BEHAVIOR THERAPY 12, 153--164 (198l)

Social Skills and Spinal Cord Injury: A Comparison of Three

Training Procedures

M I C H A E L D U N N

E L I Z A B E T H V A N H O R N

S T E V E N H . H E R M A N

Veterans Administration Medical Center, Miami, FL

A social skills a s s e s s m e n t bat tery consis t ing of paper and pencil and videotape measu res and demographic information was adminis tered to 22 male spinal cord injury patients . The Social Skills group and Social Skills + Film group then par- ticipated in a training course involving videotape feedback, lecture-discussion, and model ing in learning to manage si tuations which had been shown to be prob- lematical. A Film Only group was shown the complete educational film 4 weeks after the p reassessmen t . Ano the r group received no training. The resul ts showed no statistically significant differences among the groups on the subjective mea- sures but did show differences on the behavioral measures . Examinat ion o f group means showed that the training groups were greater than the Film Only and No- Training groups on rated overall asser t iveness . On the noncompl iance and reques t for new behavior measu res the Social Skills group was greater than the other groups. All subjects showed more overall asser t iveness and more reques ts for new behavior with males.

Adaptation to severe, traumatic physical disability has an important social component as well as the more recognized physical one. Life with a visible handicap requires management of the social consequences of asking for help, refusing help, patronization, discomfort of acquaintances, embarrassing situations, etc. A survey of 40 male SCI patients by Dunn (1977) indicated that the following specific social situations created the most difficulty: accidental bowel movement, at a party and discovering that external catheter has popped, falling out of a wheelchair, people who don't move out of the way, and putting your wheelchair in your car and

This s tudy was supported in part by the Research Service, Veterans Adminis t ra t ion, Miami, FL. The authors would like to thank Cynthia Butler and Hec tor Gonzales for their help in conduct ing the training groups and to Judith deMontmoll in for help in the a s s e s s m e n t procedures . Reprint reques ts should be addressed to the first au thor now at SCI Service, Veterans Adminis t ra t ion Medical Center , 3801 Miranda Avenue , Palo Alto, CA 94304.

153 0005- 7894/81/0153-016451.00/0 Copyright 1981 by Association for Advancement of Behavior Therapy

All rights of reproduction in any form reserved.

154 DUNN, VAN HORN, AND HERMAN

TABLE 1 DEMOGRAPHIC COMPOSITION OV THE VARIOUS GROUPS QUADS---QuADRAPLEGICS (C4 TO

C7 LESION) PARAS--PARAPLEGICS (T1 TO L5 LESION)

Social Film + Social Skills Film Only Control Skills

Number of patients 6 6 6 4

Mean age (years) 38.3 40.5 52.7 36.5

Type of injury:

quad (C4-C7) 2 3 1 2 para (T l-L5) 4 3 5 2

Mean length of injury:

(years) 4.1 13.9 21.9 3.39

Patient status:

in 4 2 3 4 out 2 4 3 0

passerby insisting on helping. The rehabilitation literature has empha- sized the importance of social rehabilitation (Cogswell, 1968; Dunn, 1975; Kahn, 1969; Kleck, 1968), but only two accounts of social skills training courses have been published (Mischel, 1978; Romano, 1976), the latter study being ancedotal and the former being a brief report using handi- capped college students.

The current study is an attempt to use assertion and social skills train- ing (see Heimberg, Montgomery, Madsen, & Heimberg, 1977 for a re- view) in an ongoing spinal cord injury (SCI) rehabilitation program using objective indices of performance and paper and pencil tests of subjective discomfort and response probability to assess the effectiveness of such a program. An additional goal is to evaluate patient acceptance of social skills training in order to incorporate such training into the rehabilitation routine.

METHOD Subjects

The 22 male subjects for this study were selected from inpatients and outpatients from the SCI Service at the Miami Veterans Administration Medical Center. All subjects had no significant psychiatric diagnoses, were able to sit in their wheelchairs for at least 2 hours, and expressed willingness to participate in the study by signing informed consents.

