Schizophrenia is a debilitating, chronic serious mental illness that impacts 1.1% of the adult US population (National Institute for the Mentally Handicapped [NIMH], 2016). Schizophrenia is characterized with a variety of symptoms including hallucinations; delusions; disorganized thinking, speech, and movements; abnormal motor behaviors such as bizarre body posture; and negative symptoms such as flat affect, social isolation, and lack of pleasure in activities. Prevalence rates of schizophrenia in Latinos are unclear as there is limited research examining the lifetime prevalence of the disorder in this population.

Lopez and colleagues (2012) noted that due to the paucity of epidemiological studies , there is a disparity in providing mental health services to Latinos with schizophrenia as it is unclear how prevalent the disorder exists among Latinos. A few studies found that cases of schizophrenia are low, primarily due to under-identifying or underreporting of psychotic disorder symptoms (e.g., Kendler, Gallagher, Abelson, & Kessler, 1996; Lewis-Fernández et al., 2009). One of the reasons for the low cases of schizophrenia may be attributed to cultural factors in which unusual experiences or behaviors are classified as cultural expressions or cultural idioms of distress rather than psychotic symptoms; clinicians and researchers do not categorize these experiences as symptoms of a psychotic disorder, and, therefore, individuals are misdiagnosed (e.g., Vega, Sribney, Miskimen, Escobar, & Aguilar-Gaxiola, 2006).

Despite the limited research on prevalence rates of schizophrenia in Latinos, there is a need to provide evidence-based psychosocial interventions to improve psychosocial functioning in Latinos with schizophrenia. Social skills training (SST) is an evidence-based practice developed to directly address interpersonal skills deficits to enhance social functioning in individuals with serious mental illness (SMI) (Bellack, Mueser, Gingerich, & Agresta, 2004). The 2009 Schizophrenia Patient Outcomes Research Team project, Substance Abuse and Mental Health Services Administration’s National Registry of Evidence-based Programs and Practices, and American Psychological Association’s Society of Clinical Psychology (Division 12) recommend social skills training for individuals diagnosed with schizophrenia (Dixon et al., 2010).

While there is abundant data to support the effectiveness of skills training as a psychosocial intervention (Dixon et al., 2010; Kurtz & Mueser, 2008), there are very few studies that have adapted and examined the effectiveness of the adapted versions of social skills training for use with Spanish-speaking Latinos with serious mental illness. One of those studies is by Kopelowicz, Zarate, Smith, Mintz, and Liberman (2003), which adapted skills training for use with Spanish-speaking Latinos with SMI by involving key family members to assist with skill practice outside of group. Participants in the adapted version of skills training reported improved functional outcomes (i.e., decreased symptoms and rehospitalizations, increased skill acquisition) compared to participants receiving routine care only.

Similar results were found in a randomly controlled study conducted in Mexico City; Valencia et al. (2010) compared an adapted version of skills training and family psychoeducation as additive treatments to routine care against routine care alone in individuals with SMI. Participants that received the adapted version of skills training and family psychoeducation reported fewer symptoms, number of relapses, and number of rehospitalizations as compared to participants who only received routine care. Finally, in a pilot study by Patterson et al. (2005), three clinics were randomly assigned to provide an adapted version of skills training or to provide a support group to older, Spanish-speaking Latinos with SMI. Results were mixed in that participants who received the adapted version of skills training reported improvement in daily functioning at 6 months post-intervention as compared to participants who were in the support group, but these improvements disappeared at 12 and 18 months post-intervention. No differences were found between the two types of groups on social functioning and symptomatology at 6, 12, and 18 months post-intervention. In sum, it appears that social skills training – whether modified or not – improves psychosocial functioning in Latinos with schizophrenia.

Treatment Plan Description

There are several models of social skills that one can follow. For this chapter, we will focus on the social skills training (SST) model by Bellack et al. (2004), and we encourage readers to become trained in the intervention and follow the SST manual to implement and maintain fidelity of this evidence-based intervention. SST groups teach a variety of interpersonal skills that improve communication by using basic behavioral principles such as role-playing, overlearning, shaping approaches, and providing positive feedback. It is a structured intervention in which each group session follows the same format: at-home practice of the previous social skills is reviewed; the purpose of the new social skill being taught is provided and discussed; steps of the new social skill are reviewed; group facilitators model the new social skill; group members review the modeled skill; group members role-play the new social skill with a group facilitator for a minimum of three times; after each role-play, group members are provided behaviorally specific positive feedback and suggestions for improvement by their peers and group facilitators; and at-home practice is assigned at the end of the group session.

