Psychiatric Rehabilitation Journal

In the public domain 2023, Vol. 46, No. 1, 83–93

ISSN: 1095-158X https://doi.org/10.1037/prj0000549

Increasing Community Engagement: Skills Used by Adults With

Schizophrenia Participating in a Psychosocial Intervention
Melanie E. Bennett1, 2, Lorrianne Kuykendall1, Kirsten Harvey1, and Alicia Lucksted2
1
VA Capital Healthcare Network Mental Illness Research, Education, and Clinical Center,
Veterans Affairs Maryland Health Care System, Baltimore, Maryland, United States
2
Department of Psychiatry, University of Maryland School of Medicine

Objective: We present findings from a qualitative study aimed at understanding the experiences of Veterans
with schizophrenia and negative symptoms who participated in trial of an intervention to increase social and
community participation called Engaging in Community Roles and Experiences (EnCoRE). Our goal was to
understand what participants (N = 36) perceived they learned in EnCoRE, how participants used what they
learned in their daily lives, and if and how participants built on these experiences in ways that might lead to
sustained change. Method: Our analysis approach was inductive (bottom up), drawing on interpretive
phenomenological analysis (IPA; Conroy, 2003), plus some top-down examination of the role of EnCoRE
elements in participants’ accounts. Results: We identified three themes: (a) Learning skills led to increased
comfort talking to people and planning activities; (b) Increased comfort led to increased confidence to try
new things; and (c) The group atmosphere offered support and accountability that helped participants
practice and refine new skills. Conclusions and Implications for Practice: The process of learning skills,
planning to use them, implementing them, and returning to the group for input helped many surmount
feelings of low interest and low motivation. Our findings support having proactive discussions with patients
about how building confidence can support improved social and community participation.

Impact and Implications

This study suggests that people living with schizophrenia can implement skills that support increased
social and community engagement. Practicing new skills in a group setting and planning for their use in
real-life situations led to increased confidence to try previously avoided activities. Integrating discussion
of confidence and avoidance dynamics and strategies for overcoming them into recovery-related
programming could help people living with schizophrenia develop greater interpersonal and social
functioning.

Keywords: schizophrenia, negative symptoms, social and community participation, rehabilitation

interventions, evidence-based practice

People living with schizophrenia often face challenges engaging long-term outcomes for individuals living with schizophrenia and
in social and community activities. A critical barrier is negative represent an unmet therapeutic need (Correll & Schooler, 2020;
symptoms that reflect diminished feelings and thoughts that support Galderisi et al., 2018; Okada et al., 2020; Patel et al., 2015). The
social interaction. Negative symptoms are associated with poor literature on psychosocial interventions for negative symptoms is

Melanie E. Bennett https://orcid.org/0000-0001-8166-157X
Support for this research was provided by grant 5I01RX001293 from the
Rehabilitation Research and Development Service of the U.S. Department of
Veteran Affairs. This research is supported by the Department of Veterans
Affairs. It is the result of work supported with resources and the use of
facilities at the VA Capitol Health Care Network (VISN 5) MIRECC and the
University of Maryland School of Medicine Department of Psychiatry. This
article reflects the authors’ personal views and in no way represents the
official view of the Department of Veterans Affairs of the U.S. Government.
The authors gratefully acknowledge the veterans who participated in this
research. This study was part of a clinical trial registered as NCT02469389 at
www.clinicaltrials.gov. The authors have no conflicts of interest to disclose.
Portions of these findings were presented in a symposium talk at the 2019
Schizophrenia International Research Society, Orlando, Florida, United States.
Melanie E. Bennett played lead role in conceptualization, funding acquisition,
investigation, writing of original draft and writing of reviewing and editing and
equal role data curation, formal analysis, project administration and supervision
and supporting role in Methodology. Lorrianne Kuykendall played supporting
role in data curation, formal analysis, project administration and writing of
reviewing and editing. Kirsten Harvey played supporting role in data curation,
formal analysis, project administration and writing of reviewing and editing.
Alicia Lucksted played lead role in data curation, formal analysis and supervi-
sion and equal role in project administration and supporting role in funding
acquisition, writing of original draft and writing of reviewing and editing.
Correspondence concerning this article should be addressed to Melanie E.
Bennett, Department of Psychiatry, University of Maryland School of
Medicine, 737 West Lombard Street, 5th Floor, Baltimore, MD 21201,
United States or VA Capital Healthcare Network Mental Illness Research,
Education, and Clinical Center, Veterans Affairs Maryland Health Care
System, 10 N. Greene Street, Baltimore, MD 21201, United States. Email:
mbennett@som.umaryland.edu

