Regular Research Article
Randomized Controlled Trial of Cognitive Behavioral Social Skills Training for Older Consumers With Schizophrenia: Defeatist Performance Attitudes and Functional Outcome

https://doi.org/10.1016/j.jagp.2012.10.014Get rights and content

Objectives

To determine whether Cognitive Behavioral Social Skills Training (CBSST) is an effective psychosocial intervention to improve functioning in older consumers with schizophrenia, and whether defeatist performance attitudes are associated with change in functioning in CBSST.

Design

An 18-month, single-blind, randomized controlled trial.

Setting

Outpatient clinic at a university-affiliated Veterans Affairs hospital.

Participants

Veteran and non-veteran consumers with schizophrenia or schizoaffective disorder (N = 79) age 45–78.

Interventions

CBSST was a 36-session, weekly group therapy that combined cognitive behavior therapy with social skills training and problem-solving training to improve functioning. The comparison intervention, goal-focused supportive contact (GFSC), was supportive group therapy focused on achieving functioning goals.

Measurements

Blind raters assessed functioning (primary outcome: Independent Living Skills Survey), CBSST skill mastery, positive and negative symptoms, depression, anxiety, defeatist attitudes, self-esteem, and life satisfaction.

Results

Functioning trajectories over time were significantly more positive in CBSST than in GFSC, especially for participants with more severe defeatist performance attitudes. Greater improvement in defeatist attitudes was also associated with better functioning in CBSST, but not GFSC. Both treatments showed comparable significant improvements in amotivation, depression, anxiety, positive self-esteem, and life satisfaction.

Conclusions

CBSST is an effective treatment to improve functioning in older consumers with schizophrenia, and both CBSST and other supportive goal-focused interventions can reduce symptom distress, increase motivation and self-esteem, and improve life satisfaction. Participants with more severe defeatist performance attitudes may benefit most from cognitive behavioral interventions that target functioning. Trial Registry: ClinicalTrials.Gov #NCT00237796 (http://clinicaltrials. gov/show/NCT00237796)

Section snippets

Design

All study procedures were approved by the institutional review board of the University of California, San Diego. After informed consent and baseline assessments, participants were randomly assigned by an independent statistician to one of two treatment conditions: CBSST or GFSC. Participants were then treated for 9 months and followed longitudinally for 9 months after treatment, with baseline, 4.5-month (mid-treatment), 9-month (end-of-treatment), 13.5-month (mid-follow-up) and 18-month

Sample

The flow of participants through the 18-month protocol is shown in Figure 1. After dropout and exclusion of participants for missing data, 81% of randomized participants were included in analyses. The groups did not differ significantly in dropout rates at any assessment point. The average age of the final sample at baseline was 55.0 (SD = 6.6; range = 46–78). The majority of the participants were Caucasian (66%), male (55%), unmarried (95%), with a high school education (M years of education =

Discussion

The results indicated that CBSST is an effective psychosocial intervention to improve functioning in older consumers with schizophrenia. Functioning trajectories over time improved in CBSST but declined in GFSC. These findings replicated the results of our prior trial6, 14 and showed that the benefits of CBSST cannot be attributed to nonspecific therapist factors, alone. Self-reported everyday functioning improved to a greater extent in CBSST than in GFSC, suggesting specific CBT and SST

References (38)

  • S.J. Bartels et al.

    Psychosocial rehabilitation and quality of life for older adults with serious mental illness: recent findings and future research directions

    Curr Opin Psychiatry

    (2009)
  • E. Granholm et al.

    A randomized, controlled trial of cognitive behavioral social skills training for middle-aged and older outpatients with chronic schizophrenia

    Am J Psychiatry

    (2005)
  • S.I. Pratt et al.

    Medication nonadherence in older people with serious mental illness: prevalence and correlates

    Psychiatr Rehabil J

    (2006)
  • T. Wykes et al.

    Cognitive behavior therapy for schizophrenia: effect sizes, clinical models, and methodological rigor

    Schizophr Bull

    (2008)
  • M.K. Benton et al.

    Social skills training with schizophrenics: a meta-analytic evaluation

    J Consult Clin Psychol

    (1990)
  • M.M. Kurtz et al.

    A meta-analysis of controlled research on social skills training for schizophrenia

    J Consult Clin Psychol

    (2008)
  • E. Granholm et al.

    Group cognitive-behavioral social skills training for older outpatients with chronic schizophrenia

    J Cog Psychother Int Quart

    (2004)
  • J.R. McQuaid et al.

    Development of an integrated cognitive-behavioral and social skills training intervention for older patients with schizophrenia

    J Psychother Pract Res

    (2000)
  • E. Granholm et al.

    Randomized controlled trial of cognitive behavioral social skills training for older people with schizophrenia: 12-month follow-up

    J Clin Psychiatry

    (2007)
  • Cited by (101)

    • Mental Health and Treatment Considerations for Older Adults

      2022, Comprehensive Clinical Psychology, Second Edition
    • Reducing negative symptoms in schizophrenia: Feasibility and acceptability of a combined cognitive-behavioral social skills training and compensatory cognitive training intervention

      2021, Psychiatry Research
      Citation Excerpt :

      With regard to community-based mental health settings specifically, Carrion and colleagues (1993) found that forgetting appointments, needing to work, and transportation-related difficulties most impacted retention rates in a study of outpatients with schizophrenia. It is possible that suboptimal public transportation also contributed to our dropout rate, given evidence for better session attendance in prior CBSST trials when transportation was provided (Granholm et al., 2013), compared to when it was not (Granholm et al., 2014). Overall, our rates of dropout and attendance align with high rates of nonadherence (17-64%) found in general community mental health clinic populations, including patients with psychosis (Cullen 2018; Dworkin et al., 1986; Üçok et al., 2007).

    • Impact of changes in social anxiety on social functioning and quality of life in outpatients with schizophrenia: A naturalistic longitudinal study

      2020, Journal of Psychiatric Research
      Citation Excerpt :

      Training for perspective-taking based on the relational frame theory (RFT) could be promising in individuals with social-cognitive dysfunctions, such as schizophrenia (Hendriks et al., 2016). DPB, which contributes to social functioning and QOL in patients with schizophrenia and shares characteristics with social anxiety, as mentioned above, has recently become a treatment target to improve functional outcome (Campellone et al., 2016; Granholm et al., 2013, 2014; Horan et al., 2010). Psychosocial treatments that include not only DPB, but also social anxiety as treatment targets may be more effective and lead to community participation (Thomas et al., 2017).

    View all citing articles on Scopus
    View full text