CBSST in Detail

Cognitive Behavioral Social Skills Training (CBSST) combines cognitive behavioral therapy (CBT) and social skills training (SST) interventions to target functional impairment in people with psychotic disorders. CBT is a form of psychotherapy that attempts to modify an individual’s interpretations of experiences that determine how the individual feels and behaves. The premise of CBT is that cognition, the process of acquiring knowledge and forming beliefs, can influence mood and behavior.  CBT techniques help consumers to identify and correct thoughts and misinterpretations of experiences that are at the root of aberrant behavior. CBT can be used to improve outcome in schizophrenia by modifying these cognitive processes. The application of CBT to schizophrenia is a promising new treatment approach that has been studied primarily in the United Kingdom. Over 30 studies have used CBT to challenge beliefs underlying delusions and hallucinations found reductions in psychotic symptom severity, delusional conviction, anxiety and depression. A comprehensive meta-analysis of CBT for psychosis clinical trials recently showed that, although the vast majority of studies focused on positive symptoms as primary treatment targets, CBT for psychosis also had beneficial impact on various functioning outcomes. SST is a primarily behavioral psychosocial intervention that focuses on practicing pragmatic living skills (e.g., role play communication training). Numerous studies of consumers with schizophrenia have shown that SST improves psychosocial functioning.

In CBSST, cognitive interventions are used to address symptoms and challenge defeatist beliefs that interfere with real-world skills execution, including expectancies (“It won’t be fun”), self-efficacy beliefs (“I always fail”), and anomalous beliefs (“Spirits will harm me”) that interfere with skill performance, despite intact skill capacity. By challenging defeatist performance beliefs, consumers are more likely to engage in functional behaviors and use the skills they have. Adding CBT to SST, therefore, provides an opportunity to address thoughts that interfere with skill performance in the real world. Importantly, the cognitive interventions in CBSST are cognitive coping skills interventions that focus on practicing simple steps for belief modification (e.g., the 3C’s—Catch It, Check It, Change It—thought challenging skill described below) that are compatible with a skills practice approaches like SST.  We have conducted randomized controlled trials comparing CBSST with treatment as usual, as well as an active goal-focused supportive contact intervention. These trials, have found that CBSST is a more effective than these control conditions for improving functioning outcome in schizophrenia.

CBSST consists of 18 sessions that are typically delivered on a weekly basis in either group or individual sessions. The intervention targets the range of multidimensional deficits that can lead to functional disability in people with schizophrenia through three modules. These modules include the CBSST Thought Challenging or Healthy Thinking Module, CBSST Social Skills Training Module, and the CBSST Problem Solving Module. 

CBSST Consumer Manual

The CBSST consumer manual is constructed in three modules that focus on challenging thoughts, improving social skills, and learning problem solving strategies.

CBSST Thought Challenging Module. Cognitive therapy is the exclusive focus of this module and these techniques are also used throughout the other two modules. The CBT interventions are cognitive coping skills focused, rather than more complex formulation or schema based work. Consumers are introduced to the general concepts of CBT, including the relationship between thoughts, actions and feelings (generic cognitive model), automatic thoughts, thought challenging by examining evidence for beliefs, and mistakes in thinking (e.g., jumping to conclusions; mind reading; all-or-none thinking). Through discussion, thought records, and homework assignments, consumers are taught to identify thoughts, identify relationships between thoughts, feelings and behaviors, and identify mistakes in thinking. Behavioral experiments are conducted inside and outside group (homework), in order to gather evidence to evaluate beliefs. Alternatives therapy, Socratic questioning, and thought chaining are used to help consumers examine the logic of beliefs and generate more adaptive alternatives to mistakes in thinking or thoughts without sufficient evidence. The primary thoughts targeted are defeatist performance beliefs about functioning activities (e.g., expecting failure, pleasure predicting, expecting harm), hallucinations (e.g., external agency, omnipotence, and omniscience of voices) and beliefs about daily events that consumers used as evidence to confirm delusions. To simplify learning and help consumers remember and use cognitive techniques in everyday life, mnemonic aids are provided (e.g., laminated wallet cards containing information about skills). For example, to foster thought challenging, we use an acronym, "The 3C's: Catch It, Check It, Change It". The "It" is a thought.

CBSST Social Skills Training Module. The primary goal of this module is to improve communication skills and psychosocial interactions (e.g., how to ask someone for support). The predominant therapeutic technique in this module is the behavioral role play. An important focus of role plays is on interacting with roommates, friends and family, making new friends and effectively interacting with case managers, other service providers and support persons. Expressing positive and negative feelings and making a positive request are emphasized to improve assertive, clear, and comfortable sharing of feelings in social interactions. Improving everyday activities and psychosocial functioning are common role play topics for these skills (e.g., asking a roommate to change their behavior; asking someone to go to the movies; assertive interactions with co-workers/ employers). Consumers critique the strengths and weaknesses of their own performance according to a list of key skills (e.g., eye contact, speech volume, etc.). Thoughts, particularly defeatist beliefs, are also assessed during the social skills module, since thoughts and attitudes often get in the way of doing the skill. Consumers can master social skills as observed in a group session, but often don't perform the same skill in the community. Frequently, thoughts and attitudes are barriers to skills performance in these real-world situations.  

CBSST Problem Solving Module. As is common in SST and CBT interventions, basic problem-solving skills are taught using the acronym, SCALE – Specify the problem, Consider all possible solutions, Assess the best possible solution, Lay out a plan, and Execute and Evaluate the outcome. The focus of this module is on developing plans for collaborating with the case manager to solve real-world problems, including improving living situations, finances, access to using public transportation, finding a volunteer or paid job, and enrolling in classes. Problems related to illness and disability are also addressed, including coping with symptoms and stress, remembering to take medications, increase leisure activities, relationships, and hygiene or health. Plans frequently target goal steps that were identified and reviewed in the goal-setting sessions. As is the case with the SST module, thoughts can interfere with an attempt to execute a plan, so thoughts that may interfere with successful execution or completion of a plan are assessed. 


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