Kim T. Mueser, PhD
Center for Psychiatric Rehabilitation and Departments of Occupational Therapy, Psychology, and Psychiatry, Boston University
People are by nature gregarious creatures. Most individuals live with others with whom they share household tasks, work with other people, engage in leisure and recreational activities with others, and share or strive for close, personally and physically intimate relationships with a select few. Humans’ unique capacity for communication and cooperative behavior has led to the development of complex social systems, mastery over the environment, and the ability to prolong and improve the quality of their lives.
Given the importance of communication to cooperative behavior, it is no surprise that interpersonal skills for expressing thoughts, feelings, needs, preferences, and desires, and for responding to others, play a key role in functioning across the broad range of social and other life domains. Problems in functioning naturally lead to unhappiness, frustration, and dissatisfaction. The ability to recognize when poor social skills in specific areas are contributing to a client’s problems or are limiting the individual’s potential for growth, and to teach more effective skills, is a critical competency for cognitive and behavioral therapists serving any clinical population.
The desire for more effective interactions with others can be used to motivate change and improve interpersonal skills. People often seek therapy because they are unhappy with their relationships. A person may lack friends and feel anxious in social situations, or he may yearn for closeness and intimacy with a romantic companion. People in close relationships may feel unhappy due to a variety of problems, such as conflict over money or child-rearing; lack of engagement or affection; difficulty expressing or responding to feelings or desires; or destructive interpersonal behaviors, such as verbal or physical abuse.
Problematic interpersonal skills can also contribute to issues at work, such as difficulties interacting with customers or responding to feedback from a supervisor. Limited interpersonal skills for situations such as shopping, requesting repairs from a landlord, or resolving a disagreement with a neighbor or roommate can also interfere with daily living and independence. When people lack adequate skills, the ability to obtain proper treatment and to manage physical and mental health conditions can also be jeopardized due to their avoidance of health care providers, the limited effectiveness of their interactions with providers, and their reduced ability to obtain social support for illness management.
A strong evidence base supports the effectiveness of interpersonal skills training for improving social and community functioning (Kurtz & Mueser, 2008; Lyman et al., 2014). Using these methods to improve interpersonal skills is especially important for clinical populations with poor psychosocial functioning, such as people with schizophrenia spectrum disorders, or for those with developmental disorders, such as autism spectrum disorders or an intellectual disability.
Interpersonal skillfulness can be defined as the smooth and seamless integration of specific behaviors that are necessary for effective communication and are critical to achieving social and instrumental goals (Liberman, DeRisi, & Mueser, 1989). Four different types of skills are commonly distinguished: nonverbal skills, paralinguistic features, verbal content, and interactive balance. Therapists usually teach complex interpersonal skills by focusing on specific components, which are built up gradually through extensive practice and feedback.
Nonverbal skills are behaviors other than speech, such as eye contact, facial expression, use of gestures, interpersonal proximity, and body orientation, that convey interest, feelings, and meaning during social interactions. Paralinguistic features are the vocal characteristics of speech, such as loudness, fluency, and affect expressed through tone and pitch (prosody). Verbal content is the appropriateness of what is said, including choice of words and phrasing, regardless of how it is said. Interactive balance pertains to the interplay of communication between two people, including the latency of time in responding to the partner’s utterance, the proportion of time spent talking, and the relevance and responsiveness to what the partner said.
Nonverbal and paralinguistic behaviors are sometimes inconsistent with the verbal content of a communication, which can undermine the person’s intent. For example, expressing a negative feeling in a quiet, faltering voice tone with an apologetic facial expression could be interpreted to mean that the person is not really upset, and that the concern can be ignored. Problems with interactive balance, such as long latencies of response due to reduced information-processing capacity in schizophrenia (Mueser, Bellack, Douglas, & Morrison, 1991), can interfere with the ebb and flow of a conversation and make it feel awkward and unrewarding to the partner. Conversely, frequently interrupting or responding too quickly can make the conversation feel rushed or hurried and can be interpreted to mean that the speaker isn’t really interested in what the other person has to say.
