Journal of Consulting and Clinical Psychology 1977, Vol. 45, No. 5, 885-890
Successful Interpersonal Skills Training with Schizophrenic Inpatients Barbara E. Finch
Charles J. Wallace
University of California, Los Angeles
Camarillo-Neuropsychiatric Institute Research Program, Camarillo, California
This article studies the effectiveness of a set of techniques for increasing the interpersonal skills of male schizophrenic inpatients. Patients participated in 12 sessions of interpersonal skills training. The effectiveness of the procedure was evaluated with both self-report and behavioral measures. The behavioral measures involved ratings of patient performance during both role-played and spontaneously enacted interpersonal situations. Several of the situations were used in training, and others were used only during the assessment sessions. To promote extrasession generalization of behaviors, dyads were formed and were given homework assignments to complete. Compared to a control group matched on age, length of total hospitalization, and pretreatment level of skills, the interpersonal skills training group significantly improved on measures of loudness, fluency, affect, latency, eye contact, content, and self-reported assertiveness. These improvements were apparent across both role-played and spontaneously enacted situations and across trained and untrained situations. The objective of the present research was to evaluate the effectiveness of a set of techniques for increasing the interpersonal skills of male schizophrenic inpatients. The set of techniques included anxiety management training and behavioral rehearsal. Several techniques were also included to teach patients to focus their attention on relevant interpersonal stimuli. The problem of focusing attention has not been specifically treated in studies of assertion training with schizophrenic patients (Bach, Lowry, & Moylan, 1972; Eisler, Hersen, & Miller, 1973; Goldsmith & McFall, 197S; Gutride, Goldstein, & Hunter, 1973; Weinman, Gelbart, Wallace, & Post, 1972). In addition, dyads were formed and were given extrasession homework assignments to facilitate generalization of inThe conclusions of this study are not to be construed as representing the policy of the Regents of the University of California. The authors wish to thank Matthew W. Buttigliere and the Psychology Service of the Veterans Administration Hospital, Sepulveda, California, for their cooperation. Requests for reprints should be sent to Charles J. Wallace, Camarillo-Neuropsychiatric Institute Research Program, Box A, Camarillo, California 93010. 885
session behaviors. Several investigators have used extrasession assignments but not within a dyadic context (Booraem & Flowers, 1972; Hedquist & Weinhold, 1970; Rathus, 1972, 1973). A secondary objective was to use an evaluation procedure characterized by four elements—(a) interpersonal situations that were relevant to the patients; (b) the inclusion of both spontaneously enacted and role-playing situations; (c) an assessor who was someone other than the therapist; and (d) the inclusion of both trained and untrained situations. Studies of assertion training have reported equivocal findings about the extent to which training generalizes beyond its immediate context. Little if any generalization has been found from training to in vivo situations (Hersen, Eisler, & Miller, 1974; Kazdin, 1974; McFall & Twentyman, 1973). In marked contrast, generalization has frequently been found but only under two conditions: (a) The assessor and therapist have been the same person (Goldsmith & McFall, 1975), and (b) role playing has been used for both trained and untrained situations (Eisler, Hersen, & Miller, 1973; Fredrickson, Jenkins, Foy, & Eisler, 1976; McFall & Twentyman,
BARBARA E. FINCH AND CHARLES J. WALLACE
886
1973). Thus, the presence of either the same person or the role-playing instructions could account for the findings of generalization. The evaluation procedures of the present research used an assessor who was not associated with the training and situations, some of which were role played and some of which were spontaneously enacted. Method Subjects Subjects were male schizophrenic inpatients residing in the same living unit at the Veteran's Administration Hospital, Sepulveda, California. Nursing staff selected an initial pool of 29 patients who fulfilled the following criteria: diagnosis of schizophrenia, between 21 and 40 years of age, a minimum of 1 year of total hospitalization, clinical impression of withdrawal and nonassertive behavior, and the ability to respond to questions and instructions cooperatively. These 29 patients were administered the Wolpe-Lazarus Assertiveness Questionnaire and were interviewed by the two therapists who conducted the assertive training sessions. The 16 most nonassertive patients were selected for the study. They averaged 29 years of age and 3 years of total hospitalization. After matching on the basis of age, length of hospitalization, and self-reported assertiveness, patients were randomly assigned to either the treatment or control group, with each condition having 8 participants.
