Interpersonal difficulties have been widely described in individuals with psychosis spectrum disorders and, specifically, they are a major feature of schizophrenia. The most common social deficits include, for example, problems in conversing, managing conflict, or acting assertively with family, friends, community members, or co-workers. These limitations are highly disabling and as a result, social skills training (SST) is considered an essential part in the treatment of schizophrenia and its inclusion is recommended in multiple clinical practice guidelines for schizophrenia.
Treatments for improving interpersonal functioning in schizophrenia
The current treatments available for improving interpersonal functioning in schizophrenia can be divided into two groups: those derived from behaviorism and those based on promoting social cognition.
Treatments derived from behaviorism
The general objective of the first group of treatments is to improve the social functioning of patients through a systematic training of socially effective behaviors; this model is based on theories of behavior modification and social learning. Some studies support the effectiveness of such interventions in improving psychosocial functioning in patients with schizophrenia, and even in reducing psychotic symptoms, relapse rate, and hospitalizations. However, more recent studies reveal that the effects of these interventions and the generalization of these effects are limited.
For instance, a meta-analysis conducted by Pilling et al.  found no significant benefit in clinical trials using SST programs. Similarly, Kurtz and Mueser  demonstrated that these interventions have a moderate effect on psychosocial functioning (d = 0.52) and a small effect on relapse reduction (d = 0.23). In the same vein, a recent review by the Cochrane Collaborationhas concluded that, to date, it remains unclear whether current SST programs are more effective than conventional treatments/traditional interventions.
The second group of treatments are focused on training different areas of social cognition to improve the interpersonal functioning of patients with schizophrenia. Social cognition refers to the various mental abilities that underlie social interactions. The abilities that have attracted the most interest in the field of schizophrenia are theory of mind (ToM), emotion recognition, and attributional style.
One of the most well-known interventions of this kind is Social Cognition and Interaction Training (SCIT). There are data that support the efficacy of SCIT in patients with schizophrenia as well as other similar programs aimed at improving facial emotion recognition, ToM or attributional style. However, Kurtz and Richardson  have found that these programs have an unequal impact on social cognition. It has been observed that their effects on facial emotion recognition are between moderate and high (identification, d = 0.71 and discrimination, d = 1.01), lower on ToM (d = 0.46) and zero on social perception, attributional style, and positive and negative symptoms of schizophrenia.
At the clinical level, the excessive use that this kind of programs make of computerized tasks for improving social cognition has also been questioned. It seems logical to assume that to effectively improve mental abilities involved in meaningful social interaction, they must be practiced in real-world interpersonal contexts, close to those experienced by patients on a regular basis.
On the other hand, at the theoretical level, there is abundant evidence that social deficits in schizophrenia are more consistently related to difficulties in understanding and integrating one’s own and others’ mental states in interpersonal situations with high emotional content, and not so much with isolated neurocognitive deficits.
In light of these findings,Ottavi et al. have developed a novel therapeutic intervention that integrates metacognitive remediation into SST for patients affected by schizophrenia: metacognition-oriented SST (MOSST).
The social skills trained in MOSST are similar to those of other conventional SST programs. However, MOSST seeks to stimulate participants to develop metacognitive skills and promote a rich understanding of the mental processes underlying social situations. MOSST also offers a unique approach for the promotion of self-reflexivity, that is, for the development of increasingly complex mental representations of the self, with one’s own thoughts, intentions, emotions, and desires. This, in turn, allows participants to understand that their own thoughts and subjective experiences are different from those of others and that their inner expectations do not have a direct effect on reality. A more detailed description of MOSST can be found in Inchausti et at.  or by clicking here.
A recent clinical trial published by our team in the Schizophrenia Bulletin, the leading medical journal which covers research relating to schizophrenia and related disorders[8, 9](available here), has demonstrated the superiority of this type of intervention over others that are based solely on systematic training of desirable social behaviors. The results of this trial suggest that combining social skills training and metacognitive skills training may produce superior and longer-lasting improvements (significant improvements persisted at 6-months after treatment) in the number and quality of interpersonal relations, as well as a significant decline in the frequency of disruptive and/or aggressive social behaviors of these patients.
With replication, these results could have important clinical implications. Firstly, because it is a relatively short program (16-weekly sessions of 90 minutes each) in which the number of participants per group rang ebetween 5 and 10, which makes it a cost-effective, manualized intervention that may produce sustained improvements in psychosocial functioning of people with schizophrenia. However, given the metacognitive emphasis of MOSST, it is important to underline that participants with greater neurocognitive impairments (e.g., in attention, memory or processing speed) may require prior neurocognitive rehabilitation, for example with platforms such as NeuronUP, for treatment to be fully effective. In this sense, neurocognitive functioning in patients with schizophrenia is an essential prerequisite for interventions likeMOSST to be truly beneficial.
- Pilling S, Bebbington P, Kuipers E, Garety P, Geddes J, Martindale B, Orbach G, Morgan C: Psychological treatments in schizophrenia: II. Meta-analyses of randomized controlled trials of social skills training and cognitive remediation. Psychol Med 2002, 32(5):783-791.
- Kurtz MM, Mueser KT: A meta-analysis of controlled research on social skills training for schizophrenia. J Consult Clin Psychol 2008, 76(3):491-504.
- Almerie MQ, Okba Al Marhi M, Jawoosh M, Alsabbagh M, Matar HE, Maayan N, Bergman H: Social skills programmes for schizophrenia. Cochrane Database Syst Rev 2015(6):Cd009006.
- Penn DL, Roberts DL, Combs D, Sterne A: Best practices: The development of the Social Cognition and Interaction Training program for schizophrenia spectrum disorders. Psychiatr Serv 2007, 58(4):449-451.
- Kurtz MM, Richardson CL: Social cognitive training for schizophrenia: a meta-analytic investigation of controlled research. Schizophr Bull2012, 38(5):1092-1104.
- Ottavi P, Pasinetti M, Popolo R, Salvatore G, Lysaker PH, Dimaggio G: Metacognition-Oriented Social Skills Training. In: Social Cognition and Metacognition in Schizophrenia. edn. Edited by Lysaker P, Dimaggio G, Brüne M. San Diego: Academic Press; 2014b: 285-300.
- Inchausti F, Garcia-Poveda NV, Prado-Abril J, Ortuño-Sierra J, Gainza-Tejedor I: Entrenamiento en habilidades sociales orientado a la Metacognición (MOSST): Marco teórico, metodología de trabajo y descripción del tratamiento para pacientes con esquizofrenia. Pap Psicol2017, 38(3):204-215.
- Inchausti F, García-Poveda NV, Ballesteros-Prados A, Fonseca-Pedrero E, Ortuño-Sierra J, Sánchez-Reales S, Prado-Abril J, Aldaz-Armendáriz JA, Mole J: A pilot study on feasibility, acceptance and effectiveness of metacognitive-oriented social skills training in schizophrenia. BMC Psychiatry 2017, 17:217.
- Inchausti F, García-Poveda NV, Ballesteros-Prados A, Ortuño-Sierra J, Sánchez-Reales S, Prado-Abril J, Aldaz-Armendáriz JA, Mole J, Dimaggio G, Ottavi P et al: The Effects of Metacognition-Oriented Social Skills Training on Psychosocial Outcome in Schizophrenia-Spectrum Disorders: A Randomized Controlled Trial. Schizophr Bull2017, in press.