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Social Skills Training as Nursing Intervention to Improve the Social Skills and Self-Esteem of Inpatients with Chronic Schizophrenia
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Social Skills Training as Nursing Intervention to Improve the Social Skills and Self-Esteem of Inpatients with Chronic Schizophrenia Ji-Min Seo, Sukhee Ahn, Eun-Kyung Byun, and Chul-Kweon Kim The effects of social skills training on the social skills and self-esteem of 66 patients with chronic schizophrenia were evaluated using the basic training and problem-solving training models. The experimental group received 16 group training sessions, and the control group received routine nursing care. The training program consisted of two parts: conversational skills and assertiveness skills. Data were collected at pretreatment and posttreatment. The conversational, interpersonal relationship, and assertiveness skills, and self-esteem of the experimental group showed significant improvement, whereas problem-solving skills did not improve. The results indicate that training in social skills is effective for improving the social skills and selfesteem of inpatients with chronic schizophrenia. D 2007 Elsevier Inc. All rights reserved.
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ATIENTS WITH CHRONIC schizophrenia lack social skills. They cannot effectively converse with people, easily make friends, or effectively solve their problems. In addition, it is difficult for them to find and retain jobs, further isolating themselves from society (Bellack, Mueser, Gingerich, & Agresta, 1997). These poor social skills are closely related to repetitive recurrences of the disease and rehospitalizations, and have been reported as important factors affecting prognosis (Granholm et al., 2005). In addition, patients with chronic mental illnesses often have low self-esteem (Silverstone & Salsali, 2003), which impedes effective interpersonal relations and negatively affects their abilities to cope with stress and problems (Brekke, Levin, Wolkon, Sobel, & Slade, 1993). In schizophrenia, the lack of psychosocial functioning is related to low selfesteem (Brekke et al., 1993). Self-esteem is one of the most important factors in preventing recurrence and in ensuring long-term success in rehabilitation among patients with chronic schizophrenia (Anthony, 1993).
A social skills training program was developed to improve the social skills of patients with chronic schizophrenia and, ultimately, to help them successfully return to society (Liberman, 1988). This training has proven to be effective in improving social adaptability, reducing psychiatric symptoms and thus reducing rehospitalization rate (Benton & Schroeder, 1990), in addition to enhancing selfesteem (Liberman et al., 1998). Together with other mental health professionals, nurses have participated in social skills training to
From the College of Nursing, Pusan National University, Busan, Korea; School of Nursing, Chungnam National University Daejeon, Korea; Bukgu Mental Health Center, Busan, Korea; and College of Medicine, DongA University, Busan, Korea. Address reprint requests to Sukhee Ahn, School of Nursing, Chungnam National University, 6 Munhwa 1-dong, Daejeon, Korea. E-mail address: [email protected] n 2007 Elsevier Inc. All rights reserved. 0883-9417/1801-0005$30.00/0 doi: 10.1016/j.apnu.2006.09.005
Archives of Psychiatric Nursing, Vol. 21, No. 6 (December), 2007: pp 317–326
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facilitate the psychosocial rehabilitation of patients with chronic schizophrenia. However, nursing studies on social skills training for patients with schizophrenia are extremely limited. Accordingly, further research is needed to clarify the usefulness of social skills training as an efficient nursing intervention. The purpose of this study is to examine the effects of social skills training conducted by psychiatric staff nurses on the social skills and self-esteem of inpatients with chronic schizophrenia in South Korea. LITERATURE REVIEW
Social Skills Training Social skills training includes training in conversational, assertiveness, problem-solving, medication management, independent living, stress management, and vocational skills (Liberman et al., 1993). Major methods used to teach these skills include the basic training model, the problemsolving training model, and the attention-focused training model for cognitive remediation (Liberman, Massel, Mosk, & Wong, 1985). Recently, an integrated psychological therapy for patients with schizophrenia that integrates cognitive–behavioral therapy into the basic training and problem-solving training models has been developed and used (Brenner et al., 1994). The basic training model, based on social learning theory, has been the most widely used, serving as the foundation for all other social skills training models (Liberman, DeRisi, & Mueser, 1989). It has been found, however, that patients fail to efficiently apply the skills they acquire with this training to their daily lives (Brown & Munford, 1983). This has been proven to be related to the lack of problem-solving abilities of patients with chronic schizophrenia (Bellack, Morrison, & Mueser, 1989). In the process of finding ways to resolve such a problem, the problem-solving training model began to gain popularity, and it has since been studied worldwide (Bellack et al., 1989). This training method focuses on precisely identifying the situation, generating alternatives, selecting optimal options, and using the chosen option (Liberman et al., 1985). Preliminary studies have reported that patients who received training with this model were able to apply their newly acquired social skills in real-life situations and thus showed improvement in
their problem-solving abilities and social adaptability (Liberman, Eckman, & Marder, 2001). The problem, however, is that this model is not effective in patients with diminished cognitive function (Green, 1993). Researchers have tried the attention-focused training model for cognitive remediation (Corrigan, Hirschbeck, & Wolfe, 1995). Most studies have resulted in some positive results in terms of test tools but have failed to improve social skills and to maintain the effects (Bellack, Mueser, Morrison, Tierney, & Podell, 1990; Kern, Green, & Go1dstein, 1995). This can be attributed to the fact that attention can be improved but cognitive impairments in various domains that are characteristic of chronic schizophrenia cannot be improved (Kern et al., 1995). Recently, there has been increasing interest in an approach that improves the comprehensive cognitive dysfunction of schizophrenia. One such psychological rehabilitation therapy program is the integrated psychological therapy developed by Brenner et al. (1994). Integrated psychological therapy has been used for patients with schizophrenia in many countries, including Germany, Switzerland, Austria, Korea, Japan, and the United States (Brenner, Hodel, Genner, Roder, & Corrigan, 1992; Müller, Brenner, & Roder, 2003). Social Skills Training in South Korea With the establishment of the Mental Health Law in South Korea in 1995, emphasis was placed on psychosocial rehabilitation. Consequently, the demand for professional trainers in social skills, including the need for psychiatric nurses who can provide social skills training, has risen. To ensure the expanded roles of psychiatric nurses in accordance with the law, psychiatric nurses should pursue more active studies and acquire the abilities needed to provide social skills training, although nursing researches on this field are limited in South Korea. Studies that have been conducted on social skills training in South Korea have primarily used the basic training model (Chun, 1994; Yang & Kim, 1999). In the late 1990s, the problem-solving training model, the attention-focused training model, and integrated psychological therapy were used, but they fell short of being widely employed. According to Yang and Kim, the conversational, interpersonal relationship, and assertiveness skills
SOCIAL SKILLS TRAINING FOR CHRONIC SCHIZOPHRENIA
improved with the basic training model, but their study was limited in that the intervention effects were measured with self-reporting questionnaires. Chun also reported that problem-solving abilities improved by using the basic training model. Two studies applied the problem-solving training model and the attention-focused training model to improving social skills (An, Oh, Hyun, & Yoo, 1997; Suh, 1998). Using an intervention of integrated psychological therapy thrice a week for 3 months, Lee et al. (1998) observed significant improvement in psychopathology but could not find improvement in cognitive functions or problem-solving skills. Jung (2002), using the same interventions as Lee et al., found improvement in auditory attention, social adaptability, and problem-solving skills, and a 6-month follow-up test found that auditory attention and social adaptability were maintained but that problemsolving skills were not. In summary, the extant psychiatric nursing literature reveals a lack of various social skills training programs, short training periods, and a lack of objective effect measurement and follow-up investigations related to social skills training, and demonstrates the need for this study. Psychiatric nurses typically play a passive role in social skills training. They tend not to be directly engaged in such training but remain engaged in traditional nursing roles. This tendency may be related to an absence of nursing studies focusing on social skills training. Existing nursing studies focusing on social skills training incorporate only the basic training model, resulting in a significant gap between nursing studies and research in the social skills training of the other core psychiatric disciplines. This study had two primary aims. The first aim was to examine the effects of social skills training on the social skills and self-esteem of inpatients with chronic schizophrenia. The second aim was to add to the body of nursing research related to the usefulness of social skills training as a psychiatric nursing intervention. METHODS
A quasi-experimental design with a nonequivalent control group was used to examine the effects of the social skills training program on the social skills and self-esteem of patients with chronic schizophrenia.
