Manuela Wild

1. Theory

Humans are social beings who live in constant interaction with their environment in order to realize their own desires and needs. The fear of social contact and evaluation by others therefore represents a well-known phenomenon in the history of mankind. Especially in today’s performance-oriented society, social competence often determines professional and personal standing. People who evaluate their own social behavior as insufficient and fear being laughed at or shamed by their environment as a result avoid situations that are dangerous for them and withdraw more and more. This can result in a great deal of suffering for those affected. This is where social skills training comes in to reduce avoidance behaviors and develop new confident behaviors.

1. Social competence

The term social competence is a poorly defined term to describe those requirements that a person needs to be able to cope and hold their own in a social environment. Certain skills seem to be crucial for the success of interpersonal relationships. Social competence goes beyond the concept of self-confidence and describes the desired, adequate social behavior of a person, “to find and realize an acceptable compromise between social adaptation and individual needs”(Ambühl, Meier& Willutzki, 2006, p.111).

Social competence is not a universal personality trait. For example, someone may be able to distinguish themselves well in their professional environment, but fail to adequately express wishes within their partnership.

Fydrich gives an overview of concrete examples of socially competent behavior (Fydrich, 2002, p.184)

Start, maintain and end conversations	cooperate
Arrange desired contacts	Help others
Smile and be friendly	Search for solutions in case of conflicts
Respond to contact offers	Require changes in disruptive behavior
End unwanted contacts	Reject unjustified claims
Give and accept compliments	Do not be interrupted
Showing and possibly articulating feelings	Express objection
Be able to say no	Apologize
Respond appropriately to criticism	Admit weaknesses
Putting yourself in the shoes of others

1. Social performance

While the term social competence refers to an individual’s knowledge of socially appropriate behavior, social performance refers to actual and observable behavior, such as eye contact, voice, nervousness, physical restlessness, speech duration, and fluency. Both are learned behaviors between which there is a causal relationship. In order to perform socially, the availability of social competence knowledge and skills is a prerequisite, and conversely, anxiety-related deficits in observable behavior hinder the development of social competence. (cf. Fydrich, 2002)

1. Social competence training

Social skill building procedures are based on the social deficit hypothesis. The underlying idea is that unlearned social skills or poorly practiced skills lead to anxiety in social situations and thus can be offset by training new behaviors appropriate to the situation.

Within behavioral therapy, various social skills trainings have been developed that are designed to practice basic skills in social, interactive, and communicative interactions with others. The basic principle of graduated approach is realized in social skills training. Trying out and practicing selected interpersonal scenes in role plays and in real situations are scientifically effective therapy techniques.

1. Origin

Over time, numerous forms of social skills training have developed due to different theoretical frameworks.

The earliest forms of behavioral self-confidence training sought to address the fears and inhibitions of self-confident people primarily at the behavioral level. These go back to Salter’s (1949) “expressive training,” which consists of six spontaneity exercises:

– Expressing feelings

– Mimic speaking

– Exercise in contradicting and attacking as an expression of one’s own opinion.

– Consistent use of the word “I” instead of indirect phrases.

– Practice in agreeing with praise or compliments received.

– Practice in improvising as an expression of feelings and needs rather than caution and planning.

This inspired Wolpe’s “Self-Assertiveness Training or Assertiveness Training Program (ATP)” (1958). Both concepts have taken the Pavlovian theory of classical conditioning as their starting point. Originally neutral stimuli become fear-inducing stimuli through conditioning and lead to avoidance behavior, from which a vicious circle develops in the affected person, because all situations in which the fear reaction could be extinguished by the absence of the expected, feared stimulus are avoided. Wolpe followed the principle of counterconditioning or reciprocal inhibition and used aggressive assertive responses as an anxiety-inhibiting tool in addition to relaxation. Wolpe introduced role-playing to the practice of behavior therapy. In the assertiveness concept, self-confident behavior is trained as a means against fears and inhibitions and not for its own sake. Wolpe earned criticism for the unclear distinction between assertive and aggressive behavior, which is why he excluded aggressive behavior from the term “assertiveness” in the early 1970s. As a well-known counterpart Lazarus is to be mentioned here, who attributes incompetent social behavior to learning deficits. Based on the learning theory approach, the “social skills models” emerged , which are designed to compensate for socially incompetent behavior by training new, situationally appropriate behaviors. This is not about fear reduction, but about building observable and learnable behaviors and skills based on social learning theory. (cf. Bauer, 2007)

In the early 1970s, it became increasingly accepted that, in addition to overcoming social anxiety and building social skills, cognitive variables such as attitude toward self, evaluations, self-assessments, and social perceptions were crucial to achieving self-confidence. Important representatives in the German-speaking world are Goldstein (1973), Lazarus (1971), and Ullrich de Muynck and Ullrich (1973).

