Skill Building: Assessing the Evidence

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 interventions are delivered by trained, credentialed professionals, either in clients’ homes or in clinical settings, such as outpatient, inpatient, or day treatment programs.

As described by Mueser and colleagues (8), social skills training targets social perception, processing, and behavioral responses. It involves behavioral instruction, role modeling and rehearsal, corrective feedback, and positive reinforcement 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 challenges characteristic of schizophrenia that affect functional areas such as work, education, and the ability to maintain relationships. Social 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 generalization to community settings, and participants are often given homework to practice on their own in their home environments. Social skills training is usually conducted in groups, which helps reduce stigma, takes advantage of peer feedback, and can be cost-effective.

Life skills training targets functional domains, such as managing one’s household, finances, personal hygiene, and daily schedule (10). This includes self-care skills, such as bathing, shaving, hair care, and brushing teeth; domestic tasks, such as washing dishes, cooking, cleaning, doing laundry, and managing money; and other tasks, such as shopping, practicing good nutrition, using transportation, and managing a schedule. Communication and social skills as well as illness management skills are also targeted in life skills training packages. Life skills training programs can be distinguished 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 of social 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 additional studies that met criteria for an RCT, and these had very small samples (13). A subsequent 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 programs are commonly implemented in the context of more comprehensive social skills training as well as in overall psychosocial rehabilitation approaches; 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 example, Arbesman and Logsdon (14) cited three RCTs supporting the effects of the Social and Independent Living Skills program as well as three others examining the effects of a cognitive-behavioral life skills program for schizophrenia. An RCT of Functional Adaptation Skills Training was conducted by Patterson and colleagues (15). Thus there is at least a handful of RCTs that provide somewhat mixed evidence regarding specific life skills approaches.

Social cognition refers to the mental operations involved in perceiving, understanding, and interpreting one’s social world. Social cognitive training programs focus on addressing deficits in at least one of four major domains of social cognition: facial affect recognition (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 example, the ability to take another person’s perspective), and attributional style (for example, the ability to make appropriate conclusions about the cause of events). These interventions address the close links between social cognition and functional outcomes among individuals with schizophrenia 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, negative symptoms, and functional outcomes (18).

Reviews of treatment studies targeting social cognition are sparse in relation to other skill-building approaches, and there has been only one formal meta-analysis of social cognitive approaches to date (19). That meta-analysis assessed a total of 19 comparison 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 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 cognitive skills. Cognitive impairment is a core symptom of schizophrenia and bipolar disorder that can persist throughout the course of these illnesses and be resistant to the effects of psychotropic medication (20). A deterioration in cognitive functioning frequently occurs during the development of schizophrenia, and most people with the disorder have neurocognitive impairment (21,22). Given the frequency of cognitive impairment among individuals with serious mental illness, a growing number of studies over the past 20 years have investigated approaches to remediating neuropsychological deficits in cognition to improve functioning. Cognitive remediation approaches range from computer-assisted to individualized person-to-person administration. They may also focus on training that ranges from the development of elementary sensory processing skills to the acquisition and appropriate deployment of cognitive strategies for bypassing and compensating for cognitive deficits.

These skills are intertwined with and support the skills addressed in social skills training and social cognitive training. Although there are differences 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.

Our review of CBT specifically 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 application of CBT, cognitive restructuring is used to change these patterns of thinking and is coupled with instruction in coping strategies. This is especially important for people who have psychotic processes and need to manage how their condition affects their stress level and behavioral reactions, either of which can exacerbate 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 experiences 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 replicate some but not all of the effects of less rigorous studies, thus qualifying conclusions about the level of evidence. Nonetheless, the corpus of over 33 RCTs to date (24) supports a rating of high for the evidence base in this research area.

Although a full review of research on ways of integrating skill-building approaches is beyond the scope of this work, we review Integrated Psychological Therapy and Illness Management and Recovery 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 comprehensive review of skill building by Mueser and colleagues (8) in 2013. Therefore, we rate the level of evidence in this area as high.

In the Illness Management and Recovery program, people with serious mental illness receive psychoeducation about mental illness and treatment, behavioral tailoring to support 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 techniques are applied to reduce the magnitude 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-skills training, relapse prevention strategies, and psychoeducation. The authors cited 40 RCTs as evidence for this group of interventions, thus supporting a high level of evidence.

There is some disagreement in the review literature regarding the effectiveness of social skills training. In 2002, Pilling and colleagues (27) conducted a meta-analysis of nine RCTs of social skills training and concluded that there was little evidence of benefit in any outcomes. However, this conclusion was contested in 2004 by Mueser and Penn (28), who questioned the methodology used in the meta-analysis. Also in 2004, Bellack (29) reviewed four meta-analyses of skills training—two of which had been published since 1995 and are included in our review (27,30). Bellack’s findings contradicted those of Pilling and colleagues, with Bellack concluding that social skills training has a significant effect on behavioral skills, social role functioning (including defined skill areas such as medication 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 Independent Living Skills Program. A 2006 analysis of 19 RCTs by Pfammatter and colleagues (9) found “large, homogeneous and enduring” positive effects for skill acquisition, as well as improvements in social functioning, assertiveness, and overall psychopathology. In the most comprehensive meta-analytic investigation to date, which included 23 RCTs, Kurtz and Mueser (11) found strong positive effects for content mastery; moderate 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 conclusion 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 positive effects of social skills training on outcomes such as relapse rates, psychotic symptoms, and quality of life. However, it is important to note that the primary targets of social skills training are social competence and social functioning rather than symptoms or relapse.

