Efficacy of open-system social skills training in inpatients with mood, neurotic and eating disorders

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1 PCN Psychiatric and Clinical Neurosciences Blackwell Science Pty Ltd 573June Open-system SST at a general hospital M. Takahashi and K. Kosaka /j x Original Article295302BEES SGML Psychiatry and Clinical Neurosciences (2003), 57, Regular Article Efficacy of open-system social skills training in inpatients with mood, neurotic and eating disorders MEGUMI TAKAHASHI MD, PhD 1,2 AND KENJI KOSAKA MD, PhD 1 1 Department of Psychiatry, Yokohama City University School of Medicine, Kanazawa, Yokohama and 2 Department of Psychiatry, Kitasato University School of Medicine, Sagamihara, Japan Abstract Open-system social skills training (SST) was performed in an open psychiatric ward of the hospital of Yokohama City University. Between June 1998 and March 2000, 223 patients were being treated for various mental disorders and 136 of these patients voluntarily participated in the open-system SST at least once. The SST participants ages were 37.2 ± 16.9 years and the admission period was ± 61.4 days, while non-participants ages were 49.8 ± 18.8 years and the admission period was 71.8 ± 55.6 days. The correlation between participation time and the admission period showed a ratio of approximately 0.5. As for diagnoses, schizophrenia, eating disorder and personality disorder patients tended to participate in SST, while organic mental disorder patients tended to be nonparticipants. After October 1998 there were 26 patients continuing to attend SST who participated in the evaluation study that compared social skills estimation before SST with that after SST by self-evaluation and by the staff using a social skills questionnaire. After SST sessions, the average staff evaluation score was 43.9% in schizophrenia, 64.4% in mood disorder, 64.9% in neurotic disorder and 55.3% in eating disorders, while they were 29.1%, 33.8%, 44.4% and 34.5% before the sessions, respectively. After the SST sessions, mood disorder patients showed a 25 30% increase of both self-estimation and staff estimation in all subcategories of social skills. These findings suggest that SST was effective for all patients motivated to improve their social skills despite diagnoses and that the SST program had different effects in each diagnosis group. Key words behavioural therapy, general hospital, mental disorders, skill evaluation, social skills training. INTRODUCTION Social skills training (SST) was developed as a cognitive behavioral therapy for psychiatric rehabilitation programs. Social skills training improves the communication skills and the adaptation ability to social lives. The effects of SST have been reported for many psychiatric disorders, such as depression and social anxiety. 1,2 Recent studies on SST, however, have mainly focused on the efficacy in schizophrenia. 3,4 Since Liberman et al. introduced this therapy to Japan in 1988, SST has mainly been provided to chronic schizophrenic patients, and a few previous studies reported its effects on schizophrenic patients alone. 5 7 There is Correspondence address: Megumi Takahashi, PhD, Department of Psychiatry, Kitasato University School of Medicine, Asamizodai, Sagamihara , Japan. megumita@kitasato-u.ac.jp Received 31 July 2002; revised 28 October 2002; accepted 4 November Regular Article no information about the application of SST to other mental disorders or the acute phase of schizophrenia in Japan. The hospital at Yokohama City University is an average sized university hospital in Japan and has 30 beds in the open psychiatric ward. Compared to psychiatric hospitals, where SST is performed, this hospital size is small but treats a wide range of mental disorders. We felt the need to incorporate communication training, such as SST, for some patients who had low social skills, which influenced the process of their illness or social adaptation ability. Depressive patients, eating disorder patients and young schizophrenic patients, who also have communication problems, do not have much opportunity to experience SST in Japan because SST is mainly performed at mental centers or special psychiatric hospitals, where such patients are uncommon. Hence it is meaningful to provide SST at psychiatric wards in a general hospital because such patients are more common.