83
84 BENNETT, KUYKENDALL, HARVEY, AND LUCKSTED
largely quantitative and finds that skills-based approaches are
associated with modest reductions in negative symptoms and im-
provements in functioning (Elis et al., 2013; Turner et al., 2018).
However, participants experience study interventions firsthand, yet
researchers rarely ask about their experiences. People living with
schizophrenia report that, more than symptom reduction scores on
ratings scales of functioning, the outcomes that mean the most to
them are person-oriented indicators of recovery that support their
living rewarding and fulfilling lives (Thomas et al., 2018). Soundy
et al. (2015) reviewed qualitative studies on recovery from patient,
family, and provider perspectives and found that relationships and
belonging facilitated recovery while social isolation and a lack of
independent community activity were barriers. To fully explore the
impact of psychosocial interventions for negative symptoms, quali-
tative methods allow for greater understanding what people learned,
how they did or did not apply what they learned in their daily lives,
and for gaining a contextualized look at an intervention’s impact.
We present qualitative findings collected as part of a randomized
controlled trial testing a multicomponent intervention that integrated
skill-building with real-life application to improve social and com-
munity participation in a sample of Veterans living with schizo-
phrenia and negative symptoms. The intervention, called Engaging
in Community Roles and Experiences (EnCoRE), is a 12-week
program that includes motivational, behavioral, and cognitive strat-
egies to help participants increase motivation, perform skillfully in
social situations, reduce negative expectancies, and plan participa-
tion in social and community activities. The conceptual framework
for EnCoRE connects a set of antecedents (behavioral skills deficits,
negative expectancies, deficits in anticipatory pleasure and intrinsic
motivation), mediators (negative symptoms), and outcomes (social/
community functioning; Horan et al., 2010; Kring & Caponigro,
2010; Leifker et al., 2009; Medalia & Brekke, 2010; Ventura et al.,
2009). After two individual meetings to identify activities with
high personal relevance, participants attend group meetings which
follow a standard format: (a) Review content and activity plans from
the previous session; (b) Learn a new topic, skill, or strategy;
(c) Complete an activity to practice the new skill or strategy; and
(d) Plan a social or community participation assignment to imple-
ment in between group meetings. The program begins with educa-
tion about negative symptoms and the ways they can be barriers to
social/community participation. At each meeting, participants set a
social/community participation goal and use a structured format
for activity planning. Several meetings focus on social skills such
as starting conversations and making plans. Participants learn to
challenge negative expectations that activities will be unpleasant or
that they will be unable to perform them well. The program includes
frequent practice via role-playing during group meetings and im-
plementing activity plans between meetings. EnCoRE is delivered
in small groups by trained interventionists of varied professional
backgrounds (e.g., psychology, counseling, social work, peer sup-
port) with experience in serious mental illness.
Through qualitative interviews, our goal was to understand what
participants perceived they learned in EnCoRE and how participants
used what they learned in their daily lives. We also wanted to know
if and how participants built on these experiences in ways that might
lead to sustained change. Information from service users can
supplement quantitative findings to yield an enriched understanding
of whether an intervention is acceptable to the target group and
whether users perceive it as beneficial. Input from this key
stakeholder group is critical to decision-making regarding dissemi-
nation and implementation (Skivington et al., 2021).
Method
Participants and Procedures of the Parent Trial
The parent trial took place at three Veterans Affairs (VA) Medical
Centers. Participants were recruited between 12/2015 and 7/2019.
Inclusion criteria were: (a) Diagnostic and Statistical Manual of
Mental Disorder, fifth edition diagnosis of schizophrenia or schizoaf-
fective disorder determined by the Structured Clinical Interview for
DSM-5 (First et al., 2015); (b) Following recommendations that trial
participants experience clinically meaningful negative symptoms
(Galderisi et al., 2021), participants met a minimum rating on the
Clinical Assessment Interview for Negative Symptoms (Kring et al.,
2013) of a “moderately severe deficit” on one or more of any
symptom domain within the affect-motivation factor (i.e., symptoms
of asociality, avolition, and anhedonia) or a minimum rating of a
“moderate deficit” on two or more affect-motivation symptom
domain; (c) Age between 18 and 75 years; (d) Seen by a mental
health service provider consistently for 2 years (to demonstrate regular
mental health care); (e) Competent to sign Informed Consent (deter-
mined with standard questions). Exclusion criteria were: (a) Docu-
mented history of serious neurological disorder; (b) Intellectual
disability (a total score <70 on the Wechsler Test of Adult Reading
Wechsler, 2001 or indicated by chart review); (c) Inability to complete
the baseline assessment over two appointments; (d) Current problem
substance use [Michigan Alcoholism Screening Test, Selzer, 1971,
score ≥5; Drug Abuse Screening Test, Skinner, 1982, score ≥6].
The parent trial randomized 105 participants to EnCoRE or a
health and wellness psychoeducation control condition. Overall, 53
participants were randomized to EnCoRE; all were offered the
postintervention qualitative interview. In this analysis, data from
the 36 participants who completed the qualitative interview are
included. Seventeen did not complete the interview: 13 were lost to
contact or refused to complete the post treatment assessment, and 4
completed the post treatment assessment but were unable to com-
plete the qualitative interview at that time.
Parent trial procedures, including for qualitative data collection,
were approved by the VA Central Institutional Review Board;
parent trial informed consent included consent for audio-recording
the interviews. Interested individuals were scheduled to complete
informed consent and screening measures to ensure eligibility. If
eligible, they completed the baseline assessment, were randomized
to condition, and were asked to complete posttreatment and 3-month
follow-up assessments.
Qualitative Interview Procedures
At the posttreatment assessment, participants randomized to
EnCoRE were invited to complete the qualitative interview. If
the participant agreed, an interviewer would arrive at the end of
the quantitative assessment to conduct the hour-long interview.
Participants were paid to complete the posttreatment assessment;
they were not paid an additional sum to complete the interview.
Interviews were conducted one-on-one in a private room by experi-
enced qualitative interviewers which included authors MB, KP, LK,
and one additional staff member; all had doctoral or masters level
 INCREASING COMMUNITY ENGAGEMENT IN SCHIZOPHRENIA 85