Effective social interactions also require social cognition skills, including the ability to accurately perceive and respond to relevant information in different social situations and to understand common “unwritten rules” of communication within a culture and setting (Augoustinos, Walker, & Donaghue, 2006). Important social information must be gleaned from the situational context in which the interaction takes place (e.g., setting, such as public, private, work, home; relationship to the individual, such as stranger, coworker, boss, friend, family member) and from the other person’s behavior. Accurately perceiving the conversational partner’s emotions from nonverbal paralinguistic cues, and understanding the person’s perspective (called theory of mind), are key social cognition skills that are frequently impaired in people with serious mental illness (Penn, Corrigan, Bentall, Racenstein, & Newman, 1997).
Aside from interpersonal skills, a variety of other factors can influence social functioning. Depression and associated beliefs of hopelessness, helplessness, and worthlessness often compromise social drive and reduce the effort people expend connecting with others. Just looking sad can make someone appear less attractive and less appealing to others (Mueser, Grau, Sussman, & Rosen, 1984), and living with a depressed person can induce depression (Coyne et al., 1987). Anxiety can lead to social avoidance or result in such preoccupation with worry that people are unable to use available skills. Anger or frustration can inhibit the ability of people to listen to the perspectives of others, leading to unrestrained expressions of negative feelings and increased interpersonal conflict.
Other psychiatric symptoms can also be problematic. Negative symptoms of schizophrenia, such as apathy and anhedonia, can reduce social drive when people expect that social interactions will require too much effort or will be unrewarding (Gard, Kring, Gard, Horan, & Green, 2007). Blunted affect (diminished facial and paralinguistic expressiveness) and alogia (poverty of speech) may make people appear less engaged during social interactions than they actually feel. Psychotic symptoms, such as hallucinations and delusions, can distract or preoccupy people, making them inattentive, unresponsive, or inappropriate during social interactions. Hypomania and mania can take a toll on an individual’s social relationships due to symptoms such as pressured speech, irritability, grandiosity, and increased involvement in activities with potentially harmful consequences (e.g., sexual liaisons, spending money). Substance use and dependency can have a major impact on social functioning, ranging from the disinhibiting effects of alcohol on aggression to the manipulation of close relationships in order to maintain a drug dependency.
The environment can also influence the ability of people to use interpersonal skills and to benefit from skills training. When there are limited opportunities for meaningful social activity, as is often the case for people institutionalized for extended periods of time (Wing & Brown, 1970), continued impaired social functioning is a foregone conclusion, regardless of the person’s interpersonal skills. Similarly, if efforts to use appropriate interpersonal skills, such as expressing feelings or preferences, are thwarted, as in the example of a depressed person living with a domineering partner, the depressed person may give up on trying to use those skills and consequently remain dissatisfied and unhappy in the relationship.
Interpersonal skills training methods date back to the 1950s and 1960s, and their clinical foundations are found in the early work of Salter (1949), Wolpe (1958), and Lazarus (1966), which focused on helping individuals overcome shyness and anxiety in close relationships. The theoretical origins of some of this work drew from previous research on operant conditioning, shaping, and social learning modeling. Skinner’s (1953) work on the use of positive reinforcement and shaping (see chapters 11 and 13) showed that it was possible to teach complex behaviors by breaking them down into simpler ones. Bandura’s (Bandura, Ross, & Ross, 1961) work on social modeling demonstrated the power of observing others in learning new social behaviors. The development of behavioral rehearsal in role-plays as a technique for facilitating the initial practice and refinement of skills further enhanced the benefits of combining social modeling and shaping to teach interpersonal skills. The systematic use of role-plays to first model skills, and then to engage individuals in behavioral rehearsals of those skills, followed by shaping feedback, resulted in an efficient method for teaching interpersonal skills under relatively controlled conditions. Clients could then practice those skills in naturally occurring situations.