Assessment Measures In addition to the Wolpe-Lazarus Questionnaire, each patient participated in a pretreatment and posttreatment behavioral test of interpersonal skills administered by a female clinical psychology graduate student who was unaware of patients' assignments to experimental or control groups. The audiotaped behavioral test consisted of seven interpersonal situations, four of which were spontaneously enacted and three of which were role played. The four spontaneous situations were receiving a compliment, expressing an opinion, refusing an unreasonable request, and accepting thanks. The three role-played situations were initiating a conversation, expressing an apology, and extending a social invitation. These situations were chosen based on the answers of the 16 patients to an assessment instrument devised by the first author to determine those interpersonal situations in which the patients were most anxious. The instrument consisted of 28 items. The patients were taught to use the Subjective Units of Discomfort Scale (SUDS) and were instructed to record their SUDS level for each item. The 11 items that were rated as most anxiety evoking by the patients were used in the construction of the
behavioral test of assertiveness. There was an overlap on 6 items, with 4 items involving "expressing an opinion." These 6 items were combined to create two of the seven interpersonal situations. There was no overlap on the other 5 items, which were used to create the remaining five interpersonal situations. The format for the assessment sessions consisted of the assessor's greeting the patient and then spontaneously complimenting him on some aspect of his appearance and asking for an opinion about the office in which the assessment took place. The three role-played scenes were then introduced and completed, and the session ended with an unreasonable request to complete 4 hours worth of paperand-pencil tests followed by thanks for coming to the session. During the interview, if the patient gave no response, the assessor waited IS sec and continued with the interview. (On six pretest occasions patients gave no response to the situations of receiving a compliment and accepting thanks.) If the patient did not understand the instructions or evidenced confusion, the assessor repeated the instructions. (This occurred in four instances.) If the patient refused to role play a situation, the assessor continued with the next situation. (No such instances occurred.) The assessor reacted to the patient's responses in a neutral manner to prevent performance feedback. Differences between the pretreatment and posttreatment assessment sessions were restricted to variations in the content of expressing an opinion and refusing an unreasonable request. The content of expressing an opinion was changed to an opinion about the hospital, and the unreasonable request was changed to asking the patient to do 4 hours of work without pay. Participants in the assertive training group received training on all but two of the situations. One of the untrained situations was spontaneously enacted (expressing an opinion), and the other was role played (expressing an apology).
Response Definition The audio recordings of the behavioral test were rated in random order at the conclusion of the study by two graduate students in psychology. They completed their ratings independently of one another, and they were not informed of the purpose of the study or the groups to which the patients had been assigned. Five behavioral components of assertiveness were rated, with four of the five using the definitions and scales of Eisler, Miller, and Hersen (1Q73). The five components were (a) loudness of speech, (b) fluency of speech, (c) affect, (d) latency of response, and (e) content. The definition of content on the present study differed from that of Eisler, Miller, and Hersen (1973). All but latency were rated using S-point scales, with 1 indicating poor and 5 indicating very good; latency was measured with a stopwatch from the end of the assessor's prompt to the beginning of the
SUCCESSFUL INTERPERSONAL SKILLS TRAINING patient's response. Because of the unavailability of videotape equipment, the assessor rated the patient's eye contact in each situation on a S-point scale, with 1 indicating very poor eye contact and 5 indicating very good. This created a methodological problem, since there was no way to obtain interrater reliability for eye contact. Interrater reliabilities for loudness, fluency, affect, and content were calculated using Cohen's K. The six occasions for which there was no response, plus any response given that was inaudible or incomprehensible, was scored as 1 on the 5-point scale of each component. KS were loudness, .84; fluency, .92; affect, .92; content, .77. The Pearson product-moment correlation coefficient for latency was .98.
Treatment Interpersonal skills training sessions were conducted by two therapists (one male and one female) for 1 hour per session, three times per week for 4 consecutive weeks. The therapists were advanced PhD candidates in clinical psychology. The male was in his late 20s and the female in her mid-30s. Both had received supervised clinical training in working with psychiatric inpatients. Also, both were experienced in conducting social skills training groups with a variety of populations. Patients assigned to the control group participated in the normal hospital routine for the 4-week period. The goals of interpersonal skills training were to increase assertive behavior both in and out of the group and to decrease anxiety in interpersonal situations.1 Generally, the two therapists modeled appropriate and inappropriate behavior in a given situation requiring socially skilled behavior. Frequently, they exaggerated the inappropriate behavior. Patients then engaged in response practice, rehearsing their behavior in the situation with either one of the therapists or with each other, and reporting their SUDS level after each rehearsal. Patients were often asked to practice their behavior two or three times to achieve a more appropriate performance. However, to keep the sessions as positive as possible, the patients were not required to rehearse more than three times even if their performance was not appropriate or their SUDS level had not decreased. Rather, they were given an opportunity to practice the behaviors in later sessions, during which they could utilize an expanded repertoire of skilled behaviors. Patients received specific instructions and were coached to improve their interpersonal skills by focusing on the six components of skilled behavior. Patients were trained to give each other feedback on these components. For example, whenever a patient spoke in low volume, the group members prompted him by saying "I can't hear you." Between-session assignments were given at the end of each session. Patients were paired according to their own preference or, if no preference was expressed, at the discretion of the therapists. The
887
assignments proceeded in a graded manner from less to more difficult. During each session, patients discussed their successes and failures in completing the previous session assignments. When appropriate, patients role played the assignments and received feedback from the group. As the assignments became more complex and patients were required to engage in social activities with each other, the patients suggested the assignments and extended invitations to other members with similar interests. In view of the day-to-day variability of symptoms in schizophrenia, each patient was asked to attend each session even if he were having a "bad" day. The patient was asked to inform the therapist at the beginning of the session if he did not wish to participate. If, during the session, he changed his mind and wanted to participate, he was free to do so. Only one patient was absent from one session. All patients experienced inattentiveness. Several procedural variations were made to reduce the effects of such lapses. As a first step in focusing attention, patients were trained to establish good eye contact. In addition, situations requiring skilled responses were purposely varied, of short duration, and were often suggested by the patients themselves. All instructions were simple and to the point. To reduce the level of complexity, patients were taught appropriately skilled responses for specific situations rather then more generalized strategies. To further facilitate attending and group participation, each patient was responsible for giving performance feedback to the active participants. If patients were not attending when another group member spoke to them, they were trained to simply say "I'm sorry, I was not attending to what you were saying," rather than trying to respond with an inappropriate response. The therapists also trained patients to give short, precise responses relevant to the group topic. If a patient began to drift off the topic, he was interrupted and his attention was redirected. If a patient gave a response that was irrelevant to the group topic, he was told so and was asked to redirect his attention. Whenever a patient wanted to change the topic, he was trained to indicate his intention. This helped both the patient and the other group members to differentiate between an intentional shift of attention and "drifting." As the group progressed, patients began to spontaneously correct each other's instances of inattentiveness.