training in research methods and completed interview training
conducted by author AL. All interviewers delivered both EnCoRE
and the comparison intervention during the trial but did not do so
with any participant whom they interviewed.
Most interviews (n = 33) took place in person; several (n = 3)
were completed by telephone when a participant could not stay
after the quantitative assessment. Interviews were audio-recorded
and transcribed by a VA-approved transcription agency and stored
behind the VA firewall. Overall, 35 interviews were audio-recorded.
One interview was not recorded due to a recording error; the
interviewer took detailed notes for use in analysis.
The interview guide is provided in Table 1. The semistructured
interview included open-ended, qualitative questions on participants’
general experiences with the program, which program components
they found the beneficial, and details about how components con-
nected to starting new activities/relationships or reconnecting with
people in their lives. Next, they were asked what they liked best and
least about EnCoRE and their thoughts on the facilitator. The last
section asked about practicalities (i.e., number and length of sessions;
accessibility). Participants were also asked what could make EnCoRE
better. Follow-up prompts were specified for when the interviewer
wanted additional insight into a participant’s experience. Here, we
focus on participants’ experience in EnCoRE and its application in
their lives; answers to the practical questions were summarized and
used internally to support future implementation.
The 36 participants who completed the qualitative interview had
a mean age of 55.81 years (SD = 8.95). Most (78%) were Black/
African American (78%) and male (89%). All were diagnosed
with a schizophrenia spectrum disorder (33% schizophrenia, 67%
schizoaffective).
Data Analysis
Our analysis approach was inductive (bottom up, Thomas, 2006),
with some top-down examination of the role of EnCoRE elements in
participants’ accounts. Our focus on participants’ experiences and
what they carried from these experiences into their personal lives drew
on interpretive phenomenological analysis (IPA) (Dowling, 2007).
IPA rests on repeated and thorough familiarity with the data as in all
qualitative analysis, with focus on not only detailed description of
phenomena as interviewees describe them but also close attention to
the meanings and subjectivity in their descriptions and to the inter-
viewers’ perceptive role (McGovern, 2017; Munhall, 2013).
Research staff proofread transcripts against recordings to ensure
accuracy. We created brief summaries of the first 6 interviews to
examine sufficiency of the interview guide, main points, surprising
data, and questions. After review and discussion, the team con-
cluded that the interview guide was working well and made only
minor adjustments. Data analysis proceeded in three phases. In
each phase, transcripts were coded by two independent study team
members, followed by review by two other team members who
integrated them into a final consensus coding, bringing any impor-
tant inconsistencies to the full team for resolution.
Phase 1: Elements Identified as Helpful
Participants described elements of EnCoRE they found helpful and
why. Pairs of coders independently read transcripts, identified relevant
passages, and excerpted them into a structured template. We created a
priori codes for each element in the curriculum: Information, Action
Planning, Social Skills Training, Making Plans, Practice via Role-
Playing, and Cognitive Restructuring. We added new codes for
additional features participants identified as valuable: Encouragement,
Building Confidence, Group Atmosphere, Accountability, Facilitator
Style, and Formalizing Skill Knowledge. Because we could not access
qualitative data analysis assistance software (due to software restric-
tions at our facility), we gathered all excerpts under each code into a
separate document. The team reviewed each document part way
through the study and again when all data were available, to discuss
our interpretations of what interviewees said and meant about each

