CURRENT ISSUE
Effect of Psychosocial Skills Training on Disease Symptoms, Insight, Internalized Stigmatization, and Social Functioning in Patients with Schizophrenia lu Asßılar1, PhD, RN, Tuba Hale Camcıog lu2, Spec., Arzu Yıldırım1, PhD, RN, Rabia Hacıhasanog 3 4 acß , RN Sezgin Erdiman , Spec. & Ebru Karaag 1 Deparment of Nursing, Erzincan University School of Health, Erzincan, Turkey 2 Sadi Konuk Educational and Research Hospital, Psychiatry Clinic, _Istanbul, Turkey €rk State Hospital, Psychiatry Clinic, Balıkesir, Turkey 3 Balıkesir Atatu 4 Institute of Health Sciences, Erzincan, Turkey
Keywords
Abstract
Disease symptoms; insight; internalized stigmatization; psychosocial skills training; social functioning. Correspondence Arzu Yıldırım, Deparment of Nursing, Erzincan University School of Health, Erzincan 24030, Turkey. E-mail: [email protected] This study was presented as an oral presentation in the II. International VI. National Congress of Psychiatric Nursing, 4–7 October, 2012, Erzurum, Turkey. Accepted October 25, 2014. doi: 10.1002/rnj.195
Purpose: This study was performed for the purpose of determining the effect of psychosocial skills training (PSST) on disease symptoms, insight, internalized stigmatization, and social functioning in patients with schizophrenia. Design: One group pretest–posttest model. Method: The study was carried out with 25 outpatients who were diagnosed with schizophrenia. The PSST was given to three groups of eight to nine patients once a week in 24 sessions, each lasting 90-120 minutes for a period of 6 months. Findings: The program had significant results in schizophrenic patients in improving the level of symptoms, increasing the level of functioning, and coping with stigmatization. Conclusion: The PSST program, adjuvant to pharmacological treatments, can be considered as a significant modality in daily practice due to its effect on improving symptoms, insight, and level of functioning and decreasing internalized stigmatization. Clinical Relevances: PSST in patients with schizophrenia can contribute to the use of evidence-based education strategies in psychiatric nursing practice to improve coping skills with the disease.
Introduction Schizophrenia is a complex mental disorder characterized by sets of positive, negative, and cognitive deficit symptoms in the areas of attention, memory, and executive functioning (Draper, Stutes, Maples, & Velligan, 2009). In schizophrenia, distinct impairments are experienced in important functioning areas such as work, interpersonal relations, and self-care. Such impairments prevent patients from developing social relationships, fulfilling their social roles or meeting their social needs, resulting in a decrease in their quality of life (Yıldız, 2011). In the treatment of schizophrenia, pharmacologic approaches and psychosocial interventions are supplemen© 2015 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 40, 341–348
tary of each other (Yıldız, 2005, 2011). Although medications are effective in reducing evident positive symptoms and relapse, they are not so effective in helping patients acquire social functioning and independent living skills (Gupta, Holshausen, Mausbach, Patterson, & Bowie, 2012; Valencia et al., 2010). For this reason, addition of psychological treatments on individual, family, or group basis to pharmacotherapy reduces relapses of the disease (Yıldız, 2005) and increases the success of patients in coping with their diseases and achieving their goals (Kern, Glynn, Horan, & Marder, 2009). Improving functioning is an important treatment target in schizophrenia (Gupta et al., 2012). The Psychosocial Skills Training (PSST) is a very important approach
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that incorporates psychological training, social skills training, group therapy, and family training. Psychosocial Skills Training comprises three major modules of the UCLA Social and Independent Living Skills modules, namely, Symptom Management (Liberman, 1986), Medication Management (Liberman, 1987) and Recreation for Leisure (Liberman, 1988). In the psychosocial skills training in schizophrenia researches carried out in Turkey, patients were found to have a reduced level of psychopathology and increased social functioning, quality of life and insight (Deveci, Esen-Danacı, Yurtsever, Deniz, & G€ urlek-Y€ uksel, 2008; Yildiz, Veznedaroglu, Eryavuz, & Kayahan, 2004; Yıldız et al., 2002). In serious mental disorders, the most important obstacle for patients’ adherence with the treatment and their attendance to the trainings is their impaired insights. Approximately 50–80% of patients with schizophrenia are reported to have insight deficit. Although outcomes of insight deficit that relate to nonadherence with the treatment and inadequacy in social functioning have been reported, a high level of insight in those with a serious mental disorder is said to adversely affect hope, selfesteem and quality of life, leading to depression and suicidal tendencies and these negative outcomes are associated with internalized stigmatization (Ampalam, Deepthi, & Vadaparty, 2012; Hasson-Ohayon et al., 2012). Internalized stigmatization is acceptance by an individual the negative stereotype judgments of the society as being true for them and withdrawing themselves from the society with negative emotions such as worthlessness and shame (Ersoy & Varan, 2007). Internalized stigmatization in schizophrenic patients hinders treatment adherence and recovery (Cam & Cuhadar, 2011; Fung, Tsang, & Cheung, 2011; Cavelti, Kvrgic, Beck, Ru¨sch, & Vauth, 2012) . It was found in a study that a high level of perceived internalized stigmatization, low self-esteem and poor insight were negative factors affecting treatment adherence (Fung, Tsang, & Corrigan, 2008) and in another study that patients who had a high level of functioning, readiness to change behavior and low level of perceived internalized stigmatization had better compliance with the treatment (Tsang, Fung, & Chung, 2010). Since evidence-based psychosocial treatments are important interventions that help independence, life satisfaction, and recovery of patients (Tsang et al., 2010), it is a major target to enable patients to assume the responsibilities regarding their own treatments and lives by obtaining the support of their families and the community (Yildiz, 2004). It was found in a study that social
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cognitive skills training had a significant impact on the social functioning of patients (Horan et al., 2009). This study aimed at determining the effect of PSST on disease symptoms, insight, internalized stigmatization, and social functioning in patients with schizophrenia. Methods Design and Subjects This pretest–posttest semi-experimental study was carried out with 25 outpatients who were diagnosed with schizophrenia under DSM-IV-TR (American Psychiatric Association, 2000) criteria at the outpatient psychiatry clinic of Erzincan State Hospital between February and August 2012. One of the patients was using a classical antipsychotic (Haloperidol 10 mg/day), three of them a classical+atypical antipsychotic (Haloperidol 10 mg/day and Amisulpride 400 mg/day) and the others an atypical antipsychotic (generally in low doses). The medications and their doses were not changed during the training program. Initially, 31 patients were enrolled, but the study was completed with 25 patients (participation 80.65%) as five patients did not complete the sessions and one patient the posttests. Inclusion/Exclusion Criteria The inclusion criteria for the patients were being an outpatient with completed acute treatment and ongoing maintenance drug therapy, being between 18 and 60 years of age (inclusive), and volunteering to take part in the study, and the exclusion criteria were being in the period of a psychotic relapse, personality disorder, alcohol-substance abuse, or mental retardation. The inclusion criteria for caregiving family members were living with their patient at least for a year, being between 18 and 65 years of age (inclusive), and agreeing to take part in the study. The exclusion criteria were having any physical disability (hearing, speaking disorders) or mental disorder (psychotic disorder, mental retardation, etc.).
