Training interpersonal problem-solving skills in ...

Interna tional Review of Psychiatry (1998), 10, 30± 34

Downloaded By: [University of Lausanne] At: 09:55 1 February 2008

Training interpersonal problem -solving skills in French-speaking Switzerland J. FAVROD, 1 A. M CQUILLAN, 1 V. POM IN I 2 & F. P. FERRERO 1 1

C linique de Psychiatrie II, DeÂ partement de psychiatrie, HoÃ pitaux Universitaires de GeneÁ ve & 2 UniversiteÂ de Lausanne, Institut de Psychologie, Switzerland

S um m ary The instrum ent, Assessm ent of Interpersonal Problem-Solving Skills (AIPSS), and the rehabilitation interv ention, Training in Interp ersonal Problem -Solving Skills (TIPSS), which were developed at U CLA in the U SA, were adapted for a French-speaking cultura l setting in Geneva , Switz erland. Pilot studies replicated the original U SA ® ndings on the AIPSS and the TIPSS. These m eth ods were practicab le with French-speaking patients and ® t readily into a French cultura l setting with little adaptation.

Introduction Im pairm ents in interpersonal functioning are a m ajor challenge in treating people suffe ring from schizophrenia. Even when ¯ orid sym ptom atology is psychopharm acologically controlled or rem itted, m any patients still have dif® culties socializing with others. Social skills training has demonstrated its ef® cacy in im proving such im pairm ents. M etaanalyses show that social skills training has a strong and positive im pact on behavioral m easures of social perform ance, self-evaluation of social com petence, discharge rate from hospital, and a m oderate im pact on relapse rate (Benton & Schroeder, 1990; C orrigan, 1991). The im pact of social skills training can also be docum ented in the generalization and m aintenance of skills acquired in training sessions. In view of these results, social skills training has becom e an essential ingredient in the treatm ent of schizophrenia in com bination w ith fam ily psychoeducation and antipsychotic m edication (Bertolote & de Girolam o, 1993). The m ost widely accepted m odel of social skills is based on a three-step sequence starting with: (1) the accurate perception and interpretation of social cues, going through (2) the decision about w hat w ould be the m ost approp riate response to the situations, and ® nishing by (3) the implementation of the app ropriate behavioral response (McFall, 1982; Trow er et al., 1978; W allace et al., 1980). T his inform ation processing or problem -so lving m odel has contributed to m ajor changes in social skills m ethodologies. C linicians have integrated cognitive variables into the traditional training of directly observed behaviors. For exam ple, social perception and decision-m aking now are considered integral to social skills training. In the m odules for training social and independent living skills, designed and validated by W allace, Liberm an and their colleagues at UC LA, social

perception is trained through questions-an d-answers that follow videotaped dem onstrations of taught skills. Problem -solvin g skills are also taught for obtaining resources necessary to accom plish the task or to overcom e potential obstacles interfering with the task. The Interpersonal Problem-Solving Skills m odule attempts to integrate cognitive skills that are particularly relevant to schizophrenic patients who present a wide range of cognitive de® cits (Liberm an & G reen, 1992). To test the ef® cacy of this m odule on the inform ation processing capacities of schizophrenic individuals, the Assessment of Interpersonal Problem-Solving Skills (AIPSS) (Donahoe et al., 1990) w as speci® cally developed to evaluate the cognitive and behavioral skills of schizophrenic patients. Assessm ent and training of interpersonal problem -so lving has been adapted and disseminated to a French cultural setting in Sw itzerland by m eans of the UC LA m odule and a French version of the AIPSS. T his international diffu sion of social skills training is a propitious event because behavior therapy is little used in the public psychiatric services of France, Belgium or Switzerland. The reasons for not using cognitive or behavio ral therapy with m entally ill patients include obstacles in system atically organizing the psychiatric m ilieu; inadequate training of professio nals in cognitive-behavioral therapy; and a lack of aw areness by clinicians of newer therapeutic options (C ottraux, 1992). Another source of resistance to the use of social skills training in schizophrenia derives from the popularity of the psycho analytic m odel w ith chronic psych iatric patients despite its failure as an ef® cacious treatment. However, for the past ® ve years public services in European countries have been under increasing pressure from tightening budget restrictions and cost containm ent policies. This will be an increasingly im portant incentive to adopt

C orrespondence to: J. Favrod, C.T.B . ouest, 10 rue des Epinettes, CH -1227 Carouge, Switzerland. 0954± 0261/98/010030± 05 $7.00