Table 1
Qualitative Interview Guide for Veteran Participant Interviews

Domain Sample questions and prompts

1. General experiences Tell me about your experience with EnCoRE.

2. Program components
3. Learning
4. Practical details
Note. EnCoRE = engaging in community roles and experiences.
What was EnCoRE like for you?
What did you like about EnCoRE? Why?
Which part of the EnCoRE program did you like the least? Why?
Is there anything from the group that you keep thinking about?
Which skills did participants apply in their lives? Which elements of the program did participants find useful?
What was one helpful thing you learned during the EnCoRE groups? How has learning this helped you in your life?
What part of EnCoRE did you find most valuable or relevant to your life? Tell me how this was valuable or
relevant to your life.
What part of EnCoRE did you find least valuable or relevant to your life?
What new activities did participants try?
During the time that you were coming to EnCoRE groups, did you try anything new? What was it?
Tell me about something that you found challenging about the EnCoRE group. Did you see this challenge as good
or bad? Can you tell me more about that?
What do you think of the group meeting twice per week—was that too much or did it feel about right?
What challenges did you have to deal with so that you could get to EnCoRE groups?
What is one thing you liked about how the groups were run?
What is one thing that could be improved about how the groups were run?
How does what you learned in EnCoRE groups fit in with what you do in other services you receive or other
groups and classes you attend?
Was the subject matter new to you? If not, were there any differences this time?
86 BENNETT, KUYKENDALL, HARVEY, AND LUCKSTED
element. After each review, one team member drafted an interpretive
memo for that element which the rest of the team reviewed and
revised. We later combined several narrowly defined elements (e.g.,
“group accountability” was incorporated into “group atmosphere”)
and created an interpretive memo about “EnCoRE as a whole” to
reflect participant comments regarding an important gestalt of the
intervention separate from individual elements.
Discussion of the nature and role of each EnCoRE element led us to
consider the relationships among them. This led us to develop several
higher order themes regarding the interplay of EnCoRE skills and
elements in participants’ experiences, which we first described within
individual elements’ interpretive memos and then further developed
in their own memos. Our final results from Phase 1 (below) are
structured to foreground these multi-element themes because they
better captured participants’ accounts of EnCoRE’s impact than
individual elements alone.
Phase 2: Engagement Stories
Study team pairs independently re-read all transcripts and identified
92 “engagement stories,” passages that described participation in
social or community activities. After discussing them, we developed a
set of codes for the type of participation reflected in each story: Initiate
a New Social Activity; Increase Engagement in an Existing Social
Activity; Initiate a New Relationship; Increase Engagement in an
Existing Relationship; Practical Life Maintenance; Reduce Interper-
sonal Conflict; Positive Internal Change; and Other. We noted
EnCoRE elements mentioned in each “story” as helpful. Research
team members entered their coding of each story into a matrix, to
which they could add short memos, for ease of later review. This
process included regular team discussions and review of the matrix to
resolve coding questions as they arose. Our multilayered discussions
yielded higher level theme development addressing the question
“What do the change stories tell us about how or why EnCoRE
helped participants engage in activities”; these themes were docu-
mented and refined over time in extensive memos.
Phase 3: Extended Use of Skills
All transcripts were also coded to capture reports of using inter-
vention skills to support continued participation in social or commu-
nity activities after the intervention had ended. This information was
categorized as follows: Repeated the Activity (e.g., Went out for
coffee with the same friend another time), Highly Similar Activity
(e.g., Went out for coffee with a different friend), Different but
Related Activity (e.g., Went out for a meal with a family member),
Entirely Different Activity (e.g., Attended a sporting event with a
family member), and Experience made Future Activities Easier (e.g.,
Having gone out for coffee, I know I can do that again).
Results
Table 2 lists analysis phases, subthemes where applicable, and
example quotations. Each participant quote is identified by a random
number, gender, and age. In the text, we have indicated the quotation
in Table 2 that corresponds to each phase and theme identified in the
results.
Phase 1 Results: Elements of EnCoRE
Identified as Helpful
Three main themes emerged regarding helpful elements of
EnCoRE: (a) Practicing skills helped participants use them in social
situations, (b) The group atmosphere offered support and account-
ability that helped participants feel comfortable practicing new
skills, and (c) Feeling comfortable and skilled –that is, Themes 1
and 2 coexisting—helped give participants confidence to try new
activities. These themes are presented with quotes reflecting parti-
cipants’ voices and experiences. The themes presented are of equal
importance in the data.
Theme 1: Practicing Skills and Strategies Helped
Participants Feel More Comfortable Using
Them in Social Situations
Participants reported that a main reason for not participating in
social/community activities was feeling unsure about constituent
skills such as how to talk with people and make plans with them.
They described four interrelated ways that EnCoRE helped them
gain skills and confidence to use them. First, learning to translate
their goals/wishes into concrete plans, via creating what we called
an Action Plan which leads one through writing down an activity’s
steps and practical considerations in order, helped. Participants
(Table 2, Rows 1–2) credited the process of “putting it down on
article” as helping them consider the steps involved, stay focused,
consider barriers, and identify solutions if things did not go
according to plan. Participants noted that Action Planning was
flexible and could accommodate changes. This made them feel
comfortable as they tried new things. For example, Participant 389
(male, age 53) said, I followed that [action plan] as best as I could.
And if I couldn’t, I would try and see if I could do it for the
following week.
Second, participants (Table 2, Rows 3–5) identified learning and
practicing conversation skills as especially helpful, because uncer-
tainty and worry about how to talk to people inhibited participation
in interactions and activities. They described how learning how to
have a conversation helped them relax into and enjoy talking to
others and listening to what they had to say.
Third, interviewees (Table 2, Rows 6–7) said repeated practice of
skills in a supportive context via role-playing led to improved
learning, confidence, and comfort. Role playing provided a safe
way to try out a skill, and, through feedback and repetition, improve
it. This made application easier; participants (Table 2, Rows 8–9)
felt prepared to handle various possible responses, which allowed
them to confidently approach a situation in real life.
Fourth, many participants (Table 2, Rows 10–12) reported that,
before EnCoRE, negative expectations would block their initiating an
interaction, going to an event, or having a good time. Participants
described learning how to examine assumptions, assess them, and make
conscious decisions about how to think. This included participants
learning not to assume that activities would go badly. For example,
Participant 630 (male, age 54) said: I learned not to feel discouraged
and not to jump to conclusions … cause I could be wrong.
In sum, (a) learning skills for navigating social interactions,
combined with (b) the concrete and practical ways they are taught
and (c) the repeated practice to refine skill execution and build
 INCREASING COMMUNITY ENGAGEMENT IN SCHIZOPHRENIA 87

