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International Review of Psychiatry (1998), 10, 9±19

Social skills training in psychiatric rehabilitation: recent ®ndings

CHARLES J. WALLACE

Clinical Research Center for Schizophrenia and Psychiatric Rehabilitation, Department of Psychiatry, University

California at Los Angeles, USA

Summary

This article is a detailed critique of six recent evaluations of the effects of social skills training on the functioning and quality of li

of individuals with schizophrenia. Given the many factors that affect individuals’ social and role functioning, the results of the s

evaluations are complex and interpretable only after careful consideration of their many methodological and procedural differenc

The general pattern of their results indicates, however, that when skills training is conducted with speci®city and highly structur

instructional techniques, signi®cant and durable increases in targeted behaviors and knowledge ensue. Social functioning a

objective quality of life improve if (1) the knowledge and skills improved by training are actually relevant to the variables assess

by the outcome me asures (e.g. workplace knowledge and skills contribute to the outcome of improved employment, not just lo

economic conditions); (2) the de®ciencies in individuals’ functioning re¯ect de®cits in the relevant behaviors and knowledge (e.

de®cits in an individual’s interpersonal skills are observable in the workplace and these skills are needed for improved employmen

and (3) the environment provides prompts and reinforcers for the use of these new behaviors and knowledge (e.g. improved workpla

interpersonal skills are rewarded by praise and increased social acceptance by peers and supervisors). Thus, unlike the rap

improvements in symptoms effected by psychotropic medication, the bene®ts of social skills training occur slowly, and only w

suf®cient, carefully conducted, training. Hence, the expectations for the bene®ts of training must re¯ect the complexity of the, man

fac tors th at affec t fu nctio ning , an d the pai nst aki ng, ca ref ul an d de tail ed na tur e of eff ect iv e tra in in g. Th e re vie w en ds wi th seve

recommendations for improving the ef®ciency and generality of training, including developing more precise assessments of individu

and roles, standardizing training and presenting it in self-directed formats, and increasing environmental supports.

Introduction

Despite the well documented effectivenessÐand

ubiquityÐof antipsychotic m edication in the treat-

ment of individuals with schizophrenia, it is no

p a na c ea. Co m plia nce with its c on tinu ou s a nd

inde®nite regimen is a challenge; its side-effects are

often unpleasant and may grow worse over time,

although less so with the newer, unconventional

neuroleptics; and it does little if anything to improve

individuals’ social and instrumental role function-

ing. This lack of imp roved functioning is particularly

problematic since numerous g overnment and `stake-holder’ organizations have stated that better role

functioning should be a principal aim of treatment.

The NIMH plan for Caring for People with Severe

Mental Illness (1991), for example, notes that four

domains:

¼ encompass the important areas ¼ [of treat-

ment outcome] ¼ (1) clinical, reduction or elim-

in ation of sym pto ms; (2 ) r eh ab ilita tiv e,

im pr ov em en t o r re sto ra tion of so cial a nd

vocational functioning; (3) humanitarian, increase

in a sense of wellbeing and personal ful®llment;

and (4) public welfare, prevention of harm.

most constructive and satisfying lives possible in t

least restrictive available settings’ (Welfare anInstitutions Code, Section 5600.1). Minneso

charges the Comm issioner of Mental Health wi

the responsibility to provide accountable servic

that `increase the level of functioning of adults wi

mental illness or restore them to a previously he

higher level of functioning’ (Comprehensive Adu

Mental Health Act, 1991).

To achieve the aim of improved functioning,

number of treatments have been developed bas

on the rationale that functioning is limited by skil

hence, improve skills and improve functionin

These treatments, despite their different labels su

as social skills training, psychosocial s kills trainin

skills training, psychosocial rehabilitation and ps

chiatric rehabilitation, have a common focus

teaching skills and a similar methodology for doi

s o: i nstr uc ti on s, m od el in g a nd p ra ct ice . T

remainder of this article will review the empiric

evidence about the effectiveness of these treatmen

and note possible directions for future research. T

review will be selective; it will not include resu

from studies in which these treatments have on

been one of several services, or the primary foc

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Environment

Opportunities

for role

functioning

Rewards for

role

functioning

Supports ± social,

financial, housing,

medical, psychiatric

Number and

mix of tasks

Sequence and

timing of tasks

Contextual factors

and task difficulty

Role

complexities

SOCIAL and ROLE

FUNCTIONING

Negative symptoms, anhedonia,

motivation to perform role

Positive symptom s, medication effects

Cognitive

impairments

Expertise in performing

role

Practice

Role skills

Quality of instruction

Quality of curriculum

Skills training

Individual

10 Charles J. Wallace

Figure 1. Factors that in¯uence social and role functioning .

Social and instrumental role functioning

Adopting the axiom that behavior is a product of

the individual and the environment, Figure 1 indi-

cates that an individual’s social and instrumental

role functioning is in¯uenced by several classes of

variables including the skills that de®ne the role,the s kills a nd m otiv es o f the ind iv idu al a nd the

support offered by the environment.

