Copyright 1990 bv the American Psychological Association, Inc. ' 0022-006X/90/S00.75
Journal of Consulting and Clinical Psychology 1990, Vol. 58, No. 6, 741-747
Social Skills Training With Schizophrenics: A Meta-Analytic Evaluation
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Mary K. Benton and Harold E. Schroeder Kent State University A meta-analytic review of 27 studies on social skills training with schizophrenics was conducted to address 3 critical issues in the literature: (a) the magnitude of treatment effects relative to different outcome measures; (b) the extent of the generalization and maintenance of treatment effects; and (c) the impact of 2 methodological issues: diagnostic clarity and training variations. Social skills training has a strong, positive impact on behavioral measures of social skill, self-rated assertiveness, and hospital discharge rate, and a moderate impact on relapse rate. In addition, when behavioral measures are used, the data support generalization and maintenance of skill gains. However, effects are only marginally significant for broader ratings of symptoms and functioning. Diagnostic homogeneity, the number of techniques used, and the amount of training do not appear to be significantly associated with outcome. Specific directions for future research are discussed.
Social skills training has been studied extensively over the .past 15 years and has become increasingly popular as a form of treatment for schizophrenia. Previous literature reviews have suggested that social skills training may be beneficial to schizophrenics (Gomes-Schwartz, 1979; Wallace et al, 1980) and to chronic psychiatric patients in general (Brady, 1984; Hersen & Bel lack, 1976). However, only limited conclusions can be drawn from these reviews because of three important unresolved issues. First, it is difficult to clearly evaluate the magnitude of the treatment effect for social skills training from narrative reviews. Only when outcomes from different studies are quantified is it possible to determine the magnitude of social skills training effects and the significance of these effects relative to other interventions. Similarly, the relative impact of training on different types of outcome measures cannot be readily assessed in nonquantitative reviews. In addition, although positive results were reported in all of the above reviews, none of them included unpublished studies, suggesting a possible bias (Strube & Hartmann, 1983) in favor of a positive outcome for social skills training. A second area of ambiguity involves the generalization and maintenance of treatment effects. Several of the previous reviewers suggested that there may be problems with generalization of treatment effects to more naturalistic interactions and maintenance over follow-up periods, although contradictory findings have been noted across studies (Gomes-Schwartz, 1979; Hersen & Bellack, 1976; Wallace et al, 1980). Unless outcomes are quantified, it is not possible to systematically analyze the extent to which other variables may account for these contraThis article is based on Mary K. Benton's master's thesis, which was supervised by Harold E. Schroeder and submitted to the Department of Psychology, Kent State University. We gratefully acknowledge the assistance of Susan Dwyer, who coded studies for the reliability analysis. Correspondence concerning this article should be addressed to Harold E. Schroeder, Department of Psychology, Kent State University, Kent, Ohio 44242.
dictory results, nor is it possible to assess the extent of treatment losses under these conditions. Finally, two serious methodological problems have confounded previous reviews of social skills training with schizophrenics. First, because a large percentage of studies either do not provide adequate diagnostic information about subjects or they include mixed samples of psychiatric patients, each of the previous reviews evaluated studies including nonschizophrenic as well as schizophrenic subjects. Gomes-Schwartz (1979) suggested that schizophrenics may not respond to behavioral interventions in the same manner as other psychiatric patients, raising a question about the validity of conclusions about schizophrenics drawn from studies using large percentages of nonschizophrenic subjects. A second methodological concern involves the variability of social skills interventions across studies. When studies differ greatly in the number of behavioral techniques used and the number of hours of training provided, it is not clear whether the conclusions drawn about the effectiveness of social skills training are equally valid for all of these variations. The goal of our study is to assess the effectiveness of social skills training for schizophrenics through a more systematic analysis of these three issues. More specifically, the current meta-analytic review addresses the following questions: (a) What is the magnitude of the treatment effect for social skills training with schizophrenics when both published and unpublished reports are evaluated? How does this effect vary across different types of outcome measures? (b) To what extent does evidence of this effect diminish in more naturalistic interactions or across extended follow-up periods? (c) Does inclusion of studies using mixed samples of chronic psychiatric subjects pose a serious threat to the validity of conclusions for schizophrenic patients? How valid is it to generalize across studies that use interventions varying widely in the sophistication and amount of training offered?
Method Studies Both a computer search and an extensive manual search were conducted to identify studies of social skills training with schizophrenic or 741
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mostly schizophrenic subject samples that provided sufficient statistics to allow calculation of an effect size. Because of the problems in the literature surrounding the definition of social skills training and subject diagnosis, explicit inclusion criteria were developed for the meta-analysis. For an intervention to be denned as social skills training, use of a minimum of three of the following core behavioral techniques was required: instructions or coaching, live modeling, taped modeling, simple rehearsal, role-play rehearsal, verbal feedback, videotaped feedback, interpersonal reinforcement, and homework assignments. Although such a cutoff is necessarily arbitrary, the majority of studies reviewed used at least three techniques in their experimental groups; some actually used interventions with only one or two techniques as control groups. Studies that involved mixed samples of psychiatric patients were included only if sample descriptions specified that (a) all subjects were "chronic," "from long stay wards," or were "mostly psychotic"; (b) subjects had a mean current hospital stay of at least 6 months or lifetime hospitalization of 1 year or more; or (c) at least 75% of the subjects were diagnosed schizophrenic. Although such samples of chronically mentally ill patients were presumed to include many schizophrenics, these samples might differ from all-schizophrenic samples. Therefore, this distinction was included as a factor in the coding scheme described next. Using these criteria, 27 studies were identified for inclusion in the meta-analysis. (See Appendix.)
Coding Studies were coded on variables of subject age and hospitalization history, study setting, amount of training provided, number and type of training techniques used, and type of outcome measure used. Because the quality of the methods used in studies has been a controversial issue in meta-analysis (Glass, McGaw, & Smith, 1981), a quality of methodology score was assigned to each effect size on the basis of ratings on 12 variables relevant to the internal and external validity of this type of study.1 To verify the reliability of the coding scheme, a coding manual was developed to define terms, and an assistant coder was recruited to recode the descriptive features of 10% of the sample included in the analysis.
Analysis of Data Calculations of effect size estimates were based on the procedures proposed by Glass et al. (1981) for computing a standardized mean difference. However, a pooled standard deviation was used instead of the control group standard deviation, and each effect size was corrected for bias as recommended by Hedges and Olkin (1985). When means and standard deviations were not available, the alternative methods suggested by Glass et al. were used. Inasmuch as some of the methods of estimation were imprecise and therefore potentially biased, the direction of the possible bias was coded. Because multiple effect size estimates could be calculated from most studies, introducing a lack of independence in the data, dependent measures were classified on the basis of common constructs (see Wolf, 1986) so that separate analyses could be conducted for different types of outcome measures. Because nonindependence remained a problem following this step, decision rules were developed for combining or choosing among the remaining effect size estimates so that only one effect size per study was included in each analysis. Decision rules were formulated to favor selection of the most conservative effect size from each study; effect size estimates were averaged together only if coded identically on variables of interest. To obtain an estimate of the treatment effect, a weighted mean effect size was calculated for each class of outcome variables, with each effect size being weighted by the inverse of its estimated variance (Hedges &
Olkin, 1985). Confidence intervals around each weighted mean effect size were calculated, and the homogeneity of the effect size was tested using the Q statistic introduced by Hedges and Olkin. The test for heterogeneity, QT, is based on the sum of squares of the individual effect size about the mean when each square is weighted by the inverse of the estimated variance of the effect size. Q has an asymptotic chisquare distribution and is analogous to the analysis of variance. Therefore, subgroups of studies may be evaluated for within-group differences ((?w) and between-groups differences (QB) following the same model. The stability of the mean effect for each class was also evaluated, first by examining the impact of omitting any effect sizes involving calculations potentially biased in a liberal direction, and second by calculating a fail-safe N. In the absence of a universally accepted significance level for effect sizes, an effect size of+.20 was arbitrarily considered nonsignificant (Orwin, 1983). Only one of the classes of dependent measures, behavioral measures of social skill, involved a sample of studies that was large enough to permit a more detailed analysis. In this analysis, a weighted least squares analysis was conducted, weighting each effect size with the inverse of its estimated variance and making the modifications recommended by Hedges and Olkin (1985). The following variables were entered as the independent variables: (a) the "naturalness" of the dependent measure (naturalistic vs. contrived measures); (b) the number of training techniques used; (c) the quality of methodology score; and (d) diagnostic homogeneity (all schizophrenic vs. mixed chronic psychiatric sample). The number of hours of training, along with a number of other possible moderator variables, was examined only on an exploratory basis because of limitations in the data available.