Results Pretreatment
Differences
To determine if there were pretreatment differences between experimental and control 1 A complete description of the assessment and treatment sessions can be obtained from the second author.
BARBARA E. FINCH AND CHARLES J. WALLACE Table 1 Mean Pretreatment and Posttreatment Ratings Group Experimental
Control
Variable
Pre
Post
Pre
LoudncBs Fluency Affect Content Eye contact. Latency Overall Wolpe-Lazarus questionnaire
1.97 1.91 1.71 1.72 1.73 4.63 1.81
4.28 4.25 3.82 4.43 3.82 2.01 4,12
2.04 1.87 1.83 1.60 1.61 4.54 1.74
2.25 1.88 1.93 1.82 1.82 4.59 1.94
13.25
19.50
13.38
13.63
Post
groups, separate split-plot factorial analyses of variance were conducted for each behavioral component using as the dependent variable the average rating of the two raters. These ratings were further averaged for the three trained spontaneous situations and for the two trained role-playing situations. The between-subjects variable of the analysis of variance was experimental versus control; the within-subjects variables were spontaneous versus role played and trained versus untrained. Results indicated no significant differences between the experimental and control groups across or in interaction with any of the other variables. The only differences were that fluency, F(l, 42) = 8.71, p < .01, and eye contact, F(l, 42) = 17.7, p < .01, were significantly better for roleplayed than for spontaneous situations. Posttreatment
Differences
Since the groups were equal on all pretreatment measures, separate split-plot factorial analyses of variance were again conducted for each behavioral component using the posttreatment ratings as the dependent variable. The independent variables were the same as above. Results indicated that the experimental group significantly exceeded the control group on each of the behavioral components, smallest F(l, 14) = 24.51, p < .01. This change was consistent across spontaneous, role-played, trained, and untrained situations. The mean preratings and postratings for each component are presented in Table 1.
Wolpe-Lazarus Questionnaire Assertiveness scores on the Wolpe-Lazarus questionnaire were analyzed using a split-plot factorial analysis of variance, with the between-subjects variable being experimental versus control and the within-subjects variable prescores versus postscores. The prepost differences were significant, F(l, 14) = 18.63, p < .01, as was the interaction, F(l, 14) = 15.27, p < .01. A test of simple main effects indicated that the experimental group was significantly more assertive during posttesting than during pretesting, but the pre to post differences were not significant for the control group. There were no differences between the two groups during pretesting. The mean Wolpe-Lazarus scores are presented in Table 1. Discussion The results clearly indicate the effectiveness of the treatment procedure. The interpersonal skills training group significantly exceeded the control group on all behavioral measures and on the self-report questionnaire. The behavioral differences appeared for both spontaneous and role-played and for both trained and untrained situations. Considering that the assessor had no contact with the patients other than during the assessment sessions, training generalized to interpersonal stimuli not immediately included during training and to situations not preceded by an instruction to role play. Of course, this is not the same as generalization to in vivo situations; nevertheless, it does represent a limited transfer of training to novel interpersonal stimuli. The differences that occurred between roleplayed and spontaneously enacted situations during the pretest suggest the importance of including spontaneous situations in the assessment process. Both the interpersonal skills training and control groups were significantly better in eye contact and fluency during the role-playing situations. Perhaps the instructions to role play act as a cue to rehearse a possible answer and to focus attention on the role model. Thus, performance in spontaneous
SUCCESSFUL INTERPERSONAL SKILLS TRAINING
situations may represent a more realistic appraisal of nonlaboratory performance. Anecdotal comments by the nursing staff and differences in discharge rates provide corroboration for the effectiveness of the training. Nursing staff spontaneously commented on both an unexpected improvement in grooming and on the increased interaction among interpersonal skills training group members. Perhaps the most significant observation is that of the eight control patients, only one was discharged, whereas five of the eight interpersonal skills group members were discharged and resumed life in the community within 3 months after treatment (p < .06, one-tailed, Fisher's exact test). Of these five, one group member entered a vocational training program, two obtained fulltime employment, one obtained part-time employment, and, although the fifth group member was not able to function at a job, he was able to maintain himself in the community. There are several components in the treatment procedure that may account for these successes. First, techniques were incorporated to train patients to focus their