IMPACTS OF SOCIAL SKILLS AND SOCIAL SKILLS TRAINING 1

Evaluating the Effectiveness of Social Skills Training on Social Skills and the Impacts of

Social Skills on Housing Retention in Persons with Mental Illness

Katelyn Hennis and Erin Almony

Department of Occupational and Recreational Therapies, University of Utah

OC TH 6000: Research Methods of OT

Dr. Lorie Richards

May 4, 2020

Introduction
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The United States Department of Housing and Urban Development defines homelessness

as a person who “lacks a fixed, regular, and adequate nighttime residence” (“The State of

Homelessness”, 2019). With 552,830 people experiencing homelessness during 2018 in the

United States, the country faces a major economic challenge. Specifically, the cost in public

funds to maintain the chronically homeless population in this country is $10.95 billion. (“Cutting

the Cost of Homelessness”, 2013). While the average cost for a taxpayer is $30,000 - $50,000

per year, which covers the use of hospitals, jails, shelters, and detox programs (“Ending Chronic

Homelessness”, n.d.).

In addition to cost, homelessness is a societal issue that impacts various important aspects

of life. According to Roy et al. (2017), homelessness is related to a decreased life expectancy,

mental health issues, physical health issues, substance abuse, increased rates in the criminal

justice system, and impaired functioning. To highlight one of the related factors; mental illness

besets the homeless population with 45% of homeless people having some type of mental health

issue ("Homelessness and Mental Illness”, 2020). According to Gabrielian et al. (2017), mental

illness has been shown to lead to complications in housing retention, while also impairing ability

to complete household tasks and sustain positive relationships. In addition there are higher

reports of eviction and conflicts between tenants and landlords among the mentally ill population

(Gabrielian et al., 2019).

People who have both a mental illness and are living in homelessness lack resources and

access to services that could improve their ability to maintain housing. Resources such as

occupational therapy services are among many, which the homeless population is less likely to

receive. This is unfortunate given occupational therapists can be beneficial in reducing substance

abuse through occupational engagement, increasing housing retention through community skills,
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and implementing psychosocial treatment, which includes social skills training (Roy et al.,

2017).

Psychosocial treatments typically consist of various activities designed to help

participants learn interpersonal and independent living skills, including social skills. By taking a

behavioral therapy approach, social skills training typically uses problem identification, goal

setting, role play, corrective feedback, behavioral practice, positive social reinforcement, and

problem solving to teach and reinforce social skills. This type of training focuses on people with

mental disorders to help improve their level of function while interacting with their community

(Kopelowicz, 2006). Overall, the training reinforces how to communicate emotions and ask for

assistance effectively, which will influence goal achievement, relationship building, and trait

attainment for independent living (Kopelowicz, 2006). While these are the goals of socials skills

training we do not know if it is effective at increasing social skills; we also do not know if the

lack of social skills impedes on housing retention. The purpose of this systematic review is to

examine if social skills training is an effective method in improving social skills. Additionally, it

will examine if a lack of social skills factors into housing retention for people with mental

illness.

Methods

This systematic review was conducted using the PubMed and PsychInfo databases. These

databases were searched using the key terms “social skills”, “homeless”, and “housing retention”

with their combinations “mental disorders, mental, mentally, psychiatric, disorder, disorders, ill,

illness, psychosocial, intervention, training, housing, assisted living, and homelessness”. The

searches generated by the two databases were uploaded into EndNote. The initial search

generated 205 articles, with an additional 2 articles pulled from other sources. Duplicates were
IMPACTS OF SOCIAL SKILLS AND SOCIAL SKILLS TRAINING 4

screened using EndNote. After duplicates were removed there were a total of 184 articles.

Following screening of titles and abstracts, 158 articles were excluded. The remaining 26 full-

text articles were then assessed. Articles were screened based on the exclusion and inclusion

criteria.

The exclusion criteria included participants under 21 years of age, articles before 2004,

no diagnoses of mental illness in the population studied, not in English, and articles that did not

address either social skills training or housing retention. The inclusion criteria included

interventions that involved social skills training, outcomes that involved housing retention,

articles written in English, interventions involving adults (age 21 and up), clinical trials that

incorporated social skills training and housing retention, and articles between the years 2004-

2020. Articles that did not meet the inclusion criteria were removed: articles not addressing

housing or people who are experiencing homelessness; broad systematic reviews, not specifically

looking at social skills training or homelessness; social interventions in the context of family and

friends rather than social skills.

A thorough evaluation of eligibility was completed, and the end result was 4 articles for

the data analysis. An additional 3 articles were used as supplementary information. Levels of

evidence of the 4 articles were determined using the Oxford 2011 Levels of Evidence table. Data

was obtained by each author individually from the studies. Data was compared and agreed upon

then entered into the evidence table (Table 1). The bias of the studies were assessed using the

PEDro scale. (Table 2).

