JSK: What got you interested in helping Veterans living with schizophrenia increase their participation in social and community activities?

MB: I conduct practice-based research to support mental health recovery for individuals with serious mental illness. For Veterans living with schizophrenia, there are different types of symptoms that can complicate recovery. They can experience positive symptoms that reflect experiences characterized by excess or exaggerated feelings or thoughts, like hallucinations (hearing or seeing things that are actually not present), delusions (holding strong beliefs that are inaccurate or mistaken), and thought disorder (having trouble keeping track of thoughts, difficulty concentrating or communicating in ways that others can understand). They can also experience what are called negative symptoms that reflect an absence or lack of feelings and thoughts that support engaging with the world around you. Many people with schizophrenia have trouble enjoying social activities, being engaged actively in their communities, and finding pleasant activities to be enjoyable. Many find it hard to be around other people and some experience difficulty with motivation: putting all the things together that it takes to get up and out and engage in meaningful social activity. I am interested in helping people figure out ways to manage those challenges and so they can do the things that are meaningful to them.

[Editor’s Note: The reader is invited to visit our Informational Guides for Veterans and Families about Schizophrenia webpage for more information].

JSK: What work has been done to help people living with schizophrenia manage these symptoms as part of their recovery?
MB: Many people living with schizophrenia take medications that can be very effective in helping manage positive symptoms. Unfortunately, medications have not been found to be very helpful for negative symptoms. Psychosocial interventions like Cognitive Behavioral Therapy for Psychosis (CBT-P) or Social Skills Training (SST) can be helpful in this regard because they are focused on helping people work towards their goals by using skills to cope with negative feelings and engage with other people. However, skills-based interventions like these have not been found to be a “sure thing” in terms of improving people’s social and community functioning. I wondered what could make interventions like these – focused on practicing new skills and learning new ways of thinking - more helpful. And what kept coming back to me was that while these interventions focus on teaching and learning, they may not pay enough attention to encouraging and supporting people to actually apply these new skills in their lives. That is, they lack a real “push” to translate learning into practice.

JSK: How did you address this in your work?
MB: We decided to offer an intervention that included this “push” in a supportive and, we hoped, helpful way! In this study, which was funded by VA Rehabilitation Research and Development, we examined the impact of a multi-component intervention that integrated skills building with real-life application to improve social and community engagement in a group of Veterans living with schizophrenia who experienced persistent negative symptoms. The intervention, called Engaging in Community Roles and Experiences (ENCORE), is a 12-week program of group meetings that support learning and implementing skills with the goal of helping participants increase engagement in personally-relevant social and community activities. In ENCORE, we spend a lot of time helping participants identify social and community activities that are important or interesting to each individual, supporting their trying them out, and using each group meeting to hear how things went and discuss what could be improved. We did this by including behavioral activation, which is a treatment generally used to help people with depression. In ENCORE, participants would develop detailed Action Plans at each visit in which they outlined, in detail, the steps for engaging in a self-identified social or community activity and how the skills they learned in that week’s meetings could be used to support success. That new knowledge could then be used to try new activities, and the process repeats with better results each time – truly an encore!

JSK: What are you hoping to find in your study results?
MB: We collected information through questionnaires, rating scales, and interviews with Veterans about their experiences. We are not finished looking at statistical results, but we will be able to use the data to learn if Veterans who participated in ENCORE were able to improve their engagement in social and community activities, both at the end of the intervention and three months later. We have taken a look at the interviews with Veterans who participated in ENCORE and have learned several things. Veterans reported that they found practicing new skills through role-playing and using Action Planning very helpful. Many stated that as they tried social and community activities, they got more confident and wanted to do more. It’s also clear that Veterans valued being in meetings with and learning from other Veterans with shared experience of having a mental illness.

JSK: What is the takeaway message from this interview for Veterans living with schizophrenia?
MB: The hurdle for many people is using what you learn to support your recovery. For example, “it takes learning skills in the clinic and practicing them in your life. Skills alone are like a muscle that doesn't get used a lot - practice outside the clinic is what builds that muscle and makes it stronger.” The takeaway for Veterans is using skills that you’re learning in your lives can help you do the things you want to do.

JSK: What is the takeaway for family members and significant others from this interview?
MB: To clarify, even the most loving families can give up trying to change things if their loved one has gotten into a pattern of not doing social things or not getting involved in community activities. What families could do is help their loved one take it slow and “dip a toe in.” So, help them start small: take a walk, make a phone call, or visit with someone for five minutes. Then over time your loved one might get more and more comfortable and then build on those things, for example, having longer visits.

JSK: What should clinicians that work with Veterans with schizophrenia take away?
MB: Delivering interventions so that they target learning and application may be the most useful for Veterans pursuing their recovery. Help Veterans develop a plan and problem-solve what could go wrong ahead of time. And the next time you see that person, ask them how it went. If it didn’t go well, what might have interfered and problem-solving those things. If it did go well, making sure the individual links that their use of a skill helped it turn out well so they will continue to use those skills.

JSK: A lot of your previous research has focused on substance use disorders in individuals with schizophrenia. How do these areas of study complement each other?
MB: Negative symptoms and substance use disorders both can pose major barriers to recovery. People living with schizophrenia who are impacted by negative symptoms or substance use disorders often find that they have to contend with higher levels of positive symptoms, more frequent relapses of their mental illness and more hospitalizations. I am interested in helping people feel prepared to handle these roadblocks so that they can continue on their recovery path and live the lives they choose.

Melanie Bennett, Ph.D.

Note: Dr. Bennett’s research on social and community engagement for Veterans with schizophrenia has been supported by a MERIT award from VA Rehabilitation Research and Development (5IO1RX001293).