All patients were selected on the basis of interest from the patients available on the ward at the time and were randomly assigned to one of the first three groups. Because of the time required to accumulate a new set of patients, the Film + Social Skills group was not selected or run until 6 months after the first three groups. Patients from this group were

SOCIAL SKILLS A N D SCI 155

selected on the same basis as the others. It is assumed that random factors determined their presence in the hospital when the fourth group was started. All patients who were asked to participate in the study agreed. Two subjects in the Film + Social Skills group, however , dropped out after the first assessment period.

Table 1 shows demographic information for the four groups.

Assessment Procedure

All subjects were assessed following the procedure developed and pre- sented by Dunn and Herman (in press). Briefly, the following measures were taken: (l) demographic information, (2) paper and pencil self-report measures: SCI Assertion Questionnaire (SCIAQ, Dunn & Herman, in press), Gambrill-Richey Assertion Inventory (Gambrill & Richey, 1975), and Rathus Assertiveness Schedule (Rathus, 1973), and (3) a performance measure, the Behavioral Assertiveness Test, modeled after Eisler, Miller, and Hersen (1973) which consisted of 16 potentially difficult social situ- ations presented on audiotape to the subjects. After each situation was presented, a male or female confederate in the room with the patient would say the phrase to which the subject must respond. 1 All responses were videotaped and later rated on the basis of overall assertiveness, noncompliance, and request for new behavior (Eisler et al., 1973) by two judges who were blind to group membership or time of assessment. These measures were defined following Eisler et al. (1973) with each subject 's response being scored 1 on noncompliance if he did not go along with the confederate ' s request and 1-5 on overall assertiveness (with 5 being high) depending on the judge 's rating.

Reliability between the two judges on the measure of overall asser- tiveness was assessed by selecting four subjects at random and perform- ing a Pearson product-moment correlation between the ratings of the judges. The scores of these same four subjects were also used to estimate the reliability of the noncompliance and request for new behavior ratings by calculating the percent agreement between the two judges (agreements divided by agreements plus disagreements × 100%). Each of the two judges ' ratings on the scenes was summed so that separate scores were available for responses to the male and female confederates in general social and disability specific scenes for the overall assertiveness, non- compliance, and request for new behavior measures.

Of the 16 scenes, six were concerned with general social situations which would be common to handicapped and nonhandicapped individuals alike. The remaining l0 scenes were specific to people in a wheelchair. Eight scenes with a male confederate and eight with a female confederate were used. The confederates were blind to group membership. In the posttest , four additional scenes were used to test generalization, two with

i For a complete list of the situations and the phrases that the confederates delivered to the subjects, please write to the first author.

156 D U N N , VAN HORN, AND HERMAN

male confederates, two with female confederates, two social, and two SCI-specific.

The subjects in the Social Skills and Film + Social Skills groups ad- ditionally completed a Student Evaluation Form in the postassessment which consisted of a 1-5 rating on the dimensions of "usefulness," "in- terest ," " importance," "quality of teaching," and "realism" on each situation in the class.

Training Procedures

Social Skills. The patients participated in a training course led by the first two authors and a female psychology intern which met for eight sessions, twice a week for 1½ hours per session. Each session dealt with one particularly anxiety arousing social situation that had been judged by SCI males as difficult to manage (Dunn, 1977). These situations were (in order Of presentation): refusing assistance in putting the wheelchair in the car, refusing social advances by a drunk in a bar, asking for help with a telephone, asking people to move out of the way, an accidental bowel movement during a job interview, falling out of the wheelchair, respond- ing to a waitress put-down, and "picking up a girl" in a bar.

The first session of the training course involved a 15-rain lecture on assertiveness and social skills and their application to SCI, a description of the components of assertiveness, videotaped role playing of the situ- ation with feedback from the course leaders and other course members, and discussion of the alternative responses to the situations. The video- taped role-playing procedure involved presenting the situation to the pa- tient with the course leaders playing the other roles and asking the patient to respond as if he were in the situation. His response was videotaped and played back to him, the group providing feedback in terms of the components of assertiveness. He was finally offered the opportunity to try the response again.