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Subjects The study was conducted in a psychiatric hospital in South Korea. Inpatients who were diagnosed with schizophrenia based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition were asked to participate in this study if they had no evidence of organic brain disorder or alcohol/drug abuse. The psychiatric nurse who performed the intervention informed eligible subjects of this study and invited them to participate. Written consent for participation was obtained from all participants. Patients were allowed to choose whether they would be in the experimental group or in the control group. Each group had 37 subjects. Three subjects (8%) in the experimental group and five subjects (13%) in the control group were excluded because they were discharged. When the study had been completed, 34 subjects remained in the experimental group and 32 subjects remained in the control group. The average age was 38.21 years in the experimental group and 35.44 years in the control group. There were more male (38) subjects than female (28) subjects, and most of the subjects in both groups had at least a high school education, had never married, and had a history of employment. For work experience, 88% in the experimental group and 72% in the control group reported having had jobs, but only 6% in the control group reported retaining a job. According to illness characteristics, the average age of onset was 25 years, indicating that most patients developed the disease in their early adulthood. The average duration of illness was 12 years, ranging from 10 to 13 years, and the average total period of hospitalizations was 6 years, with a mean of 4.5 admissions (Table 2). Procedures The social skills training program was given as group treatment, and the experimental group was divided into four subgroups with 9–10 patients each. The subjects were trained via 60–70 minutes of a social skills training course twice a week for 8 weeks. The control group received routine nursing care treatment. The social skills training program was conducted by a trained psychiatric nurse and an assistant (a social worker) who were not staff members of the subjects' ward. The psychiatric nurse who conducted the social skills training has a doctoral degree in psychiatric nursing
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and has been engaged in the education and social skills training of patients with chronic mental disorders for N 10 years. Three education sessions were held to discuss the training method and content with the psychiatric nurse before the social skills training began. The social skills training program was based on the modules developed by Bellack et al. (1997) and Liberman et al. (1989). The training program was divided into two parts: conversational skills and assertiveness skills. The conversational skills train-
Table 1. Social Skills Training Program Session
Contents
1
Program orientation
2 3 4
Nonverbal behavior Verbal behavior Contents of conversation
5 6
7
8 9
10 11
12 13
14 15
16
Assertive behavior
Pretest Providing information about social skills training Eye contact, facial expression Posture, proximics, kinesics Voice volume, speech rate, pitch, intonation Starting conversations Listening to others Maintaining conversations by asking questions Maintaining conversations by giving factual information Maintaining conversations by expressing feelings Staying on the topic set by another person What to do when someone goes off the topic Ending conversations Getting your point across Providing information about assertive skills training Making requests Refusing requests Making complaints Responding to complaints Expressing unpleasant feelings Expressing angry feelings Expressing positive feelings Giving compliments Accepting compliments Making apologies Letting someone know that you are afraid Asking for information Refusing alcohol or tobacco Compromising and negotiating Disagreeing with another's opinion without arguing Responding to untrue accusations Posttest
ing included both verbal and nonverbal communication skills. The assertiveness skills training included expressing feelings, and needs and rights in an interpersonal context (Table 1). The training method was based on the basic training model used by Bellack et al. (1997) and on the problem-solving training model used by Brenner et al. (1994). The basic training model was used for conversational skills and employed the following exercises in this order: explanation, demonstration, role play, feedback, reinforcement, and homework exercise. The problem-solving training model was used for assertiveness skills and focused on identifying the problem, defining goals, generating alternatives, weighing the advantages and disadvantages of each alternative, choosing a reasonable option, developing an implementation plan, and evaluating and rewarding progress. Outcome variables were measured using pretest/ posttest. Interpersonal relationship skills, assertiveness skills, problem-solving skills, and self-esteem were rated by self-report. Conversational skills were observed and measured by two psychiatric nurses working in the ward where the subjects were hospitalized. To minimize interobserver error, two education sessions were held to teach the observing methods to the two nurses who measured conversational skills. Measurements Social skills were measured by using four scales: conversational skills, interpersonal relationship skills, assertiveness skills, and problem-solving skills. Conversational skills were assessed using the Social Interaction Scale developed by Trower, Bryant, and Argyle (1978) and revised by Chun (1994). The 21-item scale consists of three distinct constructs: verbal behavior, nonverbal behavior, and conversational content of the subjects. It uses a 5-point rating scale; lower scores indicate a lack of conversational ability. It was designed to observe and measure a subject's behavior in everyday life. Chun had two evaluators assess their behaviors on videotape and reported interobserver reliability as .82. In this study, the Cronbach's alpha for this instrument was .95. Two nurses working in the ward where the subjects were hospitalized evaluated the subjects' behaviors in the ward, and the interobserver reliability was .90. Interpersonal relationship skills were assessed with the Relationship Changing Scale developed by
SOCIAL SKILLS TRAINING FOR CHRONIC SCHIZOPHRENIA
Guerney, Collins, Ginsberg, and Vogelsong (1977) and revised by Chun (1994). The 25-item scale is designed to assess the following aspects of interpersonal relationships: satisfaction, communication, trust, intimacy, sensitivity, openness, and understanding. The items are answered on a 5-point scale; higher scores indicate good relationships with other people. Cronbach's alpha was .88 in Chun's study and .88 in this study. Assertiveness skills were assessed using the Rathus Assertiveness Schedule (Rathus, 1973; revised by Chun, 1994). The 30-item scale was designed to measure a subject's impression of one's own assertiveness and frankness. Rathus developed and used a 6-point scale, but this study used Chun's modified 5-point scale. Higher scores indicate that subjects perceive themselves as being assertive in their relationships with other people. The scale appears to have relatively high internal consistency and stability. The split-half reliability was .77, and the test–retest reliability 8 weeks later was .78 (Rathus, 1973). Cronbach's alpha was .86 in Chun's study and .62 in this study. Problem-solving skills were assessed using the Personal Problem-Solving Inventory (Heppner & Petersen, 1982; revised by Chun, 1994). The 32-item scale consists of three distinct problemsolving constructs: confidence, approach-avoidance, and personal control. The scale measures an individual's global self-appraisal of one's problem-solving
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ability rather than the individual's actual ability. Heppner and Petersen developed a 6-point scale, but this study used Chun's modified 5-point scale. Lower scores indicate a lack of problem-solving confidence, an absence of personal control, and an avoidance problem-solving style. The ProblemSolving Inventory appears to have relatively high internal consistency and stability, with Cronbach's alpha ranging from .72 to .90 and with a 2-week test–retest coefficient ranging from .83 to .89 (Heppner, 1988). Cronbach's alpha was .84 in this study, the same as in Chun's study. Self-esteem was assessed using the Rosenberg Self-Esteem Scale (Rosenberg, 1965), a 10-item self-report measure of global self-esteem, which has been used with patients with psychiatric conditions (Silverstone & Salsali, 2003; Van Dongen, 1998). The items are answered on a 4-point scale; higher scores indicate higher selfesteem. Acceptable reliability and validity have been reported. The reproducibility coefficient was .92 (Rosenberg, 1965). Cronbach's alpha was .87 in Van Dongen's study and .73 in this study. Statistical Analysis Data were analyzed using SPSS for Windows 10.0. A probability level of .05 was established to determine statistical significance. Chi-square test and t test were used to determine the homogeneity of the demographic and illness characteristics
Table 2. Homogeneity Test for Subjects' Characteristics Between the Two Groups Variables
Age (years) [M (SD)] * Gender [n (%)] Education [n (%)]
Marital status [n (%)] † Employment history [n (%)] Employment status [n (%)] Age of onset (years) [M (SD)] * Number of hospitalizations [M (SD)] * Duration of illness (years) [M (SD)] * Length of hospitalizations (years) [M (SD)] *
Item
Male Female Middle school or less High school College and beyond Never married Married Yes No Yes No
Experimental (n = 34)
Control (n = 32)
Χ 2 or t
P
38.21 18 16 12 17 5 26 8 30 4 0 34 24.76 4.38 13.59 7.15
35.44 (7.02) 20 (62.5) 12 (37.5) 9 (28.1) 14 (43.8) 9 (28.1) 22(68.8) 10 (31.3) 23 (71.9) 9 (28.1) 2 (6.3) 30 (93.8) 25.31 (7.30) 4.72 (2.93) 10.92 (6.12) 5.04 (4.14)
1.87 .62
.067 .432
1.80
.406
.50
.584
2.79
.126
2.19
.231
-.34 -.46 1.90 1.97
.735 .649 .062 .053
*Reported as mean (SD). yThe married group includes those who were married, divorced, and widowed.