Results
Reliability of Coding Pearson product-moment reliabilities ranged from +.82 to +1.00 for the coding of the four independent variables included in the weighted least squares analysis. Reliabilities were not meaningful for many of the other variables because of the restricted range of their coding scales. However, in 84% of the cases the two coders were in perfect agreement or differed on only one judgment across the subsample of studies.
Description of Studies All of the studies located were conducted between 1972 and 1988; more than one third of the 27 studies were unpublished. The majority of the studies were conducted in the United States (81%), in inpatient settings (85%), with predominantly male subjects (63%). Only 41% of the studies used all-schizophrenic subject samples. Although 41% of the studies provided less than 10 hr of training, two studies provided more than 100 hr. The number of training techniques used ranged from 3 to 12, with most studies using 5 or 6 core behavioral techniques (Mdn = 5). Quality of methodology scores for effect sizes included in the analysis ranged from 22 to 36, with a mean of 27.48 and a standard deviation of 3.75.
1 A more detailed description of the study methods is available on request from Harold E. Schroeder.
SOCIAL SKILLS TRAINING WITH SCHIZOPHRENICS
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Behavioral Measures of Social Skill Of the 27 studies located, 23 provided usable data on behavioral measures of social skill. The specific measures thought to tap into this construct were (a) role-play tasks, n = 11; (b) taped role-play situations, n = 2; (c) confederate interactions, n = 5; (d) standardized observations in unstructured situations, n = 4; and (e) structured group interactions, n = 1. In evaluating the variable of naturalness, both role-play measures were coded as contrived, with the remaining measures coded as naturalistic. Follow-up measures, taken from 30 days to 9 months after training, were analyzed separately from posttreatment measures. When posttreatment measures for all 23 studies were examined, the weighted mean effect size was +.76, with a 95% confidence interval of+.59 to +.93 (see Table 1). Inasmuch as this confidence interval does not include zero, the treatment effect may be considered significant. The test for heterogeneity of effect size failed to reach significance, QT(22) = 13.49, p > .90,
Table 1
Summary Statistics for Five Mela-Analyses Analysis
d++*
Analysis 1: Other-rated social skills Posttreatment All studies Unbiased only Follow-up All studies
.76 (±.17) .75 (±.18)
23 22
64 61 19
Analysis 2: Self-rated assertiveness Posttreatment AH studies Unbiased only
.69 (±.26) .70 (±.30)
10 8
25 20
Analysis 3: Other-rated general functioning Posttreatment All studies Unbiased only
.34 (±.28) .11 (±.33)
Analysis 4: Self-rated symptomatology Posttreatment All studies Unbiased only
.32 (±.26) .39 (±.36)
.88 (±.46) 1.19 (±.54)
suggesting that this group of studies share a common effect size. In addition, this positive finding appears to be relatively stable, because removal of potentially biased effect sizes did not reduce the mean effect substantially, and 64 studies with null outcomes would be needed to reduce the mean effect to the nonsignificant level of+.20. The weighted least squares analysis of posttreatment measures revealed that none of the regression coefficients differed significantly from zero at a 95% level of confidence. However, some trends were noted in the data. When weighted mean effect sizes were calculated for the variable of naturalness of outcome measures, the more naturalistic measures had a somewhat lower mean effect size (d+t = +.68) than did role-play measures (d+2 = +.83), although between-groups differences were not statistically significant, (?B(1) = .74, p > .30. Similarly, the more heterogeneous samples of chronic patients yielded a lower mean effect (d+l = +.67) than did samples of schizophrenics only (d+2 =+.91), with differences again being nonsignificant, QB(1) = 1.73, p >. 10. Both the quality of methodology score and the number of training techniques had very low correlations with effect size, with r - +.07 and r = +.02 respectively. Because one study (Finch & Wallace, 1977) yielded an effect size estimate that was a significant outlier in the analysis, the weighted least squares analysis was repeated with this study omitted. Results were essentially unchanged. Two studies provided over 100 hr of social skills training, whereas 8 studies provided between 10 and 40 hr and 11 studies less than 10 hr. Effect sizes were +.85, +.80, and +.74, respectively, suggesting little gain from more extensive training. However, this finding must be interpreted with caution because so few studies provided more than 40 hr of training. Trends were examined for other possible moderator variables but, unfortunately, the size of the data base severely limited conclusions that could be drawn about these variables as well.2 Only four studies provided follow-up data in addition to posttreatment data for behavioral measures of social skill. As shown in Table 1, the weighted mean effect for follow-up measures is +1.13. The weighted mean effect size for the same four studies immediately following training was only +.67, suggesting that the higher effect at follow-up was not due simply to the superiority of these particular studies. Although the number of studies reporting follow-up data was small, the fail-safe A'of 19 indicates that this finding may be relatively stable. Self-Rated Assertiveness
Analysis 5: Community readiness Follow-up: discharge All studies Unbiased only Follow-up: relapse All studies
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14 15
.47 (±.29)
Note. Unbiased studies are those coded as unbiased or as conservatively biased in the coding scheme. Dash indicates that inasmuch as weighted mean effect size did not differ significantly from zero at a = .05, it was not necessary to calculate N&. * Weighted mean effect size, with 95% confidence interval in parentheses. b The fail-safe Vindicates the numberof null findings that would need to be found to reduce the mean effect size to +.20.
Ten of the 27 studies reported data on self-reported measures of assertiveness or social anxiety. Results were coded as positive effects if changes occurred in the direction of greater assertiveness and less social anxiety. As shown in Table 1, the weighted mean effect size for this variable was +.69, with a 95% confidence interval of from +.43 to +.95, indicating that the treatment effect is significantly different from zero. This subgroup of studies was also found to be homogeneous with regard to 1
Information regarding the other moderator variables that were explored and the trends observed may be obtained from Harold E. Schroeder.
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MARY K. BENTON AND HAROLD E. SCHROEDER
effect size, .10. Omission of potentially biased effect size estimates had little impact on the mean effect size. In addition, the positive effect observed appears to be a relatively stable finding in that the fail-safe N is more than twice the number of studies located in an extensive literature search. No further analysis was undertaken because of the small number of studies in this class.
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Other-Rated General Functioning The third class of outcome measures to be analyzed, involving 8 of the 27 studies, included broader ratings of subjects' functioning such as the Psychotic Inpatient Profile (Lorr & Vestre, 1968) and the Mood-Affect-Communication-Cooperation Test (Ellsworth, 1971). Although these scales often included ratings of social behavior, they also tapped into symptom states and were typically not based on discrete behavioral samples. As shown in Table 1, the weighted mean effect size for this class was +.34. Although homogeneous, QT(7) = 10.92, p > .10, this mean effect appears unstable. When potentially biased effect size estimates were removed, the mean effect dropped to the nonsignificant level of -K 11. Even with these effect sizes included, the fail-safe Nof6 does not provide much assurance of the stability of this finding. Self-Rated Symptomatology Of the 27 studies, 8 reported data on subjects' self-ratings of their broader symptom states, using such instruments as the Profile of Mood States (McNair, Lorr, & Droppleman, 1971) and the Hopkins Symptom Checklist (Derogatis, Lipman, Rickles, Uhlenhuth, & Covi, 1974). The weighted mean effect size of+.32 was statistically significant (see Table 1). This mean effect, although homogeneous, (?T(7) = 8.87, p > .20, would be rendered nonsignificant by only five unretrieved null outcomes. Hospital Discharge Four studies reported data on the rate of discharge from the hospital. One effect size was omitted from the analysis, however, because of indications that discharge had been planned around the study's completion. The weighted mean effect size of +1.19 for the three remaining studies was statistically significant (see Table 1). The test for heterogeneity again failed to reach significance, .50. Despite the small number of studies involved, this finding appears relatively stable in that the fail-safe N is five times greater than the actual number of data reports located in the course of a thorough search. Relapse Rate Of the 27 studies located, only 4 provided data on relapse rates, with 3 of the 4 basing relapse judgments on rehospitalization data. As indicated in Table 1, the weighted mean effect size was +.47. In addition to being statistically significant, this effect size was homogeneous, QT(3) = 2.54, p > .30. However, only five null results would be needed to render the outcome nonsignificant, suggesting that it may not be a stable finding.
