Group Interventions for Dual Group Interventions for Dual DisordersDisorders

•Resources

•What are social skills?

•Logistics of skills training groups

•Steps of social skills training

•Skills training and stages of treatment

Social Skills Training Resources

• Bellack, A. S., Mueser, K. T., Gingerich, S., & Agresta, J. (2004). Social Skills Training for Schizophrenia: A Step-by-Step Guide (Second ed.). New York: Guilford Press.

• Liberman, R. P., DeRisi, W. J., & Mueser, K. T. (1989). Social Skills Training for Psychiatric Patients. Needham Heights, MA: Allyn & Bacon.

• Monti, P. M., Abrams, D. B., Kadden, R. M., & Cooney, N. L. (2002). Treating Alcohol Dependence. (2nd ed.). New York: Guilford Publications.

• Mueser, K. T., Noordsy, D. L., Drake, R. E., & Fox, L. (2003). Integrated Treatment for Dual Disorders: A Guide to Effective Practice. New York: Guilford Press.

• Roberts, L. J., Shaner, A., & Eckman, T. A. (1999). Overcoming Addictions: Skills Training for People with Schizophrenia. New York: W.W. Norton.

What are Social Skills?

• Interpersonal skills necessary for effective communication

• Abilities and behaviors that help people achieve instrumental and interpersonal goals

• Broad categories of social skill include nonverbal, paralinguistic, verbal content, and interactive balance

Nonverbal Social Skills

• Eye contact

• Body posture

• Body orientation

• Facial expression

• Gestures

• Interpersonal distance

Paralinguistic Skills

• Voice volume

• Intonation, inflection

• Speed and pace

• Clarity

Verbal Content

• Specific verbal components of skill, such as: – Use of feeling statements– Behavioral specificity– Appropriateness of content

Expressing Positive Feelings

• Look at the person

• Say exactly what they did that pleased you

• Tell them how it made you feel

Expressing Negative Feelings

• Look at the person: speak firmly

• Say exactly what they did that upset you

• Tell them how it made you feel

• Suggest how person might prevent this happening in future

Starting A Conversation

• Choose the right time and place

• Introduce yourself or greet the person you want to talk with

• Make small talk (for example the weather or sports)

• Decide if the other person is listening or wants to talk

Refusing Drinks Or Drugs

• Say “No” first

• Suggest an alternative

• Request the person to stop asking if they persist

• Avoid making excuses

Interactive Balance

• Response latency, including either delays or interruptions when responding to another person

• Amount of speech by each person

• Responsiveness to other’s speech and affect

Social Skills Training (SST)

• Systematic approach to teaching new skills based on social learning theory

• Skills taught gradually over time with extensive practice both in session and out of session

• Broad range of applications of SST to both clinical and non-clinical populations

Relevance of Social Skills Training to Dual Disorders

• Poor premorbid functioning often precedes onset of mental illness

• Interpersonal dysfunction common in addiction• Substance use provides opportunities for

socialization• People with mental illness may use substances to

initiate or maintain relationships• Relationships may be coercive• Basic friendship skills needed as well as substance

refusal

More Facts about Social Skills

• Clients most often have mild skill impairments across multiple skill areas

• Meshing (interactive balance) is on common focal skill deficit in many clients (due to slower information processing)

• Social skills are strong predictors of community functioning, including relationships, work, independent living

Social Skills Training Groups

• Primary goal is to teach new skills, not foster insight

• Multiple training sessions often conducted weekly

• Sessions usually conducted by 2 leaders following preplanned curriculum

• Generalization of skills into clients’ natural environment is planned

Logistical Considerations

• Duration and frequency of sessions

• Number of clients (5-8)

• Reinforcement for participation (e.g., refreshments)

• Competing demands (e.g., not having group at same time as a recreational activity)

• Staff support

Leader Qualifications

• Enthusiasm

• Behavioral orientation

• Patience

• Ability to take a “shaping” approach to reinforcing gradual change

• Knowledgeable about dual disorders

• Socially skilled

Principles of Learning

• Modeling

• Reinforcement

• Shaping

• Generalization

Assessing Clients

• Does the client make others feel uncomfortable?

• Is the client able to initiate and maintain conversations?

