Skill Building: Assessing the Evidence

Article (PDF Available)inPsychiatric services (Washington, D.C.) 65(6) · April 2014with42 Reads
DOI: 10.1176/appi.ps.201300251 · Source: PubMed
Abstract
Objective: Skill building for adults involves multiple approaches to address the complex problems related to serious mental illness. Individuals with schizophrenia are often the research focus. The authors outline key skill-building approaches and describe their evidence base. Methods: Authors searched meta-analyses, research reviews, and individual studies from 1995 through March 2013. Databases surveyed were PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, Published International Literature on Traumatic Stress, ERIC, and CINAHL. Authors chose from three levels of evidence (high, moderate, and low) on the basis of benchmarks for the number of studies and quality of their methodology. They also described the evidence of service effectiveness. Results: Over 100 randomized controlled trials and numerous quasi-experimental studies support rating the level of evidence as high. Outcomes indicate strong effectiveness for social skills training, social cognitive training, and cognitive remediation, especially if these interventions are delivered through integrated approaches, such as Integrated Psychological Therapy. Results are somewhat mixed for life skills training (when studied alone) and cognitive-behavioral approaches. The complexities of schizophrenia and other serious mental illnesses call for individually tailored, multimodal skill-building approaches in combination with other treatments. Conclusions: Skill building should be a foundation for rehabilitation services covered by comprehensive benefit plans that attend to the need for service packages with multiple components delivered in various combinations. Further research should demonstrate more conclusively the long-term effectiveness of skill building in real-life situations, alone and in various treatment combinations. Studies of diverse subpopulations are also needed.
Assessing the Evidence Base Series
Skill Building: Assessing the Evidence
D. Russell Lyman, Ph.D.
Matthew M. Kurtz, Ph.D.
Marianne Farkas, Sc.D.
Preethy George, Ph.D.
Richard H. Dougherty, Ph.D.
Allen S. Daniels, Ed.D.
Sushmita Shoma Ghose, Ph.D.
Miriam E. Delphin-Rittmon, Ph.D.
Objective: Skill building for adults involves multiple approaches to address
the complex problems related to serious mental illness. Individuals with
schizophrenia are often the research focus. The authors outline key skill-
building approaches and describe their evidence base.
Methods: Authors
searched meta-analyses, research reviews, and individual studies from
1995 through March 2013. Databases surveyed were PubMed, PsycINFO,
Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social
Services Abstracts, Published International Literature on Traumatic
Stress, ERIC, and CINAHL. Authors chose from three levels of evidence
(high, moderate, and low) on the basis of benchmarks for the number of
studies and quality of their methodology. They also described the evidence
of service effectiveness.
Results: Over 100 randomized controlled trials
and numerous quasi-experimental studies support rating the level of evi-
dence as high. Outcomes indicate strong effectiveness for social skills
training, social cognitive training, and cognitive remediation, especially if
these interventions are delivered through integrated approaches, such as
Integrated Psychological Therapy. Results are somewhat mixed for life
skills training (when studied alone) and cognitive-behavioral approaches.
The complexities of schizophrenia and other serious mental illnesses call
for individually tailored, multimodal skill-building approaches in combi-
nation with other treatments.
Conclusions: Skill building should be
a foundation for rehabilitation services covered by comprehensive benefit
plans that attend to the need for service packages with multiple compo-
nents delivered in various combinations. Further research should dem-
onstrate more conclusively the long-term effectiveness of skill building in
real-life situations, alone and in various treatment combinations. Studies of
diverse subpopulations are also needed. (Psychiatric Services 65:727738,
2014; doi: 10.1176/appi.ps.201300251)
D
eveloping or regaining basic
skills needed to function
adaptively in real-world sit-
uations is essential for individuals who
are struggling with serious mental
illness, substance use disorders, or
co-occurring mental and substance
use disorders. The neurodevelopmen-
tal nature of certain severe mental
illnesses (1)in which multiple and
complex skill deficits emerge early in
development, persist through adult-
hood in the absence of targeted
treatment, and affect virtually every
aspect of life functioninghas led to
a vast array of approaches to skill
building. These approaches are typi-
cally applied in various combinations.
The inherent complexity of skill
building adds a high degree of chal-
lenge to assessing levels of evidence
and effectiveness for such a diverse
array of treatment modalities a nd
methods. In this review, we examined
four key componen ts of skill build-
ing: social skills training (including life
skills training), social cognitive training,
cognitive remediation, and cognitive-
behavioral therapies that target skills
for coping with psychotic processes.
Each of these approaches addresses
specific skill areas that underlie adap-
tive functioning and can be consid-
ered building blocks for integrated
approaches (for example, Integrated
Psychological Therapy and Illness
Management and Recovery) that help
individuals manage their illness, build
daily living skills, and succeed in
recovery.
Approaches to skill building span
many fields, including occupational
Dr. Lyman and Dr. Dougherty are with DMA Health Strategies, Lexington, Massachusetts
(e-mail:russl@dmahealth.com). Dr. Kurtz is with the Department of Psychology and the
Department of Neuroscience and Behavior, Wesleyan University, Middletown,
Connecticut. Dr. Farkas is with the Center for Psychiatric Rehabilitation, Bos ton
University. Dr. George, Dr. Daniels, and Dr. Ghose are with Westat, Rockville, Maryland.
Dr. Delphin-Rittmon is with the Office of Policy, Planning, and Innovation, Substance
Abuse and Mental Health Services Administration (SAMHSA), Rockville, Maryland. This
article is part of a series of literature reviews being published in Psychiatric Services. The
reviews were commissioned by SAMHSA through a contract with Truven Health
Analytics and were conducted by experts in each topic area, who wrote the reviews along
with authors from Truven Health Analytics, Westat, DMA Health Strategies, and
SAMHSA. Each article in the series was peer reviewed by a special panel of Psychiatric
Services reviewers.
PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' June 2014 Vol. 65 No. 6 727
therapy, psychiatric rehabilitation, ap-
plied clinical psychology, substance
abuse treatment, and neuropsychol-
ogy. Integrative approaches that com-
bine various skill-building strategies
also constitute a vast area of inquiry.
In-depth review of these areas is
beyond the scope of this report.
Instead, we provide brief summaries
of literature regarding each of the
selected skill-building components,
with emphasis on reviews and se-
lected individual studies that are most
recent and comprehensive. We note
that the interventions selected for this
review map closely to those selected
in the federally financed schizophre-
nia Patient Outcomes Research Team
(PORT) analysis and psy chosocia l
treatment recom mendations (2), and
readers are encouraged to consult the
PORT publication for a detailed anal-
ysis of the existing literature on gen-
eral treatment of schizophrenia. We
conclude with a discussion of the chal-
lenges in evaluating the effectiveness
of specific approaches in isolation, be-
cause the complexities of serious men-
tal illnesses such as schizophrenia call
for integrated, multimodal approaches
that address neuropsychological issues
together with challenges in specific skill
areas.
The objectives of this review were
to describe the components of skill
building, including a summary of
service activities and provider roles;
rate the level of research evidence
(that is, methodological quality and
number of confirming versus discon-
firming studies); and summarize the
effectiveness of the service as indi-
cated by the research literature. The
results will provide stakeholders with
an accessible summary of the evidence
for a range of skill-building services
with implications for practice. This
information will help consumers and
providers of this type of service as well
as payers and policymakers who need
to make informed choices about their
inclusion as covered benefits.