Ro le comp lexit ies

The few and simple questions that typically mea-

sure role functioning (e.g. How many hours were

y ou e mp loy ed in a c om p etitive job for the p as t

week?) belie the often complex sequence of tasks

tha t m u st b e e n ac ted to fu n ction s uc ce ss fu lly.B ei ng a w age ea rne r, for e xam ple, re qu ir es

adequate performance of myriad speci®c and gen-

eric tasks that de®ne a particular job at a particular

work s ite a t a p a rtic ular p oint in tim e . Not o nly

m ay th e m ix o f sp ec i® c a nd g en er ic ta sks v ary

considerably from site to site for the same job title,

b ut it m a y v ary c on sidera bly fro m tim e to tim e

within the same site. Furthermore, even if the mix

of tasks is relatively constant, their dif®culty level

may vary considerably depending upon such con-

textual factors as the clarity of the performancestandards, the number and preferred interactional

s ty les o f c o- wo rk ers a nd s up erv is ors , a nd e ve n

Individual

E ric sson a nd C h arn es s’ s (1 99 4) r evi ew o f t

development of `expert’ performance convincing

con®rms the adage that `practice makes perfec

Understanding and demonstrating skills duri

limited training sessions is apparently not enouto gu arantee a d eq u ate p e rform a nce in a re as

diverse as playing a musical instrument, program

ming a computer and solving mathematical pro

lems. PracticeÐdone early and oftenÐdevelo

expertise whose hallmarks are cognitive structur

and processes that allow the expert to rapidly sol

problems and use long-term memory to circumve

the limitations of short-term memory (Chase

Ericsson, 1982; Ericsson & Kintsch, 1994; Er

sson & Staszewski, 1989).

Ericsson and Charness (1994) do note that

period of highly focused instruction can be usefu

it `aims’ practice toward expert performance, and

may impart some elements of an expert’s cogniti

structure and processes. However, instruction is n

substitute for practice, and there is evidence (D

& Mayer, 1987; Ericsson et al ., 1993; Hulin et a

1990) that expertise is limited to the speci®c are

p rac tice d with m in im a l ge ne ra liza tion to oth

areas.

Unfortunately, several factors may restrict t

opportunities of individuals with schizophrenia

practice and become experts in such basic tasks

i f d d i l l

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Social skills training in psychiatric rehabilitation

tailed by the symptoms, the treatment, or both.

Furthermore, individuals’ anhedonia and negative

symptoms may reduce their willingness to engage in

sustained practice which is likely to have minimal

rewards in its early stages. There may also be disad-

vantages to adopting greater independence and los-

ing th e e con om ic s up p ort p rov id ed b y v a rious

public agencies. Finally, the medication generallyused to counteract the side-effects of antipsychotic

medication may impede the development of the

more ef®cient use of long-term memory that charac-

terizes experts (Spohn & Strauss, 1989).

Environment

Individuals’ opportunities to practice and develop

expertise may also be limited by the environment.

The importance of environmental support has been

freq ue n tly m en tion ed in the c linical l iterature

(Group for the Advancement of Psychiatry, 1992;

Liberman, 1992; NIMH, 1992), but there are few

studies demonstrating its relative contribution to

functioning and even fewer speci®c suggestions

about how an environment (other than the family)

can be altered to provide the requisite opportunities

and support. However, studies of training in a very

different contextÐbusinessÐprovide clear examples

of the importance of environmental opportunities

and support. Carnevale et a l . (1990), for example,

noted that the $30 billion spent annually on corpo-

rate training programs yields only an estimated $3

billion of improvements because the workplace does

not provide the equipment and support that trainees

need to adapt and hone their newly learned skills.

Pre- and post-training support by a supervisor is

critical for successfully transferring learning to the

workplace, and is most effective when the supervisor

provides clearly de®ned opportunities to practice

and explicit accountability for doing so (Baumgartel

et al ., 1984; Ford et al ., 1991; Huczynski & Lewis,

1980; Pentland, 1989). Additionally, workplace

cues such as reminders to use the skills and speci®c

monetary and/or interpersonal consequences con-

tribute independently of each other to the transfer of

training (Rouillier & Goldstein, 1991).

Evaluation of studies of social and instrumen-

tal role skills training

Given this admittedly simplistic model of the factors

that in¯uence social and instrumental role function-ing, several criteria may be used to evaluate the

empirical evidence about the effectiveness of skills

designed to improve? Were there opportunities f

trainees to practice their skills so that they cou

develop suf®cient expertise to function adequate

in the role(s)? Was the practice accompanied

suf®cient feedback that the repetition would lead

expertise and not just fatigue? Were there opport

nities to continue the role(s) beyond the traini

and the practice? W as there suf®cient environmensupport to sustain the trainees during the period

practice and beyond? Were the economic and `ps

chological’ costs of adopting the new role(s) b

anced by the rewards? Were the rewards deliver

consistently in the expected amount?

