A conceptual framework for work-related social skills in psychiatric rehabilitation.

Social skills and social skills training have attracted considerable attention in the field of psychiatric rehabilitation in the past two decades. There are numerous studies (Bellack, Morrison, Wixted, and Mueser, 1990; Bryant, Trower, Yardley, Urbieta, and Letemendia, 1976; Christoff & Kelley, 1985; Curran, Miller III, Zwick, Monti, and Stout, 1980; Feinberg, Rifkin, Schaffer, and Walker, 1986; Goldstein & Manderscheid, 1981) which show that psychiatric patients, especially those with schizophrenia, have significant deficits in social skills and social performance. Many rehabilitation counselors, health care professionals, and social workers have proposed conceptual frameworks for social skills in general that guide rehabilitation (Argyle, 1988; Hargie, Saunders & Dickson, 1981; McFall, 1982; Liberman, Mueser, Wallace, Jacobs, & Massel, 1986).

In recent years, it has been pointed out that social skills and social skills training are to a great extent related to specific social situations (Bromley, 1981; Douglus & Musser, 1990; Duncan & Fiske, 1977; Kelly, 1982; Phillips, 1978; Wallace, Nelson, Liberman, Aitchison, Elder, & Ferris, 1980). As a result, efforts have been made to provide specialized training in different situations. Some training programs lay emphasis on heterosexual interactions (e.g. Longer & Farrell, 1981), while others center on work-related situations (e.g. Wilkinson & Canter, 1982). It is well-known that people with schizophrenia have serious employment problems which include getting and keeping a job. This may be the result of inadequacy in social performance (Argyle, 1992). It is therefore highly strategic from a rehabilitation point of view to pay more attention to the application of social skills training in work-related situations.

A general model for social skills is insufficient to guide training in work-related situations. Instead, it is best to have a conceptual framework for work-related social skills (WSS) to serve such a purpose. It is rather disappointing to find, after a comprehensive review of the literature, that documentation in this area is extremely limited. There have been several studies recently (Farley & Hinman, 1986; Herbert & Ishikawa, 1991; Park & Gaylord-Ross, 1989) which are concerned with social skills at work. However, their focus is on people with a learning disability rather than on people with schizophrenia. Others are concerned with prisoners (e.g. Calabrese & Hawkins, 1988). In view of the scarcity of work in this area, this study was aimed at postulating a conceptual framework for WSS and at the same time testing its validity. In addition, a number of skill components were generated to act as a working guide for the development of relevant assessment and training packages.

The Framework

The importance of social skills in work situations has been fairly well documented (Argyle, 1992; Fontana, 1990; Kimbrell & Vinegard, 1975; McGoven, 1976). Yet, only a few people have comprehensively analyzed WSS. Different authors tend to interpret the term in different ways. Some of them try to make an inventory of its elements (e.g. Argyle, 1991; Fontana, 1990; Foy, Massey, Duer, Ross, and Wooten, 1979; Montague, 1988). However, a unified and consistent interpretation among the theorists and practitioners is lacking. It is certain from the authors cited above that WSS involves several variables including basic social skills, skills in interaction with seniors, fellow workers, and subordinates, and skills in handling specific work situations. A more systemic schema for WSS can be found in a paper by Salzberg, Lignugaris/Kraft, and McCuller (1988), who used the term "social-vocational competence," consisting of task-related and personal-social competence, instead of WSS. Although this model appears to be fairly systematic, it is by no means complete and directly applicable to the rehabilitation of those with schizophrenia. Apart from the components included in the above discussion, it is strongly felt that job securing social skills (JSSS) and skills in handling job situations specific to a particular job must surely also be domains of concern for WSS.

In the following section, a conceptual framework is proposed for WSS which integrates the concepts discussed above. In this model, WSS is conceptualized within a three-tier framework. This approach implies that the three tiers have a hierarchical relationship, with the first tier being more basic and the other two tiers being more advanced. The framework is represented schematically in Figure 1.

