Rehab Rounds: Improving Social Functioning in Schizophrenia by Playing the Train Game

Introduction by the column editors: Social impairments have long been recognized as a core feature of schizophrenia. Poor social, self-care, and vocational functioning are criteria for a diagnosis of schizophrenia in most diagnostic systems. Consequently, improving the social behaviors of persons with schizophrenia has been a key target of psychiatric rehabilitation techniques.One such technique, social skills training, has demonstrated effectiveness in yielding skill acquisition, durability, and generalization (1) and has been recognized as a psychosocial treatment of choice for schizophrenia (2). Nevertheless, a number of limitations to the benefits that may be achieved through skills training have been described. For example, the cognitive impairments of persons with schizophrenia, such as poor sustained attention and verbal memory deficits, have been shown to limit the acquisition of social skills (3). Moreover, one study showed that patients with negative symptoms, such as apathy, anhedonia, and amotivation, have an impaired capacity to benefit from social skills training (4). However, the results of a more recent study suggest that only persons with primary, deficit-type negative symptoms—not those with negative symptoms secondary to positive psychotic symptoms, depression, or extrapyramidal side effects—are unable to benefit from conventional social skills training (5).Recognizing these obstacles to implementing a social skills training program for persons with schizophrenia, Torres and his colleagues have created a board game called El Tren (The Train). Several characteristics of El Tren make it ideal for use with this population. First, the game is behaviorally oriented and has an emphasis on positive reinforcement and shaping. Second, it is sensitive to the cognitive limitations of the participants, emphasizing repetition and procedural learning. Third, it is designed to overcome participants' negative symptoms by being entertaining and fun. In this month's column, these authors describe El Tren and present the results of a randomized controlled study of its efficacy.