MIRECC / CoE

Table of Contents

So, What Are Social Skills?

Social skills are interpersonal behaviors that are normative and/or socially sanctioned. They include such things as dress and behavior codes, rules about what to say and not to say, and stylistic guidelines about the expression of affect, social reinforcement, interpersonal distance, and so forth.Alan Bellack et al, 2004, Page 3

According to Alan Bellack and his colleagues, “Social skills are interpersonal behaviors that are normative and/or socially sanctioned. They include such things as dress and behavior codes, rules about what to say and not to say, and stylistic guidelines about the expression of affect, social reinforcement, interpersonal distance, and so forth.”

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Research: Social Skills Training for Individuals with Serious Mental Illness

There is extensive research supporting the effectiveness of Social Skills Training for individuals with Serious Mental Illness reaching back for several decades.

Meta-analysis of Controlled Research on SST (Kurtz & Mueser, 2008)

• Significant improvement in behavioral measures of social skills
• Moderate but significant improvement in social functioning

For example, a meta-analysis in 2008 of controlled research on Social Skills Training supports the efficacy of SST for improving psychosocial functioning for individuals with Serious Mental Illness. The results of this meta-analysis demonstrate large improvements in behavioral measures of social skills due to social skills training and moderate, yet significant, improvements in social functioning.

Identified as an Evidence-Based Practice (Dixon, et. al, 2010)

• “Individuals with schizophrenia who have deficits in skills that are needed for everyday activities should be offered skills training in order to improve social interactions, independent living, and other outcomes that have clear relevance to community functioning.” p. 51

Social Skills Training was identified as an Evidence Based Practice for individuals with Serious Mental Illness by The Schizophrenia PORT (or Patient Outcomes Research Team) Update in 2009. The PORT stated that “Individuals with schizophrenia who have deficits in skills that are needed for everyday activities should be offered skills training in order to improve social interactions, independent living, and other outcomes that have clear relevance to community functioning.”

So SST is considered an evidence based practice and for this reason it is also recommended by experts in psychosocial rehabilitation.

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VA-SST Training Model

There are several models of social skills training. The model that we are going to focus on in this training is the Bellack, Mueser, Gingerich, & Agresta model, or “Social Skills Training for Schizophrenia.” This model can be used effectively with individuals schizophrenia as well as other types of serious mental illness.

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SST in the VA

SST is primarily intended for Veterans with a primary diagnosis of:

• Schizophrenia, Schizoaffective disorder, Bipolar disorder, Treatment-refractory depression (with social skill development as an area of growth)

As a broad overview, I just want to remind you that there are VA directives in place that require Veterans to have access to EBPs like SST.

VHA directives also require SST to be provided in every PRRC.

• Veterans are required to have access to evidence based psychosocial interventions like SST (Department of Veterans Affairs, 2023; Department of Veterans Affairs, 2021) and this policy has been in place for many years (Department of Veterans Affairs, 2015).
• VHA policy also requires SST to be available as a core service in every VA Psychosocial Rehabilitation and Recovery Center (Department of Veterans Affairs, 2019).

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SST Promotes Recovery

Recovery is “A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.Substance Abuse and Mental Health Services Administration (SAMHSA)

In addition to VHA mandating access to Social Skills Training for Veterans with Serious Mental Illness, it is also a recovery-oriented treatment. By recovery, we are referring to a definition of healing that is broader than symptom reduction. The Substance Abuse and Mental Health Services Administration defines recovery as “A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.”

In Social Skills Training, Veterans work toward a recovery-oriented goal. Social Skills Training teaches skills needed to increase independence and foster self-efficacy.

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Key Components of SST

1. Individual session for engagement, orientation, and goal setting

• Recovery oriented “SMART” goal is set collaboratively.
• “SMART” refers to Specific, Measurable, Attainable, Relevant, Time-bound.

2. Group sessions for teaching specific skills

• Skills taught in group sessions are drawn from the Bellack et al. SST book.

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SST Group Session Sequence

There are 12 basic steps of the social skills training group session sequence. Prior to the first step, the SST group facilitator(s) welcomes the group and sets the agenda. Here’s a summary of the steps.

Welcome and Set Agenda

Step 1: Review outside practice (for sessions other than the first session)

Step 2: Establish a rationale for the skill

Step 3: Briefly have members share a relevant experience or rationale

Step 4: Explain the steps of the skill

Step 5: Model the skill, review with members

Step 6: Have a group member role play

Step 7: Elicit and provide positive, then constructive feedback

Step 8: Have the member role play again

Step 9: Elicit and provide positive, then constructive feedback

Step 10: Repeat role play again and elicit/provide positive feedback

Step 11: Repeat Steps 6-10 with each group member

Step 12: Develop outside practice assignments

Please read below for a more detailed description of each step.

Step 1: Review outside practice (for sessions other than the first session)

When reviewing the outside practice, it is helpful to reinforce any attempt to practice the skill (even if just one step or thinking about practicing). Make sure to reference the steps of the skill when reviewing the outside practice. You may inquire about adaptations that were made based on a group member’s cultural or linguistic background or the context. Also, the steps of the skill from the previous week will typically be displayed at the front of the room for you to reference during the outside practice review.

Step 2: Establish a rationale for the skill

Ask Group members “Why is this an important skill to practice?” You may also query regarding sociocultural and community norms and factors. For example, you might say something like “Is there anything about your culture and background that is important to consider when thinking about why this skill is important to practice?”

Step 3: Briefly have members share a relevant experience or rationale

After eliciting information about rationale from the group, remember to summarize the rationale before moving on to the next step.