attention. Second, due to the greater interpersonal deficits evidenced by schizophrenics, interpersonal skills training began with basic social skills, such as good eye contact, introducing oneself with a firm handshake, etc. Third, to facilitate transfer of learning, between-session homework assignments were given to dyads, all of which were completed. Fourth, to further facilitate transfer of learning, patients were taught to become dispensers of reinforcement for each other. They were encouraged to give positive reinforcement in the form of attention and praise whenever a group member emitted an appropriate assertive response. Fifth, members were trained to give each other feedback on components of socially skilled behavior in order to better differentiate levels of performance. Goldsmith and McFall (1975) reported success in the development and evaluation of a social skills training program for psychiatric inpatients. One phase of program development involved identifying patientrelevant problem situations. They pointed out
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that the content of a program is as critical to its success as the training procedures it uses. In the present study, situations rated as most anxiety evoking by the patients were included in the behavioral test of interpersonal skills and were used as stimulus situations in interpersonal skills training. In addition, other stimulus situations that were used in training generally were not "canned" situations; they were situations submitted by the patients as relevant to their daily lives. Also, as the between-session dyadic assignments became more complex and patients were required to engage in social activities with each other, the patients suggested the activities and extended invitations to other members with similar interests. Goldsmith and McFall (197S) found that their social skills training program was as beneficial for the schizophrenic as for the neurotic and character disorder patient. They attribute this to their special training procedures that enabled each patient to participate satisfactorily in all of the assessment and training programs. Both the Goldsmith and McFall study and the present study took into account the behavioral problems of the psychotic inpatient when developing their assessment and training procedures. It may be important in future research to tease out the elements that contribute most to the treatment outcome. Perhaps a more economical training procedure can be developed that is maximally beneficial for the psychotic patient. References Bach, R. C., Lowry, D., & Moylan, J. J. Training state hospital patients to be appropriately assertive. Proceedings of the 80th Annual Convention of the American Psychological Association, 1972, 7, 383-384. (Summary) Booraem, C. D., & Flowers, J. V. Reduction of anxiety and personal space as a function of assertion training with severely disturbed neuropsychiatric inpatients. Psychological Reports, 1972, JO, 923-929. Eisler, R. M., Hersen, M., & Miller, P. M. Effects of modeling on components of assertive behavior. Journal of Behavior Therapy and Experimental Psychiatry, 1973, 4, 1-6. Eisler, R. M., Miller, P. M., & Hersen, M. Components of assertive behavior. Journal of Clinical Psychology, 1973, 20, 295-299.
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BARBARA E. FINCH AND CHARLES J. WALLACE
Fredrickson, L. W., Jenkins, J. O., Foy, D. W., & Eisler, R. M. Social-skills training to modify abusive verbal outbursts in adults. Journal of Applied Behavior Analysis, 1976, 9, 11V-127. Goldsmith, J. B., & McFall, R. M. Development and evaluation of an interpersonal skill-training program for psychiatric inpatients. Journal of Abnormal Psychology, 1975, 84, 51-58. Outride, M. E., Goldstein, A. P., & Hunter, G. F. The use of modeling and role playing to increase social interaction among asocial psychiatric patients. Journal of Consulting and Clinical Psychology, 1973, 40, 408-415. Hedquist, F. J., & Weinhold, B. K. Behavioral group counseling with socially anxious and unassertive college students. Journal of Counseling Psychology, 1970, 17, 237-242. Hersen, M., Eisler, R. M., & Miller, P. M. An experimental analysis of generalization in assertive training. Behaviour Research and Therapy, 1974, 12, 295-310. Kazdin, A. E. Effects of covert modeling and model-
ing reinforcement on assertive behavior. Journal of Abnormal Psychology, 1974, S3, 240-252. McFall, R. M., & Twentyman, C. T. Four experiments on the relative contribution of rehearsal, modeling, and coaching to assertion training. Journal of Abnormal Psychology, 1973, 81, 199218. Rathus, S. A. An experimental investigation of assertive training in a group setting. Journal of Behavior Therapy and Experimental Psychiatry, 1972, 3, 81-86. Rathus, S. A. Instigation of assertive behavior through videotape-mediated assertive models and directed practice. Behaviour Research and Therapy, 1973, 11, 57-61 Weinman, B., Gelbart, P., Wallace, M., & Post, M. Inducing assertive behavior in chronic schizophrenics: A comparison of socioenvironmental, desensitization, and relaxation therapies. Journal or Consulting and Clinical Psychology, 1972, 39, 246-252.