The first tier refers to basic skills. It consists of basic social skills (BSS) and basic social survival skills (BSSS). Basic social skills are the most basic skills such as receiving, processing, and sending skills as put forward by Liberman, Mueser, Wallace, Jacobs, Eckman, and Massel (1986). To make it more complete, assertiveness is added to this category. Basic social survival skills are such skills as grooming, politeness, and personal appearance, which are necessary for social competence. The next tier is referred to as the core skills. It is divided into two clusters of skill components: skills in handling general work-related situations and skills in handling specific work-related situations. In the simplest sense, the first cluster includes those skills needed for coping with any job irrespective of its specific nature. Job-securing social skills (JSSS) and job-retaining social skills (JRSS) can be grouped under this category. The second cluster comprises skills vital for coping with situations specific to a particular kind of job. Finally, the third tier encompasses the results to which the basic and core skills point: in other words, the benefits that a person can obtain if he possesses these skills. The benefits embrace getting a job, settling down in a job, maintaining a job, and deriving a sense of achievement and satisfaction from the job.

Methodology

In order to test the validity of the proposed framework and to generate a list of its associated representative elements, a survey was conducted which attempted to collect opinions from three groups of subjects: (a) professional workers directly involved in delivering rehabilitative services to people with schizophrenia (PW), (b) people with schizophrenia (S), and (c) ordinary workers who had not suffered from mental illness (NS).

A questionnaire consisting of three sections was designed for this purpose. The first section collected basic demographic data from the subjects. The second section consisted of six open-ended questions that asked the subjects their opinions on (a) the abilities that were necessary for a person with schizophrenia to get a job, (b) the abilities needed to keep a job, (c) the problems encountered when seeking a job, (d) the problems encountered at work, (e) the social skills required to get a job, and (f) the social skills required to keep a job. Questions 1 to 4 were aimed at assessing whether work-related social skills were important in their eyes for people with schizophrenia in seeking and maintaining a job. Questions 5 and 6 were included to see whether the responses from the participants fitted the constructs of the framework as proposed by the author. In other words, the design of section two was to assess the validity of the proposed framework in a qualitative way. The third section included forty-one items related to different constructs of WSS which tried to tap the subject's views on their degree of importance for a person with schizophrenia to secure and retain a job. The items were generated from the literature and the clinical experience of related professionals. A subject had to rate each item according to a seven-point scale, with 1 indicating total unimportance and 7 indicating extreme importance. The purpose of this section was twofold: first, it was a means of validating the framework through confirmatory factor analysis: secondly, representative items could be generated from each construct of the framework.

Sixty questionnaires, together with a letter clearly stating the purpose of the research, were sent out to sheltered workshops and half-way houses involved in providing rehabilitative services to clients with schizophrenia to invite feedback from all qualified PW participants. A total of 44 (24 males, 20 females) were returned. The response rate was 73.3 percent. The mean age of the respondents was 32.6 and the mean seniority was 4.6 year.

Similarly, thirty questionnaires were mailed to the Hong Kong Federation of Trade Unions to collect opinions from the NS participants. A total of 18 questionnaires were returned, a response rate of 60 percent. As the NS participants were recruited from a handicraft interest class organized by the trade unions, all of them were female and sewing workers. The mean age was 32.8. For practical reasons, the NS participants were not required to fill in the second section of the questionnaire.

Liaison was made for S participants with centres in charge of sheltered workshops and half-way houses. Participants who met the selection criteria were recruited through the staff. The selection criteria were as follows: males or females aged between 18 and 50; either employed or unemployed, their present or previous occupation being production and related workers, basic clerical and related workers, service workers, etc.; education level: primary 5 to form 5; diagnosed by a registered medical officer in Hong Kong as suffering from schizophrenia; had been hospitalized for not less than one year; and not suffering from mental retardation.

Altogether, 54 participants (36 males, 18 females) were selected. In order to ensure that the questionnaire was filled in properly, each of them had to complete the questionnaire in the presence of the researcher or research assistant. The purpose of their presence was merely to avoid misinterpretation and to ensure that the questionnaire was completed in accordance with the requirements. There was therefore little effect on the validity of the data as a result of the researcher's bias. Of the participants, 17 were employed and 37 were either unemployed or working in sheltered settings. The mean age was 37.8.