2 296 M. Takahashi and K. Kosaka First, we tried to clarify the characteristics of the voluntary SST participant from inpatients with mental disorders in such a general hospital. We conducted the open-system SST once a week in our ward. The open system meant that every inpatient who had an interest in SST was welcomed to each SST session and the participating period was free as long as he/she was an inpatient. Usually SST is provided to a closed group and continues for several months. However, it is difficult to make a closed group for several months at the hospital of Yokohama City University because inpatient numbers are neither big nor is admission time long. Our ward treats acute psychiatric patients and the average admission time is typically under 3 months (approx. 1 5 months). Between June 1998 and March 2000, 223 patients were treated for various mental disorders in the open psychiatric ward of the hospital of Yokohama City University. Of these, 136 patients attended our open-system SST voluntarily. We compared SST participants with non-participants and report on the participant characteristics. Second, we tried to clarify how effective a general university hospital is in providing SST. We developed the social skills questionnaire to evaluate the SST effects by self-estimation and staff estimation of social skills. This application of SST to the patients with various mental disorders was the first such trial in Japan. METHODS Analysis of social skills training participants Subjects Between June 1998 and March 2000, 223 patients with various mental disorders were admitted to the open psychiatric ward at Yokohama City University School of Medicine. Their profiles are shown in Table 1. Diagnoses were based on ICD-10 classification. 8 Procedures First we compared the age, gender, admission period and diagnoses of SST participants with those of nonparticipants. We then studied the relationships between age, admission periods, diagnoses and participation frequency. Statistical analyses were performed using STATVIEW software version 4.5. Evaluation of the social skills training effects Subjects Since we provided the open-system SST we considered the patients who participated more than twice and who agreed to participate in the SST study of evaluating SST efficacy, as regular participants. Sometimes patients voluntarily expressed their will to constant attendance to SST before attending SST sessions. In such cases we explained the SST study and also counted them as regular members if they agreed to participate. Twenty-six patients agreed to participate in this study between October 1998 and March Their profile is shown in Table 2. Assessments and analysis Self-estimation and staff estimation of the social skills was performed using a social skills questionnaire (Table 3) before and after the SST sessions. This questionnaire contained 33 items, which were categorized into five subskills: general speaking skills; personal communication skills; communication skills in the hos- Table 1. Profiles of all in-patients, SST participants and non-participants (mean ± SD) All inpatients Participants Non-participants P n Age (years) 42.1 ± ± ± 18.8 < Male/female 73/150 40/96 33/ Admission period (days) 90.6 ± ± ± Diagnoses F0: organic mental disorders F2: schizophrenia F3: mood disorders F4: neurotic disorders F5: eating disorders F6: personality disorders Others SST, social skills training. P values ware calculated between the participants group and the non-participants group.

3 Open-system SST at a general hospital 297 Table 2. Profiles of regular participants (mean ± SD) All F2 F3 F4 F5 n Age (years) 33.5 ± ± ± ± ± 1.5 Male/female 11/15 7/2 3/3 0/6 0/3 Admission period (d) ± ± ± ± ± 43.1 Frequency of participation 9.5 ± ± ± ± ± 1.5 Table 3. Social skills questionnaire General speaking skills Eye contact Using gestures Showing enthusiasm Good appearance Speaking loudly Chosing suitable sentences Personal communication skills Saying yes to other people s requests Saying no to other people s requests Asking for something from other people Asking for another thing when one request is refused Counting good points of the others Explaining own suituation Asking for an explanation Ending communication politely Promising Getting permission for a delay Negotiating with other people who have a different opinion Showing embarrassment Ignoring minor blames that are not own fault Expessing the need for help Communication skills in the hospital Asking advice from a nurse Asking the nurse when you cannnot understand Asking advice from the psychiatrist Making an appointment for counseling with the psychiarist Home communication skills Saying hello to family members Admiring family members Help with homework General communication skills Asking a question Finding communication tips while conversing Speaking about own opinion or situation Expressing positive feelings to other people Nodding pital; home communication skills; and general communication skills. These items were estimated in three steps (0, poor; 