Due to the cognitive orientation of behavior therapy towards the end of the 1970s, dysfunctional processes of information processing came to the fore as a cause of psychosocial disorders. Important approaches here were provided by Lazarus (1973), Ellis (1997), and Beck (2001).

Meichenbaum created a cognitive model of social competence and describes the three interacting components: Behavior, cognitive processes (self-verbalization and information processing), and cognitive structures, which he describes as the meaning system that governs cognitions and actions. (Meichenbaum et al., 1981).

The authors Hinsch & Pfingsten (2007) developed the group training of social skills (GSK). The manual for the standard procedure describes seven weekly sessions of 150 to 180 minutes each plus an introductory session with a number of participants of eight to ten with two trainers. The underlying explanatory model, which is conveyed to the participants at the beginning, describes cognitive and emotional processing procedures on the basis of a concrete initial situation, which lead to observable, motor behaviors that are organized as behavior patterns.

The resulting environmental reactions are perceived, processed, and stored in memory as social experience. Where and in what form problems occur is worked out in detail with the group participants.

The following classification of types of social situations forms the background of the exercise situations:

1. Situations (type R) in which it is a matter of asserting one’s own right, which is legitimized by social norms, such as the exchange of a purchased item. (See appendix)
2. Situations (Type B) involving maintaining or improving relationships, agreeing and reaching consensus, expressing one’s own feelings and needs, understanding the other person’s feelings and needs, and openly addressing one’s own insecurities. (See appendix)
3. Situations (Type S) in which the aim is to court sympathy by reinforcing one’s interaction partner, expressing one’s interest, inquiring, and making compliments; this requires a flexible response to the situational behavior of the counterpart, as is common in flirting, for example. (See appendix)

Progressive muscle relaxation according to Jacobsen is taught as relaxation training. Homework is assigned in each training session for independent practice and an hour sheet is distributed to all participants at the end to provide feedback to the therapists about the experience of each session.

Alsleben & Hand (eds., 2006) have developed Social Skills Training (SKT) as a treatment concept for reducing social phobic anxiety and increasing social skills. The manual contains a guide over 12 group therapy sessions. In addition to theoretical inputs, standardized and individual role plays and exercises, therapist-guided exposures in vivo are also included in the treatment manual. The subdivision allows individual modules to be incorporated into individual therapy as well. Introducing the topic of anxiety management with motivation building, the building block of social phobia and teaching progressive muscle relaxation. Other components of social skills training include:

Topic A includes perception and discrimination (see appendix), anxiety management, midpoint exercises.

Topic area B forms communication (see appendix) including conversation skills, establishing contact, assertiveness with the ability to set boundaries, making demands and expressing wishes, the ability to criticize and deal with conflict, and praise.

Topic Area C addresses individual background problems using a seven-step individual problem-solving approach, building social activities, and developing an individual disorder model.

In between therapy sessions, there are home exercises (see appendix) to transfer the practiced experiences into everyday life.

In their Assertiveness Training Program (ATP), Ulrich and De Muynck (1998) formulated 127 concrete exercise situations for anxiety processing, which can be hierarchized according to different criteria. These are practiced in role play in the group. Subsequently, the exercises are implemented in vivo in pubs, stores or on the street with the involvement of strangers but also with friends, acquaintances and one’s own family. In order to bring about changes in the social actions and self-image of group participants and to mitigate negative expectations, the authors address four social skills areas with their exercises:

1. Making contacts
2. The fear of rejection when saying “no” and the fear of criticism.
3. The expression of needs “being able to demand”. In the process, fears of rejection should be eliminated to the extent that wishes can be clearly expressed, such as “I see it differently, I would like it this way…”
4. Being too considerate and conforming to social norms, allowing oneself to make mistakes and exposing oneself to public scrutiny.

