Looking at Schizophrenic Disorder and other forms of severe mental illness through the SSLD lens takes us beyond the confines of a medical-disease paradigm, even though we recognize the neuro-physiological correlates and the bio-medical realities associated with the experience. The SSLD analysis focuses on needs and functions of the individual, and thus offers a good alternative to the language of symptoms. Following social cognitive theory formulations, the SSLD approach considers human action or behavior as motivated or goal directed. They are, therefore, serving certain function, albeit ineffectively. When I made the claim that individual behaviors are mostly functional, a psychiatrist friend of mine challenged my position and asked how could symptoms such as delusional thoughts be functional. The following analysis was what I offered.
We never experience another person's delusional thoughts directly. We only experience a person's report of thoughts that we consider delusional. I took this from my earlier lectures on the psychoanalytic interpretation of dreams. I used to tell my audience that we could never interpret dreams, we could only interpret dream narratives. The patient's narratives are all we have got.
When delusional thoughts are reported, the person is at least doing a few things: (1) verbalization or some form of symbolic articulation/expression such as writing or drawing, (2) (re)construction of reality; and (3) interpersonal communication.
All these are agentive actions, and can be functional in a number of possible ways. Verbalization, even in the form of self-directed monologue, serves to discharge negative emotions, and can potentially reduce anxiety. Verbalization and other forms of symbolic expression put the person in an agentive or subject position. The person thus increases control over his or her experience. Secondly, the creation of a delusional system represents a cognitive attempt to construct or reconstruct reality. Delusional thoughts are often created around an issue or a theme that is of emotional significance to the individual. It can be fear of injury or abandonment, horror related to chaos or insecurity, or an attempt to protect aspects of self or deeply valued elements of one's life-world. Delusions can often be viewed as a desperate attempt to make sense of a psychologically overwhelming situation, or an attempt to protect oneself from threat and damage. Finally, most individuals experiencing delusional thoughts would share them with others, very often knowingly to mental health professionals. Such interpersonal sharing should at least be seen as moves to gain understanding or to seek help, although they are usually ineffective in bringing about the desired outcome. Here is where SSLD fits in.
A SSLD analysis pays attention to the needs behind functional behaviors. The person reporting delusional thoughts have the need to cope with overwhelming anxiety which may be associated with perceived impending chaos. There is the need to make sense of what is happening within one's life-world both externally and internally. One needs to protect one's sense of order, including one's sense of self and identity. There is also the need to seek interpersonal connection, understanding, and help. The only problem is that talking about delusional thoughts is usually not a very effective strategy.
In SSLD, the question is what alternative strategies can be more effective.
SSLD intervention starts with engaging with the individual. The practitioner will communicate understanding of the client's difficulty and suffering. Clinical engagement and therapeutic alliance are more readily established if we recognize the client's needs and can relate empathically to the client's emotional difficulties. Without agreeing with the facticity of the content of the delusional thought, the SSLD practitioner recognizes the underlying needs and attending emotional investment. Instead of ridiculing or disputing, the SSLD practitioner works with the client to develop more effective strategies and skills for attaining goals that correspond to the client's needs. In this case, what need to be learned and developed are strategies and skills that will help protect the individual from threats, real or imagined. The individual may need to develop more effective access to information, and increase the extent of control over external environment and internal processes. Anxiety reduction or management strategies are probable part of the package. Alternative strategies to cope with confusing or threatening aspects of reality have to be developed. When the client's level of trust in the practitioner increases, with associated improvement in terms of self-efficacy, it may be time to learn appropriate skills for articulating and expressing negative emotions such as fear, confusion, insecurity, and rage. Finally, people who report delusional thoughts more often than not isolated or withdrawn, and at some point they will have to learn, some for the first time in their lives, to build connection and affiliation with others, achieving positive attachment and even intimacy.
Such functional analysis of human experience and action seen as psychotic within traditional psychiatric thinking refocuses our attention on the client's needs and challenges us to come up with effective strategies and skills for them to learn and master, leading to attainment of personal goal through appropriate means. In practice, many individuals who have been through the mental health service systems, including those who have received pharmacotherapy, need to learn to perform personal and social functions in order to attain what they need within their social contexts, through means that are more readily understood and accepted by people around them.
SSLD procedures start with translating the client's "problem" into an assessment of needs and functions, and then into goals to be attained. This problem translation exercise guides the specific strategies and skills to be learned and developed. The SSLD process is systematic and incremental. Complex strategies and skills are broken down into small, manageable incremental steps. Learning initially takes place within the safe environment of the practitioner's office, but clients are always supported to practice what they have learned in their real life, ensuring transfer of learning and sustainable therapeutic gain.