Data Collection Tools Questionnaire The questionnaire used in this study included seven questions regarding the sociodemographic characteristics (age, gender, marital status, education level, and employment status) and disease-related characteristics (duration of the disease and number of hospitalizations) of the patients. © 2015 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 40, 341–348
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The Scale for the Assessment of Positive Symptoms (SAPS) This scale was developed by Andreasen (1990) to measure the level, distribution, and severity changes of the positive symptoms of schizophrenia, and it was tested for valid€ ity and reliability by Erkocß, Arkonacß, Ataklı, & Ozmen (1991a). The scale consists of five subscales and 35 items; the total score is obtained by adding the subscale scores together (Aydemir & K€ oroglu, 2007). The scale’s alpha coefficient is 0.87 and in this study, the alpha coefficient of the scale was found to be 0.83. The Scale for the Assessment of Negative Symptoms (SANS) This scale was developed by Andreasen (1990) to measure the level, distribution, and severity changes of the negative symptoms of schizophrenia, and it was tested for validity and reliability by Erkocß, Arkonacß, Ataklı, & € Ozmen (1991b). The scale consists of five subscales and 24 items; the total score is obtained by adding the subscale scores together (Aydemir & K€ oroglu, 2007). The scale’s alpha coefficient is 0.94 and in this study, the alpha coefficient of the scale was found to be 0.91. The Schedule for Assessing the Three Components of Insight (SAI) This schedule, which is administered by a clinician to assess insight quantitatively, was developed by David (1990) based on three components: treatment compliance, awareness of illness, and acknowledgment of psychotic experiences. The SAI was tested for validity and reliability by Aslan et al. (2001). It is a semi-structured scale consisting of eight questions. A patient obtaining a high score indicates a high level of insight (Aslan et al., 2001). The scale’s alpha coefficient is 0.83 and in this study, the alpha coefficient of the scale was found to be 0.71. The Internalized Stigma of Mental Illness (ISMI) Scale This scale was developed by Ritsher, Otilingam, & Grajales (2003) and tested for validity and reliability by Ersoy and Varan (2007). The ISMI scale has five subscales and 29 items; a high score indicates that the individual has severe internalized negative stigma (Ersoy & Varan, 2007). The scale’s alpha coefficient is 0.93 and in this study, the alpha coefficient of the scale was found to be 0.93. The Social Functioning Scale (SFS) The SFS is a reliable measurement tool that was developed to assess need and impairment in social functioning (Birchwood, Smith, Cochrane, Wetton, & Copestake, 1990). The scale, which was tested for validity and reli© 2015 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 40, 341–348
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ability by Erakay (2001), has seven subscales and provides detailed information regarding daily functions (Aydemir & K€ oroglu, 2007). The scale’s alpha coefficient is 0.80 and in this study, the alpha coefficient of the scale was found to be 0.91. Collection of Data The pre- and posttests of the study were collected by two psychiatry specialists using SAPS, SANS, and SAI and by the other investigators through face-to-face interviews with the patients using the other scales. During pretest, 31 patients were administered the questionnaire, SAPS, SANS, SAI, and ISMI. The scales administered during pretest were administered once more to 25 patients a week after the 24-four session program. Procedure After completing the pretests, the PSST was given to three groups of eight to nine patients once a week (Friday between 13:00–15:00 hours and Saturday between 10:00– 12:00 and 15:00–17:00 hours) in 24 sessions each lasting 90–120 minutes for a period of 6 months. The sessions were managed by the psychiatric nurse, who is the first author, and the last author was present during the sessions as an assistant trainer. The family members giving care were also trained by administering a family-to-family support program. In the family-to-family support program, a volunteering family member (35-year old female who is a graduate of a higher education institution) was given training by the first author. The family member who received the training gave training to the other family members with the participation of the psychiatric nurse. The family members were also provided with a leaflet containing the contents of the program. The family training was given to three groups of 11–12 caregivers once a week (Friday between 10:00–12:00 and 15:00–17:00 and Saturday between 13:00–15:00) in 12 sessions each lasting 2 hours for a period of 3 months. The topics were presented slowly and briefly in a to-the-point manner using simple and understandable language without a lot of detail; mutual interactions and continuous repetitions were carried out. Before each session, the family member leading the training and the psychiatric nurse exchanged information on the subject matter of the session for approximately 2 hours. The sessions started when the number in the first group was completed. The psychiatric nurse attended the workshops of Psychiatric Rehabilitation Unit and the psy-
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chological training program for patients and their families at the Kocaeli University, Faculty of Medicine, Department of Psychiatry Daytime Hospital from March 20–24, 2006, and also the Remixing with the Society Program course at the 1st International, 5th National Psychiatric Nurses Congress, September 22-24, 2011, and benefited from specialist views. Skill-related areas in the PSST program included: developing communication and problem solving skills, learning to cope with attention and memory problems, understanding psychosis and schizophrenia, learning antipsychotic drug treatment and drug side effects, evaluating the treatment, learning to cope with persistent symptoms, recognizing and monitoring stimulating signs, avoiding alcohol and narcotics, keeping away from seeking useless treatments, learning to cope with stress, improving selfconfidence, recreational and daily activities, developing friendly relationships, and participating in social activities (Yıldız, 2011). Certain targets were established for each session and the principles of giving information, modeling, reinforcement, shaping behaviors, supporting, repetition, generalization, self-monitoring, and self-assessment, and cognitive and social learning were used. Considering the attention, memory and abstraction problems of the patients, the training contents were presented slowly, with plenty repetitions, reconsiderations and positive reinforcements; simple reactions and behaviors were followed by more complex behaviors, and the information learned was reinforced by role playing and homeworks (Yıldız, 2011). The sessions were held in the multipurpose training room at the State Hospital of Erzincan using a portable writing board. The patients and their family members were given reminders by phone and they were provided with a phone number where the psychiatric nurse could be reached at all times. Ethical Principles Before starting the study, approval was obtained from the Ethics Committee of Erzincan University Health Sciences, written permission from the Provincial Health Directorate of Erzincan, and informed consents from the patients and their caregivers. Data Analysis In analyzing the data, descriptive characteristics were given as numbers and percentage distributions. The Wilcoxon
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paired two-sample test was used for comparing the mean pretest-posttest scale scores. The statistical analyses were carried out using the 15.0 version of the SPSS software and the level of significance was accepted to be p < .05. Results Patient Characteristics Approximately 84% of the patients were male, 60% of them were never married, 40% were graduates of primary school, and 28% were employed. The mean duration of the disease was 11.04 7.97 years and the number of hospitalizations was 6.20 9.79 (Table 1). The Effects of the PSST Program After the PSST program, there was a significant decrease in the total scores of SAPS (from 19.96 13.10 to 14.04 7.65, p = .001), SANS (from 40.04 16.87 to 26.32 11.31, p = .001), the ISMI subscales of alienation (from 17.20 4.74 to 12.24 2.31, p = .001), stereotype endorsement (from 18.36 4.61 to 13.92 2.61, p = .001), perceived discrimination (from 14.52 4.19 to 11.52 2.66, p = .001), social withdrawal (from 17.96 4.84 to 11.96 1.84, p = .001) and stigma resistance Table 1 Patient characteristics (n = 25) Characteristics Gender Female Male Marital Status Never married Married Divorced Widowed Education Level Literate Primary School Secondary School High School Employment Status Never worked Unemployed Worked in temporary jobs Employed Mean age (SD) Hasi Disease duration (years) (SD) Number of hospitalizations (SD)
n
%
4 21
16.0 84.0
15 7 2 1
60.0 28.0 8.0 4.0
3 10 4 8
12.0 40.0 16.0 32.0
8 2 8 7
32.0 8.0 32.0 28.0 35.96 (8.48) 11.04 (7.97) 6.20 (9.79)