SST groups may be open groups but closed groups are preferred although not required. There is an emphasis on behavioral rehearsal, hence a minimum of three role-plays for each group member during each SST group session. The level of skills training is geared and tailored to each group member. The social skills taught are linked to a group member’s recovery-oriented goal as a way to improve psychosocial functioning. SST is primarily conducted in a group format that includes up to ten group members and offered twice a week for 60–90 min. The duration of an SST group primarily varies with content and clinical setting; an SST group may be as short as a few group sessions – if offered in an in-patient unit with a short stay – or as long as 12 weeks (24 sessions if offered twice a week), if offered in an outpatient community clinic. Although it is recommended that there be two group facilitators, one group facilitator may lead the group. Each week a new social skill is presented and taught to group members; at-home practice of the social skill is assigned to generalize learning. Positive feedback is always applied while negative feedback and criticism are highly discouraged, as SST group facilitators should create a warm, positive, and fun learning group atmosphere.

For the purposes of this chapter, we provide the phases of the intervention to consider when implementing a social skills training (SST) group along with handouts of the four basic skills to provide to Spanish-speaking group members. The treatment plan consists of a preparatory phase, individual goal-setting session, designing the SST group curriculum, and implementation of an SST group. Below are descriptions of each phase.

Preparatory Phase : Before Starting a Social Skills Group

As with the creation of any type of group intervention, preparatory work and planning are key factors that increase the likelihood for the group’s success. Group facilitators should consider the following questions when developing their SST group with Latinos: Will the potential group members share cultural backgrounds? Do they have a common first language? Do potential group members live in the same community or group home? Do the group facilitators and group members share cultural and linguistic backgrounds? By considering these questions and understanding the makeup of the group and its group members, group facilitators will be better informed to develop an appropriate social skills curriculum and to enhance the group learning experience.

Another component in preparing for an SST group is the creation of recruitment materials such as flyers that can be posted in waiting rooms and distributed among the community or with mental health providers. Recruitment materials can assist leaders in finding appropriate candidates for the SST groups. The flyers may describe the purpose and goals of the SST group, contact information of the group facilitators, expected start date and location of the SST group, and other pertinent information that may help inform potential candidates or mental health providers about the SST group.

Other preparatory work includes securing a group room and supplies for the SST group. Group facilitators should secure a room that can comfortably accommodate up to ten (10) people seated in a “U” shape. There should be enough space for an easel and two chairs situated at the front of the group. Supplies for an SST group include an easel board with large notepad or whiteboard, different colored markers, and SST handouts of the social skill being taught for that session, which may also include the at-home practice, to provide to group members. Several materials must be prepared ahead of time for each SST group session. Group leaders must write the steps of each skill being practiced for that group session on the large notepad or whiteboard. Additionally, a separate large notepad detailing the group’s rules may be posted on a separate easel board or the group room wall.

SST groups also serve as socializing opportunities in which group members may practice their social skills taught in previous SST group sessions. Thus, group leaders may want to provide coffee, tea, freshwater, healthy snacks, and/or pastries before and after each group session. These opportunities will allow group members to interact with each other and to practice their social skills with each other in an informal basis.

Identification of Potential SST Group Members

SST groups have been implemented in various clinical settings such as group homes, community outpatient clinics, or inpatient units. Potential SST group members may be self-referred or be referred by a provider. Depending on the clinical setting, it may be useful to contact mental health providers and educate them about the model and purpose of a social skills training group, especially if they are unfamiliar with this evidence-based intervention. The mental health providers can serve as referral sources for the SST group and may also be of help to group members learning these skills. For example, the group member may request the assistance of their mental health provider to complete an at-home practice of a social skill learned in a SST group session. In the tool kit, the Social Skills Orientation for Professionals was translated into Spanish to help group facilitators reach out and orient Spanish-speaking providers to the SST model and group.

Additionally, word-of-mouth referrals between SST group members and potential group members are common, especially if the clinical setting has previously offered SST groups. Many alumni or current members of SST groups speak highly of their experience and, therefore, encourage others to join an SST group for a similar experience. For potential group members unfamiliar with the format or purpose of SST groups, there is a handout that can orient them to SST. In the tool kit, the Social Skills Orientation for Clients document was translated into Spanish to help reach out to Spanish-speaking consumers interested in learning more about SST.

Individual Goal-Setting Session (IGSS)

To ensure optimal participation and adherence to an SST group, group leader(s) must first meet with each potential group member for an individual goal-setting session (IGSS). The session lasts about 30 min and is completed before the start of an SST group curriculum. The IGSS serves as a formal orientation and introduction to SST group rules/expectations, and its structured format provides a setting for potential group members to ask questions about the SST group and its format and encourages buy-in to participate and engage in the SST group. It is recommended that group facilitators review the purpose and the format of the SST group before acquiring consent from potential group members to participate in the SST group, as it is a way to maintain “respeto” for the potential group member’s willingness to engage in an SST group. The document Social Skills Orientation for Clients may be used during IGSS to guide this discussion.

