Social Skills Training

What is social skills training?

Social skills is a broad term that includes understanding what is expected of you in different social interactions — how you conduct yourself and what you say in social settings. If you’ve experienced a brain injury, you may find that it has affected your ability to interact with other people. In some cases, you may not realize there is any change until a family member, friend, teacher or caregiver notices changes in your behavior and shares that with you. Here are some examples:

• Impulse control or volume might be affected, so you may be told you are being too loud or interrupting too much.
• You may have trouble initiating or maintaining social interactions.
• You may experience a loss of facial expression or vocal intonation/rhythm which can be misperceived as depression or disinterest by friends, loved ones, or coworkers.
• You may find you cannot remember words as you are speaking, which can be frustrating and cause angry outbursts. Or it might cause you to withdraw out of fear of what people might think of you.
• You might have trouble knowing what is appropriate to say in a given situation. You might say something hurtful to someone you love, or you might say something too personal to a stranger.
• Brain injury can also affect interpreting other people’s facial expressions, the ability to pick up on emotional cues, maintaining personal space, or recognizing someone’s face who you have met before.

PTSD can also affect how you act and react in social situations. For example your response to triggers may keep you away from crowds or hypervigilant, sitting only with your back to the wall in a noisy restaurant.

Social skills training can help with these and other situations by:

• Helping you develop awareness of how you communicate and interact with others
• Providing training in strategies that can help you more effectively listen, communicate and interact with others
• Helping you learn to interpret others nonverbal communication (ex: facial expression, tone of voice and other “clues” that hint at what others may be thinking or feeling)
• Teaching strategies to help you manage your emotions and control behaviors that may make positive interactions difficult
• Giving you opportunities to practice these skills in different social settings
• Providing feedback on your practice, so you can continue to improve
• Teaching you how to be open to talking about your limitations so you can better interact with new or familiar people

This work can be very challenging. Not being able to connect with other people because of your brain injury or response to trauma can be painful. Isolation is one of the most devastating impacts of TBI and PTSD for many people, so social skills training is incredibly important. Social skills problems can also put a strain on personal relationships, can make it difficult to get or keep a job, can lead to increased emotional symptoms like depression/anxiety which can lead to overall reduced quality of life. This hard work creates better opportunities for communication and deeper bonds with friends and family.

What are social skills and social communication training like?

You can receive social skills and social communication training in any number of places including a rehabilitation facility, hospital, school, or your own home — in a group setting or on a one-to-one basis.

Please Note: Social skills deficits are commonly accompanied by problems with insight/awareness, attention, and/or executive functioning skills like self monitoring, behavior initiation, impulse control, reasoning and judgement.

You will start with an evaluation or assessment to discover where you might need assistance or improvement. The assessment process may also involve identifying whether you are experiencing problems in any other area of cognitive functioning. This is where input from your caregiver, spouse, or family member may be most helpful. If you are having trouble recognizing (or agreeing with) the problems being brought to your attention, the initial part of treatment may involve providing you with education about your injury and its consequences to help you recognize and accept that this is an area that needs work. Once you become aware and motivated to work on these difficulties, then you will work collaboratively with your therapist to identify specific goals, and learn about new strategies and new behaviors to try.

Your therapist will direct the role-plays and practice activities, provide direct and specific verbal and sometimes video feedback in a highly structured setting, and work with other caregivers and family to provide both skill practice and feedback in a coordinated fashion. Typically weekly homework is assigned, for example, journaling about trigger situations and associated reactions or required direct practice in less structured settings. The goal is to facilitate generalization of skills to real world environments and situations. Eventually, as you make progress, you’ll practice in real-life social situations, for example, a phone call with the doctor’s office, a trip to the grocery store, a walk around the block, to gauge your awareness and social skills.

You might find yourself feeling uncomfortable as you try new communication styles. You might make mistakes in your role-playing or in your real-life practice. It’s okay to experience this discomfort and to make these mistakes. The people you are working with will help you use those opportunities to learn and provide you with many chances to try again. They will help you keep the end goal in mind: close friendships, family relationships, and romantic relationships.

For some people with moderate or severe brain injury, it is possible that improvement may be gradual and limited. In those cases, it is critical for family members to provide connection, love, and communication, and when possible to share with outsiders how to best engage with their loved one.

How strong is the evidence?