Discussion The results of the current meta-analyses indicate that social skills training leads to significant improvements in the social behavior of schizophrenics when specific behavioral measures are used. Similarly, training appears to have a positive impact on schizophrenics' perceptions of themselves as more assertive and less socially anxious. In contrast, the mean effect sizes for other-rated general functioning and self-rated symptoms, although statistically significant, were only half as large, suggesting that training has only a marginal impact on these variables. The finding that social skills training may not impact broader ratings of functioning to the same extent as behavioral measures of social skills is particularly noteworthy, as it suggests a possible explanation for some of the contradictory findings regarding generalization in the previous reviews. Our study indicates that, when generalization is assessed by comparing behavioral measures of social skill in naturalistic versus role-played interactions, the mean effect size for the naturalistic measures is only slightly smaller than that for the roleplay measures. In addition, the effect size for the naturalistic measures appears to be significant in its own right, both statistically and clinically. The less optimistic reports of previous reviewers regarding generalization appear to have been based, at least in part, on the failure to differentiate between behavioral measures and the broader ratings of functioning discussed above. Because the latter measures tap into a wider range of variables than social behavior, they may be less valid indicators of the generalization of social skill gains. Although only a few studies provided follow-up data, analysis of their findings suggests that, when behavioral measures are used, the difference between trained and untrained subjects actually increases over time. Hence, the loss of treatment gains during follow-up may not be as serious a concern as previously suggested. However, this encouraging finding is limited by the small sample size and by the fact that only one of the four studies reporting follow-up data employed a naturalistic measure of outcome. The current analysis offers some additional support for generalized benefits of social skills training over longer periods of time in the superior discharge rates and the lower relapse rates found for subjects receiving training. Although based on a small sample, the magnitude of the finding for discharge rates is quite large and therefore suggests that social skills training may be an important factor in earlier release from the hospital. However, findings regarding relapse are of a more moderate magnitude, and the limitations inherent in using rehospitalization data as an indication of relapse must be considered (Falloon, 1984). Our study offers some clarification with regard to two methodological shortcomings in the literature. Comparison of allschizophrenic samples with chronically mentally ill subject samples suggests that serious validity problems are unlikely to occur when results are combined, because the difference between their mean effect sizes was not significant. However, a somewhat lower mean effect was obtained for studies involving more heterogeneous samples of chronic psychiatric patients, a finding which may simply reflect the greater chronicity of these samples. In any event, the inclusion of this group of heteroge-
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SOCIAL SKILLS TRAINING WITH SCHIZOPHRENICS
neous studies appears to exert a conservative influence when evaluating the effectiveness of social skills training for schizophrenic patients. Although the actual number of techniques used does not appear to be related to the size of the treatment effect, the small sample size of the current study precluded a more in-depth analysis of the significance of specific techniques. The skewed distribution for the number of hours of training also created problems in assessing the significance of this variable. Because only two studies provided more than 40 hr of training, it would be premature to conclude that increasing the amount of training is without value. However, current findings do suggest that significant outcomes are not limited to those studies providing large amounts of training. Thus it appears likely that the conclusions drawn about the effectiveness of social skills training are valid across the reasonably diverse applications found in the literature. The primary limitation in the current meta-analyses is the relatively small number of studies identified for inclusion, which limited the extent of the analysis. Several variables of interest, such as schizophrenic subtype, chronicity, and the use of meta-communication training, were examined in too few studies to permit any definitive conclusions. Similarly, the relatively small sample size restricted the number of independent variables that could be examined in the least squares analysis. However, these limitations are tempered by the finding of homogeneous effect sizes in all of the analyses, a finding which suggests that significant differences among subgroups of studies are unlikely. A second limitation in the present study is one common to many meta-analyses: unusable or inadequate data in the original studies. Although Glass et al. (1981) have presented some suggestions for making a "reasonable guess" for the effect size in some situations, typically the impact of making such estimates is not known. Although there is no perfect resolution to this dilemma in meta-analysis, our study examined the importance of this factor by coding for potential bias. In all cases but one, the removal of potentially biased effect sizes did not lead to a significant reduction in the mean effect size; in the analysis of other-rated functioning, a marginally significant effect size was reduced to a clearly nonsignificant one. Hence, while inadequate original data remains a problem in meta-analysis, our study, by systematically examining the impact of estimation bias, is able to draw stronger conclusions. Unfortunately, however, data from some studies, such as those using single case designs, still had to be excluded. The current study reveals several issues that have not received adequate research attention to date. First, subject variables such as the current symptom state, the severity and chronicity of the subject's illness, and the subtype of schizophrenia have been largely unexplored. The value of exploring such variables is suggested by the one study that contrasted subgroups of schizophrenics with good and poor premorbid histories. Manka (1979) indicated that, on some outcome variables, poor premorbid subjects appeared to worsen with the use of social skills training. Consistent with this finding is the proposal of Liberman, Massell, Mosk, & Wong (1985) that schizophrenics at different levels of functioning may require different training approaches. Although such a proposal has face validity, the rela-
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tive benefits of procedural modifications for different types of schizophrenics needs to be tested empirically. A related issue involves differences in affiliation motivation. Inasmuch as previous research has indicated that paranoid schizophrenics have less social motivation than nonparanoids and male schizophrenics are less motivated than female (Wallace, 1984), several interesting questions may be raised with regard to the broader motivational question. Do schizophrenics with low affiliative interest agree to participate in social skills training and, if they do, does training impact either their motivation or their skill level? Empirical tests of these questions could lead to further understanding of the mechanisms of change in social skills training as well as to the identification of patients who are currently unresponsive to training. Further research may also be beneficial with regard to the effectiveness of alternative settings and methods for the application of social skills training. For example, insufficient research has been conducted to assess the effects of social skills training for schizophrenics in outpatient settings. Similarly, only two studies have explored the use of meta-communication training. Further research in this area may be fruitful, particularly if measures can be developed that assess more directly the impact of training on specific deficits in social perception and processing. The findings of the present research also have important implications for clinical practice. Both the magnitude of treatment effects and indications that these effects generalize and are maintained over time suggest that the improvements resulting from social skills training are likely to be clinically meaningful. Of particular significance in clinical settings is evidence that training may be a factor in earlier hospital release and lower relapse rates. On the other hand, our study also highl ights the reality that social skills training is not the solution to all of the symptoms and problems in functioning that schizophrenics experience. Hence, social skills training is most appropriately viewed as one component of the broader treatment program needed to adequately address the needs of schizophrenic patients. The current findings, although only suggestive, indicate that it need not be difficult to incorporate social skills training into existing programs in that even simple training programs providing relatively small amounts of training appear to produce significant outcomes. Thus, despite the need for further research, there is little question but that social skills training should be regarded as an essential component of treatment for patients with schizophrenia. References Bach, R. C. F, Lowery, P., & Moylan, J. J. (1972). Trainingstate hospital patients to be appropriately assertive. Proceedings of the 80th Annual Convention of the American Psychological Association, 7, 383-384. Beckett, S. (1983). The assessment and training of conversational skills in schizophrenics (Doctoral dissertation, Queen's University, Kingston, Ontario, Canada, 1983). Dissertation Abstracts International, 43, 3022B. Bellack, A. S., Turner, S. M., Hersen, M., & Luber, R. F. (1984). An examination of the efficacy of social skills training for chronic schizophrenic patients. Hospital and Community Psychiatry, 35, 1023-1028. Booream, C. D, & Flowers, J. Y (1972). Reduction of anxiety and per-
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sonal space as a function of assertion training with severely disturbed neuropsychiatric inpatients. Psychological Reports, 30, 923929. Brady, J. P. (1984). Social skills training for psychiatric patients: 2. Clinical outcome studies. American Journal of Psychiatry, 141, 491-498. Brown, M. A., & Munford, A. M. (1983). Life skills training for chronic schizophrenics. Journal of Nervous and Mental Disease, 171, 466470. Carmichael, S. R. (1976a). A comparison of three group treatment methods for low assertive patients (Doctoral dissertation, University of Texas at Austin, 1976). Dissertation Abstracts International, 37, 2497B. Carmichael, S. R. (1976b). The use of self-instruction in an assertion training program with chronic institutionalized patients. Newsletter for Research in Mental Health and Behavioral Sciences, 18, 20-22. Clark, K. W (1975). Evaluation of a group social skills training program with psychiatric inpatients: Training Viet Nam era veterans in assertion, heterosexual, and job interview skills (Doctoral dissertation, University of Wisconsin—Madison, 1975). Dissertation Abstracts International, 35, 4642B. Derogatis, L. R., Lipman, R. S., & Rickles K., Uhlenhuth, E. H., & Covi, L. (1974). The Hopkins Symptom Checklist (HSCL): A self-report symptom inventory. Behavioral Science, 19,1-15. Doty, D. W (1972). Role playing and incentives in the modification of the social interaction behaviors of psychiatric patients (Doctoral dissertation, Universityof Illinois, 1972). Dissertation AbstractsInternational, 34, 87 IB. Doty, D. W (1975). Role playing and incentives in the modification of the social interaction of chronic psychiatric patients. Journal of Consulting and Clinical Psychology, 43, 676-682. Eisler, R. M., Blanchard, E. B., Fitts, H., & Williams, J. G. (1978). Social skill training with and without modeling in schizophrenic and nonpsychotic hospitalized psychiatric patients. Behavior Modification, 2, 147-172. Ellsworth, R. B. (1971). The MACCbehavioraladjustment scale(revised 1971). Los Angeles, CA: Western Psychological Services. Falloon, I. R. (1984). Relapse: A reappraisal of assessment of outcome in schizophrenia. Schizophrenia Bulletin, 10, 293-299. Finch, B. E., & Wallace, C. J. (1977). Successful interpersonal skills training with schizophrenic inpatients. Journal of Consulting and Clinical Psychology, 45. 885-890. Giantonio, C. K. (1976). Assertion training: A social skill development technique with chronic schizophrenic inpatients (Doctoral dissertation, University of Notre Dame, 1976). Dissertation Abstracts International, 37,1433B. Glass, G. V, McGaw, B., & Smith, M. L. (1981). Mela-analysis in social research. Beverly Hills, CA: Sage. Goldstein, A. P. (1973). Structured learning therapy: Toward a psychotherapy for the poor. New "York: Academic Press. Gomes-Schwartz, B. (1979). The modification of schizophrenic behavior. Behavior Modification, 3, 439-468. Gutride, M. E., Goldstein, A. P., & Hunter, G. F. (1973). The use of modeling and role-playing to increase social interaction among asocial psychiatric patients. Journal of 'Consulting and Clinical Psychology, 40, 408-415. Gutride, M. E., Goldstein, A. P., & Hunter, G. F. (1974). Structured learning therapy with transfer training for chronic inpatients. Journal of Clinical Psychology, 30, 277-280. Hedges, L. V, & Olkin, I. (1985). Statistical methods for meta-analysis. Orlando, FL: Academic Press. Hersen, M., & Bellack, A. S. (1976). Social skills training for chronic psychiatric patients: Rationale, research findings, and future directions. Comprehensive Psychiatry, 17, 559-580.