Results

Section two of the Questionnaire

Section two of the questionnaire is based on responses from professional workers and patients with schizophrenia (N=98). This paragraph reports the number of each social skills-related response and its rank from question 1 to 4. In question 1, responses which related to social skills were as follows: (a) dressing appropriately and having a good personal appearance (n=25, rank=3), (b) answering appropriately during the job interview (n=22, rank=4), (c) having good general social skills (n=12, rank=8), (d) speaking fluently during the job interview (n=7, rank=9), and (e) being polite (n=6, rank=10). In question 2, the social skills necessary to retain a job included: (a) skills to interact with colleagues harmoniously (n=24, rank=2), (b) skills to interact with seniors harmoniously (n=17, rank=5), and (c) interpersonal skills (n=12, rank=6). Social skills-related problems in securing a job, as asked in question 3 were: (a) not knowing how to answer questions during job interview (n=42, rank=1) and (b) being tense during job interview (n=8, rank=8). Responses to question 4, social skills related problems in retaining a job, consisted of: (a) being unable to interact with colleagues harmoniously (n=38, rank=1), (b) taking leave to attend follow-up medical consultations (n=16, rank=4), and (c) be unable to interact with senior harmoniously (n=10, rank=10).

Responses to questions 5 and 6 are grouped into categories in accordance with the construct as proposed in the conceptual framework. The results are depicted in Table 1.

Table 2 summarizes the main findings from section three of the questionnaire. All of the scores from the three groups were over four. This signifies that all of the participants tended to feel that their relationships with their colleagues and the associated WSS were important for survival at work. When the three groups were analyzed as a whole, the mean score was highest for BSSS (5.79) and lowest for JRSS (4.84). When the three groups were compared using oneway ANOVA, the scores were statistically different for BSSS, JSSS, and skills for interaction with fellow workers. Tukey HSD tests showed that NS participants consistently scored lower than PW and S participants. There were no significant differences between PW and S participants.

In order to test for the validity of the proposed framework and the related constructs, confirmatory factor analysis of the relevant items of section three of the questionnaire was conducted. Five main factors were extracted by principal components method with varimax rotation. The five factors extracted were: interaction with customers (i.e. skills in handling specific job-related situations), [TABULAR DATA FOR TABLE 1 OMITTED] job-securing social skills; interaction skills with supervisors; interaction skills with co-workers; and basic social skills (assertive skills). The factor loadings of relevant items for the five factors are shown in Table 3.

The items with highest score for BSSS were in interacting with others politely (M=5.92) and maintaining a good personal appearance (M=5.83). Participating appropriately in a job interview (M=5.75) were the items with the highest scores for JSSS. For JRSS, items with high scores included requesting an urgent day's leave (M=5.70), resolving conflicts with seniors (M=5.49), cooperating with colleagues to perform a group task (M=5.53), not being involved in destructive gossip (M=5.48), helping to instruct or demonstrate a task to a colleague (M=5.16), and handling complaints from clients (M=5.0).

[TABULAR DATA FOR TABLE 2 OMITTED]

Interpretation and Discussion

As questions 1 to 4 in section two of the questionnaire were open-ended, the participants had the freedom to express their opinions in accordance with their viewpoints. This arrangement ensured that their answers were unbiased. If their responses were related to social skills, this might imply that WSS was seen as important for a person with schizophrenia at work. The results were surprisingly positive. In question 1, having an adequate job interview technique ranked fourth among the responses. In question 3, not knowing the proper interview techniques was the most frequently reported answer. Similarly, in question 2, interaction with colleagues ranked second and interaction with seniors ranked fifth; in question 4, problems related to interaction with colleagues ranked first and problems related to interaction with seniors ranked fourth and tenth respectively. These data point to the fact that, although there are other factors affecting the process of securing and retaining a job, WSS play a significant role. This finding is consolidated by results from section three. The mean scores for the importance of relationships with colleagues at work among the three groups of participants ranged from 5.28 to 5.61. Oneway ANOVA revealed that differences among the groups were not significant. This, in turn, suggests that all of the participants regarded WSS as an important factor contributing to success at work.