2, average; 4, good) and achievement was calculated as percentage scores. We calculated the percentage score in each skill category and total score. This questionnaire has not been certified either for its reliability or validity but we did not have a questionnaire to be evaluated by both the patient and staff, so we decided to trial it. We compared the percentage scores before SST with those after SST among patients with different mental disorders. Statistical analyses were performed using STATVIEW software version 4.5. Social skills training conditions Open-system SST was conducted by a psychiatrist, a nurse and a social worker. Excepting the nurse, the SST staff were fixed. One-hour SST sessions were held once a week at a fixed time and place. All motivated inpatients were welcomed to every session. We usually introduced SST to new inpatients within 1 week after admission and the patients decided by themselves whether to attend. If staff felt that the patient had low social skills, she/he was encouraged to attend SST sessions but the final decision to attend was made by the patient. The SST was performed using the basic training model, 9 consisting of introduction, warm-ups and individual training themes. All participants were encouraged to deal with their own theme using role playing in each session. Each individual training theme was decided from the patients request, staff suggestion or using an original communication skills list, which included answers to questions of other patients, asking something of a nurse, thanking family members for coming etc. After confirming continuous participation, the short goal of training sessions was decided through a discussion with each patient using the social skills questionnaire. The participants consisted of between three and 12 patients at each session but numbers fluctuated less within several consequent sessions. Clinical residents and students often attended as members. We also provided separate recreational activities once per week. RESULTS Analysis of SST participants The backgrounds of all inpatients, the SST participants and SST non-participants are summarized in Table 1. The SST participants were younger and tended to have longer admission periods. As for diagnoses, patients in

4 298 M. Takahashi and K. Kosaka Table 4. Profiles of inpatients among different mental disorders (mean ± SD) F0 F2 F3 F4 F5 F6 n Age (years) 55.1 ± ± ± ± ± ± 9.4 Male/female 11/26 28/32 16/25 10/35 0/14 5/13 Admission period (days) 68.2 ± ± ± ± ± ± 37.7 Frequency of participation 2.8 ± ± ± ± ± ± 3.1 Table 5. Correlation between frequency of participation and factors of age, admission period or gender (mean ± SD) Frequency of participation Age (years) Admission period (days) Male/female ± ± / ± ± / ± ± /22 3 < n ± ± /36 > ± ± /9 Table 6. No. attendants classified by diagnoses and frequency of participation Frequency of participation F0 F2 F3 F4 F5 F < n > categories F2 (schizophrenia, schizotypal and delusional disorders), F5 (eating disorders) and F6 (disorders of adult personality and behavior) tended to become participants, while those in categories F0 (organic, including symptomatic, mental disorders) tended to be non-participants. The admission period was influenced by gender and diagnostic classification. Women tended to be inpatients longer than men (data not shown) and F2, F3 (affective disorders) and F5 patients tended to have longer inpatient periods. However, F0 and F6 patients had shorter admission periods and less participation time (Table 4). The correlation between the frequency of participation and the admission period showed a ratio of approximately 0.5. The average frequency of participation of all inpatients was 2.7. The number of patients participating more than twice was similar to that of those participating once or twice regardless of diagnosis. The frequency of participation depended on the admission period (Table 5). Those with longer admission periods and younger patients participated more frequently (Table 6). F2 and F3 patients tended to participate for a longer period if they attended SST, while F0 and F6 patients tended to participate only once or twice (Table 6). Evaluation of the social skills training effects The characteristics of regular participants are shown in Table 2. The average patient age was 33.5 years, the average admission period was days and the average participation was 9.5 times. According to staff evaluations, all regular participants demonstrated better social skills after attending SST sessions. As for selfestimation, 23 patients showed increased and three patients showed decreased skills. These three self-estimation-decreased patients initially had a high discrepancy between self-estimation and staff estimation but those discrepancies decreased at the second evaluation (data not shown). The average percentage score in each skill category was increased after attending SST sessions both in the whole group and in each diagnostic subgroup (Table 7). The percentage improvement evaluated by the patient and staff