Hogarty, G. E., Anderson, C. M., Reiss, D. J., Kornblith, S. J., Greenwald, D. P., Javna, C. D., & Madonia, M. J. (1986). Family psychoeducation, social skills training, and maintenance chemotherapy in the aftercare treatment of schizophrenics: 1. One-year effects of a controlled study on relapse and expressed emotion. Archives of General Psychiatry, 43, 633-642. Hopkins, L. M. (1985). Transfer effect of instruction, live modeling, reinforcement and overt or covert rehearsal on assertive non-verbal behaviorof hospitalized schizophrenics. Dissertation Abstracts International, 46, 998B. (University Microfilms No. DA8508674) Jaffe, P. G., & Carlson, P. M. (1976). Relative efficacy of modeling and instructions in eliciting social behavior from chronic psychiatric patients. Journal of Consulting and Clinical Psychology, 44, 200-207. Liberman, R. P., Falloon, I. R., & Aitchison, R. A. (1984). Multiple family therapy for schizophrenia: A behavioral problem-solving approach. Psychosocial Rehabilitation Journal, 7, 60-77. Liberman, R. P., Massell, H. K., Mosk, M. D, & Wong, S. E. (1985). Social skills training for chronic mental patients. Hospital and Community Psychiatry, 36, 396-403. Liberman, R. P., Mueser, K. T, & Wallace, C. J. (1986). Social skills training for schizophrenic individuals at risk for relapse. American Journal of Psychiatry, 143. 523-526. Liberman, R. P., Wallace, C. J., Falloon, I. R., & Vaughn, C. E. (1981). Interpersonal problem-solving therapy for schizophrenics and their families. Comprehensive Psychiatry, 22, 627-630. Longin, H. E., & Rooney, W M. (1973). Assertion training as a programmatic intervention for hospitalized mental patients. Proceedings of the 81st Annual Convention of the American Psychological Association, 8, 459-460. Longin, H. E., & Rooney, W M. (1975). Training denial assertion to chronic hospitalized patients. Journal of Behavior Therapy and Experimental Psychology, 6, 219-222. Lorr, M., & Vestre, N. D. (1968). Psychotic Inpatient Profile: Test and manual. Los Angeles, CA: Western Psychological Services. Lukoff, D. G. (1981). Comparison of a holistic and a social skills training program for schizophrenics (Doctoral dissertation, Loyola University, 1981). Dissertation Abstracts International, 41, 4268B. Lukoff, D. G., Wallace, C. J., Liberman, R. P., & Burke, K. (1986). A holistic program for chronic schizophrenic patients. Schizophrenia Bulletin, 12, 274-282. Machum, J. B. (1976). A comparison of the effectiveness of assertion training alone and in combination with cognitive self-instruction training with chronic hospitalized patients (Doctoral dissertation, Rutgers University, 1976). Dissertation Abstracts International, 37, 466B-467B. Manka, C. B. (1979). The response of chronic mental patients with good or poor social histories to assertion training with or without assertion homework (Doctoral dissertation, Arizona State University, 1979). Dissertation Abstracts International, 40. 5010B-501 IB. McNair, D., Lorr, M., & Droppleman, L. (1971). FITS manual for the Profile of Mood States. San Diego, CA: Educational and Industrial Testing Services. Mollick, L. R. (1977). The effect of individual and group assertion training on the behavior of hospitalized psychiatric patients (Doctoral dissertation, Rutgers University, 1977). Dissertation Abstracts International. 37, 5366B. Orwin, R. G. (1983). A fail-safe N for effect size. Journal of Educational Statistics, 8.157-159. Potelunas-Campbell, M. F. (1982). The development and evaluation of a social skills training program for supervisor/supervisee dyad interactions in a work adjustment program with female schizophrenic outpatients (Doctoral dissertation, New Vbrk University, 1982). Dissertation Abstracts International, 43, 1899A.
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SOCIAL SKILLS TRAINING WITH SCHIZOPHRENICS Rice, M. E. (1983). Improving the social skills of males in a maximum security psychiatric setting. Canadian Journal of Behavioral Science, 75,1-13. Shepherd, G. (1978). Social skills training: The generalization problem —some further data. Behavior Research and Therapy, 16, 287-288. Spencer, P. G., Gillespie, C. R., & Ekisa, E. G. (1983). A controlled comparison of the effects of social skills training and remedial drama on the conversational skills of chronic schizophrenic inpatients. British Journal of Psychiatry, 143,165-172. Strube, M. J., & Hartmann, D. P. (1983). Meta-analysis: Techniques, applications, and functions. Journal of Consulting and Clinical Psychology. 5. 14-27. Troiano, R. (1979). Assertion training with hospitalized patients: The differential effectiveness of positive and negative aspects of assertion training (Doctoral dissertation, New York University, 1979). Dissertation Abstracts International, 40, 2390B.
747
Trudeau, P. F. (1975). An examination of grooming training, assertive training, verbalized self-esteem and various ward behaviors in hospitalized psychotic adult males(Doctoral dissertation, Hofstra University, 1975). Dissertation Abstracts International, 36, 3078B. Wallace, C. J. (1984). Community and interpersonal functioning in the course of schizophrenic disorders. Schizophrenia Bulletin 10 233257. Wallace, C. J., & Liberman, R. P. (1985). Social skills training for patients with schizophrenia: A controlled clinical trial. Psychiatry Research, 75, 239-247. Wallace, C. J., Nelson, C. J., Liberman, R. P., Aitchison, R. A., Lukoff, D., Elder, J. P., & Ferris, C. (1980). A review and critique of social skills training with schizophrenic patients. Schizophrenia Bulletin 6 42-63. Wolf, F. M. (1986). Meta-analysis: Quantitative methods for research synthesis. Beverly Hills, CA: Sage.
Appendix Studies Providing Data 1. 2. 3. 4. 5. 6.
Bach, Lowery, & Moylan (1972) Beckett (1983) Bellack, Turner, Hersen, & Luber (1984) BooreamA Flowers (1972) Brown & Munford (1983) Carmichael (1976a) Carmichael(1976b) 7. Clark (1975) 8. Doty (1972) Doty (1975) 9. Eisler, Blanchard, Fitts, & Williams (1978) 10. Finch & Wallace (1977) 11. Giantonio(1976) 12. Outride, Goldstein, & Hunter (1973) Goldstein (1973) 13. Gutride, Goldstein, & Hunter (1974) Goldstein (1973) 14. Hogartyetal. (1986) 15. Hopkins (1985) 16. Jaffe& Carlson (1976) 17. Longin&Rooney(1973) Longin & Rooney (1975) 18. Lukoff(1981)
Liberman, Falloon, & Aitchison (1984) Liberman, Mueser, & Wallace (1986) Liberman, Wallace, Falloon, & Vaughn (1981) Lukoff, Wallace, Liberman, & Burke (1986) Wallace & Liberman (1985) 19. Machum(1976) 20. Manka(1979) 21. Mollick(1977) 22. Potelunas-Campbell(1982) 23. Rice (1983) 24. Shepherd (1978) 25. Spencer, Gillespie, & Ekisa (1983) 26. Troiano (1979) 27. Trudeau (1975) Note. Documents were grouped together as one study when they appeared to report data from the same experiment. The first document in each group was the primary one used in coding, with secondary documents following in alphabetical order.