Table 1
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Evidence Table
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IMPACTS OF SOCIAL SKILLS AND SOCIAL SKILLS TRAINING 7
IMPACTS OF SOCIAL SKILLS AND SOCIAL SKILLS TRAINING 8
IMPACTS OF SOCIAL SKILLS AND SOCIAL SKILLS TRAINING 9
IMPACTS OF SOCIAL SKILLS AND SOCIAL SKILLS TRAINING 10
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Results

The initial search resulted in 205 articles with an additional 2 from other sources, from

the initial search 7 articles were chosen based on our inclusion and exclusion criteria and 4 of

those articles were selected for data analysis. The studies for data analysis consisted of a pilot

comparison study, a single-blinded randomized controlled clinical trial, a non-experimental

comparative study, and a participatory action research study (PAR). Of the 4 articles, 2 involve

interventions containing social skills training and 2 different articles narrow down the factors

affecting housing retention. The 4 articles selected for review all vary in quality, which is

represented by the potential bias chart, based on the PEDro scale, seen in Table 2. Additionally,

Figure 1 presents the PRISMA diagram.

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The bias table (Table 2) displays the risk of bias found among the 4 reviewed studies and

suggests that a majority of the studies reflect either a high risk of bias or their level of bias was

uncertain. The observations regarding the levels of evidence and the risk of bias suggest a low

level of reliability, which was taken into consideration during the data interpretation.

Interventions Containing Social Skills Training

In two of the five studies reviewed, social skills training was implemented as part of the

intervention being tested. Although one study was a controlled pilot study and one was a

randomized controlled trial, they both compared the interventions incorporating social skills

training to a control group. Despite this similarity between the two studies they lacked other

commonalities and were conducted using differing methods. Bertelsen et al. (2008), was a single

blinded randomized controlled trial, which examined the long-term impacts of an intensive early

intervention program on 547 patients (ages 18-47) during first episode psychosis (schizophrenia

spectrum). The study was conducted over a 2 year span and compared the early intervention

treatment to a standard treatment group. The early intervention treatment involved three main

components; coping skills, medication management, and stress reduction, which were explored

using assertive community treatment (ACT), including family involvement and social skills

training. Bartels et al. (2004) differed in that it examined the impacts of an enhanced skills

training combined with a health management intervention on independent living skills, social

skills, and management of health care needs in people diagnosed with serious mental illness on

clinical outcomes through a controlled pilot study with a 2-year follow up. Through convenience

sampling the researchers assigned 12 people to an intervention group receiving both skills

training and health management and 12 people to a control group receiving solely health

management (Bartels et al., 2004).

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The two articles provide contrasting results. Bartels et al. (2004) found its intervention to

have a positive impact on social functioning and health functioning in comparison to the control

group. In contrast, Bertelsen et al. (2008) disproved the hypothesis that the intensive early

intervention group would have a better clinical outcome, meaning a positive effect on the course

of illness.. The data also showed that the intensive early intervention group had more participants

living independently than the control group.

Factors Affecting Housing Retention

Two of the four articles reviewed evaluated factors affecting housing retention among

veterans in Los Angeles who have experienced homelessness. Both studies relied heavily on

interviews as a means of data collection. They also collected information through electronic

health records, literature reviews, and focus groups. Although data collection was similar

between the two studies the focus on what information to collect differed between the two.

Gabrielian et al. (2019) was focused on identifying social skills that are important for both

housing retention and housing attainment for people with mental illness experiencing

homelessness. Gabrielian et al. (2017) more generally examined the variables impacting housing

retention for homeless veterans and found intrinsic motivation to be the main enabling factor. In

addition they found mental health and independent living management to also play a major role

in housing retention. Furthermore, it was found that a lack of social skills was often linked to

loss of housing due to interpersonal problems, such as assault of a landlord, following an

argument. Mental health was a variable that was strongly related to being unable to retain

housing; those participants with mental health problems were more likely to have lost housing

while those that did maintain housing displayed a better ability to communicate with the staff

(social skills).
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Table 2

PEDro Risk of Bias Table

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Figure 1

Prisma Flow Diagram

Discussion

The literature lacks evidence to confidently claim that social skills can positively impact

housing retention for people with mental illness. This is due to an extreme scarcity of research

pertaining to this population. None of the studies looked at social skills on its own, or its direct

relationship to housing retention. There is also a lack of data on mental illness and housing

retention. Stakeholders and key informants have determined that poor social skills are related to

issues in housing retention (Gabrielian, 2019). There is a need for further research and
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implementation of interventions with social skills for people who are homeless and have a

mental illness.

From a clinical standpoint, this systematic review supports that people with mental illness

are at a higher risk for losing their supported housing after having been previously homeless.

Mental health and independent living management influence housing retention (Gabrielian et al.,

2017). Mental health was a variable that was strongly related to people who were not successful

in supportive housing (Gabrielian et al., 2017). Persons who were able to retain their supportive

housing showed an enhanced ability to communicate with people in their supportive housing

community. Interpersonal problems due to lack of social skills was associated with housing loss

(Gabrielian et al., 2019).