Description of the service
This article reports the results of
a literature review that was under-
taken as part of the Assessing the
Evidence Base Series (see box on this
page). For purposes of this series, the
Substance Abuse and Mental Health
Services Administration has defined
skill building as a direct service that
helps individuals enhan ce their ca-
pacity to accomplish a task or goal
successfully. Skill-building services gen-
erally are based on psychoeducational
and cognitive-behavioral approaches.
They assist people with developing
or improving competencies in the
areas of self-help, self-care, adapta-
tion, or socialization. The ultimate
goals for people with serious mental
illness are to develop the capacity to
manage their illness and to restore or
improve levels of functioning in or-
der to function adaptively in society.
Table 1 presents a summary of this
service.
Skill-building activities help an in-
dividual learn decision-making, inter-
personal, community integration, and
functional skills. Building such skills
and supports helps individuals achieve
social integration, optimal health, and
role productivity (3,4). In the behav-
ioral health arena, most of the skill-
building literature pertains to adults
with schizophrenia. The service is
implemented in outpatient and in-
patient mental health settings, day
treatment programs, and, in some
cases, the homes of consumers. Al-
though skill-building approaches may
appear prescriptive, they are tailored
to the personal goals set by the client
in the context of a person-centered
therapeutic relationship.
In our review, we identified four
key areas of functioning that are
addressed in the fundamental skill-
building approaches summarized
here. Although we discuss them sep-
arately, these areas and the ap-
proaches developed to address them
can be considered building blocks of
adaptive functioning that often hinge
upon each another and overlap. These
key areas (and their associated skill-
building approaches) are the ability
to learn and apply social skills that
pertain to specific social and daily
living situations (social skills training);
the ability to accurately interpret
social interactions and respond ap-
propriately (social cognitive training);
the ability to use cognitive functions,
such as memory and attention, to
support psychosocial skills and think-
ing (cognitive remediation); and the
ability t o manage the distress and
disability associated with psychotic
process, depression, and other ne-
gative symptoms (cognitive-behavioral
approaches). Our review of social skills
training includes life skills training,
which targets daily living skills, also
known in the field as activities of daily
living (for example, personal hygien e),
and higher-level instrumental activities
of daily living (for example, managing
a bank account). Life skills training
covers broad areas of functioning, and
for that reason it is ofte n integrated
with other treatment approaches to
address complex problemsa com-
mon theme in skill-building practice
and research. We conclude with a
discussion of Integrated Psychological
About the AEB Series
The Assessing the Evidence Base (AEB) Series presents literature reviews
for 13 commonly used, recovery-focused mental health and substance use
services. Authors evaluated research articles and reviews specific to each
service that were published from 1995 through 2012 or 2013. Each AEB
Series article presents ratings of the strength of the evidence for the service,
descriptions of service effectiveness, and recommendations for future
implementation and research. The target audience includes state mental
health and substance use program directors and their senior staff, Medicaid
staff, other purchasers of health care services (for example, managed care
organizations and commercial insurance), leaders in community health
organizations, providers, consumers and family members, and others
interested in the empirical evidence base for these services. The research
was sponsored by the Substance Abuse and Mental Health Services
Administration to help inform decisions about which services should be
covered in public and commercially funded plans. Details about the
research methodology and bases for the conclusions are included in the
introduction to the AEB Series (7).
728 PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' June 2014 Vol. 65 No. 6
Therapy a nd Illness Management
and Recovery as examples of pro-
grams that integrate skill-building
approaches.
Methods
Search strategy
We reviewed meta-analyses, research
reviews, and individual studies from
1995 through March 2013. We con-
ducted a survey of major databases:
PubMed (U.S. National Library of
Medicine and National Institutes of
Health), PsycINFO (American Psy-
chological Association), Applied So-
cial Sciences Index and Abstracts,
Sociological Abstracts, Social Services
Abstracts, Published International
Literature on Traumatic Stress, the
Educational Resources Information
Center, and the Cumulative Index to
Nursing and Allied Health Literature.
We used combinations of the follow-
ing search terms: skills teaching, skills
training, cognitive remediation, trauma
skill building, social skills training,
psychiatric rehabilitation, skills in ac-
tivities of daily living, and occupational
therapy for substance use and mental
health. We also identified publications
through review of bibliographies and
consultation with content experts.
Inclusion and exclusion criteria
This review was limited to U.S. and
international studies in English and
focused on individuals with mental
disorders, substance use disorders, or
co-occurring mental and substance
use disorders. It included random-
ized controlled t rials (RCTs), quasi-
experimental studies, single-group
time-series design studies, and review
articles such as meta-analyses and sys-
tematic reviews.
Excluded were studies of pop-
ulations with autism spectrum and
pervasive developmental disorders,
Alzheimers disease, brain injury, intel-
lectual disabilities, Parkinsons disease,
and fetal alcohol spectrum disorder.
Also excluded were studies of the fol-
lowing services: parenting and c are-
giver skills training, HIV/AIDS risk
reduction for individuals with sub-
stance use disorders, universal preven-
tion programs, and sensory integration
interventions. Cognitive-behavioral ther-
apy (CBT) was reviewed only in re-
gard to its use in coping with the
psychotic process , although we rec-
ognize that cognitive-behavioral strat-
egies are used in many skill-building
approaches. Services that are strictly
psychoeducational were not included,
because consumer and family psycho-
education is reviewed in a separate
article in this series (5). In addition,
because of the relative lack of skill-
building research with children and
adolescents, this review focused only
on adults.
Skill-building approaches are fre-
quently used as enhancements for
other services, such as supported
employment and supported educa-
tion. However, another article in this
series is devoted solely to supported
employment (6); therefore, an in-
depth examin ation of this service and
of supported education (for which
there is relatively little research) was
not included in our review. Coping-
skills training in the treatment of
alcohol and drug use disorders has
also been studied to some extent;
however, the evidence in this impor-
tant area of treatment is limited, and
findings are not consistent. Therefore,
we did not review this intervention,
but we note that it as an area in which
more service development and re-
search may be needed.
Strength of the evidence
The methodology used to rate the
strength of the evidence is described
in detail in the introduction to this
series (7). The research designs of the
studies identified during the literature
search were independently examined.
Three levels of evidence (high, mod-
erate, and low) were used to indicate
the overall research quality of the
collection of studies. Ratings were
based on predefined benchmarks that
considered the number and method-
ological quality of the studies. If the
ratings were dissimilar, a consensus
opinion was reached.
In general, high ratings indicate
confidence in the reported outcomes
and are based on three or more RCTs
with adequate designs or two RCTs
plus two quasi-experimental studies
with adequate designs. Moderate
ratings indicate that there is some
adequate research to judge the ser-
vice, although future research could
influence reported results. Moderate
ratings are based on the following
three options: two or more quasi-
experimental studies with adequate
design; one quasi-experimental study
plus one RCT with adequate design;
or at least two RCTs with some
methodological weaknesses or at least
Table 1
Description of skill building
Feature Description
Service definition Skill building is a direct service that helps individuals enhance
their capacity to successfully accomplish a task or goal. Skill-
building services generally are based on psychoeducational
and cognitive-behavioral approaches. They assist individuals
with developing or improving competencies in the areas of
self-help, self-care, adaptation, or socialization. These skills
can help prevent relapse and aid recovery from mental and
substance use disorders.