(4.74) (52.9) (47.1) (35.3) (50.0) (14.7) (76.5) (23.5) (88.2) (11.8) (0.0) (100.0) (5.76) (3.04) (5.32) (4.55)
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Table 3. Homogeneity Test for Pretest Social Skills and Self-Esteem Between the Two Groups Variables
Experimental (n = 34) [M (SD)]
Control (n = 32) [M (SD)]
t
P
Social skills Conversational skills Interpersonal relationship skills Assertiveness skills Problem-solving skills Self-esteem
75.97 (16.00) 75.47 (15.18) 88.79 (14.06) 105.15 (17.61) 26.62 (4.63)
79.22 (18.02) 79.59 (14.87) 90.75 (13.43) 107.31 (18.35) 25.88 (5.69)
-0.78 -1.11 -0.58 -0.49 0.58
.441 .270 .566 .626 .562
between the experimental group and the control group. Analysis of covariance (ANCOVA) was used to compare the differences between the groups' outcomes at pretest and posttest while controlling for covariates. This study was powered adequately with 33 persons in each group. The sample size was based on the results of Liberman et al. (1998) and Yang and Kim (1999). Liberman et al. reported that the effect size of the social skills training program on self-respect was 1.19. In Yang and Kim, the effect size of the social skills training program on assertive behavior was .77. In this study, the effect size was set at .7. When two groups are used, alpha was set to .05, the statistical power of the test is .8, and the effect size is .70. The minimum sample size required for each group is 33 persons (Cohen, 1988). RESULTS
Homogeneity Test for Subjects' Characteristics and Pretest Scores Between the Two Groups There were no significant differences in subjects' characteristics between the two groups. However, age, duration of illness, and length of hospitaliza-
tions were close to the significance level (.05) on the test of homogeneity, and all were treated as covariates to meet the study purpose (Table 2). Social skills were divided into four subcategories: conversational skills, interpersonal relationship skills, assertiveness skills, and problem-solving skills. The mean scores of pretreatment social skills and self-esteem were analyzed by t test for group homogeneity. There were no group differences in the four subcategories of social skills and selfesteem (Table 3). Effects of Social Skills Training on Social Skills and Self-Esteem Most of the social skill variables were related to each other (r = .36–.59), with the exception of the relationships between conversational skills and assertiveness skills and between conversational skills and problem-solving skills. When examining the effect of social skills training on social skills, multivariate ANOVA was used to examine the global effects of the intervention group versus the control group on the outcome variables, while also controlling for the pretest scores. Although three demographic variables (age, duration of illness, and length of hospitalizations) approached significance on the preliminary tests of homo-
Fig 1. Differences in social skill variables, by time and group.
SOCIAL SKILLS TRAINING FOR CHRONIC SCHIZOPHRENIA
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Table 4. Group Difference in Study Variables After Controlling for Pretest Scores and Demographic Variables Experimental (n = 34)
Social skills Conversation Interpersonal relationship Assertiveness Problem solving Self-esteem
Control (n = 32)
Pretest
Posttest
Pretest
Posttest
M (SD)
M (SD)
M (SD)
M (SD)
75.97 (16.00) 75.47 (15.18)
88.85 (9.28) 87.00 (10.81)
79.22 (18.02) 79.59 (14.87)
85.09 (15.39) 79.41 (10.90)
88.79 (14.06) 105.15 (17.61) 26.62 (4.63)
94.21 (11.26) 104.47 (10.89) 28.47 (2.97)
90.75 (13.43) 107.31 (18.35) 25.88 (5.69)
88.13 (12.67) 105.97 (15.31) 26.03 (4.99)
Analysis by Group Multivariate
Univariate
F
df
P
6.77
4,54
b .001
F
7.39 15.98 7.99 0.005 4.82
P
.009 b. 001 .006 .95 .03
NOTE. The covariates were age, duration of illness, duration of hospitalization, and pretest scores for study variables.
