David Reitman and Nichole Jurbergs

Louisiana State University

I. Description of Treatment II. Theoretical Bases III. Empirical Studies IV Summary

Further Reading

GLOSSARY

feedback Information provided to an individual following a response that is intended to promote the acquisition of behavior.

modeling Action performed by a therapist or coach to illustrate important elements of a response requiring imitation by clients or patients. Feedback and instructions are also used to shape the behavioral repertoire to approximate more closely the actions of the model.

Communication skills training (CST) promotes problem-solving skills by teaching patients to resolve disputes through restructuring their attitudes, adopting and adhering to new rules of social interaction, and clearly expressing and receiving meaning. In CST, therapists frequently combine elements of behavioral, family systems, humanistic, and other approaches to reduce interpersonal problems. Although initially developed in the context of family interaction (e.g., spouse to spouse, or parent to adolescent), in recent years the approach has been found to have broad ap peal. For example, recent modifications of CST for persons with developmental disabilities have proven valuable in the treatment of challenging behavior associated with limitations in communicative ability and useful in promoting choice.

I. DESCRIPTION OF TREATMENT

Communication skills are vital for achieving goals through social interaction. CST emphasizes pragmatics, communication in a social context, and can be useful in a wide range of treatment programs for many types of individuals and situations because of a diverse, yet sound conceptual and empirical base.

As it is most commonly known, CST is used to teach problem-solving skills, most frequently to help resolve parent-adolescent and marital conflict. Because of the diversity of programs, it is useful to identify specific operations common to all CST. First, most CST seeks to promote the clear expression and reception of meaning. Effective problem-solving requires minimizing negative communication habits and speeds the process of arriving at mutually favorable solutions. By contrast, emotionally charged accusations, frequent changes of topic, and interruptions frequently impede the promotion of clear communication. CST also attempts to teach the individual how to restructure attitudes (e.g., zero-sum or all or nothing thinking) that may inhibit or derail effective problem-solving. Second, CST trains families in reflective listening (i.e., relating perceived meaning back to the speaker) in an attempt to enhance the behavioral component of problem-solving. Moreover, ensuring that clients take an active role in trying to understand one another minimizes the likelihood that a "nonparticipant" will seek to undermine solutions. A third dimension of CST focuses attention on the quality of family relations. In general, CST emphasizes a democratic approach to family relations. Issues are raised and clarified through mutual agreement and the rights of all parties are respected in arriving at a solution (i.e., equalization of decision-making power).

An early example of the CST approach is the four-step model introduced by Arthur L. Robin, Sharon L. Foster, and colleagues as a component of their problem-solving communication training (PSCT) for parents and adolescents. During the first of a course of four to six sessions, families are introduced to the model. Specifically, families are told to (1) define the problem concisely without accusations, (2) brainstorm alternative solutions, (3) evaluate solutions by listing their positive and negative consequences and deciding on a mutually satisfactory agreement, and, finally (4) specify the actions required to implement the solution. This training also involves the therapist's provision of feedback, modeling, and behavioral rehearsal (i.e., role-play) to correct negative habits. Families are also taught to self-monitor negative communication patterns such as interruptions, lack of eye contact, and sarcasm, and to replace them with more effective behaviors such as maintaining eye contact, active listening, verification of meaning, appropriate voice tone, and appropriate nonverbal posturing (e.g., leaning slightly forward to indicate interest).

At each session, a specific problem, such as chore completion, curfew obedience, or homework compliance, is discussed. Therapists then help guide families through a structured discussion and intervene when family members stray from the four-step guidelines. Therapist prompts may be in the form of a discussion of the inappropriate behavior, demonstration of more appropriate behavior, or direct feedback about the error. Often, family members are uneven in their mastery of the communications skills and will receive additional feedback and instruction during the sessions. Cognitive restructuring (i.e., challenging or reframing maladaptive thoughts) and planning for the generalization of treatment gains through homework assignments are also common features of PSCT.

Applications of CST to marital and relationship problems have been theoretically diverse and include systems-oriented and social-learning approaches. One of the best known interventions for relationship problems, behavioral marital therapy (BMT), represents an application of reinforcement principles to problems encountered in romantic relationships. Over the years, BMT has been broadened by Neil Jacobson and colleagues to include other features; however, the core of BMT appears to be the promotion of "support-understanding techniques" and problem-solving training. Support-understanding techniques encourage collaboration and positive affect. For example, each partner might first generate a list of behaviors that they would like their partner to perform. Subsequently, each partner agrees to perform three of the actions from their partner's list. Problem-solving techniques are very similar to those described by Robin and Foster.

Couple Communication is a recent example of a systems-oriented program designed by Sherod Miller and Peter A.D. Sherrard to teach important communication skills to couples in conflict. Its three main goals are to help couples communicate more effectively about day-today issues, manage and resolve conflicts more effectively, and to help build a more satisfying relationship. The intervention model aims to increase awareness of the relationship, teach skills for communicating more effectively, expand options for enriching the relationship, and increase satisfaction with the relationship itself. Although incorporating many features of more experiential and family-systems therapies (i.e., employing the use of skill mats to promote kinesthetic learning), the program is notable for its systematic incorporation of feedback, coaching, and contracting and shares these features with the model promoted by Robin, Jacobson, and others.