In a nutshell, clinicians provide interpersonal skills training by first breaking a skill down into its constituent elements, reviewing them with the client, and then modeling the skill through role-play. After discussing the demonstration, the clinician engages the client in role-play to practice the skill, followed by positive and then corrective feedback about the client’s performance. The clinician then engages the client in another role-play to further improve his or her performance, followed by additional feedback to shape the skill. Several role-plays are conducted with the client, each followed by feedback to further hone the person’s skill. Finally, the client and clinician agree on a homework assignment for a skill the client will try in real-life situations.
Skills training can be provided in individual, group, family, or couples formats. In a group format the number of participants is usually limited to six to eight in order to permit enough time for everyone to practice the skills. Skills training in a group format is generally more efficient, and it provides access to multiple role models and the support and encouragement from other group members to try new skills.
Interpersonal skills training is sometimes the primary focus of the intervention and covers a preplanned curriculum of skills addressing a specific topic area. Such programs are typically provided in a group format, such as conversations skills for people with serious mental illness (Bellack, Mueser, Gingerich, & Agresta, 2004), substance-use refusal skills for people with an addiction (Monti, Kadden, Rohsenow, Cooney, & Abrams, 2002), or conflict management skills for people with anger or aggression problems (Taylor & Novaco, 2005). Sessions typically last 1 to 1.5 hours and are conducted 1 to 3 times per week, with programs lasting from 2 to 3 months to more than a year.
Interpersonal skills training may also be part of a multicomponent program, such as dialectical behavior therapy for people with borderline personality disorder (Linehan, 1993) or a program teaching self-management skills (see chapter 14). The illness management and recovery program (Mueser & Gingerich, 2011) provides skills training to help people with serious mental illness interact more effectively with treatment providers and to increase the social support for managing their illness. Family therapy programs designed to teach families how to help a loved one manage a mental illness such as schizophrenia or bipolar disorder often incorporate communication and problem solving to reduce family stress, in addition to psychoeducation about the nature of the psychiatric illness (Miklowitz, 2010; Mueser & Glynn, 1999).
Interpersonal skills may also be taught, as the need arises, during individual psychotherapy. In these circumstances, the skills training can range from as little as ten to fifteen minutes per session over several sessions to a more extended focus over a longer period of time.
Regardless of the treatment modality used or the prominence in treatment, interpersonal skills training uses a systematic method, which table 1 summarizes. Interpersonal skills training is defined most basically by the integrated use of four techniques, described below.
Table 1. Steps of common interpersonal skills
Table 2. General approach to interpersonal skills training
Some clients have difficulty improving their skills over successive role-plays from verbal feedback and instructions alone. In such cases, additional modeling by the clinician can be useful. Prior to demonstrating the skill again, the clinician can draw the client’s attention to specific component behaviors (e.g., voice loudness, a feeling statement), followed by the client trying the skill again in role-play. In some situations it can be helpful to highlight the importance of a particular component skill by modeling it in two successive role-plays, one showing poor performance and the other good performance of the component, followed by discussion and then a role-play in which the client tries the skill again.
The sine qua non of skills training is engaging the client in multiple role-plays of the same skill and situation within a session, combined with clinician modeling, feedback, and instructions to shape the person’s performance of the skill. The nature of the feedback provided for each role-play is critical to ensuring that the client’s learning experience is a positive one, and to making the skills training as effective as possible. In order to reinforce the person’s effort to learn new skills, and to maximize her willingness to try again, genuine, positive feedback should always be given immediately following the client’s role-play, before any negative feedback is given. Feedback should be behaviorally specific, draw attention to specific aspects of the skill done well, and begin with any component skills that improved from one role-play to the next.