These criteria re¯ect the hypothesized role

skills training as one link in the causal chain th

leads to social and instrumental functioning. Th

will be considered in the review of the empiric

literature which, as noted above, is selective. It w

exclude studies in w hich skills training has beenminor element in a range of services, or in which t

primary focus has been on training vocational ski

in the speci®c context of vocational rehabilitati

programs. The review will include relatively rece

studies that have used experimental research desig

to evaluate the effects of skills training, and w

adopt a broad de®nition of `social skills rehabi

tation’.

Manchester, England

In research supported by the North West Region

Health Authority in the UK, Tarrier and his co

leagues (1993a) trained participants to reduce the

persisting symptoms, based on the rationale th

these symptoms are not only `extremely distressi

in themselves and a frequent source of anxiety an

depression, ¼ [they] also contribute signi®cantly

general disabilities and handicaps’ (p. 524). T

authors developed a ten-session program, Copi

Strategy Enhancement (CSE), that taught partipants to use one or more of four `strategies’ to cop

with persisting symptoms. These strategies direct

attention away from the symptoms by either narrow

ing or switching attention (cognitive strategies), i

creasing motor activity or momentarily disengagin

from social activity (behavioral strategies), m odif

ing sensory input (sensory strategies), or changi

physiological states (physiological strategies). T

strategies were taught in individual training sessio

and were tailored to each participant’s preferenc

and previous efforts to reduce the symptoms. Btween session homework, primarily practicing t

components of a strategy, was assigned and its ou

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simple games such as tick-tack-toe (noughts and

crosses), progressed through standardized situations

such as `getting a job’ and ended with individualized

scenarios that each participant identi®ed as being

personally nettlesome. The training sessions con-

sisted of discussing alternative s olutions; there w as

n o p ra ctice o f the ir imp lem e ntatio n, a ltho u gh

behavioral objectives were established for the inter-val between sessions with progress monitored at the

succeeding session. The effects of CSE and PS were

evaluated with several interview-based measures

administered by a non-blind assessor at pr e-training,

post-training and six-month follow-up. The mea-

s u re s inc lu de d the P re se nt S ta te E xam ina tion

(PSE), the Brief Psychiatric Rating Scale (BPRS),

the Psychiatric Assessment Scale (PAS) and the

Social Functioning Scale (SFS). All of the partici-

pants (39 enrolled; 27 completed the training; 23

were available for the six-month follow-up) wereselected based on h aving symptoms of schizophrenia

that had persisted for at least six months despite

regular ad ministration of antipsychotic medication.

The immediate effects of each treatment were

assessed by measuring participants’ changes on

i nte rv ie w-b as ed m eas ur es o f th e n um b er a nd

ef®cacy of strategies used to cope with symptoms

and the number and ef®cacy of solutions generated

to solve standardized problems (Tarrier et al .,

1993b ). Inform a tion fro m the s ym p to m c op in g

measure was also used to develop the individualizedstrategies that were taught to the CSE participants.

The results indicated that both the CSE and PS

procedures achieved their intended effects; each

group improved signi®cantly on the m easure speci®c

to its training and not on the other measure.

Unfortunately, the results for the symptom and

functioning measures were dif®cult to interpret

since the CSE participants were considerably more

symptomatic at the pre-treatment assessment than

the PS participants despite their random assignment

to conditions. T he C SE participants didsigni®cantly reduce the number and severity of their

symptoms as measured by the PSE and BPRS, with

somewhat less of a reduction on the PAS. These

red u ctio ns gen e ra lly p la ced th em a t the p os t-

training and follow-up levels of the PS participants,

who also reduced to some extent the number and

severity of their symptoms. Neither group changed

on the SFS.

Tarrier and his colleagues (1993a) concluded that

their results con®rmed the effectiveness of CSE

compared to PS despite the lack of ` ªripple outºimprovements in ¼ social functioning, as had been

predicted’ (p. 530). Although they suggested that

CSE participants’ in-session practice of the comp

nent skills of the individualized coping strategie

the functional skills addressed by the PS proc

duresÐeven the skills needed to solve individua

relevant problemsÐwere discussed and not pra

ticed. Third, the analysis of functioning was bas

on the total SFS score which may have been inse

sitive to the subtle changes in individually relevafunctioning that did occur. In contrast, the measu

of symptom change was focused speci®cally on t

individually relevant targets of the CSE procedure

Fourth, treatment was discontinued after ten se

s io ns , an d the s u pp o rt n ee de d to m a in ta in a n

expand the changes particularly in functioning m

have been prematurely withdrawn. Indeed, Tarr

et a l . (1993a) c om m e nt tha t the `u se o f b o os t

s es sions o r the e xten sion o f tre a tm en t o ve r

extended time period ¼ may be advisable’ (p. 530

San Diego, California

Similar to Tarrier and his colleagues, Bradsha

(1993) compared Coping Skills Training (CST

with Problem Solving Training (PST). CST w

based on the rationale that coping `with stress

essential to ¼ prevent relapse and improve fun

tional ability’ (p. 1102). CST consisted of four se

of instructional exercises that taught participan

how to identify and reduce physiological stressodevelop recreational activities and other plann

activities to manage time, restructure distorted

negative cognitions associated with stressful even

and interact in a manner that reduces interperson

stressors. The exercises were practiced during t

sessions by all participants, and inter-session activ

ties were assigned and completed by each parti

pant in `partnership’ with another. In contrast, PS

consisted of discussions of four generic stages

problem solving (brainstorm solutions, choose on

implement it, monitor its effects) applied to prolems generated by the participants. Neither i

session practice nor extra-session assignments we

required, and their optional use was restricted

those participants who had generated the problem

for that session’s discussion.