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(from 12.92 2.16 to 10.16 0.99, p = .001) as well as in the total scores of ISMI (from 80.96 18.24 to 59.20 9.29, p = .001) and a significant increase in the scores of SAI (from 12.48 4.09 to 17.20 1.53, p = .001) and the SFS subscales of social engagements (from 9.28 2.87 to 12.72 1.43, p = .001), interpersonal functioning (from 4.64 2.36 to 6.80 1.00, p = .001), precursor social activities (from 8.08 5.31 to 20.72 5.00, p = .001), recreational activities (from 11.80 5.69 to 19.12 4.77, p = .001), competence (from 29.48 5.90 to 33.36 3.66, p = .001), performance (from 17.00 8.50 to 24.72 6.28, p = .001), and employment/occupation (from 3.08 4.62 to 7.96 1.43, p = .001) as well as in total scores of SFS (from 83.36 26.61 to 125.40 17.21, p = .001; Table 2). Discussion In schizophrenia, withdrawal symptoms, problems in cognitive functions, environmental factors, frequent relapses, and extended symptoms of violence may play a role in the impairment of social functioning (Yıldız, 2011). Negative symptoms were found in a study to be the most important predictors of social functioning (Erol, € Unal, Aydın, & Mete, 2009). The stigmatizing effect of
the disease may contract the social environment of patients by negatively affecting the approach of the society toward ill individuals (Yıldız, 2011). Quality of life also decreases in patients who cannot meet their needs due to their deficits in social communication. For this reason, patients who are deprived of their social skills cannot establish satisfactory relationships with others and feel lonely, hampered and isolated (Liberman, 2011). A meta-analysis reported that, in schizophrenia, social cognition had a stronger association with social functioning than with neurocognition (Fett et al., 2011). The main goal in mental health services is to achieve the strengthening that helps increase patients’ self-confidence and quality of life. The key variables that affect the quality of life in patients were reported to be the level of symptoms, psychosocial intervention, and strengthening (Chou et al., 2012). Since it became evident that social skills training, as an evidence-based service, helps increase functioning of individuals with mental disability and gaining achievement of their goals, this training has an important place in healing services (Liberman, 2012). In the treatment of schizophrenia and other mental disorders, mental health service systems should adopt practices for reducing stigmatization, for patient-oriented care, and for improvement-focused and evidence-based procedures
Table 2 SAPS, SANS, SAI, ISMI, and SFS scores of patients before and after training (n = 25) Scale SAPS SANS SAI ISMI Alienation Stereotype endorsement Perceived discrimination Social withdrawal Stigma resistance Total SFS Social activity Interpersonal functioning Precursor social activities Recreational activities Competence Performance Employment/occupation Total
Z*
p-value
Pretraining
Posttraining
19.96 13.10 40.04 16.87 12.48 4.09
14.04 7.65 26.32 11.31 17.20 1.53
3.546 4.321 4.025
.001 .001 .001
17.20 18.36 14.52 17.96 12.92 80.96
4.74 4.61 4.19 4.84 2.16 18.24
12.24 2.31 13.92 2.61 11.52 2.66 11.961.84 10.16 0.99 59.20 9.29
4.210 4.124 3.935 4.293 4.203 4.374
.001 .001 .001 .001 .001 .001
9.28 4.64 8.08 11.80 29.48 17.00 3.08 83.36
2.87 2.36 5.31 5.69 5.90 8.50 4.62 26.61
4.403 3.942 4.378 4.384 4.170 4.336 4.025 4.374
.001 .001 .001 .001 .001 .001 .001 .001
12.72 6.80 20.72 19.12 33.36 24.72 7.96 125.40
1.43 1.00 5.00 4.77 3.66 6.28 1.43 17.21
*The Wilcoxon paired two-sample test. SAPS, Scale for the Assessment of Positive Symptoms; SANS, Scale for the Assessment of Negative Symptoms; SAI, Schedule for Assessing the Three Components of Insight; ISMI, Internalized Stigma of Mental Illness Scale; SFS, Social Functioning Scale.
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(Liberman, 2012). Institutionalizing healing services and making them sustainable have an important contribution to reducing the burden on the individual, family, and society. Various training programs that have been administered for patients and their families in many developed countries are not included in the routine practices in most of the clinics or mental health centers in Turkey (Yildiz, 2004). It was seen in this study that the PSST program had significant results for schizophrenic patients in improving the level of symptoms, increasing the level of functioning, and coping with stigmatization. In a study by Yildiz and associates (2004), the patients who received psychosocial skills training had improved symptom levels and an increase in their levels of social functioning and perceived quality of life as compared to those in the control group. Another study by Deveci et al., (2008) showed, there was a significant decrease in the patients’ positive and negative symptom scores and their depression levels after the psychosocial skills training, and an increase in their levels of insight and quality of life, and a nonsignificant decrease in their levels of suicidal risk. A study made by Chou and associates (2012) found, the patients’ quality of life was significantly associated with symptom level in a negative direction and with psychosocial improvements and strengthening in a positive direction. Gupta and associates, in a 2012 study, showed that after a functional adaptation skills training program, a significant improvement was seen in social functioning and interpersonal relations in the patients, and neurocognitive functioning appeared as an indicator of improved skills and behaviors. Yet another study found that, improvements were seen in social cognition, social relationships, and cognitive compliance, and a decrease in aggression in patients who were administered 18-week Social Cognition and Interaction Training (SCIT), which consisted of emotion control, figuration of events, and integration (Combs et al., 2007). It is essential in a successful psychological training program to reduce stigmatization and improve awareness of the disease (C ß am & C ß uhadar, 2011). Being knowledgeable of the disease contributes to the development of methods to facilitate coping with the disease by the families, to balancing their expectations, and to the development of harmonious treatment cooperation. Whatever the level of insight, continuing to treat patients increases the possibility of developing full insight. Therefore, psychosocial skills training is expected to have an important contribution to developing insight and reducing or healing disability (Yıldız, 2011). Inclusion of family members in
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the program is very important with respect to both increasing their knowledge about the disease, thus reducing their burden and distress, and obtaining their help in developing independent and social living skills in patients (Yildiz, 2004). Significant positive differences were found in adherence with medication, adherence to appointments, disease symptoms, social functioning and relapse, and repeated hospitalization rates in patients who received psychosocial skills training together with family psychological training as compared to the control group (Valencia et al., 2010). Real steps will have been taken for recovery only to the extent the patients are able to use the skills they acquired in social skills training in their lives. Strengthening is a natural result of acquiring social skills, because skillful patients can have better control of their lives. Social skills training is an effective treatment based on learning while practicing, not merely talking about what will be done and feeding the powerful aspects of each patient. It does not focus on symptoms or psychopathology (Liberman, 2012). Patients’ ability to use the skills they learned in their private lives contributes to their attendance to the program, encourages them, gives them hope and increases adherence with the treatment (Yildiz, 2004). The patients in the sample attended the group sessions regularly. It was stated that support groups would be established as requested by the patients and the telephone conversations between the psychiatric nurse and the patients continue with respect to medications and daily life problems. It was observed that the patients and their families were highly interested in the program and they were satisfied with it. Additionally, the families stated after the training program that they could comfortably express their emotions and thoughts without any sense of guilt or shame; they became more sensitive toward the problems and could cope with the difficulties they faced in relation to patient care, the family, and various other situations. We think this interest stemmed from the fact that the doctors constantly encouraged the patients and their families to take part in the program and that the patients and their families really needed this kind of a program. Conclusion The effectiveness of the treatment of schizophrenia increases if the patient, family, and treatment staff are in collaboration. Psychiatric nurses are able to develop and administer programs that increase decision-making skills and self-esteem, which offers the patients the opportunity © 2015 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 40, 341–348
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Key Practice Points Schizophrenia is a disease that progresses with severe impairments in the individual’s thoughts, emotions and behaviors, interpersonal relations, working life, and adaptation to society. Treatment of schizophrenia cannot be unidirectional; mental as well as social approaches should be taken into consideration. Psychiatric nurses are a member of the multidisciplinary team that provide mental social services to individuals with mental illnesses and they assume a major role in attaining cooperation between the patient, social services and health institutions. Psychiatric nurses make important contributions to patient and family outcomes by organizing mental social training and community-based structured support programs. Proliferation of community-based mental health services, including administration of psychosocial skills training programs, can contribute significantly to increasing quality of life in patients and their families.