In question 5, 87.7 percent of the responses were related to the different constructs pertaining to WSS as proposed by the framework. BSSS received the highest percentage of responses (34.1 percent) and JSSS ranked second (30.6 percent). In question 6, 94.2 percent of the responses could be classified [TABULAR DATA FOR TABLE 3 OMITTED] within the framework. JRSS received the highest percentage (73.8 percent). Also, as can be seen in Table 1, there were no responses that could not be categorized under this framework. This reflects a consistency in opinions in connection with the components of the WSS between the author and the PW and S participants. As well as support from the qualitative analysis based on the results in section two, confirmatory factor analysis of items from section three, as shown in Table 3, pointed to similar results. The five factors extracted, skills in handling specific job-related situations, job-securing skills, interaction skills with supervisor, interaction skills with co-workers, and basic social and assertive skills, complied with the constructs as proposed in the framework. Although this was not a controlled study, the results provide a preliminary substantiation to the overall configuration of the suggested model.

The mean score for BSSS (5.79) of all the participants was higher than that of other components of WSS. The participants therefore thought that BSSS was more important than the core skills such as JSSS and JRSS. Data from section two suggested the same conclusion. The response "appropriate dressing" in question 1 ranked higher than the response "performance in job interview." This supports the hierarchical nature of the tier approach to WSS. The basic skills may be treated as the foundation skills on which the core skills build. Without the basic skills, a trainee cannot proceed to receiving training in the more advanced skills. As applied to the clinical setting, training in WSS should be preceded by training in general social skills. Another point of interest is that JSSS was thought to be more important than JRSS. The data in the current study do not reveal the underlying reasons for this. It may be that other factors contribute more to the process of retaining a job than with the process of finding a job. In other words, JSSS plays a more crucial role in finding a job when compared with JRSS in relation to keeping a job. This hypothesis also receives support from the results outlined in section two. In question 3, the percentage of non-social skills related answers is was 55.0 per cent. This figure was 75.3 per cent in question 4. This means that there are more problems associated with keeping a job than in finding a job, other than those related to WSS.

Most of the scores were not statistically different among the three groups of participants. This suggests that the results were fairly consistent among these three groups of participants. If one group felt that a particular construct was important while the other two groups held different opinions, doubt may be cast upon the reliability of the findings. Consistency of results among these three groups reinforces the importance of WSS. Yet, there are still three scores (i.e., BSSS, JSSS and interaction skills with fellow workers) which showed significant differences between the groups. HSD post-hoc comparisons showed that NS participants consistently scored lower in these three components when compared with the other two groups. However, there was no significant difference between PW and S participants. This may be due to a lack of awareness of the rehabilitation needs of people with schizophrenia among the NS participants. This may, in turn, have led them to underestimate the importance of the more basic skills needed for successful interaction with fellow workers. They may take these skills for granted and assume that every person should possess them.

Finally, the items with high scores for different constructs, as stated in the results section, may be regarded as the most representative elements. They can be selected as the assessment and training components when related packages are developed clinically.

Discussion

In summary, a conceptual framework for work-related social skills which can be applied to psychiatric rehabilitation has been suggested. The framework follows a three-tiered approach, consisting of basic skills, core skills and the results subsequent to the possession of these skills. Although this was not a controlled study, preliminary support for its validity was received from professional workers in the field of psychiatric rehabilitation, ordinary workers, and people with schizophrenia. A list of the most representative skill components related to the different constructs within the framework was generated. These are significant for clinical practice.

The importance of developing a conceptual framework is not simply an academic matter. Its real importance lies in its guiding value for formulating assessment and training packages relevant to the needs of those with schizophrenia. Previous attempts (Clement-Heist, Siegel, and Gaylord-Ross, 1992; Foy et al., 1979; Mueser & Foy, 1986; Rubin & Locascio, 1985) are far from satisfactory. The most fundamental methodological limitation is a lack of a clear and coherent framework for WSS. As a result, the assessment instruments are not specific and the training is not geared towards the needs of the clients. Also, these programs, of course, are not tailor-make for people with schizophrenia.

However, with this suggested framework, a more consistent operational definition of WSS may be worked out by researchers in this field. The list of representative skill components generated, mentioned in the results section can form a pool from which items can be selected when an assessment or training package is to be compiled. For instance, participation in job interviews and a request for urgent leave from a boss may be adopted as role-play situations to assess the WSS of those with schizophrenia. It is hoped that the results of this preliminary study will help researchers to further their work in this area.

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Wing-hong Hector Tsang, 13D, Block 1, Phoenix Court, 39 Kennedy Road, Hong Kong