The primary purpose of corrective feedback is to identify specific areas of the client’s performance that could be improved upon, and to then engage the person in another role-play focusing on changing those component skills. The choice of which areas to focus on changing is determined by the salience of the deficit and the ease with which the client may change it. For example, when the client’s voice volume is very low or his tone is soft or meek, then vocal loudness, firmness, or expressivity may be an initial priority. When a simple verbal-content step of a skill is omitted from a role-play, such as describing a feeling or not being specific about something, it is often easy for clients to add that step in during the next role-play.
The clinician needs to be able to shift to providing corrective feedback without negating the warm feelings engendered by the positive feedback. The clinician can accomplish this by being brief; by providing specific, matter-of-fact corrective feedback; and by moving quickly to suggesting, in a positive, upbeat manner, how the person could improve her performance in the next role-play. It is also helpful to avoid using “but” statements after giving positive feedback (e.g., “Nice job! You had a pleasant facial expression, and you were clear about what you were pleased with in that role-play, but you left out how it made you feel”).
Follow through on home assignments. First, after establishing the rationale for practicing skills outside of session, the clinician and client should collaboratively develop home assignments to ensure understanding, buy-in, and feasibility. Second, assignments should be specific and include plans, such as how many times the client will use the skill, with whom and in what situations the client will use the skill, and how the client will remember the assignment. Third, the clinician and client should anticipate possible obstacles to follow-through on home assignments and identify solutions to those obstacles.
Although home assignments are the standard method for facilitating the generalization of skills, additional strategies are necessary for clients with major cognitive or symptoms challenges. One strategy is to use in vivo practice trips designed to provide clients with a supportive experience when trying newly learned skills in natural settings (Glynn et al., 2002). Clinicians usually provide these trips when conducting skills training in a group format, and they involve regularly scheduled group excursions to community settings where clients can try their skills.
Another strategy for facilitating generalization is to involve indigenous supporters (Wallace & Tauber, 2004). Indigenous supporters are people close to clients who usually have a nonprofessional relationship with them (e.g., family member, close friend), although paraprofessional staff may serve for people who live in residential or long-term hospital settings. By virtue of their involvement with the client outside of sessions, these people are in an ideal position to prompt and reinforce the client’s use of skills. In order to involve such people, the clinician needs to reach out (with client permission) and engage indigenous supporters so they can understand the nature of the skills training program and support its goals. Then, in regular meetings, the clinician shares information with the supportive person about recently targeted skills, identifies suitable situations for using the skills, and obtains feedback about the client’s use of skills or the person’s efforts to prompt their use.
There are likely multiple processes of change involved in how interpersonal skills training improves social functioning. The dominant conceptualization that led to the skills training model was that effective social relationships require the integration of component social skills, and that the failure to learn these skills or the loss of them through disuse contributes to poor social functioning. Based on this conceptualization, the skills training approach was developed with the aim of increasing an individual’s repertoire of interpersonal skills, through shaping and extensive practice, and helping clients reach the point where they can perform skills automatically when desired. Although interpersonal skills are stable over time in the absence of intervention, poor social skills are associated with worse psychosocial functioning, and skills training increases both social skills and social functioning (Bellack, Morrison, Wixted, & Mueser, 1990; Kurtz & Mueser, 2008); it remains to be seen if improved social skills mediate gains in social functioning.
Some people who are capable of performing interpersonal skills but fail to use them when opportunities arise appear to benefit from interpersonal skills training. For example, some clients have low self-efficacy in their ability to have successful social interactions (Pratt, Mueser, Smith, & Lu, 2005) due to factors such as depression or anticipation of social defeat (Granholm, Holden, Link, McQuaid, & Jeste, 2013). The positive, validating nature of skills training, combined with the process of collaboratively agreeing to try skills in different situations, may encourage clients to use their skills, leading to positive social experiences that challenge their inaccurate beliefs. The cognitive behavioral social skills training program seeks to capitalize on both of these processes by combining skills training with cognitive behavioral therapy aimed at challenging inaccurate perceptions of the self and others, both of which interfere with pursuing social goals (Granholm, McQuaid, & Holden, 2016).