geneity—and particularly the last two could reasonably be expected to affect outcomes— multivariate ANCOVA would make it possible to bring age, duration of illness, and length of hospitalizations into the model as covariates. The univariate effects were then examined for each category of social skills. Results showed significant differences by group (F = 6.77, df = 4,54, P b .001), indicating that the multivariate ANCOVA of social skill variables differed by group after controlling for pretest scores, age, duration of illness, and length of hospitalization. Univariate ANCOVA showed that three subcategories of social skills in the experimental group showed significant improvement after the training session (Figure 1). The mean conversational skills score of the experimental group increased to 12.88 after training, compared to the control group score of 5.88, demonstrating a significant group difference (F = 7.39, P = .009). The mean assertiveness skills score of the experimental group increased to 5.41 after the session, whereas that of the control group decreased to 2.63, also showing a significant group difference (F = 7.99, P = .006). The mean interpersonal relationship skills score of the experimental group increased to 11.53 after training, whereas that of the control group decreased to 0.19, another significant group difference (F = 15.98, P b .001). There was no significant improvement in problem-solving skills in either group (Table 4). ANCOVA was used to examine the effects of social skills training on self-esteem, with pretest scores of self-esteem and three demographic variables entered as covariates (Table 4). Selfesteem scores in the experimental group improved by 1.85 after training, whereas the control group
increased by 0.15 only, demonstrating a significant group difference (F = 4.82, P = .03). DISCUSSION
The effects of social skills training on the social skills and self-esteem of patients with chronic schizophrenia were examined by psychiatric nurses in South Korea. The overall hypothesis that social skills training would improve social skills and selfesteem was partially confirmed. We found a significant improvement in conversational skills, assertiveness skills, interpersonal relationship skills, and self-esteem after training. However, we did not find an improvement in problem-solving skills. Subjects who participated in the social skills training program successfully progressed in conversational, assertiveness, and interpersonal relationship skills compared to the control group. This improvement was independent of age, duration of illness, and length of hospitalization. Our findings support the reports of previous studies regarding significant improvement in conversational skills, assertiveness skills, and interpersonal relationship skills through social skills training in patients with chronic mental illness (Chien et al., 2003; Chun, 1994; Yang & Kim, 1999). Findings of this study show that it is possible to improve the social skills of patients with chronic schizophrenia through implementation of a special training program. Findings suggest that once patients have learned how to properly communicate and respond in interpersonal situations, they can experience positive responses from others. This, in turn, can increase confidence in interpersonal relations, decrease anxiety, and lead to improved interpersonal relationship skills. In accordance with the findings of Lee et al. (1998), we did not find an improvement in problem-
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solving skills in inpatients after the training; other studies involving outpatients (Chun, 1994; Jung, 2002; Liberman et al., 2001), however, have reported contrary results. Inpatients are hospitalized in wards and are isolated from society in general; most of the study subjects were unable to work and had rather long histories of schizophrenia. Therefore, the training might not have been as effective with them. Outpatients, on the other hand, have various opportunities to apply their learned problem-solving skills in their daily lives. Another reason for the lack of improvement in problem solving could be attributed to the fact that cognitive functioning of the subjects was not considered. Although people with chronic schizophrenia vary considerably in their cognitive functioning, cognitive flexibility is particularly necessary to produce alternative solutions to problems and is a significant predictor of the effect of social skills training on the acquisition of skills in social problem solving (Ucok et al., 2006). Previous studies have suggested that cognitive deficiencies should first be improved to enhance problem-solving skills (Green, 1993; Kern et al., 1995). The basic training model and the problemsolving training model were used as training methods in this study, but the training was limited to conversational and assertiveness skills. The training method and contents need to be reevaluated to ascertain whether they are appropriate and sufficient for improving the problem-solving skills of patients with chronic schizophrenia. The Problem-Solving Inventory is a complex instrument, and some subjects may have difficulty understanding the questions. The problemsolving capacity of patients with lower levels of cognitive functioning might be overshadowed, and the outcomes might be misleading (Ucok et al., 2006). For future research, some measure of intellectual functioning should be obtained as a baseline measure and covariate so that problemsolving skills after the training could be evaluated more accurately. Subjects who participated in social skills training showed improved self-esteem, while controlling for subjects' age, duration of illness, and length of hospitalization. This is consistent with the results of a previous study by Liberman et al. (1998). In a recent study, Kim and Song (2003) found that the self-esteem of inpatients with chronic schizophre-
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nia improved when social adjustment training was combined with practice in the field, such as on field trips or bowling outings. Acknowledging that the level of self-esteem is a core factor for the recovery and prevention of recurring mental illness (Anthony, 1993), mental health nurses should help patients sustain or improve positive selfesteem throughout treatment. To promote selfesteem, it is necessary for the training program to include outings, such as field trips and bowling, and practice in social adjustment skills, in addition to conversation and assertiveness skills. Limitations This study has several limitations. Having patients choose whether to go into the experimental group or the control group would seem to introduce unnecessary bias. Subjects who chose the social skills training may be more likely to take risks and perhaps be open to new experiences. Such personal characteristics in the experimental group might lead to an overestimation of the effect of the training. This study did not measure or control for psychiatric symptoms. Psychiatric symptoms might have an indirect negative effect on obtaining social skills by interfering with sustained attention, which is necessary if one is to detect what the problem is and how it could be solved (Ucok et al., 2006). Because we assessed social skills immediately after the training, we do not know whether, after the training, our subjects showed any improvement in social skills in real-life situations. We also do not know the long-term effects of social skills training. People who think concretely have problems generalizing and implementing newly learned skills in real-life situations when the impaired abstracting ability is due to schizophrenia, regardless of the phase or subtype of the illness (Chan, Chen, Cheung, & Cheung, 2004). It is up to educators to teach the social skills in a situation as similar as possible to the one in which the application must be made. In addition, it is necessary for mental health nurses to continue to follow up after the training until discharge from the hospital. Nurses can offer repetitive training, reinforcement, and guidance for patients so that they can effectively use new skills in natural situations. Assessing cognitive functioning and learning ability could be useful for determining different individual approaches and long-standing involvement (Ucok et al., 2006).
SOCIAL SKILLS TRAINING FOR CHRONIC SCHIZOPHRENIA
In summary, the results of studies in this area suggest that it is possible to restore at least some aspects of social skills and self-esteem in patients with schizophrenia by using special training. We believe that, to achieve optimal social skills improvement, a combination of long-lasting and individualized cognitive training modalities is necessary. Social skills training, as developed by Liberman et al. (1989) and Bellack et al. (1997), is a viable nursing intervention for hospitalized patients with chronic schizophrenia.
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improving social skills of patients with schizophrenia. Archives of Psychiatric Nursing, 17(5), 228–236. Chun, S. K. (1994). A study on the effectiveness of social skills training program for rehabilitation of the schizophrenic patients. Unpublished doctoral dissertation, Soongsil University, Seoul, Korea. Cohen, J. (1988). Statistical power analysis for the behavioral sciences. New Jersey: Lawrence Erlbaum Association. Corrigan, P. W., Hirschbeck, J. N., & Wolfe, M. (1995). Memory and vigilance training to improve social perception in schizophrenia. Schizophrenia Research, 17, 257–265. Granholm, E., McQuaid, J. R., McClure, F. S., Auslander, L. A., Perivoliotis, D., Pedrelli, P., et al. (2005). A randomized, controlled trial of cognitive behavioral social skills training for middle-aged and older outpatients with chronic schizophrenia. American Journal of Psychiatry, 162(3), 520–529. Green, M. F. (1993). Cognitive remediation in schizophrenia; Is it time yet? American Journal of Psychiatry, 150, 178–187. Guerney, B., Collins, J. D., Ginsberg, B. G., & Vogelsong, E. (1977). Relationship enhancement. San Francisco: Jossey-Bass Publishers. Heppner, P. P. (1988). The Problem-Solving Inventory: Manual. Palo Alto, CA: Consulting Psychologists Press. Heppner, P. P. & Petersen, C. H. (1982). The development and implications of a Personal Problem-Solving Inventory. Journal of Counseling Psychology, 29(1), 66–75. Jung, S. Y. (2002). A study on the development and effectiveness of integrated rehabilitation program for the mentally disordered in the community: A 6 months follow-up study. Mental Health & Social Work, 14, 127–163. Kern, R. S., Green, M. F., & Goldstein, M. J. (1995). Modification of performance on the span of apprehension, a putative marker of vulnerability to schizophrenia. Journal of Abnormal Psychology, 104, 385–389. Kim, J. H. & Song, Y. S. (2003). The effects of social adjustment training program on chronic schizophrenia patients' self-esteem and interpersonal relations. Journal of Korean of Psychiatric and Mental Health Nursing, 12(1), 47–55. Lee, M. H., Lee, H. S., Cho, H. S., Hyun, M. H., An, S. K., Yoo, S. W., et al. (1998). Effects of integrated psychological therapy for schizophrenic patients. Journal of Korean Neuropsychiatric Association, 37(6), 1074–1086. Liberman, R. P. (1988). Psychiatric rehabilitation of chronic mental patient. Washington, DC: American Psychiatric Association. Liberman, R. P., DeRisi, W. J., & Mueser, K. T. (1989). Social skills training for psychiatric patients. New York: Pergamon Press. Liberman, R. P., Eckman, T., & Marder, S. R. (2001). Rehab rounds: Training in social problem solving among persons with schizophrenia. Psychiatric Services, 52, 31–33. Liberman, R. P., Massel, 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., Wallace, C. J., Blackwell, G., Eckman, T. A., Vaccaro, J. V., & Kuehnel, T. G. (1993). Innovations in
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skills training for the seriously mentally ill: The UCLA Social and Independent Living Skills Modules. Innovations & Research, 2(2), 43–59. Liberman, R. P., Wallace, C. J., Blackwell, G., Kopelowicz, A., Vaccaro, J., & Mintz, J. (1998). Skills training versus psychosocial occupational therapy for persons with persistent schizophrenia. American Journal of Psychiatry, 155(8), 1087–1091. Müller, D. R., Brenner, H. D., & Roder, V. (2003). Effectiveness of integrated psychological treatment (IPT) for schizophrenia patients: A meta-analysis of twenty five years of research. Schizophrenia Research, 60(Suppl 1), 326. Rathus, S. A. (1973). A 30-item schedule for assessing assertive behavior. Behavior Therapy, 4, 398–406. Rosenberg, M. (1965). Society and the adolescence self-image. New Jersey: Princeton University Press. Silverstone, P. H. & Salsali, M. (2003). Low self-esteem and psychiatric patients: Part I. The relationship between low self-esteem and psychiatric diagnosis. Annals of General Hospital Psychiatry, 2(1), 2.