was at least 15% after SST sessions. Before SST, the F3 group had the lowest self-estimation percentage for overall social skills, while the F2, F3 and F5 groups had low staff estimation. After SST the self-estimation scores increased in all diagnostic groups but the staff estimation points remained low in the F2 and F5 groups compared with those of the other diagnostic groups. In the categories of communication skills, personal communication skills had low scores in all diagnostic groups on both selfestimation and staff estimation. The F2 group had low scores in general speaking skills, home communication skills and general communication skills by staff estimation at the beginning of the study. After the SST sessions, skills increased but remained at the lowest level among the diagnostic groups. The F3 group had low scores in personal communication skills and communi-

5 Open-system SST at a general hospital 299 Table 7. Percentage scores of social skills evaluated by patients and staff before and after SST sessions Total F2 F3 F4 F5 Before After Before After Before After Before After Before After Total estimation of social skills Self 42.9** 66.2** ** 69.7** 42.9* 66.2* Staff 44.4** 64.9** 29.1** 43.9** 33.8** 64.4** 44.4* 64.9* General speaking skills Self 48.8** 68.1** * 75.2* * 62.9* Staff 57.0** 73.6** ** 75.0** Personal communication skills Self 31.6** 55.6** 38.5* 56.3* 27.2** 56.7** 31.6* 55.6* Staff 31.7** 53.3** 20.0** 38.9** 21.7** 50.6** 31.7** 53.3** Communication skills in the hospital Self 60.4** 77.1** ** 89.6** Staff 58.3** 72.9** 41.7* 62.5* 37.6** 85.4** Home communication skills Self 61.1** 86.1** ** 83.3** 61.1* 86.1* Staff 52.8** 75.0** * 69.5* 52.8* 75.0* General communication skills Self 48.3** 75.0** ** 78.3** 48.3* 75.0* 49.2** 74.2** Staff 51.7* 76.6* 34.4* 46.7* Asterisk indicates significant difference between values before SST sessions and that after SST evaluated by the same person, for patient or staff. *P < 0.05; **P < SST, social skills training. cation skills in the hospital, but had average scores for general speaking skills, home communication skills and general communication skills by staff estimation. These low scores improved after several SST sessions but remained rather low in personal communication skills. The F4 group had average scores for general speaking skills, communication skills in the hospital, home communication skills and general communication skills, but personal communication skills were insufficient. The F5 group initially had somewhat fair skills in all subgroups except for personal communication skills. In all subskills, each diagnostic group had advances but remained relatively low in personal communication skills. As shown in Table 7, all subskills in the F3 group demonstrated a good recovery, and each diagnostic group had a significant increase in scores for some subskills. DISCUSSION Since SST was introduced in Japan it has mainly been performed in patients with schizophrenia. 5 7 This is the first report in which the open-system SST has been available in a general hospital in Japan. The hospital at Yokohama City University School of Medicine is an average sized general university hospital with a dementia evaluation center, so that elderly patients, who require clarification of a dementia diagnosis, are treated more frequently than usual. This influenced diagnostic category. These organic mental disorder patients often showed no interest in SST, although a few patients attended. The participants among organic mental disorders patients tended to have mild dementia and high social skills (data not shown). They may enjoy personal communication in SST sessions. Patients with schizophrenia, eating disorders and personality disorders were likely to participate in SST. Depressive patients often hesitated to attend. Through all diagnostic groups, patients participating once or twice comprised the majority. This suggests that our SST group played a role in making friends, and the admission periods were not long enough to permit participation many times after the acute phase of the mental disease. This could also explain why the average frequency of participation was only 2.7 times. Diagnoses did not make any difference in continued SST participation. A long admission period and young age were both positively correlated with participation. These results suggest that young people and patients with longer admissions were motivated to participate in SST. A young eating disorder patient said that she