Service goals Assist in illness self-management, medication management,
and management of physical health; improve life skills (for
example, activities of daily living and community living skills
such as transportation, financial management, shopping, and
cooking); and improve cognitive and intellectual skills (for
example, learning and organizational skills, attention, and
memory), interpersonal and intrapersonal skills, self-help
and advocacy skills, and skills in functional areas such as
employment and education
Populations Adults who have serious mental illnesses (usually schizophrenia,
schizophreniform, or schizoaffective disorders), adults with
substance use disorders or co-occurring mental and substance
use disorders, and adults with bipolar and other affective
disorders (limited research)
Settings for
service delivery
Outpatient mental health centers, day treatment programs,
inpatient facilities, consumers homes
PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' June 2014 Vol. 65 No. 6 729
three quasi-experimental studies with
some methodological weaknesses. Low
ratings indicate that research for this
service is not adequate to draw evidence-
based conclusions. Low ratings indi-
cate that studies have nonexperimental
designs, there are no RCTs, or there is
no more than one adequately designed
quasi-experimental study.
We accounted for other design
factors that could increase or decrease
the evidence rating, such as how the
service, populations, and interven-
tions were defined; use of statistical
methods to account for baseline dif-
ferences between experimental and
comparison groups; identification of
moderating or confounding variables
with appropriate statistical controls;
examination of attrition and follow-up;
use of psychometrically sound mea-
sures; and indications of potential re-
search bias.
Effectiveness of the service
We also described the effectiveness of
the servicethat is, how well the
outcomes of the studies met the
service goals. We compiled the find-
ings for separate outcome measures
and study populations, summarized
the results, and noted differences
across investigations. We considered
the quality of the research design in
our conclusion s about the st rength of
the evidence and the effectiveness of
the service.
Results
Level of evidence
Our literature search found that more
than 100 RCTs on skill building have
been summarized in multiple reviews,
covering decades of research that
extend into 2013. In general, individ-
ual studies that were not included in
reviews and meta-analyses did not
appear to add to the findings sum-
marized therein. Thus, with a few
exceptions, we have not included sum-
maries of individual studies in this
report; rather, we focus on the reviews
and meta-analyses that thoroughly
cover the available research.
Our review of the literature re-
vealed a high level of research evi-
dence for the different approaches to
skill building. The progression of
research reflects increasing levels of
evidence in tandem with a growing
understanding of the complex behav-
ioral and neuropsychological factors
involved in serious mental illness
most com monly schizophrenia. Meth-
odological limitations in skill-building
research published prior to 1995
include a lack of firmly established
protocols, inadequate descriptions of
the populations studied, lack of blind
research designs, failure to investigate
confounding variables, and small sam-
ples. Overall, however, research in
this area has evolved, and there have
been many rigorous studies testing
different skill-building approaches.
Below, we summarize the level of
evidence for each service approach.
Table 2 summarizes selected reviews
and meta-analyses that represent the
approaches we reviewed.
Social and life skills training. Life
skills training is usually coupled with
social skills training, and thus we
review these approaches together.
More recent approaches have also
coupled social skills training methods
with psychoeducation to help clients
develop skills relevant to illness self-
management, including medication
self-management, according to person-
centered recovery goals. The inter-
ventions are delivered by trained,
credentialed professionals, either in
clients homes or in cli nical settings,
such as outpatient, inpatien t, or day
treatment programs.
As described by Mueser and col-
leagues (8), social skills training tar-
gets social perception, processing, and
behavioral responses. It involves be-
havioral instruction, role modeling
and rehearsal, corrective feedback,
and positive reinfor cement to teach
basic social skills, such as how to
manage a greeting or an introduction
(2). It is most often used to address
social skill chall enges characteristic of
schizophrenia that affect functional
areas such as work, education, and the
ability to maintain relationships. So-
cial skills training allows participants
to receive, process, and express
socially relevant cues (9). In vivo
training, facilitated by a leader in
natural settings, helps achieve gener-
alization to community settings, and
participants are often given home-
work to practice on their own in their
home environments. Social skills train-
ing is usually conducted in groups,
which helps reduce stigma, takes ad-
vantage of peer feedback, and can be
cost-effective.
Life skills training targets func-
tional domains, such as managing
ones household, finances, per sonal
hygiene, and daily schedule (10). This
includes self-care skills, such as bath-
ing, shaving, hair care, and brushing
teeth; domestic tasks, such as washing
dishes, cooking, cleaning, doing laun-
dry, and managing money; and other
tasks, such as shopping, practicing
good nutrition, using transportation,
and managing a schedule. Communi-
cation and social skills as well as illness
management skills are also targeted in
life skills trainin g packages. Life skills
training programs can be distin-
guished from social skills training in
that they often place less of an explicit
focus on social learning principles and
have a greater focus on instrumental
skills needed to manage daily living
tasks successfully.
A 2008 review o f soc ial skills
training cited 23 existing RCTs, most
of which had adequate design, which
indicates a high level of evidence (11).
There is less evidence for life skills
training. Three Cochrane reviews
found insufficient evidence for this
approach (10,12,13), and the first
Cochrane meta-analysis in 1998 of
129 life skills programs concluded
that only two studies met criteria for
an RCT (12). Further, an update of
this review conducted ten years later
found only two add itional studies that
met criteria for an RCT, and these
had very small samples (13). A sub-
sequent Cochrane review in 2012
concluded that in this area, the
quality of scientific evidence is low
and uncertain (10).
These reviews may not do justice to
life skills programs in that these pro-
grams are commonly implemented in
the context of more compr ehensive
social skills training as w ell as in
overall psychosocial rehabilitation ap-
proaches; thus they are difficult to
assess in isolation. However, some
individual studies of life skills training
are of adequate design to support an
assessment of the evidence. For ex-
ample, Arbesman and Logsdon (14)
cited three RCTs supporting the ef-
fects of the Social and Independent
Living Skills program as well as three
730 PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' June 2014 Vol. 65 No. 6
Table 2
Selected reviews and meta-analyses of skill building included in the review
a
Study Focus of review Outcomes measured Summary of findings
Mueser et al.,
2002 (26)
Illness management approaches,
including medication man-
agement, relapse prevention,
coping skills training, and
cognitive-behavioral tailoring
Medication adherence; relapses
and rehospitalizations; severity
of symptoms, including psy-
chotic symptoms; social ad-
justment; quality of life
Behavioral tailoring improved taking medication
as prescribed; symptom severity, psychotic
symptoms, relapses, and rehospitalizations
were all reduced in multiple RCTs. Several
studies of illness management found improve-
ment in social adjustment and quality of life.
Pilling et al.,
2002 (27)
Social skills training and cog-
nitive remediation for treat-
ing negative symptoms of
schizophrenia
Social skills training: relapse,
treatment compliance, global
adjustment, social functioning,
quality of life. Cognitive re-
mediation: attention, verbal
memory, visual memory,
mental state, executive
functioning
No reliable benefits were associated with social
skills training or cognitive remediation. The
interventions were not recommended for
clinical practice.
Twamley et al.,
2003 (39)
Cognitive training for individuals
with schizophrenia
Cognitive performance, symp-
toms, everyday functioning
Cognitive training was effective in improving
cognitive performance, psychiatric symptoms,
and everyday functioning, but it was not
effective in lessening cognitive impairments
characteristic of schizophrenia.
Bellack,
2004 (29)
Psychosocial rehabilitation strat-
egies (social skills training,
cognitive-behavioral therapy,
and cognitive remediation) for
individuals with schizophrenia
and other severe mental illness
Social skills training: psychotic
symptoms, relapse, behavioral
skills, social role function, spe-
cialized behavioral skills, self-
efficacy. Cognitive-behavioral
therapy: delusions, hallucina-
tions, overall symptoms, re-
lapse, social role functioning,
depression, negative symp-
toms, durability of effects
The strongest support was for effectiveness of
social skills training, which is most appropri-
ate for treating social impairment rather than
schizophrenia more broadly. Results showed
promising preliminary support for cognitive-
behavioral therapy among people with psy-
chotic disorders.