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Suh, J. H. (1998). A study on the development and evaluation of vocational rehabilitation program for patients with schizophrenia: Using problem-solving skills training. Yonsei Social Welfare Review, 5, 97–124. Trower, P., Bryant, B., & Argyle, M. (1978). Social skills and mental health. Pittsburgh: University of Pittsburgh Press. Ucok, A., Cakir, S., Duman, Z. C., Discigil, A., Kandemir, P., & Atli, H. (2006). Cognitive predictors of skill acquisition on social problem solving in patients with schizophrenia. European Archives of Psychiatry and Clinical Neuroscience (published online on June 16). Van Dongen, C. J. (1998). Self-esteem among persons with severe mental illness. Issues in Mental Health Nursing, 19, 29–40. Yang, S. & Kim, H. S. (1999). Effects of social skills training on the interpersonal relationship, assertiveness and quality of life in chronic schizophrenic inpatients. Journal of Korean of Psychiatric and Mental Health Nursing, 8(2), 331–342.
Social Skills Training as Nursing Intervention to Improve the Social Skills and Self-Esteem of Inpatients with Chronic Schizophrenia Ji-Min Seo, Sukhee Ahn, Eun-Kyung Byun, and Chul-Kweon Kim The effects of social skills training on the social skills and self-esteem of 66 patients with chronic schizophrenia were evaluated using the basic training and problem-solving training models. The experimental group received 16 group training sessions, and the control group received routine nursing care. The training program consisted of two parts: conversational skills and assertiveness skills. Data were collected at pretreatment and posttreatment. The conversational, interpersonal relationship, and assertiveness skills, and self-esteem of the experimental group showed significant improvement, whereas problem-solving skills did not improve. The results indicate that training in social skills is effective for improving the social skills and selfesteem of inpatients with chronic schizophrenia. D 2007 Elsevier Inc. All rights reserved.
P
ATIENTS WITH CHRONIC schizophrenia lack social skills. They cannot effectively converse with people, easily make friends, or effectively solve their problems. In addition, it is difficult for them to find and retain jobs, further isolating themselves from society (Bellack, Mueser, Gingerich, & Agresta, 1997). These poor social skills are closely related to repetitive recurrences of the disease and rehospitalizations, and have been reported as important factors affecting prognosis (Granholm et al., 2005). In addition, patients with chronic mental illnesses often have low self-esteem (Silverstone & Salsali, 2003), which impedes effective interpersonal relations and negatively affects their abilities to cope with stress and problems (Brekke, Levin, Wolkon, Sobel, & Slade, 1993). In schizophrenia, the lack of psychosocial functioning is related to low selfesteem (Brekke et al., 1993). Self-esteem is one of the most important factors in preventing recurrence and in ensuring long-term success in rehabilitation among patients with chronic schizophrenia (Anthony, 1993).
A social skills training program was developed to improve the social skills of patients with chronic schizophrenia and, ultimately, to help them successfully return to society (Liberman, 1988). This training has proven to be effective in improving social adaptability, reducing psychiatric symptoms and thus reducing rehospitalization rate (Benton & Schroeder, 1990), in addition to enhancing selfesteem (Liberman et al., 1998). Together with other mental health professionals, nurses have participated in social skills training to
From the College of Nursing, Pusan National University, Busan, Korea; School of Nursing, Chungnam National University Daejeon, Korea; Bukgu Mental Health Center, Busan, Korea; and College of Medicine, DongA University, Busan, Korea. Address reprint requests to Sukhee Ahn, School of Nursing, Chungnam National University, 6 Munhwa 1-dong, Daejeon, Korea. E-mail address: [email protected] n 2007 Elsevier Inc. All rights reserved. 0883-9417/1801-0005$30.00/0 doi: 10.1016/j.apnu.2006.09.005
Archives of Psychiatric Nursing, Vol. 21, No. 6 (December), 2007: pp 317–326
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facilitate the psychosocial rehabilitation of patients with chronic schizophrenia. However, nursing studies on social skills training for patients with schizophrenia are extremely limited. Accordingly, further research is needed to clarify the usefulness of social skills training as an efficient nursing intervention. The purpose of this study is to examine the effects of social skills training conducted by psychiatric staff nurses on the social skills and self-esteem of inpatients with chronic schizophrenia in South Korea. LITERATURE REVIEW
Social Skills Training Social skills training includes training in conversational, assertiveness, problem-solving, medication management, independent living, stress management, and vocational skills (Liberman et al., 1993). Major methods used to teach these skills include the basic training model, the problemsolving training model, and the attention-focused training model for cognitive remediation (Liberman, Massel, Mosk, & Wong, 1985). Recently, an integrated psychological therapy for patients with schizophrenia that integrates cognitive–behavioral therapy into the basic training and problem-solving training models has been developed and used (Brenner et al., 1994). The basic training model, based on social learning theory, has been the most widely used, serving as the foundation for all other social skills training models (Liberman, DeRisi, & Mueser, 1989). It has been found, however, that patients fail to efficiently apply the skills they acquire with this training to their daily lives (Brown & Munford, 1983). This has been proven to be related to the lack of problem-solving abilities of patients with chronic schizophrenia (Bellack, Morrison, & Mueser, 1989). In the process of finding ways to resolve such a problem, the problem-solving training model began to gain popularity, and it has since been studied worldwide (Bellack et al., 1989). This training method focuses on precisely identifying the situation, generating alternatives, selecting optimal options, and using the chosen option (Liberman et al., 1985). Preliminary studies have reported that patients who received training with this model were able to apply their newly acquired social skills in real-life situations and thus showed improvement in
their problem-solving abilities and social adaptability (Liberman, Eckman, & Marder, 2001). The problem, however, is that this model is not effective in patients with diminished cognitive function (Green, 1993). Researchers have tried the attention-focused training model for cognitive remediation (Corrigan, Hirschbeck, & Wolfe, 1995). Most studies have resulted in some positive results in terms of test tools but have failed to improve social skills and to maintain the effects (Bellack, Mueser, Morrison, Tierney, & Podell, 1990; Kern, Green, & Go1dstein, 1995). This can be attributed to the fact that attention can be improved but cognitive impairments in various domains that are characteristic of chronic schizophrenia cannot be improved (Kern et al., 1995). Recently, there has been increasing interest in an approach that improves the comprehensive cognitive dysfunction of schizophrenia. One such psychological rehabilitation therapy program is the integrated psychological therapy developed by Brenner et al. (1994). Integrated psychological therapy has been used for patients with schizophrenia in many countries, including Germany, Switzerland, Austria, Korea, Japan, and the United States (Brenner, Hodel, Genner, Roder, & Corrigan, 1992; Müller, Brenner, & Roder, 2003). Social Skills Training in South Korea With the establishment of the Mental Health Law in South Korea in 1995, emphasis was placed on psychosocial rehabilitation. Consequently, the demand for professional trainers in social skills, including the need for psychiatric nurses who can provide social skills training, has risen. To ensure the expanded roles of psychiatric nurses in accordance with the law, psychiatric nurses should pursue more active studies and acquire the abilities needed to provide social skills training, although nursing researches on this field are limited in South Korea. Studies that have been conducted on social skills training in South Korea have primarily used the basic training model (Chun, 1994; Yang & Kim, 1999). In the late 1990s, the problem-solving training model, the attention-focused training model, and integrated psychological therapy were used, but they fell short of being widely employed. According to Yang and Kim, the conversational, interpersonal relationship, and assertiveness skills