6 300 M. Takahashi and K. Kosaka had poor social skills and poor social adjustment, and felt the need for such skills training. This may be one reason why younger patients tended to participate in SST. To confirm this point, a further well-designed systematic examination will be necessary. We developed the social skills questionnaire, which was originally developed for day care patients, to evaluate social skills. As aforementioned this questionnaire was not checked for its reliability or validity, these require validation before application of this questionnaire in further studies. At the time of the study we did not have a good questionnaire that could be evaluated easily by both the patient and the staff. The strength of this questionnaire is that it is easy to check and covers many fields. A limitation is that the evaluation steps are few and there is no clear boundary between the estimation steps. However, for the preliminary evaluation, it became a good indicator for comparing the score before SST with that after SST. Analysis of questionnaires completed by regular participants showed that SST increased staff estimation of communication skills to some degree in all diagnostic categories. According to self-estimation, 23 patients increased and three patients decreased their skills. The latter had significantly higher scores compared with the staff-estimations before SST, but the discrepancy decreased after SST. In other cases, the discrepancy between staff estimations and self-estimations decreased after SST. These findings suggest that self image becomes objective through SST. Previous studies showed an SST effect in many mental disorders and even in normal people. 1,2 Each diagnostic group in the present series was small, but each group showed significant differences in the percentage scores between before SST and after SST. These results suggest that providing SST to patients with various mental disorders has the possibility to improve their social skills despite the different diagnoses. It is necessary to consider the social skills and self image improvement due to admission and/or medication. To evaluate the SST effect strictly, it is necessary to perform a controlled study in the future. Next, we will discuss the SST effect on each diagnosed group. Recently, the SST effect on schizophrenia was extensively studied. 3,4,10 12 When SST sessions were performed biweekly for 3 months, schizophrenic patients with deficit symptoms had difficulties acquiring skills. 3 Good results were obtained when applying SST for 12 h weekly for 6 months. 4 Even though the present cases received fewer sessions compared with these previous studies, the F2 group showed improvements in social skills on estimations by themselves and by staff. However, their final achievement percentages were still low among all diagnostic groups. This suggests that they require more time to acquire skills and that they need more training. For the F2 group, the present SST system offered an introduction to SST, and some effect on their social skills improvement may motivate them to continue attending SST sessions after discharge. There have been few studies on the effect of SST on depression However, psychotherapy for chronic depression also provides communication skill change through interpersonal psychotherapy. 16 Interpersonal psychotherapy was based on supportive expressive psychotherapy or assertion training. 17 These two therapies and SST have a common point; they improve the communication skills. Thase et al. reported that three of four patients with endogenous depression showed improvements in depression and strategies to manage their difficulties. 13 However, they also reported that SST had no effect on prevention of relapse. Reed provided six biweekly sessions of SST and found improvements in depression and the functioning level in male adolescents but not so markedly in female adolescents. 14 Segrin reported a close correlation between depression and poor social skills. 15 The present F3 group initially had relatively poor skills in all subgroups of social skills. After SST sessions the F3 group demonstrated a good recovery in almost all subskill categories before discharge. These findings suggest that improvements in social skills may be associated with improvements in depression as reported previously. 13,15 However, the present F3 patients still had a low estimation of personal communication skills after SST sessions. Therefore, they may need continuous SST sessions after discharge to maintain good functioning in their social environments. The F3 group size was too small to discuss gender differences in this effect. As for neurotic disorders, the effects of SST on social phobia and anxiety disorder were reported For social phobia, SST role playing provides lower exposure stimuli so SST does not have an additional effect of behavioral therapy. 19 As aforementioned, assertion training, which was originally developed for decreased anxiety and increased self-responsiveness, has the common character of SST and its effect on neurotic disorders was reported. 21 The SST effect on anxiety disorders has not been established. 20 The present F4 group demonstrated significant improvements in total social skills and personal communication skills, suggesting that SST can also be expected to be useful for such F4 groups. For eating disorders, SST was performed as one strategy in a systematic therapeutic program. 22 The SST effects on weight gain were limited but SST provided some effects on continuation of the program by decreasing anxiety, depression and fear of negative evaluation. 22 The present F5 group showed good

