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LIFE SKILL TRAINING: PSYCHOEDUCATIONAL TRAINING AS

MENTAL HEALTH TREATMENT
HAROLD J. MAY GEORGE M. GAZDA
Easi Carolina Universiiy School of Medicine University of Georgia
MILDRED POWELL GREGG HAUSER
Veterans Adminisiraiion Medical Cenier Veterans Adminisiraiion Medical Cenier

Fifty-four patients of a Veterans Administration Medical Center were

assigned to either a life-skill training program that emphasized psy-
choeducational instruction and skill building or to a group counseling con-
trol condition. Subjects assigned to life-skill training were provided with 28
hours of instruction in interpersonal communication, purpose in life problem
solving, and physical fitness/health maintenance. Control subjects received
equal time engaged in psychiatric treatment that emphasized the analysis
and exploration of personal problems, but with no direct coping skill train-
ing. Significant differences between the two groups were found on measures
of interpersonal communication and meaningful purpose in life. Both groups
received lower staff ratings on psychopathological behavior and
demonstrated improvement on ratings of health and physical fitness upon
completion of treatment. Twelve- and 24-month follow-up data that include
rehospitalization rates are presented for each group.

The past 15 years have witnessed the emergence of the view that psychological prac-
titioners and counselors should consider educational training as a therapeutic modality.
Patterson (1967) was among the first to suggest educational training as therapeutic treat-
ment and to advocate the efficacy of an increasingly explicit teacher role for the therapist.
Subsequently, psychoeducational programs have been based on the premise that any
effective treatment must be focused rapidly and efficiently on assisting the individual to
develop or to improve specific life skills (Authier, Gustafson, Guerney, & Kasdorf, 1975;
Gazda & Brooks, 1980). Fundamental to this approach is the identification of coping
skills and therapeutic strategies for increasing these skills in persons with psychological
or emotional difficulties.

The authors express appreciation to the professional staff of the Departments of Nursing, Chaplaincy,
Psychiatry, Psychology, Rehabilitation Medicine, Social Work and Dietetics of the Veterans Administration
Medical Center, Augusta, Georgia, for their support and contribution to this study.
Reprint requests should be addressed to Harold J. May, Department of Family Medicine, East Carolina
University School of Medicine, P.O. Box 1846, Greenville, North Carolina 27834.
360 Journal of Clinical Psychology, May 1985, Vol. 41, N o . 3

Gazda and Powell (198 1) state that any effective therapy or intervention performed
with dysfunctional individuals has as its ultimate goal to assist them to develop or to im-
prove their life coping skills. The more direct the intervention strategy, the more effective
and efficient it is likely to be. In an evaluation of a treatment program in a community
mental health center, Brown (1980) compared psychoeducational training based on self-
regulatory skills to a group-counseling condition. Patients who were receiving skill train-
ing rated themselves lower on measures of anxiety and fearfulness and higher on indices
of assertiveness than the control group immediately after treatment and at 3-month
follow-up. Furthermore, fewer skill training participants were hospitalized within 1 year
after participation than were control subjects. Bogdanow (1977) also found that when
major attention was given to increasing patients’ coping skills, the probability of relapse
and rehospitalization was decreased.
Although intervention strategies focused on the acquisition of coping skills are
generally shorter-term and more goal-directed than traditional therapeutic approaches,
target skills to be acquired have varied widely. Examples of coping behaviors included in
psychoeducational training are: Anxiety management (Suinn & Richardson, 1971),
assertion (Alberti & Emmons, 1974), personal effectiveness (Liberman, King, DeRisi, &
McCann, 1975), and interpersonal communication (Powell & Clayton, 1980). In propos-
ing a general theoretical position for psychoeducational training, Gazda (198 1) suggests
that these generic life skills may be categorized according to the various areas of human
development (psychosocial, moral, physical-sexual, cognitive ego, emotional, and
vocational).
Although psychoeducational training has focused largely on emotional and psy-
chosocial life skills, research that has related physical fitness to behavioral variables such
as improved mood, self-concept and anxiety suggests the psychological benefits of fitness
training (Folkins & Sim, 1981; Morgan & Horstman, 1976). Improvements in car-
diovascular functioning after physical training, for example, have been associated with
reports of an increased sense of well-being (Buffone, 1980) and with more effective
management of emotional stress (Chapman & Mitchell, 1965).
The present study was designed to investigate the effectiveness of a comprehensive
program of life skill training (cf. Gazda, 1981) based on a psychoeducational model with
a sample of hospitalized psychiatric patients. Specifically, three skill training areas were
included: (1) interpersonal communication; (2) purpose in life problem solving; and (3)
physical fitness. These coping skill components correspond to the psychosocial, moral,
and physical areas of human development, respectively. The experimental program was
compared to a verbal counseling intervention that emphasized the analysis and discus-
sion of personal concerns. Only the participants in the psychoeducational program
received direct skills training.