The next three sessions followed the same procedure but eliminated the 15-min introductory lecture. In the last four sessions, the situation to be covered was not introduced by the instructor, and no hints were given before the patients tried their response, i.e., no instructions were given to the subjects before they tried their responses to the situation covered in the class that day. Otherwise, they were similar to the first four ses- sions. Other problems of wheelchair living were also discussed in the group as the occasion arose.

Film Only. Four weeks after the initial assessment, the patients in this group were shown a modeling film (Dunn, Van Horn, & Herman, Note 1) which showed aggressive, passive, and assertive methods of deal- ing with each of the eight situations covered in the training course and then reassessed immediately.

Control. This group was assessed and then 4 weeks later reassessed. Film + Social Skills. This group received a similar procedure to the

Social Skills group. In addition, the portion of the modeling film which corresponded to the situation covered in that session was shown at the

SOCIAL SKILLS A N D SCI 157

end of each group session. The course leaders in this group were the first two authors and a male psychology intern.

RESULTS Demographic Characteristics of the Treatment Groups

Analysis of the number of paraplegics vs quadraplegics in each of the four groups showed no statistically significant differences [XZ(3) = 1.76]. Similarly, no significant differences in mean age of the patients in each of the four groups were found. However, when length of injury was considered, a statistically significant difference was found [F(3,18)= 7.22, p < .001] with the Film Only and Control groups being injured the longest.

Although matched groups would have been preferable in the present study, the fact that patients injured the longest have been shown in pre- vious research (Dunn, 1977; Dunn & Herman, in press) to be rated by the staff as better adapted to their handicaps, makes for a more rigorous comparison among the groups; i.e., the observed difference between the training groups and the controls will be smaller than the actual difference. The differential in length of injury will have the effect of diluting the real difference. It might be argued, however, that older patients may have already changed and therefore would not be expected to show additional change. Any observed improvement would then be due to nonspecific experimental variables rather than treatment effects. Under this argu- ment, there should be a high negative correlation between age (or length of injury) and amount of change from the premeasures to the postmea- sures. To test this argument, correlations of age and length of injury with difference scores of overall assertiveness, SCIAQ anxiety, and SCIAQ response probability were performed over all 22 subjects. None of these correlations (range -.367 to +.292) were statistically significant, that is, amount of change from pre- to posttest appeared to be independent of age or length of injury.

Self-Report Inventories Separate analyses of covariance were performed on each of the self-

report inventories' posttest scores with the respective pretest score as the covariate (Nie, Hull, Jenkins, Steinbrenner, & Bent, 1975). Only the SCIAQ response probability subscale approached statistical significance with the Film + Social Skills group showing the most increase in self- reported response probability. Patients' self-perception of assertiveness, anxiety, or response probability in both general and disability specific social situations did not change as a function of the present training pro- cedures.

Behavioral Measures of Performance Pearson product-moment correlations for the ratings of overall asser-

tiveness for the two judges on four randomly selected subjects were .54,

158 D U N N , V A N H O R N , A N D H E R M A N

4.00

F~ w co co .¢

e~ 3.50

g

~3.oo

/ FILM & SOCIAL SKILLS ~ SOCIAL SKILLS

. / /

/ - " I / CONTROL

, , •,," . . . . . . . . . . . . . . . . • - , - .

/ .............. • " ...... FILM ONLY

PRE POST

FIG. 1. Rated overal l assert iveness as a funct ion of pre- and pos tas se s sment for the different groups.

• 82, .90, and .83 (mean = .77). Percent agreement for the ratings o f non- compl iance and requests for new behavior for the s a m e four subjects were 75%, 95%, 100%, and 95% (mean = 91.3%) and 95%, 100%, 100%, and 100% (mean = 98.8%), respectively• The sums o f both judges' ratings on all subjects were used in all subsequent analyses .