The standardized procedure resulted in a high generalization factor, because those who are confident in the various social situations can transfer the acquired competence to other, not specifically practiced situations.

1. Targets

The goal of social skills training is not primarily to reduce anxiety, but to build observable learnable behaviors just like self-worth and self-management. Participants should acquire new skills for coping with everyday social life and their confidence in their own coping resources should be strengthened in order to prevent the development of mental or somatic illnesses and to promote social reintegration.

Hinsch&Weigelt describe the goal of social skills training as ” the availability and application of cognitive, emotional, and motor behaviors that lead to a long-term favorable balance of positive and negative consequences for the agent in specific social situations” (2007, p.90).

Erika Güroff (2019) speaks of aspirational qualities for interpersonal interactions:

• The cognitive ability to value self and others and to empower and acknowledge self.
• Emotional serenity, lightness, security and self-confidence.
• Calmness and relaxation on a physical level.
• Authentic and appropriate behaviors such as refusing or enforcing requests.

The patient’s negative self-concept is to reconcile with his own fallibility and weaknesses, and through repeated self-reinforcement, self-deprecation is allowed to be released.

1. Indication

Teaching social skills, improving self-esteem, and overcoming social anxiety are essential in the treatment of people with mental illness. According to Pfingsten, “Social competence problems play a clinically relevant role in the etiology and/or therapy of almost all mental disorders. Very often they are precursors of other mental disorders” (2007, p.232). It is essential to determine whether competency problems are actually present in the individual patient and whether they serve a function worthy of treatment before routinely applying the training.

For socially phobic people and people with anxious-avoidant personalities, social skills training is one of the standard methods in multimodal treatment.

Both patients with social deficits and those with social performance deficits benefit from skills training. Decisive for participation is the insight of social deficits, a certain willingness to take risks, the ability to work in a group and the motivation to change, to confront fear-inducing situations. Self-indication of the participants, which is ensured at the beginning by clear information about the concept and procedure of the social competence training and by their own decision to participate in the training, increases the training motivation, leads to a lower dropout rate and facilitates the therapeutic work in the course of the training. (Pentecost, 2007)

The individual intrapsychic and interactional functionality of the competence deficits must be clarified for each patient.

• Fields of application

Especially for psychiatric patients with chronic mental disorders, social skills training has proven to be an effective intervention, which is why psychotherapy and clinical psychology are particularly important areas of application in both outpatient and inpatient settings.

Hinsch& Pfingsten (2007) give a rough overview of the wide field of application of a social skills training. For example, there are trainings for depressive and psychosomatic patients, for social phobics, for addicts, for people with personality disorders or a physical disability, and for people with eating disorders. Special developed programs are available for families, couples, (aggressive and delinquent) youth and children.

In schizophrenic and affective psychoses, participation in skills training after the acute psychotic symptoms have subsided is supportive in regaining a foothold in everyday reality.

Not only people with mental illness can benefit from social skills education, but also in the non-clinical setting, there are a variety of modification options for different target groups. For example, for people who are currently in a life situation that requires particularly pronounced social skills, such as unemployment or in the case of chronic illnesses, or for continuing vocational training, where it is a matter of expanding an interdisciplinary qualification.

A plethora of clinical studies found links between incompetent social behavior and mental disorders, aggression, delinquency, unemployment, marital and partner problems, sexual disorders, and suicide. Here is the great social opportunity for prevention and rehabilitation and the pedagogical claim to positively influence disorders through the training of social skills. (cf. Bauer, 2007)

• Practical application

3.1. Organizational framework and requirements

Training to learn new adequate social behaviors can be integrated into the treatment plan of individual therapy as well as used as group therapy. In the group, the factor that all participants share the same goals, namely learning new, competent behaviors, is particularly effective. Here we recommend a group size of 6 or 4 people. The small number of participants results from the consideration that everyone should be able to practice all scenes. Training should be done exclusively in closed groups. If a larger number of patients are required, such as in an inpatient setting, they should be instructed by two therapists.

Social skills training can be conducted in 30 group sessions of`100 minutes. Parallel individual sessions are useful. For individual patients with severe social phobia, it is recommended that behavioral exercises be conducted in a one-on-one setting. Especially for people with a pronounced fear of negative evaluation, the group or even the setting in individual therapy already represents a dreaded social situation in which it is a matter of presenting one’s own weaknesses.