METHOD
Subjects
Subjects included 54 male psychiatric patients of a Veterans Administration
Medical Center in the southeastern United States. Subjects were drawn from two treat-
ment wards in one residential building of the hospital. Participation in the study was on a
voluntary basis, and subjects were given the right to refuse any aspects of treatment.
Twenty-eight subjects volunteered and completed life skill training. They ranged in
age from 20 to 59 years (M = 37.67, S D = 11.02) and completed 12.33 years of educa-
tion (SD = 1.42). The majority were Caucasian (N = 21); previous psychiatric
hospitalizations ranged from 0 to 20 admissions (M = 3.52, SD = 4.85). Distribution of
psychiatric diagnoses for subjects who were participating in life skill training fell into the
following categories: Depression (N = lo), Schizophrenia, chronic undifferentiated type
(N = 5), Personality disorder (N = 5 ) , Anxiety disorder (N = 3), Schizophrenia, other
types (N = 2), Schizoaffective disorder (N = l), Paranoia (N = 1).
 Life Skill Training 36 I

Twenty-six subjects participated in psychiatric treatment without direct skills train-

ing. Age range was from 25 to 64 years (M = 44.42, S D = 9.55) with average
educational level of 10.08 years (SD = 4.15). Prior hospitalizations ranged from 0 to 35
admissions (M = 6.42, S D = 7.36); again, the majority of patients was Caucasian (N =
17). The distribution of psychiatric diagnoses for these subjects was as follows:
Schizophrenia, chronic undifferentiated type (N = 10); Depression (N = 8); Personality
disorder ( N = 4); Schizoaffectivedisorder (N = 2); Manic-depressive disorder (N = 1);
Alcohol abuse (N = 1).
Dependent Variables
The following measures were selected to provide an index of patient status in each
developmental area: (a) interpersonal communication: Global Scale (GS; Gazda,
Walters, & Childers, 1975); (b) purpose in life: Purpose in Life Scale (PIL; Crumbaugh
& Maholick, 1964); (c) physical fitness: Blood pressure, resting heart rate (pulse) and
forced vital capacity of lungs (respiratory capacity of lungs measured in cubic cen-
timeters). In addition to these measures, direct observation of all subjects via (d) the
Nurses Observation Scale for Inpatient Evaluation (NOSIE-30; Honigfeld, Gillis, &
Klett, 1966) was made to evaluate levels of psychopathological behavior on the ward; and
subjects completed (e) a semantic differential rating scale, designed by the authors, to
assess patient satisfaction after treatment.
Procedure
During hospital admission, informed consent statements were obtained from all
subjects prior to educational training or psychiatric treatment. Patients in significant dis-
tress (i.e., floridly psychotic, assaultive, active or acute physical or medical contrain-
dications) were screened from the study by their attending physician. All participants
continued to engage in their hospital regimen of physical, medical and/or pharmacologic
treatment in addition to voluntary participation in the study.
Experimental subjects received Life Skill Training (LST) during the first 2 weeks of
the month, while the treatment control participants received the verbal counseling condi-
tion during the latter 2 weeks of the month. This order of treatment sequencing during
the month was selected randomly prior to the onset of the study. Despite the lack of con-
current treatment conditions, all participants received either psychoeducational training
or verbal counseling during the initial 2 weeks of their hospital admission in order to en-
sure standardization of the timing of treatment.
The Global Scale (GS) and Purpose In Life Scale (PIL) were administered during
the initial week of hospitalization. In addition, physical fitness measures (blood pressure,
heart rate and forced vital capacity) were obtained during the admission physical ex-
amination. GS ratings were made during a fixed-role standardized interview (cf.
Carkhuff, 1969), in which subjects participated in a 3- to 5-minute videotaped role-play
before and after their respective treatment programs. The fixed-role, played by a staff
member trained in the use of standardized exercises, was that of a “fellow patient” who
has just entered the hospital because of his failure to adapt successfully in his home and
work environment. Each participant was instructed to “respond or talk as helpfully as
possible” to the helpee after each of the five brief statements made by the simulated
patient.
The GS was designed to embody elements of each of the core dimensions of effective
communication (empathy, respect, warmth, concreteness, genuineness, self-disclosure,
immediacy and confrontation) in each of its four operationally defined levels. The GS is a
4-point, Likert-type scale that incorporates midpoints that give the scale a 7-point
spread. Ratings of the videotaped fixed-role interviews were made by three trained raters,
who demonstrated an interrater reliability of .93. Videotaped interviews were presented
randomly, and raters were blind to the experimental or treatment control designation of
the subjects.
362 Journal of Clinical Psychology, May 1985, Vol. 41. No. 3