Since the performance measures of noncompl iance and request for new behavior are scored on an occurrence , nonoccurrence basis, each scene was rated either 1 or 0. Because this d ichotomous data is summed over scenes and raters, the distribution o f scores more c lose ly approximates the normal distribution since each subject's score can vary from 0 to 10 (in SCI) scenes or 0 to 6 (social scenes) (cf. Winer, 1971, p. 305). After

o

.90

.80

.70

.60

...................................................... FILM ONLY

SOCIAL SKILLS

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4 i - PRE POST

FIG. 2. Rated noncompl iance as a function of pre- and pos tasses sment for the different groups•

SOCIAL SKILLS AND SCI 159

.90-

~- 80- E oo §

,70 g

~ .6o2 g

~ Male

_ _ ~ Female

SociaF SCI

Type of scene

FIG. 3. Rated noncompl iance with male and female confederates as a funct ion of general social s i tuations and disability specific si tuations.

a mult ivariate analysis of covar iance (with the prescore of each behav- ioral measure as the covariate) showed a significant (p < .001) group effect, a 2 x 2 x 4 analysis of covar iance with type of scene (SCI vs. social), sex of confederate , and group as factors was per formed on each of the three dependent variables. Each of the dependent variables will be considered in turn.

Overall assertiveness. Analysis of covar iance on all four groups showed a statistically significant group effect [F(3,17) = 5.16, p < .01], sex of confederate [F(1,17) = 7.82, p = .012] and type of scene (social or SCI) x group interaction [F(3,17) = 5.06, p = .011]. Subsequent group-by-group compar isons on adjusted means revealed that: (1) the Film + Social Skills group was rated higher than the Film Only and Con- trol groups in the pos t tes t and (2) the statistically significant scene by group interaction was accounted for by the fact that only the Film + Social Skills group was rated higher on social scenes than SC1 scenes after training. Patients in all four groups were judged more assert ive with the male confederate than with the female one, in both types of scenes (p < .010). Fig. 1, which combines per formance on all scenes, shows the mean rating of overall asser t iveness as a function of pre- and post test ing for the four groups. Examinat ion of Fig. 1 shows that even though the Social Skills group started the training with high asser t iveness scores, they still improved; however , the Film + Social Skills group improved the most . The slight increase in per formance of the Control group and the decrease in per formance in the Film Only group were not statistically significant.

Noncompliance. Fig. 2 shows the mean rating of noncompl iance as a function of pre- and post test ing for the four groups. It can be seen that the Social Skills group increased in noncompl iance the most , but the other groups also improved somewhat . An increase in noncompliance is

160 DUNN~ VAN HORN, AND HERMAN

.60

.50

N. 40

.30

~ SOCIAL SKILLS

FILM & SOCIAL SKILLS CONTROL

Z

FILM ONLY

I m I PRE POST

FIG. 4. Rated requests for new behavior as a function of pre- and postassessment for the different groups.

considered to be an improvement for the purposes of this study. Analysis of covariance on all four groups showed a statistically significant group effect [F(3,17) = 4.44, p = .017] and Sex of the Confederate x Type of Scene interaction [F(1,17) = 16.26, p < .001]. Examination of group-by- group comparisons showed that the group effect was due to a statistically significant difference between the Social Skills and the Film Only groups. The Sex of Confederate x Type of Scene interaction is illustrated in Fig. 3, which shows noncompliance scores combined over times of testing and group for the two types of scenes. Noncompliance with the male confederate is greater in social situations than in SCI situations while the reverse is true for noncompliance with a female confederate. This rela- tionship holds true for all groups over both times of testing.

Request for new behavior. Fig. 4 shows the mean rating on request for new behavior for the four groups. It can be seen that the Social Skills group improved the most while the Film Only group decreased somewhat. Analysis of covariance on all four groups showed a statistically significant group effect [F (3 ,17 )= 13.38, p < .0001], sex of confederate effect IF(l,17) = 5.52, p < .05], Sex of Confederate x Type of Scene interac- tion [F(3,17) = 8.38, p = .011], and Sex of Confederate x Group inter- action [F(3,17) = 4.62, p = .01]. A group by group comparison showed that the Social Skills group was significantly higher in requests for new behavior in the posttest than the Film Only and Control groups. Exami- nation of group means revealed that the significant sex of confederate effect was due to an elevation in requests for new behavior with males across all groups and scene types. This elevation was larger in the Film Only and Film + Social Skills groups. The Sex of Confederate x Type of Scene interaction is seen in Fig. 5. While requests for new behavior are greater with males than with females in social scenes, this difference is even greater in the SCI scenes.