The central objective of the IGSS is helping potential group members identify and outline a recovery-oriented SMART (i.e., specific, measurable, achievable, realistic, and time-bound) goal for their SST group. Sometimes, potential group members will need assistance with defining a SMART goal that is recovery-oriented and related to SST. For example, a group member may initially state that his/her recovery-oriented SST goal is “to be happy at home.” In this case, the group facilitator will need to help the potential group member define a SMART goal, which could be the following: “being able to talk with my children twice a week without yelling or cursing at them.”

There will be times when group facilitators are not familiar with the potential group member. There are several assessment tools that group facilitators may use to help gather information about the potential group member’s historical and current psychosocial functioning, social skill abilities, and other pertinent information that may be useful for identifying SST recovery-oriented goals. The individual evaluation for goal-setting of SST and the social functioning interview are two assessment tools included in the tool kit and translated to Spanish for use by Spanish-speaking group facilitators. Either one or both assessments may be used during the IGSS with the main objective of collecting enough information to identify the potential group member’s SST recovery-oriented goal.

Overall, the IGSS incorporates the following elements:

  • Introduction of group leader(s) to potential group member.

  • Discuss the purpose of the SST group, plus the structured format and in-session activities (e.g., at-home practice review, skill introduction, review of the steps of the skill, modeling the skill, role-plays, positive feedback and suggestions for improvement, and assignment of at-home practice). The group facilitator emphasizes that all group members complete a minimum of three role-plays to practice the skill learned during that group session.

  • Discuss the group’s rules /expectations, plus the frequency of group sessions (e.g., twice a week for 12 sessions), group length of time (e.g., 60 min, 90 min), time and location of group, and limits of confidentiality.

  • If you do not already know the potential group member, ask the potential group member questions from the individual evaluation for goal setting of SST or the social functioning interview.

  • Review the components of recovery.

  • Identify and select a recovery-oriented SMART goal that is related to interpersonal skills. Describe the meaning of a SMART goal with potential group member.

Designing a Social Skills Training Curriculum

SST group facilitators tailor the social skills training curriculum so that specific social skills based on group member’s SST recovery-oriented goals are practiced during each session. Indeed, another main reason for completing IGSS with potential group members is to develop the SST curriculum for the cohort. After all potential group members complete their individual goal-setting session with group facilitators, a skills curriculum based on the collective SST recovery-oriented goals identified by the group members is developed. Depending on the number of SST group sessions being offered, the group facilitators will select social skills based on what the group members hope to achieve by participating in a SST group. For example, if there is an overlap of SST recovery-oriented goals – such as focusing on improving positive, respectful communication skills – among group members, then the skills selected to achieve those goals and included in an SST curriculum might include the following: “Expressing Positive Feelings,” “Responding to Complains,” “Disagreeing with Another’s Opinion Without Arguing,” “Compromise and Negotiate,” or “Asking for help.”

Only one skill should be practiced per session, as each group member will need to engage in a minimum number of three role-plays for the skill. An SST curriculum always includes the four basic skills (i.e., listening to others, making requests, expressing positive feelings, and expressing unpleasant feelings), as they are integral to every advanced social skill. For a list of additional and advanced social skills, please review the Bellack and colleagues SST manual (2004). The remaining SST group sessions will include social skills that would be of most help in achieving the recovery goals of the group members. A sample SST curriculum is shown in Table 13.1, which is an example of a tailored curriculum if the majority of SST recovery-oriented goals from group members were related to improving effective communication with others. Note that the “open sessions” are included to allow for participants to decide which skills they might want to practice a second time near the end of the group experience or for group facilitators to teach a new skill based on group member’s abilities or interests.

Table 13.1 Sample social skill training group curriculum
Full size table

Implementation of an SST Group

Now that an SST group curriculum is developed, group facilitators are almost ready to start their SST group. Prior to each SST group session, group facilitators should prepare for their group by completing the following tasks: make copies of the SST handouts to disseminate to all group members (see tool kit for Spanish versions of the basic social skills, which also includes an at-home practice section); review the new social skill with each other and select an appropriate scenario for modeling the new social skill; assign primary and secondary group leader roles, if there are two group facilitators; and prepare the group room by writing the steps of the skill on the flip board or dry-erase board and moving chairs in a semicircle facing the board. If beverages and snacks are offered before or after the group session, group facilitators also set out the food.

As noted before, to fully learn the intricacies of implementing an SST group with fidelity to the model, we encourage you to receive training in SST and use the SST manual by Bellack et al. (2004) as a guide. The manual describes the SST model and implementation of the model in detail, includes a section on troubleshooting problems that commonly arise in SST groups, provides numerous social skill handouts to use in the group, and contains a variety of resources to support the implementation of SST groups. It is our hope that this chapter provided a general overview of SST groups for those somewhat familiar with the model and provided resources for mental health providers working with Spanish-speaking consumers diagnosed with schizophrenia to improve psychosocial functioning.

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