Social Skills Training for the treatment of schizophrenia” manual (A.S.Belleck, K.T.Mueser, S.Gingerich, J.Agresta) was used for the intervention. It was decided to apply the SST to a group of patients with psychotic syndromes in order to measure its effects on the adaptive functioning and on the personal and social functioning of the subjects examined.

Assessment

Evaluation is a fundamental part of any therapeutic and rehabilitative strategy, both as an initial moment and periodic verification of the patient’s changes and of her progress, in relation to the goals they had set. The evaluation also has the fundamental function of acting as a filter to establish a therapeutic relationship, integrates the clinic with a rehabilitation program and protects against the risk of chronicity (Ba, 2003). In order to assess the achievement of the intervention objectives, the FPS and S.A.F.E. scales were administered at the beginning and end of treatment.

A. Adaptive social functions

The Scale of Adaptive Social Functions (S.A.F.E.) is an observation-evaluation scale, consisting of 19 items, used to assess the severity of the deficit in areas relating to the individual’s social, instrumental and functional skills. Each item was estimated on a five-value scale (0 = no impairment, 1 = mild impairment, 2 = moderate impairment, 3 = severe impairment, 4 = extreme impairment); Higher scores reflect greater impairments in social functioning and adaptation, lower scores reflect better social functioning and adaptation. Through the scale of Adaptive Social Functions (S.A.F.E.) the adaptive social functions were measured, and in particular the following were examined:

1. care of hygiene and aesthetics;
2. clothes and clothing;
3. nutrition nutrition and daily diet;
4. money management;
5. cleaning and maintenance of the home environment;
6. orientation and removal from home;
7. read / write;
8. impulse control;
9. respect of property;
10. ability to use the telephone;
11. conversation skills;
12. ability to manage instrumental social interactions;                                                   
13. respect and regard for others;
14. social adequacy / education;
15. social interest;
16. friendship;
17. entertainment and free time;
18. participation in residential social activities;
19. cooperation with treatment.

The higher score indicates worse functioning, the lower one better functioning.

B. Personal and Social Functioning

The scale of the Personal and Social Functioning (FPS) evaluates the functioning of the person in his / her community and allows to assign a score of global functioning, also investigating the social areas. It is a 100-point scale, divided into intervals of 10: the interval 100-91 corresponds to excellent operation in all the areas evaluated, the interval 10-1 indicates a lack of autonomy of the basic functions with the presence of extreme behaviors, with risk of death for scores below 5. Investigate four main areas:

1. Socially useful activities including work and study);
2. personal and social relationships (including relationships with family members);
3. care of appearance and hygiene;
4. disturbing and aggressive behaviors.

For each area a score is assigned attributable to the level of dysfunction ranging from 1, which is equivalent to absent, to 6 which corresponds to very serious. Psychosocial functioning, assessed through the attribution of a total score, corresponds to adequate in the range 91-100, mild difficulty between 71 and 90, manifest difficulties between 31-70 and need for continuous assistance if less than 30.

Implementation of Social Skills Training

The Social Skills Training interventions, implemented at the Borgo Sociale Regionale Roccabascerana, are made up of both “basic” skills and specific skills: the former are expressing positive emotions, making requests constructively, listening to others, expressing unpleasant emotions. The second are: conversation skills, conflict management skills, assertiveness skills (ability to express one’s own needs and rights while respecting those of others), ability to manage daily life in the territory, friendship and courtship skills; ability to manage relationships drugs and work skills and professional qualification. Through a set of psychoeducational techniques, the users involved were helped, in a structured way, to develop more effective skills for interacting with others. These techniques are based on a set of social learning principles such as modeling (learning by observation), reinforcement (verbally praising the social skill steps performed correctly), shaping (reinforcing successive approximations to the desired final behavior), automation (practicing the skill systematically until it becomes automatic) and generalization (transferring the skill learned in the training group to other contexts of daily reality by assigning homework. The teaching methodology of the skills is based on 9 phases:

1. Establish valid reasons, the rationale, for learning the skill;
2. Identify the steps that make up the skill together with the group;
3. Show the ability within a role-playing game performed by the two group leaders (modeling) and discuss it with patients;
4. Make the patient participate in the role play;
5. Give positive feedback;
6. Provide corrective feedback;
7. Involve the patient in a second role-playing game that re-presents the same situation;
8. Provide additional feedback
9. Assign homework.