Received August 27, 1976 •
Successful Interpersonal Skills Training with Schizophrenic Inpatients Barbara E. Finch
Charles J. Wallace
University of California, Los Angeles
Camarillo-Neuropsychiatric Institute Research Program, Camarillo, California
This article studies the effectiveness of a set of techniques for increasing the interpersonal skills of male schizophrenic inpatients. Patients participated in 12 sessions of interpersonal skills training. The effectiveness of the procedure was evaluated with both self-report and behavioral measures. The behavioral measures involved ratings of patient performance during both role-played and spontaneously enacted interpersonal situations. Several of the situations were used in training, and others were used only during the assessment sessions. To promote extrasession generalization of behaviors, dyads were formed and were given homework assignments to complete. Compared to a control group matched on age, length of total hospitalization, and pretreatment level of skills, the interpersonal skills training group significantly improved on measures of loudness, fluency, affect, latency, eye contact, content, and self-reported assertiveness. These improvements were apparent across both role-played and spontaneously enacted situations and across trained and untrained situations. The objective of the present research was to evaluate the effectiveness of a set of techniques for increasing the interpersonal skills of male schizophrenic inpatients. The set of techniques included anxiety management training and behavioral rehearsal. Several techniques were also included to teach patients to focus their attention on relevant interpersonal stimuli. The problem of focusing attention has not been specifically treated in studies of assertion training with schizophrenic patients (Bach, Lowry, & Moylan, 1972; Eisler, Hersen, & Miller, 1973; Goldsmith & McFall, 197S; Gutride, Goldstein, & Hunter, 1973; Weinman, Gelbart, Wallace, & Post, 1972). In addition, dyads were formed and were given extrasession homework assignments to facilitate generalization of inThe conclusions of this study are not to be construed as representing the policy of the Regents of the University of California. The authors wish to thank Matthew W. Buttigliere and the Psychology Service of the Veterans Administration Hospital, Sepulveda, California, for their cooperation. Requests for reprints should be sent to Charles J. Wallace, Camarillo-Neuropsychiatric Institute Research Program, Box A, Camarillo, California 93010. 885
session behaviors. Several investigators have used extrasession assignments but not within a dyadic context (Booraem & Flowers, 1972; Hedquist & Weinhold, 1970; Rathus, 1972, 1973). A secondary objective was to use an evaluation procedure characterized by four elements—(a) interpersonal situations that were relevant to the patients; (b) the inclusion of both spontaneously enacted and role-playing situations; (c) an assessor who was someone other than the therapist; and (d) the inclusion of both trained and untrained situations. Studies of assertion training have reported equivocal findings about the extent to which training generalizes beyond its immediate context. Little if any generalization has been found from training to in vivo situations (Hersen, Eisler, & Miller, 1974; Kazdin, 1974; McFall & Twentyman, 1973). In marked contrast, generalization has frequently been found but only under two conditions: (a) The assessor and therapist have been the same person (Goldsmith & McFall, 1975), and (b) role playing has been used for both trained and untrained situations (Eisler, Hersen, & Miller, 1973; Fredrickson, Jenkins, Foy, & Eisler, 1976; McFall & Twentyman,
BARBARA E. FINCH AND CHARLES J. WALLACE
886
1973). Thus, the presence of either the same person or the role-playing instructions could account for the findings of generalization. The evaluation procedures of the present research used an assessor who was not associated with the training and situations, some of which were role played and some of which were spontaneously enacted. Method Subjects Subjects were male schizophrenic inpatients residing in the same living unit at the Veteran's Administration Hospital, Sepulveda, California. Nursing staff selected an initial pool of 29 patients who fulfilled the following criteria: diagnosis of schizophrenia, between 21 and 40 years of age, a minimum of 1 year of total hospitalization, clinical impression of withdrawal and nonassertive behavior, and the ability to respond to questions and instructions cooperatively. These 29 patients were administered the Wolpe-Lazarus Assertiveness Questionnaire and were interviewed by the two therapists who conducted the assertive training sessions. The 16 most nonassertive patients were selected for the study. They averaged 29 years of age and 3 years of total hospitalization. After matching on the basis of age, length of hospitalization, and self-reported assertiveness, patients were randomly assigned to either the treatment or control group, with each condition having 8 participants.
