Intervention Summary

Cognitive Behavioral Social Skills Training

Cognitive Behavioral Social Skills Training (CBSST) is a psychosocial rehabilitation intervention designed to help middle-aged and older outpatients with schizophrenia and other forms of serious mental illness achieve their functioning goals related to living, learning, working, and socializing in their community of choice. The intervention integrates two components:

Cognitive behavioral therapy (CBT). Through the CBT component, consumers learn thought-challenging skills to help them correct inaccurate dysfunctional beliefs, including defeatist expectancies ("it won't be fun"), low self-efficacy ("I always fail"), anomalous beliefs ("spirits will harm me"), and ageist beliefs (e.g., "I'm too old to learn"), that interfere with goal-directed activities. This component includes compensatory aids to address the cognitive impairment associated with both aging and schizophrenia.
Social skills training (SST). Through the SST component, consumers learn communication skills and problem-solving skills, with a focus on using these skills to achieve their functioning goals. This component includes symptom management, communication role-play (including age-relevant situations, such as talking to a doctor about eyeglasses), and the use of social skills in problem solving (including age-specific scenarios, such as finding transportation and coping with hearing and vision problems).

CBSST is delivered by therapists primarily through 2-hour group psychotherapy sessions that occur once a week over 24-36 weeks, but the intervention also can be delivered through individual sessions or a combination of individual and group sessions. The intervention consists of three modules: cognitive skills, social skills, and problem-solving skills. The sequence of modules is delivered twice to compensate for cognitive impairment experienced by consumers and to provide them with a greater opportunity to practice and master skills; module repetition also improves self-efficacy for more experienced consumers who help newcomers.

CBSST should be delivered by mental health therapists who have experience working with the intervention's target population. A therapist training workshop and follow-up consultation are recommended to ensure that CBSST is delivered with the highest possible fidelity.

Descriptive Information

Areas of Interest	Mental health treatment
Outcomes	1: Psychosocial functioning 2: Acquisition of communication, problem-solving, and thought-challenging skills 3: Severity of symptoms 1: Psychosocial functioning 2: Symptom severity 3: Cognitive insight 4: Acquisition of communication, problem-solving, and thought-challenging skills
Outcome Categories	Mental health Quality of life Social functioning
Ages	26-55 (Adult) 55+ (Older adult)
Genders	Male Female
Races/Ethnicities	White Race/ethnicity unspecified
Settings	Residential Outpatient
Geographic Locations	Urban Suburban
Implementation History	CBSST was developed, and since then, it has been evaluated in three outcome studies in San Diego, California. CBSST has been implemented at 45 sites within the United States and internationally in Australia, Canada, Finland, France, Iceland, the Netherlands, Nigeria, Switzerland, and the United Kingdom. More than 1,000 consumers have received the intervention.
NIH Funding/CER Studies	Partially/fully funded by National Institutes of Health: Yes Evaluated in comparative effectiveness research studies: Yes
Adaptations	No population- or culture-specific adaptations of the intervention were identified by the developer.
Adverse Effects	No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories	IOM prevention categories are not applicable.

Quality of Research

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Granholm, E., Holden, J., Link, P. C., McQuaid, J. R., & Jeste, D. V. (in press). Randomized controlled trial of Cognitive Behavioral Social Skills Training for older consumers with schizophrenia: Defeatist performance attitudes and functional outcome. American Journal of Geriatric Psychiatry.

Supplementary Materials

Implementation of CBSST

Psychometric information for CBSST

Outcomes

Outcome 1: Psychosocial functioning
Description of Measures	Psychosocial functioning was assessed using the Independent Living Skills Survey (ILSS), a 51-item self-report measure of 10 domains of functioning (e.g., hygiene, cooking, cleaning, health maintenance, money management, socialization, leisure activities, work, school). The ILSS was administered in an interview format to participants, who responded to each item by indicating whether it was performed (score of 1) or not performed (score of 0) or by selecting "not able to demonstrate" (e.g., for food preparation items when meals were provided by assisted living staff). The average score of available items was computed for each domain, and the average score (ranging from 0 to 1) of available domains was used in analyses. Domain scores were not computed if more than half of the items were missing or had "not able to demonstrate" as the response. If a participant's domain scores could not be computed for at least 7 of the 10 domains, those scores were omitted from analyses.
Key Findings	A study was conducted with veterans and nonveterans with schizophrenia or schizoaffective disorder who were recruited from an outpatient clinic at a university-affiliated Veterans Affairs (VA) hospital. Participants were randomly assigned to the intervention group, which received CBSST, or the comparison group, which received supportive group therapy focused on helping participants achieve functioning goals. Data were collected at baseline, at the midtreatment point (4.5 months), and at the end of treatment (9 months). Results indicated that over time, participants in the intervention group had a greater increase in psychosocial functioning relative to those in the comparison group (p = .021).
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.6 (0.0-4.0 scale)