Assessments of ward behavior of subjects, via the NOSIE-30, also were made both
pre- and posttreatment. Two trained raters made independent behavioral observations
on each subject. An interrater reliability of .99 was obtained on the nurse-rater obser-
vations.
Fifteen bipolar adjectives that related to perceived satisfaction with hospital treat-
ment were included in the semantic differential scale. The bipolar adjective pairs were
ordered randomly and randomly polarized in the scale. Test administration occurred
only during the posttreatment evaluation period.
Posttreatment evaluation of blood pressure, heart rate, and respiratory capacity
also occurred after the completion of patients’ respective intervention program.
Group Descriptions
Life skill training (LST). Three training modules were selected for inclusion in the
study: Interpersonal communication, purpose in life problem solving, and physical
fitness/health maintenance. Training in each module occurred concurrently during the 2-
week period of programmed treatment.
Interpersonal communication is designed to teach group members attending, listen-
ing and responding skills. Via role play, videotape recording and group demonstration,
subjects learn the communication skills of appropriate attending behavior (verbal and
nonverbal), responding to content and feelings, and responding in a facilitative manner to
others. The human relations model of Gazda et al. (1975) served as the format for skills
training. Groups met four times per week for 1Y2 hours.
Subjects in the purpose in life training group were taught problem solving skills that
focused on the behavioral dimensions of anxiety, loneliness, grief, loss of self-worth, and
depression (Fabry, 1981; Frankl, 1974). The training model of Crumbaugh (1971, 1972)
served as a foundation of this group. Six 1-hour sessions were conducted in which sub-
jects developed behavioral and cognitive strategies for each problem area previously
defined.
Training in physical fitness and health maintenance was designed to enable group
members to develop knowledge and skills of nutrition and weight control and to perform
proper exercise. Subjects received 10 hours of instruction in nutrition and diet selection,
monitoring eating patterns and vital signs; an exercise program that involved the use of
major muscle groups was initiated for each participant.
Psychiatric treatment control group. Subjects in this group received daily group
counseling and occupational therapy and participated in ward meetings relating to group
interaction. Foci of intervention were on the analysis and exploration of individual
problems and the resolution of personal conflicts. No direct skills training via group
sessions was provided nor were subjects given a skill-building rationale of treatment.
However, after completion of the study, it was discovered that several TC subjects sought
and received some training in physical fitness and health maintenance on an individual
basis.
RESULTS
Table 1 presents the means and standard deviations of pre- and posttest scores on
the dependent measures for Life Skill Training (LST) and treatment control (TC)
groups. The first major analysis compared the scores of LST and TC subjects on six of
the outcome measures used in the study. Because LST subjects were found to be younger,
better educated, and had fewer hospital admissions, analysis of covariance statistical
procedure was selected to adjust for possible pretreatment sampling differences between
the two subject groups.
After treatment intervention, significant differences between the two groups were
evident on the GS and PIL ratings. Subjects who received LST obtained significantly
 Life Skill Training 363