Ó

1998, Institute of Psychiatry


Problem-solving skills in Switzerland m ore effective treatments, such as social skills training. Several strategies have been used to prom ote the dissem ination of social skills training with chronic psychiatric patients in French-sp eaking countries. Books and m anuals have been publish ed in French (C ham bon, 1992; Liberm an, 1991; ), as well as reviews on the ef® cacy of skills training (Favrod & Barrelet, 1993), and ® eld tests of these m ethods (C ham bon et al., 1993; 1995; Favrod et al., 1994; 1996; Grossenbacher et al., 1995; Pom ini & N eis, 1993). C ongresses and conferences have been organized on the topic. The Francophone N etwork of Rehabilitation Program s, an association created to coordinate translation effo rts and to provide potential users with educational workshops, training m aterials and assessm ent tools, has ¯ ourished. A gam e to train chronic psychotic persons in social skills called «Com petence» (Favrod et al., 1995) has been widely distributed by a pharm aceutical ® rm. U CLA modules such as Medication M anagement, Sym ptom M anagem ent, Basic C onversation and T raining in Interpersonnal Problem -Solving Skills are availab le in French as w ell as a French-Canadian Fam ily Education program (C ormier et al., 1991). Several psych iatric services currently are providing their patients w ith social skills training program s on a regular basis in Belgium, France and Switzerland, and rehabilitation program s m ay be visited in Charleroi, Lyon, Bruxelles, M arseille, N ice, N euchaÃ tel, Lausanne & G eneva.

A ssessm ent of interpersonal problem -solving skills (AIPSS) T he AIP SS (Donahoe et al., 1990) assesses social skills of schizophrenic patients according to the Receiving-P rocessing-S ending skills m odel proposed by W allace and his colleagues (1980). Receiving skills include the ability to identify the presence or absence of an interpersonal problem and to describe the problem in term s of a goal and an obstacle. Processing skills are the ability to generate options and select an approp riate solution to the problem . Sending skills refer to the ability to im plement the solution and deliver a behavioral response in a socially accepted m anner. The AIPSS is perform ed using a video cassette that presents 14 short interactions between two actors. O ne scene is a demonstration scene used to fam iliarize the patient with the procedure. T hree scenes present no problem s and ten scenes each illustrate a social interaction problem . At the beginning of each situation the im age is frozen for ® ve seconds and the exam iner indicates the person with w hom the patient has to identify. T he exam iner stops the video after each scene and asks the subject a series of questions to evaluate receiving, processing and sending skills. T he receiving and processing skills are assessed by questions which

31

require short and sim ple verbal responses. T he evaluation of sending skills requires that the exam iner engages the subject in role playing to assess the behavioral response. An exam ple of a problem scene depicted on video is a wom an listening to loud rock m usic. A m an knocks at the door. The w om an opens the door and com es face-to-fac e with the m an. T he im age on the screen is m om entarily frozen as the subject is alerted to the im m inent problem . T he m an says, Ìt’ s 10 pm , I would like to go to sleep but your m usic is too loud’ . The wom an answers, `Rock m usic has to be played loud’ . T he subject is asked to identify with the man in this scene. Speci® c criteria are used to m ark the subject’ s responses. T he AIP PS consists of six scales: identi® cation of the problem , de® nition of the problem, solution, verbal content, non-verbal perform ance when role playing and overall perform ance when role playing. The test is adm inistered with the help of a m anual which describes in detail the criteria for evaluating the subject’ s responses. The French version of the AIPSS has m odi® ed the content of a few scenes. For exam ple, in an Am erican scene, a custom er bought a defective sweater and the shop assistant will not replace it or give a refund. T he ® nal goal is to be able to talk to the m anager of the store to exchange the sweater. T his situation, which is quite com m on in the U SA, is not as frequent in Switzerland since consum ers are m ore protected. In another situation a wom an cuts into a queue line, and the subject is asked to identify w ith the person already in the queue. W hile these situations m ay happen in European French-speaking countries, they may lead to various responses, all of which m ay be judged as com petent. F or exam ple, it m ight be considered courteous for a man to let a w om an cut in a line in front of him, thereby providing an opportunity to speak w ith her. T his would be dif® cult to standardize in a test. Also, for Latin cultural settings, af® liative situations w ere under-represented in the test. T o m eet this need, new situations were developed, such as two friends who want to do som ething together but have different desires, or a m an who w ants to invite a wom an for an evening out, but the wom an is unfortunately busy at the time of the suggested date. Sm aller changes have also been m ade such as replacing a Chinese dinner date by a pizza date or changing a con¯ ict between room m ates with a con¯ ict between a m arried couple since room m ates’ accom odations are uncom mon in Europe. The AIPSS instrum ent was tested on a group of outpatients in Los Angeles (Donahoe et al., 1990). It appeared to have acceptable reliability. It showed good internal consistency, which indicated that each scale w as hom ogenous concerning the capacities it m easured. It showed good test and re-test stability, in the sense that the average score rem ained sim ilar over a short period of two weeks.