Received July 25,1989 Revision received March 30,1990 Accepted April 16,1990 •
Journal of Consulting and Clinical Psychology 1990, Vol. 58, No. 6, 741-747
Social Skills Training With Schizophrenics: A Meta-Analytic Evaluation
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Mary K. Benton and Harold E. Schroeder Kent State University A meta-analytic review of 27 studies on social skills training with schizophrenics was conducted to address 3 critical issues in the literature: (a) the magnitude of treatment effects relative to different outcome measures; (b) the extent of the generalization and maintenance of treatment effects; and (c) the impact of 2 methodological issues: diagnostic clarity and training variations. Social skills training has a strong, positive impact on behavioral measures of social skill, self-rated assertiveness, and hospital discharge rate, and a moderate impact on relapse rate. In addition, when behavioral measures are used, the data support generalization and maintenance of skill gains. However, effects are only marginally significant for broader ratings of symptoms and functioning. Diagnostic homogeneity, the number of techniques used, and the amount of training do not appear to be significantly associated with outcome. Specific directions for future research are discussed.
Social skills training has been studied extensively over the .past 15 years and has become increasingly popular as a form of treatment for schizophrenia. Previous literature reviews have suggested that social skills training may be beneficial to schizophrenics (Gomes-Schwartz, 1979; Wallace et al, 1980) and to chronic psychiatric patients in general (Brady, 1984; Hersen & Bel lack, 1976). However, only limited conclusions can be drawn from these reviews because of three important unresolved issues. First, it is difficult to clearly evaluate the magnitude of the treatment effect for social skills training from narrative reviews. Only when outcomes from different studies are quantified is it possible to determine the magnitude of social skills training effects and the significance of these effects relative to other interventions. Similarly, the relative impact of training on different types of outcome measures cannot be readily assessed in nonquantitative reviews. In addition, although positive results were reported in all of the above reviews, none of them included unpublished studies, suggesting a possible bias (Strube & Hartmann, 1983) in favor of a positive outcome for social skills training. A second area of ambiguity involves the generalization and maintenance of treatment effects. Several of the previous reviewers suggested that there may be problems with generalization of treatment effects to more naturalistic interactions and maintenance over follow-up periods, although contradictory findings have been noted across studies (Gomes-Schwartz, 1979; Hersen & Bellack, 1976; Wallace et al, 1980). Unless outcomes are quantified, it is not possible to systematically analyze the extent to which other variables may account for these contraThis article is based on Mary K. Benton's master's thesis, which was supervised by Harold E. Schroeder and submitted to the Department of Psychology, Kent State University. We gratefully acknowledge the assistance of Susan Dwyer, who coded studies for the reliability analysis. Correspondence concerning this article should be addressed to Harold E. Schroeder, Department of Psychology, Kent State University, Kent, Ohio 44242.
dictory results, nor is it possible to assess the extent of treatment losses under these conditions. Finally, two serious methodological problems have confounded previous reviews of social skills training with schizophrenics. First, because a large percentage of studies either do not provide adequate diagnostic information about subjects or they include mixed samples of psychiatric patients, each of the previous reviews evaluated studies including nonschizophrenic as well as schizophrenic subjects. Gomes-Schwartz (1979) suggested that schizophrenics may not respond to behavioral interventions in the same manner as other psychiatric patients, raising a question about the validity of conclusions about schizophrenics drawn from studies using large percentages of nonschizophrenic subjects. A second methodological concern involves the variability of social skills interventions across studies. When studies differ greatly in the number of behavioral techniques used and the number of hours of training provided, it is not clear whether the conclusions drawn about the effectiveness of social skills training are equally valid for all of these variations. The goal of our study is to assess the effectiveness of social skills training for schizophrenics through a more systematic analysis of these three issues. More specifically, the current meta-analytic review addresses the following questions: (a) What is the magnitude of the treatment effect for social skills training with schizophrenics when both published and unpublished reports are evaluated? How does this effect vary across different types of outcome measures? (b) To what extent does evidence of this effect diminish in more naturalistic interactions or across extended follow-up periods? (c) Does inclusion of studies using mixed samples of chronic psychiatric subjects pose a serious threat to the validity of conclusions for schizophrenic patients? How valid is it to generalize across studies that use interventions varying widely in the sophistication and amount of training offered?
Method Studies Both a computer search and an extensive manual search were conducted to identify studies of social skills training with schizophrenic or 741
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mostly schizophrenic subject samples that provided sufficient statistics to allow calculation of an effect size. Because of the problems in the literature surrounding the definition of social skills training and subject diagnosis, explicit inclusion criteria were developed for the meta-analysis. For an intervention to be denned as social skills training, use of a minimum of three of the following core behavioral techniques was required: instructions or coaching, live modeling, taped modeling, simple rehearsal, role-play rehearsal, verbal feedback, videotaped feedback, interpersonal reinforcement, and homework assignments. Although such a cutoff is necessarily arbitrary, the majority of studies reviewed used at least three techniques in their experimental groups; some actually used interventions with only one or two techniques as control groups. Studies that involved mixed samples of psychiatric patients were included only if sample descriptions specified that (a) all subjects were "chronic," "from long stay wards," or were "mostly psychotic"; (b) subjects had a mean current hospital stay of at least 6 months or lifetime hospitalization of 1 year or more; or (c) at least 75% of the subjects were diagnosed schizophrenic. Although such samples of chronically mentally ill patients were presumed to include many schizophrenics, these samples might differ from all-schizophrenic samples. Therefore, this distinction was included as a factor in the coding scheme described next. Using these criteria, 27 studies were identified for inclusion in the meta-analysis. (See Appendix.)
Coding Studies were coded on variables of subject age and hospitalization history, study setting, amount of training provided, number and type of training techniques used, and type of outcome measure used. Because the quality of the methods used in studies has been a controversial issue in meta-analysis (Glass, McGaw, & Smith, 1981), a quality of methodology score was assigned to each effect size on the basis of ratings on 12 variables relevant to the internal and external validity of this type of study.1 To verify the reliability of the coding scheme, a coding manual was developed to define terms, and an assistant coder was recruited to recode the descriptive features of 10% of the sample included in the analysis.
Analysis of Data Calculations of effect size estimates were based on the procedures proposed by Glass et al. (1981) for computing a standardized mean difference. However, a pooled standard deviation was used instead of the control group standard deviation, and each effect size was corrected for bias as recommended by Hedges and Olkin (1985). When means and standard deviations were not available, the alternative methods suggested by Glass et al. were used. Inasmuch as some of the methods of estimation were imprecise and therefore potentially biased, the direction of the possible bias was coded. Because multiple effect size estimates could be calculated from most studies, introducing a lack of independence in the data, dependent measures were classified on the basis of common constructs (see Wolf, 1986) so that separate analyses could be conducted for different types of outcome measures. Because nonindependence remained a problem following this step, decision rules were developed for combining or choosing among the remaining effect size estimates so that only one effect size per study was included in each analysis. Decision rules were formulated to favor selection of the most conservative effect size from each study; effect size estimates were averaged together only if coded identically on variables of interest. To obtain an estimate of the treatment effect, a weighted mean effect size was calculated for each class of outcome variables, with each effect size being weighted by the inverse of its estimated variance (Hedges &
Olkin, 1985). Confidence intervals around each weighted mean effect size were calculated, and the homogeneity of the effect size was tested using the Q statistic introduced by Hedges and Olkin. The test for heterogeneity, QT, is based on the sum of squares of the individual effect size about the mean when each square is weighted by the inverse of the estimated variance of the effect size. Q has an asymptotic chisquare distribution and is analogous to the analysis of variance. Therefore, subgroups of studies may be evaluated for within-group differences ((?w) and between-groups differences (QB) following the same model. The stability of the mean effect for each class was also evaluated, first by examining the impact of omitting any effect sizes involving calculations potentially biased in a liberal direction, and second by calculating a fail-safe N. In the absence of a universally accepted significance level for effect sizes, an effect size of+.20 was arbitrarily considered nonsignificant (Orwin, 1983). Only one of the classes of dependent measures, behavioral measures of social skill, involved a sample of studies that was large enough to permit a more detailed analysis. In this analysis, a weighted least squares analysis was conducted, weighting each effect size with the inverse of its estimated variance and making the modifications recommended by Hedges and Olkin (1985). The following variables were entered as the independent variables: (a) the "naturalness" of the dependent measure (naturalistic vs. contrived measures); (b) the number of training techniques used; (c) the quality of methodology score; and (d) diagnostic homogeneity (all schizophrenic vs. mixed chronic psychiatric sample). The number of hours of training, along with a number of other possible moderator variables, was examined only on an exploratory basis because of limitations in the data available.
Results
Reliability of Coding Pearson product-moment reliabilities ranged from +.82 to +1.00 for the coding of the four independent variables included in the weighted least squares analysis. Reliabilities were not meaningful for many of the other variables because of the restricted range of their coding scales. However, in 84% of the cases the two coders were in perfect agreement or differed on only one judgment across the subsample of studies.