Assessment Measures In addition to the Wolpe-Lazarus Questionnaire, each patient participated in a pretreatment and posttreatment behavioral test of interpersonal skills administered by a female clinical psychology graduate student who was unaware of patients' assignments to experimental or control groups. The audiotaped behavioral test consisted of seven interpersonal situations, four of which were spontaneously enacted and three of which were role played. The four spontaneous situations were receiving a compliment, expressing an opinion, refusing an unreasonable request, and accepting thanks. The three role-played situations were initiating a conversation, expressing an apology, and extending a social invitation. These situations were chosen based on the answers of the 16 patients to an assessment instrument devised by the first author to determine those interpersonal situations in which the patients were most anxious. The instrument consisted of 28 items. The patients were taught to use the Subjective Units of Discomfort Scale (SUDS) and were instructed to record their SUDS level for each item. The 11 items that were rated as most anxiety evoking by the patients were used in the construction of the
behavioral test of assertiveness. There was an overlap on 6 items, with 4 items involving "expressing an opinion." These 6 items were combined to create two of the seven interpersonal situations. There was no overlap on the other 5 items, which were used to create the remaining five interpersonal situations. The format for the assessment sessions consisted of the assessor's greeting the patient and then spontaneously complimenting him on some aspect of his appearance and asking for an opinion about the office in which the assessment took place. The three role-played scenes were then introduced and completed, and the session ended with an unreasonable request to complete 4 hours worth of paperand-pencil tests followed by thanks for coming to the session. During the interview, if the patient gave no response, the assessor waited IS sec and continued with the interview. (On six pretest occasions patients gave no response to the situations of receiving a compliment and accepting thanks.) If the patient did not understand the instructions or evidenced confusion, the assessor repeated the instructions. (This occurred in four instances.) If the patient refused to role play a situation, the assessor continued with the next situation. (No such instances occurred.) The assessor reacted to the patient's responses in a neutral manner to prevent performance feedback. Differences between the pretreatment and posttreatment assessment sessions were restricted to variations in the content of expressing an opinion and refusing an unreasonable request. The content of expressing an opinion was changed to an opinion about the hospital, and the unreasonable request was changed to asking the patient to do 4 hours of work without pay. Participants in the assertive training group received training on all but two of the situations. One of the untrained situations was spontaneously enacted (expressing an opinion), and the other was role played (expressing an apology).
Response Definition The audio recordings of the behavioral test were rated in random order at the conclusion of the study by two graduate students in psychology. They completed their ratings independently of one another, and they were not informed of the purpose of the study or the groups to which the patients had been assigned. Five behavioral components of assertiveness were rated, with four of the five using the definitions and scales of Eisler, Miller, and Hersen (1Q73). The five components were (a) loudness of speech, (b) fluency of speech, (c) affect, (d) latency of response, and (e) content. The definition of content on the present study differed from that of Eisler, Miller, and Hersen (1973). All but latency were rated using S-point scales, with 1 indicating poor and 5 indicating very good; latency was measured with a stopwatch from the end of the assessor's prompt to the beginning of the
SUCCESSFUL INTERPERSONAL SKILLS TRAINING patient's response. Because of the unavailability of videotape equipment, the assessor rated the patient's eye contact in each situation on a S-point scale, with 1 indicating very poor eye contact and 5 indicating very good. This created a methodological problem, since there was no way to obtain interrater reliability for eye contact. Interrater reliabilities for loudness, fluency, affect, and content were calculated using Cohen's K. The six occasions for which there was no response, plus any response given that was inaudible or incomprehensible, was scored as 1 on the 5-point scale of each component. KS were loudness, .84; fluency, .92; affect, .92; content, .77. The Pearson product-moment correlation coefficient for latency was .98.
Treatment Interpersonal skills training sessions were conducted by two therapists (one male and one female) for 1 hour per session, three times per week for 4 consecutive weeks. The therapists were advanced PhD candidates in clinical psychology. The male was in his late 20s and the female in her mid-30s. Both had received supervised clinical training in working with psychiatric inpatients. Also, both were experienced in conducting social skills training groups with a variety of populations. Patients assigned to the control group participated in the normal hospital routine for the 4-week period. The goals of interpersonal skills training were to increase assertive behavior both in and out of the group and to decrease anxiety in interpersonal situations.1 Generally, the two therapists modeled appropriate and inappropriate behavior in a given situation requiring socially skilled behavior. Frequently, they exaggerated the inappropriate behavior. Patients then engaged in response practice, rehearsing their behavior in the situation with either one of the therapists or with each other, and reporting their SUDS level after each rehearsal. Patients were often asked to practice their behavior two or three times to achieve a more appropriate performance. However, to keep the sessions as positive as possible, the patients were not required to rehearse more than three times even if their performance was not appropriate or their SUDS level had not decreased. Rather, they were given an opportunity to practice the behaviors in later sessions, during which they could utilize an expanded repertoire of skilled behaviors. Patients received specific instructions and were coached to improve their interpersonal skills by focusing on the six components of skilled behavior. Patients were trained to give each other feedback on these components. For example, whenever a patient spoke in low volume, the group members prompted him by saying "I can't hear you." Between-session assignments were given at the end of each session. Patients were paired according to their own preference or, if no preference was expressed, at the discretion of the therapists. The
887
assignments proceeded in a graded manner from less to more difficult. During each session, patients discussed their successes and failures in completing the previous session assignments. When appropriate, patients role played the assignments and received feedback from the group. As the assignments became more complex and patients were required to engage in social activities with each other, the patients suggested the assignments and extended invitations to other members with similar interests. In view of the day-to-day variability of symptoms in schizophrenia, each patient was asked to attend each session even if he were having a "bad" day. The patient was asked to inform the therapist at the beginning of the session if he did not wish to participate. If, during the session, he changed his mind and wanted to participate, he was free to do so. Only one patient was absent from one session. All patients experienced inattentiveness. Several procedural variations were made to reduce the effects of such lapses. As a first step in focusing attention, patients were trained to establish good eye contact. In addition, situations requiring skilled responses were purposely varied, of short duration, and were often suggested by the patients themselves. All instructions were simple and to the point. To reduce the level of complexity, patients were taught appropriately skilled responses for specific situations rather then more generalized strategies. To further facilitate attending and group participation, each patient was responsible for giving performance feedback to the active participants. If patients were not attending when another group member spoke to them, they were trained to simply say "I'm sorry, I was not attending to what you were saying," rather than trying to respond with an inappropriate response. The therapists also trained patients to give short, precise responses relevant to the group topic. If a patient began to drift off the topic, he was interrupted and his attention was redirected. If a patient gave a response that was irrelevant to the group topic, he was told so and was asked to redirect his attention. Whenever a patient wanted to change the topic, he was trained to indicate his intention. This helped both the patient and the other group members to differentiate between an intentional shift of attention and "drifting." As the group progressed, patients began to spontaneously correct each other's instances of inattentiveness.