32

J. Favrod et al.

Another study (Sullivan et al., 1990) showed that poor scores on the AIP SS differentiated outpatient schizophrenics with recent histories of exacerbations from those without such histories. T his study w as criticized for questionable validity of the instrum ent because Sullivan and her colleagues failed to include a psychiatric control group (Bellack et al., 1994). The French version of the AIPSS was studied in a collaborative, controlled study that included 145 patients from three centers in French-speaking SwitzerlandÐ Geneva, Lausanne and N euchaÃ tel (D’ Abbraccio & Siegrist, 1996). This study showed that the AIPSS discrim inated schizophrenic patients from a sam ple of patients suffering from affe ctive or anxiety disorders. T he two sam ples w ere not different with respect to age, level of education, num ber of hospitalizations or length of hospitalization. Inter-rater ® delity was satisfac tory w ith judges who were not involved in the French adaptation of the test. Internal consistency was also satisfactory.

Training in interpersonal skills (TIPS S)

problem -solving

T he Interpersonal Problem-Solving Skills (TIPSS) m odule was designed to teach psychiatric patients a m ethod of solving dif® cult interpersonal problems that arise in everyday life. In the original m odule, skills such as paying attention, describing problems or thinking of ideas for solution were taught separately. In the F rench adaptation, it was thought that the problem-solvin g process had to be emphasized more than the speci® c skills. Indeed, m ost patients invited to participate in the T IPSS program had already com pleted other UC LA modules w here the different steps of problem -so lving were already acquired. The challenge was to `drill’ patients to prom ote their integration of the general process of problem -solving rather than to fam iliarize patients w ith speci® c, individual skills. The T IP SS training program is built around social situations w hich are sim ilar in style to those used in the AIPSS, but the content is different except for three cases where they are the sam e as those used in the AIP SS. T he patients are trained to describe the problem , de® ne the problem, generate potential solutions, evaluate the consequences of each potential solution, and im plement the m ost effective solution(s). Later, the patients are invited to resolve problems which they themselves have encountered in the com m unity. The training scenes start w ith four instrum ental situations involving interactions with waitresses or shopkeepers. Four other situations deal w ith health-care providers and the last four are related to m ore expressive and af® liative relationships. In the Appendix to this article a m ore speci® c description of the TIPSS is provided.

Pilot studies Im plem entation of the F rench version of the T IP SS m odule was carried out in G eneva, Switzerland, with 11 psychiatric patients who were adm inistered pre- and post-tests using the AIPSS. Eight patients m et the criteria for D SM-III-R schizophrenia and three for schizophreniform disorder. Patients in sm all groups of three or four attended 22 sessions of two hours each. Results showed signi® cant im provem ents in their perform ances on all scales of the AIPSS except for problem identi® cation which w as already high at pre-test. Im provem ents were m aintained at one year followup (Favrod et al., 1994). In a second study, eight D SM -III-R schizophrenic patients participated in French versions of the M edication M anagem ent Skills m odule, the Basic C onversation Skills m odule and the Training in Interpersonal Problem-Solving Skills (TIPSS) m odule. Patients com pleted all three m odules in six m onths. T hey were assessed at pre-test, post-test and six m onths later with the AIPSS, am ong other dependent m easures. Patients im proved signi® cantly on the different scales of the AIP SS and gains were m aintained at six m onths follow -up. Im provem ents were observed on the Brief Psychiatric Rating Scale and the Social Adjustm ent Scale-II (C ham bon et al., 1995). D iscussion Results of these tw o pilot studies led to a new hyp othesis about the generalization of training to new situations since patients m aintained their gains in both studies and im proved on the SAS-II in the second study. In the second study, training was m ore intensive which m ay explain im provement on the Social Adjustm ent Scale-II. U nfortunately, social adjustm ent w as not m easured in the ® rst pilot study. The hypo thesis about generalization of social skills training has been tested by a controlled study which revealed that generalization does indeed occur in social skills training when these m odules are used (M arder et al., 1996). Although the work presented here is prelim inary, it is possible to draw som e conclusions. T he AIPSS app eared as sensitive to skills training in Geneva as it did in Los Angeles. T his replication shows that the proposed skills m odel m ay be app lied to another cultural context. The sequential nature of the test revealed that incorrect responses in social perception leads to poor perform ance in processing and sending skills. In other w ords, if the person de® ned the problem incorrectly, the ultimate solution of the problem w ill be im peded. T hese ® ndings validate the three-phase nature of social problem-so lving as developed by W allace and others. Concerning training in interpersonal problem


