Synapse - reconnecting lives

Our ability to communicate is just one of the many life skills that can be affected by brain disorders such as traumatic brain injury. 

It is in the area of interpersonal/social functioning that judgment and perceptual changes often lead to the most distressing disturbances. Confusion can arise due to being overwhelmed by the sheer weight of information needed to redevelop adult social skills. Insight and self-awareness can also be directly disturbed, especially by frontal lobe damage. Orbitofrontal damage in particular (injury to the very front of the brain) can disrupt an individual's ability to inhibit unwanted responses such as inappropriate anger, sexual expression, humour or tears without accompanying sadness. The potential for social isolation is very great unless at least some of these social skills can be relearned.

What are social skills?

Social skills are an incredibly complex system of behaviours that are central to communication between individuals, involving giving, receiving and interpreting messages. Social skills include verbal and nonverbal behaviour. They are influenced by culture and the immediate social group, reflect environmental factors including age, sex and status and depend upon an individual's personality, past experiences and perception of the other person.

Perhaps most importantly, social skills are learnt, not instinctive. They increase with social reinforcement from others and, when social isolation or a developmental or acquired disability impact upon social skills, require feedback from others in order to develop.

Social skills deficits may be related to impulsivity, both verbal and motor, poor visual perception of facial and body language cues, poor auditory perception of vocal cues, invasion of the personal space of others, inappropriate touching, untidiness, disorganization, and a number of other such problems. Mood swings, overreaction, and depression may also provide problems for the individual with learning disabilities.

Social skills are the foundation for getting along with others. A lack of social skills can lead to behavioural difficulties, emotional difficulties, difficulty in making friends, aggressiveness, problems in interpersonal relationships, poor self-concept, academic and work failures, concentration difficulties, isolation from peers, and depression. In short a lack of social skills is likely to lead to a degree of social isolation.
Social Skills TrainingSocial skills training (SST) is a form of behaviour therapy used by teachers, therapists, and trainers to help persons who have difficulties relating to other people.

Social skills training should rest on an objective assessment of the patient's actual problems in relating to other people. Complex social behaviours are exactly that: Complex. Each behaviour is composed of multiple small behaviours, any of which may be impaired in a person with acquired brain injury or, alternatively, may be perfectly intact. It makes no sense to focus on a behaviour that is unimpaired: Therefore, a detailed assessment of behaviour should be conducted first.

A Four Step Model for Social Skills Training

1. Identify Social Skill Deficits
2. Select Intervention Strategies
3. Implement Intervention
4. Assess and Modify Intervention as Necessary

1. Identify Social Skill Deficits

The first step in any social skills training program should be to conduct a thorough evaluation of the individual's current level of social functioning. The evaluation should detail both the strengths and weakness of the individual related to social functioning.

2. & 3. Select and Implement Intervention Strategies

Accommodation and Assimilation

When selecting intervention strategies, it is important to consider the notion of accommodation versus assimilation. Accommodation, as it relates to social skills instruction, refers to the act of modifying the physical or social environment of a person to promote positive social interactions. For example, educating family, friends and work colleagues about the problems in socialization that can be caused by an ABI.
Assimilation refers to instruction that facilitates skill development that allows the person to be more successful in social interactions. The key to a successful social skills training program is to address both accommodation and assimilation.

Providing skill instruction (assimilation) without modifying the environment to be more accepting of the person with an ABI sets the person up for failure. This happens the moment this person tries out a newly learned skill on a group of non-accepting peers. The key is to teach skills and modify the environment. This ensures that the new skill is received by peers with both understanding and acceptance.

Training Strategies

Some commonly used strategies for training social skills include:

• Peer mentors have been frequently used to promote positive social interactions. Peer mediated instruction allows us to structure the physical and social environment in a manner to promote successful social interactions.
• Role Playing/Behavioural Rehearsal is used primarily to address basic interaction skills. Role-playing consists of acting out various social interactions that the person would typically encounter.

Videotaped Self Modelling

Social skills are primarily acquired through learning that involves observation, modelling, coaching, social problem solving, rehearsal, feedback, and reinforcement-based strategies. VSM is an intervention where individuals learn skills by observing themselves performing the targeted skill. A strength of VSM is that it allows the individual to learn both through observation and through personal experience.

4. Assess and Modify the Intervention

Although "Assess and Modify" is listed as the last stage in the intervention process, it certainly is not the least important. In addition, it also is not the last thing to think about when designing a social skills program.

Assessment and modification of the interventions is an ongoing process that starts on the first day of the training and in truth never actually ends.
Self-managed social skills trainingBecause social skills are social - involving more than one person - improving your social skills requires the participation of other people who understand the position you are in and are willing to help by providing encouragement, support and, most importantly, feedback. It is very difficult to be tactful when it comes to social skills, and not everybody has the trick. You must therefore be prepared for fairly confronting criticism. Here are some tips if you are unable to access a social skills trainer:

• Enlist the help of your family and friends. This may involve first teaching them about acquired brain injury and the effect it has had upon you. Some people may not accept that you have lost skills. On the other hand, some people may be prepared to accommodate even severely inappropriate behaviour. You may need to ask people to be more critical, and to give you more feedback in the home so that you can relearn how to act appropriate in the community.
• Join a peer support group. Access to a group such as this will of course greatly depend upon where you live. Contact your local Brain Injury Association for possible groups in your area. Some groups are for everyone with a brain injury, but there are also groups for specific causes of brain injury - for example, motor vehicle accidents or stroke.
• Watch other people. Don't be too obvious about this! The best way of learning social skills is to practice them, but the second-best way is to watch other people. Of course, not everyone you may watch will behave appropriately - a good tip is to avoid reality television and focus on busy public places. Sit at a café in a shopping centre and watch the world go by.