Researchers have identified a few factors that may influence the effectiveness 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 relationship between neurocognition and social functioning, which is why social skills training, social cognitive approaches, and cognitive remediation are often bundled.

Findings for the life skills component of social skills training are somewhat mixed. Three Cochrane reviews (10,12,13) conducted between 1998 and 2012 investigated life skills programs (teaching skills in budgeting, communication, domestic living, personal 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 people 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 standard care or between life skills training 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 corroborated by Arbesman and Logsdon’s (14) review of life skills training programs. They cited six RCTs indicating that findings in support of the effectiveness of daily living skills training combined with social skills training were “strong” (15,33–37). Of these, three RCTs examined the effects of the Social and Independent Living Skills Program and found the practice to be effective in improving independent living skills (33–35). The three remaining RCTs (15,36,37) of Functional Adaptation Skills Training with older adult patients and with Latino participants who had chronic psychosis were implemented by Patterson (a developer of the program) and colleagues (37). The authors found improvement in everyday living skills for program participants, compared with those in usual care. An RCT conducted 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 disorders. The positive effects were observed immediately after treatment and at the three-month follow-up assessment, although no significant changes in psychopathology were found. Adaptive 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 methodological problems in some studies included small samples, sampling bias, and lack of blindness to treatment allocation, and these issues as well as others undoubtedly contributed to the disagreement between their review and the Cochrane systematic reviews. For example, the most recent Cochrane 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). Four of the six studies cited by Arbesman and Logsdon (33–36) were not included in the 2012 Cochrane review, although the reasons for their exclusion are not clear because these studies were not cited in the Cochrane review’s 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 protocols for improving life skills is warranted.

A review of studies 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 treatment 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 improvement on proximal measures of social cognitive skill for treated individuals compared with individuals in control groups. Participants in these studies were nearly exclusively individuals with schizophrenia and schizoaffective 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 methodological variability within each of these approaches). There is also large variability in duration of treatment (from one to 93 hours). Thus, even though the findings are positive, these confounding factors make prescriptions regarding specific interventions a challenge.

Meta-analyses in this research area reflect the rapid growth of the evidence base. A 2003 meta-analysis of cognitive remediation found methodological problems, such as small samples, poorly defined experimental and control conditions, and poor generalizability because limited populations were studied (39). In 2006, the meta-analysis by Pfammatter and colleagues (9) of six other meta-analyses found no effects of cognitive remediation in RCTs, but there were small to medium (but robust) effects on general cognitive functioning 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 functioning in everyday life when offered in the context of other psychiatric rehabilitation 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 offered in concert with other rehabilitative 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 moderate range when measured eight months, on average, after the cessation 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 been almost exclusively on people with schizophrenia and schizoaffective disorder. Thus specific recommendations regarding cognitive remediation for other disorders would be premature, although studies of cognitive remediation 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.

Recent quantitative reviews have confirmed the value of CBT for a variety of psychological difficulties among individuals with psychosis as well as negative symptoms and other problems in functioning. For example, a review by Wykes and colleagues (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 studies), 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%−100% inflation of effect sizes in studies that failed to employ raters blind to study conditions. 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 symptoms will be necessary to understand the true value of CBT for this aspect of skill building.

Many of the studies discussed above suggest that no single intervention is as effective as approaches that integrate most or all of the practices with other treatments. Indeed, our review revealed considerable overlap between skill-building approaches and between the skill areas that they address. Research indicates that integrative strategies strengthen effects, particularly with regard to decreasing symptoms and improving social skills (43–46). 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 improvements in neurocognitive and social skills as well as reduced psychopathological symptoms compared with control groups, although individuals who had been ill the longest were less likely to have positive outcomes. Stronger results were found in academic 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 treatment effects compared with those in control groups.

In a 2011 update of 36 studies of Integrated Psychological Therapy that included 1,601 people with schizophrenia, 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 conditions, Integrated Psychological Therapy had significant effects on all outcomes related to social cognition, psychosocial functioning, and neurocognition (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 during the follow-up phase, compared with those who participated in only one component. It should be noted that most studies of Integrated Psychological 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 Recovery program. In all three studies, individuals in this program showed significantly greater improvements than those in usual care in illness self-management and community functioning. The authors concluded that the evidence qualifies this approach as an “evidence-based” practice 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.

Research directly assessing the relative effectiveness of skill building across various racial and ethnic populations is limited (41). A number of studies in the reviews we have summarized typically involved young-adult or middle-aged white males (27); however, skills training programs have been adapted successfully for Latino clients (36,48), including outpatient services for older people with psychotic disorders of long duration. Some studies have included substantial numbers of participants 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 include an RCT of illness self-management conducted with hospitalized individuals with schizophrenia in Japan (33) and an RCT of successful skill-building interventions conducted in a Chinese psychiatric hospital (52). To our knowledge, no studies have reported using race or ethnicity as an independent variable for determining the relative effectiveness of skill-building approaches for people with serious behavioral health problems. This does not necessarily mean that these differences were not investigated; researchers often examine racial and ethnic differences, but they may not report the differences if they are not significant.