Outcome 2: Acquisition of communication, problem-solving, and thought-challenging skills
Description of Measures	The acquisition of communication, problem-solving, and thought-challenging skills was assessed using a version of the Comprehensive Module Test (CMT) that was adapted for use in this study. The adapted version of the CMT assessed skills as taught through CBSST.
Key Findings	A study was conducted with veterans and nonveterans with schizophrenia or schizoaffective disorder who were recruited from an outpatient clinic at a university-affiliated VA hospital. Participants were randomly assigned to the intervention group, which received CBSST, or the comparison group, which received supportive group therapy focused on helping participants achieve functioning goals. Data were collected at baseline, at the midtreatment point (4.5 months), and at the end of treatment (9 months). Results indicated that over time, participants in the intervention group had a greater increase in the acquisition of communication, problem-solving, and thought-challenging skills relative to those in the comparison group (p = .001).
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.6 (0.0-4.0 scale)

Outcome 3: Severity of symptoms
Description of Measures	Severity of symptoms was assessed using the following measures: Scale for the Assessment of Negative Symptoms (SANS). SANS assesses five symptom complexes in patients with schizophrenia: affective flattening (little or no emotional expression), alogia (impoverished thinking), avolition (lack of motivation)-apathy, anhedonia (inability to experience pleasure)-asociality, and disturbance of attention. On the basis of factor analytic studies of the SANS, two negative symptom factors were derived: Diminished Expression, defined as the average of affective flattening and alogia global ratings, and Diminished Motivation, defined as the average of avolition-apathy and anhedonia-asociality global ratings. (The disturbance of attention symptom complex was not included in analyses.) Beck Depression Inventory, second edition (BDI-II). The BDI-II is a 21-item self-report instrument that assesses the severity of depression symptoms. Each item includes a list of four statements about a particular symptom of depression, and respondents select the statement that best reflects their feelings or behavior. Beck Anxiety Inventory (BAI). The BAI is a 21-item scale that assesses the severity of self-reported anxiety. Using a 4-point scale ranging from 0 ("not at all") to 3 ("severely; I could barely stand it"), respondents rate each descriptive statement of anxiety symptoms.
Key Findings	A study was conducted with veterans and nonveterans with schizophrenia or schizoaffective disorder who were recruited from an outpatient clinic at a university-affiliated VA hospital. Participants were randomly assigned to the intervention group, which received CBSST, or the comparison group, which received supportive group therapy focused on helping participants achieve functioning goals. Data were collected at baseline, at the midtreatment point (4.5 months), and at the end of treatment (9 months). Results indicated that over time, participants in the intervention and comparison groups had improvements in negative symptoms (Diminished Motivation symptom factor of the SANS; p = .005), depression (BDI-II; p = .01), and anxiety (BAI; p = .007); however, there were no significant differences between groups in regard to these improvements.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.8 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study	Age	Gender	Race/Ethnicity
Study 1	26-55 (Adult) 55+ (Older adult)	55% Male 45% Female	66% White 34% Race/ethnicity unspecified

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

Reliability of measures
Validity of measures
Intervention fidelity
Missing data and attrition
Potential confounding variables
Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome	Reliability of Measures	Validity of Measures	Fidelity	Missing Data/Attrition	Confounding Variables	Data Analysis	Overall Rating
1: Psychosocial functioning	3.6	3.5	4.0	3.3	3.4	4.0	3.6
2: Acquisition of communication, problem-solving, and thought-challenging skills	3.5	3.4	4.0	3.3	3.4	4.0	3.6
3: Severity of symptoms	4.0	4.0	4.0	3.3	3.4	4.0	3.8

Study Strengths

The outcome measures used in the study are well known and have moderate to strong psychometric properties. The study employed a formal assessment process to determine the extent to which both CBSST and the comparison intervention were implemented with fidelity. All therapy sessions were videotaped, and 24 randomly selected sessions were rated by experts using the Cognitive Therapy Scale for Psychosis (CTS-Psy). Therapists were blind to which sessions would be rated. In addition, two therapists who provided CBSST received initial training and weekly supervision that included review of videotaped sessions. The study used a randomized experimental design, which minimized some of the confounding variables. Sophisticated and appropriate analyses were used in the study.