SOCIAL SKILLS TRAINING FOR CHRONIC SCHIZOPHRENIA
improved with the basic training model, but their study was limited in that the intervention effects were measured with self-reporting questionnaires. Chun also reported that problem-solving abilities improved by using the basic training model. Two studies applied the problem-solving training model and the attention-focused training model to improving social skills (An, Oh, Hyun, & Yoo, 1997; Suh, 1998). Using an intervention of integrated psychological therapy thrice a week for 3 months, Lee et al. (1998) observed significant improvement in psychopathology but could not find improvement in cognitive functions or problem-solving skills. Jung (2002), using the same interventions as Lee et al., found improvement in auditory attention, social adaptability, and problem-solving skills, and a 6-month follow-up test found that auditory attention and social adaptability were maintained but that problemsolving skills were not. In summary, the extant psychiatric nursing literature reveals a lack of various social skills training programs, short training periods, and a lack of objective effect measurement and follow-up investigations related to social skills training, and demonstrates the need for this study. Psychiatric nurses typically play a passive role in social skills training. They tend not to be directly engaged in such training but remain engaged in traditional nursing roles. This tendency may be related to an absence of nursing studies focusing on social skills training. Existing nursing studies focusing on social skills training incorporate only the basic training model, resulting in a significant gap between nursing studies and research in the social skills training of the other core psychiatric disciplines. This study had two primary aims. The first aim was to examine the effects of social skills training on the social skills and self-esteem of inpatients with chronic schizophrenia. The second aim was to add to the body of nursing research related to the usefulness of social skills training as a psychiatric nursing intervention. METHODS
A quasi-experimental design with a nonequivalent control group was used to examine the effects of the social skills training program on the social skills and self-esteem of patients with chronic schizophrenia.
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Subjects The study was conducted in a psychiatric hospital in South Korea. Inpatients who were diagnosed with schizophrenia based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition were asked to participate in this study if they had no evidence of organic brain disorder or alcohol/drug abuse. The psychiatric nurse who performed the intervention informed eligible subjects of this study and invited them to participate. Written consent for participation was obtained from all participants. Patients were allowed to choose whether they would be in the experimental group or in the control group. Each group had 37 subjects. Three subjects (8%) in the experimental group and five subjects (13%) in the control group were excluded because they were discharged. When the study had been completed, 34 subjects remained in the experimental group and 32 subjects remained in the control group. The average age was 38.21 years in the experimental group and 35.44 years in the control group. There were more male (38) subjects than female (28) subjects, and most of the subjects in both groups had at least a high school education, had never married, and had a history of employment. For work experience, 88% in the experimental group and 72% in the control group reported having had jobs, but only 6% in the control group reported retaining a job. According to illness characteristics, the average age of onset was 25 years, indicating that most patients developed the disease in their early adulthood. The average duration of illness was 12 years, ranging from 10 to 13 years, and the average total period of hospitalizations was 6 years, with a mean of 4.5 admissions (Table 2). Procedures The social skills training program was given as group treatment, and the experimental group was divided into four subgroups with 9–10 patients each. The subjects were trained via 60–70 minutes of a social skills training course twice a week for 8 weeks. The control group received routine nursing care treatment. The social skills training program was conducted by a trained psychiatric nurse and an assistant (a social worker) who were not staff members of the subjects' ward. The psychiatric nurse who conducted the social skills training has a doctoral degree in psychiatric nursing
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and has been engaged in the education and social skills training of patients with chronic mental disorders for N 10 years. Three education sessions were held to discuss the training method and content with the psychiatric nurse before the social skills training began. The social skills training program was based on the modules developed by Bellack et al. (1997) and Liberman et al. (1989). The training program was divided into two parts: conversational skills and assertiveness skills. The conversational skills train-
Table 1. Social Skills Training Program Session
Contents
1
Program orientation
2 3 4
Nonverbal behavior Verbal behavior Contents of conversation
5 6
7
8 9
10 11
12 13
14 15
16
Assertive behavior
Pretest Providing information about social skills training Eye contact, facial expression Posture, proximics, kinesics Voice volume, speech rate, pitch, intonation Starting conversations Listening to others Maintaining conversations by asking questions Maintaining conversations by giving factual information Maintaining conversations by expressing feelings Staying on the topic set by another person What to do when someone goes off the topic Ending conversations Getting your point across Providing information about assertive skills training Making requests Refusing requests Making complaints Responding to complaints Expressing unpleasant feelings Expressing angry feelings Expressing positive feelings Giving compliments Accepting compliments Making apologies Letting someone know that you are afraid Asking for information Refusing alcohol or tobacco Compromising and negotiating Disagreeing with another's opinion without arguing Responding to untrue accusations Posttest