to improve their social skills (Chou et al., 2012). We believe that the results of this study showed that group treatment was effective in providing support in fighting with patients’ feelings of loneliness and isolation, identifying the solutions to the problems they have encountered or may encounter in their daily lives by making frequent practices in each skill area through role playing and homework, and developing problem- solving skills–all these improving self-esteem in the patients. The PSST program, adjuvant to pharmacological treatments, can be considered as a significant modality in daily practice due to its effect on improving symptoms, insight, and level of functioning, and decreasing internalized stigmatization in schizophrenic patients.
Limitation of the Study Lack of a control group in this study is a limitation. A control group could not be formed since the number of patients who presented to the outpatient clinic, when the data were being collected between February and August 2012, was only 43, and the total number of patients who met the inclusion criteria and were willing to participate was 25. Other studies are needed to compare the results of PSST-administered patients with a control group.
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Acknowledgment We are grateful to the staff of psychiatry polyclinic, patients, and families of patients included in our study. References American Psychiatric Association. (2000). DSM-IV-TRDiagnostic and Statistical Manual of Mental Disorders (4th ed). Washington DC: American Psychiatric Association. Ampalam, P., Deepthi, R., & Vadaparty, P. (2012). Schizophrenia-insight, depression: A correlation study. Indian Journal of Psychological Medicine, 34:44–48. Andreasen, N.C. (1990). Methods for assessing positive and negative symptoms. Modern Problems of Pharmacopsychiatry, 24,73–88. Aslan, S., Kilicß, B.G., Karakilicß, H.G., Cosar, B., Isikli, S., & Isik, E.. (2001). Three components of Insight Rating Scale: Reliability and validity studies. T€ urkiye’de Psikiyatri, 3,17–24. € Aydemir, O., K€ oroglu, E.. (2007). Clinical Scales Used in Psychiatry. Ankara, Turkey: Hekimler Yayin Birligi. Birchwood, M., Smith, J., Cochrane, R., Wetton, S., & Copestake, S. (1990). The Social Functioning Scale. The development and validation of a new scale of social adjustment for use in family intervention programmes with schizophrenic patients. British Journal of Psychiatry, 157, 853–859. C ß am, O., & C ß uhadar, D. (2011). Stigma process and internalized stigma among individuals with mental illness. Psikiyatri Hemsßirelig i Dergisi, 2, 136–140. Cavelti, M., Kvrgic, S., Beck, E.M., R€ usch, N., & Vauth, R. (2012). Self-stigma and its relationship with insight, demoralization, and clinical outcome among people with schizophrenia spectrum disorders. Comprehensive Psychiatry, 53, 468–479. Chou, K.R., Shih, Y.W., Chang, C., Chou, Y.Y., Hu, W.H., Cheng, J.S., . . . Hsieh, C.J. (2012). Psychosocial rehabilitation activities, empowerment, and quality of community-based life for people with schizophrenia. Archives of Psychiatric Nursing, 26, 285–294. Combs, D.R., Adams, S.D., Penn, D.L., Roberts, D., Tiegreen, J., & Stem, P. (2007). Social Cognition and Interaction Training (SCIT) for inpatients with schizophrenia spectrum disorders: Preliminary findings. Schizophrenia Research, 91, 112–116. David, A. (1990). Insight in psychosis. British Journal of Psychiatry, 156, 798–808. Deveci, A., Esen-Danacı, A., Yurtsever, F., Deniz, F., G€ urlekY€ uksel, E. (2008). The effects of Psychosocial Skills Training on symptomatology, insight, quality of life, and suicide probability in schizophrenia. Turk Psikiyatri Derg, 19, 266–273. Draper, M.L., Stutes, D.S., Maples, N.J., & Velligan, D.I. (2009). Cognitive adaptation training for outpatients with schizophrenia. Journal of Clinical Psychology, 65, 842–853.
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Liberman, R.P. (1986). Social and Independent Living Skills: Medication-Menagemen Module, Trainer’s Manual. Los Angeles, CA: UCLA Department of Psychiatry. Liberman, R.P. (1987). Social and Independent Living Skills: Recreation for Leisure Module, Trainer’s Manual. Los Angeles, CA: UCLA Department of Psychiatry. Liberman, R.P. (1988). Social and Independent Living Skills: Symptom Management Module, Trainer’s Manual. Los Angeles, CA: UCLA Department of Psychiatry. Liberman, R.P. (2011). Disability to recovery. In: M. Yildiz (Ed.), Handbook of Psychiatric Rehabilitation, pp. 278–310. Ankara, Turkey, and Washington, DC: American Psychiatric Publishing, Inc., Turkey Association for Social Psychiatry. Liberman, R.P. (2012). Recovery from schizophrenia: Form follows functioning. World Psychiatry, 11, 161–162. Ritsher, J.B., Otilingam, P.G., & Grajales, M. (2003). Internalized stigma of mental illness: Psychometric properties of a new measure. Psychiatry Research, 121, 31–49. Tsang, H.W., Fung, K.M., & Chung, R.C. (2010). Self-stigma and stages of change as predictors of treatment adherence of individuals with schizophrenia. Psychiatry Research, 180, 10–15. Valencia, M., Rascon, M.L., Juarez, F., Escamilla, R., Saracco, R., & Liberman, R.P. (2010). Application in Mexico of psychosocial rehabilitation with schizophrenia patients. Psychiatry, 73, 248–263. Yildiz, M. (2004) Psychosocial Rehabilitation, from the individual to the community mental health (1st ed.). In: I. Sayıl (Ed.), From the Individual to the Community Mental Health, pp. 151–164. Istanbul, Turkey: Erler Typography. Yıldız, M. (2005). Sßizofreni. Understand and Learn to Live With _ Disease. Istanbul, Turkey: Okuyan Us Publishing. Yıldız, M. (2011). Psychosocial Skills Training for Schizophrenia Patients (1st ed.). Ankara, Turkey: Turkey Association for Social Psychiatry Publications. Yildiz, M., Veznedaroglu, B., Eryavuz, A., & Kayahan, B. (2004). Psychosocial skills training on social functioning and quality of life in the treatment of schizophrenia: A controlled study in Turkey. International Journal of Psychiatry in Clinical Practice, 8, 219–225. € € Yıldız, M., Yazıcı, A., Unal, S., Aker, T., Ozgen, G., Ekmekcßi, H., . . . Eryıldız, M. (2002). Social Skills Training in psychosocial therapy of schizophrenia: A multicenter study for symptom management and medication management modules. Turk Psikiyatri Derg, 13, 41–47.