Study Weaknesses

Baseline ILSS scores indicated that the two study groups differed significantly in regard to psychosocial functioning.

Documents Reviewed

Study 1

Granholm, E., McQuaid, J. R., McClure, F. S., Auslander, L. A., Perivoliotis, D., Pedrelli, P., et al. A randomized, controlled trial of cognitive behavioral social skills training for middle-aged and older outpatients with chronic schizophrenia. American Journal of Psychiatry, 162(3), 520-529.

Granholm, E., McQuaid, J. R., McClure, F. S., Link, P., Perivoliotis, D., Gottlieb, J., et al. Randomized clinical trial of cognitive behavioral social skills training for older people with schizophrenia: 12-month follow-up. Journal of Clinical Psychiatry, 68(5), 730-737.

Supplementary Materials

Granholm, E., Auslander, L. A., Gottlieb, J. D., McQuaid, J. R., & McClure, F. S. Therapeutic factors contributing to change in cognitive-behavioral group therapy for older persons with schizophrenia. Journal of Contemporary Psychotherapy, 36(1), 31-41.

Granholm, E., McQuaid, J. R., Auslander, L. A., & McClure, F. S.. Group cognitive behavioral social skills training for older adult patients with chronic schizophrenia. Journal of Cognitive Psychotherapy. Special Issue: Cognitive Theory and Therapy of Schizophrenia, 18(3), 265-279.

Granholm, E., McQuaid, J. R., McClure, F. S., Pedrelli, P., & Jeste, D. V. A randomized, controlled pilot study of cognitive behavioral social skills training for older patients with schizophrenia. Schizophrenia Research, 53, 167-169.

McQuaid, J. R., Granholm, E., McClure, F. S., Roepke, S., Pedrelli, P., Patterson, T. L., et al. Development of an integrated cognitive-behavioral and social skills training intervention for older patients with schizophrenia. Journal of Psychotherapy Practice and Research, 9(3), 149-156.

Table of information on reliability and validity of measures used in CBSST

Outcomes

Outcome 1: Psychosocial functioning
Description of Measures	Psychosocial functioning was assessed using the Independent Living Skills Survey (ILSS) and the University of California, San Diego Performance-Based Skills Assessment (UPSA). The ILSS is a self-report measure of basic functional living skills performed during the past month; it was administered in an interview format. The ILSS assesses appearance and clothing, personal hygiene, health maintenance, transportation, and leisure and community, all of which are sensitive to functional impairment in older outpatients with schizophrenia. The UPSA is a performance-based measure of the extent to which patients are capable of performing specific functional living skills. The instrument uses standardized role-playing situations to assess domains of functioning such as household chores, communication, finance, transportation, and planning recreational activities.
Key Findings	At 1-year follow-up, participants in CBSST showed statistically significant improvement in social functioning relative to participants receiving treatment as usual (p = .05). However, no differences between CBSST and treatment as usual were found in participants' capacity to perform basic everyday activities as measured by the UPSA.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.0 (0.0-4.0 scale)

Outcome 2: Symptom severity
Description of Measures	Symptom severity was assessed by the Positive and Negative Symptom Scale (PANSS) and the Hamilton Rating Scale for Depression (HAM-D). The PANSS is a 30-item interview that provides balanced representation of positive and negative symptoms of schizophrenia and gauges their relationship to one another and to global psychopathology; the HAM-D is a 21-item multiple choice questionnaire used to assess depressive symptoms.
Key Findings	No significant reduction in symptom severity was found for CBSST participants at any assessment point. However, in posthoc analysis, a greater improvement in cognitive insight with CBSST was significantly correlated with greater reduction in positive symptoms (p < .05).
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.4 (0.0-4.0 scale)