The studies that implemented social skills training had conflicting outcomes, and

therefore we cannot claim that social skills training is effective for increasing social skills.

However, social skills training found significant improvement in social functioning and health

functioning (Bartels et al., 2004). Following enhanced skills training combined with health

management intervention, Bartels et al. (2004) found improved social behaviors and decreased

inappropriate behaviors. The enhanced skills training group showed significant improvement in

personal appearance care and in social functioning (Bartels et al., 2004). Furthermore, Bertelsen

et al. (2008) found more participants living independently after early intervention following

psychosis, that incorporated social skills training, than the control group. The competence that

social skills provides can be transferable to the skills needed for housing retention.

The studies used in our systematic review present limitations. Bertelsen et al., (2008) had

a follow-up rate of only 57%. Bartels et al. (2004) was the only study that included baseline

similarities in participants. Bertelsen et al. (2008) was the only study that had random allocation
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and concealed allocation, as well as, blinding of participants and assessors. All but one of the

quantitative analysis studies had key measurement outcomes from more than 85% of

participants. The sample demographic is also a limitation across some of the studies used in this

systematic review. Bartels et al. (2004) had a lack of diversity in their sample which consisted of

only Caucasian participants age 60. Gabrielien et al. (2017) and Gabrielian et al. (2019) had only

participants who were veterans in the Los Angeles area, this creates limitations of generalizing

the data to the entire homeless population.

Social skills have been shown to have a positive effect on housing retention in people

with mental illness who are homeless; however, there needs to be more high level evidence

studies to provide further research on this topic. Occupational therapists should be aware of the

lack of high quality research for this population when addressing barriers to care and housing.

There is a need for further research to determine the effectiveness of social skills training on

social skills and the impact of social skills on housing retention for people with mental illness.
IMPACTS OF SOCIAL SKILLS AND SOCIAL SKILLS TRAINING 18

References

Bartels, S. J., Forester, B., Mueser, K. T., Miles, K. M., Dums, A. R., Pratt, S. I., . . . Perkins, L.

(2004). Enhanced skills training and health care management for older persons with

severe mental illness. Community Mental Health Journal, 40(1), 75–90. doi:

10.1023/b:comh.0000015219.29172.64

Bertelsen, M., Jeppesen, P., Petersen, L., Thorup, A., Ohlenschlaeger, J., Le Quach, P., …

Nordentoft, M. (2008). Five-year follow-up of a randomized multicenter trial of intensive

early intervention vs standard treatment for patients with a first episode of psychotic

illness. Arch Psychiatry, 65(7), 762-771. doi: 10.1001/archpsych.65.7.762

Cutting The Cost Of Homelessness In U.S. (2013, June 19). Retrieved from

https://www.forbes.com/2006/08/25/us-homeless-aid-

cx_np_0828oxford.html#1d8aaa36777e

Ending Chronic Homelessness in 2017 - U.S. Interagency ... (n.d.). Retrieved from

https://www.usich.gov/resources/uploads/asset_library/Ending_Chronic_Homelessness_i

n_2017.pdf

Gabrielian, S., Hamilton, A. B., Alexandrino, A., Hellemann, G., & Young, A. S. (2017).

‘They’re homeless in a home’: Retaining homeless-experienced consumers in supported

housing. Psychological Services, 14(2), 154-166. doi: 10.1037/ser0000119

Gabrielian, S., Hamilton, A. B., Gelberg, L., Hellemann, G., Koosis, E. R., Johnson, A., &

Young, A. S. (2019). A protocol to develop and study the effectiveness and

implementation of social skills training that improves supported housing retention for

persons with serious mental illness. Contemporary Clinical Trials Communications, 14.

doi: 10.1016/j.conctc.2019.100344
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Gabrielian, S., Hamilton, A. B., Gelberg, L., Koosis, E. R., Johnson, A., & Young, A. S. (2019).

Identifying social skills that support housing attainment and retention among homeless

persons with serious mental illness. Psychiatric Services, 70(5), 374-380. doi:

10.1176/appi.ps.201800508

Homelessness and Mental Illness: A Challenge to Our Society. (2020, February 3). Retrieved

from https://www.bbrfoundation.org/blog/homelessness-and-mental-illness-challenge-

our-society

Kopelowicz, A., Liberman, R. P., & Zarate, R. (2006). Recent advances in social skills training

for schizophrenia. Schizophrenia bulletin, 32 (Suppl 1), S12–S23.

https://doi.org/10.1093/schbul/sbl02

Roy, L., Vallee, C., Kirsh, B. H., Marshall, C. A., Marval, R., & Low, A. (2017). Occupational-

based practices and homelessness: A scoping review. Canadian Journal of Occupational

Therapy, 84(2), 98-110. doi: 10.1177/0008417416688709

The State of Homelessness in America - White House. (2019). Retrieved from

https://www.whitehouse.gov/wp-content/uploads/2019/09/The-State-of-Homelessness-in-

America.pdf