Skills Training

Professional Intervention -6

Skills Training

Interventions aimed at correcting deficits in daily living skills such as poor personal hygiene, problems managing the home or dealing with finances are ubiquitous in rehabilitation practice, forming the basis for the daily work of nurses and occupational therapists in most if not all services. 

Many of these interventions involve simple advice, coaching and modeling. 

The more elaborate schemes draw on operant conditioning theory. 

In the most elaborate but now largely defunct approach, programmes were developed in which patients collected tangible rewards (‘tokens’) for performing desired behaviors. These were hugely complex programmes that were very difficult to implement and have proven untenable outside of much specialized settings. Furthermore, the skills acquired in the hospital or clinic often failed to generalize to daily living situations, and the latter had far more complexity than could be managed by a simple contingency-based reward system.

Skills training programme teaches variety of skills, including medication self-management, basic conversation skills, grooming and self-care, job-finding and interpersonal problem solving.

A broad range of interventions are employed, including videotaped demonstrations, role-play, exercises in real situations and homework practice. Numerous clinical trials have shown benefits over standard care in terms of improved conversational skills, assertiveness and medication management. These methods have been successfully employed with patients on acute wards, individuals with residual symptoms and individuals with severe and persistent illness. Not surprisingly, given the focus on specific social behaviors, social skills training have only modest impact on symptoms, relapse and hospitalization.

Cognitive impairment predicts poor rehabilitation outcomes. It is therefore an appealing thought that the remediation of the impairments of memory and executive function commonly seen in people with severe mental illnesses might facilitate skills training and contribute to improve social functioning.

Cognitive remediation seeks to retrain and improve processes of memory, attention and speed of information processing using a variety of ‘exercise’ programmes that were originally developed for neurological rehabilitation (after head injury or stroke, for example). In a study randomized individuals with chronic schizophrenia who had documented cognitive impairment to intensive cognitive remediation or to an ‘intensive occupational therapy’ control condition. Those receiving the intensive cognitive remediation attended for individual, daily, 1 h sessions that focused on executive functioning deficits (cognitive flexibility, working memory and planning). Some improvement in cognitive function was seen with both therapies, but a differential effect in favour of cognitive remediation was found for tests of cognitive flexibility and memory. Social functioning also tended to improve in those whose cognitive flexibility scores improved with treatment.

Negative symptoms, poor social skills and neuropsychological impairments have all been shown to impair performance at work. Medication side-effects can also be problematic. Sedation can be a particular difficulty, although this is less of an issue in contemporary practice, where high-dose regimens are avoided.