Table 2
Phases and Subthemes With Example Quotations

Random
Row Quotation number Gender Age

Phase 1: Elements of EnCoRE identified as helpful; Theme 1: Practicing skills and strategies helped participants feel more comfortable using
them in social situations
1 “We did it right on the sheet and it’d say … what we wanted to do, when, where, what were some 298 Male 60
of the barriers and what would be solutions and who would you call if you needed some help.”
2 “We did an action plan and we learned how to assess our recreational activities and make plans … I 982 Female 63
went to movies, I went to the library, I read books. I went to church. That was a good thing for
me because [before] I wasn’t planning.”
3 “At one time I couldn’t start a conversation … And that’s been my problem, you know what I 630 Male 54
mean? But after she, they told me a few things and then a few things [we did] in the group, so I
could sit down and just relax myself and take my time … And say something.”
4 “Start and maintaining conversations … Because normally I’m not a talkative person. But being able 531 Male 37
to talk to somebody about sports or the weather is something I can do.”
5 “[ref: EnCoRE] showed me how to … talk to different people. It’s like you introduce yourself, tell 896 Male 46
them your topic in like a two-minute sentence, listen to their feedback, then repeat it and thank
them for whatever the conversation was.”
6 “The role-playing … was helpful because it was like a real-life situation … It was good practice … 601 Male 58
It helped you feel more confident dealing with different people and different situations.”
7 “It [ref: role-playing] was like, it gives you a chance to correct the mistakes that you made each time 214 Male 64
and make you aware of what you did wrong because not only the individual that was doing the
role play but … the other classmates were giving you their view point on the things that you did
and didn’t do.”
8 “I liked the role-playing, because, you know, I’m kind of a quiet person, and you know sometimes 351 Female 52
when people say things to me … I would just keep it inside and, you know, not say it until it gets
to the point where it boils over, and then I just blow up. Whereas … doing role-playing with us
… I could say what I want to say, but it doesn’t have to be in anger, doesn’t have to explode for
me … I can say it in a positive way where I won’t get that person upset or feel offended.”
9 “Well, she would put up on the board different things … about a situation. And then we’d role play 868 Male 60
that situation … sometimes she’d be real easy on us. Other times it would be real hard on us …
that taught me that, you know, not everybody’s gonna be agreeable with you.”
10 “I learned not to feel discouraged and not to jump to conclusions … cause I could be wrong.” 630 Male 54
11 “Now, sometimes your thoughts can be negative. And you have to do things to make them positive, 601 Male 8
so. And, from that point of view sometimes you have to think about things before you–you know
before you say it.”
12 “ … before, like, I was already making decisions before I even got into the place … I’m going to 896 Male 46
have a bad time so I come in there grumpy as heck and stay grumpy and it’s like–if I’m going to
be like that I shouldn’t have even went.”

Phase 1: Elements of EnCoRE Identified as Helpful; Theme 2: The group atmosphere offered a combination of support and accountability that helped
participants feel comfortable and motivated learning and practicing new skills
13 “Everybody in the room are Veterans, so we had that in common, so we could relate on a lot of 349 Male 49
things. Everybody had, one way or the other, had the same symptoms. We all suffer from the
same thing, so ya know, I look at it like … we all suffer from some sort of schizophrenia. If they
can open up and do this, maybe if I tried, then it’ll help me a little bit [too].”
14 “And then we had to do it by–we had to do it by–in a couple of days, so now we–now we gonna do 744 Male 69
it. We can’t come back to group and say we didn’t do nothing. So hopefully you did do
something.”
15 “And I think like if I missed the goal due to the negative symptoms, it was cool cause I could go to 784 Male 60
the group and say I didn’t do it this time, and then they said, ‘Okay, well try, you know, write it
again and try.’ So, that was the part that the group played in it.”
16 “M [ref: group facilitator] said that the group would kind of be like a kind of a nudge group to try 784 Male 60
and push us into our action plans. So, it did help.”
17 “And then we had to do it by–we had to do it by–in a couple of days, so now we–now we gonna do 374 Male 54
it. We can’t come back to group and say we didn’t do nothing. So hopefully you did do
something.”
18 “So, she gave some good information, and I mean she was an excellent teacher. I had no problem 351 Female 52
with her. You know, she’d listen, and I mean that’s all you can ask for is somebody to listen.”
19 “It was nice to know that she was a Veteran. You know, so I felt really comfortable around her … I 351 Female 52
liked her a lot, because you know I felt comfortable because when, you know, I found out she was
a Veteran. I was oh okay, you know.”
20 “[ref: Veteran facilitator] And she’s somebody, she’s just been around. You know, so you could see 630 Male 54
she was a Veteran … so she could relate on some of the experiences.”
(table continues)
88 BENNETT, KUYKENDALL, HARVEY, AND LUCKSTED

Table 2 (continued)

Random
Row Quotation number Gender Age
Phase 1: Elements of EnCoRE Identified as Helpful; Theme 3: Feeling more skilled and gaining confidence in using those skills led participants to
anticipate more success in social interactions and gave them the confidence to do things.
21 “So that [ref. action plan] helped me start going out a little bit because I wanted to complete my 833 Male 55
assignments really bad. I had to fight my way through some of it, you know, but, just with me
having the, thought that I gotta complete it so that was kinda like I guess you say I faced my fears
in a lot of situations.”
22 “I liked … how she taught us to act in different situations when we go out, how to talk, how to 333 Male 53
compromise, how to handle the situation … I was kind of procrastinating and lazy. That’s all I
had to do is get up off the couch and go, and just going there is not going to hurt me. Once I get
there, I feel okay.”
23 “Instead of being all bottled up and shut down and not speaking up for myself, things like that. And 389 Male 56
it [ref. EnCoRE] also gave me the opportunity to reach out to other folks like over the phone.
Because it’s like I’m one of the type of person that I will avoid even a telephone conversation but
it helped me to be able to pick up the phone and be able to talk to somebody on the other line and
be able to transfer what I’m trying to get across to get my point across.”
24 “ … when I approach a person now, I—I’m not—I’m not–not ashamed to look them in the face or 988 Male 63
just start talking about something, a subject or something, you know. Just talk–come straight out
with what I’m trying to get to.”
25 “I started to appreciate the fact that it [ref. EnCoRE] was getting me out to do stuff in the 672 Female 48
neighborhood and I don’t need to be as reclusive as I’ve been … It made me open my eyes and
realize how much I’ve been missing because of my conditions.”
26 “[I learned] that I could do whatever I put my mind to.” 389 Male 56
27 “It [ref. EnCoRE] got us more involved in how to talk to other people and how to listen to other 559 Male 58
people, interact with other people the right way because I have been doing it a lot of the wrong
way … I was trained as a military police investigator, so I went right to the point on a lot of
things, and then I’d go back on something and hit them back against something in a different way
but the same question … And, that’s the way I talk to someone, I’m always looking at that
instead of … being polite or whatever. I had to learn to kind of de-militarize myself, and this
helped.”
28 “It [ref. EnCoRE] helped you do things that were impossible … [to realize] you can make them 119 Male 55
happen. You don’t have to wait for things to happen. They can get your hands-on doing things
that were always put off or something. Always avoiding, always procrastinating, dawdling,
dragging feet. Just go and do them. Stop delaying.”