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Effect of Psychosocial Skills Training on Disease Symptoms, Insight, Internalized Stigmatization, and Social Functioning in Patients with Schizophrenia lu Asßılar1, PhD, RN, Tuba Hale Camcıog lu2, Spec., Arzu Yıldırım1, PhD, RN, Rabia Hacıhasanog 3 4 acß , RN Sezgin Erdiman , Spec. & Ebru Karaag 1 Deparment of Nursing, Erzincan University School of Health, Erzincan, Turkey 2 Sadi Konuk Educational and Research Hospital, Psychiatry Clinic, _Istanbul, Turkey €rk State Hospital, Psychiatry Clinic, Balıkesir, Turkey 3 Balıkesir Atatu 4 Institute of Health Sciences, Erzincan, Turkey
Keywords
Abstract
Disease symptoms; insight; internalized stigmatization; psychosocial skills training; social functioning. Correspondence Arzu Yıldırım, Deparment of Nursing, Erzincan University School of Health, Erzincan 24030, Turkey. E-mail: [email protected] This study was presented as an oral presentation in the II. International VI. National Congress of Psychiatric Nursing, 4–7 October, 2012, Erzurum, Turkey. Accepted October 25, 2014. doi: 10.1002/rnj.195
Purpose: This study was performed for the purpose of determining the effect of psychosocial skills training (PSST) on disease symptoms, insight, internalized stigmatization, and social functioning in patients with schizophrenia. Design: One group pretest–posttest model. Method: The study was carried out with 25 outpatients who were diagnosed with schizophrenia. The PSST was given to three groups of eight to nine patients once a week in 24 sessions, each lasting 90-120 minutes for a period of 6 months. Findings: The program had significant results in schizophrenic patients in improving the level of symptoms, increasing the level of functioning, and coping with stigmatization. Conclusion: The PSST program, adjuvant to pharmacological treatments, can be considered as a significant modality in daily practice due to its effect on improving symptoms, insight, and level of functioning and decreasing internalized stigmatization. Clinical Relevances: PSST in patients with schizophrenia can contribute to the use of evidence-based education strategies in psychiatric nursing practice to improve coping skills with the disease.
Introduction Schizophrenia is a complex mental disorder characterized by sets of positive, negative, and cognitive deficit symptoms in the areas of attention, memory, and executive functioning (Draper, Stutes, Maples, & Velligan, 2009). In schizophrenia, distinct impairments are experienced in important functioning areas such as work, interpersonal relations, and self-care. Such impairments prevent patients from developing social relationships, fulfilling their social roles or meeting their social needs, resulting in a decrease in their quality of life (Yıldız, 2011). In the treatment of schizophrenia, pharmacologic approaches and psychosocial interventions are supplemen© 2015 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 40, 341–348
tary of each other (Yıldız, 2005, 2011). Although medications are effective in reducing evident positive symptoms and relapse, they are not so effective in helping patients acquire social functioning and independent living skills (Gupta, Holshausen, Mausbach, Patterson, & Bowie, 2012; Valencia et al., 2010). For this reason, addition of psychological treatments on individual, family, or group basis to pharmacotherapy reduces relapses of the disease (Yıldız, 2005) and increases the success of patients in coping with their diseases and achieving their goals (Kern, Glynn, Horan, & Marder, 2009). Improving functioning is an important treatment target in schizophrenia (Gupta et al., 2012). The Psychosocial Skills Training (PSST) is a very important approach
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that incorporates psychological training, social skills training, group therapy, and family training. Psychosocial Skills Training comprises three major modules of the UCLA Social and Independent Living Skills modules, namely, Symptom Management (Liberman, 1986), Medication Management (Liberman, 1987) and Recreation for Leisure (Liberman, 1988). In the psychosocial skills training in schizophrenia researches carried out in Turkey, patients were found to have a reduced level of psychopathology and increased social functioning, quality of life and insight (Deveci, Esen-Danacı, Yurtsever, Deniz, & G€ urlek-Y€ uksel, 2008; Yildiz, Veznedaroglu, Eryavuz, & Kayahan, 2004; Yıldız et al., 2002). In serious mental disorders, the most important obstacle for patients’ adherence with the treatment and their attendance to the trainings is their impaired insights. Approximately 50–80% of patients with schizophrenia are reported to have insight deficit. Although outcomes of insight deficit that relate to nonadherence with the treatment and inadequacy in social functioning have been reported, a high level of insight in those with a serious mental disorder is said to adversely affect hope, selfesteem and quality of life, leading to depression and suicidal tendencies and these negative outcomes are associated with internalized stigmatization (Ampalam, Deepthi, & Vadaparty, 2012; Hasson-Ohayon et al., 2012). Internalized stigmatization is acceptance by an individual the negative stereotype judgments of the society as being true for them and withdrawing themselves from the society with negative emotions such as worthlessness and shame (Ersoy & Varan, 2007). Internalized stigmatization in schizophrenic patients hinders treatment adherence and recovery (Cam & Cuhadar, 2011; Fung, Tsang, & Cheung, 2011; Cavelti, Kvrgic, Beck, Ru¨sch, & Vauth, 2012) . It was found in a study that a high level of perceived internalized stigmatization, low self-esteem and poor insight were negative factors affecting treatment adherence (Fung, Tsang, & Corrigan, 2008) and in another study that patients who had a high level of functioning, readiness to change behavior and low level of perceived internalized stigmatization had better compliance with the treatment (Tsang, Fung, & Chung, 2010). Since evidence-based psychosocial treatments are important interventions that help independence, life satisfaction, and recovery of patients (Tsang et al., 2010), it is a major target to enable patients to assume the responsibilities regarding their own treatments and lives by obtaining the support of their families and the community (Yildiz, 2004). It was found in a study that social
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cognitive skills training had a significant impact on the social functioning of patients (Horan et al., 2009). This study aimed at determining the effect of PSST on disease symptoms, insight, internalized stigmatization, and social functioning in patients with schizophrenia. Methods Design and Subjects This pretest–posttest semi-experimental study was carried out with 25 outpatients who were diagnosed with schizophrenia under DSM-IV-TR (American Psychiatric Association, 2000) criteria at the outpatient psychiatry clinic of Erzincan State Hospital between February and August 2012. One of the patients was using a classical antipsychotic (Haloperidol 10 mg/day), three of them a classical+atypical antipsychotic (Haloperidol 10 mg/day and Amisulpride 400 mg/day) and the others an atypical antipsychotic (generally in low doses). The medications and their doses were not changed during the training program. Initially, 31 patients were enrolled, but the study was completed with 25 patients (participation 80.65%) as five patients did not complete the sessions and one patient the posttests. Inclusion/Exclusion Criteria The inclusion criteria for the patients were being an outpatient with completed acute treatment and ongoing maintenance drug therapy, being between 18 and 60 years of age (inclusive), and volunteering to take part in the study, and the exclusion criteria were being in the period of a psychotic relapse, personality disorder, alcohol-substance abuse, or mental retardation. The inclusion criteria for caregiving family members were living with their patient at least for a year, being between 18 and 65 years of age (inclusive), and agreeing to take part in the study. The exclusion criteria were having any physical disability (hearing, speaking disorders) or mental disorder (psychotic disorder, mental retardation, etc.).