Both CST and PST were conducted in weekly 1

hour sessions for six months with seven participan

e ach, a ll of w hom h ad b een di agn osed w i

schizophrenia based on DSM-III-R criteria, an

we re e nrolle d in a d ay h o sp ita l p ro gram in S

Diego and living independently. The effects of ttreatments were evaluated with Goal Attainme

Scaling (GAS), a method of standardizing acro

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both groups made progress in achieving their goals,

th e G A S s cor es o f t he C S T p ar ti cip an ts w ere

signi®cantly higher immediately after treatment than

those of the PST participants. Both CST and PST

participants maintained their progress at the six-

month follow-up, as well as the signi®cant difference

b etwe en the m tha t c on tinu ed to fav or the P ST

participants. Bradshaw concluded that both treat-ments were effective, but he noted that `it was not

clear ¼ [why the two groups had] ¼ a difference in

outcomes ¼ [given that] ¼ both are cognitively and

behaviorally oriented’ (pg. 1103).

However, Bradshaw’s descriptions of CST and

PST indicate that there were important procedural

differences between them that likely account for

their different outcomes. PST’s content was sponta-

neously generated by the participants, and may have

had little, if any, relationship to the information and

skills needed for major role functioning. In contrast,CST’s content was systematic and, as described, far

more closely related to major role functioning. Prac-

tice sessions and homework assignments were irreg-

ularly scheduled, if at all, for CST participants;

PST’s practice sessions and homework sessions

were frequent and regular, with the added feature of

a supportive `buddy’ arrangement for completion of

the homework assignments.

Western Psychiatric Institute and Clinic (University of Pittsburgh)

Hogarty and his colleagues examined the effects of

two treatments speci®cally designed to forestall

symptomatic relapse by modifying the `demands of

the environment or the underlying de®cits’ (Hogarty

et al ., 1986, p. 634; italics supplied by authors).

They compared the outcomes of Family Therapy

(FT) and SST with 103 participants, all of whom

met Research Diagnostic Criteria for a diagnosis of

schizophrenia (n5 67) or schizoaffective disorder (n5 36). The participants were relatively young,

Caucasian, male, never married, and had been ill for

approximately six years. They were all recruited

during their inpatient treatment (23% ®rst episode),

and all were at risk for symptomatic relapse based

o n h av ing r es id ed f or a t l ea st o ne o f th e th ree

months prior to the inpatient episode with a relative

who was high in Expressed Emotion (EE). All par-

ticipants were maintained on antipsychotic medi-

c ation, a dm in is te red a s m uc h a s p os sib le in

injectable form to reduce the effects of medicationnoncompliance.

Participants were randomly assigned to one of

on a day-to-day basis’ (Hogarty et al ., 1986, p. 634

FT was scheduled for bi-weekly sessions, with refe

ral a t th e two -y ea r te rm ina tion o f the s tu dy

clinicians w ho were staff members of the institu

that conducted the study and could continue FT

In contrast, SST sought to `indirectly ªcoolº t

emotional climate of the household ¼ by improvi

the patient’s social skills in dealing with fammembers ¼ [including] ¼ enhancing the patien

verbal and nonverbal behaviors as well as developi

more accurate social perception and judgmen

(Hogarty et a l ., 1986, p. 635). During the secon

year of training, the focus expanded to include soc

skills in interactions with nonfamilial partners. SS

was scheduled for weekly sessions for approximate

21 months, followed by three months of bi-week

sessions that prepared participants for the two-ye

termination and referral to clinicians and agenci

who could not continue SST.Although no evaluation was reported of the exte

to which participants i mproved their social skills, t

effects of both treatments on EE were evaluate

T h e res ults ind ic ate d tha t F T h ad its inten d

effects, with approximately 40% of the househol

changing from high to low EE. In contrast, 30%

th e S ST g ro up a nd 2 5% o f th e con tr ol gr ou

changed from high to low EE, suggesting that t

indirect reduction of EE via improved social ski

was not achieved.