Participants are not allowed to consume alcohol, drugs, or anxiety-dampening medications prior to the training.

3.2. Special features in the design of the relationship

The basis is a respectful attitude without pressure to perform. For patients with social skills problems, it is important to consider the following.

– High vulnerability to social failures

– Great skepticism with praise and positive feedback

– Strong tendency to conformity

– Strong need for clearly structured instructions and tasks

– High self-attention

– Strong preoccupation with aspects of self-presentation

– Exaggerated, perfectionistic demands on one’s own behavior (cf. Pfingsten, 2007).

3.3. Procedure and implementation

The therapist illustrates socially competent behavior in a model role play or shows the practice scene as a movie. The patient is then asked to act out the corresponding situation. The therapist and other group participants then provide only positive, concrete, and situational feedback on the successful behavior to reinforce any approach to the desired target behavior. It is advisable to honestly evaluate only what has been successful and has attracted positive attention, in order to gain more self-confidence through encouragement. This disregard for weaknesses is intended to gradually erase them. Negative feedback leads to reinforcement of uncertainty in the patient and implies that there is a perfect behavior.

The ability to record a role play and watch the video together provides a good feedback opportunity for the practitioner. A maximum fear increase “flooding” should be prevented during practice to prevent uncontrollable escape impulses or for aversive situation processing. A humorous therapist attitude can help get over difficult situations.

The interpersonal experiences necessary for a correction of social anxiety should be practiced independently as home exercises, outside the protected space in reality (in vivo), after practicing in role play, in order to create the transfer to everyday life and to stabilize the training success in the long term.

3.4. The TSK training program with basic and advanced exercises

The following text is based on the training program “Self-confidence and social competence” by Erika Güroff (2019). The building manual consists of 30 given exercise situations, which can be worked on by patient and therapist together. It is divided into 13 predefined basic scenes, followed by individually variable development or consolidation scenes with the subsequent transition into individual scenes. Here, after the basic skills have been taught, the respective personal problem areas are to be actively tackled in the sense of self-management. The training corresponds exactly to the requirements in the inpatient setting.

Before each exercise, the patient should assess his or her individual level of arousal (SUD) in terms of difficulty in order to adapt the exercise to it. A significant rating above 40 already represents an excessive demand. If a patient indicates an anxiety level of zero, practice should also be done to learn the basic skills. Subsequently, the patient should formulate the situation goals and learning objectives on the cognitive and behavioral level and his feelings and wishes for the respective exercise situation.

3.4.1. Concrete exercise example (Güroff, 2019, p.86ff).

BASIC EXERCISE Scene 9 It’s in front of the nose

I’m in a supermarket looking for tomatoes at the vegetable stand, for example. I know they are there but:

I want to learn that a “mistake”, a carelessness, a thoughtlessness, does not mean an embarrassment that I should fear (and thus avoid). In this case, the tomatoes are right in front of me, under my nose, so to speak, and yet I do not discover them.

I ask the saleswoman about the tomatoes.

Your therapist will now show you the exercise. You watch closely, pay attention to what you notice, especially which of the model’s behaviors seem confident and competent to you, and think about what you would like to try and learn from them.

Suggestions for your learning objectives that can be expanded by you:

Behavior

• I go directly to the person.
• I look directly at them (eye contact).
• I do not apologize, but greet.
• I hold myself upright.
• I raise my head.
• I ask my question loud and clear.
• I match my facial expression to my state of mind: I smile when I am in good spirits; I remain serious when I feel serious (I am authentic).
• When the saleswoman shows me the tomatoes and says, for example, “here in front of you”, I do not apply any self-deprecation, such as “am I perhaps stupid” or the like.
• I thank you kindly

Thoughts

• I want to be visible
• Only when people look at each other is an exchange possible.
• I don’t blame myself when I need support.
• I can show myself.
• Only when I speak loudly and clearly will I be heard.
• I am who I am; I am learning the difference between serious facial expressions and unfriendly ones.
• I may overlook something, that’s natural.
• I show appreciation when I say thank you.

Body reactions

• I know that I cannot directly influence the so-called “autonomic” body reactions.

What new experiences can this scene bring you?

Possible embarrassment, embarrassment, shame are bad experiences in everyone’s life. Mockery by others is unfortunately a common experience that even children have to go through. These taunts deeply violate the basic need for respect and appreciation and remain long in the memory. Fortunately, you as adults now have the means to deal with the old hurts. Exercises of the present type are a building block.