Table I
Means and Standard Deviations of the Pre- and Posttreatment Scores on the Dependent
Measures for Experimental and Control Groups

Pretreatment Posttreatment
Index Group N. M SD M SD
GS LST (26) 1.45 .26 2.10 .42
TC (26) 1.47 .2 I I .48 .21
PIL LST (22) 78.41 28.01 99.86 22.23
TC (22) 92.32 19.34 93.68 20.94
BPb LST (20) 126.60 11.55 123.70 7.35
TC (20) 126.45 7.69 124.55 6.37
HR LST (19) 80.11 9.28 78.32 7.05
TC (19) 84.11 9.79 8 1.79 9.91
FVC LST (19) 42.26 7.84 43.58 1.67
TC (19) 39.84 6.49 4 I .47 6.40
NOSIE LST (25) 50.24 4.14 46.86 7.58
TC (25) 51.36 7.92 46.96 7.99
Sm Dif LST (19) - - 83.60 18.04
TC (19) - - 73.75 16.61

.Number in parentheses indicates the number of patients who completed pre- and posttests.
blndicates systolic blood pressure.

higher levels of interpersonal communication skills than participants treated with no

direct skills training (F = 52.18, p <.001). Similarly, ratings of meaningful purpose in
life were significantly higher for LST subjects in comparison to TC subjects (F = 7.1612,
p <.025). The GS and PIL pretests were used as covariates for the ANCOVA. The data
for subjects' physical fitness revealed no significant differences after treatment between
Table 2
Correlated t-tests for Signipcan t Diferences on Pre- to
Posttest Ratings for Experimental and Control Groups

Measure Group t

Global Scale LST 7.62***

TC .25
PIL test LST 4.34**
TC .54
Blood pressure LST - 1.90
TC -2.51*
Heart rate LST - I .92
TC -2.67.
Vital capacity LST 2.09*
TC 5.83."
NOSIE-30 LST -3.12**
TC -3.12'.
~~

*p <.05. **p <.01. ***p <.001.

364 Journal of Clinical Psychology, May 1985, Vol. 41, No. 3

LST and TC group members on measures of blood pressures, heart rate, or forced vital
capacity. Furthermore, no significant differences were found between groups on staff
observation of subject ward behavior or symptoms.
In order to evaluate intragroup changes from pre- to posttreatment, further
statistical analyses were performed. Intragroup differences were evaluated by use of the
correlated t statistic, and results of these analyses are presented in Table 2. This table
reveals several areas of improvement for both LST and TC subjects.
Subjects who received LST demonstrated significant pre-post gains in interpersonal
communication ( 2 = 7.62, p <.001), meaningful purpose in life ( t = 4.34, p <.01), and
forced vital capacity ( t = 2.09, p <.05); a significant decrease in psychopathological
behavior also was reported ( t = 3 . 1 2 , ~<.01). Although results failed to reach a signifi-
cant level of difference, a trend toward improvement on pre-post evaluation of blood
pressure ( t = 1 . 9 0 , ~<.lo) and heart rate ( t = - 1 . 9 2 , ~<.lo) was noted for LST sub-
jects. In addition, despite no demonstrated differences between groups on satisfaction
with treatment, a trend in favor of LST subjects was observed after completion of train-
ing.