Outcome 3: Cognitive insight
Description of Measures	Cognitive insight refers to metacognitive processes involved in the evaluation and correction of distorted beliefs and misinterpretations (e.g., cognitive flexibility, objective distancing, reappraisal of symptoms). The Beck Cognitive Insight Scale (BCIS) is a self-report questionnaire that assesses metacognitive processes on two subscales: self-reflectiveness (e.g., "I have jumped to conclusions too fast," "If someone points out that my beliefs are wrong, I am willing to consider it") and self-certainty (e.g., "My interpretations of my experiences are definitely right," "I can trust my own judgement at all times").
Key Findings	At the end of treatment, participants in CBSST had significantly greater cognitive insight scores compared with participants receiving treatment as usual, indicating comparatively greater objectivity in reappraising psychotic symptoms (p < .01). However, this difference was not maintained at 1-year follow-up.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	2.9 (0.0-4.0 scale)

Outcome 4: Acquisition of communication, problem-solving, and thought-challenging skills
Description of Measures	A Comprehensive Module Test (CMT) was used to assess knowledge of the specific skills and information taught in CBSST (communication, problem-solving, and thought challenging). The CMT was originally developed by the University of California, Los Angeles Center for Research on Severe Mental Illness (now the UCLA Center for Research on Treatment & Rehabilitation of Psychosis). The measure also attempts to assess the application of this knowledge by presenting specific social situations or problems (e.g., "You want to meet someone at a senior center") and probing for the application of acquired skills (e.g., steps in problem-solving: define the problem, generate solutions, list advantages and disadvantages, etc). The developer modified the measure to also include a cognitive component, which assesses patients' knowledge of acquired cognitive skills (e.g., "What are the 3 C's?") and application of these skills to symptoms and situations (e.g., "You think people were talking about you before you entered a room; what should you do?").
Key Findings	At the end of treatment, CBSST participants showed significantly greater skill acquisition than participants receiving treatment as usual (p < .01). This gain was maintained at 1-year follow-up (p < .05).
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	2.3 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study	Age	Gender	Race/Ethnicity
Study 1	26-55 (Adult) 55+ (Older adult)	74% Male 26% Female	80% White 20% Race/ethnicity unspecified

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

Reliability of measures
Validity of measures
Intervention fidelity
Missing data and attrition
Potential confounding variables
Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome	Reliability of Measures	Validity of Measures	Fidelity	Missing Data/Attrition	Confounding Variables	Data Analysis	Overall Rating
1: Psychosocial functioning	3.5	1.5	4.0	3.0	2.5	3.5	3.0
2: Symptom severity	3.5	4.0	4.0	3.0	2.5	3.5	3.4
3: Cognitive insight	3.5	1.0	4.0	3.0	2.5	3.5	2.9
4: Acquisition of communication, problem-solving, and thought-challenging skills	0.0	1.0	4.0	3.0	2.5	3.5	2.3

Study Strengths

The measures used for outcome 1 (increased psychosocial functioning) have evidence of reliability. Instruments used for outcome 2 (reduced symptom severity) show good evidence of validity. This was a well-designed randomized study with evaluators blinded to group assignment. The treatment incorporated evidence-based practices modified for older adults with schizophrenia, addressing the cognitive and social issues documented in this population. Training procedures was manualized and administered by adequately trained personnel who were supervised by senior personnel using videotaped reviews. Attrition and missing data were reported and handled appropriately. Analyses were thorough and appropriate. Careful attention was paid to treatment fidelity.

Study Weaknesses

The Comprehensive Module Test (CMT) does not have reliability data other than repeated administrations of the tool with follow-up that appears to show knowledge was maintained over time. The sample size was modest, and no evidence was presented to show that the statistically significant outcomes are related to real-world improved function for the study population. A potential confounding variable was the use of predominantly Caucasian males in the sample, which may impact generalizability. The discussion of validity was inadequate for most of the measures.

Readiness for Dissemination

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Granholm, E. Cognitive Behavioral Social Skills Training (CBSST) for schizophrenia [PowerPoint presentation].

Granholm, E. Cognitive Behavioral Social Skills Training for schizophrenia: Practical syllabus.

Granholm, E., Holden, J., & McQuaid, J. Cognitive Behavioral Social Skills Training (CBSST): Cognitive skills module consumer workbook. San Diego: Regents of the University of California.

Granholm, E., Holden, J., & McQuaid, J. Cognitive Behavioral Social Skills Training (CBSST): Problem-solving skills module consumer workbook. San Diego: Regents of the University of California.

