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 Strategies1.1. Psychiatric stabilization2.2. “Persuasion” groups3.3. Family psychoeducation4.4. Rehabilitation5.5. Structured activity6.6. Education7.7. 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-monitoring2. 2. Social skills training3. 3. Social network interventions4. 4. Self-help groups
5. 5. Substitute activities6. 6. Close monitoring7. 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 groups2. 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
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