Phase 2: Engagement stories

29 “I did a few things that I don’t normally do. I went out to the community center and I interacted with 886 Male 60
other people while I was out … ”
30 “I had a picnic … that was from one of the Action Plans. And we went out … me and my cousin 988 Male 63
… got some money, we put together, got some hot dogs, hamburgers, whatever and sodas and
carried it out to the park and spread it on the—set the table up and stuff. And we ate and had
barbecues and hamburgers on the grill and hotdogs … all my cousins. They came and we had a
great time.”
31 “I planned to be with my brother on his birthday and go to the casino which I did. I did that … I 193 Male 62
made a plan to do it and we did it.”
32 “I saw my friend just—I’ve seen him for the past two weekends. And, you know, I hadn’t seen him 672 Female 48
in like 9 months … Because like I can call him up and if he’s available and I’m available we’ll
see each other but we don’t necessarily make plans. So, we made a few plans, went to a
barbeque.”
33 “I had a pizza party … I told my–asked my sister, I was like we should have a pizza party. You 956 Male 47
invite a couple of your friends and I’ll invite a couple of my associates, have it over to the house
and just chill, talk, eat pizza … I’d been planning stuff ahead of time … I just did the steps
correctly, you know.”
34 “I started coming to the VA more.” 744 Male 69
35 “My father said, hey, man, you’re starting to go out in the neighborhood … I see you. Yeah, I’m 956 Male 47
starting to do things in the neighborhood. We’re doing something up at the VA [ref. EnCoRE], so
we gotta do stuff with neighbors and do something with the community a little bit. He said that’s
good then. Keep up the good work, man.”
36 “Going visiting and visiting with my daughters and my sisters and family members. You know, 193 Male 62
going places, you know … I wasn’t socializing as much until I went to these classes [ref.
EnCoRE], and then I started socializing a little bit more.”
37 “Got together with a friend and we just met at a certain location, at his place and just went to the 119 Male 55
theater and saw a movie. It was really good … It was a lot of fun … the EnCoRE kept coming
up with some kind of plan to do something … and I would pick the easy things like go to a
movie with somebody. Doing it by yourself is impossible, you keep forgetting, so to go with
somebody that’ll remind you to go, that works.”
38 “I started to appreciate the fact that it [ref. EnCoRE] was getting me out to do stuff in the 672 Female 48
neighborhood and I don’t need to be as reclusive as I’ve been.”
(table continues)
 INCREASING COMMUNITY ENGAGEMENT IN SCHIZOPHRENIA 89

Table 2 (continued)

Random
Row Quotation number Gender Age
Phase 3: Extended use of skills to support continued social and community activities
39 “But now I am planning … like recreational things. I go to the movies, go skating, go play tennis, 982 Female 63
go bowling, stuff like that.”
40 “I’m volunteering … I go over there two to three times a week, a few hours a day. I’m going back 559 Male 58
whenever I leave here … I got off my butt and started doing something that involves me because
that’s part of my recovery also. That’s what I see, and it helps. [ref: EnCoRE] allowed me to do
that. It allowed me to reach out.”
41 “I’ve been actually visiting more, I’ll say but I still, kind of like with my family and my close 833 Male 55
friends, you know, but I have been meeting other people in the process. So you know, I went out
and shot pool, I met people then, so I met people like that and it was a good experience.”
Note. EnCoRE = engaging in community roles and experiences; VA = Veterans Affairs.