Data Collection Tools Questionnaire The questionnaire used in this study included seven questions regarding the sociodemographic characteristics (age, gender, marital status, education level, and employment status) and disease-related characteristics (duration of the disease and number of hospitalizations) of the patients. © 2015 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 40, 341–348
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The Scale for the Assessment of Positive Symptoms (SAPS) This scale was developed by Andreasen (1990) to measure the level, distribution, and severity changes of the positive symptoms of schizophrenia, and it was tested for valid€ ity and reliability by Erkocß, Arkonacß, Ataklı, & Ozmen (1991a). The scale consists of five subscales and 35 items; the total score is obtained by adding the subscale scores together (Aydemir & K€ oroglu, 2007). The scale’s alpha coefficient is 0.87 and in this study, the alpha coefficient of the scale was found to be 0.83. The Scale for the Assessment of Negative Symptoms (SANS) This scale was developed by Andreasen (1990) to measure the level, distribution, and severity changes of the negative symptoms of schizophrenia, and it was tested for validity and reliability by Erkocß, Arkonacß, Ataklı, & € Ozmen (1991b). The scale consists of five subscales and 24 items; the total score is obtained by adding the subscale scores together (Aydemir & K€ oroglu, 2007). The scale’s alpha coefficient is 0.94 and in this study, the alpha coefficient of the scale was found to be 0.91. The Schedule for Assessing the Three Components of Insight (SAI) This schedule, which is administered by a clinician to assess insight quantitatively, was developed by David (1990) based on three components: treatment compliance, awareness of illness, and acknowledgment of psychotic experiences. The SAI was tested for validity and reliability by Aslan et al. (2001). It is a semi-structured scale consisting of eight questions. A patient obtaining a high score indicates a high level of insight (Aslan et al., 2001). The scale’s alpha coefficient is 0.83 and in this study, the alpha coefficient of the scale was found to be 0.71. The Internalized Stigma of Mental Illness (ISMI) Scale This scale was developed by Ritsher, Otilingam, & Grajales (2003) and tested for validity and reliability by Ersoy and Varan (2007). The ISMI scale has five subscales and 29 items; a high score indicates that the individual has severe internalized negative stigma (Ersoy & Varan, 2007). The scale’s alpha coefficient is 0.93 and in this study, the alpha coefficient of the scale was found to be 0.93. The Social Functioning Scale (SFS) The SFS is a reliable measurement tool that was developed to assess need and impairment in social functioning (Birchwood, Smith, Cochrane, Wetton, & Copestake, 1990). The scale, which was tested for validity and reli© 2015 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 40, 341–348
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ability by Erakay (2001), has seven subscales and provides detailed information regarding daily functions (Aydemir & K€ oroglu, 2007). The scale’s alpha coefficient is 0.80 and in this study, the alpha coefficient of the scale was found to be 0.91. Collection of Data The pre- and posttests of the study were collected by two psychiatry specialists using SAPS, SANS, and SAI and by the other investigators through face-to-face interviews with the patients using the other scales. During pretest, 31 patients were administered the questionnaire, SAPS, SANS, SAI, and ISMI. The scales administered during pretest were administered once more to 25 patients a week after the 24-four session program. Procedure After completing the pretests, the PSST was given to three groups of eight to nine patients once a week (Friday between 13:00–15:00 hours and Saturday between 10:00– 12:00 and 15:00–17:00 hours) in 24 sessions each lasting 90–120 minutes for a period of 6 months. The sessions were managed by the psychiatric nurse, who is the first author, and the last author was present during the sessions as an assistant trainer. The family members giving care were also trained by administering a family-to-family support program. In the family-to-family support program, a volunteering family member (35-year old female who is a graduate of a higher education institution) was given training by the first author. The family member who received the training gave training to the other family members with the participation of the psychiatric nurse. The family members were also provided with a leaflet containing the contents of the program. The family training was given to three groups of 11–12 caregivers once a week (Friday between 10:00–12:00 and 15:00–17:00 and Saturday between 13:00–15:00) in 12 sessions each lasting 2 hours for a period of 3 months. The topics were presented slowly and briefly in a to-the-point manner using simple and understandable language without a lot of detail; mutual interactions and continuous repetitions were carried out. Before each session, the family member leading the training and the psychiatric nurse exchanged information on the subject matter of the session for approximately 2 hours. The sessions started when the number in the first group was completed. The psychiatric nurse attended the workshops of Psychiatric Rehabilitation Unit and the psy-
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chological training program for patients and their families at the Kocaeli University, Faculty of Medicine, Department of Psychiatry Daytime Hospital from March 20–24, 2006, and also the Remixing with the Society Program course at the 1st International, 5th National Psychiatric Nurses Congress, September 22-24, 2011, and benefited from specialist views. Skill-related areas in the PSST program included: developing communication and problem solving skills, learning to cope with attention and memory problems, understanding psychosis and schizophrenia, learning antipsychotic drug treatment and drug side effects, evaluating the treatment, learning to cope with persistent symptoms, recognizing and monitoring stimulating signs, avoiding alcohol and narcotics, keeping away from seeking useless treatments, learning to cope with stress, improving selfconfidence, recreational and daily activities, developing friendly relationships, and participating in social activities (Yıldız, 2011). Certain targets were established for each session and the principles of giving information, modeling, reinforcement, shaping