Table 3
Follow-up Data on LST and TC Subjects

LST TC
~~

Rehospitalization
12 months 6 7
24 months 29 29
Employment (at 24 months)
Employed 22% 21%
Unemployed 78% 79%
Exercise pattern (at 24 months)
Little or none 22% 21%
Occasional 56% 50%
Regular (> 3 times/wk) 22% 29%
Exercise and diet plan maintained? (at 24 months)
Yes 56% 14%
No 44% 86%
Satisfied with treatment? (at 24 months)
No 0% 0%
Slightly 22% 0%
Moderately 33% 21%
Very 45% 79%
Current Method Health Treatment
Yes 89% 64%
No 11% 36%
Frequency
Weekly 0% 22%
Monthly 74% 77%
> Monthly 26% I I%
Medication 89% 43%
 Lge Skill Training 365

TC participants also obtained improved pre- to posttest ratings on several measures.

Results presented in Table 2 indicate significant improvement in forced vital capacity (t
= 5.83, p <.001) and significant decreases in blood pressure ( t = 2 . 5 1 , ~
<.05), heart rate
( t = -2.67, p <.05), and psychopathology ( t = -3.12, p <.01). Findings of this study
suggest that while subjects who received psychoeducational training broadened their
repertoire of coping skills, both groups benefitted from intensive hospital treatment.
Follow-~pStudy
In order to investigate the longitudinal nature of the treatment effects, follow-up
data were obtained from participants in both the LST and TC groups. Because the
hospital in which this study was conducted serves as a regional treatment institution, the
geographic distribution of subjects posthospitalization prevented in-depth personal inter-
viewing. However, data on 12- and 24-month rehospitalization rates were obtainable for
all study subjects. In addition, a brief questionnaire that pertained to employment, daily
living activities, health and exercise, treatment satisfaction, and current mental health
care was mailed to subjects 24 months after discharge.
Of the 54 subjects who participated in this study, follow-up questionnaires were
mailed to 44 subjects for whom a mailing address was known. Ten subjects had no known
deliverable address. Of the 44 questionnaires mailed, 23 were returned for a response rate
of 52%. This response rate reflected 32% of the original LST group and 54% of the TC
group.
Table 3 presents the follow-up data on both LST and TC subjects for rehospitaliza-
tion rates and other questionnaire information. Table 3 reveals that rehospitalization
rates for both LST and TC groups were virtually identical, with 6 LST subjects and 7 TC
subjects readmitted for further treatment during the first year after hospitalization. Both
groups had a total of 29 readmissions during the 2 years after initial treatment. Employ-
ment rates for both groups were highly similar at 2-year follow-up, with almost 80% of
each group unemployed or disabled. The majority of subjects reported at least some oc-
casional exercise during the week; 86% of the LST subjects indicated that they had main-
tained the diet and exercise patterns begun during hospitalization. Both groups appeared
satisfied with treatment received during their hospital admission; 78% of LST subjects
were at least moderately satisfied, while nearly 80% of TC subjects were very satisfied.
However, it is also apparent that most subjects in this study have required continued
mental health care as outpatients at least on a monthly basis.
DISCUSSION
This study investigated the effectiveness and efficiency of psychoeducational training
as mental health treatment. Findings suggest that a treatment regimen of skill-based
training results in increased acquisition of life-coping skills and that these therapeutic
gains may be achieved over a relatively short period of treatment.
Subjects in the LST program obtained significantly higher ratings in interpersonal
communication skills than did the TC participants. These findings are consistent with
previous studies (Powell & Clayton, 1980; Vitalo, 1971) that have reported that
systematic training in human relations skills results in improved levels of interpersonal
communication for psychiatric patients. It is apparent that hospitalized psychiatric
patients are fully capable of improving communication skills by means of a direct,
systematic training program.
Participation in skill-based training also resulted in increased ratings of expressed
purpose in life for subjects in the LST group, yet treatment control subjects failed to alter
their scores from pretest levels. Because psychiatric patients frequently obtain low
ratings of meaningful purpose in life (Crumbaugh, 1972), results of this study suggest
that significant improvement in perceived purpose in life can be achieved through short-
term, skill-based problem solving.
366 Journal of Clinical Psychology, M a y 1985, Vol. 41, No. 3