ing included both verbal and nonverbal communication skills. The assertiveness skills training included expressing feelings, and needs and rights in an interpersonal context (Table 1). The training method was based on the basic training model used by Bellack et al. (1997) and on the problem-solving training model used by Brenner et al. (1994). The basic training model was used for conversational skills and employed the following exercises in this order: explanation, demonstration, role play, feedback, reinforcement, and homework exercise. The problem-solving training model was used for assertiveness skills and focused on identifying the problem, defining goals, generating alternatives, weighing the advantages and disadvantages of each alternative, choosing a reasonable option, developing an implementation plan, and evaluating and rewarding progress. Outcome variables were measured using pretest/ posttest. Interpersonal relationship skills, assertiveness skills, problem-solving skills, and self-esteem were rated by self-report. Conversational skills were observed and measured by two psychiatric nurses working in the ward where the subjects were hospitalized. To minimize interobserver error, two education sessions were held to teach the observing methods to the two nurses who measured conversational skills. Measurements Social skills were measured by using four scales: conversational skills, interpersonal relationship skills, assertiveness skills, and problem-solving skills. Conversational skills were assessed using the Social Interaction Scale developed by Trower, Bryant, and Argyle (1978) and revised by Chun (1994). The 21-item scale consists of three distinct constructs: verbal behavior, nonverbal behavior, and conversational content of the subjects. It uses a 5-point rating scale; lower scores indicate a lack of conversational ability. It was designed to observe and measure a subject's behavior in everyday life. Chun had two evaluators assess their behaviors on videotape and reported interobserver reliability as .82. In this study, the Cronbach's alpha for this instrument was .95. Two nurses working in the ward where the subjects were hospitalized evaluated the subjects' behaviors in the ward, and the interobserver reliability was .90. Interpersonal relationship skills were assessed with the Relationship Changing Scale developed by
SOCIAL SKILLS TRAINING FOR CHRONIC SCHIZOPHRENIA
Guerney, Collins, Ginsberg, and Vogelsong (1977) and revised by Chun (1994). The 25-item scale is designed to assess the following aspects of interpersonal relationships: satisfaction, communication, trust, intimacy, sensitivity, openness, and understanding. The items are answered on a 5-point scale; higher scores indicate good relationships with other people. Cronbach's alpha was .88 in Chun's study and .88 in this study. Assertiveness skills were assessed using the Rathus Assertiveness Schedule (Rathus, 1973; revised by Chun, 1994). The 30-item scale was designed to measure a subject's impression of one's own assertiveness and frankness. Rathus developed and used a 6-point scale, but this study used Chun's modified 5-point scale. Higher scores indicate that subjects perceive themselves as being assertive in their relationships with other people. The scale appears to have relatively high internal consistency and stability. The split-half reliability was .77, and the test–retest reliability 8 weeks later was .78 (Rathus, 1973). Cronbach's alpha was .86 in Chun's study and .62 in this study. Problem-solving skills were assessed using the Personal Problem-Solving Inventory (Heppner & Petersen, 1982; revised by Chun, 1994). The 32-item scale consists of three distinct problemsolving constructs: confidence, approach-avoidance, and personal control. The scale measures an individual's global self-appraisal of one's problem-solving
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ability rather than the individual's actual ability. Heppner and Petersen developed a 6-point scale, but this study used Chun's modified 5-point scale. Lower scores indicate a lack of problem-solving confidence, an absence of personal control, and an avoidance problem-solving style. The ProblemSolving Inventory appears to have relatively high internal consistency and stability, with Cronbach's alpha ranging from .72 to .90 and with a 2-week test–retest coefficient ranging from .83 to .89 (Heppner, 1988). Cronbach's alpha was .84 in this study, the same as in Chun's study. Self-esteem was assessed using the Rosenberg Self-Esteem Scale (Rosenberg, 1965), a 10-item self-report measure of global self-esteem, which has been used with patients with psychiatric conditions (Silverstone & Salsali, 2003; Van Dongen, 1998). The items are answered on a 4-point scale; higher scores indicate higher selfesteem. Acceptable reliability and validity have been reported. The reproducibility coefficient was .92 (Rosenberg, 1965). Cronbach's alpha was .87 in Van Dongen's study and .73 in this study. Statistical Analysis Data were analyzed using SPSS for Windows 10.0. A probability level of .05 was established to determine statistical significance. Chi-square test and t test were used to determine the homogeneity of the demographic and illness characteristics
Table 2. Homogeneity Test for Subjects' Characteristics Between the Two Groups Variables
Age (years) [M (SD)] * Gender [n (%)] Education [n (%)]
Marital status [n (%)] † Employment history [n (%)] Employment status [n (%)] Age of onset (years) [M (SD)] * Number of hospitalizations [M (SD)] * Duration of illness (years) [M (SD)] * Length of hospitalizations (years) [M (SD)] *
Item
Male Female Middle school or less High school College and beyond Never married Married Yes No Yes No
Experimental (n = 34)
Control (n = 32)
Χ 2 or t
P
38.21 18 16 12 17 5 26 8 30 4 0 34 24.76 4.38 13.59 7.15
35.44 (7.02) 20 (62.5) 12 (37.5) 9 (28.1) 14 (43.8) 9 (28.1) 22(68.8) 10 (31.3) 23 (71.9) 9 (28.1) 2 (6.3) 30 (93.8) 25.31 (7.30) 4.72 (2.93) 10.92 (6.12) 5.04 (4.14)
1.87 .62
.067 .432
1.80
.406
.50
.584
2.79
.126
2.19
.231
-.34 -.46 1.90 1.97
.735 .649 .062 .053
*Reported as mean (SD). yThe married group includes those who were married, divorced, and widowed.
(4.74) (52.9) (47.1) (35.3) (50.0) (14.7) (76.5) (23.5) (88.2) (11.8) (0.0) (100.0) (5.76) (3.04) (5.32) (4.55)
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Table 3. Homogeneity Test for Pretest Social Skills and Self-Esteem Between the Two Groups Variables
Experimental (n = 34) [M (SD)]
Control (n = 32) [M (SD)]
t
P
Social skills Conversational skills Interpersonal relationship skills Assertiveness skills Problem-solving skills Self-esteem
75.97 (16.00) 75.47 (15.18) 88.79 (14.06) 105.15 (17.61) 26.62 (4.63)
79.22 (18.02) 79.59 (14.87) 90.75 (13.43) 107.31 (18.35) 25.88 (5.69)
-0.78 -1.11 -0.58 -0.49 0.58
.441 .270 .566 .626 .562
between the experimental group and the control group. Analysis of covariance (ANCOVA) was used to compare the differences between the groups' outcomes at pretest and posttest while controlling for covariates. This study was powered adequately with 33 persons in each group. The sample size was based on the results of Liberman et al. (1998) and Yang and Kim (1999). Liberman et al. reported that the effect size of the social skills training program on self-respect was 1.19. In Yang and Kim, the effect size of the social skills training program on assertive behavior was .77. In this study, the effect size was set at .7. When two groups are used, alpha was set to .05, the statistical power of the test is .8, and the effect size is .70. The minimum sample size required for each group is 33 persons (Cohen, 1988). RESULTS
Homogeneity Test for Subjects' Characteristics and Pretest Scores Between the Two Groups There were no significant differences in subjects' characteristics between the two groups. However, age, duration of illness, and length of hospitaliza-
tions were close to the significance level (.05) on the test of homogeneity, and all were treated as covariates to meet the study purpose (Table 2). Social skills were divided into four subcategories: conversational skills, interpersonal relationship skills, assertiveness skills, and problem-solving skills. The mean scores of pretreatment social skills and self-esteem were analyzed by t test for group homogeneity. There were no group differences in the four subcategories of social skills and selfesteem (Table 3). Effects of Social Skills Training on Social Skills and Self-Esteem Most of the social skill variables were related to each other (r = .36–.59), with the exception of the relationships between conversational skills and assertiveness skills and between conversational skills and problem-solving skills. When examining the effect of social skills training on social skills, multivariate ANOVA was used to examine the global effects of the intervention group versus the control group on the outcome variables, while also controlling for the pretest scores. Although three demographic variables (age, duration of illness, and length of hospitalizations) approached significance on the preliminary tests of homo-
Fig 1. Differences in social skill variables, by time and group.