Results Pretreatment
Differences
To determine if there were pretreatment differences between experimental and control 1 A complete description of the assessment and treatment sessions can be obtained from the second author.
BARBARA E. FINCH AND CHARLES J. WALLACE Table 1 Mean Pretreatment and Posttreatment Ratings Group Experimental
Control
Variable
Pre
Post
Pre
LoudncBs Fluency Affect Content Eye contact. Latency Overall Wolpe-Lazarus questionnaire
1.97 1.91 1.71 1.72 1.73 4.63 1.81
4.28 4.25 3.82 4.43 3.82 2.01 4,12
2.04 1.87 1.83 1.60 1.61 4.54 1.74
2.25 1.88 1.93 1.82 1.82 4.59 1.94
13.25
19.50
13.38
13.63
Post
groups, separate split-plot factorial analyses of variance were conducted for each behavioral component using as the dependent variable the average rating of the two raters. These ratings were further averaged for the three trained spontaneous situations and for the two trained role-playing situations. The between-subjects variable of the analysis of variance was experimental versus control; the within-subjects variables were spontaneous versus role played and trained versus untrained. Results indicated no significant differences between the experimental and control groups across or in interaction with any of the other variables. The only differences were that fluency, F(l, 42) = 8.71, p < .01, and eye contact, F(l, 42) = 17.7, p < .01, were significantly better for roleplayed than for spontaneous situations. Posttreatment
Differences
Since the groups were equal on all pretreatment measures, separate split-plot factorial analyses of variance were again conducted for each behavioral component using the posttreatment ratings as the dependent variable. The independent variables were the same as above. Results indicated that the experimental group significantly exceeded the control group on each of the behavioral components, smallest F(l, 14) = 24.51, p < .01. This change was consistent across spontaneous, role-played, trained, and untrained situations. The mean preratings and postratings for each component are presented in Table 1.
Wolpe-Lazarus Questionnaire Assertiveness scores on the Wolpe-Lazarus questionnaire were analyzed using a split-plot factorial analysis of variance, with the between-subjects variable being experimental versus control and the within-subjects variable prescores versus postscores. The prepost differences were significant, F(l, 14) = 18.63, p < .01, as was the interaction, F(l, 14) = 15.27, p < .01. A test of simple main effects indicated that the experimental group was significantly more assertive during posttesting than during pretesting, but the pre to post differences were not significant for the control group. There were no differences between the two groups during pretesting. The mean Wolpe-Lazarus scores are presented in Table 1. Discussion The results clearly indicate the effectiveness of the treatment procedure. The interpersonal skills training group significantly exceeded the control group on all behavioral measures and on the self-report questionnaire. The behavioral differences appeared for both spontaneous and role-played and for both trained and untrained situations. Considering that the assessor had no contact with the patients other than during the assessment sessions, training generalized to interpersonal stimuli not immediately included during training and to situations not preceded by an instruction to role play. Of course, this is not the same as generalization to in vivo situations; nevertheless, it does represent a limited transfer of training to novel interpersonal stimuli. The differences that occurred between roleplayed and spontaneously enacted situations during the pretest suggest the importance of including spontaneous situations in the assessment process. Both the interpersonal skills training and control groups were significantly better in eye contact and fluency during the role-playing situations. Perhaps the instructions to role play act as a cue to rehearse a possible answer and to focus attention on the role model. Thus, performance in spontaneous
SUCCESSFUL INTERPERSONAL SKILLS TRAINING
situations may represent a more realistic appraisal of nonlaboratory performance. Anecdotal comments by the nursing staff and differences in discharge rates provide corroboration for the effectiveness of the training. Nursing staff spontaneously commented on both an unexpected improvement in grooming and on the increased interaction among interpersonal skills training group members. Perhaps the most significant observation is that of the eight control patients, only one was discharged, whereas five of the eight interpersonal skills group members were discharged and resumed life in the community within 3 months after treatment (p < .06, one-tailed, Fisher's exact test). Of these five, one group member entered a vocational training program, two obtained fulltime employment, one obtained part-time employment, and, although the fifth group member was not able to function at a job, he was able to maintain himself in the community. There are several components in the treatment procedure that may account for these successes. First, techniques were incorporated to train patients to focus their attention. Second, due