Problem-solving skills in Switzerland solving, results from our pilot studies indicated that such an intervention is feasible with F rench-speaking patients. O ur adaptations of the Los Angeles m aterial have been m ore concerned with content than form . At the content level, af® liative behavior w as accentuated rather than instrumental behavior. T his w as needed for cultural acceptance. Indeed, in European countries Am erican social skills training is better know n under the label of àssertiveness’ training because Am erican trainers have stressed the im portance of assertiveness, effectiveness or ef® cacy in social relationship s. In European cultures, values such as af® liation or intimacy are m ore highly valued in social interactions (Furnham, 1985). Considering the form of social skills training, few changes have been m ade. In the training of social problem -so lving skills, the structure of the program w as changed to teach m ore af® liative skills as a m eans of prom oting generalization. Also the m odule w as introduced after completion of m ore basic program s such as the M edication M anagement m odule or the Basic Conversation Skills m odule. Patients readily accepted the techniques used. T he m ain problem w as developing a French vocabulary to nam e the different techniques. T his m ay appear as a m ere detail but French-speaking people are less inclined to be ¯ exible w ith their m other tongue than other people. Thus, to prom ote acceptance of the technology by clinicians, it was necessary to be very careful w ith the choice of w ords. For exam ple, it was dif® cult to translate into F rench words such as `skills’ or `shaping’ . F or `skills’ the French word `habileteÂ ’ has been used, despite the fact that the term, `habileteÂ s’ , m ay appear outdated in everyday French. The advantage of this translation is to allow heuristic clarity between the terms of com petence (com peÂ tence in F rench) and skill. Com petence im plies a judgement about som eone’ s perform ance in a given context and skills are the behavio ral and cognitive com ponents of this perform ance. In the 1980s this translation led to num erous debates in scienti® c m eetings, taking up a lot of time and preventing the audience from hearing other aspects of social skills training. This illustrates how the vocabulary used to describe treatment techniques m ay be im portant in the adoption of a new technology in another culture. To conclude, we have observed social skills training progressing in French-speaking areas of the European continent. The uptake of this technology is slow but sure. Looking beyond published results of the UC LA m odules, it is important to recall that these program s not only im prove patients’ perform ances but also change the way health care providers see chronic m ental patients. The form at of the m odule engages group leaders in a new style of therapeutic relationship w ith their patients based on a collaborative process rather than on a hierarchical or authoritarian form of interaction.

33

Through skills training, trainers are able to attend directly to patients’ needs and m ay have a better understanding of the m any challenges that patients m eet in their everyday life, in contrast w ith the inform ation obtained through traditional interviews. As sm all, step-by-st ep progress occurs directly in front of their eyes, clinicians m ay, in turn, develop a m ore positive and optimistic view of the chronically m entally ill and their potential for rehabilitation and recovery. Patients can be seen as capable of learning and growth even if they are suffering from schizophrenia, one of the m ost devastating of the psych iatric illnesses. This is certainly one of the m ost im portant changes that the UC LA m odules have brought to French-speaking clinicians. R eferen ces