confidence reduced the inhibiting uncertainty about interpersonal
interactions that many participants experience.
Theme 2: The Group Atmosphere Offered a
Combination of Support and Accountability That
Helped Participants Feel Comfortable and
Motivated Learning and Practicing New Skills
Participants (Table 2, Rows 13–15) appreciated both support and
accountability from facilitators and from other group members.
Feeling heard, understood, respected, and accepted supported skill
acquisition and practice. Participants were motivated to complete
their action plans but felt good knowing that if they did not, the
group would support them in refining their plan and completing it
the next time.
Participants (Table 2, Rows 16–18) described characteristics of the
facilitators as contributing substantially to this helpful environment—
being a good listener, having a positive attitude, being supportive.
Participants also valued facilitators being “tough” (gently challeng-
ing, holding people accountable) while also being encouraging and
supportive. As Participant 784 (male, age 60) stated about the group
facilitator: [she] said that the group would kind of be like a kind of a
nudge group to try and push us into our action plans. So, it did help.
Participants (Table 2, Rows 19–20) mentioned that a Veteran as a
group facilitator added to the comfortable, understanding atmosphere
of the groups. Participants felt that the Veteran facilitator could relate
to their experience and that they could relate to her.
Theme 3: Feeling More Skilled and Gaining
Confidence in Using Those Skills Led Participants to
Anticipate More Success in Social Interactions and
Gave Them the Confidence to Do Things
Having learned skills and gained confidence, participants (Table 2,
Rows 21–24) were much more willing to try new activities. They felt
less overwhelmed, more capable, and saw social activities as more
“doable.” As Participant 333 (male, age 53) explained: That’s all I
had to do is get up off the couch and go, and just going there is not
going to hurt me. Once I get there, I feel okay. Many participants
(Table 2, Rows 25–28) also described an important realization—that
there are more positive ways to interact in the world. Some talked
about unlearning old negative habits or learning new ways of
thinking. Several felt that they had learned how to do things “the
right way” or learned to “express themselves,” in areas or ways they
did not know before. Participant 389 (male, age 56) explained:
[I learned] that I could do whatever I put my mind to.
Taken together, these themes illustrate a process of change. Skill
acquisition was made possible by a positive group atmosphere
combining encouragement with accountability. This content and
process combination resulted in interviewees feeling more capable
and less inhibited, allowing them to try new things. The mastery
from repeated practice furthered their confidence and, for some, led
to shifts in thinking about what is possible for social interactions in
their lives.
Phase 2 Results: Engagement Stories
Examples of participating in social/community activities illustrate
the implementation of skills and confidence into real-life contexts.
Findings from Phase 2 coding of these “engagement stories”—
briefly told specific events of significance to participants—are
presented in Figure 1. Participants (Table 2, Rows 29–33) partici-
pated in new social activities and increased their participation in
existing social relationships. For example, Participant 886 (male,
age 60) said: I did a few things that I don’t normally do. I went out to
the community center and I interacted with other people while I was
out. Others (Table 2, Rows 34–38) reflected using skills they learned
in EnCoRE to plan enjoyable activities. Participant 193 (male, age
62) related: Going visiting and visiting with my daughters and my
sisters and family members. You know, going places, you know … I
wasn’t socializing as much until I went to these classes [ref.
EnCoRE], and then I started socializing a little bit more. These
stories show that it is the synergy of the skills/strategies and the
group process that helps participants try more and engage more in
social and community activities.
Phase 3 Results. Extended Use of Skills to Support
Continued Social and Community Activities
Some participants (Table 2, Rows 39–41) offered that they carried
with them knowledge and confidence gained in EnCoRE that they
could do activities again when desired. For example, Participant 982
(female, age 63) said: But now I am planning … like recreational
things. I go to the movies, go skating, go play tennis, go bowling, stuff
like that. Because the interviews did not expressly explore this topic,
the data are limited to what interviewees reported spontaneously.
90 BENNETT, KUYKENDALL, HARVEY, AND LUCKSTED

Figure 1
Summary of Phase 2 Coding (Engagement Stories)
Elements of EnCoRE Identified in Engagement Stories
80
67
70
60
Axis Title

50
38
40
30 25
20
20 11 13 12 11
5 5 8
10 4 1 2 4 4
0

Axis Title

Main Element Secondary Element

Types of Social and Community Activities Identified in Engagement

Stories
45 41
40
35
# of times identified

29
30
25
20 17
15 12 13 12
10 7 6
5
0
Initiate new Increase Initiate new Increase Practice life Reduce Positive Other
social activity existing relationship existing maintenance interpersonal internal
social activity relationship conflict change
Axis Title

Note. EnCoRE = engaging in community roles and experiences.