Results and Conclusions

The choice to implement Social Skills Training for a group of patients with psychotic syndromes was aimed at evaluating its effectiveness and related improvements on adaptive functioning and the personal and social functioning of the subjects examined. The comparison of the results obtained from the Scale of Adaptive Social Functions (S.A.F.E.) allows us to note that, after one year of treatment, there are significant improvements in adaptive social functions and others on the verge of significance. As highlighted in Fig. 1, (insert figure 1) the significant improvements highlighted are: SAFE 1 personal care / hygiene and aesthetics, SAFE 2 clothes and apparel, SAFE 4 Money management, SAFE 8 impulse control, SAFE 11 conversation skills , SAFE 12 skills in managing instrumental social interactions, SAFE 16 friendship, SAFE 17 fun and leisure, SAFE 18 participation in residential social activities. The improvements to the limits of significance are: SAFE 3 food, nutrition and daily diet, SAFE 5 cleaning and maintenance of domestic environments, SAFE 13 Respect and regard for others (insert fig. 2). In addition, the comparison of the data obtained from the FPS scale- evaluation of personal and social functioning allows to confirm through a standardized and scientifically proven evaluation, an improvement of the overall functioning with reference to the four main areas: socially useful activities, personal and social relationships, care of appearance and hygiene, as well as behavior disturbing and aggressive. The graph in figure 3 FPS scale scores allows you to evaluate the scores obtained in the Personal and Social Functioning scale, before and after the implementation of the group Social Skills Training, in which the guests of the Borgo Sociale Roccabascerana accommodation house participated, highlighting a improvement of the areas subjected to evaluation. (insert fig 3) In particular, the results of our study confirm what is reported in the international literature referring to the social dysfunctions / deficits of patients with psychotic syndromes. This means that after one year of treatment with SST, there was an improvement in the score of the overall functioning, in reference to the four areas that it evaluates, and in the adaptive social functions of the patients examined. The SST, applied in a group context, helping patients to reduce anxiety, frustration and isolation, allows the learning of social skills such as communicating with others in a more competent and effective way by increasing their interpersonal skills, use competent communication methods in different relational contexts, manage failures and develop problem-solving skills.

References

1. Alan S. Bellack, Kim T. Mueser, Susan Ginerich, Julie Agresta. Social Skills Training for the treatment of shizophrenia. Scientific publishing center.
2. Morosini P, Lorenzo M.Luisa B Vado Skill Assessments and Goal Setting. 1998. Erikson.
3. Barbieri L, Boggian, Lamonaca D. Problem Solving in rehabilitation practice. Practical guide. 2012 Erikson.
4. Ba. G. Psychiatric and psychosocial rehabilitation tools and techniques. 2003. Franco Angeli.
5. Clinical and psychiatric rehabilitation manual. From theoretical knowledge to practice of mental health services. Psychiatric rehabilitation (Vol. 2) by Antonio Vita, Liliana Dell’Osso, Armida Mucci 2019. Giovanni Fioriti Editore
6. Social Adaptivefuctions scale (S.A.F.E.) by Harvey, Davidson, Mueser, Parrella, White, Powchik 1997
7. Quarterly magazine of social and health policy, health and territory, social skills training Rosanna Perone, Luisa Fossati, Veronica Massai, Alessandra Rispoli, Agnese Barbacci, Stelvio Sestini, Oriana Corbelli Year XXXIV July-September 2013
8. Italian Journal of Psychopathology, Results of Social Skills Training applied to patients with psychotic syndromes R. Perone, L. Bartolini, D. Pecori, S. Domenichetti, V. Massai, A. Rispoli, A. Barbacci