Skill Building: Assessing the Evidence

• Published in: Psychiatric services (Washington, D.C.) Vol. 65; no. 6; p. 1
• Main Authors: Lyman, D Russell, Kurtz, Matthew M, Farkas, Marianne, George, Preethy, Dougherty, Richard H, Daniels, Allen S, Ghose, Sushmita Shoma, Delphin-Rittmon, Miriam E
• Format: Journal Article
• Language: English
• Published: Arlington American Psychiatric Publishing, Inc 01.06.2014
• Subjects: Mental disorders; Schizophrenia; Skill development
• ISSN: 1075-2730; 1557-9700

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. 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. 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. 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. Developing or regaining basic skills needed to function adaptively in real-world situations is essential for individuals who are struggling with serious mental illness, substance use disorders, or co-occurring mental and substance use disorders. The neurodevelopmental nature of certain severe mental illnesses (1) -- in which multiple and complex skill deficits emerge early in development, persist through adulthood in the absence of targeted treatment, and affect virtually every aspect of life functioning -- has led to a vast array of approaches to skill building. These approaches are typically applied in various combinations. The inherent complexity of skill building adds a high degree of challenge to assessing levels of evidence and effectiveness for such a diverse array of treatment modalities and methods. In this review, we examined four key components of skill building: 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 adaptive functioning and can be considered 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 therapy, psychiatric rehabilitation, applied clinical psychology, substance abuse treatment, and neuropsychology. Integrative approaches that combine 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 selected 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 schizophrenia Patient Outcomes Research Team (PORT) analysis and psychosocial treatment recommendations (2), and readers are encouraged to consult the PORT publication for a detailed analysis of the existing literature on general treatment of schizophrenia. We conclude with a discussion of the challenges in evaluating the effectiveness of specific approaches in isolation, because the complexities of serious mental 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 disconfirming studies); and summarize the effectiveness of the service as indicated 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.