Other processes of change that may contribute to the effects of interpersonal skills training are exposure and greater emotional acceptance (see chapters 18 and 24). Role-plays elicit small amounts of discomfort in a safe environment, and repeated exposure to these situations as clients pursue their social goals may reduce their avoidance of social situations that likewise produce some discomfort.
Juan was a thirty-two-year-old Latino man with schizotypal personality disorder. His presenting concern was problems at work. Juan was a computer technology consultant who worked for a large firm, where he provided repairs and software updates for the laptops and personal computers of employees. He expressed concern that he often felt uncomfortable at work and was afraid of losing his job. The clinician spent two sessions with Juan obtaining background information and a more thorough work history before delving into specific situations at work that Juan found difficult to manage.
The clinician learned that Juan had difficulty interacting with employees whose computers he fixed, responding to feedback from his supervisor, and socializing with his other consultant coworkers. With Juan’s help, the clinician set up and engaged him in a series of role-plays to evaluate his interpersonal skills in these situations. This assessment indicated that Juan had difficulty engaging in small talk with employees when he came to fix their computers, as well as with coworkers during informal interactions or breaks. He also found it hard to respond to employees who were anxious about getting their computer fixed. Juan didn’t see why he had to interact so much with employees and coworkers, and he thought they should just leave him alone so he could do his work. Finally, Juan had difficulty listening to negative feedback from his supervisor and eliciting suggestions for improving his job performance.
To address these problems, the clinician identified several skills to teach Juan, initially using the same role-play situations developed for the assessment to teach the skills, and then developed additional role-play situations to facilitate further in-session practice. The clinician also spent time talking with Juan about the importance of informal (or “trivial”) social interactions at work and helped him conceptualize “interpersonal skills” in those situations as being similar to his technological expertise—just another part of his job. The clinician targeted improving conversational skills to reduce Juan’s discomfort interacting with coworkers and employees; these skills included identifying suitable topics for informal socializing (e.g., sports, the weather, local news), active listening to others, responding to the comments of others by providing his own perspective, and gracefully ending brief conversations.
To address situations in which employees were anxious about the repair of their computers, the clinician taught Juan to acknowledge their concerns by paraphrasing back to them their concerns, and to then provide reassurance that he would address their concerns with a timely repair. To improve Juan’s ability to respond to his supervisor’s feedback, the clinician taught him to reflect back what he heard his supervisor say to ensure he had proper understanding, to seek clarification regarding how he could improve his performance, and to request feedback following attempts to implement the desired changes.
Skills training was provided in twenty-four sessions over a six-month period. They spent most of each session role-playing newly learned skills, which were introduced every two or three sessions; developing plans for Juan to practice these skills at work; using role-plays to review practice assignments and conduct additional training as needed; and reviewing previously taught skills. Juan was readily engaged in the skills training, and over the course of treatment his interpersonal skills improved across the targeted situations, with notably less discomfort at work. Toward the end of treatment, Juan reported that he had been recommended for a raise because his supervisor had noted significant improvements in his work.
Effective interpersonal skills play an important role in the quality of close relationships, and they have a strong bearing on other life domains, such as work, school, or parenting, as well as self-care and independent living. Poor interpersonal skills in specific areas are a common factor contributing to distress and maladjustment, and they underlie many of the problems for which people seek psychotherapy. Teaching interpersonal skills is a core competency required of all practicing cognitive and behavioral clinicians. Clinicians can teach interpersonal skills by using a systematic training method that involves breaking down complex skills into simpler components or steps, modeling the skill in role-plays, engaging the client in role-plays to practice the skill, providing positive and corrective feedback after each role-play to hone client performance, and developing home assignments for clients to practice skills outside of session. Interpersonal skills training improves social functioning and community adjustment and can help with problems of vocational functioning, substance abuse, family and/or couples conflict, and collaboration with treatment providers.
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