to the greater interpersonal deficits evidenced by schizophrenics, interpersonal skills training began with basic social skills, such as good eye contact, introducing oneself with a firm handshake, etc. Third, to facilitate transfer of learning, between-session homework assignments were given to dyads, all of which were completed. Fourth, to further facilitate transfer of learning, patients were taught to become dispensers of reinforcement for each other. They were encouraged to give positive reinforcement in the form of attention and praise whenever a group member emitted an appropriate assertive response. Fifth, members were trained to give each other feedback on components of socially skilled behavior in order to better differentiate levels of performance. Goldsmith and McFall (1975) reported success in the development and evaluation of a social skills training program for psychiatric inpatients. One phase of program development involved identifying patientrelevant problem situations. They pointed out
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that the content of a program is as critical to its success as the training procedures it uses. In the present study, situations rated as most anxiety evoking by the patients were included in the behavioral test of interpersonal skills and were used as stimulus situations in interpersonal skills training. In addition, other stimulus situations that were used in training generally were not "canned" situations; they were situations submitted by the patients as relevant to their daily lives. Also, as the between-session dyadic assignments became more complex and patients were required to engage in social activities with each other, the patients suggested the activities and extended invitations to other members with similar interests. Goldsmith and McFall (197S) found that their social skills training program was as beneficial for the schizophrenic as for the neurotic and character disorder patient. They attribute this to their special training procedures that enabled each patient to participate satisfactorily in all of the assessment and training programs. Both the Goldsmith and McFall study and the present study took into account the behavioral problems of the psychotic inpatient when developing their assessment and training procedures. It may be important in future research to tease out the elements that contribute most to the treatment outcome. Perhaps a more economical training procedure can be developed that is maximally beneficial for the psychotic patient. References Bach, R. C., Lowry, D., & Moylan, J. J. Training state hospital patients to be appropriately assertive. Proceedings of the 80th Annual Convention of the American Psychological Association, 1972, 7, 383-384. (Summary) Booraem, C. D., & Flowers, J. V. Reduction of anxiety and personal space as a function of assertion training with severely disturbed neuropsychiatric inpatients. Psychological Reports, 1972, JO, 923-929. Eisler, R. M., Hersen, M., & Miller, P. M. Effects of modeling on components of assertive behavior. Journal of Behavior Therapy and Experimental Psychiatry, 1973, 4, 1-6. Eisler, R. M., Miller, P. M., & Hersen, M. Components of assertive behavior. Journal of Clinical Psychology, 1973, 20, 295-299.
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BARBARA E. FINCH AND CHARLES J. WALLACE
Fredrickson, L. W., Jenkins, J. O., Foy, D. W., & Eisler, R. M. Social-skills training to modify abusive verbal outbursts in adults. Journal of Applied Behavior Analysis, 1976, 9, 11V-127. Goldsmith, J. B., & McFall, R. M. Development and evaluation of an interpersonal skill-training program for psychiatric inpatients. Journal of Abnormal Psychology, 1975, 84, 51-58. Outride, M. E., Goldstein, A. P., & Hunter, G. F. The use of modeling and role playing to increase social interaction among asocial psychiatric patients. Journal of Consulting and Clinical Psychology, 1973, 40, 408-415. Hedquist, F. J., & Weinhold, B. K. Behavioral group counseling with socially anxious and unassertive college students. Journal of Counseling Psychology, 1970, 17, 237-242. Hersen, M., Eisler, R. M., & Miller, P. M. An experimental analysis of generalization in assertive training. Behaviour Research and Therapy, 1974, 12, 295-310. Kazdin, A. E. Effects of covert modeling and model-
ing reinforcement on assertive behavior. Journal of Abnormal Psychology, 1974, S3, 240-252. McFall, R. M., & Twentyman, C. T. Four experiments on the relative contribution of rehearsal, modeling, and coaching to assertion training. Journal of Abnormal Psychology, 1973, 81, 199218. Rathus, S. A. An experimental investigation of assertive training in a group setting. Journal of Behavior Therapy and Experimental Psychiatry, 1972, 3, 81-86. Rathus, S. A. Instigation of assertive behavior through videotape-mediated assertive models and directed practice. Behaviour Research and Therapy, 1973, 11, 57-61 Weinman, B., Gelbart, P., Wallace, M., & Post, M. Inducing assertive behavior in chronic schizophrenics: A comparison of socioenvironmental, desensitization, and relaxation therapies. Journal or Consulting and Clinical Psychology, 1972, 39, 246-252.
Received August 27, 1976 •