• Can he/she express feelings?

• Can he/she get others to respond positively?

• Is he/she socially isolated?

Rules for Social Skills Group

• Stay on the group topic

• No interrupting

• No name calling or cursing

• Respect confidentiality

Steps of Social Skills Training

• 1. Establish rationale for the skill– Elicit reasons for learning the skill from group

participants– Acknowledge all contributions– Provide additional reasons not mentioned by

group members

Steps (cont.)

• 2. Discuss steps of the skill– Break the skill down into 3 or 4 steps– Write the steps on a board or poster– Discuss the reason for each step– Check for understanding of each step

Steps (cont.)

• 3. Model the skill in a role play– Explain that you will demonstrate the skill in a

role play– Plan out the role play in advance– Use two leaders to model the skill– Keep the role play short and simple

Steps (cont.)

• 4. Review the role play with the participants– Discuss whether each step of the skill was used

in the role play– Ask group members to evaluate the

effectiveness of the role play– Keep the review brief and to the point

Steps (cont.)

• 5. Engage a client in a role play of the same situation– Request the client to try the skill in a role play

with one of the leaders– Ask the client questions to make sure he or she

understands their goal– Instruct members to observe the client– Start with a client who is more skilled or is

likely to be compliant

Steps (cont.)

• 6. Provide positive feedback– Elicit positive feedback from group members

about the client’s skills– Encourage feedback that is specific– Cut off any negative feedback– Praise effort and provide hints to group

members about good performance

Steps (cont.)

• 7. Proved corrective feedback– Elicit suggestions for how client could do the

skill better next time– Limit feedback to one or two suggestions– Strive to communicate the suggestion in a

positive, upbeat manner

Steps (cont.)

• Engage the client in another role play of the same situation– Request that the client change one behavior in

the role play– Check by asking questions to make sure the

client understands the suggestion– Try to work on behaviors that are salient and

changeable

Steps (cont.)

• 9. Provide additional feedback– Focus first on the behavior that the client was requested

to change– Engage client in 2-4 role plays with feedback after each

one– Use other behavior shaping strategies to improve skills,

such as coaching, prompting, supplemental modeling– Be generous but specific when providing positive

feedback

Steps (cont.)

• 10. Assign homework– Give an assignment to practice the skill– Ask group members to identify situations in

which they could use the skill– When possible, tailor the assignment to each

client’s level of skill

Follow-Up Sessions

• Review homework• Set up role plays based on client’s personal

experiences-actual or anticipated• If no experiences, use other role play situations• For each client, engage in 1-4 role plays• Use positive feedback and other teaching

strategies to improve skill over several role plays

Supplementary Skills Training Techniques

• Coaching

• Prompting

• Contrast modeling

• Discrimination training

Curriculum for SST

• Starting & maintaining conversations• Conflict management• Assertiveness• Community living• Friendship and dating• Medication management• Vocational / work• Drug and alcohol abuse

Additional Skills

• Social-sexual skills (e.g., asking a partner to wear a condom)

• Avoiding stressful situations• Discussing health concerns with a doctor or nurse• Telephone skills (e.g., making appointments,

leaving messages, dealing with telemarketers)• Leisure & recreation skills

CONVERSATION SKILLS• Listening to others• Starting conversations• Maintaining conversations by:

– asking questions– giving factual information– expressing feelings

• Ending conversations• Staying on the topic set by another person• What to do when someone goes off the

topic• Getting your point across

CONFLICT MANAGEMENT SKILLS

• Compromise and negotiation

• Disagreeing with another’s opinion

without arguing

• Responding to untrue accusations

• Leaving stressful situations

Stage-wise Skills Training for Stage-wise Skills Training for Dual DisordersDual Disorders

• Appropriate at all stages of treatment

• Early stages (engagement, persuasion) focus on motives for using substances

• Later stages (active tx., relapse prevention) also address high risk situations, including refusal skills

What Do We Do During What Do We Do During Engagement?Engagement?

• GoalGoal: : To establish a working alliance with the client

• Clinical StrategiesClinical Strategies1.1. Outreach2.2. Practical assistance3.3. Crisis intervention4.4. Social network support5.5. Legal constraints

What Do We Do During What Do We Do During Persuasion?Persuasion?