Kopelowicz
et al.,
2006 (31)
Social skills training for individ-
uals with schizophrenia
Disease management, indepen-
dent living skills
Inconsistent evidence was found for effective-
ness of social skills training on psychopa-
thology. Social skills training should not be
considered as a stand-alone treatment, but it
is important to include it as part of a holistic
rehabilitation program.
Pfammatter
et al.,
2006 (9)
Social skills training, cognitive re-
mediation, cognitive-behavioral
therapy, and coping interven-
tions for people with schizo-
phrenia, families, and others
Social skills training: acquisition
of social skills and assertive-
ness, psychopathology, hos-
pitalization rates. Cognitive
remediation: executive func-
tioning, cognitive processing.
Cognitive-behavioral therapy:
acquisition of cognitive strate-
gies, symptom severity
Social skills training: inconsistent findings in
RCTs did not support the large effects found
in quasi-experimental studies of acquisition
of social skills and assertiveness and low to
moderate effects for reductions in psycho-
pathology and hospitalization rates. Author
meta-analysis of 19 RCTs confirmed large
and enduring effects on social skills, moderate
improvement in social functioning, a slight
reduction in psychopathology, and a significant
decrease in hospitalization rate at follow-up.
Cognitive remediation: RCTs did not support
evidence of effectiveness. Quasi-experimental
studies supported small to moderate effects
on general cognitive functioning. Cognitive-
behavioral therapy: studies supported me-
dium to large effects on severity of symptoms
through cognitive restructuring and cognitive
enhancement strategies, with stability at
follow-up.
Roder et al.,
2006 (46)
Integrated Psychological Ther-
apy for individuals with
schizophrenia
b
Neurocognition, psychopathol-
ogy, psychosocial functioning
Integrated Psychological Therapy was more
effective than control conditions across all
outcomes, including symptoms, psychosocial
functioning, and neurocognition. Results
were consistent across settings (inpatient and
outpatient, academic and nonacademic) and
phases of treatment (acute and chronic).
Continues on next page
PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' June 2014 Vol. 65 No. 6 731
Table 2
Continued from previous page
Study Focus of review Outcomes measured Summary of findings
McGurk et al.,
2007 (40)
Cognitive remediation for indi-
viduals with schizophrenia
Cognitive performance, symp-
toms, psychosocial functioning
A medium effect was found for improved
cognitive performance, a slightly lower effect
for improved psychosocial functioning, and
a small effect for improved symptoms.
Studies in which adjunctive psychiatric re-
habilitation was provided found significantly
greater effects on psychosocial functioning
than studies that provided cognitive remedi-
ation alone.
Kurtz and
Mueser,
2008 (11)
Social skills training for individ-
uals with schizophrenia
Content mastery, performance-
based skill measures, commu-
nity functioning, negative
symptoms, general symptoms,
relapse
Impact of social skills training was strongest for
content mastery, followed by performance-
based measures of social and independent
living skills and psychosocial functioning.
Impact was least strong for negative symp-
toms. Impact was weakest on relapse and
positive symptoms.
Wykes et al.,
2008 (24)
Cognitive-behavioral therapy for
individuals with schizophrenia
Positive and negative symptoms
of psychosis, functioning,
mood, hopelessness or suici-
dality, social anxiety
Cognitive-behavioral therapy had modest effects
on positive and negative symptoms, func-
tioning, mood, and social anxiety, but it may
exacerbate hopelessness or suicidality.
Dixon et al.,
2010 (2)
Psychosocial interventions (in-
cluding skills training) for
individuals with schizophrenia
Interpersonal and everyday living
skills as indicated by proximal
(for example, role play) and
distal (for example, community
functioning) measures
Skills training that is focused on clearly defined
activities, situations, and problems can im-
prove social interactions, independent living,
and other community functioning outcomes
for individuals with schizophrenia. Evidence
was weaker regarding the effect of skills
training on relapse, symptoms, and general
psychopathology.
Arbesman and
Logsdon,
2011 (14)
Occupational therapy interven-
tions for individuals with seri-
ous mental illness
Independent living skills Skills training improved independent living
skills.
Roder et al.,
2011 (25)
Integrated Psychological Ther-
apy for individuals with
schizophrenia
b
Documented symptoms, neuro-
cognitive and social function-
ing, quality of life, well-being,
treatment satisfaction
Integrated Psychological Therapy was more
effective than control conditions across out-
comes (including symptoms, psychosocial
functioning, and neurocognition), settings
(inpatient and outpatient, academic and non-
academic), and phases of treatment (acute
and chronic). Those who had been ill longer
were less likely to improve.
Wykes et al.,
2011 (23)
Cognitive remediation therapy
for individuals with
schizophrenia
Cognition, symptoms,
functioning
Cognitive remediation had durable effects on
global cognition and functioning but unreli-
able effects on symptoms. Effects were the
strongest when patients were clinically stable,
cognitive remediation was provided in com-
bination with other psychiatric rehabilitation,
and a strategic approach was adopted along
with adjunctive rehabilitation.
Anaya et al.,
2012 (41)
Cognitive remediation for indi-
viduals with schizoaffective
disorder, affective psychosis,
and unipolar and bipolar af-
fective disorders
Cognitive functioning Cognitive remediation was at least as effective
for affective and schizoaffective disorders as it
was for schizophrenia.
Kurtz and
Richardson,
2012 (19)
Behavioral training programs for
individuals with poor social
cognitive functioning
Proximal social cognitive mea-
sures, treatment generalization
(symptoms and observer-rated
community and institutional
functioning)
Social cognitive training had moderate to large
effects on facial affect recognition and small
to moderate effects on theory of mind, but
it did not affect social cue perception or
attribution style. For measures of generaliza-
tion, moderate to large effects were noted on
total symptoms and observer-rated commu-
nity and institutional functioning. Effects of
social cognitive training programs on positive
and negative symptoms of schizophrenia were
nonsignificant.
Continues on next page
732 PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' June 2014 Vol. 65 No. 6
others examining the effects of a cog-
nitive-behavioral life skills program
for schizophrenia. An RCT of Func-
tional Adaptation Skills Training was
conducted by P atterson and co l-
leagues (15). Thus there is at least a
handful of RCTs that provide some-
what mixed evidence regarding spe-
cific life skills approaches.
Social cognitive training. Social
cognition refers to the m ental oper-
ations involved in perce iving, under-
standing, and interpreting ones social
world. Social cognitive training pro-
grams focus on addressing deficits in
at least one of four major domains of
social cognition: facial affect recog-
nition (for example, differentiating
a happy from a sad face), social
perception (for example, detecting
and appropriately responding to social
cues, such as body language or vocal
intonation), theory of mind (for ex-
ample, the ability to take another
persons perspective), and attribu-
tional style (for example, the ability
to make appropriate conclusions about
the cause of events). T hese interven-
tions address the close links between
social cognition and functional out-
comes among individuals with schizo-
phrenia or other severe mental illness
(16,17) in light of growing evidence
that social cognitive deficits mediate
the relationships between other domains
of functioning, such as cognition, neg-
ative symptoms, and functional out-
comes (18).