Relearn: you can afford to make a lot of small blunders and scatterbrains without having to expect a repeat of the slight. If shame and grievance are a big issue for you, your therapist will be able to offer you more in-depth help during therapy sessions.

Now think about your two to three most important goals from the table, your SUDs, find a partner and do the role play.

Action

Now apply the Golden Rule (I evaluate my own exercise and that of the group members only from the point of view of what was successful, what stood out positively. I do not deal with weaknesses or mistakes, I ignore them. I am completely honest!), first yourself, then the other group members or the therapist.

How do you feel now?

Excited?, relieved?, happy?, surprised?, curious?, elated?, confused?, cheeky?,?

3.4.2. Success control

After the baseline exercises, there will be an intermediate measurement using Ulrich and de Muynck’s (1998) U-questionnaire and FAF, Questionnaire for the Assessment of Aggressiveness Factors. The final measurement should be performed immediately after termination and after another three months. In terms of relapse prevention, group members can be encouraged to stay in touch and continue to cultivate the technique of role-playing together. (Güroff, 2019)

Before offering social skills training, it is beneficial for prospective therapists to increase their own empathy and understanding of prospective patients by trying out the exercises themselves.

• Evidence

A large body of research demonstrates the efficacy of social skills training for many disorders and various patient populations ( e.g., Pfingsten 1987; Pfingsten & Hinsch, 1997; Ulrich de Muynck & Ulrich, 1976). Margraf and Schneider state that their use is particularly comprehensively validated ” for depression, partner problems, and schizophrenic and substance-related disorders. In alcoholism, they can be considered, with other interventions, an evidence-based procedure of the highest level” (2018, p. 483).

Especially for clinically relevant social anxiety, multimodal training is considered the tool of choice. Other work demonstrating the effectiveness of social skills training for social phobias has been conducted in the research groups led by Stravinsky (1982, 1987), Trower (1978), Alden (1989), and Mersch (1991, 1995). According to older meta-analyses, the assumption arose “that social skills training is effective for social phobias, but would possibly be surpassed in effectiveness by other intervention methods such as exposure or cognitive therapy” (Pfingsten, 2007, p.235). However, this reasoning is based on the older training concepts.

In the meta-analysis by Ruhmland and Margraf (2001), action-based therapeutic approaches or combinations with such treatment modules are shown to be superior to purely cognitive ones in cognitive-behavioral therapy programs (2002, p.194).

In clinical practice, according to Koban and Neumann (2001), the combination of cognitive therapy, stimulus confrontation, and social skills training in a group setting is considered the therapy method of choice. The authors state the following impact factors for group training. The ongoing exposure provided by the group situation, the reduction of feelings of isolation regarding the disorder, the opportunity to model other group members and therapists, and more opportunities for feedback and role-playing.

The combined effect of social skills training on the one hand to reduce the mental disorder and at the same time to increase the patient’s personal resources helps to overcome the deficit-oriented aspects of treatment strategies.

Literature

• Alsleben, H. & Hand, I., (Eds.). Social skills training. Group therapy for social anxiety and deficits. (2006) Munich, Jena: Urban&Fischer.
• Bauer, Mathilde (2007). Interventions. In: Hinsch, R. & Pfingsten, U. (2007). Group Social Skills Training GSK. Weinheim, Basel: Beltz.
• Fydrich, T. (2002). Social competence and social performance in social phobia. In: U. Stangier & T. Fydrich (Eds.). Social phobia/social anxiety disorder. Psychological foundations-diagnostic therapy (pp. 181-203), Göttingen: Hogrefe.
• Güroff, E. (2019). Self-confidence and social skills. The TSK training program with basic and advanced exercises. Stuttgart: Klett-Cotta.
• Hinsch, R. & Pfingsten, U. (2007). Group Social Skills Training GSK. Weinheim, Basel: Beltz.
• Koban, C. & Neumann, B. (2001).Group therapy for social anxiety and competence deficits. In: Psychotherapy in Dialogue 2(1): pp. 63-70.
• Margraf,J. & Schneider, S. (209). Textbook of behavior therapy. Volume 1: Fundamentals, diagnostics, procedures, framework. 3rd ed. Heidelberg: Springer.