The primary focus of the evaluation was symtomatic relapse, de®ned as either a Type I relapse

a c ha nge fro m n on p sy ch o tic a t d is ch a rge fro

inp atie nt trea tm e nt to e ithe r s ch izoph ren ia

schizoaffective disorder according to R DC criteria

or a Type II relapseÐa substantial exacerbation

persisting symptoms. A ll categorizations of relap

inc lu din g the c on clus io n th a t a relap se h ad n

occurred, was a consensus judgement of all mem

bers of the treatment team. The results at the end

®rst year of treatment indicated that both FT an

SST had signi®cant and substantially lower rates relapse (19% and 20%, respectively) than the co

trol group (41%), with no relapses in the FT 1 SS

g rou p (0 % ). B y th e en d of th e s ec on d y ea r

treatment, all groups’ relapse rates increased (FT

29%; F T 1 S ST to 25%; S S T to 50%), with t

SST group’s approaching that of the control grou

(62%; Hogarty et al ., 1991). Inspection of a surviv

curve presented in Hogarty et al . (1991), howeve

indicates that the relapse rate of the SST group w

almost identical to those of the FT and FT 1 SS

groups until the 21st month of treatment, at whipoint the additional SST relapses occurred. G iv

the change in the SST’s schedule of training se

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d ucte d t he tr eatm ent s. T h e r esu lts f or t ho se

participants who did not relapse one year into the

study were relatively few, and occurred in the con-

text of m ultiple measures and comparisons. How-

ever, as Hogarty et al . (1991) note, `if there is any

pattern of effects observed, it favors the SST-alone

condition at both the symptom and the performance

level’ (p. 342). The results for those who did notrelapse for the entire study (24 month survivors)

were even less clear, but, as Hogarty et al . note, they

`favored the FT condition and combined FT 1 SST

treatment groups’ (p. 343). T hese few effects and

their ambiguous patterns may perhaps re¯ect the

narrow focus of SST on the interpersonal skills

needed to cope with familial interactions; only for

part of the second years of training did the focus

expand to include nonfamilial interactions and

situations.

West Los Angeles Veterans Administration Medical

Center and UCLA

Marder et al . (1996) compared the effects of SST

and Supportive Group Therapy (SGT) on symp-

tomatic relapse and role functioning. The compari-

son was conducted as part of a study of the effects

of supplementing an ongoing regimen of low-dose

injectable medication (5 to 10mg of ¯uphenazine

decanoate every seven to 14 days) with time-limitedoral medication at the appearance of idiosyncratic

prodromes. Participants were 80 individuals diag-

nosed with schizophrenia according to DSM-III-R

criteria con®rmed by symptom pro®les assessed

with the Present State Examination. All had been

stabilized for a minimum of two months on the low

dose injectable medication, and all were receiving

care at a Veteran’s Administration Medical Center.

After the stabilization period, participants were

ra nd om ly a ss igned to e ither S ST o r S GT . S ST

consisted of six months of bi-weekly sessions usingthe M edication M anagement and Symptom Man-

agement Modules of the UCLA Social & Indepen-

dent Living Skills Modules (Liberman et al ., 1993);

followed by six months of weekly sessions using the

Training in Interpersonal Problem Solving Module;

and concluded with 12 months of weekly `Success-

ful Living’ sessions focused on the skills required for

participants to achieve their own personal goals

(Hierholzer & Liberman, 1986). The modules are

highly structured and thoroughly speci®ed curricula

that each use seven `learning activities’ (introduc-tion, videotaped demonstration, role-play, solving

resource management problems, solving outcome

tioning (Training in Interpersonal Problem Solvi

Mo du le ), s elect a nd e va lu a te leisu re a nd re

reational activities (Recreation for L eisure Module

and engage in friendly conversations (Basic Conve

sation Skills Module). The SGT sessions, whi

followed the same schedule as SST, were design

to assist participants to set personal goals and sol

problems that might impede their achievement. Tsessions used expressive and supportive group the

apy techniques (open-ended questions, re¯ectio

empathy, etc.) and ex plicitly avoided the use of ski

training techniques.

Participants’ prodromes were assessed in a week

interview, and an idiosyncratically determin

increase triggered a decision that supplemental or

medication, 5mg ¯uphenazine administered twice

day, was needed. However, to evaluate the effects

th e s up plem en t, p ar ti ci pan ts w er e r an dom

assigned to receive either the oral medication orplacebo. Both the participants and the assesso

were blind to the speci®c assignment. In the event

continued deterioration, open label medication w

provided.

The effects of the procedures were evaluated wi

monthly administrations of the BPRS and sem

annual administrations of the Social Adjustme

Scale II (SAS-II). In addition, the speci®c effects

the SST procedures were evaluated with an inte

view and role-play test of participant’s knowled

and performance of the speci®c material taught the M edication Management and Symptom Ma

agement modules. T he results of the module tes

indicated that participants signi®cantly and substa

tially increased their knowledge and performance

the skills, and retained these improvements over

one-year follow-up (Eckman et al ., 1992).

The results for the BPRS and SAS-II indicat

tha t the o utco m es we re a c om p le x intera cti

between medication and training. For the BPR

the risk o f s ym p to m atic relap se, d e ®n e d a s

increase of four points or more on the sum of thThought Disturbance and Hostility factors or

increase of three or more on either, was signi®cant

higher for participants who received placebo an

SGT compared to those who received placebo an

SST. The difference between SST and SGT w

not signi®cant for participants who received the or

supplement, and Marder et al . conclude that `SS

may affect exacerbation risk most in high-risk ind

v id u als wh os e m e dica tion m a na gem e nt is s u

optimal’ (p. 14). Indeed, for those individuals, t

risk of relapse with SST was equivalent to that findividuals who receive supplemental oral med

cation.