• GoalGoal: : To motivate the client to address substance abuse as a problem

• Clinical StrategiesClinical Strategies

1.1. Psychiatric stabilization

2.2. “Persuasion” groups

3.3. Family psychoeducation

4.4. Rehabilitation

5.5. Structured activity

6.6. Education

7.7. Motivational interviewing

What Do We Do During What Do We Do During Active Treatment?Active Treatment?

• Goal:Goal: To reduce client’s use/abuse of substance

• Clinical StrategiesClinical Strategies1. 1. Self-monitoring

2. 2. Social skills training

3. 3. Social network interventions

4. 4. Self-help groups

5. 5. Substitute activities

6. 6. Close monitoring

7. 7. Cognitive-behavioral techniques to address: High risk situations Craving Motives for substance use

Socialization Persistent symptoms Pleasure enhancement

What Do We Do During What Do We Do During Relapse Prevention?Relapse Prevention?

• Goals:Goals: To maintain awareness of vulnerability and expand recovery to

other areas

• Clinical StrategiesClinical Strategies

1.1. Self-help groups

2. 2. Cognitive-behavioral and supportive interventions to enhance functioning in:

Work, relationships, leisure activities, health, and quality of life

Motives for Substance Use and Motives for Substance Use and Relevant SkillsRelevant Skills

• Socialization: conversational skills, making friends

• Leisure & recreation: developing new recreational activities

• Coping: expressing negative feelings, cognitive restructuring to address anxiety & depression

High Risk SituationsHigh Risk Situations

• Offers to use at a party

• Running into a former dealer

• Feeling depressed or anxious

• Invitation to use with boy/girlfriend

• Money or paycheck in pocket

Curriculum for SST for DDCurriculum for SST for DD

• Conversational skills• Friendship and intimacy skills• Expressing negative feelings• Conflict management• Relapse prevention planning• Dealing with offers to use substances from friends,

family, dealers

Persuasion GroupsPersuasion Groups

• Primarily for persuasion stage• Keep short (or take a break)• Co-facilitated• Open format• Non-confrontational• Recurrent use common• Refreshments

Persuasion GroupsPersuasion Groups

• Peer role models

• Self-help materials not useful

• Psychoeducation about substance abuse and mental illness

• Weekly meetings

• Use of hospitalizations, trouble with the law, etc.

Curriculum-based Persuasion Curriculum-based Persuasion Groups (Mueser et al., 2003)Groups (Mueser et al., 2003)

• 21-sessions

• Psychoeducational/motivational

• Focus initially on mental illness, then substance abuse, then recovery

• Combines education with group process

• Geared for persuasion stage, but appropriate for later stages of treatment

Group Session OutlineGroup Session Outline

• #1: Intro to group members & facilitators

• #2: Introduction to concept of recovery

• #3:Schizophrenia & related disorders

• #4: Mood disorders

• #5: Anxiety disorders

• #6: Stress-vulnerability model

Stress-Vulnerability ModelStress-Vulnerability Model

BiologicalVulnerability

SubstanceAbuse

Medication Stress Coping

Severityof SMI

Group Session Outline (cont.)Group Session Outline (cont.)

• #7: Medications for psychiatric disorders• #8: Substance use: Introduction• #9: Substance use: Motives & consequences• #10: Substance use: Treatment• #11: Coping with negative feelings:

Anxiety/fear• #12: Coping: Depression/sadness

Group Session Outline (cont.)Group Session Outline (cont.)

• #13: Coping: Anger• #14: Coping: Guilt & shame• #15: Dealing with social situations:

Alternatives to social use• #16: Dealing with social situations:

Substance use situations• #17: Leisure & recreation• #18: Health & wellness

Group Session Outline (cont.)Group Session Outline (cont.)

• #19: Goal setting & recovery I: Building confidence to change

• #20: Goal setting & recovery II: Establishing a personal recovery plan

• #21: Termination

ConclusionsConclusions

• SST is economical & provides opportunities for social support for clients with DD

• SST can be combined with psychoeducation and persuasion methods

• Extensive curriculum to draw upon for providing skills training interventions

• “A Better Life” (SST for DD) translated into Norwegian & piloted successfully