Reviews of treatment studies target-
ing social cognition are sparse in relation
to other skill-building approaches,
and there has been only one for-
mal meta-analysis of social cognitive
approaches to date (19). That meta-
analysis assessed a total of 19 com-
parison studies that included a total
of 692 clients; 16 of these studies
involved randomization, indicating a
level of evidence that, although high,
does not have a research base as
extensive as some other areas of skill
building.
Cognitive remediation. Cognitive
remediation is a group of behavioral
interventions that apply science-based
learning techniques to enhance skills
in attention, memory, language, and
problem solving and other key cogni-
tive skills. Cognitive impairment is
a core symptom of schizophrenia and
bipolar disorder that can persist
throughout the course of these ill-
nesses and be resistant to the effects
of psychotropic medication (20). A
deterioration in cognitive functioning
frequently occurs during the develop-
ment of schizophrenia, and most
people with the disorder have neuro-
cognitive impairment (21,22). Given
the frequency of cognitiv e impair-
ment among individuals with serious
mental illness, a growing number of
studies over the past 20 years have
investigated approaches t o reme-
diating neuropsychological def icits
in cognition to improve functioning.
Cognitive remediation approaches range
from computer-assisted to individual-
ized person-to-person administration.
They may also focus on training that
ranges from the development of ele-
mentary sensory processing skills to
the acquisition and appr opriate de-
ployment of cognitive strategies for
bypassing and compensating for cog-
nitive deficits.
These skills are intertwined with
and support the skills addressed in
social skills training and social cogni-
tive training. Although there are dif-
ferences in curricula across various
cognitive remediation interventions,
they all share a focus on improving
cognitive skills through repeated task
practice or the acquisition of cognitive
strategies for bypassing deficits. Over
40 RCTs to date support the efficacy
of this intervention (23); thus the
evidence base is rated as high.
Cognitive-behavioral therapy. Our
review of CBT specifical ly targeted
how CBT strategies are used in skill
building (in particular with regard to
how one interprets life events), the
ways in which systematic negative
biases in thinking influence these
interpretations, and the consequences
of such interpretations for the way
one feels and behaves. In this appli-
cation of CBT, cognitive restructuring
is used to change these patterns of
thinking and is coupled with instruc-
tion in coping strategies. This is es-
pecially important for people who
Table 2
Continued from previous page
Study Focus of review Outcomes measured Summary of findings
Tungpunkom
et al.,
2012 (10)
Life skills programs for individ-
uals with chronic mental
health problems
Life skills, relapse, mental state,
global state, service outcomes,
general functioning, behavior,
adverse effects, engagement
with services, satisfaction with
treatment, quality of life, eco-
nomic outcomes
No significant change was noted in life skills.
Samples were so small that any firm
conclusions are impossible. None of the
outcomes were significantly different be-
tween the life skills, peer support, and control
groups.
Mueser et al.,
2013 (8)
Psychosocial treatment (includ-
ing social skills training and
supported education) for indi-
viduals with schizophrenia
Social skills training: skills acqui-
sition, content mastery, asser-
tiveness, social and community
functioning, social and daily
living skills, psychopathology.
Supported education: work or
school outcomes
Strong evidence was found for effectiveness of
social skills training in improving aspects of
social competence. Integrated programs, in-
cluding supported education, were associated
with improvements in work and school
compared with usual treatment.
a
Reviews are listed in chronological order. Individual studies are not included in the table because the focus of this article is on reviews and meta-
analyses. Abbreviation: RCT, randomized controlled trial
b
Integrated Psychological Therapy is a cognitive-behavioral therapy program that combines neurocognitive and social cognitive interventions with
psychosocial rehabilitation that includes building social, self-care, and vocational skills.
PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' June 2014 Vol. 65 No. 6 733
have psych otic processes and need to
manage how their cond ition affects
their stress level and behavioral reac-
tions, either of which can exacer-
bate disabilities. According to this
approach as applied to schizophrenia,
emotional and behavioral responses to
specific psychotic experiences can
increase overall distress and decrease
functioning. Thus the goal of therapy
is not to eliminate psychotic experi-
ences per se but rather to provide
alternate ways of understanding these
experiences and, in turn, reduce
associated distress and disabling
behaviors.
The targets of this therapy have
been highly variable from study to
study. There are also concerns that
more rigorous research designs repli-
cate some but not all of the effects of
less rigorous studies, thus qualifying
conclusions about the level of evi-
dence. Nonetheless, the corpus of
over 33 RCTs to date (24) supports
a rating of high for the evidence base
in this research area.
Integrated approaches. Although
a full review of research on ways of
integrating skill-building approaches
is beyond the scope of this work, we
review Integrated Psychological Ther-
apy and Illness Management and Re-
covery as two examples of structured
integrative approaches.
Integrated Psychological Therapy
combines neurocognitive and social
cognitive remediation with social skills
training and social problem solving. At
least 21 RCTs of this approach (using
cognitive remediation in conjunction
with other skill-building approaches)
were cited by Roder and colleagues
(25) in 2011; two additional RCTs on
this approach were cited in a compre-
hensive review of skill building by
Mueser and colleagues (8) in 2013.
Therefore, we rate the level of evi-
dence in this area as high .
In the Illness Management and
Recovery program, people with seri-
ous mental illness receive psycho-
education about mental illness and
treatment, behavioral tailoring to sup-
port treatment adherence, formulation
of a relapse prevention plan, and
instruction in coping strategies for
serious and persistent symptoms in
order to help them achieve their
personal recovery goals (8). CBT tech-
niques are applied to reduce the mag-
nitude of symptoms and associated
distress. A comprehensive 2002 review
by Mueser and colleagues (26) of illness
self-management approaches covered
CBT and various other intervention
strategies with which it is integrated,
including coping-s kills training, re-
lapse prevention strategies, and psy-
choeducation. The authors cited 40
RCTs as eviden ce for this group of
interventions, thus supporting a high
level of evidence.
Effectiveness of the service
Social and life skills training. There is
some disagreement in the review
literature regarding the effective-
ness of social skills training. In 2002,
Pilling and colleagues (27) conducted
a meta-analysis of nine RCTs of social
skills training and concluded that
therewaslittleevidenceofbenefit
in any outcomes. However, this con-
clusion was contested in 2004 by
Mueser and Penn (28), who ques-
tioned the m ethodology used in the
meta-analysis. Also in 2004, Bellack
(29) reviewed four meta-analyses of
skills trainingtwo of which had
been published since 1995 and are
includedinourreview(27,30).
Bellacks findings contradicted those
of Pilling and colleagues, with Bellack
concluding that social skills training
has a significant effect on behavioral
skills, social role functioning (includ-
ing defined skill areas such as med-
ication management), and client
satisfaction and self-efficacy but not
on symptom reduction and relapse.
Similar findings were described in
a 2006 review by Kopelowicz and
colleagues (31), which also included
studies of the Social and Indepen-
dent Living Skills Program. A 2006
analysis of 19 RCTs by Pfammatter
and colleagues (9) found large, ho-
mogeneous and enduring positive
effects for skill acquisition, as well as
improvements in social functioning,
assertiveness, and overall psychopa-
thology. In the most comprehensive
meta-analytic investigation to date,
which included 23 RCTs, Kurtz and
Mueser (11) found strong positive
effects for content mastery; moder-
ate effects for social and daily living
skills, community functioning, and
negative symptoms; and a smaller
but still significant effect for relapse
prevention and other symptoms.
In their 2013 review, Mueser and
colleagues (8) reported that findings
from meta-analyses support the con-
clusion that social skills training improves
certain aspects of social competence.
