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Schizophrenia: Practical Strategies for Relapses & Reducing Symptoms
10 CEUs Schizophrenia: Practical Strategies for Relapses & Reducing Symptoms

Section 12
Cognitive Behavioral Social Skills Training for Schizophrenia

Question 12 | Test | Table of Contents | Schizophrenia CEU Courses
Social Worker CEU, Psychologist CE, Counselor CEU, & MFT CEU

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In the last section, we discussed anger due to schizophrenia.  Our discussion included three main topics.  These three topics were anger related to delusions, strategies for coping with anger, and problem solving strategies for clients with schizophrenia.

In this section, we will discuss cognitive difficulties. We will examine five basic cognitive skills.  Our discussion will focus on how schizophrenia affects each basic cognitive skill and ways to cope with the resulting cognitive difficulties. The five basic cognitive skills we will examine are attention and concentration, information processing speed, memory and learning, executive functions, and social cognition. As you listen to this track, you may consider evaluating my methods of coping with cognitive difficulties. You are encouraged to adapt these techniques for your own use, or integrate them directly into your sessions.  Also, you may consider playing this track for the caregiver of your client for implementation of these techniques at home.

5 Basic Cognitive Skills

♦ #1  Attention and Concentration
First, let’s look at attention and concentration. Joseph’s cognitive difficulty was due to sounds which made it difficult for him to maintain attention and concentration. Joseph, age 22, stated, "If there’s like a radio or TV on in the background, I can’t pay attention to anything. I can’t even concentrate on having a conversation." Are you treating a client like Joseph whose increased sensitivity to visual or auditory stimuli affects his concentration?  If so, perhaps the Attention Span Shape Up technique can help.

♦ "Attention Span Shape Up" Technique - 2 Steps
Joseph gradually began to increase the duration of his focused attention by using the Attention Span Shape Up technique. 

--a. First, I worked with Joseph to determine how long he could focus on a specific task.  Prior to becoming ill, Joseph liked to play computer games.  Therefore, I monitored Joseph as he attempted to play a simple game on my office computer.  Because Joseph’s concentration was affected by noise, I made sure that possible distractions, such as fans, air conditioners, or telephones, were eliminated. Joseph was able to maintain his focus for about three minutes before he lost track of what he was doing. 

--b. Second, I asked Joseph to work out a schedule of breaks with respect to his current attention span.  Joseph decided to play the computer game for two and a half minutes, take a short break, and then continue. In addition to determining the Joseph’s attention span and scheduling appropriate breaks, the final step in the Attention Span Shape Up technique was to gradually increase Joseph’s duration of focus. 

Over the next few weeks, I worked with Joseph to increase his attention span from three minutes to seven minutes.  During this time, I was careful not to overtax Joseph by increasing his attention goals to much.  Would you agree that higher expectations for clients like Joseph can lead to discouragement? 

♦ #2  Information Processing Speed
The second type of cognitive difficulty affects information processing speed. Clearly, schizophrenia can cause clients to require more time to solve problems and complete tasks, which in turn can cause social problems, such as being late, ineffective communication, or lack of preparedness. To help clients whose cognitive difficulties relate to information processing speed, I have found that practicing certain tasks can be productive. 

For example, if your client has trouble unlocking the front door when she comes home, perhaps she could label her keys and practice unlocking the door three times. When her time improves, she could start practicing unlocking the door five times. Would you agree that for client’s with decreased information processing speed, practice can help with certain tasks?

♦ #3  Memory and Learning
In addition to attention and concentration and information processing speed, the third basic cognitive skill that we will discuss is memory and learning. Much like the other two cognitive skills we have covered, difficulty with memory and learning is common in clients with schizophrenia for several reasons. Other cognitive difficulties can contribute to memory and learning problems. 

Also, psychotic symptoms can distract a client from learning. Long term memory problems can occur when the client fails to view particular information as personally relevant or important.  Think of your client who has memory and learning problems. Consider the benefits of identifying which other cognitive difficulties affect your client’s memory and learning abilities. Could identification of other cognitive difficulties help you resolve your client’s memory and learning problems?

♦ #4  Executive Functions
As you know, executive functions encompass a broad range of more complex cognitive skills critical to aspects of daily living.  Executive functions may include the ability to plan, to solve problems, to grasp concepts, and to reason logically. Generally speaking, cognitive difficulties regarding executive functions are the result of additional difficulties with the other cognitive skills, such as memory and concentration. 

Therefore, identifying other cognitive difficulties which affect executive functions can be a productive way to help a client begin to overcome cognitive difficulties. Problems in executive functions can lead to a variety of different life challenges, such as poor money management, inability to identify and take steps toward personal goals, and failure to anticipate certain consequences of certain actions. Could your client’s difficulty with executive functions be related to other cognitive difficulties?

