Social Skill Case Example
(6-12-08)

George

George M. was a 47 year old, biracial male. He had been raised by his grandmother. His mother had been Hispanic, a prostitute, and died of an accidental drug overdose when George was "young." His grandmother's family had not accepted George because his father was unknown but obviously black. George reportedly had significant learning and behavior problems in school, and eventually dropped out at age 16. He had never earned his GED.

George had been arrested a number of times, usually for vagrancy, public drunkenness, shop lifting, or other minor offenses. He had served several sentences in county jails is several areas, and one brief prison sentence for armed robbery (George did not carry a weapon but the organizer of the event did, no one was injured but they were rapidly apprehended, and George's partner quickly negotiated a deal: George served 18 months of a 5 year sentence.

George had intermittently abused alcohol and a number of other drugs. He had been through detox programs in two states, and "almost" completed one drug treatment program.

George had received a variety of mental health diagnoses over his life: Conduct Disorder as a youth, Schizophrenia and substance abuse diagnoses as a young man, and most recently diagnoses of depression, Bipolar Disorder. and substance abuse.

George had a very poor work history and had seldom been able to sustain employment. He had often worked in restaurants and through temporary employment agencies.

Amazingly enough, George showed average tested intelligence (WAIS-III FSIQ 93) and was literate (reading comprehension about 6.5 grade, standard score 88).

George was currently homeless. He had applied for Social Security and been denied due to possible malingering in the evaluation. He had been terminated from the local mental health center for noncompliance and missing appointments. He was receiving medication through the local free clinic: a low dose of a neuroleptic (Geodon), a mood stabilizer/anticonvulsant (Depakote), and an antidepressant (Zoloft). George reported he took his medication regularly. He had had clean drug screens for the past several months through his probation office. He was seen for services through the state vocational rehabilitation office.

Problems at initial contact:

temper control & aggressive behavior

inappropriate language: "Fuck them", "dirty Spicks",
"cock suckers", "kiss my ass", "coons", "racist
bastards", "retards", "Jesus freaks", "breaking my
balls"

ruminative thinking

mistreated, discriminated against, accused unjustly

social anxiety

poor personal hygiene: dirty, body odor, scratching self

unemployment

social isolation

disorganization and psychotic thinking under stress

paranoia, treat sensitivity, hostile attributions

homeless

unemployed

history of alcohol and drug abuse

smoking 2 to 3 packages of cigarettes per day

Treatments

wk 1 individual session medication
rapport building & planning
referral to community shelter

wk 2 indiv. session medication shelter
social skill training

wk 3 indiv. session med shelter
social skill training
referral to AA and to MH support group

wk 4 biweekly indiv ses med shelter support groups
social skill training

wk 5 biweekly indiv ses med shelter groups
social skill training
volunteer work at shelter

wk 6 biweekly indiv ses med shelter groups volunteer
social skill training

wk 7 weekly indiv session med shelter groups vol
social skill training
job interviews

wk 8 weekly indiv session med shelter groups vol
social skill training
job interviews

wk 9 weekly indiv session shelter groups vol
social skill training
employment
unscheduled crisis session

wk 10 weekly indiv session med shelter groups
social skill training
job interviews

wk 11 weekly indiv session med shelter groups vol
social skill training
job interviews

wk 12 weekly indiv session med shelter groups vol
social skill training
employment

wk 13 weekly indiv session med shelter groups vol
social skill training
employment

wk 14 weekly indiv session med shelter groups
social skill training
employment

wk 15 weekly indiv session med shelter groups
social skill training
employment

wk 16 weekly indiv session med shelter groups
social skill training
employment
seeking housing

wk 17 weekly indiv session med groups
social skill training
employment
apartment

wk 18 weekly indiv session med groups
social skill training
employment
apartment

wk 19 weekly indiv session med groups
social skill training
employment
apartment

wk 21 indiv session med groups
social skill training
employment
apartment

wk 23 indiv session med groups
social skill training
employment
apartment

wk 24 indiv session med groups
social skill training
employment
apartment
referral community agency

wk 25 indiv session med groups
social skill training
employment
apartment
transition to community agency

wk 27 indiv session med groups
employment
apartment
termination

course of treatment: 27 weeks, 31 sessions, augmented by psychotropic medication, support groups, and community resources

follow-up: two years

outcome: employment, independent residence, participation in social activities of support groups, maintenance with group therapy in social service agency, successful maintenance of parole status

possible factors contributing to success:

relationship with therapist

successful management of medications

normal cognitive abilities

success with accessing community resources

social skill training

avoidance of substance use

 

George's social skill training goals

1a. eye contact and attention to other
1b. bathing and clean clothes

2a. voice loudness and clarity
2b. posture

3a. listen and restatement
3b. deep breath for stress control

4a. greetings
4b. withdrawal if stressed
4c. self-monitoring of feelings

5a. appropriate replies
5b. turn taking
5c. judgments regarding appropriate topics

6a. job interviewing
6b. refusing requests

7a. making requests
7b. responding to compliments

8a. managing difficulties

9a. eye contact
9b. paraphrase

10a. monitoring conversation
10b. anger control

11a. expressing gratitude

12a. sharing interests
12b. dealing with offers of drugs

13a. negotiating
13b. compromise

14. expressing positive feelings

15. casual conversation

treatment techniques:

interviewing skills; contracting & planning
(empathy, honesty, clear expectations)

behavioral rehearsal

direct instructions

modeling

feedback

videotape feedback

stress management & treatment compliance monitoring