With regard to more distal outcomes,
Kopelowicz and colleagues (31) found
that existing reviews and meta-analyses
have not consistently supported posi-
tive effects of social skills training on
outcomes such as relapse rates, psy-
chotic symptoms, and quality of life.
However, it is important to note that
the primary targets of social skills train-
ing are social competence and social
functioning rather than symptoms or
relapse.
Researchers have identified a few
factors that may influence the effec-
tiveness of social skills training. Mueser
and colleagues (8) noted that deficits in
attention may limit the effects of social
skills training approaches. Roberts and
Velligan (32) also suggested that social
cognition appears to mediate the re-
lationship between neurocognition and
social functioning, which is why social
skills training, social cognitive ap-
proaches, and cognitive remediation
are often bundled.
Findings for the life skills compo-
nent of social skills training are some-
what mixed. Three Cochrane reviews
(10,12,13) conducted between 1998
and 2012 investigated life skills pro-
grams (teaching skills in budgeting,
communication, domestic living, per-
sonal self-care, and community living).
Their results are best summarized by
the most recent review (10), in which
the authors stated that there is no
good evidence to suggest that life
skills programs are effective for peo-
ple with chronic mental illnesses. In
particular, there were no significant
differences in life skills performance,
psychotic process, or quality-of-life scores
between life skills training and stan-
dard care or between life skills train-
ing and support groups. Furthermore,
the authors questioned the wisdom of
pressuring clients to participate in life
skills training, voiced concerns about
wasting time and money on the
practice, and even suggested that it
could be harmful.
These findings were not corrobo-
ratedbyArbesmanandLogsdons
734 PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' June 2014 Vol. 65 No. 6
(14) review of life skills training pro-
grams. They cited six RCTs indicating
that findings in support of the effec-
tiveness of daily living skills training
combined with social skills training
were strong (15,3337). Of these,
three RCTs examined the effects of
the Social and Independent Living
Skills Program and found the practice
to be effective in improving indepen-
dent living skills (3335). The three
remaining RCTs (15,36,37) of Func-
tional Adaptation Skills Training with
older adult patients and with Latino
participants who had chronic psycho-
sis were implemented by Patterson (a
developer of the program) and col-
leagues (37). The authors found im-
provement in everyday living skills for
program participants, compared with
those in usual care. An RCT con-
ducted by Patterson and colleagues,
for example, demonstrated that the
Functional Adaptation Skills Program
was effective in improving everyday
living skills for middle-aged and older
participants with chronic psychotic dis-
orders. The positive effects were ob-
served immediately after treatment
and at the three-month follow-up asses-
sment, although no significant changes
in psychop athology were found. Adap-
tive skills for living in the community
are the primary target of this and other
life skills interventions, and improving
psychotic symptoms and preventing
relapse are not primary treatment
goals. Therefore, it is not surprising
that significant results usually have not
been found for symptom reduction in
studies of life skills training.
Arbesman and Logsdon (14) noted
that methodol ogical problems in
some studies included small samples,
sampling bias, and lack of blindness to
treatment allocation, and these issues
as well as others undoubtedly con-
tributed to the disagreement between
their review and the Cochrane sys-
tematic reviews. For example, the
most recent Coch rane review (10)
cited high risk of reporting bias and
lack of reported protocols in two
studies by Patterson and colleagues
(15,37), as well as high risk of attrition
bias in one of these studies (37). Fou r
of the six studies cited by Arbesman
and Logsdon (3336) were not in-
cluded in the 2012 Cochrane review,
although the reasons for their exclu-
sion are not clear because these studies
were not cited in the Cochrane re-
views summary of excluded studies.
Despite the conflicting findings of
these reviews, the positive results
of studies cited by Arbesman and
Logsdon indicate that additional well-
designed research using specific pro-
tocols for improving life skill s is
warranted.
Social cognitive training. A review
of studie s of social cognitive training
indicated moderate to large effects of
social cognitive training on facial
affect recognition (18 studies), small
to moderate effects on theory-of-
mind measures (seven studies), and
generalization of treatme nt effects to
overall symptoms and to ratings of
community and inpatient functioning
(six studies) (38). Of the 16 RCTs in
this meta-analysis, all showed im-
provement on proximal measures of
social cognitive skill for treated indi-
viduals compared with individuals in
control groups. Participants in these
studies were nearly exclusively indi-
viduals with schizophren ia and schiz-
oaffective disorder, although initial
trials for patients with bipolar disorder
have been promising (38). We note
the heterogeneity of approaches in
this area (for example, treatment of
a specific deficit area versus broad-
based strategies, as well as methodo-
logical variability within each of these
approaches). There is also large vari-
ability in duration of treatment (from
oneto93hours).Thus,eventhoughthe
findings are positive, these confounding
factors make prescriptions regarding
specific interventions a challenge.
Cognitive remediation. Meta-analyses
in this research area reflect the rapid
growth of the evidence base. A 2003
meta-analysis of cognitive re me di at i on
found methodological problems, such as
small samples, poorly defined experi-
mental and control conditions, and poor
generalizability because limited pop-
ulations were studied (39). In 2006,
the meta-analysis by Pfammatter
and colleagues (9) of six other meta-
analyses found no effe cts of cogni-
tive remediation in RCTs, but there
were small to medium (but robust) ef-
fects on general cognitive function-
ing in quasi-experimental studies.
The authors concluded that findings
support the effectiveness of cognitive
remediation on attention, executive
functioning, memory, and social
cognition.
This conclusion is largely supported
by more recent work, with the caveat
that cognitive remediation effects are
more likely to generalize to function-
ing in everyday life when offered in
the context of other psychiatric re-
habilitation interventions. In the
two most recent and comprehensive
meta-analyses of controlled cognitive
remediation studies to date (23,40),
medium-sized effects were found on
measures of cognition and of daily
functioning. When these cognitive
remediation interventions were of-
fered in concert with other rehabili-
tative treatments, improvements in
psychosocial functioning were found
relative to rehabilitation alone, but
not when cognitive remediation plus
usual services was compared with
usual services alone. In addition,
durability studies showed that the
effects of cognitive remediation on
cognitive skills remained in the mod-
erate range when measured eight
months, on average, after the cessa-
tion of treatment. Unfortunately, the
substantial heterogeneity of approaches
to remediation of cognitive skills (for
example, strategy-based versus drill-
and-practice approaches) and the
mixed results on effectiveness make
it difficult to offer recommendations
regarding specific interventions. The
focus of these studies has bee n almost
exclusively on people with schizo-
phrenia and schizoaffective disorder.
Thus specific recom mendations re-
garding cognitive remediation for
other disorders would be premature,
although studies of cognitiv e remedi-
ation for cognitive deficits in affective
disorders show promise (41). It should
also be noted that recently published
consensus recommendations by McGurk
and colleagues (42) describe the specific
parameters of cognitive remediation
programs that are likely to be successful
in improving psychosocial functioning.
Cognitive-behavioral therapy. Re-
cent quantitative reviews have con-
firmed the value of CBT for a variety
of psychological difficulties among
individuals with psychosis as well as
negative symptoms and other prob-
lems in functioning. For example,
a review by Wykes and colleagues
PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' June 2014 Vol. 65 No. 6 735
(24) of 33 trials showed that there
were beneficial effects of CBT in the
moderate range on target symptoms
(33 studies), positive symptoms (32
studies), negative symptoms (23 stud-
ies), functioning (15 studies), mood
(13 studies), and social anxiety (two
studies), whether or not they were
targeted by CBT. Of note, the authors
observed a 50%2100% inflation of
effect sizes in studies that failed to
employ raters blind to study condi-
tions. When only the most rigorously
designed studies were included,
effects of CBT on negative symptoms
became nonsignificant. These results
suggest that more controlled studies
with stronger designs and methods
that specifically target negative symp-
toms will be necessary to understand
the true value of CBT for this aspect
of skill building.