CST can be useful in helping patients with disabilities such as mental retardation or autism to communicate effectively in social settings. Although significant modifications are required to adapt CSTs for the communication impaired and developmentally disabled, Fred P. Orelove and Dick Sobsey have outlined a program to teach basic functional communication to children with severe or multiple disabilities. Before implementing such a program, four decisions must be made: (1) which communication functions would be most useful to the individual, (2) what specific content or messages should be communicated, (3) which form (mode) of communication should be selected—vocal, gestural, or graphic, (4) how each item should be taught. After these decisions have been made, a program of assessing and teaching specific patterns of communication can be implemented based on five fundamental principles: maximization (striving for the greatest increase in appropriate communication), functionality (focusing on social outcomes), individualization (uniquely assessing each child and what he or she requires), mutuality (aiming at both communication partners and their context assessment and intervention), and normalization (teaching common communication unless there is an undeniable benefit to the individual in teaching different skills). Another program, designed by Laura G. Klinger and Geraldine Dawson, is intended to facilitate social interaction, specifically for children with autism. It comprises two strategy levels and is based on the five general principles outlined by Orelove and Sobsey. Level One involves facilitating attention to people, social contingency, and turn-taking. Level Two targets imitation, early communication, and joint attention skills. These strategies may be implemented by parents, teachers, psychologists, and other developmental specialists.

Interventions have also been designed based on the premise of teaching communication skills as an alternative to challenging behavior. In their review of functional communication interventions, David P Wacker and Joe Reichle describe a number of simple and effective programs that involve two common steps. First, factors maintaining problem target behaviors must be identified. Second, the maintaining factors (e.g., rewards) must be made available only when the specified appropriate communicative response is made. These interventions are performed in three general phases: assessment, initial intervention, and expanded intervention aimed at generalizing and maintaining outcomes. V Mark Durand and colleagues have explored several factors that increase the success of functional communication training in reducing challenging behavior. The four main factors are response match, response mastery, response milieu, and the consequences of the challenging behavior. "Response match" means that the newly trained response should produce the same consequence as the targeted challenging behavior. For example, raising a hand should garner attention in the same way that striking a peer would have prior to training. Other concepts such as "response mastery" and "response milieu" speak to the importance of ensuring that the newly trained functional communication response becomes more efficient in producing changes in individual's environment than the formerly high-frequency problem behavior. Taken together, the diverse applications of CST are impressive in scope.

II. THEORETICAL BASES

Communication skills training has gradually evolved from a treatment approach focused on reducing family conflict to a much broader array of therapies concerned with the resolution of human conflict in areas ranging from the home to business and institutional settings. The initial conceptual underpinnings of CST, however, spring from a humanistic, social-learning perspective suggesting that conflict is often produced by perceived differences in power. As originally conceptualized by Robin and colleagues, PSCT suggests that adolescents initially argue with their parents in a developmentally appropriate quest for independence. Unfortunately, overly "authoritarian" responses from parents sometimes lead to increased conflict. Reacting in a more "democratic" manner, that is, emphasizing mutual solutions and the equalization of decision-making power, replaces negative communication with a social environment more likely to yield solutions to problems arising in parent-child relations. This early form of CST was based on the principles of behavior modification, experimental problem solving, and effective communication.

Behavioral marital therapy emerged most directly from reinforcement and social learning theory. The early BMT notion of behavioral exchange was modeled on behavioral formulations of the marital relationship in terms of contingency contracting and seeking to foster changes in partner behavior. In more recent years, BMT has expanded to incorporate a theoretically diverse number of treatment techniques, including a greater focus on communication and problem-solving skills, and more acceptance-based procedures. The Couple Communication program is based on systems-theory concepts and principles. Viewing a relationship as a "system," and more specifically as a "self-managing-adaptive system," implies that relationships are not static and that the behavior of the partners constitutes the dynamic of their relationship. The Couple Communication program and the concepts and skills taught in the program are designed to enhance the couple's ability to communicate effectively and become their own best problem solvers.

The theoretical justification for employing CST for persons with developmental disabilities is that the difficulties of these individuals are due largely to deficits in social communication, rather than simply speech production. Research in this field has only recently begun to focus on the social-emotional domain rather than on cognitive or linguistic deficits. Functional communication training is derived from learning theory and behavior analysis. Adherents of this perspective argue for the functionality or adaptiveness of the existing problem behavior (for example, self-injury may communicate physical discomfort) and note that when taught an appropriate communicative alternative, such as a gesture to obtain medical care, individuals with developmental disabilities will often show substantial reductions in self-injury and other forms of problem behavior.