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pants who either received placebo supplementation

or remained stable for the two years of treatment

and did not have an increase in prodromes, there

wa s n o s igni® c ant d iffe re nc e b e twee n S S T a nd

SGT. Additionally, the effects of SST on adjust-

ment were largest for participants with an early

onset of their illnesses (before 24 years old). Marder

et al . conclude that `skills training may be mostbene®cial to those patients with a relatively early

onset that has left them with fundamental de®cits in

social and interpersonal skills. Furthermore, SST

appears optimally effective ¼ [for improved adjust-

ment] ¼ for those patients who either remain clini-

cally stable, or, if unstable, receive effective early

drug intervention’ (p. 16). H owever, considering the

results for relapse, SST may have bene®ts in differ-

ent areas of functioning for all but relatively skilled

and stable individuals.

University of Calgary

Dobson et al . (1995) compared the effects of SST

with those of social milieu treatment (SMT). Both

were conducted for nine weeks on a four day per

week schedule. SST was divided into three three-

w ee k se gm e nts ; b as ic c om m un ica tio n sk ill s,

assertiveness training, individual communication

and goal setting. Training techniques included

instruction, communication games, role-plays, mod-eling, and daily homework. A manual was developed

to guide the trainers who were continually moni-

tored to ensure that they accurately conducted the

training. SMT gave participants a choice of struc-

tured activities including supportive discussion,

exercise, horticulture, and art and crafts. Partici-

p ants we re 3 3 individu als d ia gnosed w ith

schizophrenia according to DSM-III-R criteria,

s elec te d o n the b a sis o f a Ge ne ra l P os itive a nd

Negative Symptom Scale (PANSS; Kay et al ., 1987)

score below the 50th percentile. The 33 were ran-domly assigned to the conditions.

T h e e ffec ts o f the c on d itio ns were e va lu ate d

exclusively on improvements in symptomatology,

measured by the PANSS and the Symptom Check-

list-90 (SCL-90). Both were administered before,

twice during (three week and six week), and imme-

diately after treatment, with a follow-up assessment

at three months for both groups and six months for

the SST group. The results indicated that, despite

the limitation in the range of potential improvement

introduced by the selection criterion, `there wasgenerally more change for the SST group than the

SMT group, notably on the ¼ PANSS’ (p. 22). The

Rehospitalization rates during the year after tre

ment were the same for both groups, although th

SST participants were hospitalized for fewer da

(m ean o f 3.47 v ersu s 15.42, p, 0.08). Unfort

nately, these results are dif®cult to interpret sin

Dobson et al . did not measure functioning, partic

larly interpersonal functioning which was the p

m a ry ta rget o f S ST , a nd th e re wa s a s igni® careduction in medication for both groups coincide

with the administration of their treatment.

University of Brisbane

Hayes et a l . (1995) compared the effects of SS

with those of discussions groups (DG) conduct

w ith a r el at iv el y l ar ge sa mp le of p ar tic ip an

( N 5 63). Like the Dobson et al . study, participan

were chosen based on a DSM-III-R diagnosis schizophrenia and relatively low to moderate sym

tomatology (ratings of not more than three on BPR

items assessing hallucinations, delusions, and loos

ness of associations). SST consisted of 36 sessio

c on d uc te d o ve r 18 we ek s, with n in e a d dition

booster sessions conducted over the following s

months. The curriculum `emphasized p ositive tim

use skills, interpersonal skills, and social proble

solving skills’ (p. 10). The curriculum also includ

a segment that taught participants how to commun

cate concerns about their illness and their medictio n s. S k ills we re tau gh t with d e mon stra tion

role-played practice, and written homework assig

ments that were reviewed at the beginning of ea

session. Th e discussion groups focused on the iden

ical topics, and used `open ended questions, par

phrasing, re¯ecting, and summarizing’ (p. 10)

lieu of demonstrations and in-session role-play

Manuals were written that detailed the speci®c pr

c ed u re s for e ach c on dition a nd p e rs on ne l we

trained to implement them. The sessions were co

tinually monitored to ensure that they were conduted as speci®ed.

Several measures of social skills, symptomatolog

relapse, social adjustment, quality of functionin

use of time, and satisfaction with treatment we

administered at pre-treatment, post-treatment, an

follow-up (six months after the post-treatmen

Un fo rtun ately, the rate o f m is se d s es sion s a n

dropouts was relatively high and equal for bo

groups; at the post-treatment assessment, only 37

the initial 63 participants had attended half or mo

of the scheduled sessions, and at follow-up, only 3of them were available for assessment. The resu

for the study `completers’ indicated that the inte

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for all participants or for the completers only. Par-

ticipants’ satisfaction with treatment was equally

high for both groups.