Integrated approaches. Many of
the studies discussed above suggest
that no single intervention is as ef-
fective as approaches that integrate
most or all of the practices with
oth er treatments. Indee d, our review
revealed considerable overlap be-
tween skill-building approaches and
between the skill areas that they
address. Research indicates that in-
tegrative strategies strengthen effects,
particularly with regard to decreasing
symptoms and improving social skills
(4346). Here we discuss effectiveness
findings for Integrated Psychological
Therapy and Illness Management and
Recovery, two examples of approaches
to integrating skill-building components.
A 2006 meta-analysis of Integrated
Psychological Therapy by Roder and
colleagues (46) found significant im-
provements in neurocognitive and
social skills as well as reduced psy-
chopathological symptoms compared
with control groups, although individ-
uals who had been ill the longest were
less likely to have positive outcomes.
Stronger results were found in aca-
demic settings than in nonacademic
settings and in inpatient settings than
in outpatient settings; nonetheless,
participants whose symptoms had
been stabilized and those with acute
conditions showed significant treat-
ment effects compared with those in
control groups.
In a 2011 update of 36 studies of
Integrated Psychological Therapy that
included 1,601 people with schizo-
phrenia, Roder and colleagues (25)
reported on 21 studies that were
RCTs and a number of others that
employed matched comparison groups.
Compared with the control con-
ditions, Integrated Psychological Ther-
apy had significant effects on all
outcomes related to social cognition,
psychosocial functioning, and neuro-
cognition (proximal outcomes) as well
as on negative and positive symptoms
and general psychopathology (more
distal outcomes). Effect sizes were
larger for proximal outcomes (for
example, they were in the high range
for social cognition) than for distal
outcomes, such as ongoing symptoms.
Individuals who participated in all of
the components of this treatment
approach continued to improve dur-
ing the follow-up phase, compared
with those who participated in only
one component. It should be noted
that most studies of Integrated Psy-
chological Therapy were conducted in
Europe, thus limiting our knowledge
about its effectiveness in the United
States.
In their 2013 review of Illness
Management and Recovery, Mueser
and colleagues (8) noted that three
RCTs have been completed in the
United States, Israel, and Sweden
since the formal development of the
Illness Management and Reco very
program. In all three studies, individ-
uals in this progr am showed signifi-
cantly greater improvements than
those in usual care in illness self-
management and community func-
tioning. The authors concluded that
the evidence qualifies this approach as
an evidence-based practic e rather
than a promising practice. In a 2013
review, McGuire and colleagues (47)
cited the evidence of three additional
quasi-experimental trials and three
pre-post treatment trials. The authors
noted that methodological issues,
such as barriers to implementation,
require further study.
Specific populations. Research di-
rectly assessing the relative effective-
ness of skill building across various
racial and ethnic populations is limited
(41). A number of studies in the re-
views we have summarized typically
involved young-adult or middle-aged
white males (27); however, skills training
programs have been adapted success-
fully for Latino clients (36,48), in-
cluding outpatient services for older
people with psychotic disorders of
long duration. Some studies have in-
cluded substantial numbers of partic-
ipants with different ethnic and racial
backgrounds in their study samples
(49), including a number of studies with
participants who were predominantly
African American (50,51). Examples
of other cross-cultural studies inclu de
an RCT of illness self-management
conducted with hospitalized individ-
uals with schizophrenia in Japan (33)
and an RCT of successful skill-building
interventions conducted in a Chinese
psychiatric hospital (52). To our knowl-
edge, no studies have reported using
race or ethnicity as an independent
variable for determining the relative
effectiveness of skill-building ap-
proaches for people with serious be-
havioral health problems. This does
not necessarily mean that these dif-
ferences were not investigated; re-
searchers often examine racial and
ethnic differences, but they may not
report the differences if they are not
significant.
Discussion
Skill building represents a vast area of
the field of psychiatric rehabilitation,
and there i s a high level of evidence
for most skill-building approaches (see
box on next page). This review almost
exclusively assessed meta-analyses and
comprehensive reviews rather than in-
dividual studies, in part because they
help organize and evaluate the exten-
sive body of literature on this topic.
Overall, the evidence in support of the
short-term effectiveness of various skill-
building approaches is robust. The
evidence in support of the effective-
ness of CBT is mixed, in that it is
strong for addressing the psychotic
process but less robust regarding
other areas of functioning. The evi-
dence in support of life skills pro-
grams is somewhat mixed and lower
than the levels of evidence for social
skills training, social cognitive training,
cognitive remediation, and integrated
approaches such as In tegrated Psy-
chological Therapy or Illness Man-
agement and Recovery.
Clearly, the complex interplay be-
tween training in specific skills and
736 PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' June 2014 Vol. 65 No. 6
the numerous interventions needed
to address the cognitive, neuropsy-
chological, interpersonal, and mental
status of each individual brings signif-
icant challenges to service planning
and research. For example, the effects
of life skills training may be amplified
and may operate synergistically when
it is combined with other psychosocial
rehabilitation interventions, especially
those that address the neuropsycho-
logical building blocks of cognition
and behavior. Combining approaches,
as in Integrated Psychological Ther-
apy, appears to achieve a higher level
of effectiveness for proximal out-
comes tar geted by the intervention,
compared with distal outcomes. Fur-
ther research on combinations of skill-
building approaches will help address
the significant issue of genera lizing
functional gains to rea l-world con-
texts over the long terman on-
going challenge for clinicians as well
as researchers.
These points also underscore the
challenges for cons umers, decision
makers, and payers, who must decide
which skill-building services to use
and support. Our review indicates that
combined approaches that include
social skills training, social cognitive
training, cognitive remediation, and
CBT are necessary. Our findings also
suggest that the specific types of skill-
building services should be based
on an individuals constellat ion of
skills, challenges, and motivations. In-
tegrated Psychological Therapy and
Illness Management and Recovery are
examples of how various approaches
can be combined successfully. Select-
ing or supporting only one approach
is likely to be a mistake. Rather, con-
tinuously adjusting the service mix
on the basis of an individuals prog-
ress and needs has the best chance
of achieving outcomes and being
cost-effective in practice, even though
evaluation of highly individualized in-
terventionspresentschallengesto
researchers.
Future research should examine
the possible differential effects of skill
building across specific subpopula-
tions, as well as t he eff ects of m od-
erating variables, such as treatment
setting, medication type and dosage,
age, and baseline skill levels. Research
should also examine the potential for
skill-building approaches to improve
outcomes in the treatm ent of sub-
stance use disorders and co-occurring
mental and substance use disorders.
Meta-analyses need to pay close r at-
tention to fidelity in implementing
evidence-based practices and to the
training and qualificat ions of service
providers.
More research on intermediate and
long-term effectiveness would also be
helpful, with increased focus on the
complex issue of how the remediation
or acquisition of specific skills trans-
lates into sustained adaptive function-
ing in real-world contexts. Emerging
approaches in person-centered, self-
directed care also call for ongoing
investigation of the role of self-
determination and personal empow-
erment in skill building and other
aspects of recovery, which has been
a tenet of practice in this area but
remains largely unstudied.