Study findings in the area of physical fitness and health maintenance are more
equivocal than results of training in communication skills or purpose in life problem solv-
ing. LST participants improved their physical fitness, as reflected in increased
respiratory capacity, while TC subjects improved respiratory functioning and decreased
blood pressure and heart rate. These results are especially encouraging given the
relatively brief, 2-week duration of treatment. Although the LST group engaged in a
daily exercise program to improve physical conditioning and muscle tone and were in-
structed in vital sign monitoring, it is possible that the unstructured activities of recrea-
tion for the TC subjects may have approximated the planned exercise regimen of LST.
Also, the discovery that subjects in the TC group had requested and received instruction
in physical fitness and health maintenance on an individual basis suggests that
experimental-control group differences would be minimal. Finally, the dietary restric-
tions of a controlled hospital environment may have equalized gains for both groups.
This study has indicated that hospitalized subjects can improve their physical fitness
as measured by several physiologic indices. The issue of generalizability and continuation
of fitness levels, however, remains to be addressed by future research. Further
longitudinal studies are necessary to assess whether the motivational aspects of LST (i.e.,
education in exercise patterns, nutrition and diet selection, monitoring of eating patterns)
can facilitate continued improvement in fitness and health maintenance. It also may be
useful to appraise an individual’s attitudinal change toward exercise and fitness subse-
quent to a skill-based training approach, thereby broadening the base of outcome
measures to include both physiologic as well as psychologic variables.
Although pre- to posttreatment ratings by ward staff indicated significant decreases
in observed behavior pathology for both groups, results in favor of the LST group were
only mildly apparent. However, findings of the study provide further evidence that symp-
tomatic change may occur after brief, time-limited treatment. This result supports the
previous research of Glick, Hargreaves, Drues, Showstack, and Katzow (1977), which
found no reliable outcome differences between short-term and long-term hospitalization.
Limitations imposed by experimentally non-controlled variables, such as psy-
chopharmacologic treatment, should be recognized in interpreting the results of this
study. Despite attempts to equalize the amount of time spent in treatment for each
group, the effects of chemotherapy on subject improvement may hamper generalization
of outcome results.
Unfortunately, available follow-up data on rehospitalization rates, employment,
self-reported diet/exercise patterns, and patient satisfaction suggest that neither skill-
based training intervention nor traditional insight-oriented therapy emerged as superior
to the other on these measures. The limited number of subjects who were able to be con-
tacted on follow-up (32% of LST; 54% of TC) brings into question the representativeness
of this sample in comparison to the original study population. However, because
rehospitalization rates at 12 and 24 months were available for all of the original subjects,
these measures could be viewed as more useful for longitudinal comparison. Inspection
of these hospitalization rates reveals a pattern that is virtually identical between the two
groups at both review dates. Based on the available data, it remains to be determined
whether the acquisition of coping skills will become a valid and reliable predictor of im-
proved psychological adjustment for chronic psychiatric patients. However, at the pre-
sent time it appears that non-traditional, skill-based training was unable to alter
rehospitalization rates for these patients during the 2 years posttreatment.
In an age of growing cost accountability, the economic impact of short-term, skill-
based training in mental health facilities should be explored. Because the psy-
choeducational model of LST may result in rapid skill acquisition and decreased
behavior pathology in participants, the cost-benefits of this treatment regimen should be
addressed in follow-up studies. The economic advantage of shorter hospitalizations when
skill-based training is employed may become more apparent, particularly if further
research and evaluation support the efficacy of short-term psychoeducational training.
 Life Skill Training 367

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