B ACKER , T.E., L IBERM AN , R.P. & K UEH NEL , T.G. (1986). Dissemination and adoption of innovative psychosocial interventions. Journal of Consultin g and Clinical Psychology , 54 , 111± 118. B ELLACK , A.S., S A YERS , M ., M UESER , K.T. & B ENN ETT , M. (1994). Evaluation of social problem -solving in schizophrenia. Journal of Abnorm al Psychology, 103 , 371± 378. B ENT ON , M .K. & S CHR OED ER , H.E. (1990). Social skills training with schizophrenics: a meta-analytic evaluation. Journa l of C onsultin g and C linica l Psychology, 58 , 741± 747. B ERTO LO TE , J.M . & D E G IROLA M O , G. (1993). E ssential treatm ents in psychiatry. Geneva: Division of M ental Health, World Health Organization. C H AM BON O. & M ARIE-C ARD IN E , M . (1992). L a reÂ adaptation socia le des psychotiques chroniques: approche cognitiv ocomportementale. Paris: Presses Universitaires de France. C H AM BON , O., F AVRO D , J., Y AM AM O TO , T. & M A RIEC ARD IN E M . (1993). ReÂ adaptation sociale, qualiteÂ de vie et ameÂ lioration des habileteÂ s relationnelles des psychotiques chroniques: le module `habileteÂ s eÂ leÂm entaires de conversation’ . Journa l de Therapie C om portem enta le et Cognitiv e , 3, 78± 83. C H AM BON , O., M ARIE-C ARD IN E , M ., C O TT RAUX , J., G ARCIA , J.P., F AVRO D , J. & D ELEU , G. (1995). Im pact d’ un program me global d’ entraõÃ nement aux habileteÂ s sociales sur le fonctionnement social et la qualiteÂ de vie subjective de schizophreÁ nes. Journa l de TheÂ rapie Com portem entale et Cognitive , 5 , 37± 43. C O TT RAUX , J. (1992). Rehabilitation of schizophrenic patients with social skills training in France: why resistance? In: F. P. F ERRO , A. E. H A YNAL & N. S A RTO RIU S (Eds), Schizophrenia and affective psychoses: nosology in contem porary psych iatry (pp. 183± 191). Rome: John Libbey CIC srl. C O RM IER , H., G UIM ON D , G. JO NCAS , G., L EBLAN C G ., M O RIN , R. & V AILLAN CO URT , S. (1991). Profamille. Quebec: UniteÂ de psychiatrie soile et preÂ ventive, C entre de recherche UniversiteÂ Laval Robert-Giffard. C O RRIGAN , P. W . (1991). Social skills training in adult psychiatric populations: a meta-analysis. Journa l of Beh avior Therapy & E xperim ental Psychiatry , 22 , 203± 210. D’ A B BRACCIO , M . & S IEGR IST , E. (1996). Evaluation de l’ AIPSS: un instrument de m esure de l’ habileteÂ s aÁ la reÂ solution de probleÁm es interpersonnels en reÂ habilitation psychiatrique. Unpublished m anuscript. Lausanne: UniversiteÂ de Lausanne. D ON AH O E , C.P., C ART ER , M.J., B LOEM , W .D., L EFF , G ., L ASI, N. & W ALLACE C .J. (1990). Assessment of