Conclusions
The current body of research has
established the value of skill-building
approaches. Although further re-
search will help clarify their effects
on some outcomes, research is not
needed to support the decision to
include skill-building approaches as
covered services, particularly for
individuals with schizophrenia and
other psychotic disorders. Payers,
providers, and people who use skill-
building services can be confident
that the various components of this
service are effective when they are
used in combination and with other
therapeutic interventions. This re-
view should help stakeholders at all
levels make d ecisions about including
skill-building components in covered
benefits as treatment alternatives
for providers and for people need-
ing this complex array of treatment
strategies.
Acknowledgments and disclosures
Development of the Assessing the Evi-
dence Base Series was supported by contracts
HHSS283200700029I/HHSS28342002T, HHSS-
283200700006I/HHSS283 42003T, and HHSS-
2832007000171/HHSS28300001T from 2010
through 2013 from the Substance Abuse and
Mental Health Services Administration (SAMHSA).
The authors acknowledge the contributions of
Mary Blake, C.R.E., Suzanne Fields, M.S.W.,
and Kevin Malone, B.A., from SAMHSA; John
OBrien, M.A., from the Centers for Medicare
& Medicaid Services; Garrett Moran, Ph.D.,
from Westat; and John Easterday, Ph.D., Linda
Lee, Ph.D., Rosanna Coffey, Ph.D., and Tami
Mark Ph.D., from Truven Health Analytics.
The views expressed in this article are those of
the authors and do not necessarily represent the
views of SAMHSA.
The authors report no competing interests.
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738 PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' June 2014 Vol. 65 No. 6
    • "When the reconfiguring of these interventions is done sensitively, without violating fidelity to the key, effective components of the interventions, there is growing evidence that patients from other cultures and countries can benefit from participating in treatment programs that were initially designed elsewhere. Overall, evidence in support of the effectiveness of SST for Spanish-speaking people with schizophrenia has been recognized in a recently completed, comprehensive literature review (Lyman et al., 2014 ). However, to address the important issue of incorporating the benefits of skills-training modalities into real-world contexts, two fundamental issues should be addressed. "
    [Show abstract] [Hide abstract] ABSTRACT: A review was conducted on the cross-cultural adaptation, effectiveness, and validation of social-skills training (SST), an evidence-based practice that originated in the English language, carried out in the Spanish language for persons with schizophrenia in Latin America, Spain, and the United States. This review of research delineates the methodology of the published literature that contained a wide variety of studies from empirically based evaluation of case reports to randomized, controlled trials. The weight of the evidence from all three regions revealed greater benefits to Spanish-speaking patients who received SST in symptoms, skill acquisition and community functioning than for patients who received customary treatment. To ensure the cross-cultural effectiveness of rehabilitation practices originating in English-speaking countries, it is essential that adaptations beyond language translations be made to meet the unique expectations, norms, values, and customs of Spanish-speaking patients and families in the three regions that are the focus of this report.
    Article · Jul 2015
    • "Current, continuous, and cumulative trauma-focused cognitive behavior therapy (CCC-TF-CBT), (Kira, 2013; Kira, Ashby, Omidy, & Lewandowski, in press), a part of this packaged model, include four core components (behavioral, pre-cognitive, cognitive, and social), with eight intervention modes: Two behavioral interventions modes: 1) prioritizing safety, and addressing current and ongoing threats and dangers: distinguishing real danger from exaggerated, down played (avoided) and the real challenges (e.g, Najavits, 2002; Murray, Cohen, & Mannarino, 2013 ); 2) practicing basic skills training to deal with real threats and dangers (e.g. problem solving, assertiveness training, mindfulness training, anger management, personal and group-based emotion regulation, and enhancing participation and engagement) (e.g., Lyman et al., 2014; Liu, Huang, & Wang, 2014 ); two pre-cognitive intervention modes; 3) stimulating " will to live and survive and related meaningful effective coping strategies (e.g., Bonanno & Mancini, 2008, Kira, Alawneh, Aboumediene, Lewandowski, & Laddis, 2014); and 4) identity work, identities reconfiguration, and identity development that may include: redefinition of identities (e.g., gender sexual, racial, religious, national, species in addition to; personal and collective self-esteem and self-efficacy) (e.g., Scheepers, Spears, Manstead, & Doosje, 2009; Gaertner & Dovidio, 2005 ) and three cognitive intervention modes; 5) psycho-education of continuous traumatic stress and cumulative and proliferation and stress generation dynamics (e.g., ); 6) inoculation against stress proliferation and accumulation dynamics and training to identify and disrupt such existing dynamics; and 7) narration and writing intervention and one social intervention modes (e.g., Travagina, Margolaa, & Revensonb, 2015); 8) reconnection, advocacy and social Justice using Scientist-Practitioner-Advocate (SPA) model (Mallinckrodt, Miles, & Levy, 2014). Diagram 1 visualizes this model. "
    Full-text · Article · Jan 2015
    • "Current, continuous, and cumulative trauma-focused cognitive behavior therapy (CCC-TF-CBT), (Kira, 2013; Kira, Ashby, Omidy, & Lewandowski, in press), a part of this packaged model, include four core components (behavioral, pre-cognitive, cognitive, and social), with eight intervention modes: Two behavioral interventions modes: 1) prioritizing safety, and addressing current and ongoing threats and dangers: distinguishing real danger from exaggerated, down played (avoided) and the real challenges (e.g, Najavits, 2002; Murray, Cohen, & Mannarino, 2013 ); 2) practicing basic skills training to deal with real threats and dangers (e.g. problem solving, assertiveness training, mindfulness training, anger management, personal and group-based emotion regulation, and enhancing participation and engagement) (e.g., Lyman et al., 2014; Liu, Huang, & Wang, 2014 ); two pre-cognitive intervention modes; 3) stimulating " will to live and survive and related meaningful effective coping strategies (e.g., Bonanno & Mancini, 2008, Kira, Alawneh, Aboumediene, Lewandowski, & Laddis, 2014); and 4) identity work, identities reconfiguration, and identity development that may include: redefinition of identities (e.g., gender sexual, racial, religious, national, species in addition to; personal and collective self-esteem and self-efficacy) (e.g., Scheepers, Spears, Manstead, & Doosje, 2009; Gaertner & Dovidio, 2005 ) and three cognitive intervention modes; 5) psycho-education of continuous traumatic stress and cumulative and proliferation and stress generation dynamics (e.g., ); 6) inoculation against stress proliferation and accumulation dynamics and training to identify and disrupt such existing dynamics; and 7) narration and writing intervention and one social intervention modes (e.g., Travagina, Margolaa, & Revensonb, 2015); 8) reconnection, advocacy and social Justice using Scientist-Practitioner-Advocate (SPA) model (Mallinckrodt, Miles, & Levy, 2014). Diagram 1 visualizes this model. "
    [Show abstract] [Hide abstract] ABSTRACT: Much clinical and trauma work has focused on interventions with individuals experiencing interpersonal violence and past traumas. Refugees' experiences include past and present and chronic intergroup and interpersonal traumas with cumulative linear and nonlinear dynamics. Refugees face unique social and political traumatogenic ecologies that can play at least an equivalent or even more significant role in traumatic stress compared with that of survivors of interpersonal trauma who do not experience atrocities such as exile, political and religious persecution, and torture. Evolving paradigms of intervention need to be developed to integrate individual and ecological models of recovery that focus on the whole person within her or his social and political ecology and on past as well as present traumatogenic experiences; in addition, these paradigms need to mobilize refugees' resilience.
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