Social interaction and communication is an integral part of life. Specific interventions for improving functional communication skills (specifically those targeting pragmatic communication and recognizing emotions from facial expressions) are currently the evidence-based practice standard for individuals with TBI and social skills impairments. There is also a practice option to consider the use of group based interventions for treating TBI related social communication deficits.

Personal Stories

• Daniel Dovenbarger and Mark Dirlam discuss how to communicate as a couple.
  From BrainLine
• Rosemary and Hugh Rawlins discuss how relationships change after brain injury.
  From BrainLine

Where can I go to get this treatment?

Your primary care provider can help you find specialists that work in social skills and social communication training. Specialists include speech-language pathologists, neuropsychologists, psychologists, social workers, occupational therapists and other health care professionals. Your work will probably be most productive with a professional who has had specialized training in conducting cognitive rehabilitation and social skills training in particular, as well as experience working with people with TBI or PTSD. You can also practice the social skills and communication strategies you learn in treatment with a trusted caregiver, family member, or close friend.

Where can I go to find more information?

• Tips for Communicating with People with TBI and PTSD
  From BrainLine
• Social Communication Skills After Brain Injury — Information about changes in communication after brain injury and tips on how to help.
  From BrainLine
• Social Skills After Traumatic Brain Injury — From Model Systems Knowledge Translation Center, an overview of social skills training and treatment options.
  From MSKT
• BrainSTARS: Social Skills — A part of the manual, Brain Injury: Strategies for Teams And Re-education for Students, which helps parents and teachers of children with brain injury.
  From BrainLine
• The Group Interactive Structured Treatment — “GIST combines a structured goal-oriented curriculum with an interactive group process.”

References

Cicerone, K. D., Dahlberg, C., Kalmar, K., Langenbahn, D. M., Malec, J. F., Bergquist, T. F., Felicetti, T., Giacino, J. T., Harley, J. P., Harrington, D. E., Herzog, J., Kneipp, S., Laatsch, L., & Morse, P. A. (2000). Evidence-based cognitive rehabilitation: Recommendations for clinical practice. Archives of Physical Medicine and Rehabilitation, 81(12), 1596–1615.

Cicerone, K. D., Dahlberg, C., Malec, J. F., Langenbahn, D. M., Felicetti, T., Kneipp, S., Ellmo, W., Kalmar, K., Giacino, J. T., Harley, J. P., Laatsch, L., Morse, P. A., & Catanese, J. (2005). Evidence-Based Cognitive Rehabilitation: Updated Review of the Literature From 1998 Through 2002. Archives of Physical Medicine and Rehabilitation, 86(8), 1681–1692.

Cicerone, K. D., Goldin, Y., Ganci, K., Rosenbaum, A., Wethe, J. V., Langenbahn, D. M., Malec, J. F., Bergquist, T. F., Kingsley, K., Nagele, D., Trexler, L., Fraas, M., Bogdanova, Y., & Harley, J. P. (2019). Evidence-Based Cognitive Rehabilitation: Systematic Review of the Literature From 2009 Through 2014. Archives of Physical Medicine and Rehabilitation, 100(8), 1515–1533.

Cicerone, K. D., Langenbahn, D. M., Braden, C., Malec, J. F., Kalmar, K., Fraas, M., Felicetti, T., Laatsch, L., Harley, J. P., Bergquist, T., Azulay, J., Cantor, J., & Ashman, T. (2011). Evidence-Based Cognitive Rehabilitation: Updated Review of the Literature From 2003 Through 2008. Archives of Physical Medicine and Rehabilitation, 92(4), 519–530.

LaMotte, A. D., Taft, C. T., Weatherill, R. P., & Eckhardt, C. I. (2017). Social skills deficits as a mediator between PTSD symptoms and intimate partner aggression in returning veterans. Journal of Family Psychology, 31(1), 105–110.

Rietdijk, R., Power, E., Attard, M., Heard, R., & Togher, L. (2020). Improved Conversation Outcomes After Social Communication Skills Training for People With Traumatic Brain Injury and Their Communication Partners: A Clinical Trial Investigating In-Person and Telehealth Delivery. Journal of Speech, Language, and Hearing Research, 63(2), 615–632.

Togher, L., McDonald, S., Tate, R., Rietdijk, R., & Power, E. (2016). The effectiveness of social communication partner training for adults with severe chronic TBI and their families using a measure of perceived communication ability. NeuroRehabilitation, 38(3), 243–255.