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Table 4. Group Difference in Study Variables After Controlling for Pretest Scores and Demographic Variables Experimental (n = 34)
Social skills Conversation Interpersonal relationship Assertiveness Problem solving Self-esteem
Control (n = 32)
Pretest
Posttest
Pretest
Posttest
M (SD)
M (SD)
M (SD)
M (SD)
75.97 (16.00) 75.47 (15.18)
88.85 (9.28) 87.00 (10.81)
79.22 (18.02) 79.59 (14.87)
85.09 (15.39) 79.41 (10.90)
88.79 (14.06) 105.15 (17.61) 26.62 (4.63)
94.21 (11.26) 104.47 (10.89) 28.47 (2.97)
90.75 (13.43) 107.31 (18.35) 25.88 (5.69)
88.13 (12.67) 105.97 (15.31) 26.03 (4.99)
Analysis by Group Multivariate
Univariate
F
df
P
6.77
4,54
b .001
F
7.39 15.98 7.99 0.005 4.82
P
.009 b. 001 .006 .95 .03
NOTE. The covariates were age, duration of illness, duration of hospitalization, and pretest scores for study variables.
geneity—and particularly the last two could reasonably be expected to affect outcomes— multivariate ANCOVA would make it possible to bring age, duration of illness, and length of hospitalizations into the model as covariates. The univariate effects were then examined for each category of social skills. Results showed significant differences by group (F = 6.77, df = 4,54, P b .001), indicating that the multivariate ANCOVA of social skill variables differed by group after controlling for pretest scores, age, duration of illness, and length of hospitalization. Univariate ANCOVA showed that three subcategories of social skills in the experimental group showed significant improvement after the training session (Figure 1). The mean conversational skills score of the experimental group increased to 12.88 after training, compared to the control group score of 5.88, demonstrating a significant group difference (F = 7.39, P = .009). The mean assertiveness skills score of the experimental group increased to 5.41 after the session, whereas that of the control group decreased to 2.63, also showing a significant group difference (F = 7.99, P = .006). The mean interpersonal relationship skills score of the experimental group increased to 11.53 after training, whereas that of the control group decreased to 0.19, another significant group difference (F = 15.98, P b .001). There was no significant improvement in problem-solving skills in either group (Table 4). ANCOVA was used to examine the effects of social skills training on self-esteem, with pretest scores of self-esteem and three demographic variables entered as covariates (Table 4). Selfesteem scores in the experimental group improved by 1.85 after training, whereas the control group
increased by 0.15 only, demonstrating a significant group difference (F = 4.82, P = .03). DISCUSSION
The effects of social skills training on the social skills and self-esteem of patients with chronic schizophrenia were examined by psychiatric nurses in South Korea. The overall hypothesis that social skills training would improve social skills and selfesteem was partially confirmed. We found a significant improvement in conversational skills, assertiveness skills, interpersonal relationship skills, and self-esteem after training. However, we did not find an improvement in problem-solving skills. Subjects who participated in the social skills training program successfully progressed in conversational, assertiveness, and interpersonal relationship skills compared to the control group. This improvement was independent of age, duration of illness, and length of hospitalization. Our findings support the reports of previous studies regarding significant improvement in conversational skills, assertiveness skills, and interpersonal relationship skills through social skills training in patients with chronic mental illness (Chien et al., 2003; Chun, 1994; Yang & Kim, 1999). Findings of this study show that it is possible to improve the social skills of patients with chronic schizophrenia through implementation of a special training program. Findings suggest that once patients have learned how to properly communicate and respond in interpersonal situations, they can experience positive responses from others. This, in turn, can increase confidence in interpersonal relations, decrease anxiety, and lead to improved interpersonal relationship skills. In accordance with the findings of Lee et al. (1998), we did not find an improvement in problem-
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solving skills in inpatients after the training; other studies involving outpatients (Chun, 1994; Jung, 2002; Liberman et al., 2001), however, have reported contrary results. Inpatients are hospitalized in wards and are isolated from society in general; most of the study subjects were unable to work and had rather long histories of schizophrenia. Therefore, the training might not have been as effective with them. Outpatients, on the other hand, have various opportunities to apply their learned problem-solving skills in their daily lives. Another reason for the lack of improvement in problem solving could be attributed to the fact that cognitive functioning of the subjects was not considered. Although people with chronic schizophrenia vary considerably in their cognitive functioning, cognitive flexibility is particularly necessary to produce alternative solutions to problems and is a significant predictor of the effect of social skills training on the acquisition of skills in social problem solving (Ucok et al., 2006). Previous studies have suggested that cognitive deficiencies should first be improved to enhance problem-solving skills (Green, 1993; Kern et al., 1995). The basic training model and the problemsolving training model were used as training methods in this study, but the training was limited to conversational and assertiveness skills. The training method and contents need to be reevaluated to ascertain whether they are appropriate and sufficient for improving the problem-solving skills of patients with chronic schizophrenia. The Problem-Solving Inventory is a complex instrument, and some subjects may have difficulty understanding the questions. The problemsolving capacity of patients with lower levels of cognitive functioning might be overshadowed, and the outcomes might be misleading (Ucok et al., 2006). For future research, some measure of intellectual functioning should be obtained as a baseline measure and covariate so that problemsolving skills after the training could be evaluated more accurately. Subjects who participated in social skills training showed improved self-esteem, while controlling for subjects' age, duration of illness, and length of hospitalization. This is consistent with the results of a previous study by Liberman et al. (1998). In a recent study, Kim and Song (2003) found that the self-esteem of inpatients with chronic schizophre-
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nia improved when social adjustment training was combined with practice in the field, such as on field trips or bowling outings. Acknowledging that the level of self-esteem is a core factor for the recovery and prevention of recurring mental illness (Anthony, 1993), mental health nurses should help patients sustain or improve positive selfesteem throughout treatment. To promote selfesteem, it is necessary for the training program to include outings, such as field trips and bowling, and practice in social adjustment skills, in addition to conversation and assertiveness skills. Limitations This study has several limitations. Having patients choose whether to go into the experimental group or the control group would seem to introduce unnecessary bias. Subjects who chose the social skills training may be more likely to take risks and perhaps be open to new experiences. Such personal characteristics in the experimental group might lead to an overestimation of the effect of the training. This study did not measure or control for psychiatric symptoms. Psychiatric symptoms might have an indirect negative effect on obtaining social skills by interfering with sustained attention, which is necessary if one is to detect what the problem is and how it could be solved (Ucok et al., 2006). Because we assessed social skills immediately after the training, we do not know whether, after the training, our subjects showed any improvement in social skills in real-life situations. We also do not know the long-term effects of social skills training. People who think concretely have problems generalizing and implementing newly learned skills in real-life situations when the impaired abstracting ability is due to schizophrenia, regardless of the phase or subtype of the illness (Chan, Chen, Cheung, & Cheung, 2004). It is up to educators to teach the social skills in a situation as similar as possible to the one in which the application must be made. In addition, it is necessary for mental health nurses to continue to follow up after the training until discharge from the hospital. Nurses can offer repetitive training, reinforcement, and guidance for patients so that they can effectively use new skills in natural situations. Assessing cognitive functioning and learning ability could be useful for determining different individual approaches and long-standing involvement (Ucok et al., 2006).
SOCIAL SKILLS TRAINING FOR CHRONIC SCHIZOPHRENIA
In summary, the results of studies in this area suggest that it is possible to restore at least some aspects of social skills and self-esteem in patients with schizophrenia by using special training. We believe that, to achieve optimal social skills improvement, a combination of long-lasting and individualized cognitive training modalities is necessary. Social skills training, as developed by Liberman et al. (1989) and Bellack et al. (1997), is a viable nursing intervention for hospitalized patients with chronic schizophrenia.
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