Granholm, E., Holden, J., & McQuaid, J. Cognitive Behavioral Social Skills Training (CBSST): Social skills module consumer workbook. San Diego: Regents of the University of California.

Other program materials:

Communication Skills Test
Comprehensive Module Tests: Instructions to Subjects
CTS-Psy [therapist rating scale]
Implementation and Supervision of Cognitive Behavioral Social Skills Training (CBSST)
Problem Solving Skills Test
Thought Challenging Skills Test

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

Availability of implementation materials
Availability of training and support resources
Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation Materials	Training and Support Resources	Quality Assurance Procedures	Overall Rating
2.8	3.3	3.3	3.1

Dissemination Strengths

The consumer workbooks are appropriate for the intended audience and focus on individual goal setting and problem solving. They include practical tools, such as worksheets and checklists, to support the recovery process. The program Web site offers an overview of the program and describes how the three modules (cognitive skills, problem-solving skills, social skills) are integrated. An on-site training workshop is available, which helps therapists develop skills to effectively work with consumers. Workshop materials offer practical guidelines for program implementation and ongoing supervision. The developer is available to provide consultation and supervision for both therapists and their supervisors, which can help build program capacity and sustainability over time. The developers are available to rate audio- or videotaped consumer sessions using the CTS-Psy, an observational fidelity tool that supports therapist competence. In addition, there are three comprehensive skills tests, which measure consumer knowledge acquisition for each module.

Dissemination Weaknesses

Implementation and intervention guidance for therapists is provided through participation in an optional training workshop rather than through a treatment manual, leaving those who cannot attend training without sufficient guidance on intervention delivery. Although training for organizations is available, it is unclear how an individual can pursue training opportunities. It is also unclear if opportunities exist for therapists to develop advanced capabilities or to network with each other. Although the developer has used various standardized outcome measures in researching the program, no specific materials or guidance for evaluating program outcomes are provided.

Materials Reviewed

CBSST for Schizophrenia Syllabus

CBSST Manual (Blue Module): Asking for Support

CBSST Manual (Green Module): Solving Problems

CBSST Manual (Red Module): Changing Your Thinking

Granholm, E., & McQuaid, J. Cognitive Behavioral Therapy (CBT) for Psychosis [PowerPoint handout].

Granholm, E. Demonstration Video: CBT for Psychosis [DVD].

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

Availability of implementation materials
Availability of training and support resources
Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation Materials	Training and Support Resources	Quality Assurance Procedures	Overall Rating
2.5	1.5	0.5	1.5

Dissemination Strengths

The treatment manuals give clear instructions for session-by-session implementation. The provided forms and examples facilitate the group process and increase the likelihood that clients will do homework. The DVD illustrates how one might use program concepts in practice. The manual and DVD may be a useful training tool for clinicians who are familiar with cognitive behavioral therapy and who are highly experienced in working with clients with serious mental disorders. The continual sequencing of feedback from the client can serve as a quality assurance mechanism.

Dissemination Weaknesses

This is a complex curriculum with no clear integration of concepts. It is unclear how a clinician should sequence components of the intervention and whether all components are required to obtain good treatment outcomes. The manuals are for group intervention, while the DVD demonstrates individual work. No guidance is provided as to how clinicians should choose group versus individual intervention. The DVD does not fully explain the context of the examples provided, so the concepts being presented and their utility in specific client situations may not be clear to some viewers. While the slide presentation stresses the importance of therapeutic alliance, none of the implementation materials demonstrate the use of alliance in the intervention or provide training on developing this alliance. Little information is provided to support training, coaching, or ongoing technical assistance. Programmatic accountability for interpretation and ongoing quality assurance are also not specifically addressed.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description	Cost	Required by Developer
CBSST consumer workbooks (set of 3)	$30 per set	Yes
2-day, on-site CBSST training workshop	$2,500 per day for up to 30 participants or $3,750 per day for 30-60 participants, plus travel expenses	No
On-site, videoconference, or phone follow-up consultation with the developer for participants who attended the training workshop	$250 per hour, plus travel expenses if necessary	No
Brief phone or email support	Included in the cost of the follow-up consultation	No
Skills tests (set of 3)	Free	No
CTS-Psy ratings of audio- or videotaped consumer sessions	$150 per hour	No