S ev eral fac to rs m a ke the se res ults s om e wha t

dif®cult to interpret. It is possible that the high rate

of dropout and poor attendance may have resulted

in losing those participants most likely to bene®t

from SST. Restricting the analyses to completersstill included participants who attended as few as

50% of the scheduled sessions, perhaps too few for

SST to have an effect. Although DG did not include

speci®c in-session demonstrations and role-plays, it

did include the same topics, and the group mem-

bers’ discussions may have provided the support,

advice and prompts needed for their performance of

s kil ls th at m a y h av e b een a lr ea dy t ho ro ug hl y

instatedÐif not performedÐin their behavioral

repertoires. Interestingly, the average age of onset

for the 63 wh o b e ga n the s tu d y wa s 25, s ligh tlygreater than the `dividing line’ of 24 that Marder et

al . (1996) reported as separating those who bene®t

from skills training and those who do not. Thus, an

unreported number of participants may not have

needed the speci®c training provided in the SST

group, and their lack of performance of the skills

may have been caused by the factors suggested in

Figure 1. Indeed, Hayes et al . conducted a post-hoc

hierarchical multiple regression analysis that indi-

cated the importance of social skills in community

functioning. Th ey found that post-test interpersonalskills were signi®cantly and positively correlated

with post-test social adjustment and symptoms over

and above pre-test adjustment and symptoms.

Conclusions

The results of these six sets of studies offer ®ndings

to please everyone from adherents of social skills

rehabilitation (e.g. Liberman, 1992) to s keptics (e.g.

Hogarty et al ., 1991). The studies that measured the

immediate effects of training (Tarrier et al ., Marder

et al ., Hayes et al .) demonstrated that training does

achieve increases in the targeted skills w hen conduc-

ted with reasonable speci®city using simple instruc-

tional techniques including demonstration and

practice. When these skills are relevant to the com-

plexities of the roles and functioning assessed by the

outcome measures, when trainees can bene®t from

training because they lack the skills, and when the

environment provides prompts and reinforcers for

use of the skills, improved functioning ensues, as

clearly indicated by the West Los Angeles±UCLA/

VA study of Marder and his colleagues.

adjustment, particularly on instrumental role pe

formance, can be explained by psychosocial trea

ment or medication. Globally, patients get `bett

but not well’ ¼ relatively few patients appear

a ch ieve i nd ep en de nt li vi ng an d c on ti nu

employment that is uninterrupted by intermitte

relap se d urin g the y ea rs wh en the y rem a in

greatest risk (p. 345).

This pessimistic assessment of the usefulness

skills training is perhaps better interpreted as

commentary on the multitude of intertwined facto

that affect functioning, the limited role of training

imp ro ving it, th e d if®c u lty o f c on d uc ting we

focused training accompanied by suf®cient practic

and the need to adapt clinical services to this com

plex reality.

The wide range of results reported by the six se

o f s tu d ies re¯ ec ts the c on sidera ble d iffe re nc

among their content, training techniques, and sens

tivity of outcome measures. For example, Tarrier

al . based their C SE procedures on the assumpti

that improved coping with persistent symptom

would result in improved role functioning. As ind

c ate d p rev iou sly, the y c on c lu de d tha t the CS

group’s unimproved functioning re¯ected a relati

independence of symptoms and functioning an

consequent irrelevance of CSE’s content. The P

grou p’ s u n im p rov ed fun c tion in g m a y h a ve a l

re¯ected irrelevant content that focused only

global skills and not speci®c complexities, as well

a lack o f p ra c tice tha t m ay h a ve b ee n a c ritic

omission given Ericsson and Charness’s (1994) co

clusions. Both CSE and PS were brief, and suppo

was apparently not available after it ended.

Hogarty et al .’s SST focused for the ®rst year o

the interpersonal skills needed to improve relatio

ships with familial members, and only shifted duri

months 12 to 21 to focus on interaction skills wi

nonfamilial individuals. There is no indication th

SST focused on nonrelationship skills that may habeen important for improved functioning. In co

trast, FT explicitly augmented its focus on interpe

s on al s kills with tec h niq ue s to e nlis t a fam ily

assistance to `reintegrate ¼ [their relative] ¼ in

normal roles in community systems (work/schoo

(Hogarty et a l ., 1986, p. 634). Furthermore, SS

was faded beginning with month 21, and terminat

three months later with referral to clinicians an

agencies who were unable to continue treatmen

FT was not faded, and it ended at 24 months wi

referral to `in-house’ clinicians who were able continue it. Additionally, the measures of adju

ment (e.g. Katz Adjustment Scales, Relatives) we

8/12/2019 1920911



¼ by means of graduated internal coping strate-

gies, attempts to provide a growing awareness of

personal vulnerability. Goals are to increase fore-

sight through the accurate appraisal of emotional

states, their appropriate expression, and assess-

ment of the reciprocal response of others. Strate-

g ies are supp lem ented b y p hase-s peci® c

psychoeducation and behavior therapy (Hogartyet al .,1995, p. 379).

PT is highly individualized, maximizing the likeli-

hood of clinical success at the cost of requiring well

trained and experienced clinicians to do the individ-

ualization and the increased dif®culty of conducting

a systematic evaluation.