7 Open-system SST at a general hospital 301 improvements in self evaluation of general speaking skills and general communication skills, suggesting that they could change their negative self-image through SST sessions. The low scores for personal communication skills after SST sessions suggests that they need continuous training to achieve good functional levels in their living area. The F5 group was too small to confirm this hypothesis directly so it is necessary to evaluate more cases. We could not provide different SST groups for different diagnostic groups because of staff limitations. However, a combined group could provide natural communication opportunities to different aged people. This situation is natural in general and will be sufficient for SST introduction. For an advanced stage it will become necessary to form separate diagnostic groups that will come to share disease-specific problems. The hospital at Yokohama City University School of Medicine could not provide continuous SST sessions after discharge because of staff limitations. We hope that these participants continue to attend effective SST sessions at the community level such as job training groups or day-care groups after discharge. Our open-system SST has other limitations in that participant numbers were different in each session and the total frequency of participation was limited to several times etc., but there were still good points. This setting can provide SST to small-sized psychiatric wards and can introduce SST to broad diagnostic category patients who do not have the chance to participate in SST using the present SST-providing system in Japan. Because even several sessions could have some effect on self-estimation in many diagnostic category patients, we recommend easily accessible SST to many acute-phase psychiatric patients. Because we failed to set up an adequate control group to strictly evaluate the SST effect, it is necessary to perform such a study using the easily accessible SST system in the near future. CONCLUSIONS An easily accessible open-system SST could provide the opportunity to clarify what SST is to the patients in broader diagnostic categories and to improve their self-esteem and behavioral patterns. REFERENCES 1. Brady JP. Social skills training for psychiatric patients, I. Concepts, methods, and clinical results. Am. J. Psychiatry 1984; 141: Brady JP. Social skills training for psychiatric patients, II. Clinical outcome studies. Am. J. Psychiatry 1984; 141: Kopelowicz A, Liberman RP, Mintz J, Zarate R. Comparison of efficacy of social skills training for deficit and nondeficit negative symptoms in schizophrenia. Am. J. Psychiatry 1997; 154: Liberman RP, Wallace CJ, Blackwell G, Kopelowicz A, Vaccaro JV, Mintz J. Skills training versus psychosocial occupational therapy for persons with persistent schizophrenia. Am. J. Psychiatry 1998; 155: Sarada Y. Social skills training and effects for patients with schizophrenia. Seishin Shinkeigaku Zasshi 1992; 94: (in Japanese). 6. Ikebuchi E, Nakagome K, Tsugawa R et al. Effects of social skills training on disabilities of schizophrenia. Jpn. J. Pychiatr. Treat. 1996; 11: (in Japanese). 7. Ikebuchi E. Cognitive remediation of schizophrenia: With special reference to SST (social skillss training). Seishin Shinkeigaku Zasshi 1999; 101: (in Japanese). 8. World Health Organization. The ICD-10 Classification of Mental and Behavioural Diaorders: Clinical Descriptions and Diagnostic Guidelines. World Health Organization, Geneva, Liberman RP, Derisi WJ, Mueset KT. Guiding People to Assert Themselves and Improve Their Social Skills Training. Research Press, Champaign, Penn DL, Mueser KT. Research update on the psychosocial training of schizophrenia. Am. J. Psychiatry 1996; 153: Lauriello J, Bustillo J, Keith SJ. A critical review of research on psychosocial treatment of schizophrenia. Biol. Psychiatry 1999; 46: Bustillo JR, Lauriello J, Horan WP, Keith SJ. The psychosocial treatment of schizophrenia: An update. Am. J. Psychiatry 2001; 158: Thase ME, Hersen M, Bellack AS, Himmelhoch JM, Kornbelith SJ, Greenwald DP. Social skills training and endogenous depression. J. Behav. Ther. Exp. Psychiatry 1984; 15: Reed MK. Social skills training to reduce depression in adolescents. Adolescence 1994; 29: Segrin C. Social skills deficits associated with depression. Clin. Psychol. Rev. 2000; 20: Thase ME. Long-term nature of depression. J. Clin. Psychiatry 1999; 60 (Suppl. 14): Frank E, Kupfer DJ, Wagner EF et al. Efficacy of interpersonal psychotherapy as a maintenance treatment of recurrent depression. Arch. Gen. Psychiatry 1991; 48: Stravynski A, Greenberg D. The treatment of social phosbia: A critical assessment. Acta Psychiatr. Scand. 1998; 98: Stravynski A, Arbel N, Bounader J et al. Social phobia treated as a problem in social functioning: A controlled comparison of two behavioural group approuches. Acta Psychiatr. Scand. 2000; 102:

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