Description of Studies All of the studies located were conducted between 1972 and 1988; more than one third of the 27 studies were unpublished. The majority of the studies were conducted in the United States (81%), in inpatient settings (85%), with predominantly male subjects (63%). Only 41% of the studies used all-schizophrenic subject samples. Although 41% of the studies provided less than 10 hr of training, two studies provided more than 100 hr. The number of training techniques used ranged from 3 to 12, with most studies using 5 or 6 core behavioral techniques (Mdn = 5). Quality of methodology scores for effect sizes included in the analysis ranged from 22 to 36, with a mean of 27.48 and a standard deviation of 3.75.
1 A more detailed description of the study methods is available on request from Harold E. Schroeder.
SOCIAL SKILLS TRAINING WITH SCHIZOPHRENICS
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Behavioral Measures of Social Skill Of the 27 studies located, 23 provided usable data on behavioral measures of social skill. The specific measures thought to tap into this construct were (a) role-play tasks, n = 11; (b) taped role-play situations, n = 2; (c) confederate interactions, n = 5; (d) standardized observations in unstructured situations, n = 4; and (e) structured group interactions, n = 1. In evaluating the variable of naturalness, both role-play measures were coded as contrived, with the remaining measures coded as naturalistic. Follow-up measures, taken from 30 days to 9 months after training, were analyzed separately from posttreatment measures. When posttreatment measures for all 23 studies were examined, the weighted mean effect size was +.76, with a 95% confidence interval of+.59 to +.93 (see Table 1). Inasmuch as this confidence interval does not include zero, the treatment effect may be considered significant. The test for heterogeneity of effect size failed to reach significance, QT(22) = 13.49, p > .90,
Table 1
Summary Statistics for Five Mela-Analyses Analysis
d++*
Analysis 1: Other-rated social skills Posttreatment All studies Unbiased only Follow-up All studies
.76 (±.17) .75 (±.18)
23 22
64 61 19
Analysis 2: Self-rated assertiveness Posttreatment AH studies Unbiased only
.69 (±.26) .70 (±.30)
10 8
25 20
Analysis 3: Other-rated general functioning Posttreatment All studies Unbiased only
.34 (±.28) .11 (±.33)
Analysis 4: Self-rated symptomatology Posttreatment All studies Unbiased only
.32 (±.26) .39 (±.36)
.88 (±.46) 1.19 (±.54)
suggesting that this group of studies share a common effect size. In addition, this positive finding appears to be relatively stable, because removal of potentially biased effect sizes did not reduce the mean effect substantially, and 64 studies with null outcomes would be needed to reduce the mean effect to the nonsignificant level of+.20. The weighted least squares analysis of posttreatment measures revealed that none of the regression coefficients differed significantly from zero at a 95% level of confidence. However, some trends were noted in the data. When weighted mean effect sizes were calculated for the variable of naturalness of outcome measures, the more naturalistic measures had a somewhat lower mean effect size (d+t = +.68) than did role-play measures (d+2 = +.83), although between-groups differences were not statistically significant, (?B(1) = .74, p > .30. Similarly, the more heterogeneous samples of chronic patients yielded a lower mean effect (d+l = +.67) than did samples of schizophrenics only (d+2 =+.91), with differences again being nonsignificant, QB(1) = 1.73, p >. 10. Both the quality of methodology score and the number of training techniques had very low correlations with effect size, with r - +.07 and r = +.02 respectively. Because one study (Finch & Wallace, 1977) yielded an effect size estimate that was a significant outlier in the analysis, the weighted least squares analysis was repeated with this study omitted. Results were essentially unchanged. Two studies provided over 100 hr of social skills training, whereas 8 studies provided between 10 and 40 hr and 11 studies less than 10 hr. Effect sizes were +.85, +.80, and +.74, respectively, suggesting little gain from more extensive training. However, this finding must be interpreted with caution because so few studies provided more than 40 hr of training. Trends were examined for other possible moderator variables but, unfortunately, the size of the data base severely limited conclusions that could be drawn about these variables as well.2 Only four studies provided follow-up data in addition to posttreatment data for behavioral measures of social skill. As shown in Table 1, the weighted mean effect for follow-up measures is +1.13. The weighted mean effect size for the same four studies immediately following training was only +.67, suggesting that the higher effect at follow-up was not due simply to the superiority of these particular studies. Although the number of studies reporting follow-up data was small, the fail-safe A'of 19 indicates that this finding may be relatively stable. Self-Rated Assertiveness
Analysis 5: Community readiness Follow-up: discharge All studies Unbiased only Follow-up: relapse All studies
743
14 15
.47 (±.29)
Note. Unbiased studies are those coded as unbiased or as conservatively biased in the coding scheme. Dash indicates that inasmuch as weighted mean effect size did not differ significantly from zero at a = .05, it was not necessary to calculate N&. * Weighted mean effect size, with 95% confidence interval in parentheses. b The fail-safe Vindicates the numberof null findings that would need to be found to reduce the mean effect size to +.20.
Ten of the 27 studies reported data on self-reported measures of assertiveness or social anxiety. Results were coded as positive effects if changes occurred in the direction of greater assertiveness and less social anxiety. As shown in Table 1, the weighted mean effect size for this variable was +.69, with a 95% confidence interval of from +.43 to +.95, indicating that the treatment effect is significantly different from zero. This subgroup of studies was also found to be homogeneous with regard to 1
Information regarding the other moderator variables that were explored and the trends observed may be obtained from Harold E. Schroeder.
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MARY K. BENTON AND HAROLD E. SCHROEDER
effect size, .10. Omission of potentially biased effect size estimates had little impact on the mean effect size. In addition, the positive effect observed appears to be a relatively stable finding in that the fail-safe N is more than twice the number of studies located in an extensive literature search. No further analysis was undertaken because of the small number of studies in this class.
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Other-Rated General Functioning The third class of outcome measures to be analyzed, involving 8 of the 27 studies, included broader ratings of subjects' functioning such as the Psychotic Inpatient Profile (Lorr & Vestre, 1968) and the Mood-Affect-Communication-Cooperation Test (Ellsworth, 1971). Although these scales often included ratings of social behavior, they also tapped into symptom states and were typically not based on discrete behavioral samples. As shown in Table 1, the weighted mean effect size for this class was +.34. Although homogeneous, QT(7) = 10.92, p > .10, this mean effect appears unstable. When potentially biased effect size estimates were removed, the mean effect dropped to the nonsignificant level of -K 11. Even with these effect sizes included, the fail-safe Nof6 does not provide much assurance of the stability of this finding. Self-Rated Symptomatology Of the 27 studies, 8 reported data on subjects' self-ratings of their broader symptom states, using such instruments as the Profile of Mood States (McNair, Lorr, & Droppleman, 1971) and the Hopkins Symptom Checklist (Derogatis, Lipman, Rickles, Uhlenhuth, & Covi, 1974). The weighted mean effect size of+.32 was statistically significant (see Table 1). This mean effect, although homogeneous, (?T(7) = 8.87, p > .20, would be rendered nonsignificant by only five unretrieved null outcomes. Hospital Discharge Four studies reported data on the rate of discharge from the hospital. One effect size was omitted from the analysis, however, because of indications that discharge had been planned around the study's completion. The weighted mean effect size of +1.19 for the three remaining studies was statistically significant (see Table 1). The test for heterogeneity again failed to reach significance, .50. Despite the small number of studies involved, this finding appears relatively stable in that the fail-safe N is five times greater than the actual number of data reports located in the course of a thorough search. Relapse Rate Of the 27 studies located, only 4 provided data on relapse rates, with 3 of the 4 basing relapse judgments on rehospitalization data. As indicated in Table 1, the weighted mean effect size was +.47. In addition to being statistically significant, this effect size was homogeneous, QT(3) = 2.54, p > .30. However, only five null results would be needed to render the outcome nonsignificant, suggesting that it may not be a stable finding.