Bradshaw’s results may represent the fortuitous

use of an outcome measure that assessed attainment

of individual goals rather than independent living

and instrumental role skills, and the Dobson et a l .study evaluated their training procedures solely in

terms of symptom reduction, an outcome that was

at best only obliquely related to the content and

methods of the training. Furthermore, Dobson et al .

confounded their results with decreases in medi-

cation that were instituted during training. In con-

trast, Hayes et a l . a dm inistered a ran ge o f we ll

chosen outcome measures to evaluate two treat-

m e nts tha t c on sisted o f the s am e we ll s pe ci®e d

content; their results did indicate that both had

desirable effects, but the differences between themwere slight. Unfortunately, the high rate of dropouts

a nd the v a riable ra te s o f a tten d an ce m a y h a ve

reduced the effectiveness of both treatments, partic-

ularly SST since it relied on demonstration and

p ra ctice to a ch ie ve e ffec ts o ve r a nd a b ove d is-

cussion.

Hogarty et al . d irec tly a dd re sse d the iss ue o f

dropouts and variable attendance by dividing their

participants into treatment `takers’ and `partial tak-

ers’, basing most of the analyses on data collected

from the takers. FT takers were de®ned as thosewho attended a family education workshop and

àttempted to implement a management procedure

at home, or, in a rare case, attended six or m ore

family sessions’ (p. 636). In contrast, SST takers

were de®ned as those who `completed the baseline

assessments of social skills de®cits plus at least one

session in skills rehearsal’, and control takers were

de®ned as those who attended at least `two individ-

ual sessions of supportive therapy provided by the

nurse clinician’ (p. 636). Hogarty et al . do not pro-

v ide inform atio n a bo ut th e n u mb er of s es sion sattended by their participants, and a possible `dose-

response’ relationship between the amount of train-

cial `real world’ obstacles, and the differences in th

effectiveness of different instructional technologi

(e.g. `reciprocal teaching’; Palincsar & Brow

1984). Unfortunately, the bene®ts of skills traini

are neither as immediate nor as widespread as tho

of psychotropic medication; they accrue slowly an

only with suf®cient teaching resources applied wi

care. Hogarty et al .’s expectation that skills traininshould result in many individuals’ achieving ìnd

pendent living and continued employment that

uninterrupted by intermittent relapse during t

years when they remain at greatest risk’ may exce

what is possible given even a generous allocation

resources.

Focusing on the details, however, risks bei

absorbed by them and losing sight of the `forest f

the trees’. Figure 1 suggests that training is just o

of the variables that affect functioning, and there a

certainly several that account for large proportioof the variance of outcomes. Noncompliance wi

m e dica tion , a ge o f o n se t, a d dictio n to d ru gs

alcohol, performance of intolerable behaviors su

as assault, and the environment’s tolerance for dev

ance and expectations for performance are but a fe

o f t he m. T re atm en t a nd p rev enti on p ro gr am

directed to each may achieve large improvements

outcomes, particularly symptoms and rehospitaliz

tion rates. However, even with medication comp

a n ce a nd e nv iro nm e nts wh ose to le ra n ce is n

exceeded by individuals’ behaviors, their role funtioning is typically far less than adequate, and ski

training becomes an effective component in indivi

uals’ treatment.

Recommendations for further research

Given the factors that in¯uence social and instr

mental role functioning, there are several areas f

future research. First, b etter methods of assessi

roles, individuals and environments would be mohelpful. Clinicians could allocate scarce treatme

resources based on information about the complex

ties of the speci®c role(s) to which an individu

aspires, the skills in the individual’s current beha

ioral repertoire, and the degree and predictability

environmental supports and rewards. This alloc

tion could be the result of an algorithm that pr

s cr ib es the balan ce of sk ills training an

environmental manipulations that maximizes t

probability of improving the individual’s functio

ing. The algorithm could itself be developed bason research investigating the process of èxpe

clinician’s decision-making, yielding a system th

8/12/2019 1920911



achieve better outcomes by focusing their efforts on

delivering training rather than producing it. Current

technology such as computer-based interactive

training may provide an ef®ciently delivered format

that allows a relatively high degree of individuation.

Furthermore, the current efforts to improve individ-

uals’ persistent cognitive de®cits with `cognitive

rehabilitation’ techniques may also help them toparticipate more ef®ciently in skills training.

T hi rd, d ev el opi ng tec hn iq ues t o ex pl icitl y

increase environmental support could be helpful. In

keeping with the Americans with Disability Act,

these techniques could be used to accommodate

individuals with varying levels of skills, or to provide

v ar ia tion s i n s up po rt a s a n i nd iv idu al’s sk ills

increased with training.

F ou rth, d is sem in a tion o f s kills tra in ing m a y

require changes in the philosophies and practices of

the service delivery system. Such treatments gener-a lly d o n ot ® t the typ ic al p sy ch oth e ra py a nd /o r

medication models, and how best to accomplish

these changes and then disseminate these tech-

niques is yet to be determined.

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