behaviors, supporting, repetition, generalization, self-monitoring, and self-assessment, and cognitive and social learning were used. Considering the attention, memory and abstraction problems of the patients, the training contents were presented slowly, with plenty repetitions, reconsiderations and positive reinforcements; simple reactions and behaviors were followed by more complex behaviors, and the information learned was reinforced by role playing and homeworks (Yıldız, 2011). The sessions were held in the multipurpose training room at the State Hospital of Erzincan using a portable writing board. The patients and their family members were given reminders by phone and they were provided with a phone number where the psychiatric nurse could be reached at all times. Ethical Principles Before starting the study, approval was obtained from the Ethics Committee of Erzincan University Health Sciences, written permission from the Provincial Health Directorate of Erzincan, and informed consents from the patients and their caregivers. Data Analysis In analyzing the data, descriptive characteristics were given as numbers and percentage distributions. The Wilcoxon
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paired two-sample test was used for comparing the mean pretest-posttest scale scores. The statistical analyses were carried out using the 15.0 version of the SPSS software and the level of significance was accepted to be p < .05. Results Patient Characteristics Approximately 84% of the patients were male, 60% of them were never married, 40% were graduates of primary school, and 28% were employed. The mean duration of the disease was 11.04 7.97 years and the number of hospitalizations was 6.20 9.79 (Table 1). The Effects of the PSST Program After the PSST program, there was a significant decrease in the total scores of SAPS (from 19.96 13.10 to 14.04 7.65, p = .001), SANS (from 40.04 16.87 to 26.32 11.31, p = .001), the ISMI subscales of alienation (from 17.20 4.74 to 12.24 2.31, p = .001), stereotype endorsement (from 18.36 4.61 to 13.92 2.61, p = .001), perceived discrimination (from 14.52 4.19 to 11.52 2.66, p = .001), social withdrawal (from 17.96 4.84 to 11.96 1.84, p = .001) and stigma resistance Table 1 Patient characteristics (n = 25) Characteristics Gender Female Male Marital Status Never married Married Divorced Widowed Education Level Literate Primary School Secondary School High School Employment Status Never worked Unemployed Worked in temporary jobs Employed Mean age (SD) Hasi Disease duration (years) (SD) Number of hospitalizations (SD)
n
%
4 21
16.0 84.0
15 7 2 1
60.0 28.0 8.0 4.0
3 10 4 8
12.0 40.0 16.0 32.0
8 2 8 7
32.0 8.0 32.0 28.0 35.96 (8.48) 11.04 (7.97) 6.20 (9.79)
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(from 12.92 2.16 to 10.16 0.99, p = .001) as well as in the total scores of ISMI (from 80.96 18.24 to 59.20 9.29, p = .001) and a significant increase in the scores of SAI (from 12.48 4.09 to 17.20 1.53, p = .001) and the SFS subscales of social engagements (from 9.28 2.87 to 12.72 1.43, p = .001), interpersonal functioning (from 4.64 2.36 to 6.80 1.00, p = .001), precursor social activities (from 8.08 5.31 to 20.72 5.00, p = .001), recreational activities (from 11.80 5.69 to 19.12 4.77, p = .001), competence (from 29.48 5.90 to 33.36 3.66, p = .001), performance (from 17.00 8.50 to 24.72 6.28, p = .001), and employment/occupation (from 3.08 4.62 to 7.96 1.43, p = .001) as well as in total scores of SFS (from 83.36 26.61 to 125.40 17.21, p = .001; Table 2). Discussion In schizophrenia, withdrawal symptoms, problems in cognitive functions, environmental factors, frequent relapses, and extended symptoms of violence may play a role in the impairment of social functioning (Yıldız, 2011). Negative symptoms were found in a study to be the most important predictors of social functioning (Erol, € Unal, Aydın, & Mete, 2009). The stigmatizing effect of
the disease may contract the social environment of patients by negatively affecting the approach of the society toward ill individuals (Yıldız, 2011). Quality of life also decreases in patients who cannot meet their needs due to their deficits in social communication. For this reason, patients who are deprived of their social skills cannot establish satisfactory relationships with others and feel lonely, hampered and isolated (Liberman, 2011). A meta-analysis reported that, in schizophrenia, social cognition had a stronger association with social functioning than with neurocognition (Fett et al., 2011). The main goal in mental health services is to achieve the strengthening that helps increase patients’ self-confidence and quality of life. The key variables that affect the quality of life in patients were reported to be the level of symptoms, psychosocial intervention, and strengthening (Chou et al., 2012). Since it became evident that social skills training, as an evidence-based service, helps increase functioning of individuals with mental disability and gaining achievement of their goals, this training has an important place in healing services (Liberman, 2012). In the treatment of schizophrenia and other mental disorders, mental health service systems should adopt practices for reducing stigmatization, for patient-oriented care, and for improvement-focused and evidence-based procedures
Table 2 SAPS, SANS, SAI, ISMI, and SFS scores of patients before and after training (n = 25) Scale SAPS SANS SAI ISMI Alienation Stereotype endorsement Perceived discrimination Social withdrawal Stigma resistance Total SFS Social activity Interpersonal functioning Precursor social activities Recreational activities Competence Performance Employment/occupation Total
Z*
p-value
Pretraining
Posttraining
19.96 13.10 40.04 16.87 12.48 4.09
14.04 7.65 26.32 11.31 17.20 1.53
3.546 4.321 4.025
.001 .001 .001
17.20 18.36 14.52 17.96 12.92 80.96
4.74 4.61 4.19 4.84 2.16 18.24
12.24 2.31 13.92 2.61 11.52 2.66 11.961.84 10.16 0.99 59.20 9.29
4.210 4.124 3.935 4.293 4.203 4.374
.001 .001 .001 .001 .001 .001
9.28 4.64 8.08 11.80 29.48 17.00 3.08 83.36
2.87 2.36 5.31 5.69 5.90 8.50 4.62 26.61
4.403 3.942 4.378 4.384 4.170 4.336 4.025 4.374
.001 .001 .001 .001 .001 .001 .001 .001
12.72 6.80 20.72 19.12 33.36 24.72 7.96 125.40
1.43 1.00 5.00 4.77 3.66 6.28 1.43 17.21
*The Wilcoxon paired two-sample test. SAPS, Scale for the Assessment of Positive Symptoms; SANS, Scale for the Assessment of Negative Symptoms; SAI, Schedule for Assessing the Three Components of Insight; ISMI, Internalized Stigma of Mental Illness Scale; SFS, Social Functioning Scale.