Step 4: Explain the steps of the skill

Have group members read the steps of the skill. After each step is read, you will ask something such as “Why is this step important?” You may also discuss how the steps of the skill may be modified based on the culture and background of the group member and the specifics of the situation. “How may the steps be modified depending on your community or based on the relationship you have with a specific person?”

Step 5: Model the skill, review with members

The primary facilitator demonstrates the steps of the skill. Before starting the model, tell the group members "Watch me, I’m going to model the skill." Following the model, the implementation of each step is reviewed the group members.

Step 6: Have a group member role play

The role play should be brief and straightforward and be focused on the skill.

Each role play should have a clear beginning and a clear end. For example, the group leader may say “Begin role play” and “End role play” to make it clear.

The role play is personalized for each group member, ideally based on their SMART goal. The “Scenes for use in role plays” listed in Part II. of the Bellack et al. (2004) book are generally not used.

The culture and background of the group member and the specifics of the situation are considered when personalizing the role play. For example, you may ask “Is there any way you need to adjust the steps of this skill to be more effective in this situation either due to your relationship or due to culture?”

Once personalized, the role play buddy’s part should generally stay essentially the same in all 3 role plays.

Make scenario and role of role play buddy clear to entire group before role play.

Facilitators may use both verbal coaching and non-verbal prompting during roleplays to help Veterans learn social skills in in person SST groups. 

Step 7: Elicit and provide positive, then constructive feedback

Feedback on role plays should include LOTS of positives plus give VERY SPECIFIC instructions regarding what the Veteran engaged in the role play can do “even better” after first 2 role plays (1-2 maximum constructive suggestions). Be clear about what the constructive feedback is before starting the role play.

Step 8: Have the member role play again 

Step 9: Elicit and provide positive, then constructive feedback

Step 10: Repeat role play again and elicit/provide positive feedback 

Step 11: Repeat Steps 6-10 with each group member

Step 12: Develop outside practice assignments Important points to highlight when going through the sequence:

Outside practice should be ideally personalized and relevant to the Veteran’s SMART goal. Make sure the practice assignment is specific (who, what, when, where). Set up an outside practice that is focused on effectiveness by taking into consideration social, cultural, and linguistic factors.

This is the standard SST group session sequence that is followed in all SST groups.

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SST Curriculum Topics

The Social Skills Training curriculum in the Bellack et al. book is divided into 9 basic categories or topic areas, each containing between 3 to 11 specific skills.

The Categories include:

• Basic skills
• Conversational
• Assertiveness
• Conflict Management
• Communal Living
• Friendship and Dating
• Skills in Health maintenance as well as Communicating with providers
• Vocational or work skills
• And coping skills for drug and alcohol use

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Social Skills Example: Making Requests

1. Look at the person.
2. Say exactly what you would like the person to do.
3. Tell the person how it would make you feel if they did what you requested.

"I would like you to..."

"I would really appreciate it if you would..."

"It's very important to me that you help me with..."

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Current VA SST Provider Training Model*

1. Required Readings/Independent Study
2. SST Web Course
3. Experiential Learning Session**
4. 6 Months of Consultation (includes a Consultation Orientation Session)

*Includes criterion-based performance requirements for successful completion. Note: all participants in EBP training programs are also required to complete the Shared Decision Making web course prior to or within 2 weeks of training program acceptance.

**In rare circumstances, a training participant may serve as a roleplay buddy for 3 SST group sessions where an SST National or Regional Trainer is the primary facilitator rather than participate in an Experimental Learning Session. This substitution needs to be pre-approved by the VA SST Training Program Manager.

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SST Training

• Only VA mental health employees can participate in the VA SST Training Program.
• Participants in the VA SST Training Program are currently required to lead in-person SST groups as part of the consultation period.
• SST provided in person is an evidence based practice (EBP)

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SST Overview and Refresher Webcourse

• The VA SST Training Program has created a web course that provides a helpful overview of SST, including videos of a staff simulated SST group.
• It can be accessed by both VA staff and the public.
• What is Social Skills Training for Serious Mental Illness (SST)? An Overview and Refresher

• Can obtain 1.5 CEs

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Citations

• Department of Veterans Affairs, Veterans Health Administration (2023). Uniform mental health services in VHA medical points of service (VHA Handbook 1160.01).
• Department of Veterans Affairs, Veterans Health Administration (2021). Evidence-based psychotherapies and psychosocial interventions for mental and behavioral health conditions (VHA Directive 1160.05).
• Department of Veterans Affairs, Veterans Health Administration (2019). Psychosocial Rehabilitation and Recovery Services (VHA Directive 1163).
• Dixon, L.B., et al. (2010). The 2009 schizophrenia PORT psychosocial treatment recommendations and summary statements. Schizophrenia Bulletin, 36(1), 48-70.
• Kurtz, M.M., & Mueser, K.T. (2008). A meta-analysis of controlled research on social skills training for schizophrenia, Journal of Consulting and Clinical Psychology, 76(3), 491-504.
• VISN 5 MIRECC: www.mirecc.va.gov/visn5/training/social_skills.asp
• SAMHSA Recovery: www.samhsa.gov/recovery

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Questions?

• If you are a VA mental health provider and would like to be added to the VA SST Training Interest list, please reach out to Lache Wilkins, M.S., Program Coordinator, Lache.Wilkins@va.gov
• You can also reach out to Elizabeth Gilbert, Ph.D., Program Manager with questions: Elizabeth.Gilbert@va.gov