Discussion The results of the current meta-analyses indicate that social skills training leads to significant improvements in the social behavior of schizophrenics when specific behavioral measures are used. Similarly, training appears to have a positive impact on schizophrenics' perceptions of themselves as more assertive and less socially anxious. In contrast, the mean effect sizes for other-rated general functioning and self-rated symptoms, although statistically significant, were only half as large, suggesting that training has only a marginal impact on these variables. The finding that social skills training may not impact broader ratings of functioning to the same extent as behavioral measures of social skills is particularly noteworthy, as it suggests a possible explanation for some of the contradictory findings regarding generalization in the previous reviews. Our study indicates that, when generalization is assessed by comparing behavioral measures of social skill in naturalistic versus role-played interactions, the mean effect size for the naturalistic measures is only slightly smaller than that for the roleplay measures. In addition, the effect size for the naturalistic measures appears to be significant in its own right, both statistically and clinically. The less optimistic reports of previous reviewers regarding generalization appear to have been based, at least in part, on the failure to differentiate between behavioral measures and the broader ratings of functioning discussed above. Because the latter measures tap into a wider range of variables than social behavior, they may be less valid indicators of the generalization of social skill gains. Although only a few studies provided follow-up data, analysis of their findings suggests that, when behavioral measures are used, the difference between trained and untrained subjects actually increases over time. Hence, the loss of treatment gains during follow-up may not be as serious a concern as previously suggested. However, this encouraging finding is limited by the small sample size and by the fact that only one of the four studies reporting follow-up data employed a naturalistic measure of outcome. The current analysis offers some additional support for generalized benefits of social skills training over longer periods of time in the superior discharge rates and the lower relapse rates found for subjects receiving training. Although based on a small sample, the magnitude of the finding for discharge rates is quite large and therefore suggests that social skills training may be an important factor in earlier release from the hospital. However, findings regarding relapse are of a more moderate magnitude, and the limitations inherent in using rehospitalization data as an indication of relapse must be considered (Falloon, 1984). Our study offers some clarification with regard to two methodological shortcomings in the literature. Comparison of allschizophrenic samples with chronically mentally ill subject samples suggests that serious validity problems are unlikely to occur when results are combined, because the difference between their mean effect sizes was not significant. However, a somewhat lower mean effect was obtained for studies involving more heterogeneous samples of chronic psychiatric patients, a finding which may simply reflect the greater chronicity of these samples. In any event, the inclusion of this group of heteroge-
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SOCIAL SKILLS TRAINING WITH SCHIZOPHRENICS
neous studies appears to exert a conservative influence when evaluating the effectiveness of social skills training for schizophrenic patients. Although the actual number of techniques used does not appear to be related to the size of the treatment effect, the small sample size of the current study precluded a more in-depth analysis of the significance of specific techniques. The skewed distribution for the number of hours of training also created problems in assessing the significance of this variable. Because only two studies provided more than 40 hr of training, it would be premature to conclude that increasing the amount of training is without value. However, current findings do suggest that significant outcomes are not limited to those studies providing large amounts of training. Thus it appears likely that the conclusions drawn about the effectiveness of social skills training are valid across the reasonably diverse applications found in the literature. The primary limitation in the current meta-analyses is the relatively small number of studies identified for inclusion, which limited the extent of the analysis. Several variables of interest, such as schizophrenic subtype, chronicity, and the use of meta-communication training, were examined in too few studies to permit any definitive conclusions. Similarly, the relatively small sample size restricted the number of independent variables that could be examined in the least squares analysis. However, these limitations are tempered by the finding of homogeneous effect sizes in all of the analyses, a finding which suggests that significant differences among subgroups of studies are unlikely. A second limitation in the present study is one common to many meta-analyses: unusable or inadequate data in the original studies. Although Glass et al. (1981) have presented some suggestions for making a "reasonable guess" for the effect size in some situations, typically the impact of making such estimates is not known. Although there is no perfect resolution to this dilemma in meta-analysis, our study examined the importance of this factor by coding for potential bias. In all cases but one, the removal of potentially biased effect sizes did not lead to a significant reduction in the mean effect size; in the analysis of other-rated functioning, a marginally significant effect size was reduced to a clearly nonsignificant one. Hence, while inadequate original data remains a problem in meta-analysis, our study, by systematically examining the impact of estimation bias, is able to draw stronger conclusions. Unfortunately, however, data from some studies, such as those using single case designs, still had to be excluded. The current study reveals several issues that have not received adequate research attention to date. First, subject variables such as the current symptom state, the severity and chronicity of the subject's illness, and the subtype of schizophrenia have been largely unexplored. The value of exploring such variables is suggested by the one study that contrasted subgroups of schizophrenics with good and poor premorbid histories. Manka (1979) indicated that, on some outcome variables, poor premorbid subjects appeared to worsen with the use of social skills training. Consistent with this finding is the proposal of Liberman, Massell, Mosk, & Wong (1985) that schizophrenics at different levels of functioning may require different training approaches. Although such a proposal has face validity, the rela-
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tive benefits of procedural modifications for different types of schizophrenics needs to be tested empirically. A related issue involves differences in affiliation motivation. Inasmuch as previous research has indicated that paranoid schizophrenics have less social motivation than nonparanoids and male schizophrenics are less motivated than female (Wallace, 1984), several interesting questions may be raised with regard to the broader motivational question. Do schizophrenics with low affiliative interest agree to participate in social skills training and, if they do, does training impact either their motivation or their skill level? Empirical tests of these questions could lead to further understanding of the mechanisms of change in social skills training as well as to the identification of patients who are currently unresponsive to training. Further research may also be beneficial with regard to the effectiveness of alternative settings and methods for the application of social skills training. For example, insufficient research has been conducted to assess the effects of social skills training for schizophrenics in outpatient settings. Similarly, only two studies have explored the use of meta-communication training. Further research in this area may be fruitful, particularly if measures can be developed that assess more directly the impact of training on specific deficits in social perception and processing. The findings of the present research also have important implications for clinical practice. Both the magnitude of treatment effects and indications that these effects generalize and are maintained over time suggest that the improvements resulting from social skills training are likely to be clinically meaningful. Of particular significance in clinical settings is evidence that training may be a factor in earlier hospital release and lower relapse rates. On the other hand, our study also highl ights the reality that social skills training is not the solution to all of the symptoms and problems in functioning that schizophrenics experience. Hence, social skills training is most appropriately viewed as one component of the broader treatment program needed to adequately address the needs of schizophrenic patients. The current findings, although only suggestive, indicate that it need not be difficult to incorporate social skills training into existing programs in that even simple training programs providing relatively small amounts of training appear to produce significant outcomes. Thus, despite the need for further research, there is little question but that social skills training should be regarded as an essential component of treatment for patients with schizophrenia. References Bach, R. C. F, Lowery, P., & Moylan, J. J. (1972). Trainingstate hospital patients to be appropriately assertive. Proceedings of the 80th Annual Convention of the American Psychological Association, 7, 383-384. Beckett, S. (1983). The assessment and training of conversational skills in schizophrenics (Doctoral dissertation, Queen's University, Kingston, Ontario, Canada, 1983). Dissertation Abstracts International, 43, 3022B. Bellack, A. S., Turner, S. M., Hersen, M., & Luber, R. F. (1984). An examination of the efficacy of social skills training for chronic schizophrenic patients. Hospital and Community Psychiatry, 35, 1023-1028. Booream, C. D, & Flowers, J. Y (1972). Reduction of anxiety and per-
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
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MARY K. BENTON AND HAROLD E. SCHROEDER
sonal space as a function of assertion training with severely disturbed neuropsychiatric inpatients. Psychological Reports, 30, 923929. Brady, J. P. (1984). Social skills training for psychiatric patients: 2. Clinical outcome studies. American Journal of Psychiatry, 141, 491-498. Brown, M. A., & Munford, A. M. (1983). Life skills training for chronic schizophrenics. Journal of Nervous and Mental Disease, 171, 466470. Carmichael, S. R. (1976a). A comparison of three group treatment methods for low assertive patients (Doctoral dissertation, University of Texas at Austin, 1976). Dissertation Abstracts International, 37, 2497B. Carmichael, S. R. (1976b). The use of self-instruction in an assertion training program with chronic institutionalized patients. Newsletter for Research in Mental Health and Behavioral Sciences, 18, 20-22. Clark, K. W (1975). Evaluation of a group social skills training program with psychiatric inpatients: Training Viet Nam era veterans in assertion, heterosexual, and job interview skills (Doctoral dissertation, University of Wisconsin—Madison, 1975). Dissertation Abstracts International, 35, 4642B. Derogatis, L. R., Lipman, R. S., & Rickles K., Uhlenhuth, E. H., & Covi, L. (1974). The Hopkins Symptom Checklist (HSCL): A self-report symptom inventory. Behavioral Science, 19,1-15. Doty, D. W (1972). Role playing and incentives in the modification of the social interaction behaviors of psychiatric patients (Doctoral dissertation, Universityof Illinois, 1972). Dissertation AbstractsInternational, 34, 87 IB. Doty, D. W (1975). Role playing and incentives in the modification of the social interaction of chronic psychiatric patients. Journal of Consulting and Clinical Psychology, 43, 676-682. Eisler, R. M., Blanchard, E. B., Fitts, H., & Williams, J. G. (1978). Social skill training with and without modeling in schizophrenic and nonpsychotic hospitalized psychiatric patients. Behavior Modification, 2, 147-172. Ellsworth, R. B. (1971). The MACCbehavioraladjustment scale(revised 1971). Los Angeles, CA: Western Psychological Services. Falloon, I. R. (1984). Relapse: A reappraisal of assessment of outcome in schizophrenia. Schizophrenia Bulletin, 10, 293-299. Finch, B. E., & Wallace, C. J. (1977). Successful interpersonal skills training with schizophrenic inpatients. Journal of Consulting and Clinical Psychology, 45. 885-890. Giantonio, C. K. (1976). Assertion training: A social skill development technique with chronic schizophrenic inpatients (Doctoral dissertation, University of Notre Dame, 1976). Dissertation Abstracts International, 37,1433B. Glass, G. V, McGaw, B., & Smith, M. L. (1981). Mela-analysis in social research. Beverly Hills, CA: Sage. Goldstein, A. P. (1973). Structured learning therapy: Toward a psychotherapy for the poor. New "York: Academic Press. Gomes-Schwartz, B. (1979). The modification of schizophrenic behavior. Behavior Modification, 3, 439-468. Gutride, M. E., Goldstein, A. P., & Hunter, G. F. (1973). The use of modeling and role-playing to increase social interaction among asocial psychiatric patients. Journal of 'Consulting and Clinical Psychology, 40, 408-415. Gutride, M. E., Goldstein, A. P., & Hunter, G. F. (1974). Structured learning therapy with transfer training for chronic inpatients. Journal of Clinical Psychology, 30, 277-280. Hedges, L. V, & Olkin, I. (1985). Statistical methods for meta-analysis. Orlando, FL: Academic Press. Hersen, M., & Bellack, A. S. (1976). Social skills training for chronic psychiatric patients: Rationale, research findings, and future directions. Comprehensive Psychiatry, 17, 559-580.