34

J. Favrod et al.

interpersonal problem-solving skills. Psych iatry , 53 , 329± 339. F AVRO D , J. (1993). HabileteÂ s sociales: QueÂ beÂ cisme deÂsuet ou concept moderne? Journa l de TheÂ rapie Com portem entale et Cognitive , 3 , 66± 67. F AVRO D , J. & B ARRELET , L. (1993). Ef® caciteÂ de l’ entraõÃ nement des habileteÂ s sociales avec les personnes atteintes de schizophreÂ nie. Journal de TheÂ rapie Com portem entale et C ognitive , 3 , 84± 94. F AVRO D , J. A ILLO N , N. & B ARD OIT , G. (1995) `CompeÂtence’ un chevel de Troy dans les soins. C ahiers psychiatriques Genevois, 18, 47± 53. F AVRO D , J., H U GUELET P. & C H AM B ON , O. (1996). LèÂducation au traitment neuroleptique peut-elle reÂ duire les coutÃ s? Une eÂ valuation pilote. L EnceÂ phale , 12 , 331± 336. F AVRO D , J., Z ABALA- B LAN CO , I., L EBIGRE , F. & M C Q UILLAN , A. (1994). Effets d’ un program me d’ entraõÃ nem ent des habileteÂ s sociales avec des patients psychiatriques. Journal de TheÂ rapie C om portem enta le et Cognitive , 1, 6± 13. F URN H AM , A. (1985). Social skills training: a European perspective. In: L. L’ A BATE & M . A. M ILAN (Eds) Handbook of social skills training and research. New York: John Wiley. G R OSSEN BA CH ER , B., F AVRO D , J., C H AUSSO N , E. & B ARRELET , L. (1995). EntraõÃ nement a Á la conversation avec des patients psychiatriques chroniques. C ahiers psych iatriques genev ois , 18, 55± 66. L IBERM AN , R.P. (1988). Psych iatric rehabilitation of chronic m ental patients . Washington DC: American Psychiatric Press. French translation (1991). ReÂ habilitation psychiatrique des malades mentaux chroniques. Paris: Masson. L IBERM AN , R.P. & G REEN , M .F. (1992). Whiter cognitivebehavioral therapy for schizophrenia. Schizophrenia Bulletin , 18, 27± 35. M C F A LL , R.M . (1992). A review and reform ulation of the concept of social skills: Behavioral Assessm ent, 4, 1± 33. P O M INI , V. & N EIS , L. (1993). Module `ConnaõÃ tre et geÂ rer sa meÂ dication neuroleptique’ : Une eÂ tude eÂ valuative francophone. Journa l de TheÂ rapie Com portementale et Cognitive , 3 , 68± 77. S ULLIVAN , G., M ARD ER , S., L IBERMA N , R.P., D O N AH O E , C.P. & M IN TZ , J. (1990). Social skills and relapse history in outpatient schizophrenics. Psych iatry, 53 , 340± 345. T RO W ER , P., B RYAN T , B. & A RGU LE , M . (1978). Socia l skills and m enta l health. Pittsburgh: University of Pittsburgh Press. W ALLACE , C.J., N ELSO N , C.J., L IBER M AN , R.P. A ITCH ISO N , R.A., L UKO FF , D., E LDER , J.P. & F ERR IS , C. (1980). A review and critique of social skills training with schizophrenic patients. Schizophrenia Bulletin , 6 , 42± 63.

perception. Questions are addressed to participants, in turn, so as to include the whole group. Questions are: `Where did the situation take place?’ , `Who was involved in the situation?’ , `W hat did they say?’ , `What were they doing?’ , `What were any important details?’ . If the participants are unable to answer there questions, the scene is replayed and the questions are asked again. Therapists dem onstrate for the patients, through modeling and instructions, how to pay attention to social situations. Once the problem is de® ned, the trainer helps the patients to ® nd solutions while asking them to refrain from making value judgements too quickly. The trainer encourages the participants and praises them for their efforts and attentiveness. Then the trainer helps the group to evaluate the positive and negative consequences of each solution, noting the advantages and disadvantages on a list which is written on a blackboard or ¯ ip-chart. W hen all the aspects have been considered, the trainer asks each person whether the advantages outweigh the disadvantages, or vice versa, for each solution. Once all the options have been reviewed, the trainer asks each participant to choose one or a combination of solutions to solve the problem. Finally, the trainer engages the participants in role plays of the best solution(s). He or she invites the participants to pay particular attention to non-verbal behaviours. The trainer asks the participants to comm ent on what they liked during the performance, and elicits positive feedback from them for each other. If the person’ s performance shows speci® c weaknesses or excesses (e.g. volume of voice too high, poor visual contact), the trainer gives instructions for improvement in performance. If the performance is globally poor (e.g. inappropriate affect, lack of assertiveness), the trainer or another patient takes the place of the subject and models a more appropriate performance. When working on real problems brought by group mem bers, the members are given the task of putting into practice their solution(s) in the real setting before the next meeting when the results will be evaluated. Here are two examples of training scenes.

A ppendix: TIPSS M odule

Scene (2): Too m uch self-disclosure

A typical session starts with a preliminary period during which the patients are welcomed by the therapists and put at ease. Then the patients are invited to watch a problem situation recorded on video after being asked to image themselves ìn the shoes’ of the actor confronted by the problem . Once the introductory scene is ® nished, the patients are questioned to assess their attention and social

At a party, the host introduces a man and a woman (patients have to identify with the m an). Then the host leaves them to welcome other people. The man starts a social conversation with the wom an by asking her how she knows the host. The woman begins the conversation by complaining about her personal dif® culties and psychiatric symptoms.

Scene (1): No money to pay for a restaurant dinner

A m an and a woman are sitting at a table in a restaurant (the patients have to identify themselves with the man). The woman thanks the m an for the invitation and the nice time she has had with him. The m an acknowledges her compliment and then asks the waiter for the bill. The waiter arrives with the bill. The man looks for his wallet, but cannot ® nd it. He tells the waiter that he is sorry but he has forgotten his money. The waiter answers that the place does not take credit.