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(Liberman, 2012). Institutionalizing healing services and making them sustainable have an important contribution to reducing the burden on the individual, family, and society. Various training programs that have been administered for patients and their families in many developed countries are not included in the routine practices in most of the clinics or mental health centers in Turkey (Yildiz, 2004). It was seen in this study that the PSST program had significant results for schizophrenic patients in improving the level of symptoms, increasing the level of functioning, and coping with stigmatization. In a study by Yildiz and associates (2004), the patients who received psychosocial skills training had improved symptom levels and an increase in their levels of social functioning and perceived quality of life as compared to those in the control group. Another study by Deveci et al., (2008) showed, there was a significant decrease in the patients’ positive and negative symptom scores and their depression levels after the psychosocial skills training, and an increase in their levels of insight and quality of life, and a nonsignificant decrease in their levels of suicidal risk. A study made by Chou and associates (2012) found, the patients’ quality of life was significantly associated with symptom level in a negative direction and with psychosocial improvements and strengthening in a positive direction. Gupta and associates, in a 2012 study, showed that after a functional adaptation skills training program, a significant improvement was seen in social functioning and interpersonal relations in the patients, and neurocognitive functioning appeared as an indicator of improved skills and behaviors. Yet another study found that, improvements were seen in social cognition, social relationships, and cognitive compliance, and a decrease in aggression in patients who were administered 18-week Social Cognition and Interaction Training (SCIT), which consisted of emotion control, figuration of events, and integration (Combs et al., 2007). It is essential in a successful psychological training program to reduce stigmatization and improve awareness of the disease (C ß am & C ß uhadar, 2011). Being knowledgeable of the disease contributes to the development of methods to facilitate coping with the disease by the families, to balancing their expectations, and to the development of harmonious treatment cooperation. Whatever the level of insight, continuing to treat patients increases the possibility of developing full insight. Therefore, psychosocial skills training is expected to have an important contribution to developing insight and reducing or healing disability (Yıldız, 2011). Inclusion of family members in
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the program is very important with respect to both increasing their knowledge about the disease, thus reducing their burden and distress, and obtaining their help in developing independent and social living skills in patients (Yildiz, 2004). Significant positive differences were found in adherence with medication, adherence to appointments, disease symptoms, social functioning and relapse, and repeated hospitalization rates in patients who received psychosocial skills training together with family psychological training as compared to the control group (Valencia et al., 2010). Real steps will have been taken for recovery only to the extent the patients are able to use the skills they acquired in social skills training in their lives. Strengthening is a natural result of acquiring social skills, because skillful patients can have better control of their lives. Social skills training is an effective treatment based on learning while practicing, not merely talking about what will be done and feeding the powerful aspects of each patient. It does not focus on symptoms or psychopathology (Liberman, 2012). Patients’ ability to use the skills they learned in their private lives contributes to their attendance to the program, encourages them, gives them hope and increases adherence with the treatment (Yildiz, 2004). The patients in the sample attended the group sessions regularly. It was stated that support groups would be established as requested by the patients and the telephone conversations between the psychiatric nurse and the patients continue with respect to medications and daily life problems. It was observed that the patients and their families were highly interested in the program and they were satisfied with it. Additionally, the families stated after the training program that they could comfortably express their emotions and thoughts without any sense of guilt or shame; they became more sensitive toward the problems and could cope with the difficulties they faced in relation to patient care, the family, and various other situations. We think this interest stemmed from the fact that the doctors constantly encouraged the patients and their families to take part in the program and that the patients and their families really needed this kind of a program. Conclusion The effectiveness of the treatment of schizophrenia increases if the patient, family, and treatment staff are in collaboration. Psychiatric nurses are able to develop and administer programs that increase decision-making skills and self-esteem, which offers the patients the opportunity © 2015 Association of Rehabilitation Nurses Rehabilitation Nursing 2015, 40, 341–348
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Key Practice Points Schizophrenia is a disease that progresses with severe impairments in the individual’s thoughts, emotions and behaviors, interpersonal relations, working life, and adaptation to society. Treatment of schizophrenia cannot be unidirectional; mental as well as social approaches should be taken into consideration. Psychiatric nurses are a member of the multidisciplinary team that provide mental social services to individuals with mental illnesses and they assume a major role in attaining cooperation between the patient, social services and health institutions. Psychiatric nurses make important contributions to patient and family outcomes by organizing mental social training and community-based structured support programs. Proliferation of community-based mental health services, including administration of psychosocial skills training programs, can contribute significantly to increasing quality of life in patients and their families.
to improve their social skills (Chou et al., 2012). We believe that the results of this study showed that group treatment was effective in providing support in fighting with patients’ feelings of loneliness and isolation, identifying the solutions to the problems they have encountered or may encounter in their daily lives by making frequent practices in each skill area through role playing and homework, and developing problem- solving skills–all these improving self-esteem in the patients. The PSST program, adjuvant to pharmacological treatments, can be considered as a significant modality in daily practice due to its effect on improving symptoms, insight, and level of functioning, and decreasing internalized stigmatization in schizophrenic patients.
Limitation of the Study Lack of a control group in this study is a limitation. A control group could not be formed since the number of patients who presented to the outpatient clinic, when the data were being collected between February and August 2012, was only 43, and the total number of patients who met the inclusion criteria and were willing to participate was 25. Other studies are needed to compare the results of PSST-administered patients with a control group.
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Acknowledgment We are grateful to the staff of psychiatry polyclinic, patients, and families of patients included in our study. References American Psychiatric Association. (2000). DSM-IV-TRDiagnostic and Statistical Manual of Mental Disorders (4th ed). Washington DC: American Psychiatric Association. Ampalam, P., Deepthi, R., & Vadaparty, P. (2012). Schizophrenia-insight, depression: A correlation study. Indian Journal of Psychological Medicine, 34:44–48. Andreasen, N.C. (1990). Methods for assessing positive and negative symptoms. Modern Problems of Pharmacopsychiatry, 24,73–88. Aslan, S., Kilicß, B.G., Karakilicß, H.G., Cosar, B., Isikli, S., & Isik, E.. (2001). Three components of Insight Rating Scale: Reliability and validity studies. T€ urkiye’de Psikiyatri, 3,17–24. € Aydemir, O., K€ oroglu, E.. (2007). Clinical Scales Used in Psychiatry. Ankara, Turkey: Hekimler Yayin Birligi. Birchwood, M., Smith, J., Cochrane, R., Wetton, S., & Copestake, S. (1990). The Social Functioning Scale. The development and validation of a new scale of social adjustment for use in family intervention programmes with schizophrenic patients. British Journal of Psychiatry, 157, 853–859. C ß am, O., & C ß uhadar, D. (2011). Stigma process and internalized stigma among individuals with mental illness. Psikiyatri Hemsßirelig i Dergisi, 2, 136–140. Cavelti, M., Kvrgic, S., Beck, E.M., R€ usch, N., & Vauth, R. (2012). Self-stigma and its relationship with insight, demoralization, and clinical outcome among people with schizophrenia spectrum disorders. Comprehensive Psychiatry, 53, 468–479. Chou, K.R., Shih, Y.W., Chang, C., Chou, Y.Y., Hu, W.H., Cheng, J.S., . . . Hsieh, C.J. (2012). Psychosocial rehabilitation activities, empowerment, and quality of community-based life for people with schizophrenia. Archives of Psychiatric Nursing, 26, 285–294. Combs, D.R., Adams, S.D., Penn, D.L., Roberts, D., Tiegreen, J., & Stem, P. (2007). Social Cognition and Interaction Training (SCIT) for inpatients with schizophrenia spectrum disorders: Preliminary findings. Schizophrenia Research, 91, 112–116. David, A. (1990). Insight in psychosis. British Journal of Psychiatry, 156, 798–808. Deveci, A., Esen-Danacı, A., Yurtsever, F., Deniz, F., G€ urlekY€ uksel, E. (2008). The effects of Psychosocial Skills Training on symptomatology, insight, quality of life, and suicide probability in schizophrenia. Turk Psikiyatri Derg, 19, 266–273. Draper, M.L., Stutes, D.S., Maples, N.J., & Velligan, D.I. (2009). Cognitive adaptation training for outpatients with schizophrenia. Journal of Clinical Psychology, 65, 842–853.
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