Hogarty, G. E., Anderson, C. M., Reiss, D. J., Kornblith, S. J., Greenwald, D. P., Javna, C. D., & Madonia, M. J. (1986). Family psychoeducation, social skills training, and maintenance chemotherapy in the aftercare treatment of schizophrenics: 1. One-year effects of a controlled study on relapse and expressed emotion. Archives of General Psychiatry, 43, 633-642. Hopkins, L. M. (1985). Transfer effect of instruction, live modeling, reinforcement and overt or covert rehearsal on assertive non-verbal behaviorof hospitalized schizophrenics. Dissertation Abstracts International, 46, 998B. (University Microfilms No. DA8508674) Jaffe, P. G., & Carlson, P. M. (1976). Relative efficacy of modeling and instructions in eliciting social behavior from chronic psychiatric patients. Journal of Consulting and Clinical Psychology, 44, 200-207. Liberman, R. P., Falloon, I. R., & Aitchison, R. A. (1984). Multiple family therapy for schizophrenia: A behavioral problem-solving approach. Psychosocial Rehabilitation Journal, 7, 60-77. Liberman, R. P., Massell, H. K., Mosk, M. D, & Wong, S. E. (1985). Social skills training for chronic mental patients. Hospital and Community Psychiatry, 36, 396-403. Liberman, R. P., Mueser, K. T, & Wallace, C. J. (1986). Social skills training for schizophrenic individuals at risk for relapse. American Journal of Psychiatry, 143. 523-526. Liberman, R. P., Wallace, C. J., Falloon, I. R., & Vaughn, C. E. (1981). Interpersonal problem-solving therapy for schizophrenics and their families. Comprehensive Psychiatry, 22, 627-630. Longin, H. E., & Rooney, W M. (1973). Assertion training as a programmatic intervention for hospitalized mental patients. Proceedings of the 81st Annual Convention of the American Psychological Association, 8, 459-460. Longin, H. E., & Rooney, W M. (1975). Training denial assertion to chronic hospitalized patients. Journal of Behavior Therapy and Experimental Psychology, 6, 219-222. Lorr, M., & Vestre, N. D. (1968). Psychotic Inpatient Profile: Test and manual. Los Angeles, CA: Western Psychological Services. Lukoff, D. G. (1981). Comparison of a holistic and a social skills training program for schizophrenics (Doctoral dissertation, Loyola University, 1981). Dissertation Abstracts International, 41, 4268B. Lukoff, D. G., Wallace, C. J., Liberman, R. P., & Burke, K. (1986). A holistic program for chronic schizophrenic patients. Schizophrenia Bulletin, 12, 274-282. Machum, J. B. (1976). A comparison of the effectiveness of assertion training alone and in combination with cognitive self-instruction training with chronic hospitalized patients (Doctoral dissertation, Rutgers University, 1976). Dissertation Abstracts International, 37, 466B-467B. Manka, C. B. (1979). The response of chronic mental patients with good or poor social histories to assertion training with or without assertion homework (Doctoral dissertation, Arizona State University, 1979). Dissertation Abstracts International, 40. 5010B-501 IB. McNair, D., Lorr, M., & Droppleman, L. (1971). FITS manual for the Profile of Mood States. San Diego, CA: Educational and Industrial Testing Services. Mollick, L. R. (1977). The effect of individual and group assertion training on the behavior of hospitalized psychiatric patients (Doctoral dissertation, Rutgers University, 1977). Dissertation Abstracts International. 37, 5366B. Orwin, R. G. (1983). A fail-safe N for effect size. Journal of Educational Statistics, 8.157-159. Potelunas-Campbell, M. F. (1982). The development and evaluation of a social skills training program for supervisor/supervisee dyad interactions in a work adjustment program with female schizophrenic outpatients (Doctoral dissertation, New Vbrk University, 1982). Dissertation Abstracts International, 43, 1899A.
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
SOCIAL SKILLS TRAINING WITH SCHIZOPHRENICS Rice, M. E. (1983). Improving the social skills of males in a maximum security psychiatric setting. Canadian Journal of Behavioral Science, 75,1-13. Shepherd, G. (1978). Social skills training: The generalization problem —some further data. Behavior Research and Therapy, 16, 287-288. Spencer, P. G., Gillespie, C. R., & Ekisa, E. G. (1983). A controlled comparison of the effects of social skills training and remedial drama on the conversational skills of chronic schizophrenic inpatients. British Journal of Psychiatry, 143,165-172. Strube, M. J., & Hartmann, D. P. (1983). Meta-analysis: Techniques, applications, and functions. Journal of Consulting and Clinical Psychology. 5. 14-27. Troiano, R. (1979). Assertion training with hospitalized patients: The differential effectiveness of positive and negative aspects of assertion training (Doctoral dissertation, New York University, 1979). Dissertation Abstracts International, 40, 2390B.
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Trudeau, P. F. (1975). An examination of grooming training, assertive training, verbalized self-esteem and various ward behaviors in hospitalized psychotic adult males(Doctoral dissertation, Hofstra University, 1975). Dissertation Abstracts International, 36, 3078B. Wallace, C. J. (1984). Community and interpersonal functioning in the course of schizophrenic disorders. Schizophrenia Bulletin 10 233257. Wallace, C. J., & Liberman, R. P. (1985). Social skills training for patients with schizophrenia: A controlled clinical trial. Psychiatry Research, 75, 239-247. Wallace, C. J., Nelson, C. J., Liberman, R. P., Aitchison, R. A., Lukoff, D., Elder, J. P., & Ferris, C. (1980). A review and critique of social skills training with schizophrenic patients. Schizophrenia Bulletin 6 42-63. Wolf, F. M. (1986). Meta-analysis: Quantitative methods for research synthesis. Beverly Hills, CA: Sage.
Appendix Studies Providing Data 1. 2. 3. 4. 5. 6.
Bach, Lowery, & Moylan (1972) Beckett (1983) Bellack, Turner, Hersen, & Luber (1984) BooreamA Flowers (1972) Brown & Munford (1983) Carmichael (1976a) Carmichael(1976b) 7. Clark (1975) 8. Doty (1972) Doty (1975) 9. Eisler, Blanchard, Fitts, & Williams (1978) 10. Finch & Wallace (1977) 11. Giantonio(1976) 12. Outride, Goldstein, & Hunter (1973) Goldstein (1973) 13. Gutride, Goldstein, & Hunter (1974) Goldstein (1973) 14. Hogartyetal. (1986) 15. Hopkins (1985) 16. Jaffe& Carlson (1976) 17. Longin&Rooney(1973) Longin & Rooney (1975) 18. Lukoff(1981)
Liberman, Falloon, & Aitchison (1984) Liberman, Mueser, & Wallace (1986) Liberman, Wallace, Falloon, & Vaughn (1981) Lukoff, Wallace, Liberman, & Burke (1986) Wallace & Liberman (1985) 19. Machum(1976) 20. Manka(1979) 21. Mollick(1977) 22. Potelunas-Campbell(1982) 23. Rice (1983) 24. Shepherd (1978) 25. Spencer, Gillespie, & Ekisa (1983) 26. Troiano (1979) 27. Trudeau (1975) Note. Documents were grouped together as one study when they appeared to report data from the same experiment. The first document in each group was the primary one used in coding, with secondary documents following in alphabetical order.
Received July 25,1989 Revision received March 30,1990 Accepted April 16,1990 •