♦ #5  Social Cognition
In addition to attention and concentration, information processing speed, memory and learning, and executive functions, the fifth basic cognitive skill commonly affected by schizophrenia is social cognition.  An example of a cognitive difficulty related to social cognition may be the client’s inability to read a person’s feelings through facial expression and voice tone.  Clients diagnosed with schizophrenia who have difficulty with social cognition may find it hard to perceive another person’s intentions or perspective.  Mick, a client of mine diagnosed with schizophrenia, had decreased social cognition. 

Mick, age 37, had difficulty understanding common social rules, and had trouble ‘taking a hint’ or ‘getting a clue’ in certain situations.  Mick stated, "I guess my problem is that I don’t know when to talk or what not to say.  Sometimes I’m unsure of what people mean when they tell me things."  Mick’s sister, Jean, clarified.  She stated, "If I tell Mick he smells bad, I’m not trying to put him down.  I’m just trying to let him know he needs to shower, but he doesn’t get it.  It’s like he can’t read between the lines.  And he’ll strike up a conversation with a perfect stranger like it’s no big deal.  Even if it’s obvious the stranger doesn’t want to talk, Mick will start jabbering about his bowel problems, or something ridiculous like that." 

Consider your client’s social behavior.  Is his or her social cognition affected by schizophrenia?  If so, then perhaps the coping strategies in the Social Awareness technique could benefit your client.

♦ "Name That EmotionTechnique, 3 Steps  
To help Mick with his social cognition, I implemented the Name That Emotion technique.  To implement this technique, I spoke with Mick’s sister Jean. 

Step 1: I stated, "First, consider using explicit feeling statements.  Instead of telling Mick that he smells bad, you could be direct by telling him he needs to shower and use deodorant." 

Step 2: The second step Jean used in the Name That Emotion technique, was discussing social norms with Mick. Jean stated, "Maybe it would help if I talked to Mick about what to say and what not to say when he talks to people he doesn’t know very well."  Jean matter-of-factly informed Mick about how much to reveal about himself to people he is meeting for the first time. 

Step 3: In addition to using explicit feeling statements and discussing social norms, the third step in the Name That Emotion technique was for Mick to practice recognizing facial expressions.  Jean implemented the third step by playing "Name That Emotion" with Mick.  First, Jean wrote down the names of different emotions, and put them into a hat. 

Then Jean and Mick took turns pulling out an emotion and displaying that emotion through facial expressions.  Mick and Jean attempted to guess the emotion the other person was displaying.  What about your Mick?  Could the Social Awareness technique help him increase his social cognition?

In this section, we have discussed cognitive difficulties.  We examined five basic cognitive skills.   The five basic cognitive skills we will examined are attention and concentration, information processing speed, memory and learning, executive functions, and social cognition. 

In the next section, we will discuss a model for helping clients understand the experience of enjoyment.  This discussion will be based on Bryant’s three stages of enjoyment.  These three stages of enjoyment are anticipation, savoring the experience, and reminiscing.

Schizophrenia in Children and Adolescents 

- Freed, C., Rando-Smelcer, C., McNabb, H. R., Stotts, J., and Wood, W. G. (2013). Schizophrenia in Children and Adolescents. TDMHSAS Best Practice Guidelines. p. 232-261.

Peer-Reviewed Journal Article References:
Barrios, M., Guilera, G., Hidalgo, M. D., Cheung, E. C. F., Chan, R. C. K., & Gómez-Benito, J. (2020). The most commonly used instruments in research on functioning in schizophrenia: What are they measuring? European Psychologist, 25(4), 283–292.

Granholm, E., Holden, J., Link, P. C., & McQuaid, J. R. (2014). Randomized clinical trial of cognitive behavioral social skills training for schizophrenia: Improvement in functioning and experiential negative symptoms. Journal of Consulting and Clinical Psychology, 82(6), 1173–1185.

Michel, L., Danion, J.-M., Grangé, D., & Sandner, G. (1998). Cognitive skill learning and schizophrenia: Implications for cognitive remediation. Neuropsychology, 12(4), 590–599.

Raskin, S. A., Maye, J., Rogers, A., Correll, D., Zamroziewicz, M., & Kurtz, M. (2014). Prospective memory in schizophrenia: Relationship to medication management skills, neurocognition, and symptoms in individuals with schizophrenia. Neuropsychology, 28(3), 359–365.

Riehle, M., & Lincoln, T. M. (2018). Investigating the social costs of schizophrenia: Facial expressions in dyadic interactions of people with and without schizophrenia. Journal of Abnormal Psychology, 127(2), 202–215.

Sum, M. Y., Chan, S. K. W., Tse, S., Bola, J. R., & Chen, E. Y. H. (2021). Internalized stigma as an independent predictor of employment status in patients with schizophrenia. Psychiatric Rehabilitation Journal, 44(3), 299–302.

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