Nonetheless, these anecdotes raise the possibility that participants
experienced a lasting shift in their perspective on social interactions.
Discussion
This qualitative study explored the experiences of Veterans living
with schizophrenia and negative symptoms who participated in a
program to increase social and community participation. In semi-
structured interviews, participants discussed the skills they learned,
the confidence they gained, and the ways they used the skills to
increase participation in social and community activities. These
findings can be applied in several ways in psychiatric rehabilitation
settings to prepare and support individuals to increase community
engagement. First, the process of learning skills, planning to use
them, implementing them, and returning to the group for input
helped many surmount feelings of low interest and low motivation.
In-session practice led to real-life trying, which led to overcoming
discomfort, which led to increased confidence to try activities again.
Our results underline previous findings that interventions that teach
new skills, systematically plan for participants to implement them in
their lives, and problem-solve based on participants’ actual experi-
ences support social and community engagement. For example,
Social Skills Training, an evidence-based practice that breaks down
social skills into component parts and supports skills acquisition
through repeated practice (Bellack et al., 2004), yields lower ratings
of negative symptoms and improvements in functioning (Turner
et al., 2018). Behavioral activation approaches that include sched-
uling rewarding activities, daily monitoring of activity completion,
and engaging social supports to overcome barriers have been found
to improve depression, substance use, and other psychiatric and
 INCREASING COMMUNITY ENGAGEMENT IN SCHIZOPHRENIA
medical conditions (Daughters et al., 2010, 2018; Hopko et al.,
2011; Magidson et al., 2014; Mazzucchelli et al., 2009; Pagoto et al.,
2013). In EnCoRE, integrating Social Skills Training and behavioral
activation with motivational interviewing seems to support the
transition from learning a skill to trying something new (Balán
et al., 2016). All of these approaches can be delivered in psychiatric
rehabilitation settings. Training in these practices is standardized,
widely available, and applicable to the full range of professionals
who work in these settings.
Second, negative symptoms are often viewed as a sign of laziness
or disinterest, or as irremediable characteristics of schizophrenia
(Correll & Schooler, 2020; Galderisi et al., 2018; Thirthalli, 2021).
However, people living with schizophrenia often report limiting
their social and community involvement due to stigma, discomfort
around others, and a lack of confidence. Gee and colleagues (Gee
et al., 2019) interviewed 24 young adults receiving services for early
psychosis about their experience with negative symptoms and found
that interviewees reported avoiding social situations due to internal-
ized stigma and feeling shame about having a serious mental illness.
In our interviews, EnCoRE participants reported increased confi-
dence with social engagement and increased social behaviors. This
corroborates that for individuals living with negative symptoms,
skills, and confidence can be addressed successfully via psychoso-
cial interventions. Practitioners can integrate confidence building
into rehabilitation work in ways that support community engage-
ment by providing education about the process our study partici-
pants articulated: trying an activity leads to positive feelings which
leads to more activity which leads to confidence, and so on. That is,
people seem to build confidence by trying something that makes
them uncomfortable or that they have avoided and seeing that they
can do it and enjoy it.
Third, participants reported that learning skills helped them try
new activities which helped them build confidence for continued
participation. This is in line with findings that defeatist perfor-
mance beliefs, negative thoughts about one’s ability to success-
fully engage in and complete goal-directed activities (Grant &
Beck, 2009; Ventura et al., 2014), may influence negative symp-
toms and associated poor functional outcomes (Campellone et al.,
2016). The quantitative findings from this study’s parent trial
(citation blinded for article review) indicated possible efficacy
of EnCoRE at posttreatment among those with greater dysfunc-
tional attitudes at baseline ( p = .0526) that continued at a 3-month
following, albeit with attenuated significance ( p = .0877). Our
findings and those in the literature support having proactive
discussions about how building confidence can support improved
social and community participation. Integrating explanation of
these confidence and avoidance dynamics and strategies for over-
coming them into psychoeducation and other recovery-related
programming within psychiatric rehabilitation services could
help individuals living with schizophrenia develop greater inter-
personal and social functioning.
Finally, negative symptoms are challenging to address in treat-
ment (Correll & Schooler, 2020; Thirthalli, 2021). Our conversa-
tions with clinicians regarding the VA treatment context for
Veterans living with schizophrenia and negative symptoms echoed
commonly cited barriers: practical obstacles (e.g., lack of money
and transportation), low support outside of the treatment setting, and
frustration about what to do when encouragement and practical
suggestions are not sufficient. Pairing skills training with focused
91
behavioral activation-based activity planning may be a fruitful
strategy and, as noted above, can be easily learned by diverse
providers, offering an approach that is person-centered and recov-
ery-oriented. Participants identified group support and accountabil-
ity as impactful. Being around Veterans living with schizophrenia
and having a Veteran group interventionist helped them feel that
others could relate to their experience. These features could be
replicated across psychiatric rehabilitation and other mental health
treatment settings.
Study strengths include the richness of interviews that focus on
how learning via a structured intervention can support behavioral
change. Hearing that EnCoRE was acceptable and beneficial, in
participants’ own words, helps to highlight the impact that a
psychosocial intervention can have supporting the changes that
participants perceive as meaningful; there is increasing use of
qualitative interviewing with trials to support this deeper degree
of understanding (DiBenedetti et al., 2018). Quantitative measures
are selected based on their use in previous research but run the risk of
not capturing the most important changes that participants make. For
example, many measures of social functioning in serious mental
illness, including some of those utilized in the parent trial, award
higher ratings for employment, independent living, and highly
social activities (e.g., being around many people). These aspects
of functioning may be less relevant for some people living with
schizophrenia, especially those who are older and of limited finan-
cial means such as those in our trial. Here, qualitative interviews
captured detailed information on participants’ experiences and
illustrate how learning new skills within a supportive group atmo-
sphere can lead to more social and community participation.
Several weaknesses should be noted. Our findings are derived
from the experiences of only 36 adults living with schizophrenia and
negative symptoms. Because the intervention was designed to help
people who, because of their illness, struggled with anhedonia
and asociality, we followed guidelines (Galderisi et al., 2021)
that suggest a minimum level of clinically meaningful negative
symptoms for study entry. We also excluded individuals with
substance use disorders. Although the components of EnCoRE
have been tested in samples of people with schizophrenia generally
(Rabinowitz et al., 2013) and in those with substance use disorders
(Martínez-Vispo et al., 2018), our eligibility requirement may limit
the generalizability of the findings or represent a missed opportunity
to collect data on patients with comorbid substance use disorders as
part of their clinical presentation. Future research could study
EnCoRE utilizing broader inclusion criteria to determine if indivi-
duals with these conditions can benefit. In addition, we conducted
one–time qualitative interviews to gather stakeholder perspectives. A
fuller process evaluation that includes follow-up stakeholder input,
examination of facilitators of and barriers to EnCoRE delivery, and
the fit of EnCoRE in different rehabilitation and mental health
treatment settings (Skivington et al., 2021) would provide critical
information for wider scale implementation. The fact that participants
were U.S. military veterans may limit generalizability; we recom-
mend future research to replicate our fundings among non-Veteran
samples. This qualitative interview study was conducted in conjunc-
tion with a research trial in which research interventionists delivered
EnCoRE. In future research, the practical potential of EnCoRE as an
effective intervention for negative symptoms associated with schizo-
phrenia needs to be tested in the context of routine clinical services
such as under a pragmatic trial design (Ford & Norrie, 2016).
92 BENNETT, KUYKENDALL, HARVEY, AND LUCKSTED
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Received May 8, 2022
Revision received October 12, 2022
Accepted October 14, 2022 ▪