Finally, it should be added that SSLD procedures usually work better in a group context. The group also provides emotional support and helpful feedback, while members can facilitate each other's learning. SSLD groups can also evolve into highly effective self-help groups, and members can learn skills related to group functioning, including coordination, organization and leadership skills.
The SSLD model is premised on multiple contingency thinking, which seeks to respond to particular individual needs and circumstances. The following list does not exhaust all the possible strategies and skills to be learned. Neither are all the components applicable to every person. It provides an idea of the areas covered, and the incremental steps to be taken in some of the areas.
- Daily routine; taking care of basic needs
- Self-recording and assessment of activities, events, and subjective experience (e.g., behavioral and mood diaries)
- Internal exploration: understanding own needs, fears, and aspirations
- Emotional regulation
- Stress management
- Information on symptoms and treatment, including medication and side effects
- Occupation: learning to engage in pleasurable/rewarding activities
- Engagement and initiating contact
- Listening skills
- Disclosure, sharing, and reciprocity
- Boundary recognition and management
- Goal attainment and instrumental skills (including help seeking)
- Interpreting social situations
- Appropriate role social performance
- Managing demanding situations (e.g., job interview, conflict, intimacy)
- Understanding other people's experience, developing empathy
- Assessment of other people's needs
- Specific care-giving behavior: incremental learning from emotional support to instrumental problem solving
Organizational and leadership skills
- From passive to active participation: appropriate group participation skills
- Assuming group tasks: incremental progress through simple tasks such as preparing food, to calling up members, to assuming responsibility for a part of the program
- Program planning and event coordination
- Group maintenance function
- Leadership skills development
More advanced modules focus on specific aspects of interpersonal and social functioning, such as dating and developing intimacy, persuasion, marketing, conflict resolution, responsive-assertiveness, handling guilt-tripping, and so on. There are also SSLD applications designed for specific situations such as couple relationship, parent-child interaction and cross-cultural communication.
In 1979, I had my first clinical experience with social skills training, mainly following the model developed by Michael Argyle and his colleagues1. As a clinical psychologist at the Yang Memorial Social Service Centre in Hong Kong, I was seeing a number of clients with long histories of schizophrenic disorder, averaging 10 years. Most of them had early onset starting in their adolescent years, and all of them had been hospitalized, some for extended periods of time.
In the 1970s mental health services in Hong Kong were very different than what they are today. When I completed my clinical psychology training, which was modeled after the British and accredited by the British Psychological Society, there were less than 20 clinical psychologists for the entire population of 6 million. Psychotherapy was not readily available, and other forms of psychosocial services were very inadequate. Medication was the major treatment, with chlorpromazine type drugs such as Largactil popularly prescribed, and electro-convulsive therapy (ECT) often performed.
I initially grouped a few patients together, and help them learn and develop social skills, while at the same time running educational programs to increase understanding of schizophrenic disorder and treatment among themselves and their family. When these members became more active socially, and their self-efficacy improved, I started coaching them to learn to run programs for themselves, as well as providing care and support for each other. I was also following a self-programming group approach that I had learned as a youth volunteer years ago. The members soon learn to plan and run their own programs, mainly for recreation and socializing.
The group continued for over ten years, years after I left the job as their clinical psychologists in 1984. From the colleagues who followed up with them, I learned that they were performing exceptional mutual-help function, assisting each other to deal with major crisis and threats of relapse. This positive experience significantly enhanced my interest and confidence in social skills training, which subsequently led to the development of SSLD.
In the years that followed, I have maintained my interest in helping individuals with schizophrenic disorder through learning and developing more effective social and interpersonal skills. Apart from individual psychotherapy, I also worked through group consultation and training. After coming to Canada in 1989, I have run programs based on social skills training for community organizations such as the Hong Fook Mental Health Association. This work has continued after the creation of the SSLD model in 2005. More recent activities involving application of the SSLD model to schizophrenic disorder include grand round presentation at the Mt. Sinai Hospital Department of Psychiatry in Toronto, training workshop and case conference with their Assertive Community Treatment (ACT) Team. In the last few years, I have introduced the SSLD approach to China. A special training program for the psychiatrists at the Tsinghua University Medical School in Beijing focusing on schizophrenic disorder has been developed.
1.Argyle, M. (1972). The psychology of interpersonal behaviour (2nd ed.). Middlesex: Penguin. Trower, P., Bryant, B., and Argyle, M. (1978). Social skills and mental health. London: Methuen.