SOCIAL SKILLS AND SCI 161

70*

.60-

¢~ .50 E

~ 40-

g .30-

:~ 20-

1

~ ] Male

Female

Social SCI

Type of scene

Fl6 .5 . Rated reques ts for new behavior with male and female confedera tes as a funct ion of general social s i tuations and disability specific si tuations.

Generalization scenes . Performance in four situations which had not been encountered before were evaluated at posttest on the three depen- dent variables; analyses of variance were done as before. No statistically significant group differences were found. All groups were judged to be more noncompl ian t with male confedera tes than with female ones IF(I,18) = 14.23, p < .001] and made more requests for new behavior in social situations than in SCI situations [F(I,18) = 26.79, p < .001].

Patient acceptance. On a 5-point scale (with 5 being high) the mean rating over all five scales for both training groups was 4.4 with a range of 3.9 to 5.0, indicating high patient acceptance of the training procedures.

DISCUSSION The present study represents an initial at tempt to examine an important

but little explored area of rehabilitation; i.e., social adaptation to a per- manent, visible physical disability. After objective measures of perfor- mance and self-reported discomfort in potentially stressful social situa- tions were obtained, training in the management of these situations which involved videotape feedback, viewing a modeling film or a combination of them was compared with a group which received no treatment. Al- though no statistically significant differences were found on the self-re- port measures, performance on the three behavioral measures showed a statistically significant improvement in those groups receiving social skills training. In spite of the confounding effects of running one group 6 months

162 D U N N , VAN HORN, AND HERMAN

later than the other, and the trend toward younger age in two groups, both of which may limit the generality of the present research, our results would support the following conclusions: (1) viewing of the modeling film appeared to contribute significantly to the increase in overall assertive- ness (a measure which involves nonverbal as well as verbal skills) but did not contribute to the effectiveness of the skills training in noncompliance- and requests for new behavior (measures which mainly involve verbal behavior) and (2) viewing the modeling film alone appeared to result in a decrease in performance and an increase in self-reported anxiety al- though these changes were statistically nonsignificant. This result may be similar to Shipley's research (Note 2) which shows that one-time expo- sure to a presurgical film produces an increase in anxiety in repressors who need repeated exposure to decrease anxiety.

It should be noted that the group which only saw the training film did not receive an Opportunity to discuss the situations or practice its re- sponse to them before retesting. It is recommended that the training film be used in the context of an ongoing group with an experienced leader where opportunities for discussion, practice, and feedback can occur.

The modeling film in the Film + Social Skills group was used at the end of the session in order to prevent the patients from using the modeled responses until they had tried them themselves. Even though this group improved the most on overall assertiveness, we have in subsequent groups used the film early in each session.

The statistically significant interactions between type of scene and sex of confederate in noncompliance and request for new behavior are diffi- cult to explain at this time. The fact that the subjects were more non- compliant with male confederates in social situations than SCI situations, and made more requests for new behavior of males than of females, may be due to a general lack of assertiveness in the male veteran population or may be the result of a higher proportion of female staff in SCI reha- bilitation settings. The former possibility is less likely due to Eisler, Her- sen, Miller, and Blanchard's (1975) study which showed that male Vet- erans Administration psychiatric patients were rated m o r e assertive with women. Their emphasis on the situational specificity of assertiveness in terms of sex and familiarity is supported and extended by the present results which show the additional effect of disability related vs general social situations. Further research should explore the interrelationships of type of situation, sociocultural background, type of handicap, and geographical background on assertiveness in a larger sample of rehabili- tation clients.