III. EMPIRICAL STUDIES

A large body of research on CST has pointed to its effectiveness in a variety of applications. Robin has conducted a host of studies that demonstrate the versatility of his CST approach with the most recent applications in the context of eating disorders. The effectiveness of his problem-solving communication training program has been established in both hypothetical (analogue) and actual therapy settings during structured treatment programs. Improvements in problem-solving have also been noted outside of training settings. For example, in one study, reductions in parent-adolescent conflict in the home were still evident up to 10 months following therapy A lack of generalization is sometimes cited as a treatment limitation in other studies and reviews. Evidence of both parent and adolescent satisfaction with the improvements in family interaction has also been noted.

BMT is among the most heavily researched treatment programs of any kind. Findings have suggested that it is superior to no-treatment controls and placebo and equivalent to or more effective than other forms of marital therapy. Although generalization and maintenance of treatment effects and the clinical significance of results have sometimes been a concern, researchers continue to work to improve outcomes. Empirical support for the Couple Communication program is less robust than for BMT, but some evidence of increases in constructive communication skill use, relationship satisfaction, and maintenance of treatment effects have been reported.

V M. Durand, David Wacker, Brian Iwata, and a host of others have found solid support for the use of functional communication and other behaviorally oriented skills training as a treatment modality for challenging behavior among persons diagnosed with developmental disabilities. The data have been encouraging in the assessment and treatment of problems such as aggression, self-injurious behavior, and stereotyped behavior, as well as other problems associated with autism. Moreover, these studies have been conducted in a variety of settings (e.g., schools, group homes, and vocational settings) and implemented by professionals, paraprofessionals, and family members alike.

IV. SUMMARY

The main elements that unite all the CST programs are the clear expression and reception of meaning, re structuring of inappropriate attitudes (on the part of each member of the interaction unit), and equalization of decision-making power. CST programs typically utilize the above model to reframe disagreements and to generate solutions to recurrent problems that plague the family or relationship partners. There are now a large number of empirical studies that support the efficacy and wide applicability of CST in the family context, including specific applications for problems that intersect the interpersonal sphere such as alcoholism, sexual dysfunction, and depression.

In recent years, CSTs have also been developed for patients with developmental disabilities. Indications are that persons with disabilities and their caretakers also benefit from structured programs that teach persons in the caretaker-patient relationship how to communicate more effectively in the social milieu. Once the strategies for each individual have been developed based on an ideographic assessment, they may be implemented by parents, teachers, and other specialists involved in the individual's care. Communication skills programs may also be used to design more effective interventions for challenging behavior. When implemented, their goal is to replace problem behavior, such as self-injury, with socially appropriate communication. These programs, too, appear to have a high success rate. Although technically difficult to implement and sometimes effortful or unpleasant for participants, it is expected that further development of CST programs will be undertaken with increasingly diverse populations.

See Also the Following Articles

Anger Control Therapy ■ Family Therapy ■ Funtional Communication Training ■ Interpersonal Psychotherapy ■ Language in Psychotherapy ■ Parent-Child Interaction Therapy ■ Psychodynamic Couples Therapy

Further Reading

Durand, V. M., Berotti, D., & Weiner, J. (1993). Functional communication training: Factors affecting effectiveness, generalization, and maintenance. In J. Riechle & D. P. Wacker (Eds.), Communicative alternatives to challenging behavior: Integrating functional assessment and intervention strategies: Vol. 3. Baltimore, MD: Paul H. Brookes.

Foster, S. L., & Robin, A. L. (1998). Parent-adolescent conflict and relationship discord. In E. J. Mash & R. A. Barkley (Eds.), Treatment of childhood disorders (2nd ed.). New York: Guilford.

Holtzworth-Munroe, A., & Jacobson, N. S. (1991). Behavioral marital therapy. In A. S. Gurman & D. P. Kniskern (Ed.), Handbook of family therapy (Vol. 2). Philadelphia, PA: Brunner-Mazel.

Jacobson, N. S. (1984). A component analysis of behavioral marital therapy: The relative effectiveness of behavior exchange and communication/problem solving training. Journal of Consulting Clinical Psychology, 52, 295.

Klinger, L. G., & Dawson, G. (1992). Facilitating early social and communicative development in children with autism. In S. F Warren & J. Reichle (Eds.), Causes and effects in communication and language intervention. Baltimore, MD: Paul H. Brookes.

Miller, S., & Sherrard, P. A. D. (1999). Couple communication: A system for equipping partners to talk, listen, and resolve conflicts effectively. In R. Berger & M. T. Hannah

(Eds.), Preventive approaches in couples therapy. Lillington, NC: Edwards Brothers.

Orelove, F P., & Sobsey, D. (1996). Educating children with multiple disabilities: A transdisciplinary approach (3rd ed.). Baltimore, MD: Paul H. Brookes.

Robin, A. L. (1981). A controlled evaluation of problemsolving communication training with parent-adolescent conflict. Behavioral Therapy, 12, 593.

Robin, A. L., & Foster, S. L. (1989). Negotiating parent-adolescent conflict: A behavioral-family systems approach. New York: Guilford.

Robin, A. L., Kent, R., O'Leary, D., Foster, S. L., & Prinz, R. (1977). An approach to teaching parents and adolescents problem-solving communication skills: A preliminary report. Behavioral Therapy, 8, 639.

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