CLINICAL HANDBOOK OF SCHIZOPHRENIA

244 IV. PSYCHOSOCIAL TREATMENTThe many studies that compare SST and treatment as usual are rarely described sufficientlyto determine whether group differences reflect clinically significant effects of SSTor poor results for the comparison groups. Other studies have developed new controltreatments for comparison purposes, but these also make comparisons difficult. Outcomecriteria have included symptoms, relapse, behavioral skill, and community functioning.Skills ratings have included diverse role-play tests, some of which closely parallel whatwas taught in treatment, and many of which have uncertain relationships to social rolefunctioning in the community. Until very recently, assessment of community outcomes reliedon patient self-report, with only a few studies securing reports from significant othersor other informants (e.g., work supervisors). No studies that we are aware of have conductedin vivo observations to determine the extent of generalization, which remains themost critical question for evaluating the effectiveness of SST. Subject populations haveranged from very impaired, long-term inpatients to acute inpatients, to stabilized outpatientsseen in a variety of clinical settings. Training content and duration also have variedconsiderably, and have occasionally combined SST with other interventions, includingcognitive rehabilitation, case management, family therapy, and pharmacotherapy. Medicationeffects have rarely been controlled or examined in combination with SST and frequentlyhave not even been described.Nevertheless, several trends emerge from the three decades of SST research. SST isclearly effective at increasing the use of specific behaviors (e.g., eye contact, asking questions,voice volume) and improving function in the specific domains that are the primaryfocus of the treatment (e.g., conversational skill, ability to perform on a job interview).SST techniques have also become a standard component of interventions for a variety ofbehavioral problems in which social skill is a component, such as teaching substanceabusers how to refuse drugs, and teaching people at risk for HIV how to negotiate forsafe sex. The specific contribution of skills training in these approaches has generally notbeen experimentally teased out, but it is widely assumed to be effective when the treatmentpackage has proven to be successful. However, the one critical question that has notbeen clearly answered either in specific SST programs or when SST is bundled into othertreatments is the extent to which learning in the clinic translates into either specific behavioralchanges or generally improved role functioning in the community.A survey of the SST literature identified eight narrative reviews and four meta-analysespublished in peer-reviewed (English language) journals since 1990, including four articlespublished since 2000 (Bellack, 2004). Each review employed different inclusion criteria,and covered from five to 68 articles. Only one meta-analysis (Pilling et al., 2002),which had several methodological limitations (e.g., covered a small number of studies,did not adjust for study quality or sample size), concluded that SST was not substantiallyeffective. The other reviews led us to the following conclusions regarding the empiricalsupport for SST interventions: First, SST is not substantially effective for reducing symptomsor preventing relapse. This finding is not surprising given that SST does not directlytarget either of these domains. SST would only be expected to affect symptoms or relapserates to the extent that it teaches skills that help to reduce social failure that would otherwisecause sufficient stress to exacerbate symptoms. This diathesis–stress model dependson several mediating factors that are themselves unproven (e.g., that social failure producessufficient stress to precipitate relapse). Second, SST has a reliable and significanteffect on behavioral skills that can be maintained for up to 2 years. Third, SST has a positiveimpact on social role functioning, although the findings for this outcome domain arenot entirely consistent. The results are better for defined skills areas (e.g., medicationmanagement, HIV prevention skills, work-related social skills) than for more generalmeasures of social functioning. Fourth, SST appears to have a positive effect on patientsatisfaction and self-efficacy: Patients feel more self-confident in (targeted) social situa-