Generality of the current results and assessment of the relative impor- tance of the individual components of the training courses are not ques- tions that can be answered in the present study. The small number of groups exposed to our training procedures limit generality and do not allow examinations of the relative contribution of the videotape feedback, instructions, or modeling components. It should be emphasized that the procedures described herein represent one approach which should be

SOCIAL SKILLS AND SCI 163

included among other approaches (more traditional in nature) in the total rehabilitation of the SCI patient. Further, it is not yet clear that social skills training contributes to "rehabilitation" at all, although our research (Dunn & Herman, in press) shows that the measures of overall asser- tiveness and requests for new behavior were significantly positively cor- related with rated adjustment and social mobility, respectively.

Despite the limitations of the current study, it appears that the major purposes have been fulfilled; i.e., (1) social skills training is a procedure applicable to the social rehabilitation of male SCI patients, (2) patient acceptance of these procedures indicates that social rehabilitation tech- niques can be integrated into the clinical routine of a medical rehabilita- tion service, and (3) groups involving videotape feedback, modeling, and instructions make significant gains in performance in situations which severely physically handicapped individuals must face in their reentry into society.

REFERENCE NOTES 1. Dunn, M., Van Horn, E., & Herman, H. Social skills and the SCI patient. Videotape

available from National Audio Visual Center, Washington, DC, # N A C 004-179, 1976. 2. Shipley, R. H. An extinction~habituation approach to preparation for stressful medical

procedures. Presented at the Annual Convention, Association for Advancement of Be- havior Therapy, Atlanta, 1977.

REFERENCES Cogswell, B . E . Self socialization: Readjustment of paraplegics in the community. Jour-

nal of Rehabilitation, 1968, 34, 11-13. Dunn, M. Psychological intervention in spinal cord injury: An introduction. Rehabilitation

Psychology, 1975, 22, 165-178. Dunn, M. Social discomfort in the patient with spinal cord injury. Archives of Physical

Medicine and Rehabilitation, 1977, 58, 257-260. Dunn, M., & Herman, H. Assertiveness and social skills training in physical disability.

In D. M. Doleys, R. L. Meredith, & R. Ciminero (Eds.), Behavioral psychology in medicine: Assessment and treatment strategies. New York: Plenum, in press.

Eisler, M., Miller, M., & Hersen, M. Components of assertive behavior. Journal of Clin- ical Psychology, 1973, 29, 295-299.

Eisler, M., Hersen, M., Miller, M., & Blanchard, E . B . Situational determinants of as- sertive behaviors. Journal of Consulting and Clinical Psychology, 1975, 43, 330-340.

Gambrill, E. D., & Richey, C. A. An assertion inventory for use in assessment and research. Behavior Therapy, 1975, 6, 550-561.

Heimberg, G., Montgomery, D., Madsen, H. J., & Heimberg, S. Assertion training: A review of the literature. Behavior Therapy, •977, 8, 953-971.

Kahn, E. Social functioning of the patient with spinal cord injury. Journal of the American Physical Therapy Association, 1969, 49, 757-762.

Kleck, R. Physical stigma and nonverbal cues emitted in face to face interactions. Human Relations, 1968, 21, 19-28.

Mischel, H. Assertion training with handicapped persons. Journal of Counseling Psy- chology, 1978, 23, 238-241.

Nie, N. H., Hull, C. H., Jenkins, J. G., Steinbrenner, K., & Bent, D. H. Statistical Package for the Social Sciences (2nd Ed.). New York: McGraw-Hill, 1975.

164 DUNN, VAN HORN, AND HERMAN

Rathus, S .A. A thirty-item schedule for assessing assertive behavior. Behavior Therapy, 1973, 4, 398-406.

Romano, M . D . Social skills training with the newly handicapped. Archives of Physical Medicine and Rehabilitation, 1976, 57, 302-303.

Winer, B.J . Statisticalprinciples in experimental design. New York: McGraw-Hill, 1971.

RECEIVED: November 7, 1978; REVISED: July 2, 1980 FINAL ACCEPTANCE: July 14, 1980